Blog Post Four
Small Steps Towards BIG Change: Revamping Canada’s Healthcare System
Introduction:
The journey to transform Canada's healthcare system into one that ensures timely access to primary care and surgical procedures is akin to fixing a complex puzzle. The puzzle pieces are the numerous inefficiencies plaguing our highly fragmented healthcare system(s). Taking inspiration from a Yale University-led initiative in the USA aims to eliminate these inefficiencies, one percent at a time.
The vastness and many influential players in the US healthcare system make sweeping changes almost impossible to implement. Hence, the adoption of the 1% improvement concept.
While the Canadian healthcare system is much smaller – approximately $331B Canadian dollars compared to $4.3T US dollars – the idea remains the same - multiple minor improvements will lead us to the finish line. However, due to our government-funded system, more significant changes are more feasible in Canada.
In my previous blog posts, I highlighted Canada's acute shortage of physicians, particularly in primary
care. Therefore, any proposal that hinges on MORE physicians is untenable, as resolving this shortage in the short to medium term is impossible(see chart below).
CIHI and RBC Economics project a serious shortage of doctors by 2028
Given this starting point, the areas ripe for change are what I categorize as "administrative" changes and technological changes.
In this post, I will briefly touch upon these areas and delve deeper into each in future posts. However, I want to highlight some changes that should be implemented immediately. These changes are inexpensive and require nothing more than the will to act.
Before we delve into these changes, let's briefly discuss a topic that once held immense promise as the potential saviour of our global healthcare systems – Clayton Christensen's theory of disruptive innovation. The theory posited that smaller, more agile companies would disrupt larger established companies by offering simpler, cheaper alternatives to existing products or services. The expectation was that these smaller "outside" players would dramatically change and improve global healthcare.
Unfortunately, this has not materialized, primarily due to the healthcare industry's resistance to change.
So, where do we start? Let's begin with Administrative Changes that Must Change Now
While provincial governments often label every initiative as a "game-changer," the reality is that there are no game-changers. Instead, we make incremental changes routinely to eliminate inefficiencies, improve primary care access, and reduce surgical waiting times. We can always hope for a significant breakthrough, but "hope" is not a strategy. Therefore, more modest changes are likely to be the norm.
Significant change is not impossible, but incremental improvements are more likely in healthcare reform. Here are a few examples of what I call "administrative" changes that can be implemented almost immediately and at a minimal cost but have yet to be implemented despite years of calls for these changes.
Pan-Canadian licensure for all Canadian doctors. The
Canadian Medical Association has been advocating for this
for years! All Canadian-trained doctors take the same
national board exams before being granted a medical license in
Canada. So why not issue a "national" license to practice medicine in
Canada? The cost of implementing this is almost negligible, but
provincial medical boards have resisted this for years. It's time to
STOP resisting and make this happen. If provincial boards
genuinely care about our patients, they must make it
happen NOW, not years from now!
In the interim, if Pan-Canadian licensure is not forthcoming, allow doctors to move from province to province easily by immediately providing an interim license once the incoming province has made a simple phone call to the doctor's current medical examining board to ensure that the physician is in good standing. Then allow them six months to complete the arduous task of getting licensure in their new jurisdiction while they work. Also, reduce the costs for licensure – it's currently prohibitively expensive and burdensome. Issuing a temporary license is a simple and almost cost-free solution – save for one phone call. This should be implemented immediately!
Expanding the scope of practice of pharmacists, nurse practitioners (NP), and physician assistants across Canada is another administrative change that also must happen immediately. BC has expanded the scope of practice of nurse practitioners and has helped bridge the gap for access to primary care in rural
and remote areas of BC. Some in BC are unhappy with this, but it has helped with the shortage of general
practitioners in those remote and rural communities. In most cases, the only thing standing in the way of this change are provincial medical examining boards – read DOCTORS.
Plenty of evidence shows the efficacy of NP working alone or with physicians.
Here are just a few of the studies that support the use of NP.
Another "administrative" measure that provinces can make is how they
compensate doctors, especially family physicians, in "family practice." BC just
moved from a fee-for-service model to what they call the longitudinal family
physician (LFP) model.
Previously, BC paid family physicians $31 for a 15-minute visit on a fee-for-service basis. The new payment system still needs work as it is still exceptionally difficult for doctors to run their own offices (paid for out of their pocket) and make as much as they would by simply working in a hospital as a "hospitalist" or ER doctor. Much work remains to be done on the family physician's
"business model" to make it an attractive option for new graduates.
The fee-for-service model does not reflect how physicians
practice today, given the demographics of their patients.
Today, patients are older and have more chronic diseases and
comorbidities which require more face time with a
family physician and likely more research and consultation
with specialists, which is currently not compensated. To
illustrate this point, last year in Canada, the majority of positions
for geriatric care residency training were not filled.
The reason is fee-for-service. We old folks move slowly,
have multiple problems, and likely have someone with us
when we visit our doctor. The 15-minute appointment is not
possible and not amenable to the fee-for-service model.
BC's change in doctor compensation is a move in the right
direction, but more must be done.
Technology – Why Aren't We Doing More?
Now, let's look at how technology can help with our shortage of primary care doctors. This one will be more expensive, and there is a learning curve to this, but imperative if we are ever going to improve our healthcare system.
