Sharing innovative practices across provincial borders

This week, P.E.I. Health Minister Doug Currie decided to look across provincial borders for ideas to solve emergency room closures on the island.

The Minister headed to Nova Scotia to seek out some innovative models of practice that might help improve their situation. Specifically, they will look at the way some hospitals have used paramedics and other health care workers in new and innovative ways to improve care. Collaborative emergency centres were a focus of their journey.

Looking across the country to share innovations is key to having a consistent, high-quality health system in Canada. Why reinvent the wheel when another province may have experienced similar issues and come up with an innovative solution?

Learning from one another is the focus of our Health Innovation Portal. The Portal aims to support the identification of innovative health care practices, programs, services and policies, and make them available to the public. We’ve collected hundreds of innovative practices from across the country, and they’re easily searchable by region, topic, date or source.

Continuing our focus on innovation, we asked Canadian college and university students to find practices they felt were leading positive change in the health system, and submit them in essay format as part of our 4th annual Health Innovation Challenge. The Challenge deadline was January 18, 2013, so we’re looking forward to sharing what they’ve come up with in the near future!

We hope that more jurisdictions, and health care decision influencers at every level, will look to their neighbours across Canada to help them improve their provincial health systems.

We need to break out of the bubble

Jason Nickerson is a respiratory therapist and a PhD Candidate in population health at the University of Ottawa.

Because of our need to strengthen capacity within the primary care system, it is of extreme importance that we pay attention to the perspectives of those working within it. The release of the report, How do Canadian Primary Care Physicians Rate the Health System? provides such a perspective, and should signal our need to evolve not only discussion, but innovation, on how to ensure that Canadians continue to see value for money spent on healthcare.

For decades, Canadian health policy experts and practitioners have wrestled with the question of how to improve Canadians’ access to primary health care. This debate has taken place within a fractured and fragmented health care delivery system, which by all rights can hardly be characterized as a national system at all. Rather, high quality health care is frequently delivered within confined bubbles, few of which are connected in any pragmatic way that is easily navigable for patients or caregivers. An effective health care system must have seamless linkages between community care, primary care, acute care, and continuing care, something that this report finds is lacking in Canada. We need to focus more on systems, rather than on individual problems.

Regrettably, progress has been lamentably slow. As the report notes: “Canada ranks poorly compared to other countries on many factors related to access to primary care and coordination of care between primary and specialist providers.” This is not a new problem, nor is it one that has suffered from a lack of investment. Rather, a considerable number of projects and alternative models of practice have been initiated throughout Canada, some with considerable success, and many that have lacked scalability outside of the confines of the practices where they have been initiated.

What we must acknowledge is that many of the constraints faced in accessing primary care must be addressed through considerable structural reforms to the governance and organization of Canada’s health systems (and they are a plurality, rather than one cohesive system). Far too few clinicians are able to practice to the full extent of their scopes of practice, limiting the “bang for our buck” in training and deploying them; effective referral networks and procedures are often lacking in many systems or are stymied by bureaucratic and procedural constraints that make referrals or collaboration impractical; health information systems have been deployed to collect large quantities of health information, yet frequently fail to manage information in a meaningful way across different providers and care systems.

While much has been written with regard to our need to improve healthcare in Canada, we need to move beyond simplistic solutions that have largely focused on change, rather than reform. Proposals such as interprofessional education or electronic charting have arguable potential to enact these changes, but have been poor at actually reforming the structural, regulatory, or institutional barriers that impede the optimal roll-out of these innovations. Clinicians who are not empowered (or allowed) to initiate, titrate, or discontinue treatments or refer patients to colleagues in different professions are unlikely to provide optimal interprofessional care nor see the benefits of interprofessional education. Computerized charting or imaging that offers no ability to transfer records in a useful way across health authorities or clinics offers no advantage to patients nor health systems. What’s more is that frontline clinicians identify inefficiencies and deficiencies within these systems and develop work-arounds to them, which may directly undermine investments made.

