#PrimaryCare2025 vision calls for better connectivity

Connected care through a better integrated digital health infrastructure in Ontario is a key part of the vision for a reformed healthcare system outlined this week in a white paper released by a group of primary care leaders.

Primary Care 2025 lays out a roadmap for health care in the province based on inter-disciplinary primary care hubs where providers would have responsibility for geographically defined populations. Linking primary care to all other aspects of care in the community would be facilitated by “an inter-operable electronic medical record (EMR).”

In discussing how care has been provided during the COVID-19 pandemic, the study authors note that the lack of shared EMR created a challenge of data access. “While adoption of electronic medical records in Ontario ranges, many physicians are still using EMRs in the same fashion in which they used paper records: as a standalone patient record accessible only to the family physician in that practice,” the report states.

“(A) robust cross-platform referral management modules would help coordinate referrals to eliminate costs or delays to care while helping to coordinate diagnostic workups to avoid repetitive and unnecessary testing. A shared database enables communication among providers as well as supporting systematic sharing of best practices. The economies of scale can be significant.”

The report goes on to say that implementing an EMR that contained both health and social care data by 2025 “would provide more seamless care for patients who require care by multiple sectors, facilitating collaboration between the primary care provider and providers working in home, community, mental health and addictions care.

The study authors point to a particular issue in Ontario with the separation of public health labs from primary care EMRs. “The inability to understand risk for a whole population for which primary care has a shared responsibility is a challenge that must be overcome in a post pandemic era. This is one example of the need to strengthen the connection between primary care and public health.”

The report as calls for the ability of all providers including those providing homecare to be able to communicate via instant messaging. “In the pre-pandemic era, most Ontarians did not have access to virtual care via phone or video appointment. Only small numbers of Ontario patients were able to communicate via email with their primary care team.” The report also contains a number of other recommendations intended to reform the system from medical education to more consideration of the social determinants of health

The Generalist Manifesto: Reforming primary care in Ontario

A vision of health care in Ontario after the COVID-19 pandemic based on interprofessional, team-based primary care hubs providing care to geographically defined populations has been published in a white paper by a leading group of primary care physicians and nurse practitioners in the province.

The report comes in a global climate of ongoing concerns about the lack of physicians choosing to practice general family medicine.

Describing themselves as “an independent group of Ontario primary care clinicians, leaders and researchers” the authors of Primary Care 2025 include such prominent Ontario family physicians as Drs. Tara Kiran, David Kaplan, Meridith Vanstone and Sarah Newbery, prominent nurse practitioners and representatives from the Association of Family Health Teams of Ontario and the Ontario College of Family Physicians.

The group presents a series of recommendations which places generalist primary care at the centre of a reformed health care system. They note their model is based on the concept of the Patient Medical Home which is already widely endorsed by medical associations in Canada and advances the development of Ontario Health Teams which have already been established in the province.

The authors acknowledge the approach may be challenging to implement. It is likely to prompt many questions from fee-for-service primary care doctors (who make up 25% of primary care physicians in the province), specialists and those working in the acute-care sector. However the group’s authors state that addressing one of the province’s key priorities – the elimination of hallway medicine in hospitals “cannot happen without an investment in primary community care.”

The report discusses primary care in the province before, during and after the COVID-19 pandemic noting that “the disruption of the pandemic galvanized a cultural shift away from many embedded assumptions about how different elements of the healthcare system should work.”

The core recommendation of the report is the creation of primary care hubs “with responsibility for 100% enrollment of a geographically defined population. This goal would be facilitated through blended capitation payment models for family physicians “which will be matched with resources to establish and maintain a high-functioning team of interprofessional care providers.” This implies province-wide expansion of the type of family health team model which had been introduced into the province but is currently not accepting new teams. The report notes There is a 10-fold variation across Ontario in access to team-based care…the patients least likely to be enrolled in a primary care team are those who are poor, new immigrants, and medically complex.”

“Within 6 months, we recommend that patient-enrollment models are opened to new graduates, and team-based resources are expanded to those Ontario Health Teams s which are currently poorly resourced. … By 2025, all patients should have access to team-based care that is appropriate to their needs, no matter what setting they live in,” the report says. Referring to the estimated 1.5 million people in the province who don’t currently have a primary care provider, the report said the goal is for “all citizens in Ontario to be
assigned to a most responsible provider for their care delivery.”

In discussing the pandemic, the group notes that fee-for-service family physicians in the province “experienced significant challenges in being able to manage their practices and sustain care through the pandemic because of the directive to cease non-essential services. This left these practices with no income. In contrast, physicians remunerated through patient enrollment models continued to receive payment for their practice population and were not at risk of needing to close their clinics because of lack of funding.”

