Monthly Archives: June 2017

The “Big Squeeze” on hospital budgets in Ontario: Get ready for the backlash

 

Since shortly after the 2008-2009 downturn, Ontario’s relatively modest economic growth has meant for public services a prolonged period of austerity. For the healthcare sector, where annual growth had previously been in the 6.5% range, the change from the base of 2010-11 to 2.6% per annum, representing a slight decline in real per capita terms, has been painful. This reduction in spending growth has been largely borne by the hospital sector, where after contracted salary increases, inflation, etc., are factored in, there has been essentially zero growth for nearly a decade. Continued restraint in health spending, which now exceeds 40% of the total, anchors the government’s 2017/18 balanced budget projection.

At the same time, the much discussed demographic shift has started. The Baby Boomers are starting to retire: the number of Canadians over the age of 65 will double in 20 years and those over 85 will quadruple. While this is surely a reason to celebrate, it also presents daunting challenges. How do we transform our acute, episodic illness focused, hospital dominated “system” into one that also accommodates to the new health care landscape filled by people with multiple, complex, chronic diseases who need, want, and should have care in their own homes and communities?

The solution, so the thinking has been, would be for us to invest more in chronic care and community-based solutions rather than in hospital care. The new care model would be more appropriate for the chronic disease paradigm, closer to home, more team-based, and cheaper. Meanwhile, hospitals would be freed up to do what they are supposed to be doing – looking after acutely ill people – rather than being overfilled with patients waiting for home and long term care. Squeezing hospital budgets will force efficiency, and we can invest proportionally more in the community resources that patients increasingly need.

So how is it turning out?

Hospitals have certainly been squeezed. Effectively flat budgets have forced some efficiencies, like some decreases in lengths of stay (despite increasing complexity of patients) and some limited improvement in wait times for targeted surgical procedures. But in broad strokes, what has happened (very simply) are hospital program cuts; real reform continues to be frustrated by the “system’s” siloism and the agonizing slowness in expanding the capacity of home and community care to relieve hospitals of ALC patients[1] and of primary care to provide care for patients 24/7. Meanwhile, the volume of patients presenting to hospital increases unabated. Emergency Departments and hospitals are more congested than ever, alternate-level-of-care (ALC) patient numbers are at an all-time high, and occupancy rates hovering around 100% (and often higher) have made “Code Gridlock” (a term used to describe the inability to move patients through the system because of congestion) a daily rather than an occasional reality. Hospital leadership teams are increasingly consumed with just getting through the day – managing patient flow – rather than having time to think strategically about reform. And so, hospitals find themselves in a position where they can’t control their inputs, can’t control their outputs, and cannot make investments outside their walls in order to influence either.

There has been some progress. The HealthLinks initiative, which aims to deliver better, more efficient care to the sickest 5% of our population, is a good example. Despite all the hype, the recent re-jigging of Community Care Access Centre (CCAC) services into a LHIN-controlled model promises no meaningful impact. No home and community care initiative is making enough of an impact to slow the relentless increase in demand for hospital services. Those in charge of and working in Ontario’s hospitals are well aware that the Ontario Government is determined to keep healthcare spending in line with economic growth and avoid a repeat of the mid-1990s when a period of austerity was followed by a catch-up spending boom . But hospitals are in crisis. They have deferred significant capital spending. They have squeezed all the efficiency they can out of their operations. Health professionals and hospital leaders are exhausted. And the demographic tsunami has only begun. Genuine reform of the healthcare “system” has to get in gear very soon because a backlash is imminent.

If patients keep coming in increasing numbers and nothing is done about their ALC patients, hospitals will need a significant cash infusion very soon. As the congestion continues to worsen, any efficiency gains that have been made will be threatened. It is crucial that new investments be targeted at “anti-gridlock” initiatives. The creation of a “pull” culture (where patients are actively moved along to the next point in their care trajectory) to replace the current “push” culture, together with a funding model whereby money follows the patient wherever they are in the system would help. Running hospitals at full capacity on the weekends, as we do during the week, would also make a big difference. Enhanced regionalization would help to knit the silos closer together. And getting community-based and hospital-based teams together to better manage the transition points in patient care is absolutely essential. It is at the transition points where mistakes are made, negative perceptions are born, and inefficiencies are generated.

There is no doubt that we need to “de-hospitalize” our system to a significant degree. But it is clear that crude budget cutting has not accomplished the reform we need. Hospitals have been squeezed, but the transition to a community-based health system remains in its very early days. These years of squeezing the sponge have bought us time, not change. And now we are out of time.

