CRH Medical (CRHM) 10-K 13 Mar 19 2018 FY Annual report Financial data

Document and Entity Information

Document and Entity Information - USD ($) $ in Millions	12 Months Ended
	Dec. 31, 2018	Mar. 12, 2019	Jun. 30, 2018
Document And Entity Information [Abstract]
Document Type	10-K
Amendment Flag	false
Document Period End Date	Dec. 31, 2018
Document Fiscal Year Focus	2018
Document Fiscal Period Focus	FY
Trading Symbol	CRHM
Entity Registrant Name	CRH MEDICAL CORPORATION
Entity Central Index Key	0001461119
Current Fiscal Year End Date	--12-31
Entity Well-known Seasoned Issuer	No
Entity Current Reporting Status	Yes
Entity Voluntary Filers	No
Entity Filer Category	Accelerated Filer
Entity Shell Company	false
Entity Small Business	true
Entity Emerging Growth Company	true
Entity Ex Transition Period	false
Entity Common Stock, Shares Outstanding		71,712,288
Entity Public Float			$ 215.8

Consolidated Balance Sheets

Consolidated Balance Sheets - USD ($)	Dec. 31, 2018	Dec. 31, 2017
Current assets:
Cash and cash equivalents	$ 9,946,945	$ 12,486,884
Trade and other receivables, net	19,467,803	15,486,312
Income tax receivable	2,243,319	374,943
Prepaid expenses and deposits	822,119	889,882
Inventories	402,544	423,445
Total current assets	32,882,730	29,661,466
Non-current assets:
Property and equipment, net	303,291	364,366
Intangible assets, net	179,384,263	170,127,415
Deferred asset acquisition costs	116,025
Deferred tax assets	6,301,687	3,802,258
Total non-current assets	186,105,266	174,294,039
Total assets	218,987,996	203,955,505
Current liabilities:
Trade and other payables	5,763,222	5,661,844
Employee benefits	827,436	500,754
Notes payable and bank indebtedness	2,239,637	989,637
Deferred consideration	1,043,645	906,956
Earn-out obligation	2,920,583
Short-term advances	26,783
Member loan	49,000	435,000
Total current liabilities	12,870,306	8,494,191
Non-current liabilities:
Deferred consideration	1,183,092	2,226,737
Notes payable and bank indebtedness	67,621,470	60,061,105
Earn-out obligation		1,875,427
Deferred tax liabilities	21,951
Total non-current liabilities	68,826,513	64,163,269
Equity
Common stock, no par value; 72,055,688 and 73,018,588 shares issued and outstanding at December 31, 2018 and 2017, respectively	55,372,884	54,614,601
Additional paid-in capital	9,329,335	8,219,760
Accumulated other comprehensive income (loss)	(66,772)	(66,772)
Retained earnings	12,916,565	11,078,608
Total equity attributable to shareholders of the Company	77,552,012	73,846,197
Non-controlling interest	59,739,165	57,451,848
Total equity	137,291,177	131,298,045
Total liabilities and equity	$ 218,987,996	$ 203,955,505

Consolidated Balance Sheets (Pa

Consolidated Balance Sheets (Parenthetical) - $ / shares	Dec. 31, 2018	Dec. 31, 2017
Statement of Financial Position [Abstract]
Common stock, no par value	$ 0	$ 0
Common stock, shares issued	72,055,688	73,018,588
Common stock, shares outstanding	72,055,688	73,018,588

Consolidated Statements of Oper

Consolidated Statements of Operations and Comprehensive Income - USD ($)	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017
Revenue:
Total revenue	$ 112,749,380	$ 95,006,145
Expenses:
Total expenses	92,454,250	74,186,860
Operating income	20,295,130	20,819,285
Finance income		(11,825,256)
Finance expense	4,567,327	6,310,406
Net finance (income) expense	4,567,327	(5,514,850)
Income before tax	15,727,803	26,334,135
Income tax expense	2,711,886	7,159,065
Net and comprehensive income	13,015,917	19,175,070
Attributable to:
Shareholders of the Company	4,679,921	12,078,853
Non-controlling interest	8,335,996	7,096,217
Net income	$ 13,015,917	$ 19,175,070
Earnings per share attributable to shareholders
Basic	$ 0.064	$ 0.164
Diluted	$ 0.063	$ 0.161
Weighted average shares outstanding:
Basic	72,582,733	73,712,670
Diluted	74,085,172	75,056,003
Anesthesia Services [Member]
Revenue:
Total revenue	$ 101,790,165	$ 83,505,140
Expenses:
Total expenses	81,079,150	62,135,447
Product [Member]
Revenue:
Total revenue	10,959,215	11,501,005
Expenses:
Total expenses	5,022,737	4,997,550
Corporate Expense [Member]
Expenses:
Total expenses	$ 6,352,363	$ 7,053,863

Consolidated Statements of Chan

Consolidated Statements of Changes in Equity - USD ($)	Total	Common Stock [Member]	Contributed Surplus [Member]	Accumulated Other Comprehensive Loss [Member]	Retained Earnings (Deficit) [Member]	Non-Controlling Interest [Member]
Beginning Balance at Dec. 31, 2016	$ 96,918,935	$ 52,706,484	$ 6,987,072	$ (66,772)	$ 881,695	$ 36,410,456
Beginning Balance , shares at Dec. 31, 2016		72,745,939
Total net and comprehensive income for the year	19,175,070				12,078,853	7,096,217
Stock based compensation expense	4,036,070		4,036,070
Common shares purchased on exercise of options	$ 153,026	$ 218,436	(65,410)
Common shares purchased on exercise of options , shares	247,500	247,500
Common shares issued on vesting of share units	$ (67,021)	$ 2,670,951	(2,737,972)
Common shares issued on vesting of share units , shares		1,292,549
Common shares repurchased in connection with normal course issuer bid and cancelled (note 10(e))	(2,708,488)	$ (928,244)			(1,780,244)
Common shares repurchased in connection with normal course issuer bid and cancelled, shares		(1,267,400)
Common shares repurchased in connection with normal course issuer bid and held as treasury shares (10,400 treasury shares) (note 10(e))	$ (154,722)	$ (53,026)			(101,696)
Common shares repurchased in connection with normal course issuer bid and held as treasury shares , shares	72,400
Cancellation of treasury shares (held as treasury shares as of 12/31/2017)	(1,267,400)
Distributions to members	$ (12,899,353)					(12,899,353)
Acquisition of non-controlling interest (note 4)	26,844,528					26,844,528
Ending Balance at Dec. 31, 2017	131,298,045	$ 54,614,601	8,219,760	(66,772)	11,078,608	57,451,848
Ending Balance , shares at Dec. 31, 2017		73,018,588
Total net and comprehensive income for the year	13,015,917				4,679,921	8,335,996
Stock based compensation expense	2,800,750		2,800,750
Common shares issued on vesting of share units		$ 1,691,175	(1,691,175)
Common shares issued on vesting of share units , shares		364,000
Common shares repurchased in connection with normal course issuer bid and cancelled (note 10(e))	(3,743,548)	$ (925,076)			(2,818,472)
Common shares repurchased in connection with normal course issuer bid and cancelled, shares		(1,254,500)
Common shares repurchased in connection with normal course issuer bid and held as treasury shares (10,400 treasury shares) (note 10(e))	$ (31,308)	$ (7,816)			(23,492)
Common shares repurchased in connection with normal course issuer bid and held as treasury shares , shares	10,400	0
Cancellation of treasury shares (held as treasury shares as of 12/31/2017)	(72,400)	(72,400)
Distributions to members	$ (19,289,740)					(19,289,740)
Acquisition of non-controlling interest (note 4)	13,241,061					13,241,061
Ending Balance at Dec. 31, 2018	$ 137,291,177	$ 55,372,884	$ 9,329,335	$ (66,772)	$ 12,916,565	$ 59,739,165
Ending Balance , shares at Dec. 31, 2018		72,055,688

Consolidated Statements of Ch_2

Consolidated Statements of Changes in Equity (Parenthetical) - shares	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017
Statement of Stockholders' Equity [Abstract]
Treasury stock	10,400	72,400

Consolidated Statements of Cash

Consolidated Statements of Cash Flows - USD ($)	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017
Operating activities:
Net income	$ 13,015,917	$ 19,175,070
Adjustments for:
Depreciation of property, equipment and intangibles	31,486,055	23,834,400
Stock-based compensation	2,800,750	4,036,070
Unrealized foreign exchange	(4,494)	73,735
Deferred income tax expense (recovery)	(2,407,176)	2,755,707
Change in fair value of contingent consideration	971,627	(11,825,256)
Accretion on contingent consideration and deferred consideration	166,575	600,602
Amortization of deferred financing fees	260,363	204,057
Loss on extinguishment of debt		1,408,221
Change in current tax receivable (payable)	(1,936,436)	(1,106,541)
Change in trade and other receivables	(3,981,491)	(5,649,573)
Change in prepaid expenses	171,911	(339,071)
Change in inventories	20,902	(122,685)
Change in trade and other payables	101,379	2,432,159
Change in employee benefits	326,681	273,880
Cash provided by operating activities	40,992,563	35,750,775
Financing activities
Proceeds from member loans	303,351	566,819
Repayment of member loans	(662,568)	(131,819)
Repayment of notes payable and bank indebtedness	(14,250,000)	(52,543,750)
Proceeds on bank indebtedness	22,800,000	68,200,000
Payment of deferred consideration	(1,000,000)	(900,000)
Distributions to non-controlling interest	(19,289,740)	(12,899,353)
Proceeds on settlement of derivative asset		1,313,874
Proceeds from the issuance of shares relating to stock-based compensation		(6,626)
Repurchase of shares for cancellation	(3,774,856)	(2,863,210)
Cash (used in) provided by financing activities	(15,873,813)	735,935
Investing activities
Acquisition of property and equipment	(35,105)	(125,285)
Deferred asset acquisition costs	(116,025)
Acquisition of anesthesia services providers	(27,509,811)	(33,376,849)
Cash used in investing activities	(27,660,941)	(33,502,134)
Effects of foreign exchange on cash and cash equivalents	2,252	(4,696)
Increase (decrease) in cash and cash equivalents	(2,539,939)	2,979,880
Cash and cash equivalents, beginning of year	12,486,884	9,507,004
Cash and cash equivalents, end of year	9,946,945	12,486,884
Supplemental disclosure of cash interest and taxes paid:
Cash interest paid	(3,180,808)	(3,563,837)
Taxes paid	$ (7,055,498)	$ (5,509,915)

Reporting entity

Reporting entity	12 Months Ended
	Dec. 31, 2018
Accounting Policies [Abstract]
Reporting entity	1. Reporting entity: CRH Medical Corporation (“CRH” or “the Company”) was incorporated on April 21, 2001 and is incorporated under the Business Corporations Act (British Columbia). The Company provides anesthesiology services to gastroenterologists in the United States through its subsidiaries and sells its patented proprietary technology for the treatment of hemorrhoids directly to physicians in the United States and Canada. CRH principally operates in the United States and is headquartered from its registered offices located at Unit 578, 999 Canada Place, Vancouver, British Columbia, Canada.

Basis of preparation

Basis of preparation	12 Months Ended
	Dec. 31, 2018
Organization, Consolidation and Presentation of Financial Statements [Abstract]
Basis of preparation	2. Basis of preparation: (a) Change in basis of presentation: As a non-U.S. On June 30, 2018, we performed the test and determined that we no longer met the definition of a FPI. As such, from January 1, 2019, the Company is required to prepare consolidated financial statements in accordance with United States Generally Accepted Accounting Principles (“US GAAP”), report with the SEC on domestic forms, and comply with SEC rules and regulations applicable to domestic issuers. These consolidated financial statements have been prepared in accordance with US GAAP beginning December 31, 2018 on a retrospective basis. The Company’s historical financial statements were previously presented under International Financial Reporting Standards (IFRS) as issued by the International Accounting Standards Board (IASB) up to and including the Company’s September 30, 2018 interim report. (b) Functional and presentation currency: These consolidated financial statements are presented in United States dollars, which is the Company’s presentation currency. The functional currency of the Company and its subsidiaries is the United States dollar. (c) Use of estimates, assumptions and judgments: The preparation of the Company’s consolidated financial statements requires management to make judgments, estimates and assumptions that affect the application of accounting policies, the reported amounts of assets and liabilities, the disclosure of contingent assets and liabilities at the date of the financial statements and the reported amounts of revenues and expenses during the reporting period. Reported amounts and note disclosures reflect the overall economic conditions that are most likely to occur and anticipated measures management intends to take. Actual results could differ from those estimates. ( i Estimates and underlying assumptions are reviewed on an ongoing basis. Revisions to accounting estimates are recognized in the period in which the estimates are revised and in any future periods affected. Significant areas requiring the use of management estimates relate to the assessment for impairment and useful lives of intangible assets, determining the fair value of share units and derivatives, estimates supporting reported anesthesia revenues, the recoverability of trade receivables, the valuation of certain long term liabilities and other assets, including liabilities relating to contingent consideration, the vesting term for share units with market and non-market ( ii Significant judgments made by management in the process of applying accounting policies and that have the most significant effect on the amounts recognized in the consolidated financial statements includes the determination of control for the purposes of consolidation and the Company’s assessment of whether an acquisition is a business acquisition or an asset acquisition.

