Spectres haunting Canadian medicare

Many spectres are haunting what the Globe and Mail’s André Picard (@picardonhealth) has just described as the crumbling edifice that is the Canadian healthcare system.

Perhaps the biggest and scariest ­– many would describe it alternately as a zombie that refuses to stay dead – is that of privatization and two-tiered medicine. Those in government who deny the existence of this particular ghost would say what we are seeing in provinces such as Ontario and Quebec are only the increased use of private companies in the provision of publicly funded health care.

The lack of funds to support the increasingly costly public system and loud calls for those who can afford it to deal with growing access issues by allowing them to pay for services makes the next step and allowing private companies to offer care in a parallel system for those who can afford it almost irresistible. This has already become widespread for diagnostic imaging services such as CTs and MRIs. The growth of personalized or precision medicine where new treatments and drugs can be better tailored to individual patients for better outcomes but usually at a significantly increased cost can also feed into this.

The spectre of privatization now appears to be roaming all the spaces that make up the Canadian medicare system. It is so pervasive now that the Canadian Medical Association has announced it will be launching a series of consultations this fall to look at the balance between public and private healthcare delivery “and what role, if any, increased private care should play in a publicly funded health system.”

Howling around the crumbling infrastructure of medicare is the banshee of public health. The recent COVID-19 pandemic showed just how far governments and the public were willing to go to sacrifice individual rights for the greater public good and equitable health for all. The answer was, only so far. Prior to COVID-19 public health budgets in some jurisdictions were being slashed and with many saying the pandemic is over there seems a palatable desire to reduce public health initiatives that may or may not be needed in the future.

A more recent spectre in the healthcare house, portrayed by many Casper, the friendly ghost, is that of artificial intelligence (AI). Generative AI models hold huge promise in augmenting and relieving the pressures on healthcare providers in both clinical care and for administrative duties. But AI algorithms fed by massive amounts of patient data also provide the opportunity for Canadian jurisdictions to cut out the middleman (i.e., the physician) and offer medical advice to the public and patients at a far lower cost. One health policy commentator has characterized this as a spectre where those using the public system have access to AI-supported chatbots while those who can afford it can access real human physicians.

On the “I’m not dead yet” list of spectres is that of patient and caregiver engagement/partnership. The pandemic showed how quickly direct patient/caregiver involvement in care can be jettisoned to serve what many within the system see as the greater good of infection control or a more streamlined top-down management system. Many patient advocates in Canada and abroad have noted patient involvement in what should be a “patient-centred” system have still not returned to pre-pandemic levels. A just-published paper by many leading Canadian patient advocates has shown just how challenging it can be to do patient engagement right. With growing pressures on the Canadian healthcare system and challenges on just getting access to any care it is not hard to imagine a future where the principles of patient partnership are sacrificed to maintain whatever limited levels of care the public system can afford.

Affordability raises another terrifying spectre in the Canadian context and that is the use of medical assistance in dying (MAiD) to meet economic goals. Whether apocryphal or not, cases have already been made public of people being offered MAiD for reasons other than intractable suffering.

Many ghosts haunting our healthcare system. But as we enter summer (albeit a hazy one with that other scary spectre climate change threatening us all), a feel-good ghost-busters movie seems to be just what we need.

(Photo by Ján Jakub Naništa)

Ontario’s family doctors getting guidance on best use of AI

Artificial Intelligence (AI)-assisted scribes are at the front of the queue when it comes to tools using AI being assessed to help Ontario family physicians in their practices.

OntarioMD is partnering with the Ontario Medical Association (OMA) and the eHealth Centre of Excellence to evaluate the value of clinical AI scribes to reduce the administrative burden in primary care.

This work is part of a comprehensive process that has been undertaken by OntarioMD to assess the potential role for AI in primary care. Ontario MD is a subsidiary of the OMA funded by the province to deliver digital health solutions to clinicians.

At the recent e-Health conference in Toronto, the organization hosted a lunchtime session led by Dr. Chandi Chandrasena, chief medical officer, to brief delegates on its work on AI. Underlying OntarioMD’s focus in this area is a belief that use of AI tools could help move physicians away from transactional tasks and allow them to focus more on patient care. If such tools are integrated seamlessly into physician workflows, Dr. Chandrasena said, they have the potential to help physicians avoid burnout.

Work that has been done by OntarioMD resulted in several key observations about the AI’s potential in family medicine as detailed at the session by Simon Ling, executive director for products and services at OntarioMD.

Ling noted the AI market is growing rapidly in Ontario. An initial environmental scan undertaken by OntarioMD showed Canadian vendors are active in all areas where AI may have potential uses of community-based physicians.

In tracing patient interactions with community physicians, OntarioMD detailed how AI solutions could assist in the pre-visit, visit, and post-visit stages. During the patient visit, the organization noted that AI could assist during the patient visit with documentation (AI scribe), diagnostic support, as a virtual assistant (e.g. with scheduling and prescription writing), and clinical decision support.

