Policy Issues: eHealth in Ontario

HLTH 405 / Canadian Health PolicyWinter 2012

School of Kinesiology and Health Studies

Course Instructor: Alex Mayer, MPA

Briefing Notes

Generally, very well done!

Briefing NotesMost Common Mistakes:

• Did not substantiate the problem with statistical evidence!

• Lack of specific information provided

• Saying that there is an “increase in rates of drug abuse” is not sufficient

• Using Fallacious Logic to say that there is a problem worth addressing

• Suggesting that “Obesity is on the rise, therefore physical activity must be decreasing”

• Suggesting that “U.S. rates are increasing, therefore there must be a similar problem in Canada”

Briefing NotesMost Common Mistakes:

• Did not make evidence-based recommendations!• Locked in on the ‘common-sense’ option too quickly

• Made a guess as to what would work best, based on intuition rather than evidence

• Did not try to compare the effectiveness and cost of different approaches

• Did not present statistical evidence to prove an option’s effectiveness

Briefing NotesMost Common Mistakes:

• Did not understand the purpose of a Communications section!

• This section is used to highlight a messaging strategy

• To allay potential concerns in specific segments of the population

• To promote a policy’s benefits

• Should include specific talking points

E.g. “The Liberal government’s introduction of full-day kindergarten is a hard-won victory for young families in Ontario! It will save parents money, improve educational outcomes, and prime our province for continued economic growth in a competitive future.”

Last Week…Government intervention in the marketplace is justified when there is

• Market Failure:The market for a good or service is not resulting in an optimal gain in societal welfare due to unequal power and/or information between buyers and sellers, or due to the nature of the good.

• Equity Concerns: Socially unacceptable outcome where some segment of the population is going without an essential good or service, due to a lack of resources.

Last Week…5 Instances of Market Failure

o Informational Asymmetry

o Non-Competitive Markets

o Principal-Agent Problem

o Negative Externalities

o Public Goods

Last Week…Net Present Value and DiscountingIf you are trying to assess the costs or benefits of your policy recommendation, be sure that your analysis is making an ‘apples to apples’ comparison. A $50 savings in 1980 is not worth the same as a $50 savings in 2012.

The inflation rate (CPI % change) measures the rise in the price of a basket of goods. If the price of goods rises by 3.3% over 2011-2012, then the relative value of money has declined by this amount.

E.g. My grandmother likes to tip people with a couple of quarters ($0.50). This may seem rude, but in 1950, two quarters were worth the equivalent of $5 in today’s market! So you see, my grandmother is actually an excellent tipper… Kind of.

Last Week…Net Present Value and Discounting

E.g. My grandmother likes to tip people with a couple of quarters ($0.50). This may seem rude, but in 1950, two quarters were worth the equivalent of $5 in today’s market! So you see, my grandmother is actually an excellent tipper… Kind of.

Last Week…Net Present Value and Discounting

Try the inflation calculator below to figure out the net present value of a $50 savings generated in 1980.

Bank of Canada Inflation Calculator:

http://www.bankofcanada.ca/rates/related/inflation-calculator/

Last Week…Net Present Value and Discounting

Inflation, however, is only one part of the equation. The other is ‘opportunity cost’.

Say I want to buy a TV; I have the option of paying in a lump sum or paying the same amount but spread out over 12 monthly payments.

In order to figure out the true cost of each proposition, I have to calculate the ‘opportunity cost’: The value of the next best opportunity foregone, say by investing the money and earning interest. O.C. = $P * (1 + r%)t

Last Week…Net Present Value and DiscountingE.g. Buying a $1000 TV.

Opportunity cost of TV (lump sum): Had I not bought the TV, I could have invested that money and earned 5% interest instead!

$P (1 + r%)t = O.C.

$1000 (1 + 0.05)1 = $1050

Opportunity Cost = $1050

Opportunity cost of TV (monthly payments): If I buy the TV by making monthly payments of $83, the opportunity cost is the foregone interest.