[1] https://www.google.ca/search?q=Walker+report%2COntario+ALC&oq=Walker+report%2COntario+ALC&aqs=chrome..69i57.14513j0j7&sourceid=chrome&ie=UTF-8


Authored by members of the Queen’s Health Policy Council:

Don Drummond
Chris Simpson
Duncan G. Sinclair
David Walker
Ruth Wilson

Do-Able Actions to Improve Co-ordination of Healthcare

 

That fundamental reform of healthcare throughout Canada is required has been increasingly obvious for at least two decades, long enough for five full-term governments and a whole generation of health professionals to do something about it. There have been some changes. Healthcare’s governance has been partially devolved to some provincial regions and elsewhere de- and re-centralized without conclusions drawn about the most effective model to achieve change. Teamwork in primary care has been fostered through a wide variety of programs but no evidence has appeared as yet strong enough to trigger policy decisions to drive widespread adoption of multi-professional teams as the best way to provide Canadians with 24/7 primary, home, and community care. Mental health and addiction have finally appeared on the radar but remain far from optimally linked into what is glibly referred to as “the system”. The latter continues to lack coordination, collaboration, or even effective communication among its elements; “siloism” lives on. The collection, distribution, and management of clinical and health information remains barely out of the starting gate as banking and many other sectors continue to pull away, reaping the potential of the digital (new industrial) revolution. Canada is teased as the home of pilot projects that never get scaled up or adopted. National and provincial reports on healthcare’s reform abound. What’s lacking is action.

It is clear that short of the country’s having a severe and prolonged crisis, our governments are not soon going to grasp the nettle of making fundamental changes to Medicare, setting up arms-length governance for “the system”, national or provincial/territorial, or making e-health a reality. But change we must, and now. What can be done?

Two do-able actions are propitious.

The first is for institutional “players” in the regions into which provinces and territories naturally divide – hospitals, primary care, long-term care, mental health, community services, etc. – to get together and devise ways of working together; in short to create regional systems of healthcare. Regional health authorities (RHAs) (Ontario’s LHINs) might be able to help support such experiments in system-building, perhaps with some funds but at the least with advisory bodies structured to provide for an appropriately mixed membership of experienced providers of healthcare services and community leaders with patient and population perspectives. But new models of working together could be planned and at least partially executed with or without any supportive action. The only imperative of those proposing local/regional system-building is that every proposal have a robust and practical plan to evaluate, in short order, the results measured in financial, clinical outcome, and patient and family satisfaction terms. Sometime down the road that evidence will be useful.

The second is for health professionals – family physicians, specialists, nurse-practitioners, nurses, physio- and occupational therapists, home care providers, etc. – region by region, to seize the initiative to form coordinating bodies to identify the issues that constitute barriers to the ready transfer of patient responsibilities among them and ways to reduce or eliminate them. This too could be done under the aegis of a RHA/LHIN but here too such quasi-governmental sponsorship need not be necessary. A region’s health professionals could do this all on their own.

These two actions would foster regional experimentation on how, within the limits of existing central policy, to improve and enhance the communication and coordination among the elements of a healthcare system. An equally important objective would be to improve patient and family satisfaction with the services provided, their outcomes, and if not save money at least achieve qualitative improvements for no additional cost.

Local and regional experimentation of this kind is now inhibited by the deadening effect of central governments’ (and too-often RHA/LHIN’s) top-down bureaucratic control of virtually every initiative and action within the so-called system. The potential of such experimentation is cut short by a sort of one-size-fits-all mentality probably derived from governmental fear that any variability in outcomes will put the political imperative of inclusivity in jeopardy. Every element in “the system” is heavily stressed after many years of budgetary stringency; providers are jaded by incessant demands for consultation on every operational aspect that too-often leads nowhere except to the expenditure of time fruitlessly away from the bedside.

What’s to be done? Enable local/regional experimentation by providers and consumers on how to build among them the foundation of an effective and real health/healthcare system.


Authored by members of the Queen’s Health Policy Council:

Don Drummond
Chris Simpson
Duncan G. Sinclair
David Walker
Ruth Wilson

Are the Health Professions Self-Regulators Doing Their Jobs?

 

Professional self-regulation is anchored on the principle that professionals can be depended upon to protect the public by putting ahead of their own the well-being of those they serve. It is extended to the health and other professions to avoid governments having to retain the substantial knowledge and expertise necessary to regulate directly those conducting sophisticated professional activities. Self-regulation is a privilege delegated to the health professions by governments respectfully confident that it will be discharged faithfully in the public interest.