Considerable work remains if we are to see Canada’s primary health care systems ranked among the best in the world. However, this cannot be achieved in the absence of coordinated reforms to link innovations and ensure the constructive evolution of Canada’s healthcare delivery systems. We currently have pockets of innovation and excellence, and what we need is a coordinated scaling-up of modern systems geared toward prevention, treatment, and accountability.

Why should we care?

Dr. Alan Katz, Research Director, Department of Family Medicine, University of Manitoba

Why should we care what family doctors think about primary care delivery in Canada?
For at least two reasons. First, the future of our single payer healthcare system depends on a highly efficient primary care system. Because of this, provincial governments have started investing heavily in improving our primary care system. Second, because much of the change needs to happen in the offices of primary care providers where family doctors play a key leadership role. So this survey serves two purposes. It tells us what has changed over the last six years and it tells us what family doctors think about the system. There appears to be good news (e.g., increased use of electronic medical records) and bad news (e.g., poor access to care on short notice, inadequate use of regular clinical performance reviews) in the results of the survey. There are also results that are difficult to interpret (Are the docs with EMRs using them to full capacity? Why do so few physicians report the availability of incentives for home visits?).

Our healthcare system is complex. There are many ways of studying what happens in healthcare. In addition to excellent surveys like the 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians, we need to use other methods to study the system so that we know more than just what doctors think and say.

Canadian researchers are world leaders in the use of administrative claims data to study both the healthcare system and the health of the population. This research uses the routinely collected information that is used to run the system like physician payment claims to provincial governments, hospital discharge information and drug prescriptions filled by pharmacies, to look at the system from a different perspective.

Our research at the Manitoba Centre for Health Policy http://umanitoba.ca/faculties/medicine/units/mchp/ using many linkable administrative claims databases has looked at some of these same questions. Our answers are not based on the responses of a small group of physicians but include all contacts with the healthcare system for all residents of Manitoba (there are a few rare exceptions). For example, our work has shown that many family doctors do not use their EMRs to their full capacity!

http://mchp-appserv.cpe.umanitoba.ca/reference/PIN_full_report.pdf

One of the most concerning things about the results of this survey is the poor co-ordination of care between hospital care and primary care. Our work suggests that this may be due to patients seeing more than one primary care physician. Patients are often referred to specialists by a different physician to the one they usually see. We cannot tell why this is the case but it raises questions: Did the patient see the different primary care physician because they were unhappy with the care of their own doctor? Did the referral result because the new physician did not know the patient’s medical history well enough? Would a more formal process of patient registration with a primary care practice (such as has been introduced in Ontario) improve care co-ordination? What do you think?

EMR Progress in Canada: A Reaction to the January 2013 Health Care Matters Bulletin 7

Lynne Zucker is Vice President, Clinical Systems Integration, Canada Health Infoway

I just read the recent How do Canadian primary care physicians rate the health system?, an excellent analysis of the 2012 Commonwealth Fund International Health Policy Survey.  This bulletin provides a comprehensive Canadian context for the Commonwealth Fund results, including clear provincial and international comparisons and data trends from previous surveys. I found it easy to read and informative. 

What did I take away?  While the results for Canada are trending in the right direction overall, Canada is not a global leader in many of the primary care areas highlighted in this survey.

The Health Council of Canada rightly identifies adoption of electronic medical record systems (EMR) by primary care physicians as a bright spot, with adoption rates nearly doubling since 2006.  This good news is tempered by the fact that Canada continues to lag many countries in this category and will have to continue to play catch up.

That said, all countries have work to do with regards to ensuring multifunctional EMR capacity.  These systems have capabilities such as order entry management, generating patient information, generating panel information, and routine clinical decision support.  Some countries with very high overall adoption rates, such as Norway (98 per cent) have much lower scores in terms of multifunctional capacity (four per cent).