Month 1: $83 + $83* IR (5%/12 * 12 months) = $83 + $4.15

Month 2: $83 + $83* IR (5%/12 * 11 months) = $83 + $3.80

Month 3: $83 + $83* IR (5%/12 * 10 months) = $83 + $3.46

Opportunity Cost = $1023

Diminishing O.C. in foregone interest

Last Week…Net Present Value and Discounting

Combining these two concepts: the time value of money and opportunity cost… We can come up with there following equation.

$FV = $PV * (1 + r%)t

Where real rate of return, r:

r% = interest% - inflation%

Last Week…Net Present Value and Discounting

$FV = $PV * (1 + r%)t or $PV = $FV / (1 + r%)t

Where ‘real rate of return’ or ‘discount rate’, r:

r% = interest% - inflation% and t = years

The Government of Ontario plans to spend $5M per year over 5 years to build new bike lanes once Toronto finalizes its new transit investment strategy. The Bank of Canada website says that the 3-year moving average for inflation is 3% and the government’s next best alternative is not to incur debt, thereby eliminating interest on long-term bonds of 6% per annum?

What is the net present value of this investment?

Last Week…Net Present Value and Discounting

$PV [Year 4] = $5M/ (1 + 3%)4 = $4.44M

$PV [Year 3] = $5M/ (1 + 3%)3 = $4.58M

$PV [Year 2] = $5M/ (1 + 3%)2 = $4.71M

$PV [Year 1] = $5M/ (1 + 3%)1 = $4.85M

$PV [Year 0] = $5M/ (1 + 3%)0 = $5.00M

$PV of Project Outlays $23.58M

So in comparing the cost of the bike lane project to the cost of, say, building a dedicated street for cyclists for $25M this year, the bike lane project is actually $1.42M less expensive in an apples-to-apples comparison.

If they provided equivalent benefits, the bike lane project would be the more cost-effective option!

eHealth Applications

Topics for today’s lecture:

Policy Issue #3: eHealth• What is it?

• eHealth Ontario o The strategy

o The scandal

o Signs of progress

• Future applicationso EMR

o RM&R

o ePrescribing

eHealth: What is it?

DefinitioneHealth: (n)

“A consumer-centered model of health care where

stakeholders collaborate utilizing information and

communications technologies (ICTs), including

Internet technologies, to manage health; arrange,

deliver and account for care; and manage the health

care system.

Canada Health Infoway

Canada’s eHealth Story• In 2000, the First Minister’s agreement on health

sees the forging of a federal-provincial-territorial agreement to build up “infostructure” in Canada’s health care system.

• “Canada E-Health 2000” conference sees 400 stakeholders meet to discuss progress on a national action plan for eHealth.

• In 2001, Canada’s Health Infoway is operational.

Canada Health Infoway

• Introduction to eHealth in Canadahttp://www.youtube.com/watch?feature=player_embedded&v=3SYtv5jh4tQ#!

eHealth Consultations

Obstacles to better health care in Ontario

o Paper-based information management

o Limited integration of local applications and data

o Limited information-sharing across providers

o Varying technological capacity across the health system

o Fragmented and incomparable data

o Lack of common data and technical standards

o Underinvestment in technology

o No provincially coordinated strategy for eHealth funding and planning!

eHealth in Ontario• 2002: Creation of the Smart Systems for Health

Agency (SSH)

• 2003: SSH begins its operations with 6 key priorities• Develop a common unique patient identifier in Ontario

• Establish privacy and security requirements for eHealth

• Design an Ontario EHR starting with Hospital-to-Primacy Care Physician information exchange

• Initiate an ePharmacy Initiative for Ontario

• Expand on Telehealth’s success and capabilities

• Evolve a Wait List Management Initiative for key health services

eHealth in Ontario• 2006: Deloitte is hired to conduct an operational

review of SSH’s activities.

• The final report finds that SSH has not delivered sufficient value-for-money for the $650M invested thus far. It recommends an aggressive agency-turnaround plan.

• Smart Systems for Health (SSH) is reborn as eHealth Ontario in 2008, with heavy-hitting CEO Sarah Kramer at its helm.

eHealth in Ontario• In 2008, Ontario’s new eHealth Strategy is

developed.