That confidence, at least in the medical profession, has been shaken recently by the increasing incidence of addiction and deaths attributable to opioid over-prescribing and of charging patients willing to pay for preferential access to some diagnostic and other procedures, a direct contravention of the Canada Health Act. Yet, strangely, the general tenor of discussion tends to look to Canada’s provincial and federal governments to do something to rectify these clearly medical/surgical issues rather than to the Colleges of Physicians and Surgeons that hold the power of self-regulation in each province. Is the confidence of governments in the self-regulating professions misplaced? Is it the interest of the profession itself that is being protected rather than the public interest? Is it that the self-regulating bodies are placing too much of their confidence in the professional integrity of their members and need to increase their investment in and tighten up their regulatory processes? Or is it that the self-regulators are benignly ignorant of what is really going on in the professional practices they are supposed to be regulating? Important questions of this type need to be answered, and soon!

The principle of professional self-regulation is worthy of preservation. On it rests the confidence of the general public that each health professional, whether physician, surgeon, nurse, physiotherapist, dentist, or whatever, will keep the welfare of his or her patients top of mind at all times. On it rests also the confidence of the democratically elected governments formally charged with protecting the public interest. Once lost, professional practice would quickly become just like every other commercial activity in which the public interest is protected by a combination of the heavy hand of direct regulation by governments and the principle of caveat emptor.

The confidence of governments and the public in the efficacy of self-regulation of the medical profession (and perhaps of other health professionals) has been badly shaken. Its rebuilding is urgently required.


Authored by members of the Queen’s Health Policy Council:

Don Drummond
Chris Simpson
Duncan G. Sinclair
David Walker
Ruth Wilson

Governing the Primary Healthcare Home

 

If healthcare is to be “people-centered”, as it must be, every Canadian will have to have a primary healthcare home, a place where s/he is known and can confidently seek help with problems large and small that bear on his or her health, broadly defined. It doesn’t take much imagination to generate an image of such a home. Take the old-fashioned family physician’s office, add a number of others so its services cover a broader spectrum and are available 24/7 – more physicians, some nurse practitioners, nurses, home care providers, a pharmacist, physio- and occupational therapist or two, a dietitian, psychologist, social worker, and some office staff – and you have it. The family health teams that have been developing both spontaneously and with government support since the dawn of the 21st century form a pretty good nucleus. Community Health Centres (CHCs) have been in place longer and are all but there, particularly in relation to their governance/leadership by Boards of Directors drawn from the populations they serve.

Hospitals, another provider of public healthcare services, have been led by community Boards for many years; they still are in some Provinces. In others their governance is by publicly appointed Regional Health Authorities. The prime function of governance is to ensure that the organization operates in accordance with a clearly defined set of values toward the achievement of a specified mission and within the framework of an agreed-upon strategic plan. But it is also a fundamental principle that the organization concerned should be intimately connected to the community it serves, that it is kept aware of the community’s or region’s particular cultural characteristics and needs, and, most importantly, has through the members of its Board of Directors, a ready channel of person-to-person, non-bureaucratic communication with patients, families, and the community as a whole. The goal of making healthcare services people-centered requires many changes to the current ‘system’ but none is more important to the establishment of primary healthcare homes than giving people a voice in the leadership of the teams that provide them with primary medical, home and community care.

Although public governance is well-accepted in hospitals, Canada’s system of primary medical care provision has been for a long time one of public funding for private provision of services —most doctor’s offices function as small businesses. Physicians have traditionally seen their main accountability as being to their patients. The idea of being governed publicly is a relatively new one for doctors, but the addition of other doctors, nurses, and other publicly (and conceivably some privately-funded) providers to the team makes the need for visible answerability to the community more pressing.

How should that answerability be best achieved? The answer to that key question is best found in the partnership between each primary health team’s professional members, its physicians, nurses, and other providers and those members it serves, patients and families who have registered with the team or perhaps even with more than one such team in a defined region. A one-size-fits-all prescription for primary care with its mandate expanded to include home and community care is almost certainly unable to meet optimally the needs of Canadian communities and of teams in all their diversity. But if primary healthcare services are to be genuinely people-centered, the teams that provide them should be governed by the people they serve.