Significant accounting policies

Significant accounting policies	12 Months Ended
	Dec. 31, 2018
Accounting Policies [Abstract]
Significant accounting policies	3. Significant accounting policies: The accounting policies have been applied consistently by the subsidiaries of the Company. (a) Basis of consolidation: These consolidated financial statements include the accounts of the Company and its subsidiaries. Subsidiaries are entities controlled by the Company through voting control and for anesthesia business, control over the assets and business operations of the subsidiary through operating agreements. Control exists when the Company has the continuing power to govern the financial and operating polices of the investee. Subsidiaries are included in the consolidated financial results of the Company from the effective date of acquisition up to the effective date of disposition or loss of control. Minority interests, if any, are valued at fair value at inception. All significant intercompany transactions and balances have been eliminated in consolidation. (b) Cash equivalents The Company considers all highly liquid investments with an original maturity of 90 days or less, when acquired, to be cash equivalents. (c) Foreign currency: Transactions in foreign currencies are translated to the respective functional currencies of the subsidiaries of the Company at exchange rates at the dates of the transactions. Period end balances of monetary assets and liabilities in foreign currency are translated to the respective functional currencies using period end foreign currency rates. Foreign currency gains and losses arising from settlement of foreign currency transactions are recognized in earnings. Non-monetary assets and liabilities denominated in foreign currencies that are measured at fair value are translated to the functional currency at the exchange rate at the date on which the fair value was determined. Non-monetary items that are measured at historical cost in a foreign currency are translated using the exchange rate at the date of the transaction. (d) Inventories: Inventories are measured at the lower of cost, determined using the first-in first-out Net realizable value is the estimated selling price in the Company’s ordinary course of business, less the estimated costs of completion and selling expenses. All inventory held is finished goods inventory. (e) Property and equipment, net: Property and equipment are measured at cost less accumulated depreciation and accumulated impairment losses. The estimated useful lives and the methods of depreciation for the current and comparative periods are as follows: Asset Basis Rate Computer equipment Declining balance 30% Computer software Declining balance 100% Furniture and equipment Declining balance 20% Leasehold improvements Straight-line Shorter of initial lease term or useful life Injection mold Straight-line 5 years These depreciation methods most closely reflect the expected pattern of consumption of the future economic benefits embodied in the asset. Estimates for depreciation methods, useful lives and residual values are reviewed at each reporting period-end and adjusted if appropriate. (f) Intangible assets: Intangible assets, consisting of acquired exclusive professional service agreements to provide anesthesia services and the cost of acquiring patents, are recorded at historical cost. For patents, costs also include legal costs involved in expanding the countries in which the patents are recognized to the extent expected cash flows from those countries exceed these costs over the amortization period and costs related to new patents. The amortization term for professional services agreements are based on the contractual terms of the agreements. Intangible assets with finite lives are amortized on a straight-line basis over their estimated useful lives and are measured at cost less accumulated amortization and accumulated impairment losses. Intangible assets with finite lives are amortized over the following periods: Asset Basis Rate Intellectual property rights to the CRH O’Regan System Straight-line 15 years Intellectual property new technology Straight-line 20 years Exclusive professional services agreements Straight-line 4.5 to 15 years (g) Impairment: Non-financial assets: The carrying amounts of the Company’s non-financial assets, other than inventories and deferred tax assets are reviewed at each reporting date to determine whether there are any events or changes in circumstances indicated that the carrying value may not be recoverable. Example factors that could trigger impairment reviews include significant underperformance relative to historical or projected future operating results, significant changes in the use of the acquired assets or strategy for the overall business and significant negative economic trends. Depending on the specific asset and circumstances, assets are assessed for impairment as an individual asset, as part of an asset group or at the reporting unit (RU”) level. A reporting unit is an operating segment or one level below an operating segment if certain conditions are met. For the purpose of impairment testing, assets are grouped together into the smallest group of assets that generates cash inflows from continuing use that are largely independent of cash inflows from other assets or groups of assets. If indicators of impairment exist, an asset or asset group is impaired if its carrying amount exceeds its fair value, being the projected future discounted cash flows that are directly associated with and that are expected to arise as a direct result of the use and eventual disposition of the asset or asset group. Projected cash flows are based upon historical results adjusted to reflect management’s best estimate of future market and operating conditions which may differ from actual cash flows. Significant assumptions included in projected cash flows include anesthesia revenue growth rates, discount rates, and operating cost growth rates. (h) Income taxes: The Company is subject to income taxes in Canada and the United States. Judgment is required in determining the provision for income taxes and income tax assets and liabilities, including evaluating uncertainties in the application of accounting principles and complex tax laws. The Company records a provision for income taxes for the anticipated tax consequences of the reported results of operations using the asset and liability method. Under this method, it recognizes deferred income tax assets and liabilities for the expected future tax consequences of temporary differences between the financial reporting and tax bases of assets and liabilities. Deferred tax assets and liabilities are measured using the enacted tax rates that are expected to apply to taxable income for the years in which those tax assets and liabilities are expected to be realized or settled. The Company recognizes the deferred income tax effects of a change in tax rates in the period of the enactment. The Company records a valuation allowance to reduce its deferred tax assets to the net amount that management believes is more likely than not to be realized. The Company recognizes the effect of income tax positions only if those positions are more likely than not of being sustained. Recognized income tax positions are measured at the largest amount that is greater than fifty percent likely of being realized. The Company records interest related to unrecognized tax benefits in interest expense and penalties in operating expenses. Income tax expense is comprised of current and deferred tax. (i) Share-based compensation: The Company records share-based compensation related to equity classified stock options and share units granted using the fair value based method estimated using either the Black-Scholes model or Binomial method. The vesting components of graded vesting employee awards, with only a service vesting condition, are accounted for as separate share-based arrangements. Each vesting installment is measured separately and expensed over the related installment’s vesting period. Compensation cost is measured at fair value at the date of grant and expensed as employee benefits over the period in which employees unconditionally become entitled to the award. Forfeitures are estimated in recognizing share-based compensation, such that the amount ultimately recognized as an expense is based on the number of awards that do meet the related service and non-market performance conditions at the vesting date. Prior to January 1, 2018, each vesting tranche of equity classified non-employee non-employee 2018-07 (j) Share capital: Common shares are classified as equity. Incremental costs directly attributable to the issue of common shares, stock options and share options are recognized as a deduction from equity, net of any tax effects. (k) Earnings per share: The Company presents basic and diluted earnings per share (EPS) data for its common shares. Basic EPS is calculated by dividing the net income or loss attributable to common shareholders of the Company by the weighted average number of common shares outstanding during the period, adjusted for own shares held, if applicable. Diluted EPS is determined by adjusting the income or loss attributable to common shareholders and the weighted average number of common shares outstanding, adjusted for own shares held if applicable, for the effects of all dilutive potential common shares. Diluted EPS for year-to-date year-to-date (l) Segment reporting: The Company’s operating segments consist of the sale of medical products and the provision of anesthesia services. (m) Finance costs: Finance cost is primarily comprised of interest on the Company’s notes payable and bank indebtedness and also includes the amortization of costs incurred to obtain loan financing and any fees in respect of arranging loan financing. Deferred finance costs are amortized using the effective interest method over the term of the related loan financing. Deferred finance costs are presented as a reduction to the related liability. (n) Asset acquisitions: Asset acquisitions are accounted for using the cost accumulation and allocation method. The acquisition cost includes directly related acquisition costs. The cost of the acquisition is allocated to the net assets acquired on a relative fair value basis. Contingent consideration, where the arrangement is not a derivative, is recognized when it is probable and estimable. After the initial acquisition accounting, changes in contingent and deferred consideration are recorded within finance (income) expense. The Company’s policy is to recognize any non-controlling non-controlling (o) Revenue recognition: Our anesthesia service revenues are derived from anesthesia procedures performed under our professional services agreements. The fees for such services are billed either to a third party payor, including Medicare or Medicaid or to the patient. We recognize anesthesia service revenues, net of contractual adjustments and implicit price concessions, which we estimate based on the historical trend of our cash collections and contractual adjustments. Anesthesia services procedures for each patient qualify as a distinct service obligation, as they are provided simultaneously with other readily available resources during the service procedure. The transaction price is variable and not constrained. Variable consideration relates to contractual allowances, credit provisions and other discounts. The standard requires management to estimate the transaction price, including any implicit concessions from the credit approval process. The Company adopted a portfolio approach to estimate variable consideration transaction price by payor type (patient, government and/or insurer) and the specifics of the services being provided. These portfolios share characteristics such that the results of applying a portfolio approach are not materially different than if the standard was applied to individual patient contracts. Revenue is recognized upon completion of the services to the customer (patient) for practical reasons as the service period is performed over a short time period. The Company recognizes revenue from product sales at the time the product is shipped, which is when title passes to the customer, and when all significant contractual obligations have been satisfied, collection is probable and the amount of revenue can be estimated reliably. Product sales contracts generally contain a single distinct performance obligation, but multiple performance obligations may exist when multiple product types are ordered by a physician in a contract. The transaction price for product sales is fixed and no variable consideration exists. Contract consideration is allocated to each distinct performance obligation in the contract based upon available stand-alone selling prices obtained from historical sales transactions for each product. The Company recognizes revenue from product sales at the point in time when control of the goods passes to the customer (physician) when the product is shipped, which is when title passes to the customer and an obligation to pay for the goods arises. Shipping services performed after control has passed to the customer, if any, is a separate performance obligation, but was determined to be nominal. (p) Adoption of new accounting standards: i) Revenue from Contracts with Customers This standard establishes a comprehensive framework for determining whether, how much and when revenue is recognized. The Company adopted the standard effective January 1, 2018 applying the full retrospective method, resulting with the standard being applied to the prior reporting period with a cumulative effect of adjustment, if any, recognized as at January 1, 2017. The Company has elected to make use of the following practical expedients: • incremental costs of obtaining a contract are recognized as an expense when incurred because the amortization period of the asset that the Company otherwise would have recognized is one year or less; and • the promised amount of consideration has not been adjusted for the effects of a significant financing component because, at contract inception, the period between when the Company transfers a promised good or service to a customer and when the customer pays for that good or service will be one year or less. The adoption of this standard did not have a material impact on the results of operations or cash flows and there was no adjustment to retained earnings as at January 1, 2017. However, the standard did require the Company’s provision for net uncollectable accounts, previously recognized as bad debt expense in anesthesia services expenses, to be recognized as a reduction to anesthesia service revenues. There was no impact to the Company’s other operating segments. For the year ended December 31, 2017, the adoption of the standard resulted in a reduction of anesthesia services revenue and a similar reduction of anesthesia services expenses of $5,235,934. ii) Financial Instruments – Overall In January 2016, FASB issued ASU No. 2016-01, Financial Instruments – Overall iii) Employee Share-based Payments In March 2016, FASB issued ASU No. 2016-09, Improvements to Employee Share-Based Payment Accounting iv) Clarifying the Definition of a Business In January 2017, FASB issued ASU No. 2017-01, Business Combinations (Topic 805) – Clarifying the Definition of a Business” v) Nonemployee Share-Based Payment Accounting In June 2018, FASB issued ASU No. 2018-07, Compensation – Stock Compensation (Topic 718) – Improvements to Non-Employee non-employee non-employee non-employee non-employee (q) New standards and interpretations not yet applied: (i) ASU 2016-02 Leases In February 2016, FASB issued ASU No. 2016-02 Leases No. 2017-13, right-of-use (ii) Credit Losses In June 2016, FASB issued ASU No. 2016-13, Financial Instruments – Credit Losses (Topic 326)” The Company is in the process of evaluating the impact of this standard on its balance sheet, results of operations and cash flows.

Asset acquisitions

Asset acquisitions	12 Months Ended
	Dec. 31, 2018
Business Combinations [Abstract]
Asset acquisitions	4. Asset acquisitions: During the year ended December 31, 2018, the Company completed five asset acquisitions. These asset acquisitions have been included in the anesthesia segment of the Company and represents the following: Acquired Operation Date Acquired Consideration Shreveport Sedation Associates LLC (“SSA”) March 2018 $ 9,495,184 Western Ohio Sedation Associates LLC (“WOSA”) May 2018 $ 6,483,698 Lake Washington Anesthesia LLC (“LWA”) July 2018 $ 5,041,939 Lake Erie Sedation Associates LLC (“LESA”) September 2018 $ 4,233,115 Tennessee Valley Anesthesia Associates LLC (“TVAA”) December 2018 $ 2,255,875 The results of operations of the acquired entities have been included in the Company’s consolidated financial statements from the date of acquisition as the Company has control over these entities. The following table summarizes the fair value of the consideration transferred and the allocated costs of the assets and liabilities acquired at the acquisition date. SSA WOSA LWA LESA TVAA Total Cash $ 9,404,148 $ 6,409,000 $ 5,000,000 $ 4,180,000 $ 2,200,000 $ 27,193,148 Acquisition Costs 91,036 74,698 41,939 53,115 55,875 316,663 Purchase consideration $ 9,495,184 $ 6,483,698 $ 5,041,939 $ 4,233,115 $ 2,255,875 $ 27,509,811 Non-controlling $ — $ 6,229,435 $ 4,844,217 $ — $ 2,167,409 $ 13,241,061 $ 9,495,184 $ 12,713,133 $ 9,886,156 $ 4,233,115 $ 4,423,284 $ 40,750,872 Assets and liabilities acquired: Exclusive professional services agreements $ 9,391,036 $ 12,713,133 $ 9,886,155 $ 4,233,115 $ 4,423,284 $ 40,646,723 Prepaid expenses and deposits 104,149 — — — 104,149 Pre-close — — 652,506 — 652,506 Pre-close — — (652,506 ) — (652,506 ) Fair value of net identifiable assets and liabilities acquired $ 9,495,185 $ 12,713,133 $ 9,886,155 $ 4,233,115 $ 4,423,284 $ 40,750,872 Exclusive professional services agreements – amortization term 7 years 10 years 7 years 10 years 7 years CRH ownership interest 100 % 51 % 51 % 100 % 51 % The value of the acquired intangible assets, being exclusive professional services agreements, relate to the acquisition of exclusive professional services agreements to provide professional anesthesia services. The amortization term for the agreements is based upon contractual terms within the acquisition agreement and professional services agreement. The non-controlling non-controlling The Company has obtained control over the acquired assets via the Company’s majority ownership in the shares of the entities and its agreements with the non-controlling For those asset acquisitions where CRH ownership interest is less than 100%, in conjunction with the acquisition, both the Company and the non-controlling non-interest SSA WOSA LWA LESA TVAA Total CRH member loan $ — $ 193,800 $ — $ — $ 51,000 $ 244,800 Non-controlling $ — $ 186,200 $ — $ — $ 49,000 $ 235,200 Amount outstanding at December 31, 2018 $ — $ — $ — $ — $ 100,000 $ 100,000 In conjunction with the LWA acquisition, the non-controlling The Company also incurred legal costs of $116,025 associated with its acquisition of the assets of Anesthesia Care Associates, LLC (“ACA”) which closed subsequent to December 31, 2018 (see note 17). These costs are deferred as of December 31, 2018 on the statements of financial position. In October 2018, the Company entered into an agreement with Digestive Health Specialists (“DHS”), located in North Carolina, to assist DHS in the development and management of a monitored anesthesia care program. Under the terms of the agreement, CRH is a 15% equity owner in the anesthesia business, Triad Sedation Associates LLC, and receives compensation for its billing and collection services. Under the terms of the limited liability company agreement, CRH has the right, at CRH’s option, to acquire an additional 36% interest in the anesthesia business at a future date, but no sooner than November 2019. The Company assessed and concluded that CRH does not have significance influence over TSA. The option agreement was determined to be an executory contract and both the equity interest and option agreement were determined to have only nominal value upon grant and as at December 31, 2018. During the year ended December 31, 2017, the Company completed six asset acquisitions. All asset acquisitions completed during the period have been included in the anesthesia segment of the Company and include the following: Acquired Operation Date Acquired Consideration DDAB, LLC (“DDAB”) February 2017 $ 5,278,940 Osceola Gastroenterology Anesthesia Associates, LLC (“OGAA”) March 2017 $ 3,452,247 West Florida Anesthesia Associates, LLC (“WFAA”) August 2017 $ 5,904,980 Central Colorado Anesthesia Associates, LLC (“CCAA”) September 2017 $ 7,909,243 Raleigh Sedation Associates, LLC & Blue Ridge Sedation Associates, PLLC (“RSA”) September 2017 $ 7,328,060 Alamo Sedation Associates, LLC (“ASA”) September 2017 $ 3,503,379 The results of operations of the acquired entities have been included in the Company’s consolidated financial statements from the date of acquisition as the Company has control over these entities. The following table summarizes the fair value of the consideration transferred and the allocated costs of the assets and liabilities acquired at the acquisition date. DDAB OGAA WFAA CCAA RSA ASA Total Cash and acquisition costs $ 4,089,791 $ 3,401,819 $ 5,840,000 $ 7,888,919 $ 7,248,960 $ 3,500,000 $ 31,969,489 Acquisition costs 5,370 50,428 64,980 20,324 79,100 3,379 223,581 Contingent consideration 1,183,779 — — — — — 1,183,779 Purchase consideration $ 5,278,940 $ 3,452,247 $ 5,904,980 $ 7,909,243 $ 7,328,060 $ 3,503,379 33,376,849 Non-controlling 5,071,922 2,301,498 4,831,346 7,599,077 7,040,685 — 26,844,528 $ 10,350,862 $ 5,753,745 $ 10,736,326 $ 15,508,320 $ 14,368,745 $ 3,503,379 $ 60,221,377 Assets and liabilities acquired: Exclusive professional services agreements 10,350,862 $ 5,753,745 $ 10,724,338 $ 15,508,320 $ 14,368,745 $ 3,503,379 $ 60,209,389 Pre-close 525,000 — — — — — 525,000 Pre-close (525,000 ) — — — — — (525,000 ) Prepaid expenses and deposits — — 11,988 — — — 11,988 Fair value of net identifiable assets and liabilities acquired $ 10,350,862 $ 5,753,745 $ 10,736,326 $ 15,508,320 $ 14,368,745 $ 3,503,379 $ 60,221,377 Exclusive professional services agreements – amortization term 4.5 years 5 years 15 years 7 years 5 years 7 years CRH ownership interest 51 % 60 % 55 % 51 % 51 % 100 % The value of the acquired intangible assets, being exclusive professional services agreements relate to the acquisition of exclusive professional services agreements to provide professional anesthesia services. The amortization terms for the agreements are based upon contractual terms within the acquisition agreements and professional services agreements. The non-controlling non-controlling The Company has obtained control over the acquired assets via the Company’s majority ownership in the shares of the entities and its agreements with the non-recurring For those asset acquisitions where CRH ownership interest is less than 100%, in conjunction with the acquisition, both the Company and the non-controlling non-interest DDAB OGAA WFAA CCAA RSA ASA Total CRH member loan $ — $ 90,000 $ 82,500 $ 178,500 $ 204,000 $ — $ 555,000 Non-controlling $ — $ 60,000 $ 67,500 $ 171,500 $ 196,000 $ — $ 495,000 Amount outstanding at December 31, 2018 $ — $ — $ — $ — $ — $ — $ — In conjunction with the acquisition, the non-controlling

Trade and other receivables

Trade and other receivables	12 Months Ended
	Dec. 31, 2018
Receivables [Abstract]
Trade and other receivables	5. Trade and other receivables: 2018 2017 Trade receivables, gross $ 19,373,260 $ 15,325,553 Other receivables 141,141 260,759 Less: allowance for doubtful accounts (46,598 ) (100,000 ) $ 19,467,803 $ 15,486,312 Anesthesia segment – trade receivables, gross 18,199,847 13,405,303 Product segment – trade receivables, gross 1,173,413 1,920,250 $ 19,373,260 $ 15,325,553

Trade and other payables

Trade and other payables	12 Months Ended
	Dec. 31, 2018
Payables and Accruals [Abstract]
Trade and other payables	6. Trade and other payables: 2018 2017 Trade payables $ 1,316,821 $ 2,042,487 Payments due to former owners of acquired entities — 76,403 Accruals and other payables 4,446,401 3,542,954 $ 5,763,222 $ 5,661,844

Property and equipment

Property and equipment	12 Months Ended
	Dec. 31, 2018
Property, Plant and Equipment [Abstract]
Property and equipment	7. Property and equipment: Property and equipment consist of the following: December 31, 2018 2017 Computer equipment and software $ 94,566 $ 82,055 Furniture and equipment 237,616 215,021 Leasehold improvements 5,784 5,784 Injection mold 408,062 408,062 Property and equipment $ 746,028 $ 710,922 Less: Accumulated depreciation (442,737 ) (346,556 ) Property and equipment, net $ 303,291 $ 364,366