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eHealth in Ontario – A Shift

No dedicated provincial eHealth Strategy

Funded, Cabinet approved Strategy

Government responsible for Strategy eHealth

Government as stewards; eHealth Ontario responsible for

eHealth Strategy

Diffuse/competing/confusing accountability

Single point of accountability at eHealth Ontario

Duplication, fragmentation and Proliferation of eHealth efforts

Provincial strategy deliveredthrough local, regional and province-wide solutions

Technology planHealth System Transformation Strategy

3 Clinical Priorities

To ReduceER length of stay

Wait times

Measure ER length of stay Wait for post acute

care

Wait Times

Enable public reporting and performance management

Expedite patient referrals out

of acute care where appropriate

Divert ER visits to more appropriate

community care settings

To Increase

Focus of ERs on urgent patients

Access to community services

Measure

% prescriptions ordered online

% reduction in adverse drug events

Medication Management

Enable online prescriptions andmedication History

Provide decision support for physiciansordering drugs

Alert of potential adverse drug events

To Reduce

Adverse drug events Physician office visits Hospitalizations Deaths

Measure % patients receiving

best practice care

Diabetes Management

Monitor patient compliance with evidence-based interventions

Alert physicians when best practicesnot being followed

Report on care gaps

Blindness Heart attacks Amputations Renal failure Deaths

To Reduce

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Ontario eHealth Solutions

Diabetes Management

• Baseline Dataset• Diabetes Registry• EMR interoperability with

Diabetes Registry• OLIS interoperability with

Diabetes Registry

Medication Management

ePrescribing Demonstration Project

• Drug Information System (DIS)• Drug Profile Viewer (DPV)• Systemic Treatment

Computerized Physician Order Entry (CPOE)

Wait Times• eReferral and Resource

Matching• Emergency Department

Reporting System (EDRS)• Wait Time Information System

(WTIS)

eHealth Scandal• 2009: The “eHealth Scandal”

A loosening of managerial policies around hiring private-sector consultants, meant to make eHealth Ontario more efficient, actually leads to more problems after the AG’s report finds that $1B had been spent with little to show for it.

Oct 7, 2009. News Report (Global TV)

http://www.youtube.com/watch?v=txkoB8s5qZ8&feature=results_video&playnext=1&list=PL9EFAFB182DCE4C29

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Doctors Use Electronic Patient Medical Records

* Not including billing systems.

Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

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Third Time’s A Charm?

eHealth Reboot (Feb 24, 2012)

http://www.youtube.com/watch?v=F7kYDCtuTnQ

•Baseline Dataset

•Diabetes Registry

• Provides primary care MDs with a Diabetes Patient List

• Testing reports inform MDs of most recent dates for 3 key tests for diabetes patients (blood glucose, cholesterol, retinal eye exam)

• Reports give MDs %patients whose tests were within recommended guidelines so they can identify care gaps

• Fancier version of the baseline dataset• Will connect to OLIS give to notify MDs

when patients are due for tests or when lab results are higher than normal

• Will connect to EMRs so that a new diagnosis instantaneously gets added to a patient’s medical record and generates a care plan

• Will eventually provide patients with self-management tools

Diabetes Management

Medication Management ePrescribing Dem

onstration Project

• Drug Information System (DIS)

• Drug Profile Viewer (DPV)

MDs can electronically ‘push’ prescription directly to a local pharmacist

Prescriptions can be printed in order to avoid deciphering MD’s handwriting

• Will allow multiple health practitioners to ePrescribe

• Will produce comprehensive medication profiles and tools for predicting allergic reactions, drug-to-drug interactions and accurate dosages

• Will give health providers connected to eHealth Ontario access to ODB claims records so that all pharmaceuticals consumed by elderly and welfare patients will be visible at the point-of-care

Wait Times•eReferral and Resource Matching

•Emergency Department Reporting System (EDRS)

•Wait Time Information System (WTIS)

•Hospitals to plan post-discharge care for patients at the time of intervention

•RM&R Solution will communicate with community care providers to flag a patient’s discharge date to ensure that someone is tasked with, and accountable for, providing follow-up care

•Will record and publicly report ED wait times online, for both high and low acuity patients

•Will record and publicly report wait times for many types of surgeries and diagnostic imaging, and for both adult and children.

A Bit of A Winding Road

What Would You Have Done Differently?

Have a great week!