International comparison of primary care EMR use

© 2012 Commonwealth Fund International Health Policy Survey

In spite of the challenges ahead, I finished reading the bulletin with a sense of optimism. Why?  I can see how many of the initiatives being planned and/or implemented today will result in even stronger results in the next round of this survey.  More provinces are leveraging the available funds from Canada Health Infoway to launch or grow EMR programs for physicians and nurse practitioners.  With the right combination of incentives and support in place, I expect to see the recent significant growth in EMR adoption continue.  Infoway’s investments in peer support programs and clinician education programs will contribute to an increase in the advanced uses of EMRs. This in turn will impact future survey results.   For example, it will increase the number of physicians who can identify patient groups by diagnosis, lab results or appointment reminders.  Our work on EMR interoperability and the priority many jurisdictions are placing on connecting EMRs to hospitals and other parts of the health system will also result in improved survey results in the areas of notification of emergency visits, information from hospital discharge and reports from specialists.

Recognizing our progress to-date and taking up the challenges reflected by these survey results provides a set of opportunities for Canada Health Infoway and the primary care community. What do these results say to you?

Quality of primary care depends on where in Canada you live

Dr. Tara Kiran is a family physician and researcher at St. Michael's Hospital. She also works part-time as a Primary Care Advisor for the Toronto Central Local Health Integration Network.

Canadians are proud of Medicare and consistently report being satisfied with the health care services they receive. But, perhaps they should be demanding better.

The most recent Health Council of Canada report highlights findings from the 2012 Commonwealth Fund survey of primary care physicians in ten high-income countries. In almost all areas – from access to care coordination to use of information technology – Canada ranks at or near the bottom.

Canada’s poor performance relative to other countries shouldn’t be too surprising. After all, Canada ranked at or near the bottom in a similar survey from 2009. What did surprise me, though, was the considerable variation in quality of primary care among provinces.

Results from Quebec were consistently far below the Canadian national average. Only 22% of Quebec primary care physicians report that their patients can get same or next day appointments compared to the Canadian average of 47% (the lowest national average among all countries). Only 8% of Quebec physicians said they are notified when their patients go the emergency department compared to the Canadian average of 30%.  And only 26% of Quebec physicians said they use electronic medical records compared to the Canadian average of 57% (the second lowest national average among all countries).

In contrast, physicians in Ontario, BC, and Nova Scotia all reported better same or next day access than the Canadian average. Ontario physicians were far more likely to report providing patients with after-hours coverage and sharing this responsibility with other practices.  Physicians in Ontario, BC, and Nova Scotia were also consistently more likely to use information technology in their practice, review their performance against targets, and receive financial incentives for certain areas of care.

Ontario and BC are two provinces that have invested heavily in improving their primary care system. Over the last decade, most primary care physicians in Ontario have joined new practice models, signing contractual agreements with government which require or incentivize them to formally enroll patients and mandate after hours care provision. Ontario physicians in some practice models are financially penalized if their patient goes to a walk-in clinic and financially rewarded if their patients meet certain quality of care targets. Adoption of electronic medical records is subsidized in most models and required in some. And, a province-wide quality improvement program has helped hundreds of physicians improve access in their clinics.

BC took a different but similarly ambitious approach to reform. Since 2002, the General Practices Services Committee– a partnership between the BC Medical Association and BC Ministry of Health – has championed several initiatives ranging from new financial incentives for chronic illness management, changes to billing codes to encourage telephone and email consultation with patients, and a comprehensive practice support program that includes training on improving access for patients.

Other provinces have also dabbled in primary care reforms but as pointed out by the Health Council of Canada years ago, we have not systematically studied the results of reform efforts across the country or spread successful approaches.

The wide range in quality of care measures between provinces should make us question the notion of a “Canadian” health care system. The federal government has defended its hands off approach to health care but without its influence, Canadians living in different provinces will continue to have very different health care experiences – to the detriment of some of our citizens.