Authored by members of the Queen’s Health Policy Council:

Don Drummond
Chris Simpson
Duncan G. Sinclair
David Walker
Ruth Wilson

Aligning Primary Care Compensation to Health Outcomes

 

For primary healthcare homes to meet the expectations of patients, their families, and communities, incentives linked to the health outcomes they need to achieve are essential. Those expectations include the ‘triple aim’:

  • Improved indices of health status within the served population and measures of individual outcomes of care
  • Patient, care-giver, and community satisfaction
  • Demonstrable efficiency and effectiveness

Financial incentives are obvious. Prominent among the others are the team’s status and standing in its community and freedom for the primary care team to innovate – to make its own decisions on how to operate within the policy guidelines established by the responsible regional authority and/or government.

Today’s ‘triple aim’ expectations of primary care teams require much more than visits to the doctor’s office. They require the provision of a wide range of health services, many bordering on social services, and many delivered in people’s homes and communities rather than in the office. They require an increasing focus on people with many and varied chronic conditions that cannot be repaired, people who need on-going care, support, assistance, and comfort provided by a wide range of health professionals in addition to doctors more than they need symptom relief, although they need that too. The fee-for-service compensation system relied on in the past is completely inappropriate as an incentive mechanism for the contemporary primary care team.

A method of financing the Accountable Care Organization (ACO) model, pioneered under the publicly-supported Medicare program in the United States, already applies, in part, to many primary care teams in Canada. Over half of primary care physicians in Canada are now recompensed through a variety of alternatives to fee-for-service. Basically, financing of the ACO is by capitation whereby the team is paid a fixed sum annually for each person registered with it and is expected in return to provide all registrants the services needed to maintain them in good health. The ACO/primary healthcare home is expected to be:

  • Accountable for the quality, cost, and overall care of a defined population
  • Made up of sufficient provider members, employees, and affiliates to provide a full range of primary, home, and community services
  • Able legally to receive and distribute recompense to its members, staff and affiliates in relation to the services they provide
  • Governed by a leadership structure that ensures patient centeredness and includes clinical and administrative oversight
  • Equipped with the capacity to promote evidence-based practice and patient engagement and to assess regularly the health of the population served, its satisfaction with the services provided, and the quality of outcomes achieved.

The principles at work are that the team is funded for each person registered with it as his or her primary care home, the amount being based on the age and social characteristics of the served population and the public resources currently spent on their primary, home, and community care. With respect to the latter, the team is able to charge fees and accept the remittance of insurance payments for its provision of services not currently paid for publicly. After its formation, the primary care team’s funding would be adjusted upwards or downwards by up to 20% in direct relationship to measurements of its efficiency and effectiveness, the quality of its outcomes, and the satisfaction of its registrants and their families with its services, thereby providing a financial incentive both for good work in competition with other primary care teams. Another is an agreement with the regional authority or government to split any annual reduction in the overall cost of service provided to the served population while maintaining competitive standards of quality and satisfaction.

Moving to such a form of recompense for primary healthcare homes will require a major adjustment in how providers are currently remunerated. Fee schedules and salary levels negotiated centrally by professional associations and unions are antithetical to funding a team. New forms of primary care governance, better measures of patient satisfaction, meaningful measures of quality outcomes, and legal frameworks allowing funds to be distributed by the team to its providers are a few of the challenges.(1) Fortunately, there are some promising examples of teams in Canada taking this approach. They need to be emulated widely.

(1.) http://www.dorvalmedical.ca/wp-content/uploads/2014/01/Measuring-Comprehensive-Primary-Care-for-System-Benefit-Draft.pdf


Authored by members of the Queen’s Health Policy Council:

Don Drummond
Chris Simpson
Duncan G. Sinclair
David Walker
Ruth Wilson

Better Access for Patients to Their Health/Medical Record

 

Ask anybody, “what’s in your medical record?” Chances are nobody has ever seen theirs; they don’t even have a clue where it is. Most people’s records are scattered here and there among the offices of their family physician, dentist, optometrist, physiotherapist, some specialist physicians and surgeons, one or more hospitals, a home care provider, etc., many of them in different cities, provinces, and sometimes countries. Chances are also that few people know that the records are their personal property – they own them. They have been led to believe over the years that those files behind the desk or on the shelves behind the doctor’s receptionist or increasingly on that computer in the examining room belong to the providers who provide them with safekeeping; they believe also, correctly, that healthcare’s providers control access to them. That patients themselves do not have free access to their own health/medical records and that they don’t control whom else should have that privilege is bizarre.

As it stands at present, despite the marvels of ‘cloud computing’, anybody (including hospitals and other providers) would be hard pressed to pull together his or her medical record, even that extending back only for the last couple of years. As for a more inclusive health record, that would be nearly impossible. Yet the technology exists to make both, health and medical records, readily available to everybody in Canada. It can and should be deployed to do so.