The OntarioMD presentation detailed how two major vendors in Ontario – TELUS Health and WELL Health have stated their strong commitment to developing AI solutions for physicians.

However, Ling said there is currently a lack of integration between existing AI solutions and EMRs being used by Ontario family physicians as well as the absence of a “coherent blueprint” connecting AI solutions with healthcare needs. In addition, OntarioMD feels there is still limited information on the accuracy of AI models used in healthcare as well as data on the effectiveness of AI solutions.

While AI scribes top the list of tools being assessed by OntarioMD, speakers at the lunchtime session also talked of the potential for AI solutions to help prepare patients to visit their physicians and to provide them with guidance after these visits.

In another presentation at the e-Health conference, Dr. Kaveh Safavi, senior managing director of global health for Accenture shared to-date unreleased data on which tasks  Canadian physicians, doctors and nurses think will become automated. Topping the list in 2022 poll were:

• 82% Patient registration (check-in)
• 82% Service billing and remuneration
• 77% Inventory management
• 76% Scheduling for providers
• 75% Patient scheduling and follow-ups

It’s a medical practice, Jim – but not as we know it

Image: Dr. Kaveh Safavi

Artificial intelligence (AI) – whether old school AI algorithms using “big data” or new normative models using large language models (such as chat GPT) – is already fundamentally changing how some Canadian physicians work and will impact the very nature of medical practice itself.

But whether changing approaches to diagnosis and management augmented by AI are actually going to make practice more satisfying and combat the smoldering fires of burnout driven by increasing demands placed on physicians is still very much an unknown.

As with any conferences focusing on health technology right now, recent Canadian health care conferences such as the major e-Health conference held in Toronto last week had the role of AI has a major topic of discussion.

Speakers at both #ehealth2023 and the CADTH annual symposium that preceded it in Ottawa provided tangible examples of how major Canadian healthcare institutions are already using AI to improve care delivery. But arguably the most provocative and thought-provoking presentation was the opening plenary at e-Health from Dr. Kaveh Safavi, senior managing director of global health for Accenture.

In discussing the future of healthcare and the potential roles for AI, Dr. Safavi noted “we are fundamentally changing the nature of how we do work, and it will be different in half a decade or a decade for now.” Using technology to replace tasks in healthcare will mean redistributing remaining tasks and essentially changing the healthcare workforce to a combination of “fixed and adaptive workers”, he said.

Dr. Safavi also challenged the widely held believe that using AI to help relieve physicians and nurses of the administrative burdens they currently face will allow them to focus on more complex tasks and make reduce burnout. Doctors complain bitterly about doing administrative tasks but complain even more when these tasks are being taken away because it means they must work at peak capacity continuously, he said.

Interestingly at the very same conference other speakers maintained that allowing physicians to focus on patient care and deal with complex cases and patient care would do exactly what Dr. Safavi said it will not – namely improve physician well-being and reduce burnout.

For AI to be used productively in healthcare, Dr. Safavi said, practitioners will need to know how to ask the right questions of the AI tools and interact with them. A panel discussion focused specifically on the role of AI in healthcare at e-Health agreed that medical schools needed to integrate effective use of AI into medical education.

“When we think about how we train clinicians today and you look at medical schools and nursing schools, I think we’re a little behind the curve,” said Aloha McBride, global health sector leader with EY Consultants, adding basic training about AI needs to be incorporated into undergraduate and postgraduate curricula.

“Clinicians especially need to be able to understand why it is that this particular algorithm is presenting them with this particular recommendation. And probably more importantly, they need to be able to explain it to their patients.”

Another speaker on the same panel, Rachel Dunscombe, former CEO of the National Health Service (NHS) Digital Academy said that within the NHS in the UK, senior clinical leaders are already being provided with such training.

As noted, speakers at both e-Health and the CADTH meetings showed how AI is already being integrated into care delivery at major Toronto hospitals.

In the closing session at CADTH, Dr. Muhammad Mamdani, vice president of data science and advanced analytics at Unity Health Toronto said much of healthcare is data driven and AI can assist in using data better for diagnosis, prognosis and treatment. He described how a predictive AI algorithm is being used at Unity Health to monitor internal medicine patients to assess risk and that this is reducing mortality rates.

At e-Health, Dr. Bradly Wouters, executive vice president of science and research at the University Health Network in Toronto described how clinicians at Princess Margaret Cancer Centre are implementing use of an AI algorithm to quickly and accurately develop a treatment plan for use of radiation therapy.

Other examples were also given about the impact of combining big data with machine-learning to develop clinical support tools.

(This is part 1 of a 2-part series dealing with discussions of AI at e-Health. The second part will discuss how AI could best benefit community-based family physicians)