Intangible assets

Intangible assets	12 Months Ended
	Dec. 31, 2018
Goodwill and Intangible Assets Disclosure [Abstract]
Intangible assets	8. Intangible assets: Professional Patents Total Cost Balance as at January 1, 2017 155,635,148 532,598 156,167,746 Additions through asset acquisitions (note 4) 60,209,389 — 60,209,389 Balance as at December 31, 2017 $ 215,844,537 $ 532,598 $ 216,377,135 Additions through asset acquisitions (note 4) 40,646,723 — 40,646,723 Balance as at December 31, 2018 $ 256,491,260 $ 532,598 $ 257,023,858 Professional Patents Total Accumulated depreciation Balance as at January 1, 2017 21,999,771 500,664 22,500,435 Amortization expense 23,752,532 (3,247 ) 23,749,285 Balance as at December 31, 2017 $ 45,752,303 $ 497,417 $ 46,249,720 Amortization expense 31,387,429 2,446 31,389,875 Balance as at December 31, 2018 $ 77,139,732 $ 499,863 $ 77,639,595 Professional Patents Total Net book value December 31, 2018 $ 179,351,528 $ 32,735 $ 179,384,263 December 31, 2017 $ 170,092,234 $ 35,181 $ 170,127,415 At December 31, 2018, the Company identified indicators of impairment in respect of four of its professional services agreements. Upon performing undiscounted cash flow models for these assets, the Company identified only two assets that required further review for impairment. The Company performed discounted cash flow modelling for these assets and compared the resultant discounted cash flows expected over the life of the assets to the carrying amounts as at December 31, 2018. The income approach is used for the quantitative assessment to estimate the fair value of the assets, which requires estimating future cash flows and risk-adjusted discount rates in the Company’s discounted cash flow model. The overall market outlook and cash flow projections of the reporting unit involves the use of key assumptions, including anesthesia growth rates, discount rates and operating cost growth rates. Due to uncertainties in the estimates that are inherent to the Company’s industry, actual results could differ significantly from the estimates made. Many key assumptions in the cash flow projections are interdependent on each other. A change in any one or combination of these assumptions could impact the estimated fair value of the reporting unit. As a result of this test, no write-downs to the intangible assets were required. At December 31, 2017, the Company identified indicators of impairment in respect of two of its professional services agreements. Upon performing undiscounted cash flow models for these assets, no impairment was indicated. Various of the Company’s professional services agreements are subject to renewal terms. The weighted average period before the Company’s professional services agreements are up for renewal is 4 years. The Company anticipates that it will be able to renew all contract terms under its professional services agreements. The weighted average remaining amortization period for the Company’s professional services agreements is 6.23 years. Based on the Company’s professional services agreements in place at December 31, 2018, the Company anticipates that the amortization expense to be incurred by the Company over the next five years is as follows: Amortization For professional services agreements as at December 31, 2018: 2019 $ 33,674,000 2020 33,593,000 2021 28,287,000 2022 21,565,000 2023 17,419,000 $ 134,538,000

Notes payable

Notes payable	12 Months Ended
	Dec. 31, 2018
Debt Disclosure [Abstract]
Notes payable	9. Notes payable: December 31, 2018 2017 Current portion $ 2,239,637 $ 989,637 Non-current 67,621,470 60,061,105 Total loans and borrowings $ 69,861,107 $ 61,050,742 The Bank of Nova Scotia (“Scotia Facility”) On November 24, 2015, the Company entered into a credit facility with the Bank of Nova Scotia. The facility, which had a maturity date of April 30, 2018, provided financing of up to $55,000,000, after amendment on June 15, 2016. On June 26, 2017, the Company amended the Scotia Facility to provide financing of up to $100,000,000 via a revolving and term facility. The amended facility has a maturity date of June 26, 2020. In conjunction with this amendment, the Company incurred fees of $445,598 which were capitalized. As at December 31, 2018, the Company had drawn $70,250,000 on the amended facility (2017 – $61,700,000). Since there was no reduction in borrowing capacity as a result of this amendment, no existing deferred or new financing fees were expensed upon this modification. The Facility is repayable in full at maturity, with scheduled principal repayments on a quarterly basis beginning September 30, 2017 based on the initial principal issued under the term facility. The facility bears interest at a floating rate based on the US prime rate, LIBOR or bankers’ acceptance rates plus an applicable margin. At December 31, 2018, interest on the facility is calculated at LIBOR plus 2.50% on the revolving portion and term portion of the facility. The Facility is secured by the assets of the Company. As at December 31, 2018 the Company is required to maintain the following financial covenants in respect of the Facility: Financial Covenant Required Ratio Total funded debt ratio 2.50:1.00 Fixed charge coverage ratio 1.15:1.00 The Company is in compliance with all covenants at December 31, 2018. The consolidated minimum loan payments (principal) for all loan agreements in the future are as follows: Minimum At December 31, 2018 2019 $ 2,500,000 2020 67,750,000 $ 70,250,000

Share capital

Share capital	12 Months Ended
	Dec. 31, 2018
Text Block [Abstract]
Share capital	10. Share capital: (a) Authorized: 100,000,000 common shares without par value. (b) Issued and outstanding – common shares: Other than in connection with shares issued in respect of the Company’s share unit and share option plans and in connection with the Company’s normal course issuer bid (note 16(e)), there were no share transactions in the years ended December 31, 2018 and 2017. (c) Stock option plan: Under the Company’s Stock Option Plan, the Company may grant options to its directors, officers, consultants and eligible employees. The plan provides for the granting of stock options at the fair market value of the Company’s stock at the date of grant, and the term of options range from two to ten years. The Board of Directors may, in its sole discretion, determine the time during which options shall vest and the method of vesting. All options under the Plan will be subject to vesting provisions determined by the Board of Directors, over a period of not less than 18 months, in equal portions on a quarterly basis. Options granted to consultants providing investor relations activities will vest at the end of 12 months or longer from the date of issuance. As of December 31, 2018, the Company is authorized to grant 2,258,097 awards under its stock options plan, but has chosen not to issue further awards under its stock option plan. A summary of the status of the plan as of December 31, 2018 and 2017 is as follows (options are granted in CAD and USD amounts are calculated using prevailing exchange rates): Number of Weighted average CAD USD Outstanding, January 1, 2017 1,603,124 $ 0.63 $ 0.47 Issued — — — Exercised (247,500 ) 0.32 0.25 Forfeited (10,937 ) 0.60 0.48 Expired — — — Outstanding, December 31, 2017 1,344,687 0.69 0.55 Issued — — — Exercised — — — Forfeited — — — Expired — — — Outstanding, December 31, 2018 1,344,687 0.69 0.50 All options are vested as of December 31, 2018 and 2017. For those options that vested in 2017, the intrinsic value of the options that vested was $1,198,495 and the fair value of the options that vested was $147,730. The following table summarizes information about the stock options outstanding as at: December 31, 2018: Exercise price Options outstanding Options exercisable $CAD $USD Number Weighted Weighted Weighted Number Weighted Weighted 0.44 – 0.51 1,344,687 5.05 0.69 0.50 1,344,687 0.69 0.50 All options are vested as of December 31, 2018 and 2017. December 31, 2017: Exercise price Options outstanding Options exercisable $CAD $USD Number Weighted Weighted Weighted Number Weighted Weighted 0.60 – 0.70 0.48 – 0.56 1,344,687 6.05 0.69 0.55 1,272,812 0.68 0.54 As of December 31, 2017, 1,272,812 options are vested. For the year ended December 31, 2018, the Company recognized $468 (2017 – $22,179), in compensation expense as a result of stock options awarded and vested. Compensation expense is recorded in the consolidated statement of operations and comprehensive income and is allocated to product sales expenses, corporate expenses and anesthesia expenses on the same basis as the allocations of cash compensation. (d) Share unit plan: In June 2017, the shareholders of the Company approved a Share Unit Plan. Employees, directors and eligible consultants of the Company and its designated subsidiaries are eligible to participate in the Share Unit Plan. In accordance with the terms of the plan, the Company will approve those employees, directors and eligible consultants who are entitled to receive share units and the number of share units to be awarded to each participant. Each share unit awarded conditionally entitles the participant to receive one common share of the Company upon attainment of the share unit vesting criteria. The vesting of share units is conditional upon the expiry of time-based vesting conditions or performance-based vesting conditions or a combination of the two. Once the share units vest, the participant is entitled to receive the equivalent number of underlying common shares; the Company issues new shares in satisfying its obligations under the plan. As at December 31, 2018, the Company is authorized to grant 1,057,534 awards under its share unit plan. A summary of the status of the plan as of December 31, 2018 and 2017 is as follows: Time based Performance Outstanding, January 1, 2017 1,068,000 2,350,000 Issued 324,000 — Exercised (302,000 ) (1,000,000 ) Forfeited (53,500 ) — Expired — — Outstanding, December 31, 2017 1,036,500 1,350,000 Vested — — Expected to vest 1,036,500 1,100,000 Outstanding, January 1, 2018 1,036,500 1,350,000 Issued 452,125 150,000 Exercised (364,000 ) — Forfeited (79,375 ) — Expired — — Outstanding, December 31, 2018 1,045,250 1,500,000 Vested — — Expected to vest 1,045,250 1,100,000 Time based Performance Outstanding, January 1, 2017 1,036,500 1,350,000 Weighted average contractual life (years) 2.96 8.86 Outstanding, December 31, 2017 1,045,250 1,500,000 Weighted average contractual life (years) 2.74 7.99 During the year ended December 31, 2018, the Company granted 452,125 time based share units and 150,000 performance based share units. The weighted average fair value for the time based units at the date of grant was $3.45 (CAD$4.71) per unit and the weighted average fair value per unit for the performance based share units granted in the in the period was $2.78 (CAD$3.79) per unit. The fair value per unit was based on the market value of the underlying shares at the date of issuance. During the year ended December 31, 2018, the Company issued 364,000 shares in respect of the 364,000 time-based share units which vested during the year. During the year ended December 31, 2017, the Company issued 324,000 share units (“Time based share units”). The weighted average fair value per unit was $3.31 (CAD$4.16) based on the market value of the underlying shares at the date of issuance. During the year ended December 31, 2017, 1,000,000 of those Performance based share units which vest upon the Company meeting certain market-based performance targets vested. Upon vesting, the Company issued 1,000,000 common shares. The Company also issued net shares of 292,549 in respect of 302,000 time-based share units which vested during the year. During the year ended December 31, 2018, the Company recognized $2,800,280 (2017 – $4,013,891), in compensation expense in relation to the granting and vesting of share units. (e) Normal Course Issuer Bid: On November 6, 2017, the Board of Directors of the Company approved a normal course issuer bid to purchase outstanding shares of the Company. On November 8, 2018, the Company’s normal course issuer bid was renewed. Under the renewed bid, the Company may purchase up to 7,044,410 shares pursuant to the bid, representing no more than 10.0% of the Company’s shares outstanding on October 31, 2018. All purchases of shares under the bid are made pursuant to an Automated Share Purchase Plan. Subject to any block purchases made in accordance with the rules of the TSX, the bid is subject to a daily repurchase maximum of 46,958 shares. Shares are purchased at the market price of the shares at the time of purchase and are purchased on behalf of the Company by a registered investment dealer through the facilities of the TSX or alternative Canadian and US marketplaces. During 2018, the Company repurchased 1,264,900 of its shares for a total cost, including transaction fees, of $3,784,733 (CAD$4,945,155). As at December 31, 2018, 1,254,500 of these shares have been cancelled with the remaining 10,400 shares cancelled on January 4, 2019. As of December 31, 2017, the Company repurchased 1,339,800 of its shares for a total cost, including transaction fees, of $2,872,713 (CAD$3,669,120). As at December 31, 2017, 1,267,400 of these shares had been cancelled with the remaining 72,400 shares cancelled on January 5, 2018. (f) Earnings per share: The calculation of basic earnings per share for the years ended December 31, 2018 and 2017 is as follows: 2018 2017 Net earnings Weighted Per share Net earnings Weighted Per share Net earnings attributable to shareholders: Earnings per common share: Basic $ 4,679,921 72,582,733 $ 0.064 $ 12,078,853 73,712,670 $ 0.164 Share options 1,122,708 925,286 Share units 379,731 418,047 Diluted $ 4,679,921 74,085,172 $ 0.063 $ 12,078,853 75,056,003 $ 0.161 For the year ended December 31, 2018, 221,979 options (2017 – 539,624) and 2,095,260 share units (2017 – 2,094,363) were excluded from the diluted weighted average number of common shares calculation. The average market value of the Company’s shares for purposes of calculating the dilutive effect of share options was based on quoted market prices for the period during which the options were outstanding. The treasury method is used to determine the calculation of dilutive shares.

Income taxes

Income taxes	12 Months Ended
	Dec. 31, 2018
Income Tax Disclosure [Abstract]
Income taxes	11. Income taxes: (a) Income tax expense is comprised of the following: 2018 2017 Current tax expense $ 5,119,062 $ 4,403,358 Deferred tax expense (recovery): (2,407,176 ) 2,755,707 Total tax expense (recovery) $ 2,711,886 $ 7,159,065 The reconciliation of income tax computed at statutory tax rates to income tax expense, using a 27% (2017 – 23%) statutory rate, is: 2018 2017 Net income before tax – Canada $ 5,957,089 $ 10,239,231 Net income before tax – United States 9,770,714 16,094,904 Net income before tax – All jurisdictions $ 15,727,803 $ 26,334,135 Tax expense at statutory income tax rates $ 4,259,890 $ 6,060,003 Permanent differences 503,964 (513,050 ) Income attributable to non-controlling (2,245,809 ) (1,571,060 ) Foreign income taxed at different rates (26,042 ) 1,458,302 Impact of change in tax rates 216,295 1,767,124 Other 3,588 (42,254 ) Total tax expense (recovery) $ 2,711,886 $ 7,159,065 In 2018, the Canadian statutory tax rate increased from 26% to 27% due to a 1% increase in the provincial rate. The Company’s statutory tax rate in Canada in 2017 was lower, at 23%, as a result of the IBA patent program in Canada, which was cancelled at the end of 2017. On December 22, 2017, in the United States the 2017 Tax Cuts and Jobs Act (the 2017 Act) was enacted into law. The 2017 Act contains several key tax provisions, including a reduction of the corporate income tax rate to 21% effective January 1, 2018, among others. At December 31, 2017, the Company’s deferred tax balances for its U.S. subsidiaries have been re-measured (b) Deferred tax assets and liabilities: The Company had the following deferred tax assets and liabilities resulting from temporary differences recognized for financial statement and income tax purposes. 2018 2017 Deferred tax assets: Property and equipment $ 356 3,501 Intangible assets 4,752,898 2,448,322 Finance related costs 375,182 472,428 Reserves — 34,048 Share transaction costs 87,337 196,508 Stock-based compensation 534,926 410,448 Earn-out 732,986 499,052 Deferred tax liabilities: Property and equipment (40,357 ) (3,396 ) Deferred consideration (18,388 ) (44,255 ) Reserves (55,568 ) (41,205 ) Unrealized foreign exchange (20,698 ) — Finance related costs (68,938 ) (173,193 ) Net deferred tax asset $ 6,279,736 $ 3,802,258 Deferred tax assets by jurisdiction 2018 2017 Canada: Deferred tax asset $ 87,343 $ 200,009 Deferred tax liability (109,294 ) (173,194 ) Net deferred tax asset (liability) $ (21,951 ) $ 26,815 United States: Deferred tax asset $ 6,396,340 $ 3,864,298 Deferred tax liability (94,654 ) (88,855 ) Net deferred tax asset (liability) $ 6,301,687 $ 3,775,443 The realization of deferred income tax assets is dependent on the generation of sufficient taxable income during future periods in which the temporary differences are expected to revers. If it is more likely than not that all or a portion of deferred tax assets will not be realized, a valuation allowance is provided against such deferred tax assets. In making such determination, the Company considers all available positive and negative evidence, including future reversals of existing taxable temporary differences, projected future taxable income, tax-planning As at December 31, 2018 and 2017, the Company had no valuation allowance against its deferred income tax assets. The Company currently does not have any unrecognized tax benefits or uncertain tax positions. The Company currently files income tax returns in Canada and the US, the jurisdiction in which the Company believes that it is subject to tax. Management is not aware of any material income tax examination currently in progress by any taxing jurisdiction. Tax years ranging from 2016 to 2018 remain subject to Canadian income tax examinations. Tax years ranging from 2015 to 2018 remain subject to U.S. income tax examinations.

