Canadian Virtual Health Library on Health Council’s clinical practice guidelines video project

Jennifer Bayne, Executive Director (Acting), CVHL/BVCS on behalf of the CVHL/BVCS Board of Directors

We commend the Council for leading a thoughtful, systematic analysis of how CPGs can become more useful and, hence, more used, across Canada. Access to quality information, such as CPGs, for all Canadian health professionals is the mandate of the Canadian Virtual Health Library/Bibliothèque virtuelle canadienne de la santé (CVHL/BVCS). On our website is a bilingual database that brings together the many free resources offering quality information relevant to Canada, including many trustworthy and credible sources of CPGs.

Underlying this work, and CVHL/BVCS generally, is a coordinated network of libraries, which have collections and expertise to connect health professionals to guidelines as well as resources to support their use, such as videos for professionals and plain language explanations to share with patients.

Guidelines are notorious for lacking a standard format. Whether CPGs are available in a journal, on a society web site, or through various agencies or levels of government, libraries have experience tracking them down. For example, the Canadian Medical Association's Infobase leads professionals to citations but not necessarily to the full guideline. This is where library collections and expertise come in, completing the link between clinician and CPG. CVHL/BVCS endeavors to make CPGs available virtually but also provides the back-up needed to address individual needs, including tracking down CPGs relevant to local practice. Through shared purchasing and economies of scale, commercial sources of CPGs and other high quality sources of evidence will become more widely available. When they graduate from university, newly trained professionals jump over the "e-resource cliff," losing access to the rich range of full text publications online provided by university libraries.

Taking another viewpoint, guideline development is restricted to settings with broad access to full text publications, which excludes many associations and organizations based outside of academia. CVHL/BVCS is moving to bridge this gap and ensure universal access to quality information, both for professionals not affiliated to a university and for staff in organizations synthesizing the literature into CPGs for professionals.

Integration of CPGs at the systems level requires a cross-disciplinary approach that builds capacity to adapt CPGs to local practice and extend them to address complex cases and different cultures and settings. Cross-disciplinary areas, such as substance abuse prevention, and complex cases with multi-morbidities go beyond existing CPGs.

CVHL/BVCS pools and shares collective knowledge for one-stop shopping. It supports clinicians in an approach tailored to local clinical capacity while reflecting the best evidence from various disciplines. This support encompasses extension of CPGs using the international literature, which increasingly recognizes multi-morbidity. As a hub for collaboration with a pan-Canadian mandate, CVHL/BVCS enables development of information technology solutions and collective repositories beyond the reach of single organizations or even regional consortia. To link CPGs in the electronic clinical environment, a knowledge base structured by clinical codes such as SNOMED are essential. Such an organized knowledge base integrating the myriad of resources, both free and commercial, including CPGs, needed by Canadian health professionals is a central goal of CVHL/BVCS.

We wish the Health Council of Canada every success in encouraging wider use of CPGs and hope that CVHL/BVCS can play a part by making quality information, such as CPGs, universally accessible.

Integration of performance measures into CPGs

Dr.Patrice Lindsay, Director, Performance and Standards, Canadian Stroke Network, and Appointed Member, Canadian Task Force on Preventive Health Care

Accountability in healthcare has become the modern mantra for healthcare organizations at all levels -- from local hospitals, regional health authorities and provincial ministries of health. The intention is to ensure that Canadians are getting equal access to healthcare services in a timely manner and in the right setting with the appropriate expertise to meet the needs of the patient. As straight-forward as this sounds, the challenges in meeting accountability demands are numerous and complex. 

In a significant step forward in Canada, the provincial Health Ministers now are emphasizing the value and role of CPGs in increasing consistency and defining what healthcare organizations will be accountable for delivering. The Canadian Best Practice Recommendations for Stroke Care are a strong example of the potential impact of guidelines on accountability at a program, regional and provincial level. The recommendations are featured in video 3 of the Health Council’s video series on CPGs.

The Canadian Best Practice Recommendations for Stroke Care were developed through a partnership of the Canadian Stroke Network and the Heart and Stroke Foundation. Prior to guideline development in 2006, clinicians across Canada referred to guidelines from other countries, and there was a lack of standardization, even within the same city or organization. Now, they have become the 'go to' resource for all stroke programs in Canada, and for many stroke providers internationally. This widespread uptake of these guidelines has led to significant and measurable systems change and improvements in stroke care and patient outcomes.