Specifically referencing the need for personal protective equipment (PPE), the report stated “many, and probably most, practices in Ontario found themselves without PPE supply sufficient to be able to see patients safely in person, even many weeks into the pandemic. Primary care was the lowest in the priority for receiving pandemic or emergency supplies from government stores.” The group goes on to say that this lack of PPE “is just one illustration of the need for networking and infrastructure support for primary care providers within geographical areas. Primary care practices should be networked, with each network recognized as an important partner within their Ontario Health team.”

The group specifically references calls for primary care practices to offer care on a 24/7 basis stating that “we encourage the use of multiple measures of access that are patient informed, as research has shown patients do not always prefer the “same day or next day” metric of access commonly used by news media and politicians.”

It also says that the pandemic “laid bare “the importance of the social determinants of health, and the vulnerabilities that many of our patients face related to employment, housing, transportation, race, and racism. Embedding primary care, social and health services in a medical neighbourhood will also encourage the delivery of trauma-informed culturally safe care and begin to address some of the structural determinants of health such as racism.” The report added that reforms will facilitate social prescribing by establishing partnerships with established agencies.

The report calls for better use of digital technologies to support the provision of connected care calling for the Creation of an integrated digital platform, “inclusive of home care, acute care, mental health and community support services to support a single, easy communication system for all primary care providers in the network integrated into primary care electronic medical records (EMR)s.

The group also calls direction attention to medical school training and would like to see “record numbers” of medical students choosing generalist primary care as a career by 2025. “Specifically, we are not targeting family medicine residency as a choice, but the choice to pursue comprehensive generalist care after graduation. Policy incentives will be needed to encourage family physicians to combine their area of focused practice with a generalist practice or with strong collaboration with generalists, rather than a retreat into a very small clinical area with limited community relevance and connection.”

The report also makes a strong commitment to involving patients and caregivers in care noting how “after significant improvements in patient and family-partnered care over the last decade, including strong shifts to co-designed care in many places, the perspectives of patients and families were largely excluded from COVID catalyzed changes to the healthcare system.” The report says there is an immediate need to acknowledge the importance of meaningful patient partnerships including the important role of caregivers.

The report’s authors acknowledge the proposed changes we propose in this report are likely to result in a loss of professional autonomy for family physicians because of a loss of choice in how they arrange and organize their practice. They also not that the group preparing the report did not include physicians working in a fee-for-service model, or patient or community stakeholders, “although we believe that as our recommendations move forward, their input about operationalization will be essential”.

“While the cost of change may be painful, it will be nothing compared to the cost of not changing,” the report concludes, with the group noting the white paper is intended to start a conversation on the issue.

Points to Ponder (#HIMSSEurope20 – Day 4)

Inspiring speeches and provocative statements marked the the fourth day of plenary sessions at the virtual HIMSS Europe 20 conference.

From the always quotable inspirational remarks by Erik Gerritsen, Vice Minister for Heath, Welfare and Sport in the Netherlands to bold statements about the role of nursing in digital health by Dr. Pamela Cipriano, 1st Vice President, International Council of Nurses and  Dr. Crystal Oldman, chief executive for The Queen’s Nursing Institute in the UK there was no shortage of eloquence.

But I would like to feature comments from two less prominent speakers who nonetheless challenged attendees to think more deeply about both the role of digital health in care and also patient advocates.

Sergiou (l) and Dr. Serra during HIMSS Europe digital session

Both Dr. Guillem Serra and Theo Sergiou spoke at a session on community based care. Dr. Serra is a Spanish physician and CEO of MediQuo, an app with more 600,00 downloads designed to allow physicians to contact their patients by video, telephone and/or SMS. Sergiou has been a cancer patient since an early age and at 19 years old  is now a member of the NHS Youth Forum and a patient advocate.

First Dr. Serra (abridged):

When I used to practice medicine, I used to talk to my patients a lot using WhatsApp. I think that the success stories in the digital world are based in human interaction. We can see it in Instagram and WhatsApp and Facebook and even in TikTok. All of these success stories come from communities, they come from relationships. They don’t come from replacing users with chat bots. I don’t like the idea that the face-to-face visit should be copied in the digital world. I believe that the the relationship between doctors and patients in the digital world should be quite different. When I’m talking with my patients in the digital world I’m not doing the same thing that I’m doing in a face to face visit. We launched MediQuo to be the replacement of WhatsApp in health care; to be an easy way for patients to talk to doctors and have immediate access. Patients don’t have problems every day, or every week, or even every month (but) to be successful in the digital world, you have to engage the users every day, every week, every month. So we created the communities. They have the same rules of WhatsApp but are managed by health care professionals; peer to peer communications between patients that share the same interest as you, anonymously. And with this, we multiplied our engagement in the app today so that today 20% of our users who come to talk to doctors actually join these communities.