Why?

In the first place, ensuring the accuracy and completeness of the information in those records would be a great idea; doing so could even be a life-saver. Who better to do it than the individual whose record it is? It is also the ambition of health service providers everywhere, and indeed of the so-called “systems” of which they are members, to be people-centered. It is pretty hard to claim progress toward that goal if the people most intimately involved, patients, don’t themselves have as ready access to their own records as those treating them. Why should those same patients not also exercise control over who else can have access to their records, whether in whole or in part, when, and under what circumstances? They do have full access to and control over their financial records. It is hard to conceive of reasons why they should not have the same for their health and medical records.

Healthcare’s providers are increasingly working in teams, especially in primary care. The day of the solo practitioner’s well-known personal collection of patients is fast being replaced by the team of physician, nurse, dietitian, physiotherapist, pharmacist, social worker, etc., working with a much larger number of patients and families, often seeing them in clinic, frequently after-hours. Having access to each patient’s electronic health/medical record in these circumstances is essential for the members of the provider team and certainly more convenient for the patient than repeating his or her story over and over again.

Some would claim that medical records are too complicated and written in terms too esoteric for all but a few patients to understand. That’s a great argument for abandoning obscurantist professional argot in favour of writing medical and health records in plain language. That claim also fails against the growing reality that Canadians are, on the whole, well educated. They are also, courtesy of the internet, made increasingly savvy through websites, patient support groups, and the like about the diseases and conditions that affect them and members of their families. With access to a lot more knowledge about their health and diseases than they did even a few years ago, yesteryear’s paternalism is passé. It is also highly desirable for patients to be much more involved in what amounts to partnerships with the providers of healthcare services to manage their own care. How better to do so than for patients and their providers to work together to keep track of their progress and setbacks in a health and medical record readily available to both? This will become increasingly important with the adoption of recently invented wearable devices to record activity measures and physiological functions as patients go about their daily lives.

Patients are the principal stakeholders in healthcare. They need and should have access to and control of their health and medical records. There is no reason, technological or otherwise, why they should not.


Authored by members of the Queen’s Health Policy Council:

Don Drummond
Chris Simpson
Duncan G. Sinclair
David Walker
Ruth Wilson

A Call for Better Health Information Governance

 

Being well informed about what’s going on in healthcare and its outcomes is in everybody’s interest. Provincial, Territorial, and the Federal governments need the information to manage their “systems”. Providers need it to assess their effectiveness. The public needs it to know if their interactions with hospitals, doctors and others are efficiently conducted and consistent with high standards. Few ask but they also should know if they are getting their money’s worth. And Canada as a whole needs information to know how we stack up against other countries. Currently we can hold nobody accountable for providing that information because there’s nobody in charge. Health information management has no leadership, no governance.

Canada Health Infoway[1], established in 2001 as a federal:provincial initiative funded by the federal government, was never intended to be a governance. Its mission was to develop the technologies, standards, and other ingredients necessary to tie together the widely diverse health information systems used by Canada’s individual and institutional providers, provinces, territories, and the federal government. Despite its diligent efforts and the expenditure of over $2 billion, Infoway’s vision of a unified “digital health ecosystem” remains off on the far horizon. Why? Largely because collectively we have shied away from establishing that most key of other ingredients, a governing body we can hold accountable for tying together those still diverse health information programs into a single interconnected digital system that meets all our needs. There will be no unified digital health ecosystem in Canada without leadership. Governance is essential.

How can governance over an integrated Canadian health information system be established? First let’s acknowledge some realities that are not going to change:

  • Healthcare is primarily a provincial/territorial responsibility
  • There will continue to be fourteen healthcare “systems”, one in each province and territory, each with its differences, and one, somewhat different again, run by the federal government
  • Dominance, much less direction, by a single government, especially the federal one, is unacceptable
  • In the absence of an integrated health information system, every jurisdiction will suffer increasingly from the absence of the collective processes and outcome measures essential to improve its own healthcare system, render it more affordable, better able to meet the needs of the people it serves, and to assure taxpayers’ that their money is being well spent.
  • Absent a functional national health information management system, Canada will continue its slide to the bottom of international comparisons of the efficacy of comparable countries’ health systems

The Council of the Federation (CoF) offers a way to provide that system with leadership. Established in 2003 as part of their joint commitment “to play a leadership role in revitalizing the Canadian federation and (build) a more constructive and cooperative federal system[2]”, the Council is a joint endeavor of the Provinces and Territories. It is entirely feasible for it to invite the federal government as a participant in a process, conducted under the Council’s aegis, to establish a neutral, independent, a-political body charged with creating, leading, and governing a coordinated Canadian health information management system. It should be small, made up of perhaps 8 to 10 respected leaders drawn from across Canada, broadly experienced in the application of information derived from digital systems to manage large enterprises including health, and none of them ‘representative’ of any government. It would derive its authority and be accountable to the CoF and its invited federal participant.