A key innovation in the stroke guideline development was including a set of validated performance measures and linking them directly to the evidence-based practice recommendations. At the time of guideline release, there did not appear to be any other published CPGs that had included performance indicators so directly. The stroke CPGs inform healthcare providers on what they should be doing, and the performance measures inform the providers on how well they are delivering that care. These indicators are clearly defined in our Stroke Performance Measurement Manual (www.strokebestpractices.ca). These key performance indicators formed the foundation of our national stroke audit for the 2008-09 fiscal year. When the audit results were released, decision-makers and system leaders were able to track back to the guidelines and identify services where performance was good, as well as identify areas where quality improvement initiatives were required. Since the release of the Quality of Stroke Care in Canada 2011 report, several new stroke units have been developed, door-to-needle times for clot-busting drugs have been reduced, and more patients are getting access to stroke prevention therapies. Further, the data has led to the establishment of national and regional benchmarks for stroke care delivery in Canada. Providers now have a mechanism to compare their care delivery with validated benchmarks and targets.

Integration of performance measures into any CPG is valuable and does not require significant resources. The decision to do this should be made prior to conducting evidence searches so that key questions regarding performance indicators can be searched simultaneously.

Developing and disseminating guidelines is no longer enough. It is really only a part of the responsibility of guideline groups, especially when the guidelines define the nature of accountability for care. The whole package includes performance measures to identify how well care is delivered; educational materials to support the clinicians in learning 'how' to deliver the care described in guidelines; and instruction on how to measure that care. Finally, the package needs to include effective dissemination strategies that go beyond publishing the guideline document. 

Understanding Clinical Practice Guidelines: A Video Series Primer

We developed a series of videos to provide an overview of clinical practice guidelines (CPGs) in Canada through the eyes of those who design, disseminate, and use them.

CPGs are evidence-based recommendations that help health care professionals make better clinical decisions. When designed and used properly, CPGs can play an important role in the Canadian health care system.

In November 2011, we collaborated with the Canadian Medical Association on a national summit to focus attention on CPGs at the policy level and develop a shared understanding of national priorities. Governments have also been working together to bring greater attention to CPGs across Canada. The provincial and territorial premiers identified CPGs as a priority area of focus in health care and reported in July 2012 on the role of CPGs in reducing variations in clinical care.

These videos are meant to offer greater insight into what CPGs are, how they are used, how they are disseminated and implemented, and what impact they can have.

Video 1: What are CPGs

This video provides an introduction to CPGs: what they are, who can benefit from their use, and why patients and health care providers should take an interest in them.

Video 2: Challenges for CPGs
This video discusses the complexities that affect widespread usage of CPGs. National experts share their thoughts on the challenges that designers and users of CPGs face.

Video 3: Integration of CPGs at the system level
This video profiles Canadian organizations that have garnered recognition for their system-level approaches to CPGs. The groups highlighted include: 

1. The Canadian Taskforce on Preventive Health Care 
2. Canadian Stroke Strategy 
3. Cancer Care Ontario 
4. Registered Nurses’ Association of Ontario Best Practice Guidelines 

Video 4: Opportunities and future considerstaions for CPGs
This video looks at where efforts are needed to realize the benefits of CPGs on improving patient outcomes and health care system performance in Canada. We discuss the future and next steps for CPGs with national experts.

Ten years since the Romanow Report: Retrospect and prospect

On November 9, 2012, I provided closing remarks at the 10th anniversary event for the Romanow Report. The event drew key stakeholders from throughout the health care system, including up-and-coming leaders eager to learn from insights of the Honourable Roy Romanow and other invited guests.

The event was an opportunity to reflect on the issues and public expectations that brought about the final report of the Royal Commission on the Future of Health Care in Canada. We talked about the report, what had occurred in the 10 years since its release, and what is left to be done.

Romanow's vision, shaped by Canadians ten years ago, is still relevant and alive today. Conference presenters and discussion with audience members illustrated progress in every area of the report themes and pillars over the past decade. There are many examples of innovations, best practices and prototypes needing to be shared in order to continue producing positive change.

However, we have not achieved the substantial transformation in any one area of the report that Romanow and fellow Canadians originally envisioned. While many do understand the potential benefits of an integrated patient/public system, for example, this is not our current reality.

Canadians still see the health system as part of their identity, and the good news is that we seem to value the Romanow vision and have made some progress. The bad news is that our system now ranks about 30th in the world, is not leading to optimal outcomes, and is not financially sustainable.

It is time for all leaders – clinical, administrative and political – to bite the bullet, risk real change and implement integrated transformation that is true to the collective Canadian vision and to our evolving realities.  The Romanow Report was and remains a viable platform to restore the Canadian health system to the top ten in the world.