From slides by Dr. Serra

And Sergiou discussing patient advocates:

I would say I’ve kind of been indoctrinated into the healthcare mindset. So I won’t be the best person in about a year’s time to sit and be a patient advocate. I will still have my patient experience but I’m slowly become a professional. (It should be) like schools in the UK have governors, who are parents and they constantly change to keep that fresh, unique current experience there… Throughout COVID it has shown how it used to be where the only way to engage patients was to get them angry. That’s why a lot of patient advocates are very angry people. It was so much effort that only the people that were truly angry were the ones getting to the finish line. Whereas now, I’ve learned that this is changing and you’re getting a lot more people with a variety of experiences.

You may agree of disagree with some or all of the above but the speakers have raised issues worth pondering – much like every other presentation we have heard this week.

AI and the Giant Rabbits of Helsinki (#HIMSSEurope20 – Day 3)

When we visited Helsinki last summer to attend HIMSS Europe, we were amazed while visiting the botanical gardens to see several large rabbits. I mean, these things were huge – perhaps mutant Arctic hares conjured by Finnish wizards.

I recently discovered the reality was much more prosaic. For more than 30 years, the city has been dealing with an infestation of escaped domestic rabbits which have never been controlled and the rabbits we saw were just an example of this.

And so, AI.

At HIMSS Europe 20, which should have been held in Helsinki again, but thanks to COVID-19 has become a virtual experience, the majority of plenary sessions on this third day of the conference were dedicated to discussing various aspects of artificial intelligence or machine learning.

One of the key messages to emerge from those sessions is that AI is no longer something marvellous (hence the extremely tortured analogy to the giant rabbits). Rather, the speakers and panelists positioned it as another tool which needs to be fitted into the spectrum of useful technological aids to make clinicians work easier and improve health outcomes.

“AI is not magic so what it can do should not be overstated,” said David Champeaux, a leader in digital and AI innovation in health care and currently chief growth officer for Cherish Health. Valentin Tablan, chief AI officer at IESO Digital Health made the same point stressing that people continue to have unrealistic expectations of AI and there needs to be an acknowledgement that AI is fallible.

AI is really just another form of data-based technology, said Dr. Indra Joshi, director of AI at NHSx.

Speakers at HIMSS stressed that the main value of AI would be in augmenting the existing workflow of clinicians. This more mundane outlook is supported by a survey released by Accenture at this meeting last year, which noted the main investments in AI in health care will come in the administrative sector.

Just as discussions at this meeting yesterday centred on the need for trust and transparency to support data sharing, so speakers today similarly spoke of the need for public trust in how AI functions. In Canada we continue to depend on often over-hyped media reports on AI advances. In contrast, an initiative from the University of Helsinki and the Finnish company Reaktor translated into all EU official languages and made available to more than 500,000 students basic education about AI.

Similarly, Petra Wilson, European Program Director for the Personal Connected Health Alliance noted that clinicians needed to have confidence that the AI applications they use are safe and appropriate for the task at hand. Clinicians will only accept AI if it makes their life easier and fits into existing workflows, said Dr. Mathias Goyen, chief medical officer for GE Healthcare EMEA.

Perhaps even more radically, Christopher Ross, CIO for the Cleveland Clinic said there needed to be recognition that not every clinical problem or situation needed “an AI cannon” pointed at it if when similar technologies can do the job.

Despite the general theme of deglamourizing AI there remains an aura of excitement and anticipation around the promise of this technology in health care. A number of AI-based clinical apps were demonstrated during the day and Ross noted there are 200 projects involving AI in various stages of development at the Cleveland Clinic. Dr. Joshi also noted that the NHS has just recently completed a competition to select several AI-based projects for development. The reframing of the role of AI in healthcare already seems to be gaining acceptance in a broader clinical audience. Results from a Philips survey of 500 young physicians and nurses in 5 countries released this week showed that since COVID-19, telehealth has overtaken AI as the technology that would most improve their experiences.

Privacy vs. the public good: The delicate health data balance (#HIMSSEurope20 – Day 2)

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“Trust and transparency.”

One couldn’t write a summary of the second day of proceedings at the virtual HIMSS Europe 2020 conference without starting with those words. The phrase was used repeatedly by speakers during keynote sessions of the day which focused squarely on health data and how it needs to be shared to support population health and improve health outcomes.

Much of the unspoken framework for the discussion was provided by legislation specific to the European Union governing the collection and sharing of patient data, especially the General Data Protection Regulation adopted in 2018. But common themes of the need for governments and health organizations to have the trust of patients and be transparent in their planned uses of personal health data would certainly resonate with North American audiences.

“Trust is not something you can change in weeks or months. You must show again and again that health data is protected and will be used judiciously,” said Dr. Ran Balicer, professor of public health and founder of the Clalit Institute in Israel.