Net finance expense

Net finance expense	12 Months Ended
	Dec. 31, 2018
Text Block [Abstract]
Net finance expense	12. Net finance expense Recognized in earnings in the years ended December 31: 2018 2017 Finance income: Foreign exchange gain $ — $ — Net change in fair value of financial liabilities at fair value through earnings (note 13) — (11,825,256 ) Total finance income $ — $ (11,825,256 ) Finance expense: Interest and accretion expense on borrowings $ 3,168,762 $ 3,322,321 Accretion expense on earn-out 166,575 600,602 Amortization of deferred financing fees 260,363 204,057 Net change in fair value of financial liabilities at fair value through earnings 971,627 — Foreign exchange loss — 88,084 Extinguishment of notes payable and bank indebtedness — 2,044,867 Other — 50,475 Total finance expense $ 4,567,327 $ 6,310,406 Net finance (income) expense $ 4,567,327 $ (5,514,850 )

Financial instruments

Financial instruments	12 Months Ended
	Dec. 31, 2018
Investments, All Other Investments [Abstract]
Financial instruments	13. Financial instruments: The Company’s financial instruments consist of cash and cash equivalents, trade and other receivables, trade and other payables, employee benefit obligations, short term advances, loans, notes payable and bank indebtedness, deferred consideration and the Company’s earn-out earn-out earn-out An established fair value hierarchy requires the Company to maximize the use of observable inputs and minimize the use of unobservable inputs when measuring fair value. A financial instrument’s categorization within the fair value hierarchy is based upon the lowest level of input that is available and significant to the fair value measurement. There are three levels of inputs that may be used to measure fair value: • Level 1 – quoted prices (unadjusted) in active markets for identical assets or liabilities; • Level 2 – inputs other than quoted prices included within Level 1 that are observable for the asset or liability, either directly (i.e. as prices) or indirectly (i.e. derived from prices); and • Level 3 – inputs for the asset or liability that are not based on observable market data (unobservable inputs). Liabilities December 31, Level 1 Level 2 Level 3 Earn-out $ 2,920,583 $ — $ — $ 2,920,583 Total $ 2,920,583 $ — $ — $ 2,920,583 Liabilities December 31, Level 1 Level 2 Level 3 Earn-out $ 1,875,427 $ — $ — $ 1,875,427 Total $ 1,875,427 $ — $ — $ 1,875,427 The Company’s earn-out earn-out earn-out earn-out earn-out earn-out earn-out The fair value measurements are sensitive to the discount rate used in calculating the fair values as well as the probability assessments used. A 1% increase in the discount rate would reduce the fair value of the earn-out Reconciliation of level 3 fair values: Earn-out Balance as at January 1, 2018 $ 1,875,427 Payment — Recorded in finance expense: Accretion expense 73,529 Fair value adjustment 971,627 Balance as at December 31, 2018 $ 2,920,583 The Company’s financial instruments are exposed to certain financial risks, including credit risk, and market risk. (a) Credit risk: Credit risk is the risk of financial loss to the Company if counterparty to a financial instrument fails to meet its contractual obligations and arises principally from the Company’s cash and cash equivalents, and trade receivables. The carrying amount of the financial assets represents the maximum credit exposure. The Company limits its exposure to credit risk on cash and cash equivalents by placing these financial instruments with high-credit quality financial institutions and only investing in liquid, investment grade securities. The Company has a number of individual customers and no one customer represents a concentration of credit risk. No one customer accounts for more than 10% of the Company’s consolidated revenue. The Company establishes a provision for losses on accounts receivable if it is determined that all or part of the outstanding balance is uncollectable. Collectability is reviewed regularly and an allowance is established or adjusted, as necessary, using a combination of the specific identification method, historic collection patterns and existing economic conditions. Estimates of allowances are subject to change as they are impacted by the nature of healthcare collections, which may involve delays and the current uncertainty in the economy. (b) Market risk: Market risk is the risk that changes in market prices, such as and interest rates, will affect the Company’s income or the value of the financial instruments held. ( ii As at December 31, 2018, the Company’s only interest bearing liability is its Scotia Facility. With respect to the Company’s Scotia Facility, with all other variables held constant, a 10% point increase in the interest rate would have reduced net income by approximately $295,000 (2017 – $164,000) for the year ended December 31, 2018. There would be an equal and opposite impact on net income with a 10% point decrease.

Commitments and contingencies

Commitments and contingencies	12 Months Ended
	Dec. 31, 2018
Commitments and Contingencies Disclosure [Abstract]
Commitments and contingencies	14. Commitments and contingencies: (a) The following are the minimum payments required for the lease of premises: Less than one year $ 364,068 One to three years 229,764 Four to five years — Thereafter — Total $ 593,832 Rent expense for the year ended December 31, 2018 was $227,743 (2017 – $236,455). (b) The Company is a party to a variety of agreements in the ordinary course of business under which it may be obligated to indemnify third parties with respect to certain matters. These obligations include, but are not limited to contracts entered into with physicians where the Company agrees, under certain circumstances, to indemnify a third party, against losses arising from matters including but not limited to medical malpractice and product liability. The impact of any such future claims, if made, on future financial results is not subject to reasonable estimation because considerable uncertainty exists as to final outcome of these potential claims.

Related party transactions

Related party transactions	12 Months Ended
	Dec. 31, 2018
Related Party Transactions [Abstract]
Related party transactions	15. Related party transactions: Balances and transactions between the Company and its wholly owned and controlled subsidiaries have been eliminated on consolidation and are not disclosed in this note. Details of the transactions between the Company and other related parties are disclosed below: (a) Related party transactions: During the year ended December 31, 2018, the Company made product sales totaling $29,685 (2017 – $39,485) to one company owned or controlled by one of the Company’s Directors. The transaction terms with related parties may not be on the same price as those that would result from transactions among non-related

Segmented information

Segmented information	12 Months Ended
	Dec. 31, 2018
Segment Reporting [Abstract]
Segmented information	16. Segmented information: The Company operates in two industry segments: the sale of medical products and the provision of anesthesia services. The revenues relating to geographic segments based on customer location, in United States dollars, for the years ended December 31, 2018 and 2017 are as follows: 2018 2017 Revenue: Canada and other $ 271,803 $ 238,342 United States 112,477,577 94,767,803 Total $ 112,749,380 $ 95,006,145 The Company’s revenues are disaggregated below into categories which differ in terms of the economic factors which impact the amount, timing and uncertainty of revenue and cash flows. 2018 2017 Revenue: Commercial Insurers $ 86,992,218 $ 72,264,107 Federal Insurers 14,246,626 10,568,096 Physicians 10,959,215 11,501,005 Other 551,321 672,937 Total $ 112,749,380 $ 95,006,145 The Company’s property and equipment, intangibles, other assets and total assets are located in the following geographic regions as at December 31, 2018 and 2017: 2018 2017 Property and equipment: Canada $ 276,621 $ 347,676 United States 26,670 16,690 Total $ 303,291 $ 364,366 Intangible assets: Canada $ 32,735 $ 35,181 United States 179,351,528 170,092,234 Total $ 179,384,263 $ 170,127,415 Total assets: Canada $ 9,293,796 $ 4,595,719 United States 209,694,200 199,359,786 Total $ 218,987,996 $ 203,955,505 The financial measures reviewed by the Company’s Chief Operating Decision Maker are presented below for the years ended December 31, 2018 and 2017. The Company does not allocate expenses related to corporate activities. These expenses are presented within “Other” to allow for reconciliation to reported measures. 2018 Anesthesia Product sales Other Total Revenue $ 101,790,165 $ 10,959,215 $ — $ 112,749,380 Operating costs 81,079,150 5,022,737 6,352,363 92,454,250 Operating income (loss) $ 20,711,015 $ 5,936,478 $ (6,352,363 ) $ 20,295,130 2017 Anesthesia Product sales Other Total Revenue $ 83,505,140 $ 11,501,005 $ — $ 95,006,145 Operating costs 62,135,447 4,997,550 7,053,863 74,186,860 Operating income (loss) $ 21,369,693 $ 6,503,455 $ (7,053,863 ) $ 20,819,285 Additionally, the company incurs the following in each of its operating segments: 2018 Anesthesia Product sales Other Total Finance income $ — $ — $ — $ — Finance expense 1,138,200 — 3,429,127 4,567,327 Depreciation and amortization expense 31,394,245 68,509 23,301 31,486,055 2017 Anesthesia Product sales Other Total Finance income $ (11,825,256 ) $ — $ — $ (11,825,256 ) Finance expense 600,602 — 5,709,804 6,310,406 Depreciation and amortization expense 23,762,012 56,907 15,481 23,834,400

Subsequent event

Subsequent event	12 Months Ended
	Dec. 31, 2018
Subsequent Events [Abstract]
Subsequent event	17. Subsequent event: On January 1, 2019, a subsidiary of the Company entered into a membership interest purchase agreement to acquire a 100% interest in Anesthesia Care Associates, LLC (”ACA”), a gastroenterology anesthesia services provider in Indiana. The purchase consideration, paid via cash, for the acquisition of the Company’s 100% interest was $5,239,003 plus deferred acquisition costs of $116,025. The allocated cost of the exclusive professional service agreement which was acquired as part of this acquisition was $5,355,028.

Significant accounting polici_2

Significant accounting policies (Policies)	12 Months Ended
	Dec. 31, 2018
Accounting Policies [Abstract]
Basis of consolidation	(a) Basis of consolidation: These consolidated financial statements include the accounts of the Company and its subsidiaries. Subsidiaries are entities controlled by the Company through voting control and for anesthesia business, control over the assets and business operations of the subsidiary through operating agreements. Control exists when the Company has the continuing power to govern the financial and operating polices of the investee. Subsidiaries are included in the consolidated financial results of the Company from the effective date of acquisition up to the effective date of disposition or loss of control. Minority interests, if any, are valued at fair value at inception. All significant intercompany transactions and balances have been eliminated in consolidation.
Cash equivalents	(b) Cash equivalents The Company considers all highly liquid investments with an original maturity of 90 days or less, when acquired, to be cash equivalents.
Foreign currency	(c) Foreign currency: Transactions in foreign currencies are translated to the respective functional currencies of the subsidiaries of the Company at exchange rates at the dates of the transactions. Period end balances of monetary assets and liabilities in foreign currency are translated to the respective functional currencies using period end foreign currency rates. Foreign currency gains and losses arising from settlement of foreign currency transactions are recognized in earnings. Non-monetary assets and liabilities denominated in foreign currencies that are measured at fair value are translated to the functional currency at the exchange rate at the date on which the fair value was determined. Non-monetary items that are measured at historical cost in a foreign currency are translated using the exchange rate at the date of the transaction.
Inventories	(d) Inventories: Inventories are measured at the lower of cost, determined using the first-in first-out Net realizable value is the estimated selling price in the Company’s ordinary course of business, less the estimated costs of completion and selling expenses. All inventory held is finished goods inventory.
Property and equipment, net	(e) Property and equipment, net: Property and equipment are measured at cost less accumulated depreciation and accumulated impairment losses. The estimated useful lives and the methods of depreciation for the current and comparative periods are as follows: Asset Basis Rate Computer equipment Declining balance 30% Computer software Declining balance 100% Furniture and equipment Declining balance 20% Leasehold improvements Straight-line Shorter of initial lease term or useful life Injection mold Straight-line 5 years These depreciation methods most closely reflect the expected pattern of consumption of the future economic benefits embodied in the asset. Estimates for depreciation methods, useful lives and residual values are reviewed at each reporting period-end and adjusted if appropriate.
Intangible assets	(f) Intangible assets: Intangible assets, consisting of acquired exclusive professional service agreements to provide anesthesia services and the cost of acquiring patents, are recorded at historical cost. For patents, costs also include legal costs involved in expanding the countries in which the patents are recognized to the extent expected cash flows from those countries exceed these costs over the amortization period and costs related to new patents. The amortization term for professional services agreements are based on the contractual terms of the agreements. Intangible assets with finite lives are amortized on a straight-line basis over their estimated useful lives and are measured at cost less accumulated amortization and accumulated impairment losses. Intangible assets with finite lives are amortized over the following periods: Asset Basis Rate Intellectual property rights to the CRH O’Regan System Straight-line 15 years Intellectual property new technology Straight-line 20 years Exclusive professional services agreements Straight-line 4.5 to 15 years
Impairment	(g) Impairment: Non-financial assets: The carrying amounts of the Company’s non-financial assets, other than inventories and deferred tax assets are reviewed at each reporting date to determine whether there are any events or changes in circumstances indicated that the carrying value may not be recoverable. Example factors that could trigger impairment reviews include significant underperformance relative to historical or projected future operating results, significant changes in the use of the acquired assets or strategy for the overall business and significant negative economic trends. Depending on the specific asset and circumstances, assets are assessed for impairment as an individual asset, as part of an asset group or at the reporting unit (RU”) level. A reporting unit is an operating segment or one level below an operating segment if certain conditions are met. For the purpose of impairment testing, assets are grouped together into the smallest group of assets that generates cash inflows from continuing use that are largely independent of cash inflows from other assets or groups of assets. If indicators of impairment exist, an asset or asset group is impaired if its carrying amount exceeds its fair value, being the projected future discounted cash flows that are directly associated with and that are expected to arise as a direct result of the use and eventual disposition of the asset or asset group. Projected cash flows are based upon historical results adjusted to reflect management’s best estimate of future market and operating conditions which may differ from actual cash flows. Significant assumptions included in projected cash flows include anesthesia revenue growth rates, discount rates, and operating cost growth rates.
Income taxes	(h) Income taxes: The Company is subject to income taxes in Canada and the United States. Judgment is required in determining the provision for income taxes and income tax assets and liabilities, including evaluating uncertainties in the application of accounting principles and complex tax laws. The Company records a provision for income taxes for the anticipated tax consequences of the reported results of operations using the asset and liability method. Under this method, it recognizes deferred income tax assets and liabilities for the expected future tax consequences of temporary differences between the financial reporting and tax bases of assets and liabilities. Deferred tax assets and liabilities are measured using the enacted tax rates that are expected to apply to taxable income for the years in which those tax assets and liabilities are expected to be realized or settled. The Company recognizes the deferred income tax effects of a change in tax rates in the period of the enactment. The Company records a valuation allowance to reduce its deferred tax assets to the net amount that management believes is more likely than not to be realized. The Company recognizes the effect of income tax positions only if those positions are more likely than not of being sustained. Recognized income tax positions are measured at the largest amount that is greater than fifty percent likely of being realized. The Company records interest related to unrecognized tax benefits in interest expense and penalties in operating expenses. Income tax expense is comprised of current and deferred tax.
Share-based compensation	(i) Share-based compensation: The Company records share-based compensation related to equity classified stock options and share units granted using the fair value based method estimated using either the Black-Scholes model or Binomial method. The vesting components of graded vesting employee awards, with only a service vesting condition, are accounted for as separate share-based arrangements. Each vesting installment is measured separately and expensed over the related installment’s vesting period. Compensation cost is measured at fair value at the date of grant and expensed as employee benefits over the period in which employees unconditionally become entitled to the award. Forfeitures are estimated in recognizing share-based compensation, such that the amount ultimately recognized as an expense is based on the number of awards that do meet the related service and non-market performance conditions at the vesting date. Prior to January 1, 2018, each vesting tranche of equity classified non-employee non-employee 2018-07
Share capital	(j) Share capital: Common shares are classified as equity. Incremental costs directly attributable to the issue of common shares, stock options and share options are recognized as a deduction from equity, net of any tax effects.
Earnings per share	(k) Earnings per share: The Company presents basic and diluted earnings per share (EPS) data for its common shares. Basic EPS is calculated by dividing the net income or loss attributable to common shareholders of the Company by the weighted average number of common shares outstanding during the period, adjusted for own shares held, if applicable. Diluted EPS is determined by adjusting the income or loss attributable to common shareholders and the weighted average number of common shares outstanding, adjusted for own shares held if applicable, for the effects of all dilutive potential common shares. Diluted EPS for year-to-date year-to-date
Segment reporting	(l) Segment reporting: The Company’s operating segments consist of the sale of medical products and the provision of anesthesia services.
Finance costs	(m) Finance costs: Finance cost is primarily comprised of interest on the Company’s notes payable and bank indebtedness and also includes the amortization of costs incurred to obtain loan financing and any fees in respect of arranging loan financing. Deferred finance costs are amortized using the effective interest method over the term of the related loan financing. Deferred finance costs are presented as a reduction to the related liability.
Asset acquisitions	(n) Asset acquisitions: Asset acquisitions are accounted for using the cost accumulation and allocation method. The acquisition cost includes directly related acquisition costs. The cost of the acquisition is allocated to the net assets acquired on a relative fair value basis. Contingent consideration, where the arrangement is not a derivative, is recognized when it is probable and estimable. After the initial acquisition accounting, changes in contingent and deferred consideration are recorded within finance (income) expense. The Company’s policy is to recognize any non-controlling non-controlling
Revenue recognition	(o) Revenue recognition: Our anesthesia service revenues are derived from anesthesia procedures performed under our professional services agreements. The fees for such services are billed either to a third party payor, including Medicare or Medicaid or to the patient. We recognize anesthesia service revenues, net of contractual adjustments and implicit price concessions, which we estimate based on the historical trend of our cash collections and contractual adjustments. Anesthesia services procedures for each patient qualify as a distinct service obligation, as they are provided simultaneously with other readily available resources during the service procedure. The transaction price is variable and not constrained. Variable consideration relates to contractual allowances, credit provisions and other discounts. The standard requires management to estimate the transaction price, including any implicit concessions from the credit approval process. The Company adopted a portfolio approach to estimate variable consideration transaction price by payor type (patient, government and/or insurer) and the specifics of the services being provided. These portfolios share characteristics such that the results of applying a portfolio approach are not materially different than if the standard was applied to individual patient contracts. Revenue is recognized upon completion of the services to the customer (patient) for practical reasons as the service period is performed over a short time period. The Company recognizes revenue from product sales at the time the product is shipped, which is when title passes to the customer, and when all significant contractual obligations have been satisfied, collection is probable and the amount of revenue can be estimated reliably. Product sales contracts generally contain a single distinct performance obligation, but multiple performance obligations may exist when multiple product types are ordered by a physician in a contract. The transaction price for product sales is fixed and no variable consideration exists. Contract consideration is allocated to each distinct performance obligation in the contract based upon available stand-alone selling prices obtained from historical sales transactions for each product. The Company recognizes revenue from product sales at the point in time when control of the goods passes to the customer (physician) when the product is shipped, which is when title passes to the customer and an obligation to pay for the goods arises. Shipping services performed after control has passed to the customer, if any, is a separate performance obligation, but was determined to be nominal.
Adoption of new accounting standards	(p) Adoption of new accounting standards: i) Revenue from Contracts with Customers This standard establishes a comprehensive framework for determining whether, how much and when revenue is recognized. The Company adopted the standard effective January 1, 2018 applying the full retrospective method, resulting with the standard being applied to the prior reporting period with a cumulative effect of adjustment, if any, recognized as at January 1, 2017. The Company has elected to make use of the following practical expedients: • incremental costs of obtaining a contract are recognized as an expense when incurred because the amortization period of the asset that the Company otherwise would have recognized is one year or less; and • the promised amount of consideration has not been adjusted for the effects of a significant financing component because, at contract inception, the period between when the Company transfers a promised good or service to a customer and when the customer pays for that good or service will be one year or less. The adoption of this standard did not have a material impact on the results of operations or cash flows and there was no adjustment to retained earnings as at January 1, 2017. However, the standard did require the Company’s provision for net uncollectable accounts, previously recognized as bad debt expense in anesthesia services expenses, to be recognized as a reduction to anesthesia service revenues. There was no impact to the Company’s other operating segments. For the year ended December 31, 2017, the adoption of the standard resulted in a reduction of anesthesia services revenue and a similar reduction of anesthesia services expenses of $5,235,934. ii) Financial Instruments – Overall In January 2016, FASB issued ASU No. 2016-01, Financial Instruments – Overall iii) Employee Share-based Payments In March 2016, FASB issued ASU No. 2016-09, Improvements to Employee Share-Based Payment Accounting iv) Clarifying the Definition of a Business In January 2017, FASB issued ASU No. 2017-01, Business Combinations (Topic 805) – Clarifying the Definition of a Business” v) Nonemployee Share-Based Payment Accounting In June 2018, FASB issued ASU No. 2018-07, Compensation – Stock Compensation (Topic 718) – Improvements to Non-Employee non-employee non-employee non-employee non-employee
New standards and interpretations not yet applied	(q) New standards and interpretations not yet applied: (i) ASU 2016-02 Leases In February 2016, FASB issued ASU No. 2016-02 Leases No. 2017-13, right-of-use (ii) Credit Losses In June 2016, FASB issued ASU No. 2016-13, Financial Instruments – Credit Losses (Topic 326)” The Company is in the process of evaluating the impact of this standard on its balance sheet, results of operations and cash flows.