If you’d like to see some of the presentations from the event, visit CAHSPR’s youtube channel. 

 Cheryl Doiron, Councillor, Health Council of Canada

 

Learning from primary care physicians

While we often hear about surveys of the public’s views and experiences with health care, we don’t often hear from physicians. What do they think about the health system and the care their patients receive?

Primary care has been the focus of considerable policy attention across Canada and internationally. Government-led initiatives are promoting changes like greater use of electronic medical records (EMRs), interprofessional team-based care, and innovations in practice management to help primary care physicians see more patients, more effectively. How widespread are these changes and what impact are they having?

To help answer these and related questions, The Commonwealth Fund spearheaded an international survey of more than 10,000 primary care physicians in Canada and 10 other OECD countries. Today, The Commonwealth Fund published its analysis of the findings in Health Affairs.

We’ve also been busy analyzing the survey results. For some years now, we’ve been a co-funder of The Commonwealth Fund’s annual international health policy surveys. Several key organizations joined us in co-funding larger, more representative survey samples in Canada – the Alberta Health Quality Council, Health Quality Ontario, the Quebec Health and Welfare Commissioner, and Canada Health Infoway.

Today, Canada Health Infoway released some key findings from the survey on EMR adoption in particular. Have a look at their release here. We will also be expanding on both the Commonwealth Fund’s analysis in Health Affairs and Canada Health Infoway’s release. Watch for our results in January 2013 – Bulletin 7 in our Canadian Health Care Matters series. Our bulletin will focus on several key areas of health system performance – access to primary care, coordination among health care providers, and the uptake of information technology. We’ll also report on the use of incentive payments to drive improvements in primary care and on primary care physicians’ general perceptions of the system and the care their patients receive.

This year, for the first time, we are able to report on province-by-province results. We’ve identified a number of variations among the provinces in some of these areas – not surprising given that each province and territory runs its own health system based on its local priorities and policies. The purpose of our comparative analysis is to shed light on the relative impact of improvement initiatives.

We’ll also show how Canada as a whole compares to other countries in the survey. And we’ll look at trends over time by charting how key aspects of primary care have changed (or not) based on similar surveys of physicians in 2006 and 2009.

Look for our report this January at: www.healthcouncilcanada.ca.

Sukirtha Tharmalingam, Senior Policy Analyst, Health Council of Canada 

Conference Board of Canada’s Summit on Sustainable Health and Health Care

Last week I attended the Conference Board of Canada’s Summit on Sustainable Health and Health Care. Leaders from all spectrums of health care were present, including organizations, companies, health ministries and authorities, providers, and patients. Daniel Muzyka, President and CEO of the Conference Board of Canada opened with the statement that we should all be committed to having the best health care system and the healthiest population.

Several speakers indicated that Canada does well in acute care, primarily because our public health care system has been built around hospitals, doctors and curing illness. Where we are ailing is in the areas of access, chronic disease management, community care, and care for our elderly. It was said repeatedly that the U.S. should not be our comparator, as the U.S. system is much different from ours and they are often lagging much further behind other countries in terms of health care sustainability. Canadian comparisons are better made to other countries with similar health care systems that are high performing.

André Picard spoke about transforming health care in Canada. He indicated that Canada has the least effective, least efficient, and least accessible system in the world (not including the U.S.). He said in order to move forward, we need to have goals and outcomes and define sustainability as not just maintaining the status quo, but determining the priorities for moving forward, and striving for innovation.

Anna Reid, the president elect of the Canadian Medical Association talked about the social determinants of health as being crucial. She said we need to focus on vulnerable populations to eliminate health disparities – a sentiment that was echoed in other presentations.

Hélène Campbell, a 21-year-old double lung transplant recipient gave an inspiring talk about her experiences in the health care system and how social media gave her a platform to advocate for organ and tissue donation. Her advice to health care leaders was to use patient stories as an impetus for change, to tackle issues one small thing at a time, and to keep communication among providers, patients, and families moving forward.

The lack of health innovation in Canada was addressed by a panel of experts who encouraged Canadians to find opportunities to innovate at a system level. At the Health Council, we recently launched our health innovation portal which features innovative practices in health care across Canada. It’s there for everyone to share and learn from.

This summit provided an opportunity to learn about current research and hear different perspectives on how health care can be sustained and improved upon in Canada. We’ll draw upon the many insights gained at the summit to inform our ongoing work on health care reform.