It was fantastic to see the British celebrate their pride in their National Health Service at the opening ceremonies of the recent Summer Olympics. We need continued investment and thoughtful oversight of health care from our federal government to ensure we can maintain similar pride in Canadian Medicare.

Primary care at critical juncture

Dr. Brian Goldman is a veteran ER physician and one of Canada's most trusted medical broadcasters as host of CBC Radio One’s “White Coat, Black Art”

When Commissioner Roy Romanow handed down his report on the Future of Health Care in Canada, he had this to say about primary care:

“There is almost universal agreement that primary health care offers tremendous potential benefits to Canadians and to the health care system.”

It’s more than motherhood to suggest that primary care is critical to the health of Canadians.  Many studies have demonstrated that people who lack access to primary care are more likely to have untreated diabetes, high blood pressure, dyslipidemia, and a host of other chronic diseases. 

My own father is a case in point.  Healthy most of his life, he got by on good genes.  Instead of a residency-trained family doctor, my dad saw a superannuated GP who was (frankly) well past his ‘best before’ date.  Oh, my dad had annual check ups.  But I got the sense that the good GP would listen to his heart and lungs, marvel at his resilience, pat him on the head, and send him on his way.

By the time my dad needed some real medicine, he was too busy looking after my mother as she developed Alzheimer’s disease.  It all came crashing down on him a little more than two years ago, when he developed an acute case of pneumonia and had to be admitted to hospital.

This is a guy who had never set foot in a hospital in my lifetime.  But that was about to change – big time.

‘Tip of the iceberg’ doesn’t begin to describe my dad’s medical condition.  Along with pneumonia, the emergency doctor who examined him found that he was in congestive heart failure.  Within the first hour of his arrival in the ED, the ST-segments on his electrocardiogram went up, indicating a heart attack.  An angiogram showed severe three-vessel coronary artery disease that was not amenable to bypass or angioplasty.   So, the doctors put him on intensive medical therapy to manage his blocked arteries and all of the risk factors that caused them.

As far as risk factors go, my dad had the trifecta:  severe dyslipidemia, poorly controlled hypertension, and type 2 diabetes complicated by chronic kidney disease. When he finally got out of hospital, his discharge summary contained seven separate diagnoses.  My dad was sent home on ten prescription medications and a complex regime of monitoring and treatment. 

You see my point.  Even though my dad had a nominal physician, none of his risk factors for serious chronic illness were addressed until well after the fact.  Imagine what it’s like for people who have no access to primary care at all.

As host of “White Coat, Black Art” on CBC Radio One, I’ve seen the consequences of a lack of primary care up close.  In Peterborough, I visited an orphan patient clinic, a pilot designed to give people who hadn’t seen a doctor in years the opportunity to “get a tune up” by a nurse practitioner along with tests and referrals to specialists as needed.  I saw patient after patient whose health had been neglected beyond belief.  Most were like my dad, but worse.  I even saw one older gentleman who received a diagnosis of lung cancer that had probably been smoldering for years.

As Roy Romanow said in his Commission Report, access to primary care isn’t just essential to patients but to the system.  Sooner or later, even orphan patients will end up in the ER requiring far more care than would have been necessary if they’d had access to decent primary care.  That costs you and I a lot of public money.

That’s why I was particularly interested in reading a new report by the Health Council of Canada entitled, “How do Canadian primary care physicians rate the health system?”  The report contains results fro the 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

The problems reported by Canadian primary care physicians are telling.  According to the report, only 47% of Canadian primary care doctors offer same-day or next-day appointments, making them least likely to do so compared to physicians in nine other countries.  The report also found that Canadian physicians are least likely to make home visits or have after-hours arrangements so that patients can avoid a trip the ER.  While the report found several provinces do better than others, the overall picture is one of mediocrity in the area of access.

Beyond access, other problems uncovered in the report point to a glaring lack of efficiency that clearly hampers the delivery of primary care.  Thirty-eight percent of primary care physicians surveyed said they often have trouble getting specialized diagnostics for their patients.  Only 16% of family doctors said hospitals sent them information needed for follow-up care within 48 hours of patients being discharged.  Only 26% said they always receive a report from a consulting specialist.