Significant accounting polici_3

Significant accounting policies (Tables)	12 Months Ended
	Dec. 31, 2018
Accounting Policies [Abstract]
Estimated Useful Lives and the Methods of Depreciation for Current and Comparative Periods	The estimated useful lives and the methods of depreciation for the current and comparative periods are as follows: Asset Basis Rate Computer equipment Declining balance 30% Computer software Declining balance 100% Furniture and equipment Declining balance 20% Leasehold improvements Straight-line Shorter of initial lease term or useful life Injection mold Straight-line 5 years
Intangible Assets Finite Lives Amortized Over Period	Intangible assets with finite lives are amortized on a straight-line basis over their estimated useful lives and are measured at cost less accumulated amortization and accumulated impairment losses. Intangible assets with finite lives are amortized over the following periods: Asset Basis Rate Intellectual property rights to the CRH O’Regan System Straight-line 15 years Intellectual property new technology Straight-line 20 years Exclusive professional services agreements Straight-line 4.5 to 15 years

Asset acquisitions (Tables)

Asset acquisitions (Tables)	12 Months Ended
	Dec. 31, 2018
Business Combinations [Abstract]
Summary of Asset Acquisitions	During the year ended December 31, 2018, the Company completed five asset acquisitions. These asset acquisitions have been included in the anesthesia segment of the Company and represents the following: Acquired Operation Date Acquired Consideration Shreveport Sedation Associates LLC (“SSA”) March 2018 $ 9,495,184 Western Ohio Sedation Associates LLC (“WOSA”) May 2018 $ 6,483,698 Lake Washington Anesthesia LLC (“LWA”) July 2018 $ 5,041,939 Lake Erie Sedation Associates LLC (“LESA”) September 2018 $ 4,233,115 Tennessee Valley Anesthesia Associates LLC (“TVAA”) December 2018 $ 2,255,875 During the year ended December 31, 2017, the Company completed six asset acquisitions. All asset acquisitions completed during the period have been included in the anesthesia segment of the Company and include the following: Acquired Operation Date Acquired Consideration DDAB, LLC (“DDAB”) February 2017 $ 5,278,940 Osceola Gastroenterology Anesthesia Associates, LLC (“OGAA”) March 2017 $ 3,452,247 West Florida Anesthesia Associates, LLC (“WFAA”) August 2017 $ 5,904,980 Central Colorado Anesthesia Associates, LLC (“CCAA”) September 2017 $ 7,909,243 Raleigh Sedation Associates, LLC & Blue Ridge Sedation Associates, PLLC (“RSA”) September 2017 $ 7,328,060 Alamo Sedation Associates, LLC (“ASA”) September 2017 $ 3,503,379
Summary of Fair Value of Consideration Transferred and Allocated Costs of Assets and Liabilities Acquired at Acquisition Date	The following table summarizes the fair value of the consideration transferred and the allocated costs of the assets and liabilities acquired at the acquisition date. SSA WOSA LWA LESA TVAA Total Cash $ 9,404,148 $ 6,409,000 $ 5,000,000 $ 4,180,000 $ 2,200,000 $ 27,193,148 Acquisition Costs 91,036 74,698 41,939 53,115 55,875 316,663 Purchase consideration $ 9,495,184 $ 6,483,698 $ 5,041,939 $ 4,233,115 $ 2,255,875 $ 27,509,811 Non-controlling $ — $ 6,229,435 $ 4,844,217 $ — $ 2,167,409 $ 13,241,061 $ 9,495,184 $ 12,713,133 $ 9,886,156 $ 4,233,115 $ 4,423,284 $ 40,750,872 Assets and liabilities acquired: Exclusive professional services agreements $ 9,391,036 $ 12,713,133 $ 9,886,155 $ 4,233,115 $ 4,423,284 $ 40,646,723 Prepaid expenses and deposits 104,149 — — — 104,149 Pre-close — — 652,506 — 652,506 Pre-close — — (652,506 ) — (652,506 ) Fair value of net identifiable assets and liabilities acquired $ 9,495,185 $ 12,713,133 $ 9,886,155 $ 4,233,115 $ 4,423,284 $ 40,750,872 Exclusive professional services agreements – amortization term 7 years 10 years 7 years 10 years 7 years CRH ownership interest 100 % 51 % 51 % 100 % 51 % The following table summarizes the fair value of the consideration transferred and the allocated costs of the assets and liabilities acquired at the acquisition date. DDAB OGAA WFAA CCAA RSA ASA Total Cash and acquisition costs $ 4,089,791 $ 3,401,819 $ 5,840,000 $ 7,888,919 $ 7,248,960 $ 3,500,000 $ 31,969,489 Acquisition costs 5,370 50,428 64,980 20,324 79,100 3,379 223,581 Contingent consideration 1,183,779 — — — — — 1,183,779 Purchase consideration $ 5,278,940 $ 3,452,247 $ 5,904,980 $ 7,909,243 $ 7,328,060 $ 3,503,379 33,376,849 Non-controlling 5,071,922 2,301,498 4,831,346 7,599,077 7,040,685 — 26,844,528 $ 10,350,862 $ 5,753,745 $ 10,736,326 $ 15,508,320 $ 14,368,745 $ 3,503,379 $ 60,221,377 Assets and liabilities acquired: Exclusive professional services agreements 10,350,862 $ 5,753,745 $ 10,724,338 $ 15,508,320 $ 14,368,745 $ 3,503,379 $ 60,209,389 Pre-close 525,000 — — — — — 525,000 Pre-close (525,000 ) — — — — — (525,000 ) Prepaid expenses and deposits — — 11,988 — — — 11,988 Fair value of net identifiable assets and liabilities acquired $ 10,350,862 $ 5,753,745 $ 10,736,326 $ 15,508,320 $ 14,368,745 $ 3,503,379 $ 60,221,377 Exclusive professional services agreements – amortization term 4.5 years 5 years 15 years 7 years 5 years 7 years CRH ownership interest 51 % 60 % 55 % 51 % 51 % 100 %
Summary of Asset Acquisition Loan Contribution	The terms of the loans are such that they will be repaid first, prior to any future distributions and are non-interest SSA WOSA LWA LESA TVAA Total CRH member loan $ — $ 193,800 $ — $ — $ 51,000 $ 244,800 Non-controlling $ — $ 186,200 $ — $ — $ 49,000 $ 235,200 Amount outstanding at December 31, 2018 $ — $ — $ — $ — $ 100,000 $ 100,000 The terms of the loans are such that they will be repaid first, prior to any future distributions and are non-interest DDAB OGAA WFAA CCAA RSA ASA Total CRH member loan $ — $ 90,000 $ 82,500 $ 178,500 $ 204,000 $ — $ 555,000 Non-controlling $ — $ 60,000 $ 67,500 $ 171,500 $ 196,000 $ — $ 495,000 Amount outstanding at December 31, 2018 $ — $ — $ — $ — $ — $ — $ —

Trade and other receivables (Ta

Trade and other receivables (Tables)	12 Months Ended
	Dec. 31, 2018
Receivables [Abstract]
Summary of Trade Receivables and Other Receivable	2018 2017 Trade receivables, gross $ 19,373,260 $ 15,325,553 Other receivables 141,141 260,759 Less: allowance for doubtful accounts (46,598 ) (100,000 ) $ 19,467,803 $ 15,486,312 Anesthesia segment – trade receivables, gross 18,199,847 13,405,303 Product segment – trade receivables, gross 1,173,413 1,920,250 $ 19,373,260 $ 15,325,553

Trade and other payables (Table

Trade and other payables (Tables)	12 Months Ended
	Dec. 31, 2018
Payables and Accruals [Abstract]
Summary of Trade and Other Payables	2018 2017 Trade payables $ 1,316,821 $ 2,042,487 Payments due to former owners of acquired entities — 76,403 Accruals and other payables 4,446,401 3,542,954 $ 5,763,222 $ 5,661,844

Property and equipment (Tables)

Property and equipment (Tables)	12 Months Ended
	Dec. 31, 2018
Property, Plant and Equipment [Abstract]
Summary of Property and Equipment	Property and equipment consist of the following: December 31, 2018 2017 Computer equipment and software $ 94,566 $ 82,055 Furniture and equipment 237,616 215,021 Leasehold improvements 5,784 5,784 Injection mold 408,062 408,062 Property and equipment $ 746,028 $ 710,922 Less: Accumulated depreciation (442,737 ) (346,556 ) Property and equipment, net $ 303,291 $ 364,366

Intangible assets (Tables)

Intangible assets (Tables)	12 Months Ended
	Dec. 31, 2018
Goodwill and Intangible Assets Disclosure [Abstract]
Summary of Intangible Assets	Professional Patents Total Cost Balance as at January 1, 2017 155,635,148 532,598 156,167,746 Additions through asset acquisitions (note 4) 60,209,389 — 60,209,389 Balance as at December 31, 2017 $ 215,844,537 $ 532,598 $ 216,377,135 Additions through asset acquisitions (note 4) 40,646,723 — 40,646,723 Balance as at December 31, 2018 $ 256,491,260 $ 532,598 $ 257,023,858 Professional Patents Total Accumulated depreciation Balance as at January 1, 2017 21,999,771 500,664 22,500,435 Amortization expense 23,752,532 (3,247 ) 23,749,285 Balance as at December 31, 2017 $ 45,752,303 $ 497,417 $ 46,249,720 Amortization expense 31,387,429 2,446 31,389,875 Balance as at December 31, 2018 $ 77,139,732 $ 499,863 $ 77,639,595 Professional Patents Total Net book value December 31, 2018 $ 179,351,528 $ 32,735 $ 179,384,263 December 31, 2017 $ 170,092,234 $ 35,181 $ 170,127,415
Summary of Amortization Expense to be Incurred by Company Over Next Five Years	Based on the Company’s professional services agreements in place at December 31, 2018, the Company anticipates that the amortization expense to be incurred by the Company over the next five years is as follows: Amortization For professional services agreements as at December 31, 2018: 2019 $ 33,674,000 2020 33,593,000 2021 28,287,000 2022 21,565,000 2023 17,419,000 $ 134,538,000

Notes payable (Tables)

Notes payable (Tables)	12 Months Ended
	Dec. 31, 2018
Summary of Detailed Information about Financial Covenants Ratios	As at December 31, 2018 the Company is required to maintain the following financial covenants in respect of the Facility: Financial Covenant Required Ratio Total funded debt ratio 2.50:1.00 Fixed charge coverage ratio 1.15:1.00
Summary of Notes Payable/Consolidated Minimum Loans Payments	The consolidated minimum loan payments (principal) for all loan agreements in the future are as follows: Minimum At December 31, 2018 2019 $ 2,500,000 2020 67,750,000 $ 70,250,000
Notes Payable [Member]
Summary of Notes Payable/Consolidated Minimum Loans Payments	December 31, 2018 2017 Current portion $ 2,239,637 $ 989,637 Non-current 67,621,470 60,061,105 Total loans and borrowings $ 69,861,107 $ 61,050,742

Share capital (Tables)

Share capital (Tables)	12 Months Ended
	Dec. 31, 2018
Text Block [Abstract]
Summary of Stock Option Activity	A summary of the status of the plan as of December 31, 2018 and 2017 is as follows (options are granted in CAD and USD amounts are calculated using prevailing exchange rates): Number of Weighted average CAD USD Outstanding, January 1, 2017 1,603,124 $ 0.63 $ 0.47 Issued — — — Exercised (247,500 ) 0.32 0.25 Forfeited (10,937 ) 0.60 0.48 Expired — — — Outstanding, December 31, 2017 1,344,687 0.69 0.55 Issued — — — Exercised — — — Forfeited — — — Expired — — — Outstanding, December 31, 2018 1,344,687 0.69 0.50
Schedule of Information With Respect to Stock Options Outstanding and Exercisable	The following table summarizes information about the stock options outstanding as at: December 31, 2018: Exercise price Options outstanding Options exercisable $CAD $USD Number Weighted Weighted Weighted Number Weighted Weighted 0.44 – 0.51 1,344,687 5.05 0.69 0.50 1,344,687 0.69 0.50 All options are vested as of December 31, 2018 and 2017. December 31, 2017: Exercise price Options outstanding Options exercisable $CAD $USD Number Weighted Weighted Weighted Number Weighted Weighted 0.60 – 0.70 0.48 – 0.56 1,344,687 6.05 0.69 0.55 1,272,812 0.68 0.54
Summary of Status of Plan for Other Equity Instruments	A summary of the status of the plan as of December 31, 2018 and 2017 is as follows: Time based Performance Outstanding, January 1, 2017 1,068,000 2,350,000 Issued 324,000 — Exercised (302,000 ) (1,000,000 ) Forfeited (53,500 ) — Expired — — Outstanding, December 31, 2017 1,036,500 1,350,000 Vested — — Expected to vest 1,036,500 1,100,000 Outstanding, January 1, 2018 1,036,500 1,350,000 Issued 452,125 150,000 Exercised (364,000 ) — Forfeited (79,375 ) — Expired — — Outstanding, December 31, 2018 1,045,250 1,500,000 Vested — — Expected to vest 1,045,250 1,100,000 Time based Performance Outstanding, January 1, 2017 1,036,500 1,350,000 Weighted average contractual life (years) 2.96 8.86 Outstanding, December 31, 2017 1,045,250 1,500,000 Weighted average contractual life (years) 2.74 7.99
Summary of Calculation of Basic Earnings Per Share	The calculation of basic earnings per share for the years ended December 31, 2018 and 2017 is as follows: 2018 2017 Net earnings Weighted Per share Net earnings Weighted Per share Net earnings attributable to shareholders: Earnings per common share: Basic $ 4,679,921 72,582,733 $ 0.064 $ 12,078,853 73,712,670 $ 0.164 Share options 1,122,708 925,286 Share units 379,731 418,047 Diluted $ 4,679,921 74,085,172 $ 0.063 $ 12,078,853 75,056,003 $ 0.161