Shilpi Majumder, Policy Lead, Health Council of Canada

The Online Chronic Disease Self-Management Program: A Health Council webinar

In September we held a webinar on online chronic disease self-management programs. Dr. Bruce Beaton hosted the panel discussion based on our recent report, Self-Management Support for Canadians with Chronic Conditions: A Focus for Primary Health Care. After the webinar, some participants had questions that remained unanswered. We went back to the panel and got the responses. Below is a sample of one of the interesting discussions created – for all the Q&A, click here.

Q: Are there any programs being developed to build capacity in self-management systems for providers?

Patrick McGowan

Patrick McGowan, Professor, School of Public Health and Social Policy, University of Victoria, BC: Self-management support are the strategies and techniques that health professionals use with patients in their clinical practice – which is different from the online program that is being provided to people with chronic health conditions. There are lots of articles and booklets describing self-management support. Perhaps the best resource would be the recent Health Council of Canada report entitled Self-management support for Canadians with chronic health conditions: A focus for primary health care. Unfortunately, I am not aware of any online training available for health professionals.

Peter Sargious

Peter Sargious, Medical Director of Chronic Disease with Alberta Health Services, Calgary, AB: Within Alberta, there are a number of programs available to support providers to build their capacity in self-management support. The Alberta Health Services provincial CDM division has developed a number of online education modules including CDM 101 that emphasizes self -management support via relationship building and collaborative partnerships between patient and provider. This team is also building a ‘health coaching’ initiative starting with some pilot projects later this year. There are currently over 45 ‘Choices and Changes’ facilitators within the province.

Crowdsourcing for Health Innovation

Wayne Leung, Digital Communications Specialist, Health Council of Canada

A few weeks ago a team from the Health Council attended Crowdsourcing for Health Innovation. The event, hosted by St. Elizabeth Healthcare, brought health system planners, managers and policy-makers together with digital communications professionals and other members of the Technorati to explore the concept of “crowdsourcing” and how it could be applied to health care.

The concept of crowdsourcing can loosely be defined as the self-organizing of communities of engaged users/clients/customers to participate in the creation of some end product. A good example is Wikipedia, the online encyclopedia based entirely on user-generated content.

The keynotes for the event are veritable superstars in the digital world; Jeff Howe, a journalism professor at Northeastern University who coined the term crowdsourcing, and Rahaf Harfoush, who was a digital strategist for Barak Obama’s first presidential campaign.

While crowdsourcing has been broadly applied across a variety of sectors, the health care sector has lagged. Howe pointed to a “culture of resistance” that seems to pervade in health care and impedes innovation.

The pair did share some interesting health care-related examples. Howe cited the example of the monomeric retroviral protease, a molecule in AIDS research. After engaging the video gaming community to find ways to “fold” the molecule within a given sets of constraints gamers, who have keen pattern recognition skills, found a solution within two weeks.

Harfoush then cited the example of the Open Source Drug Discovery Program allowing researchers to bypass patent-heavy pharmaceutical field to develop new drugs.

Howe went on to say that vast amounts of untapped data exist in the health care system. Patients possess knowledge of their symptoms and their pathology, and this information isn’t being gathered or harnessed. Given the Health Council’s recent reporting on patient engagement I wondered if crowdsourcing has applications as a means to improve patient engagement.

The concept of crowdsourcing is rife with potential for application throughout the health care sector and I’m looking forward to exploring ways to harness its potential for our work at the Health Council.

Sharing Innovative Practices

Mark Dobrow, Director, Analysis and Reporting, Health Council of Canada

I attend many meetings across the country on the good, the bad and the ugly of our health care system. In recent years, it is rare that at one of these meetings or conferences, I won’t hear someone say pejoratively that ‘Canada is the home of the pilot study.

To be frank, I’m growing a little weary of hearing it. While I appreciate the message that we need less study and more action, this anti-pilot study chorus also creates, however unintended, an underlying message that the testing and evaluating of innovative ideas is in some way sub-optimal.

Personally, I would encourage more pilot studies of innovative ideas and practices, but at the same time I would also expect that the results of those pilot studies be made available where others can benefit from them. Unfortunately, this is where things break down in Canada. Even though we live in the digital age, we don’t always take full advantage to facilitate the exchange of ideas. While most innovative practices are not going to be written up in academic journals, if you’re contributing to innovation in this country, where do you share this information? If you are seeking innovative ideas, where to you look for this information?

The federal, provincial and territorial governments have highlighted this challenge, making the identification of best practices and the highlighting of health innovation a key part of the Health Council’s mandate. The Health Innovation Portal represents a key part of our effort to address this, putting in one place all things related to health innovation that we do.