And, when it comes to self-improvement, family doctors present a mixed bag.  The report found that the use of electronic medical records (EMRs) has doubled to 57% since 2006.  Rates of e-prescribing are on the rise.  However, it’s clear that the power of EMRs has yet to be realized fully.  The report found that overall, only 41% of primary care physicians say they could easily generate a list of their patients by diagnosis – an essential feature for timely patient call-backs and practice audits.

To me, the biggest problem with modern health care is lack of accountability.  This report says primary care is no exception.  Compared to other countries, the report found that Canadian primary care physicians are among the least likely to work in a practice that reviews clinical performance against quality benchmarks.

In my opinion, with this report, we are moving beyond demands for more doctors to asking whether family medicine and primary care are taking Canadians where they need and want to go.

There was no way my dad would be able to carry on health-wise without the care and guidance of a smart family physician.  I will be forever grateful to the family doc who took my dad on as a patient.   At age 89 and with a list of ongoing medical problems as long as your arm, it would have been so easy for any family doctor to take a pass on my dad.  I am especially grateful that he is not just smart but committed to using new technologies and other enhancements to do what he does well even better.

What are primary care physicians across Canada saying about the health system?

Today, we’re excited to release the 7th bulletin in our Canadian Health Care Matters series, which reports on health system performance. For the first time in the series, we report on the perspectives of primary care physicians - who are most Canadians’ first point of contact with the health care system - on how they rate the care their patients receive.

Every year the Commonwealth Fund conducts an international health policy survey, offering comparative insight into health care experiences across countries. Our report looks at results from the 2012 survey of over 10,000 physicians in Canada and 9 other countries. We’ve been pleased to co-fund the Commonwealth Fund surveys for many years, and several key organizations (the Alberta Health Quality Council, Health Quality Ontario, the Quebec Health and Welfare Commissioner, and Canada Health Infoway) have joined us to allow for larger, more representative survey samples across Canada.

In this bulletin, we focus on several key areas of health system performance: access to primary care, coordination among health care providers, the uptake of information technology, and initiatives to drive practice improvement. With larger sample sizes, we were able to compare how health care experiences vary from province to province. We also assessed how Canada ranks internationally, and finally examined how our performance has changed over time using similar survey questions from 2006 and 2009.

Although the importance of primary care has been gaining attention from policy-makers across Canada, we found wide variations in performance among provinces, pointing to the potential for improvement. While provinces have clearly achieved progress in some aspects of care, nationally we continue to lag behind leading countries in access to care and the use of information technology.

As governments across the country continue to invest in primary health care, this bulletin highlights where provinces can learn from one another, and where we might look to international examples for guidance.

Download our report, How do Canadian primary care physicians rate the health system?, and let us know if our findings resonate with you.

Sukirtha Tharmalingam, Senior Policy Analyst, Health Council of Canada

2013 at the Health Council of Canada

Happy New Year to all our blog readers! We’re so glad to have you on board and hope that you will continue to find value in our work.

2013 is going to be an exciting year at the Health Council of Canada, so we wanted to tell you about some of our upcoming projects.

January 18 is the deadline for our Health Innovation Challenge for college and university students. We’ve already received lots of great entries, with more to come! You’ll see the shortlist announcement on March 11, 2013, so stay tuned.

In about two weeks, we’ll release our report called, How do Canadian primary care physicians rate the health system? Results from the 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians. This is the 7th edition in our Canadian Health Care Matter series, and presents physicians’ experiences with the health care system.