Electronic Medical Records
Electronic medical records (EMRs) are a digital lifetime record of an individual's complete medical history. The benefits of this system include:
1. Contains up-to-date information on an individual's
medical history that is typically maintained electronically
by a single provider.
2. With up-to-date information, your doctor/medical
team can make faster and more accurate treatment
decisions, i.e., the patient is allergic to Fill in the blank.
3. A greater degree of
coordinated care will be between your family physician, a
specialist, and the hospital. Everyone is looking at the
same information in real-time from all sources.
4. There will be no need to repeat medical history
because our memories are poor, and we won't forget
things when we go to the doctor.
5. Access to real-time medical records will eliminate
duplicate lab tests and provide caregivers with a
complete list of all prescribed medications.
6. EMRs can reduce administrative costs for both
physicians and hospitals and reduce the risk of medical
errors.
7. EMR can be used to book medical appointments
and can send reminders to patients of upcoming visits,
eliminating missed appointments.
8. EMRs can be shared with home-based caregivers
so they can help with the monitoring and administration of
medications and treatments.
The list goes on but suffice it to say that the broad use of interoperable EMRs is essential if Canada's healthcare system(s) ever hopes to function effectively in the 21st century. After using cloud-based EMRs for over ten years, I can attest to their convenience, ease of use, and cost and time savings.
EMRs are a must-have moving forward for Canada's healthcare system.
The question is, how will this come about? Currently, every province has its own form of EMR, and some, like Ontario's, are more advanced and comprehensive than the other provinces.
Making these systems interoperable (working together) will be a monumental task, so the answer maybe to adopt the most advanced system and use this system across Canada or struggle with trying to make these various systems work together.
A more viable option may be to standardize 400-500 of the most commonly used forms and codes across all systems and narrowly make this smaller subset of the EMRs interoperable between all provinces and territories.
A last resort would be for all provinces and territories to have at least a highly functional EMR system that can provide a highly functional and easy-to-use digital record system that all stakeholders can use.
Expand the use of Telehealth
Thanks to COVID-19, the use of telehealth expanded dramatically in Canada. But Canada still lags far behind many countries in the use of telehealth/telemedicine, even though Canada, specifically, Dr. Maxwell House of Memorial University pioneered the use of telehealth back in the mid-1970s. Dr. House's telemedicine project was initially aimed at providing psychiatric services to remote
communities in Newfoundland and Labrador.
This innovative approach proved to be very effective, and it demonstrated the potential of telemedicine for improving access to healthcare in remote and underserved communities. What happened?
Sadly, Canada allowed that leadership position to erode, and we now lag behind countries like the UK and the USA in this area. There is an enormous amount of untapped potential in the use of telemedicine to improve healthcare outcomes, reduce physician burnout, and increase access to care, particularly in remote areas of Canada and the barriers that existed in the past are eroding.
The high cost of computers, high-resolution cameras and monitors no longer exist. Internet access is possible even in remote areas thanks to satellite systems like Starlink. These systems are lightning-fast and affordable and should be shared in the community when not used for medical purposes.
Today, most of the barriers impeding the expansion of telehealth are "administrative" again. To expedite implementation these Important issues must be answered:
How do doctors get paid?
How is the lack of interoperability of medical records or no EMRs at all for some patients going to be overcome?
How will the lack of Pan-Canadian licensure physicians providing these services impact service delivery?
How will Pan-Canadian oversight and articulation of telemedicine standards and protocols be handled, and by whom?
Recent studies have shown that patients preferred virtual appointments to in-person visits for services like prescription refills, discussing lab results and regular mental health visits. Expanding the use of virtual medicine also has the potential for significant cost savings and generally provide increased access, and more importantly, more timely access to both primary and specialty
care across Canada for patients in remote areas. The benefits of telemedicine are enormous, however, there are hurdles to overcome, but the benefits far outweigh the costs, and it is long past time for Canada to speed up the use of this technology.
The Virtual Hospital
One of the newest innovations is the development of the "virtual hospital" combined with a team approach to medicine. This can have a major impact on patient outcomes and physician stress as teams confront complex cases instead of a single physician. During COVID-19 Australia provided “virtual hospital” services in some hospitals with positive results. More research has to be done to
determine the efficacy of this delivery model, but initial data suggests high patient satisfaction.
Conclusion
No single initiative will solve Canada's healthcare crisis or shortage of doctors. It will take a series of small refinements and
the elimination of inefficiencies throughout the system to improve Canada’s healthcare network. The will be no game-
changers. However, when these additional improvements are combined, they can make a noticeable difference without having
to add one more doctor to the mix. The reality is we must start implementing changes to Canada's healthcare system without depending on more doctors. The goal must be to improve the overall efficiency of the "healthcare system" so that our physicians can achieve more output without putting more stress on those same physicians.
It is the "system" that is broken and must be improved, not the individual doctors and nurses working within this broken and inefficient system. No doubt more doctors and nurses will help, but before that happens, the healthcare system must be improved to: 1. make the system more efficient, and 2. more sustainable into the future, as the demands of an aging population will only increase.
In my next post, Transforming Canada's Healthcare System: A Comprehensive Solution to the Crisis, I'll outline where Canada needs to go in the long term to return our healthcare system to one all Canadians will be happy with. This post will include many of the issues discussed in this blog post, the need for more healthcare professionals, and how to get there. As always, your opinions and
suggestions are both welcomed and encouraged.
Transforming Canada's Healthcare System, One Day at a Time.