While all sessions stressed this theme it was clear the sentiment of this particular conference audience favoured data-sharing for secondary purposes. Polled on whether to enable efficient global data collaborations, privacy regulations should be temporarily adjusted and lowered in times of pandemics and health crises, 46% of respondents replied positively, with others evenly split between disagreeing and not knowing.

“Our new world in the use of data … really depends on the free availability and interchange of data between different organizations” said Dr. Charles Alessi, chief clinical officer for HIMSS. “Data is the fuel for change in our health care system and we want to make sure we have good access to that data,” reiterated Petra Wilson, European program director for the Personal Connected Health Alliance.

Sessions on population health and precision health demonstrated the scope of health data has broadened significantly in recent years to incorporate not just lifestyle data but also information on the social determinants of health. Dr. Mahmood Adil, medical director of Public Health Scotland, gave a brief but compelling presentation about how Scotland is gathering these data regionally and using it to improve health outcomes.

While a discussion on precision health and the use of algorithms to support personally driven decision support and provide proactive care sounded futuristic, Dr. Balicer says this is already a reality.

As has been the case since the beginning of the week, the COVID-19 pandemic coloured the nature of proceedings. Once again, the emphasis was on the positive impact of the pandemic – in this instance, evidence that public willingness to share their personal health data appears to have increased since the onset of the pandemic to speed tracking and help in vaccine development.

Mary Harney, former minister of health and children in Ireland, said people should view the sharing of their personal health data as an investment in themselves as it would contribute to initiatives resulting in better health.

Following another day once again very short on direct patient participation, the sessions ended on a positive note for patients.

“Keep fighting for your data,” said Dr. Erwin Böttinger, professor and chair of the Digital Health Center, Hasso Plattner Institute, reiterating a point made earlier by Dr. Mark Davis, chief medical officer for IBM Watson Health who said it was fundamentally important for individuals to have control of their own health data.

(Photo: Helsinki Central Station – in honour of the city where this conference was to be held)

COVID-19: It’s all silver lining (#HIMSSEurope20 – Day 1)

Cheerleading about the benefits of digital health defines any Healthcare Information Management Systems Society (HIMSS) conference – and #HIMSSEurope20 is certainly no exception.

Having been postponed from June and moved from Helsinki into the virtual world because of the COVID19 pandemic, what makes this year’s HIMSS Europe conference unique is that there is actually lots of cheer about in the digital health community right now.

The requirement that health care systems transform from in-person to virtual visits to maintain physical distancing and the safety of both patients and physicians as well as other providers has forced health care around the world to embrace virtual care and digital health solutions to an unprecedented degree.

This silver lining to the current pandemic was the main theme throughout the first day of plenary sessions at the conference hosted in a sophisticated digital setting with attendees from 98 countries around the world.

This was not the venue to discuss the COVID19-related death tolls in Italy and Spain and elsewhere, the elderly dying unattended in long-term care homes, and the ominous threat of the second wave. Rather, hyperbole ran rampant as representatives from the UK to Portugal discussed how physicians and hospitals adapted to the new reality within days if not weeks. “No country would have been able to manage COVID without digital health” said Lav Agarwal, joint secretary of the Indian ministry of health and family welfare.

Second to virtual care as a topic were examples of how electronic records and patient portals facilitated the efficient management of COVID testing and contact tracing and bed management in critical care. However, speakers such as Dr. Tracy Pankhurst, chief clinical information officer at University Hospitals, Birmingham also noted that the public would be “horrified” at the inability of many systems to collect and process the most basic data needed measure the pandemic in part because of the lack of interoperability and common definitions.

To their credit, many speakers from HIMSS CEO Hal Wolff and World Health Organization regional director for Europe Hans Kluge on down touched on the inequitable impact of COVID and the disproportionate toll it has taken on the disadvantaged – coupled with the need to make sure digital solutions bridge rather than widen this gap.

In panels weighted heavily with family physicians and critical care specialists, the key role primary care physicians have played in adapting their practices to digital visits and in managing the pandemic was also an underlying theme. Striking was the situation in Catalonia detailed by Dr. Josep Vidal-Alaball, head of the Central Catalonia Innovation and Research Primary Care Unit. He described how many small family physician offices had to close as physicians and staff went into quarantine while at the same time family physicians had to assume care in long-term care homes.

Another digital health theme touched on first again by Wolff was the need to balance the protection of individual privacy with the desire to have aggregate data to support population health initiatives – a discussion which seems to have dropped into the background in Canada.

Once again in the early stages of this conference, the leading positions held by Finland and Estonia in implelmenting digital health solutions as well as impressive scaling of digital health in the British National Health Service were in evidence. But it was also noted that around the globe the implementation of telemedicine has been inconsistent both between countries and within jurisdictions.

While Canada is obviously not a major player in this Eurocentric conference it is interesting that we are one of the only two non-European countries to have a pavilion on the virtual 3D exhibition floor, showcasing digital health companies based here.