In March, we’ll publish a report on health quality improvement, followed by our Progress Report 2013 in May. This is a continuation of our past two Progress Reports (2011 and 2012), and will cover these topics:

• Access and wait times 
• Primary care reform and electronic health records 
• Pharmaceuticals management 
• Health promotion, disease prevention, and public health 
• Aboriginal Health 

This year we’ll continue to add stellar examples of health system innovation to our Health Innovation Portal and on YouTube for those in video format. A Spring focus will be wait times, with plenty of other themes to be covered this year. You can find the portal at www.healthcouncilcanada.ca/innovation and innovation video content at www.youtube.com/healthcc.

In the fall, we will host our annual national symposium. You can have a look at details from last year’s symposium here. We’ll keep you posted on a topic for the upcoming event!

Lastly, late in the year we will release a report on Aboriginal seniors. This is part of our body of work on Aboriginal health, which includes our last two reports on Aboriginal maternal and child health, and urban Aboriginal health care.

Thanks for a great 2012 – we hope you will stay with us for all the activity of 2013! Remember to subscribe to the blog and sign up for our e-newsletter to stay in the loop on reports, webinars and other activities

Creating cultural safety for Aboriginal people in urban health care

Dr. Catherine Cook is a Councillor with the Health Council of Canada and the Vice President of Population and Aboriginal Health for the Winnipeg Regional Health Authority in Manitoba. Dr. Cook is also Métis. 

**This is an editorial initially published in the Winnipeg Free Press.

Most Canadians are aware that many First Nations, Inuit, and Métis people have poorer health and more challenging living conditions than the larger Canadian population. In 2010, the Health Council of Canada started a multi-year project to learn about programs and strategies that have the potential to reduce these health disparities between Aboriginal and non-Aboriginal Canadians.

Last spring, the Health Council of Canada travelled across the country to learn more about health care for Aboriginal people in urban settings. Approximately half of Canada’s 1.3 million Aboriginal population live in cities, but they don’t use mainstream health care services at the same rate as other Canadians. Aboriginal people are less likely to seek help when they have symptoms and more likely to be diagnosed at a later stage of disease than non-Aboriginal people, a delay that can make treatment more difficult or no longer possible. Although this has been documented in the research literature, it’s not as well known by health care service providers, that many Aboriginal people don’t trust the system enough to use it.

The Health Council held meetings with health care providers and policy makers in Saskatoon, Winnipeg, Vancouver, Edmonton, Toronto, Montreal and St. John’s. Many participants were from First Nations, Inuit, and Métis communities, and they generously shared both their personal and professional insights and experiences.

Participants described Aboriginal people’s feelings of discomfort, powerlessness, and fear when trying to use the health care system. To quote one participant, “they have had experiences like being treated with contempt, judged, ignored, stereotyped, racialized, and minimized.” One story exemplified the type of racist assumptions that many Aboriginal people experience. An injured Aboriginal man was brought to an emergency department, where he was not allowed to lie on a bed. When a physician asked why the patient was not lying down, the nurse explained that the man was dirty, and would just return to the street after leaving the hospital. In fact, the patient was employed, owned a home, and had been attacked on his way home from work.

Most health care professionals are well intentioned and unaware that they are acting out deeply entrenched stereotypes of Aboriginal people that exist throughout Canadian society. Health care professionals may not realize that they are the reason a First Nation, Inuit or Métis patient does not follow a treatment protocol or doesn’t return for appointments.

Despite these challenges, there is good news – very good news. Across the country there are programs underway to create health care environments that are free of racism, where Aboriginal people can feel welcome and safe. For example, in recent years there has been an increase in cultural competency training for health professionals and an increase in the use of Aboriginal support workers who serve as cultural interpreters between Aboriginal patients and the mainstream health care system. These programs and others are described in the Health Council’s recent report, Empathy, dignity and respect: Creating cultural safety for Aboriginal people in urban health care.

Canadian health care systems have a responsibility to reach out to populations that are suffering from poor health or not using services, to find out why, and to adapt health care services to better meet their needs. Making specific efforts to ensure that the health care system is culturally safe for Aboriginal people is important not only to improving their health - it is also a concrete way to show respect and work towards reconciliation.