A key part of the Health Innovation Portal is the searchable database of innovative practices. It currently includes over 240 innovative practices representing a wide range of health care themes from across the country. Our goal was to create a user-friendly search tool with useful outputs that can be tailored to your needs.

We will be updating the Health Innovation Portal on an ongoing basis, so your feedback is welcomed and encouraged. But more than that, your contributions to the database are what will make this tool of value to the Canadian health care system. If you are making extra efforts to improve health care in your area, you need to let others know.

Please send us details on your innovative practices along with information on what you have learned from them to innovation@healthcouncilcanada.ca and we will review them for the database. The result – better ideas for better health care.

Health Innovation Portal connects

Ingrid Sketris, Councillor, Health Council of Canada

I am pleased to see the launch of the Health Council’s Health Innovation Portal. It will be a mechanism to both identify innovative practices and programs across Canada and facilitate their dissemination. Once these practices are identified, this portal will allow interested individuals to follow new developments and updated evaluations.

I am a member of an innovative program in Nova Scotia- the Drug Evaluation Alliance of Nova Scotia (DEANS). DEANS is a multidisciplinary, multisectoral alliance to optimize drug use in Nova Scotia (NS). DEANS includes representatives from the Nova Scotia Department of Health and Wellness (DHW), health professionals, program administrators, e.g., from the Nova Scotia Prescription Monitoring Program (PMP), and academic researchers and their trainees.

DEANS encourages appropriate drug use by identifying areas where optimization of drug use is needed, developing interventions to provide targeted, evidence- informed information to patients and providers and evaluating the impact of the interventions. DEANS supports the development of interventions based on a rigorous review of the literature, knowledge of the local context and the experience of committee members and other local experts. DEANS sponsored interventions include live and web based interprofessional educational programs, academic detailing and the provision of prescribing profiles to physicians.

Evaluation is a component of all DEANS initiatives. Some evaluations assess participant satisfaction with the delivery of the program and have participants identify how they will use the information to optimize patient care. Other evaluations have been more extensive, including examining the effect of the intervention on drug utilization and hospitalizations. A new initiative is the Katie program which assists clinicians in appraising new information and applying it to their practice. The website also has links to other sources of information about knowledge translation and effective continuing health professional education.

Examining the impact, uptake and adaptation of innovative practices and programs by other jurisdictions is complex and requires diverse evaluation approaches that employ methodologies such as quantitative, qualitative, and mixed research methods. The Health Innovation Portal will enable decision makers and researchers working in innovative areas both with the ability to find others working in the same program and policies areas and to identify appropriate methods to evaluate the success of their innovative approaches.

Health Innovation – the importance of measurement

Dr. Anne Snowdon, Professor and Chair, International Centre for Health Innovation, Richard Ivey School of Business

Each province and territory in Canada faces unique challenges as they struggle to meet growing demands for health services and escalating costs of health care. To ensure sustainability, we need to be innovative, meaning we must re-design health services to achieve greater quality and be more effective. But we must do more than just innovate - we need to measure the impact of innovation at the health system level, and disseminate our findings widely.

While no single jurisdiction has completely redesigned their health system to achieve sustainability, some have made progress through innovative practices to improve the quality of care and health outcomes. The question for health care leaders is: how do we learn from the success and failures of others to adequately address challenges within our own health systems?

Despite changes in health systems in Canada and around the world, we have limited evidence of the impact of these changes from a health outcomes or cost effectiveness perspective. Strategies for innovation must be supported by empirical evidence. In short, we have to measure innovation impact to understand how it is working and how we can build on success. Evidence-based innovation of this kind would generate best practices that could be shared across the country and around the world through dynamic knowledge translation models - a virtual network of partners working together and sharing evidence so that other countries can learn from, adopt or adapt proven solutions for their own health systems.

At the same time, we must also develop a performance management system that examines and captures the impact of innovation adoption on both system performance and population health across the continuum of care.

In Canada, each province and territory across the country is a living laboratory ripe with the potential for innovative best practices. For example, innovation to support primary care and integration is emerging independently in three Canadian provinces: Ontario, Quebec and Alberta. So far, there has been almost no measurement of the impact of these innovative primary care models. The resulting lack of knowledge transfer between these jurisdictions has meant missed opportunities for sharing lessons learned that could benefit all health systems across the country.

Without measurement of the impact of innovation, there continue to be missed opportunities for sharing lessons learned that could benefit other jurisdictions, not only within Canada, but internationally. Therefore it is important that we continue to build platforms for sharing in order to drive system innovation to support sustainability.