Income taxes (Tables)

Income taxes (Tables)	12 Months Ended
	Dec. 31, 2018
Income Tax Disclosure [Abstract]
Summary of Income Tax Expense (Recovery)	(a) Income tax expense is comprised of the following: 2018 2017 Current tax expense $ 5,119,062 $ 4,403,358 Deferred tax expense (recovery): (2,407,176 ) 2,755,707 Total tax expense (recovery) $ 2,711,886 $ 7,159,065 The reconciliation of income tax computed at statutory tax rates to income tax expense, using a 27% (2017 – 23%) statutory rate, is: 2018 2017 Net income before tax – Canada $ 5,957,089 $ 10,239,231 Net income before tax – United States 9,770,714 16,094,904 Net income before tax – All jurisdictions $ 15,727,803 $ 26,334,135 Tax expense at statutory income tax rates $ 4,259,890 $ 6,060,003 Permanent differences 503,964 (513,050 ) Income attributable to non-controlling (2,245,809 ) (1,571,060 ) Foreign income taxed at different rates (26,042 ) 1,458,302 Impact of change in tax rates 216,295 1,767,124 Other 3,588 (42,254 ) Total tax expense (recovery) $ 2,711,886 $ 7,159,065
Summary of Deferred Tax Assets and Liabilities	The Company had the following deferred tax assets and liabilities resulting from temporary differences recognized for financial statement and income tax purposes. 2018 2017 Deferred tax assets: Property and equipment $ 356 3,501 Intangible assets 4,752,898 2,448,322 Finance related costs 375,182 472,428 Reserves — 34,048 Share transaction costs 87,337 196,508 Stock-based compensation 534,926 410,448 Earn-out 732,986 499,052 Deferred tax liabilities: Property and equipment (40,357 ) (3,396 ) Deferred consideration (18,388 ) (44,255 ) Reserves (55,568 ) (41,205 ) Unrealized foreign exchange (20,698 ) — Finance related costs (68,938 ) (173,193 ) Net deferred tax asset $ 6,279,736 $ 3,802,258 Deferred tax assets by jurisdiction 2018 2017 Canada: Deferred tax asset $ 87,343 $ 200,009 Deferred tax liability (109,294 ) (173,194 ) Net deferred tax asset (liability) $ (21,951 ) $ 26,815 United States: Deferred tax asset $ 6,396,340 $ 3,864,298 Deferred tax liability (94,654 ) (88,855 ) Net deferred tax asset (liability) $ 6,301,687 $ 3,775,443

Net finance expense (Tables)

Net finance expense (Tables)	12 Months Ended
	Dec. 31, 2018
Text Block [Abstract]
Summary of Net Finance Expense	Recognized in earnings in the years ended December 31: 2018 2017 Finance income: Foreign exchange gain $ — $ — Net change in fair value of financial liabilities at fair value through earnings (note 13) — (11,825,256 ) Total finance income $ — $ (11,825,256 ) Finance expense: Interest and accretion expense on borrowings $ 3,168,762 $ 3,322,321 Accretion expense on earn-out 166,575 600,602 Amortization of deferred financing fees 260,363 204,057 Net change in fair value of financial liabilities at fair value through earnings 971,627 — Foreign exchange loss — 88,084 Extinguishment of notes payable and bank indebtedness — 2,044,867 Other — 50,475 Total finance expense $ 4,567,327 $ 6,310,406 Net finance (income) expense $ 4,567,327 $ (5,514,850 )

Financial instruments (Tables)

Financial instruments (Tables)	12 Months Ended
	Dec. 31, 2018
Investments, All Other Investments [Abstract]
Schedule of Fair Value of Financial Instruments	Liabilities December 31, Level 1 Level 2 Level 3 Earn-out $ 2,920,583 $ — $ — $ 2,920,583 Total $ 2,920,583 $ — $ — $ 2,920,583 Liabilities December 31, Level 1 Level 2 Level 3 Earn-out $ 1,875,427 $ — $ — $ 1,875,427 Total $ 1,875,427 $ — $ — $ 1,875,427
Summary of Reconciliation of Level 3 Fair Values	Reconciliation of level 3 fair values: Earn-out Balance as at January 1, 2018 $ 1,875,427 Payment — Recorded in finance expense: Accretion expense 73,529 Fair value adjustment 971,627 Balance as at December 31, 2018 $ 2,920,583

Commitments and contingencies (

Commitments and contingencies (Tables)	12 Months Ended
	Dec. 31, 2018
Commitments and Contingencies Disclosure [Abstract]
Summary of Minimum Payments Required for the Lease of Premises	(a) The following are the minimum payments required for the lease of premises: Less than one year $ 364,068 One to three years 229,764 Four to five years — Thereafter — Total $ 593,832

Segmented information (Tables)

Segmented information (Tables)	12 Months Ended
	Dec. 31, 2018
Segment Reporting [Abstract]
Summary of Revenues Relating to Geographic Segments	The revenues relating to geographic segments based on customer location, in United States dollars, for the years ended December 31, 2018 and 2017 are as follows: 2018 2017 Revenue: Canada and other $ 271,803 $ 238,342 United States 112,477,577 94,767,803 Total $ 112,749,380 $ 95,006,145
Summary of Revenue from Contract with Customer	The Company’s revenues are disaggregated below into categories which differ in terms of the economic factors which impact the amount, timing and uncertainty of revenue and cash flows. 2018 2017 Revenue: Commercial Insurers $ 86,992,218 $ 72,264,107 Federal Insurers 14,246,626 10,568,096 Physicians 10,959,215 11,501,005 Other 551,321 672,937 Total $ 112,749,380 $ 95,006,145
Summary of Property and Equipment, Intangibles and Other Assets Located in Geographic Regions	The Company’s property and equipment, intangibles, other assets and total assets are located in the following geographic regions as at December 31, 2018 and 2017: 2018 2017 Property and equipment: Canada $ 276,621 $ 347,676 United States 26,670 16,690 Total $ 303,291 $ 364,366 Intangible assets: Canada $ 32,735 $ 35,181 United States 179,351,528 170,092,234 Total $ 179,384,263 $ 170,127,415 Total assets: Canada $ 9,293,796 $ 4,595,719 United States 209,694,200 199,359,786 Total $ 218,987,996 $ 203,955,505
Summary of Operating Segments	The financial measures reviewed by the Company’s Chief Operating Decision Maker are presented below for the years ended December 31, 2018 and 2017. The Company does not allocate expenses related to corporate activities. These expenses are presented within “Other” to allow for reconciliation to reported measures. 2018 Anesthesia Product sales Other Total Revenue $ 101,790,165 $ 10,959,215 $ — $ 112,749,380 Operating costs 81,079,150 5,022,737 6,352,363 92,454,250 Operating income (loss) $ 20,711,015 $ 5,936,478 $ (6,352,363 ) $ 20,295,130 2017 Anesthesia Product sales Other Total Revenue $ 83,505,140 $ 11,501,005 $ — $ 95,006,145 Operating costs 62,135,447 4,997,550 7,053,863 74,186,860 Operating income (loss) $ 21,369,693 $ 6,503,455 $ (7,053,863 ) $ 20,819,285 Additionally, the company incurs the following in each of its operating segments: 2018 Anesthesia Product sales Other Total Finance income $ — $ — $ — $ — Finance expense 1,138,200 — 3,429,127 4,567,327 Depreciation and amortization expense 31,394,245 68,509 23,301 31,486,055 2017 Anesthesia Product sales Other Total Finance income $ (11,825,256 ) $ — $ — $ (11,825,256 ) Finance expense 600,602 — 5,709,804 6,310,406 Depreciation and amortization expense 23,762,012 56,907 15,481 23,834,400

Significant Accounting Polici_4

Significant Accounting Policies - Estimated Useful Lives and the Methods of Depreciation for Current and Comparative Periods (Detail)	12 Months Ended
	Dec. 31, 2018
Leasehold Improvements [Member]
Property, Plant and Equipment [Line Items]
Basis	Straight-line
Lease term or useful life	Shorter of initial lease term or useful life
Injection Mold [Member]
Property, Plant and Equipment [Line Items]
Basis	Straight-line
Lease term or useful life	5 years
Computer Equipment and Software [Member]
Property, Plant and Equipment [Line Items]
Basis	Declining balance
Rate	30
Computer Software [Member]
Property, Plant and Equipment [Line Items]
Basis	Declining balance
Rate	100
Furniture And Equipment [Member]
Property, Plant and Equipment [Line Items]
Basis	Declining balance
Rate	20

Significant Accounting Polici_5

Significant Accounting Policies - Intangible Assets Finite Lives Amortized Over Period (Detail)	12 Months Ended
	Dec. 31, 2018
Intellectual Property Rights to the CRH O'Regan System [Member]
Finite-Lived Intangible Assets [Line Items]
Basis	Straight-line
Rate	15 years
Intellectual Property New Technology [Member]
Finite-Lived Intangible Assets [Line Items]
Basis	Straight-line
Rate	20 years
Exclusive Professional Services Agreements [Member]
Finite-Lived Intangible Assets [Line Items]
Basis	Straight-line
Minimum [Member] | Exclusive Professional Services Agreements [Member]
Finite-Lived Intangible Assets [Line Items]
Rate	4 years 6 months
Maximum [Member] | Exclusive Professional Services Agreements [Member]
Finite-Lived Intangible Assets [Line Items]
Rate	15 years

Significant Accounting Polici_6

Significant Accounting Policies - Additional Information (Detail) - USD ($)	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017
Significant Accounting Policies [Line Items]
Minimum percentage likelihood to recognize tax benefit from uncertain tax position	50.00%
Revenue, practical expedient, incremental cost of obtaining contract	true
Revenue, practical expedient, financing component	true
Reduction of anesthesia services expenses	$ 92,454,250	$ 74,186,860
Reduction of anesthesia services expenses	112,749,380	95,006,145
Capitalization of acquisition costs	116,025
Accounting Standards Update 2016-09 [Member]
Significant Accounting Policies [Line Items]
Tax expense related to awards		952,495
Accounting Standards Update 2017-01 [Member]
Significant Accounting Policies [Line Items]
Capitalization of acquisition costs		223,581
Accounting Standards Update 2017-01 [Member] | Intangible Assets [Member]
Significant Accounting Policies [Line Items]
Net allocation of expenses		381,794
Accounting Standards Update 2017-01 [Member] | Non-Controlling Interest [Member]
Significant Accounting Policies [Line Items]
Net allocation of expenses		173,194
Accounting Standards Update 2017-01 [Member] | Retained Earnings (Deficit) [Member]
Significant Accounting Policies [Line Items]
Net allocation of expenses		14,274
Anesthesia Services [Member]
Significant Accounting Policies [Line Items]
Reduction of anesthesia services expenses	81,079,150	62,135,447
Reduction of anesthesia services expenses	$ 101,790,165	83,505,140
Anesthesia Services [Member] | Accounting Standards Update 2014-09 [Member]
Significant Accounting Policies [Line Items]
Reduction of anesthesia services expenses		5,235,934
Anesthesia Services [Member] | Difference between Revenue Guidance in Effect before and after Topic 606 [Member] | Accounting Standards Update 2014-09 [Member]
Significant Accounting Policies [Line Items]
Reduction of anesthesia services expenses		(5,235,934)
Anesthesia Services [Member] | Difference between Revenue Guidance in Effect before and after Topic 606 [Member] | Accounting Standards Update 2017-01 [Member]
Significant Accounting Policies [Line Items]
Reduction of anesthesia services expenses		$ (194,326)

Asset Acquisitions - Additional

Asset Acquisitions - Additional Information - 2018 Acquisitions (Detail)	Jul. 01, 2018USD ($)	Dec. 31, 2018USD ($)Acquisition	Dec. 31, 2017USD ($)Acquisition	Oct. 31, 2018
Business Acquisition [Line Items]
Number of asset acquisitions completed | Acquisition		5	6
Asset acquired control, description		The Company has obtained control over the acquired assets via the Company’s majority ownership in the shares of the entities and its agreements with the non-controlling interest shareholders.	The Company has obtained control over the acquired assets via the Company’s majority ownership in the shares of the entities and its agreements with the non-recurring interest shareholders.
Business combination loan contribution description		For those asset acquisitions where CRH ownership interest is less than 100%, in conjunction with the acquisition, both the Company and the non-controlling interest shareholder contributed loans. The terms of the loans are such that they will be repaid first, prior to any future distributions and are non-interest bearing.	For those asset acquisitions where CRH ownership interest is less than 100%, in conjunction with the acquisition, both the Company and the non-controllinginterest shareholder contributed loans. The terms of the loans are such that they will be repaid first, prior to any future distributions and are non-interest bearing.
Short-term advances		$ 26,783
Anesthesia Services [Member]
Business Acquisition [Line Items]
Business acquisition, Legal costs		$ 316,663	$ 223,581
Anesthesia Services [Member] | Triad Sedation Associates LLC [Member]
Business Acquisition [Line Items]
Percentage of equity interest				15.00%
Option to acquire additional interest		36.00%
Lake Washington Anesthesia LLC [Member] | Anesthesia Services [Member]
Business Acquisition [Line Items]
Working capital advance	$ 254,351
Short-term advances		$ 26,783
Business acquisition, Legal costs		41,939
Anesthesia Care Associates, LLC [Member] | Anesthesia Services [Member]
Business Acquisition [Line Items]
Business acquisition, Legal costs		$ 116,025

Asset Acquisitions - Summary of

Asset Acquisitions - Summary of Asset Acquisitions (Detail) - Anesthesia Services [Member] - USD ($)	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017
Business Acquisition [Line Items]
Consideration	$ 27,509,811	$ 33,376,849
DDAB LLC [Member]
Business Acquisition [Line Items]
Date Acquired		2017-02
Consideration		$ 5,278,940
Osceola Gastroenterology Anesthesia Associates, LLC [Member]
Business Acquisition [Line Items]
Date Acquired		2017-03
Consideration		$ 3,452,247
West Florida Anesthesia Associates, LLC [Member]
Business Acquisition [Line Items]
Date Acquired		2017-08
Consideration		$ 5,904,980
Central Colorado Anesthesia Associates, LLC [Member]
Business Acquisition [Line Items]
Date Acquired		2017-09
Consideration		$ 7,909,243
Raleigh Sedation Associates, LLC & Blue Ridge Sedation Associates, PLLC [Member]
Business Acquisition [Line Items]
Date Acquired		2017-09
Consideration		$ 7,328,060
Alamo Sedation Associates, LLC [Member]
Business Acquisition [Line Items]
Date Acquired		2017-09
Consideration		$ 3,503,379
Shreveport Sedation Associates LLC [Member]
Business Acquisition [Line Items]
Date Acquired	2018-03
Consideration	$ 9,495,184
Western Ohio Sedation Associates LLC [Member]
Business Acquisition [Line Items]
Date Acquired	2018-05
Consideration	$ 6,483,698
Lake Washington Anesthesia LLC [Member]
Business Acquisition [Line Items]
Date Acquired	2018-07
Consideration	$ 5,041,939
Lake Erie Sedation Associates LLC [Member]
Business Acquisition [Line Items]
Date Acquired	2018-09
Consideration	$ 4,233,115
Tennessee Valley Anesthesia LLC [Member]
Business Acquisition [Line Items]
Date Acquired	2018-12
Consideration	$ 2,255,875

