Health Committee on March 12th, 2015

[The Chair, Conservative, Ben Lobb]

Well done. We're right at seven minutes, maybe just five seconds over.

Ms. McLeod, you're up.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

I too would like thank all the witnesses as we bring a very interesting study to a close.

First of all, I'd perhaps want to start with Sabrina Wong from the UBC Centre for Health Services and Policy Research.

I want to pick up on two of your recommendations or comments. You talked about researching around payment models and how that facilitates or doesn't facilitate collaborative care.

Certainly, one of the perhaps most creative examples I ever saw in terms of a funding model within B.C. was the adjusted clinical group payments based on that Johns Hopkins modelling, where they tried to pay a team based on the numbers and the acuity of the patients. It seemed to flounder and flop. I always thought that it was actually quite a good way to compensate for a model of care.

Can you talk a little more about what research has been done and what research hasn't been done? I'm very curious.

[Sabrina Wong]

That's a really good question. Pay attention to the Naylor report that Dr. Tholl also mentioned. That's going to be released soon. I think they're still working on that committee.

There is some work that's coming out, mostly from the U.S., the U.K., and the Netherlands. I believe they have thought about using bundled payments. Bundled payments and mixed payments pay for episodes of care. You wrap the bundle of payments around the episode of care. I think this works really well for defined cases, such as a hip replacement, where you know what some of the costs are going to be. What you do is that the payment pays for all the providers who would take care of that patient for that episode of care.

What it does is it helps people to collaborate across the different sectors, the acute care sector and the community sector, and there are agreements that are worked out that can then.... There is the risk-sharing across the places of care. As well, there could be gains if the care goes well for the patient. That's one thing. Bundled payments may not work as well in terms of episodes of care in a place like primary care, but they could work well in terms of thinking about paying for a year-long bundled payment to primary care, extending the time out 60 or 90 days.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Again, that was a model that I thought showed great promise but floundered. Maybe there wasn't a readiness at that time. Maybe the readiness is further along.

For my next question, I know that one of your other recommendations was around electronic medical records. It's interesting, because the federal government has provided significant funding over the years in terms of what we're doing and where we're going. We've seen some physicians go on their own and some of them go through support, and there are provincial programs. I guess my bigger thought is, are we getting integrated in terms of what needs to be readily available?

I'll use an example. Today there are comments about different provinces and different immunization rates. Public health nurses may be doing immunizations in one location and family doctors.... Half the time, even the family doctor doesn't know what immunization has been done, because we don't have good system connectivity. Are we getting anywhere with that? What is your perspective? You did highlight that as a recommendation.

[Sabrina Wong]

In terms of interoperability across different sectors in public health, acute care, and primary care laboratory data, we need to work towards that. I think we're starting to think about integrating our systems. There's going to be some work done in the Vancouver Island Health Authority to try to do it so that they get to electronic health records.

In terms of electronic medical records, there is the Canadian Primary Care Sentinel Surveillance Network, the CPCSS network, where we do extract data from different electronic medical records across the country and can then start to tell you about things such as immunization rates or who has been immunized, those kids who have a primary care physician.... There is some movement in terms of being able to utilize the electronic medical records not only at the point of care, but for surveillance as well.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Of course if the public health system does it rather than the primary care physician, there is that whole connectivity.

There is not enough time for many questions that I'd like to ask.

Mr. Durafourt, you talked about loan forgiveness. I thought your comments were interesting in terms of the on-the-ground practicality of what happens. I have actually talked to some other physicians, some resident doctors. There is your practical aspect, but my question to them was whether they thought that loan forgiveness was helping to drive behaviour. That's part of the purpose of the changes we've made representing a number of rural communities, which are very desperately shy of physician services. That little carrot out there for a debt-ridden student, which I always thought sounded pretty good, is it your sense that it makes a difference for the choices that students make, or would the ones who were going to go rural, the 1,150, have gone rural anyway?

[Bryce Durafourt]

It's a great question.

We don't have data to know whether this program is encouraging more family physicians or nurses to move to these areas. What we do think is that if we want to get physicians to rural areas, we need to do it by having incentive programs rather than mandatory return of service agreements, or disincentive programs, or limiting the ability of physicians to practise in urban areas. We want people to go to areas where they will want to stay and practise. That could mean also doing a better job of recruiting medical students from rural areas, because we know that they are twice as likely to return to practise in rural areas than their urban counterparts. The bottom line is we don't have that data, but we certainly think that it helps.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Great. Thank you.

[The Chair, Conservative, Ben Lobb]

Ms. Fry.

[Hedy Fry, Liberal, Vancouver Centre, BC]

I want to thank everybody again for coming and presenting some very interesting stuff.

Cathy just stole most of my questions, so I won't be redundant and go over them, but I want to ask Ms. Wong about some interesting concepts that she brought up.

One of them is to look at how you monitor the standards for competencies when you have a multidisciplinary team. Given that the competencies are going to be very different, how do you see that happening? Are there models we can look at?

You talked a little bit about looking at best practices. Who do you think is best placed, in fact, what level of government is best placed, to actually put forward these best practices? How do you encourage people to take on best practices? What are the incentives you would use to get people to take on best practices so we don't keep reinventing the wheel all the time?

[Sabrina Wong]

Those are really good questions.