With apologies to the songwriter Jimmy Webb[3], our situation is somewhat analogous to the cake ruined in the rain. We know what we want to bake – an integrated health information management system that benefits us all. We have misplaced the recipe but can draw on people in Canada and elsewhere who have baked cakes like this before. We have most of the ingredients – the various unconnected digital systems out there throughout Canada; the few technologies we may not have are readily available off the shelf. And we have the bakers – CIHI, Statistics Canada, and Canada Health Infoway. It remains for the Council of the Federation with the added participation of our national government to create the missing master chef, a governance, the authoritative leadership of an information management system, and put it to work.

[1] www.infoway-inforoute.ca/en/

[2] http://www.canadaspremiers.ca/en/

[3] www.google.ca/webhp?sourceid=chrome-instant&ion=1&espv=2&ie=UTF-8#q=jimmy+webb+macarthur+park+lyrics&*


Authored by members of the Queen’s Health Policy Council:

Don Drummond
Chris Simpson
Duncan G. Sinclair
David Walker
Ruth Wilson

What Price a Secret: High and Unnecessary in the Case of Health and Medical Records

 

A common jibe in academic circles is that the best way to keep a secret is to publish it. The argot of specialties and their practitioners’ acronym-laden prose make journal articles incomprehensible to all but ‘insiders’. So it is also for most medical and the few health records that exist. Each is written by a doctor, nurse, or other practitioner (amazingly many still in longhand) primarily to jog his or her memory about salient issues when next the patient is seen and also to inform other professionals about his or her interactions with a patient. Impenetrable as they may be to all but the cognicenti, including their owners, their confidentiality is also fiercely protected by privacy legislation and a virtual thicket of rules and regulations overseen by armies of bureaucrats and ultimately courts wielding stiff penalties for failing to keep everything safe and secure from prying eyes.

What’s in there that’s so secret? Most would agree that their medical and health records should be as secret as their financial records. With respect to the latter, well accepted policies and tried technologies have been in place for many years. The Haligonian on a visit to Vancouver pulls out her bank card in a public place without a second’s thought and uses her PIN to access her financial records to get the money or credit she needs to pay for her lunch. Contrast that with what would happen were she to get hit by a bus on leaving the restaurant. The Nova Scotia MSI card in her purse would assure the Vancouver’s emergency room triage person that she is insured in a Canadian province, but that’s it – not even the patient would have access to any of those deep, dark secrets like her blood type, current medications, or even the ‘phone number of her next of kin or family physician back home. The physicians and nurses caring for her in the ER would have to go on only what she can remember; and she has just been hit by a bus! Perhaps she’s unconscious; somebody would have had to rifle through the private stuff in her purse to get at that MSI card, stuff she may consider far more deserving of secrecy than whatever is contained in her health/medical record.

Our current privacy fetish is not only a threat to Canadians’ health and well being, it is also a threat to reform of our very healthcare “system”. It denies society access to the aggregated data that could and should be derived from analyses of our collective medical and health records, data that could give governments and the public the evidence needed to govern and manage our ‘system’ better. That denial comes at a very high and unnecessary price, unnecessary because the technology is readily available to achieve the same end. It is already widely used in the financial industry to assure the confidentiality and security of every individual’s records and at the same time make available anonymised data for analyses, system improvement, and everybody’s benefit.

Ironically, in addition to the weather and Presidential antics south of our border, their health, diseases, conditions, and current interactions with doctors and other healthcare providers are among Canadian’s most frequent topics of conversation. The exceptions are that generally people don’t talk about their mental illnesses except to fellow sufferers or about venereal diseases and other matters related to sexuality. Sadly, stigma still attaches to both of these taboo subjects. A good argument can be made that more discussion, facilitated by more extensive and better data on the incidence and successful management of such conditions, would serve to decrease that stigma and improve greatly the interactions of sufferers with people who still consider mental illness, addiction, and sexually transmitted diseases as somehow shameful.