Asset Acquisitions - Summary _2

Asset Acquisitions - Summary of Fair Value of Consideration Transferred and Allocated Costs of Assets and Liabilities Acquired at Acquisition Date (Detail) - Anesthesia Services [Member] - USD ($)	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017
Business Acquisition [Line Items]
Cash	$ 27,193,148	$ 31,969,489
Acquisition costs	316,663	223,581
Contingent consideration		1,183,779
Purchase consideration	27,509,811	33,376,849
Non-controlling interest	13,241,061	26,844,528
Fair value of net identifiable assets and liabilities acquired	40,750,872	60,221,377
Assets and liabilities acquired:
Exclusive professional services agreements	40,646,723	60,209,389
Pre-close accounts receivable	652,506	525,000
Pre-close accounts payable	(652,506)	(525,000)
Prepaid expenses and deposits	104,149	11,988
Fair value of net identifiable assets and liabilities acquired	$ 40,750,872	60,221,377
Exclusive professional services agreements - amortization term	0 years
Shreveport Sedation Associates LLC [Member]
Business Acquisition [Line Items]
Cash	$ 9,404,148
Acquisition costs	91,036
Purchase consideration	9,495,184
Fair value of net identifiable assets and liabilities acquired	9,495,184
Assets and liabilities acquired:
Exclusive professional services agreements	9,391,036
Prepaid expenses and deposits	104,149
Fair value of net identifiable assets and liabilities acquired	$ 9,495,185
Exclusive professional services agreements - amortization term	7 years
CRH ownership interest	100.00%
Western Ohio Sedation Associates LLC [Member]
Business Acquisition [Line Items]
Cash	$ 6,409,000
Acquisition costs	74,698
Purchase consideration	6,483,698
Non-controlling interest	6,229,435
Fair value of net identifiable assets and liabilities acquired	12,713,133
Assets and liabilities acquired:
Exclusive professional services agreements	12,713,133
Fair value of net identifiable assets and liabilities acquired	$ 12,713,133
Exclusive professional services agreements - amortization term	10 years
CRH ownership interest	51.00%
Lake Washington Anesthesia LLC [Member]
Business Acquisition [Line Items]
Cash	$ 5,000,000
Acquisition costs	41,939
Purchase consideration	5,041,939
Non-controlling interest	4,844,217
Fair value of net identifiable assets and liabilities acquired	9,886,156
Assets and liabilities acquired:
Exclusive professional services agreements	9,886,155
Pre-close accounts receivable	652,506
Pre-close accounts payable	(652,506)
Fair value of net identifiable assets and liabilities acquired	$ 9,886,155
Exclusive professional services agreements - amortization term	7 years
CRH ownership interest	51.00%
Lake Erie Sedation Associates LLC [Member]
Business Acquisition [Line Items]
Cash	$ 4,180,000
Acquisition costs	53,115
Purchase consideration	4,233,115
Fair value of net identifiable assets and liabilities acquired	4,233,115
Assets and liabilities acquired:
Exclusive professional services agreements	4,233,115
Fair value of net identifiable assets and liabilities acquired	$ 4,233,115
Exclusive professional services agreements - amortization term	10 years
CRH ownership interest	100.00%
Tennessee Valley Anesthesia LLC [Member]
Business Acquisition [Line Items]
Cash	$ 2,200,000
Acquisition costs	55,875
Purchase consideration	2,255,875
Non-controlling interest	2,167,409
Fair value of net identifiable assets and liabilities acquired	4,423,284
Assets and liabilities acquired:
Exclusive professional services agreements	4,423,284
Fair value of net identifiable assets and liabilities acquired	$ 4,423,284
Exclusive professional services agreements - amortization term	7 years
CRH ownership interest	51.00%
DDAB LLC [Member]
Business Acquisition [Line Items]
Cash		4,089,791
Acquisition costs		5,370
Contingent consideration		1,183,779
Purchase consideration		5,278,940
Non-controlling interest		5,071,922
Fair value of net identifiable assets and liabilities acquired		10,350,862
Assets and liabilities acquired:
Exclusive professional services agreements		10,350,862
Pre-close accounts receivable		525,000
Pre-close accounts payable		(525,000)
Fair value of net identifiable assets and liabilities acquired		$ 10,350,862
Exclusive professional services agreements - amortization term		4 years 6 months
CRH ownership interest		51.00%
Osceola Gastroenterology Anesthesia Associates, LLC [Member]
Business Acquisition [Line Items]
Cash		$ 3,401,819
Acquisition costs		50,428
Purchase consideration		3,452,247
Non-controlling interest		2,301,498
Fair value of net identifiable assets and liabilities acquired		5,753,745
Assets and liabilities acquired:
Exclusive professional services agreements		5,753,745
Fair value of net identifiable assets and liabilities acquired		$ 5,753,745
Exclusive professional services agreements - amortization term		5 years
CRH ownership interest		60.00%
West Florida Anesthesia Associates, LLC [Member]
Business Acquisition [Line Items]
Cash		$ 5,840,000
Acquisition costs		64,980
Purchase consideration		5,904,980
Non-controlling interest		4,831,346
Fair value of net identifiable assets and liabilities acquired		10,736,326
Assets and liabilities acquired:
Exclusive professional services agreements		10,724,338
Prepaid expenses and deposits		11,988
Fair value of net identifiable assets and liabilities acquired		$ 10,736,326
Exclusive professional services agreements - amortization term		15 years
CRH ownership interest		55.00%
Central Colorado Anesthesia Associates, LLC [Member]
Business Acquisition [Line Items]
Cash		$ 7,888,919
Acquisition costs		20,324
Purchase consideration		7,909,243
Non-controlling interest		7,599,077
Fair value of net identifiable assets and liabilities acquired		15,508,320
Assets and liabilities acquired:
Exclusive professional services agreements		15,508,320
Fair value of net identifiable assets and liabilities acquired		$ 15,508,320
Exclusive professional services agreements - amortization term		7 years
CRH ownership interest		51.00%
Raleigh Sedation Associates, LLC & Blue Ridge Sedation Associates, PLLC [Member]
Business Acquisition [Line Items]
Cash		$ 7,248,960
Acquisition costs		79,100
Purchase consideration		7,328,060
Non-controlling interest		7,040,685
Fair value of net identifiable assets and liabilities acquired		14,368,745
Assets and liabilities acquired:
Exclusive professional services agreements		14,368,745
Fair value of net identifiable assets and liabilities acquired		$ 14,368,745
Exclusive professional services agreements - amortization term		5 years
CRH ownership interest		51.00%
Alamo Sedation Associates, LLC [Member]
Business Acquisition [Line Items]
Cash		$ 3,500,000
Acquisition costs		3,379
Purchase consideration		3,503,379
Fair value of net identifiable assets and liabilities acquired		3,503,379
Assets and liabilities acquired:
Exclusive professional services agreements		3,503,379
Fair value of net identifiable assets and liabilities acquired		$ 3,503,379
Exclusive professional services agreements - amortization term		7 years
CRH ownership interest		100.00%

Asset acquisitions - Summary _3

Asset acquisitions - Summary of Asset Acquisition Loan Contribution (Detail) - USD ($)	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017
Acquisition Date [Line Items]
Amount outstanding at December 31, 2018	$ 49,000	$ 435,000
Anesthesia Services [Member]
Acquisition Date [Line Items]
CRH member loan	244,800	555,000
Non-controlling interest member loan	235,200	495,000
Amount outstanding at December 31, 2018	100,000
Western Ohio Sedation Associates LLC [Member] | Anesthesia Services [Member]
Acquisition Date [Line Items]
CRH member loan	193,800
Non-controlling interest member loan	186,200
Tennessee Valley Anesthesia LLC [Member] | Anesthesia Services [Member]
Acquisition Date [Line Items]
CRH member loan	51,000
Non-controlling interest member loan	49,000
Amount outstanding at December 31, 2018	$ 100,000
Osceola Gastroenterology Anesthesia Associates, LLC [Member] | Anesthesia Services [Member]
Acquisition Date [Line Items]
CRH member loan		90,000
Non-controlling interest member loan		60,000
West Florida Anesthesia Associates, LLC [Member] | Anesthesia Services [Member]
Acquisition Date [Line Items]
CRH member loan		82,500
Non-controlling interest member loan		67,500
Central Colorado Anesthesia Associates, LLC [Member] | Anesthesia Services [Member]
Acquisition Date [Line Items]
CRH member loan		178,500
Non-controlling interest member loan		171,500
Raleigh Sedation Associates, LLC & Blue Ridge Sedation Associates, PLLC [Member] | Anesthesia Services [Member]
Acquisition Date [Line Items]
CRH member loan		204,000
Non-controlling interest member loan		$ 196,000

Asset Acquisitions - Addition_2

Asset Acquisitions - Additional Information - 2017 Acquisitions (Detail)	Mar. 31, 2017USD ($)	Dec. 31, 2018Acquisition	Dec. 31, 2017Acquisition
Business Acquisition [Line Items]
Number of asset acquisitions completed | Acquisition		5	6
DDAB LLC [Member] | Anesthesia Services [Member]
Business Acquisition [Line Items]
Working capital advance | $	$ 71,819

Trade and Other Receivables - S

Trade and Other Receivables - Summary of Trade Receivables and Other Receivable (Detail) - USD ($)	Dec. 31, 2018	Dec. 31, 2017
Balance Sheet Related Disclosures [Line Items]
Accounts receivables	$ 19,373,260	$ 15,325,553
Other receivables	141,141	260,759
Less: allowance for doubtful accounts	(46,598)	(100,000)
Receivables net current	19,467,803	15,486,312
Anesthesia Services [Member]
Balance Sheet Related Disclosures [Line Items]
Accounts receivables	18,199,847	13,405,303
Product Sales [Member]
Balance Sheet Related Disclosures [Line Items]
Accounts receivables	$ 1,173,413	$ 1,920,250

Trade and Other Payables - Summ

Trade and Other Payables - Summary of Trade and Other Payables (Detail) - USD ($)	Dec. 31, 2018	Dec. 31, 2017
Debt Instruments [Abstract]
Trade payables	$ 1,316,821	$ 2,042,487
Payments due to former owners of acquired entities		76,403
Accruals and other payables	4,446,401	3,542,954
Total	$ 5,763,222	$ 5,661,844

Property and Equipment - Summar

Property and Equipment - Summary of Property and Equipment (Detail) - USD ($)	Dec. 31, 2018	Dec. 31, 2017
Property, Plant and Equipment [Line Items]
Property and equipment, Gross	$ 746,028	$ 710,922
Less: Accumulated depreciation	(442,737)	(346,556)
Property and equipment, net	303,291	364,366
Computer Equipment and Software [Member]
Property, Plant and Equipment [Line Items]
Property and equipment, Gross	94,566	82,055
Furniture and Equipment [Member]
Property, Plant and Equipment [Line Items]
Property and equipment, Gross	237,616	215,021
Leasehold Improvements [Member]
Property, Plant and Equipment [Line Items]
Property and equipment, Gross	5,784	5,784
Injection Mold [Member]
Property, Plant and Equipment [Line Items]
Property and equipment, Gross	$ 408,062	$ 408,062

Intangible Assets - Summary of

Intangible Assets - Summary of Intangible Assets (Detail) - USD ($)	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017
Finite-Lived Intangible Assets [Line Items]
Beginning balance	$ 216,377,135	$ 156,167,746
Additions through asset acquisitions (note 4)	40,646,723	60,209,389
Ending balance	257,023,858	216,377,135
Beginning balance	46,249,720	22,500,435
Amortization expense	31,389,875	23,749,285
Ending balance	77,639,595	46,249,720
Net balance	179,384,263	170,127,415
Professional Services Agreements [Member]
Finite-Lived Intangible Assets [Line Items]
Beginning balance	215,844,537	155,635,148
Additions through asset acquisitions (note 4)	40,646,723	60,209,389
Ending balance	256,491,260	215,844,537
Beginning balance	45,752,303	21,999,771
Amortization expense	31,387,429	23,752,532
Ending balance	77,139,732	45,752,303
Net balance	179,351,528	170,092,234
Patents [Member]
Finite-Lived Intangible Assets [Line Items]
Beginning balance	532,598	532,598
Ending balance	532,598	532,598
Beginning balance	497,417	500,664
Amortization expense	2,446	(3,247)
Ending balance	499,863	497,417
Net balance	$ 32,735	$ 35,181

Intangible Assets - Additional

Intangible Assets - Additional Information (Detail)	12 Months Ended
	Dec. 31, 2018USD ($)Services	Dec. 31, 2017Services
Intangible Assets, Net (Excluding Goodwill) [Abstract]
Number of professional services agreements identified with impairment indicators	4	2
Number of professional services agreements identified for impairment upon undiscounted cash flow models	2
Renewal term of professional services agreements	4 years
Impairment of Intangible Assets | $	$ 0
Weighted average amortization period	6 years 2 months 23 days

Intangible Assets - Summary o_2

Intangible Assets - Summary of Amortization Expense to be Incurred by Company Over Next Five Years (Detail) - Professional Services Agreements [Member]	Dec. 31, 2018USD ($)
Finite Lived Intangible Assets, Future Amortization Expense [Line Items]
2019	$ 33,674,000
2020	33,593,000
2021	28,287,000
2022	21,565,000
2023	17,419,000
Amortization Expense	$ 134,538,000

Notes Payable - Summary Of Note

Notes Payable - Summary Of Notes Payable (Detail) - USD ($)	Dec. 31, 2018	Dec. 31, 2017
Notes Payable [Line Items]
Total loans and borrowings	$ 70,250,000
Scotia Facility [Member]
Notes Payable [Line Items]
Current portion	2,239,637	$ 989,637
Non-current portion	67,621,470	60,061,105
Total loans and borrowings	$ 69,861,107	$ 61,050,742

Notes Payable - Additional Info

Notes Payable - Additional Information (Detail) - Scotia Facility [Member] - USD ($)	Jun. 26, 2017	Nov. 24, 2015	Dec. 31, 2018	Dec. 31, 2017	Jun. 15, 2016
Notes Payable [Line Items]
Credit facility maturity date	Jun. 26, 2020	Apr. 30, 2018
Credit facility maximum borrowing capacity	$ 100,000,000				$ 55,000,000
Amendment fees incurred	$ 445,598
Credit facility drawn amount			$ 70,250,000	$ 61,700,000
Borrowings, adjustment to interest rate basis			2.50%
Borrowing interest rate			LIBOR plus 2.50%
Increase decrease in borrowing capacity			$ 0
Deferred or new financing fees			$ 0

Notes Payable - Summary of Deta

Notes Payable - Summary of Detailed Information about Financial Covenants Ratios (Detail)	12 Months Ended
	Dec. 31, 2018
Debt Disclosure [Abstract]
Total funded debt ratio	2.50
Fixed charge coverage ratio	1.15

Notes Payable - Summary Of Cons

Notes Payable - Summary Of Consolidated Minimum Loan Payments (Detail)	Dec. 31, 2018USD ($)
Debt Disclosure [Abstract]
2019	$ 2,500,000
2020	67,750,000
Total loans and borrowings	$ 70,250,000

Share Capital - Additional Info

Share Capital - Additional Information (Detail)	Jan. 04, 2019shares	Jan. 05, 2018shares	Nov. 08, 2017shares	Dec. 31, 2018USD ($)$ / sharesshares	Dec. 31, 2018CAD ($)$ / sharesshares	Dec. 31, 2017USD ($)$ / sharesshares	Dec. 31, 2017CAD ($)$ / sharesshares
Schedule Of Employee Service Share Based Compensation Expense Allocation [Line Items]
Number of shares authorized				100,000,000	100,000,000
Stock option description				All options under the Plan will be subject to vesting provisions determined by the Board of Directors, over a period of not less than 18 months, in equal portions on a quarterly basis. Options granted to consultants providing investor relations activities will vest at the end of 12 months or longer from the date of issuance.	All options under the Plan will be subject to vesting provisions determined by the Board of Directors, over a period of not less than 18 months, in equal portions on a quarterly basis. Options granted to consultants providing investor relations activities will vest at the end of 12 months or longer from the date of issuance.
Share based payment awards issued				0	0	0	0
Number of other equity instruments issued						292,549	292,549
Share-based compensation expense | $				$ 468		$ 22,179
Compensation expense related to granting and vesting of share unit | $				$ 2,800,280		$ 4,013,891
Shares approved in normal course issuer bid			7,044,410
Maximum percentage of shares approved in normal course issuer bid			10.00%
Maximum daily repurchase in normal course issuer bid			46,958
Repurchase of shares				1,264,900	1,264,900	1,339,800	1,339,800
Total cost, including transaction fee				$ 3,784,733	$ 4,945,155	$ 2,872,713	$ 3,669,120
Repurchased shares canceled	10,400	72,400		72,400	72,400	1,267,400	1,267,400
Shares repurchased in connection with normal course issuer bid and cancelled, shares				1,254,500	1,254,500
Restricted Stock Units (RSUs) [Member]
Schedule Of Employee Service Share Based Compensation Expense Allocation [Line Items]
Share based payment awards, authorized to grant				1,057,534	1,057,534
Employee Stock Option [Member]
Schedule Of Employee Service Share Based Compensation Expense Allocation [Line Items]
Share based payment awards issued				0	0
Number of shares authorized to grant				2,258,097	2,258,097
Number of other equity instruments issued						1,198,495	1,198,495
Share-based compensation arrangement by share-based payment award, options, vested in period, fair value | $						$ 147,730
Number of other equity instruments vested						1,272,812	1,272,812
Share options [Member]
Schedule Of Employee Service Share Based Compensation Expense Allocation [Line Items]
Shares excluded from diluted weighted average number of common shares calculation				221,979	221,979	539,624	539,624
Share units [Member]
Schedule Of Employee Service Share Based Compensation Expense Allocation [Line Items]
Shares excluded from diluted weighted average number of common shares calculation				2,095,260	2,095,260	2,094,363	2,094,363
Time Based Restricted Share Unit [Member]
Schedule Of Employee Service Share Based Compensation Expense Allocation [Line Items]
Number of other equity instruments issued				364,000	364,000	324,000	324,000
Number of other equity instruments vested				364,000	364,000	302,000	302,000
Weighted average exercise price of other equity instruments issued | (per share)						$ 3.31	$ 4.16
Time Based Restricted Share Unit [Member] | Additional Share Unit Issuance [Member]
Schedule Of Employee Service Share Based Compensation Expense Allocation [Line Items]
Number of other equity instruments issued				452,125	452,125
Weighted average exercise price of other equity instruments issued | (per share)				$ 3.45	$ 4.71
Performance Based Restricted Stock Units [Member] | Additional Share Unit Issuance [Member]
Schedule Of Employee Service Share Based Compensation Expense Allocation [Line Items]
Number of other equity instruments issued				150,000	150,000
Weighted average exercise price of other equity instruments issued | (per share)				$ 2.78	$ 3.79

