Aspiring to a new standard of healthcare for Canada
Chief Medical Officer,
Information technology (IT) has a fundamental role to play in transforming Canada’s healthcare system. Over the past decade, large investments and incentive programs have helped to establish a foundation of IT infrastructure and systems that enable healthcare providers to shift from manual environments to more efficient approaches that deliver up-to-date and accurate information.
Despite considerable investment, many systems remain islands of information unconnected to each other. The fragmentation of health information is a major inhibitor of collaboration between health providers. Further, technology adoption remains anemic, with many physicians continuing to rely on paper in their practices.
Nevertheless, the investments made to date have created a foundation for us to move to a new stage of systems investment. By introducing new policies and programs that are purpose-built to move beyond technology adoption to achieve meaningful health outcomes, we can create opportunities for Canada to improve healthcare delivery in a fiscally sustainable way.
This paper explores some of these opportunities. It highlights international examples of programs and policies that could be adapted for the Canadian context and examines the impact of incentive programs to-date in provinces across the country. Finally, a three-stage model presents a pragmatic approach to achieving a new standard of care for the benefit of all Canadians.
Current state: The healthcare playing field in Canada
Healthcare is the largest industry in Canada and the playing field is complex. Fourteen health systems — 13 provinces and territories and one federal (that includes First Nations and military)— operate autonomously. Transforming the health system will require many parties working toward a common goal. Despite this complexity, the general consensus is a desire for fundamental change, not incremental improvement. Here’s why:
- Canada is trending towards spending a quarter of a trillion dollars annually on healthcare by 2020.I
- Provincial health spending in Ontario and Quebec already consumes more than half of total program spending. By 2017, that will also be true for British Columbia, Alberta, Saskatchewan and New Brunswick.II
- Treating chronic disease consumes more than half of all direct healthcare spending. This pressure on the healthcare system will intensify in conjunction with the aging population,which is expected to nearly double to 25% of the population by 2036.
However, healthcare costs are only one aspect of Canada’s complex topography. When it comes to health system performance, Canada ranks 10th of 11 countries compared in the Commonwealth Fund’s 2013 International Health Policy Report. Moreover, patient experience with the healthcare system is under strain and declining. Canada ranks 7th among 15 peer countries with respect to its medical error incident rate, has the longest access times to a doctor or nurse when in need of care, has the most extreme delays for specialist appointments, and has the highest use of emergency rooms, compared to the 11 developed countries in the Commonwealth Fund’s Report.
Funding policy and information technology are two mission-critical levers for achieving change that can lead to sustainable results.
Leading by example:
Incentive programs around the world
It is early days for policies and programs that support improved health outcomes. While rigorous evidence of costs and impacts are not fully available at this stage, there is a strong correlation between the use of health IT and better healthcare: countries with the highest performing healthcare systems also employ health IT extensively to improve care delivery and meet key performance indicators (KPIs) that are regulated through government policies and incentive programs.
While the details of these programs vary, they have three key elements in common:
- Policies hold healthcare practitioners accountable for achieving specific levels of performance against key performance indicators (KPIs).
- KPIs fall into distinct performance-based categories, such as cost savings, better quality patient experience or improved chronic disease management.
- The use of electronic medical record (EMR) technology by primary care clinicians is central to achieving performance targets.
In the UK, which ranks first in health system performance according to a 2014 Commonwealth Fund Survey, governments have stimulated change by paying a premium to physicians that attain a level of practice performance as defined by the Quality and Outcomes Framework (QOF). Early indications show that the QOF has resulted in better recorded care, enhanced processes, and improved outcomes in managing chronic disease.
Today, 98 percent of UK physicians use EMRs. In addition, electronic transactions between primary care physicians and pharmacists are widely used for prescriptions, and are also used among healthcare professionals for the storage and distribution of digital images, such as scans and x-rays.
Similarly, in Sweden, which ranks third in health system performance, more than 90 percent of primary care physicians use electronic patient records for diagnostic data, and about 90 percent of prescriptions are sent to pharmacies electronically.III In general, both the quality of IT systems and their level of use are high in Swedish hospitals as well as in primary care.
EMR solutions represent the most significant opportunity for health IT to drive healthcare performance improvement at a systemic level.
The UK approach
The UK has implemented the Quality and Outcomes Framework (QOF), which includes an annual reward and incentive program based on detailed general practice performance targets. The QOF covers four main domains, each with a set of performance indicators against which practices score points according to their level of achievement. The four domains are:
- Patient experience
- Additional services
Clinics are awarded points for managing common chronic diseases, such as asthma and diabetes, how well the practice is organized, how patients view their experience at the clinic, and the amount of extra services offered, such as child health and
There are early indications that the framework has resulted in better recorded care, enhanced processes, and improved outcomes, such as the control of glycated haemoglobin (HbA1c) and high blood pressure in people with diabetes.
In the Netherlands, which is among the first countries in the world to develop a comprehensive tool for reporting on 125 indicators related to quality, access and affordability of healthcare, 97 percent of practitioners use EMRs in their practice. Information for 8 million patients (about half the population) is exchanged via regional electronic health records, and a national, searchable system referred to as “healthcare Google” makes records available through a searchable database accessible to eligible practitioners throughout the country.
In the US, since the HITECH act (Health Information Technology for Economic and Clinical Health) was enacted in 2008, physician adoption of EMR technology to meet five meaningful use core objectives has increased by at least 66 percent. Of particular note, the percentage of physicians engaging in e-prescribing doubled to 73 percent by 2012, and physicians’ capability to meet the four other meaningful use core objectives related to improving quality, safety and efficiency grew by 66 percent to 90 percent.IV