Some argue that were medical and health records not to be as tightly closed as they are, insurance companies could somehow get access to an individual’s record and deny him or her coverage because of a pre-existing condition. Those seeking insurance coverage are required to disclose their pre-existing conditions. It is not the policy role of governments in assuring the confidentiality of health and medical records to facilitate the submission of fraudulent insurance applications. And in any case, medical and health records should not be ‘open’; they should be, like financial records, centrally aggregated and stored and protected by a PIN in the hands of their owners.

With respect to the secrecy of medical and health records, the price we’re paying is both too high and unnecessary.


Authored by members of the Queen’s Health Policy Council:

Don Drummond
Chris Simpson
Duncan G. Sinclair
David Walker
Ruth Wilson

Measure to Manage Healthcare

 

To paraphrase Peter Drucker’s famous aphorism, you can’t manage, much less improve, what you don’t measure. This applies in spades to Canadian healthcare. Despite reams of administrative data, we really don’t know much about individual transactions between patients and their providers and even less about their outcomes. We remain remarkably uninformed about both the efficiency and effectiveness of a program on which we spent about $228 billion in 2016, 70% of it in public funds. Our “system” is not quite flying blind but we have far from a clear view of where we are, where we’ve been, or where we’re going!

We look to CIHI[1], Statistics Canada, and provincial Quality Councils[2] for data on how Canada’s healthcare “systems” are meeting our needs. Perforce they all deal primarily with administrative and clinical data collected in and by hospitals to measure the incidence of failures of patient:provider interactions. These data are important but to manage the “system” well we need to be more broadly informed on what each of its elements is contributing to the health and well being of the population.

It is an iron law of statistics that measures of all transactions will be distributed throughout a spectrum ranging from, at the extremes, abject failures to outstanding successes. With respect to the outcomes of a hospital stay or treatment by any provider, we should expect that distribution to be strongly skewed toward a return to health and no recurrence. Important as measures of failures are, they are but one tail of the distribution of outcomes, hopefully a small tail at that. To get a real handle on what society is getting for the expenditure of some 11% of GDP on healthcare services, it is vital to measure the whole spectrum of the distribution of outcomes from the failures, through the so-sos, and goods, to the outstandings. The very shape of the distribution would tell us a lot about where to put our efforts to make healthcare more effective and less costly. Assessing the outcome of a procedure or stay in hospital, for example, requires more than measuring whether or not it was followed by an infection or readmission; of the care provided an elderly person by a personal support worker if a fall occurred subsequently; or of a visit to a family physician if the patient went later to an emergency room.

We do know from international comparisons[3] by an American Foundation (itself somewhat discomfiting) that Canada and the United States stand second-last and last of 11 countries respectively as “clear outliers” in their healthcare systems’ performance! These comparisons of quality, safety, efficiency, equity, cost, and the overall health of the populations served are based, in the main, on well-tested surveys of patients and physicians. While highly credible as sources for a high level report card of system performance, such surveys are insufficiently granular to inform governance or management decisions whether by a health authority, hospital, primary care team, or community service provider. Real measures of transactional efficacy and of the outcomes achieved are required.

The need for more and better measures is well recognized. Haj-Ali and Hutchison reported recently[4] on the creation of a framework to measure how primary care meets the needs of its providers, system planners, patients and their families, governments, and of the general public. There remains, however, a long way to go before this work and studies like it extending to the many other healthcare services can be converted into practical measures of effectiveness and efficiency. Conceptual frameworks are one thing; measures of individual transactions and outcomes are something else. To what extent and how cost-effectively do various tests and images improve the safety and effectiveness of a patient’s diagnosis and treatment? How much is added to a family’s quality of life by regular home care services? How near normal is the range of activities of patients with knee replacements and how long does it take to achieve it?

You can bet that the owner of every corner store right through to those responsible for the governance and management of our largest corporations can tell you to the penny the cost of their every transaction and the impact of each on customer appeal and the bottom line. Why is getting transactional and outcome measures so hard and taking so long in healthcare? For the most part records bearing on the interactions between providers and patients exist. To get measures of their efficiency they need to be digitized, converted to a common standard, compared, aggregated, and rendered anonymous for analysis; the technology is available as are Canadian agencies[5] capable of doing the work.

Statistics Canada and CIHI have reported[6] on the need for and ways to collect more and better outcome data. Using the now nearly ubiquitous cell phone, tablet, and personal computer technology, Patient-Reported Outcome Measures (PROMs) and their results (PROs) can be readily obtained from patients and their families. Could it be that our provincial governments don’t want their publics and providers and their patients and families to know the results – what the spectrum of Canadian healthcare’s outcomes really looks like?