Share Capital - Summary of Stoc

Share Capital - Summary of Stock Option Activity (Detail)	12 Months Ended
	Dec. 31, 2018$ / sharesshares	Dec. 31, 2018$ / sharesshares	Dec. 31, 2017$ / sharesshares	Dec. 31, 2017$ / sharesshares
Disclosure of Compensation Related Costs, Share-based Payments [Abstract]
Number of options, Beginning balance	1,344,687	1,344,687	1,603,124	1,603,124
Issued	0	0	0	0
Exercised			(247,500)	(247,500)
Forfeited			(10,937)	(10,937)
Expired	0	0	0	0
Number of options, Ending balance	1,344,687	1,344,687	1,344,687	1,344,687
Weighted average exercise price, Beginning balance | (per share)	$ 0.69	$ 0.55	$ 0.63	$ 0.47
Weighted average exercise price, Issued | (per share)	0	0	0	0
Weighted average exercise price, Exercised | (per share)			0.32	0.25
Weighted average exercise price, Forfeited | (per share)			0.60	0.48
Weighted average exercise price, Expired | (per share)	0	0	0	0
Weighted average exercise price, Ending balance | (per share)	$ 0.69	$ 0.50	$ 0.69	$ 0.55

Share Capital - Schedule Of Inf

Share Capital - Schedule Of Information With Respect To Stock Options Outstanding And Exercisable (Detail) - Exercise Price Range One [Member]	12 Months Ended
	Dec. 31, 2018$ / shares$ / sharesshares	Dec. 31, 2017$ / sharesshares	Dec. 31, 2017$ / shares$ / sharesshares	Dec. 31, 2018$ / sharesshares	Dec. 31, 2017$ / sharesshares
Compensation Related Costs Share Based Payments Disclosure [Line Items]
Exercise price | (per share)	$ 0.44	$ 0.60	$ 0.48
Exercise price | (per share)	$ 0.51	$ 0.70	$ 0.56
Number of options	1,344,687	1,344,687	1,344,687	1,344,687	1,344,687
Options outstanding Weighted average remaining contractual life (years)	5 years 18 days	6 years 18 days	6 years 18 days
Options outstanding Weighted average exercise price ($CAD) | (per share)	$ 0.69	$ 0.69	$ 0.69	$ 0.50	$ 0.55
Number of options	1,344,687	1,272,812	1,272,812	1,344,687	1,272,812
Options exercisable Weighted average exercise price ($CAD) | (per share)	$ 0.69	$ 0.68	$ 0.68	$ 0.50	$ 0.54

Share Capital - Summary of Stat

Share Capital - Summary of Status of Plan for Other Equity Instruments (Detail) - shares	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017
Time Based Share [Member]
Compensation Related Costs Share Based Payments Disclosure [Line Items]
Beginning balance	1,036,500	1,068,000
Issued	452,125	324,000
Exercised	(364,000)	(302,000)
Forfeited	(79,375)	(53,500)
Expired	0	0
Ending balance	1,045,250	1,036,500
Vested	0	0
Expected to vest	1,045,250
Expected to vest		1,036,500
Weighted average contractual life (years)	2 years 8 months 26 days	2 years 11 months 15 days
Performance Based Share [Member]
Compensation Related Costs Share Based Payments Disclosure [Line Items]
Beginning balance	1,350,000	2,350,000
Issued	150,000
Exercised		(1,000,000)
Expired	0	0
Ending balance	1,500,000	1,350,000
Vested	0	0
Expected to vest	1,100,000
Expected to vest		1,100,000
Weighted average contractual life (years)	7 years 11 months 26 days	8 years 10 months 9 days

Share Capital - Summary of Calc

Share Capital - Summary of Calculation of Basic Earnings Per Share (Detail) - USD ($)	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017
Earnings Per Share, Basic, by Common Class, Including Two Class Method [Line Items]
Basic	$ 4,679,921	$ 12,078,853
Diluted	$ 4,679,921	$ 12,078,853
Shares	72,582,733	73,712,670
Diluted	74,085,172	75,056,003
Basic	$ 0.064	$ 0.164
Diluted	$ 0.063	$ 0.161
Share options [Member]
Earnings Per Share, Basic, by Common Class, Including Two Class Method [Line Items]
Shares	1,122,708	925,286
Share units [Member]
Earnings Per Share, Basic, by Common Class, Including Two Class Method [Line Items]
Shares	379,731	418,047

Income Taxes - Summary of Incom

Income Taxes - Summary of Income Tax Expense (Recovery) (Detail) - USD ($)	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017
Income Tax Disclosure [Line Items]
Current tax expense	$ 5,119,062	$ 4,403,358
Deferred tax expense (recovery):	(2,407,176)	2,755,707
Total tax expense (recovery)	2,711,886	7,159,065
Net income before tax - All jurisdictions	15,727,803	26,334,135
Tax expense at statutory income tax rates	4,259,890	6,060,003
Permanent differences	503,964	(513,050)
Income attributable to non-controlling interest	(2,245,809)	(1,571,060)
Foreign income taxed at different rates	(26,042)	1,458,302
Impact of change in tax rates	216,295	1,767,124
Other	3,588	(42,254)
Total tax expense (recovery)	2,711,886	7,159,065
Canada [Member]
Income Tax Disclosure [Line Items]
Net income before tax - All jurisdictions	5,957,089	10,239,231
UNITED STATES
Income Tax Disclosure [Line Items]
Net income before tax - All jurisdictions	$ 9,770,714	$ 16,094,904

Income Taxes - Additional Infor

Income Taxes - Additional Information (Detail) - USD ($)	Jan. 01, 2018	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Income Tax Disclosure [Line Items]
Company's statutory tax rate	21.00%	27.00%	23.00%
unrecognized tax benefits		$ 0	$ 0
Unrecognized tax benefits		$ 0
Canada [Member]
Income Tax Disclosure [Line Items]
Company's statutory tax rate		27.00%	26.00%	23.00%
Company's provincial rate		1.00%

Income Taxes - Summary of Defer

Income Taxes - Summary of Deferred Tax Assets and Liabilities (Detail) - USD ($)	Dec. 31, 2018	Dec. 31, 2017
Deferred tax assets:
Property and equipment	$ 356	$ 3,501
Intangible assets	4,752,898	2,448,322
Finance related costs	375,182	472,428
Reserves		34,048
Share transaction costs	87,337	196,508
Stock-based compensation	534,926	410,448
Earn-out obligation	732,986	499,052
Deferred tax liabilities:
Property and equipment	(40,357)	(3,396)
Deferred consideration	(18,388)	(44,255)
Reserves	(55,568)	(41,205)
Unrealized foreign exchange	(20,698)
Finance related costs	(68,938)	(173,193)
Net deferred tax asset	6,279,736	3,802,258
Net deferred tax asset	6,279,736	3,802,258
Canada [Member]
Deferred tax assets:
Deferred tax asset	87,343	200,009
Deferred tax liabilities:
Net deferred tax asset		26,815
Deferred tax liability	(109,294)	(173,194)
Net deferred tax liability	(21,951)
Net deferred tax asset		26,815
UNITED STATES
Deferred tax assets:
Deferred tax asset	6,396,340	3,864,298
Deferred tax liabilities:
Net deferred tax asset	6,301,687	3,775,443
Deferred tax liability	(94,654)	(88,855)
Net deferred tax asset	$ 6,301,687	$ 3,775,443

Net Finance Expense - Summary o

Net Finance Expense - Summary of Net Finance Expense (Detail) - USD ($)	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017
Finance income:
Foreign exchange gain	$ 0	$ 0
Net change in fair value of financial liabilities at fair value through earnings (note 13)		(11,825,256)
Total finance income		(11,825,256)
Finance expense:
Interest and accretion expense on borrowings	3,168,762	3,322,321
Accretion expense on earn-out obligation and deferred consideration	166,575	600,602
Amortization of deferred financing fees	260,363	204,057
Net change in fair value of financial liabilities at fair value through earnings	971,627
Foreign exchange loss		88,084
Extinguishment of notes payable and bank indebtedness		2,044,867
Other		50,475
Total finance expense	4,567,327	6,310,406
Net finance (income) expense	$ 4,567,327	$ (5,514,850)

Financial Instruments - Schedul

Financial Instruments - Schedule of Fair Value of Financial Instruments (Detail) - USD ($)	Dec. 31, 2018	Dec. 31, 2017
Fair Value Assets Measured On Recurring and Nonrecurring Basis [Line Items]
Total Liabilities	$ 2,920,583	$ 1,875,427
Earn-out obligation [Member]
Fair Value Assets Measured On Recurring and Nonrecurring Basis [Line Items]
Total Liabilities	2,920,583	1,875,427
Fair Value, Inputs, Level 3 [Member]
Fair Value Assets Measured On Recurring and Nonrecurring Basis [Line Items]
Total Liabilities	2,920,583	1,875,427
Fair Value, Inputs, Level 3 [Member] | Earn-out obligation [Member]
Fair Value Assets Measured On Recurring and Nonrecurring Basis [Line Items]
Total Liabilities	$ 2,920,583	$ 1,875,427

Financial Instruments - Additio

Financial Instruments - Additional Information (Detail) - USD ($)	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017
Fair Value, Inputs, Level 3 [Member]
Financial Instruments [Line Items]
Increase (decrease) in fair value of earn-out obligation	$ 971,627
Accretion expense related to earn-out obligation	73,529
10% Point Increase in Interest Rate [Member] | Interest Rate Risk [Member]
Financial Instruments [Line Items]
Increase (decrease) in net income	(295,000)	$ (164,000)
10% Point Decrease in Interest Rate [Member] | Interest Rate Risk [Member]
Financial Instruments [Line Items]
Increase (decrease) in net income	$ 295,000	164,000
Fair Value, Measurements, Recurring [Member] | Fair Value, Inputs, Level 3 [Member]
Financial Instruments [Line Items]
Discount rate	1.00%
Increase (decrease) in fair value of earn-out obligation	$ 13,870
Accretion expense related to earn-out obligation	73,531	$ 473,738
Fair Value, Measurements, Recurring [Member] | Fair Value, Inputs, Level 3 [Member] | Measurement Input, Discount Rate [Member]
Financial Instruments [Line Items]
Increase (decrease) in fair value of earn-out obligation	$ 971,625
Fair Value, Measurements, Recurring [Member] | Minimum [Member] | Fair Value, Inputs, Level 3 [Member] | Measurement Input, Discount Rate [Member]
Financial Instruments [Line Items]
Discount rate		3.59%
Fair Value, Measurements, Recurring [Member] | Maximum [Member] | Fair Value, Inputs, Level 3 [Member] | Measurement Input, Discount Rate [Member]
Financial Instruments [Line Items]
Discount rate	4.69%

Financial Instruments - Summary

Financial Instruments - Summary of Reconciliation of Level 3 Fair Values (Detail) - Fair Value, Inputs, Level 3 [Member]	12 Months Ended
	Dec. 31, 2018USD ($)
Fair Value, Liabilities Measured on Recurring Basis, Unobservable Input Reconciliation [Line Items]
Beginning balance	$ 1,875,427
Payment	0
Accretion expense	73,529
Fair value adjustment	971,627
Ending balance	$ 2,920,583

Commitments and Contingencies -

Commitments and Contingencies - Summary of Minimum Payments Required for the Lease of Premises (Detail)	Dec. 31, 2018USD ($)
Commitments and Contingencies Disclosure [Abstract]
Less than one year	$ 364,068
One to three years	229,764
Four to five years	0
Thereafter	0
Total	$ 593,832

Commitments and Contingencies_2

Commitments and Contingencies - Additional Information (Detail) - USD ($)	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017
Commitments and Contingencies Disclosure [Abstract]
Rental expense	$ 227,743	$ 236,455

Related Party Transactions - Ad

Related Party Transactions - Additional Information (Detail) - USD ($)	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017
Related Party Transaction [Abstract]
Product sales	$ 29,685	$ 39,485
Amounts owing by or to related party	$ 0	$ 0

Segmented Information - Additio

Segmented Information - Additional information (Detail)	12 Months Ended
	Dec. 31, 2018Segment
Segment Reporting [Abstract]
Number of segments	2

Segmented Information - Summary

Segmented Information - Summary of Revenues Relating to Geographic Segments (Detail) - USD ($)	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 112,749,380	$ 95,006,145
Canada and Other [Member]
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	271,803	238,342
UNITED STATES
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 112,477,577	$ 94,767,803

Segmented Information - Summa_2

Segmented Information - Summary of Revenue from Contract with Customer (Detail) - USD ($)	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017
Disaggregation of Revenue [Line Items]
Revenue	$ 112,749,380	$ 95,006,145
Commercial Insurers [Member]
Disaggregation of Revenue [Line Items]
Revenue	86,992,218	72,264,107
Federal Insurers [Member]
Disaggregation of Revenue [Line Items]
Revenue	14,246,626	10,568,096
Physicians [Member]
Disaggregation of Revenue [Line Items]
Revenue	10,959,215	11,501,005
Other [Member]
Disaggregation of Revenue [Line Items]
Revenue	$ 551,321	$ 672,937

Segmented Information - Summa_3

Segmented Information - Summary of Property and Equipment, Intangibles and Other Assets Located in Geographic Regions (Detail) - USD ($)	Dec. 31, 2018	Dec. 31, 2017
Segment Reporting, Asset Reconciling Item [Line Items]
Property and equipment	$ 303,291	$ 364,366
Intangible assets	179,384,263	170,127,415
Total assets	218,987,996	203,955,505
UNITED STATES
Segment Reporting, Asset Reconciling Item [Line Items]
Property and equipment	26,670	16,690
Intangible assets	179,351,528	170,092,234
Total assets	209,694,200	199,359,786
Canada [Member]
Segment Reporting, Asset Reconciling Item [Line Items]
Property and equipment	276,621	347,676
Intangible assets	32,735	35,181
Total assets	$ 9,293,796	$ 4,595,719

Segmented Information - Summa_4

Segmented Information - Summary of Operating Segments (Detail) - USD ($)	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017
Segment Reporting Information [Line Items]
Revenue	$ 112,749,380	$ 95,006,145
Operating costs	92,454,250	74,186,860
Operating income (loss)	20,295,130	20,819,285
Finance income		(11,825,256)
Finance expense	4,567,327	6,310,406
Depreciation and amortization expense	31,486,055	23,834,400
Anesthesia Services [Member]
Segment Reporting Information [Line Items]
Revenue	101,790,165	83,505,140
Operating costs	81,079,150	62,135,447
Operating income (loss)	20,711,015	21,369,693
Finance income		(11,825,256)
Finance expense	1,138,200	600,602
Depreciation and amortization expense	31,394,245	23,762,012
Product Sales [Member]
Segment Reporting Information [Line Items]
Revenue	10,959,215	11,501,005
Operating costs	5,022,737	4,997,550
Operating income (loss)	5,936,478	6,503,455
Depreciation and amortization expense	68,509	56,907
Other [Member]
Segment Reporting Information [Line Items]
Operating costs	6,352,363	7,053,863
Operating income (loss)	(6,352,363)	(7,053,863)
Finance expense	3,429,127	5,709,804
Depreciation and amortization expense	$ 23,301	$ 15,481

Subsequent Event - Additional I

Subsequent Event - Additional Information (Detail) - USD ($)	Jan. 01, 2019	Dec. 31, 2018	Dec. 31, 2017
Subsequent Event [Line Items]
Deferred acquisition costs		$ 116,025
Anesthesia Services [Member]
Subsequent Event [Line Items]
Exclusive professional services agreements		$ 40,646,723	$ 60,209,389
Subsequent Event [Member] | Anesthesia Services [Member] | Anesthesia Care Associates, LLC [Member]
Subsequent Event [Line Items]
Ownership interest acquired	100.00%
Total cash consideration	$ 5,239,003
Deferred acquisition costs	116,025
Exclusive professional services agreements	$ 5,355,028