In terms of the competency-based question, we actually have a grant in to the Canadian Institutes of Health Research to try to study this some more. What we want to try to do is map the dimensions of care and the indicators particularly in primary care to competencies, because we know that nurses and even medical office assistants can help to move towards timely access to care. That should not all be an accountability attributable only to physicians. It's really a team-based approach that we need.

What we're trying to do is to move towards performance measurement and monitoring to have a system whereby we can actually look at creating information systems for the indicators and then to also map the competencies on. That would take working with the different regulatory bodies.

In terms of your other question, I think William Tholl talked about the fact that Dr. Ivy Bourgeault, is heading up the Pan-Canadian Health Human Resources Network. They are actually collecting best practices across the country. To be able to then take that a step further would be to try to really assess those that could be scaled up.

We have to get away from thinking that each province is so different and each context is so different and try to figure out how we can learn from each other. I think the initiative, the strategy for patient-oriented research and the primary and integrated health care innovations networks, should try to do some of that where we can try to create a continuous learning environment whereby we learn from each other and scale up those innovations that work and actually get rid of the ones that don't work early on; so turf them sooner rather than later, rather than let years and years go by.

[Hedy Fry, Liberal, Vancouver Centre, BC]

That's absolutely true. The question is who is going to bell the cat? Who's going to decide how you turf and what are the incentives and the disincentives? What are the incentives to adopt best practices, to measure outcomes, and to look at indicators for measurement, or to keep an old practice because it's simply easier to do even though it doesn't give the right outcomes?

What are the incentives and disincentives that one would put into place? No matter what a research body finds, it doesn't have the ability to do incentives and disincentives.

How do you see that coming about, the practicality of that?

[Sabrina Wong]

I think you report it to the public and allow the public to have some input. These are things the public isn't necessarily aware of. There ought to be some public reporting of their dollars going into the health care system. If we can report it to them in a way that's meaningful, I think you would get a lot of traction.

This has been done in Australia, where they did a national immunization report. What the National Health Performance Authority showed was that in one state that is largely middle class they were the ones who had the lowest immunization rates. What happened was the state government, as a public protection, legislated that they had to have their kids immunized before they went into the school system.

That was kind of a thought-out thing. There's obviously consequences to that as well, but I do think public reporting would be helpful.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Okay, thank you.

Dr. Bhatla, I want to ask you a question about this scope of practice, i.e., virtual, going to the patient instead of the patient coming to you, which could save a ton of money especially in remote and rural care.

How do you see this gaining traction? Is there enough money to make this become a national initiative or at least a provincial north-south initiative? Do you think this could happen? How long do you think it would take to get a system like that up and running, and optimizing the system to help with, for example, the demographics of some provinces that have extreme distance between cohorts of people living in small communities?

How can we get that to happen? How long will it take to move that? Is there enough work done on it?

[Dr. Raj Bhatla]

I'm tempted to say it's a money issue, but I don't think it is. It's a situation where you want to create systems that do connect with each other. We've talked about interoperability.

I'll give you an example out of dermatology that's interprofessional, can save tons of money, and has done great with wait times. It's a simple solution where you start using technology to take pictures of a dermatological lesion. You send them electronically safely to a centre where dermatologists can look at them and decide which ones need further review. Some do and will need to see a dermatologist, but there will be a large percentage that can be looked at and treatment recommendations given right away to family doctors to execute.

That requires the technology to potentially go between provinces, or even between institutions, depending on your province. It requires someone at the other end who can take a picture, usually a health care provider, but not a physician necessarily, and a way to store the data and transmit the information safely and securely.

It doesn't cost a lot of money, but you have to have those systems working.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Can the Canada Health Infoway pull that together?

[Dr. Raj Bhatla]

I think they can do an even better job doing that. I wouldn't be an expert on Canada Health Infoway, but I think that could be one of the facilitators to allow this to happen and has a huge potential.

[Hedy Fry, Liberal, Vancouver Centre, BC]

I'm looking at you.

[The Chair, Conservative, Ben Lobb]

Do you have another question?

[Hedy Fry, Liberal, Vancouver Centre, BC]

It was not so much a question, as to get Mr. Tholl to elaborate on his determining optimal scope of practice, and that the current system does more to hinder that than to help it to happen.

Can you expand on that statement?

[William Tholl]

Sure, in the limited time available, I have a couple of points.

To pick up on the earlier discussion around SPOR, I agree fully with Sabrina when she says we have a lot to learn from one jurisdiction to another, but right now there's no clearing house.

I'm on the SPOR review panels, and there are 10 separate SPOR business plans, but there is no provision for the sharing of that information that's built into the SPOR. I say we need the super-SPOR, something that sits above the individual SPORs and the support unit executive directors. That would be one example.

A second example is, as I mentioned, what I think is a great report, “From Innovation To Action”, prepared by premiers Ghiz and Wall. The initiative stopped in July 2012 because of a lack of ongoing secretariat support.

Those would be two examples of learning what works in terms of optimal scope of practice. The Taber, Alberta, example was also given in that report. There's no reason that we can't generalize the key learnings from the Taber, Alberta, primary care network, as another example.

There's no clearing house at present. Ivy has one place where we were tracking these data, but its funding is being terminated at the end of March.

[The Chair, Conservative, Ben Lobb]

We've had a great discussion.

That'll do it for today, and we'll see everybody back in a week's time.

The meeting is adjourned.