We need but to agree to use standards in common, link together our software systems, share the clinical information all of us have in one form or another, and devise new methods to measure what we are getting as a society for our $228 billion. It’s time to get on with it!

[1] Canadian Institute for Health Information

[2] in Alberta, Ontario, and Saskatchewan

[3] http://www.commonwealthfund.org/~/media/files/publications/fund-report/2014/jun/1755_davis_mirror_mirror_2014.pdf

[4] Wissam Haj-Ali and Brian Hutchison. 2017. Establishing a primary care performance measurement framework for Ontario. Healthcare Policy, 12(3) February: 66-79

[5] CIHI, Statistics Canada, Quality Councils

[6] https://secure.cihi.ca/free_products/HealthOutcomes2012_EN.pdf


Authored by members of the Queen’s Health Policy Council:

Don Drummond
Chris Simpson
Duncan G. Sinclair
David Walker
Ruth Wilson

On opioids the buck should stop with health professionals and their regulatory Colleges

 

The continuing increase in the prescribing of opioids in Ontario[1] is a classic example of tragedy of the commons. Like the many years of overprescribing antibiotics that now threaten society’s ability to overcome bacterial infections, the cause of this tragedy rests to a considerable extent with Canada’s physicians and dentists. For twenty years health professionals have been encouraged to treat chronic pain with opioids, being told by drug companies and pain experts that it was heartless to not attempt to alleviate suffering with these medications. Yet now it is apparent that far too many physicians and dentists have failed to associate the connection between their prescribing habits and the widely reported opioid crisis Canada is experiencing[2] and are continuing to make it worse, not better. Where does the buck stop in dealing with this tragedy?

It seems obvious that it should stop with each prescribing health professional and his or her adherence to the high moral and ethical principle to do no harm. Clearly many are doing harm both to the individual patients to whom they are giving unnecessarily powerful, addictive drugs and to society as a whole. Prescribers struggle to reduce opioid prescriptions for chronic pain in the face of limited access to other options for treating chronic pain, and strong resistance from patients who are tolerant or in many cases addicted to opioids. But in the end they have the responsibility and the power to taper and discontinue these powerful medications.

Physicians and dentists come within the ranks of the self-regulated professions throughout Canada’s provinces and territories. The regulatory Colleges should urgently update their guidelines on opioid prescribing practices, monitor the adherence of physicians and dentists to them, and take disciplinary action against those who do not do so. The College of Physicians and Surgeons of British Columbia has taken an important first step by adopting enforceable standards for prescribing.4 The current opioid crisis in Canada is a wake-up call both to individual health professionals and their regulatory Colleges to pay closer attention to well-formulated evidence-based clinical guidelines lest they be, in future, replaced by hard and fast rules permitting no exceptions founded on professional judgement. Such guidelines, of course, must be free of inappropriate influences from pharmaceutical manufacturers[3].

In addition to prescribers, pharmacists and their regulatory Colleges could play an important role in resolving the opioid crisis[4], the Colleges through the development of guidelines and protocols and pharmacists through their role as the gatekeepers of prescription drugs. Pharmacists are in a position to identify opioid diversion and misuse. With extension of their authority to reduce the volume of opioid prescriptions as they now can for other drugs they could help to eliminate inappropriate prescribing.

Failing the buck’s stopping with individual physicians and dentists, society will insist that it stop with our provincial and federal governments. A compendium of governmental responses to the opioid crisis was released in 2016[5]. It described many promising actions but, understandably, taking responsibility for monitoring and enforcing adherence to clinical guidelines relating to prescribing opioids was not among them. Nor should it be. Individual physicians and dentists and their regulatory Colleges are primary owners of this major problem in Canada’s public health.

[1] http://opioidprescribing.hqontario.ca/

[2] http://www.cpha.ca/uploads/policy/opioid-statement e.pdf

4  https://www.cpsbc.ca/files/pdf/PSG-Safe-Prescribing.pdf

[3] https://www.theglobeandmail.com/news/national/health-minister-orders-opoiod-review-after-conflicy-of-interest-revelations/article35053108/

[4] suggestion by Queen’s MPA student Grace Tahhan

[5] https://www.canada.ca/en/health-canada/services/substance-abuse/opioid-conference/joint-statement-actiion-address-opioid-crisis./htm


Authored by members of the Queen’s Health Policy Council:

Don Drummond
Chris Simpson
Duncan G. Sinclair
David Walker
Ruth Wilson