Author Profile: Featured Essay

Surviving The Perfect Storm: How Participatory Medicine & e-Patients Can Save Healthcare

November 6th, 2011 by Dianne Carmichael | 1 Comment

Our nation is often defined by our passion for hockey, our taste for beer, and our universal health care system. There is little question that Canada’s hockey prowess endures; our beer remains cold. But our healthcare system? Overburdened. And totally ill prepared to endure the coming tsunami that threatens to submerge it.

The perfect storm of an ageing, demanding baby boom population combined with the increased incidence of multiple chronic conditions, expensive technologies and new drugs is converging to effectively capsize an already challenged system. It is a global problem. And one Canada must urgently tackle.

Projections are that by 2030 health care spending will consume 80% of provincial budgets.
Chronic disease represents some 80% of healthcare system interactions and more than 70%
of healthcare expenditures. Of those aged 65+, 80% report suffering one or more chronic
conditions.

Baby boomers have been the drivers of everything from pablum to disposable diapers. Soon, over 24% of our population will by 65+ and once again this cohort will be a driver of change. This time to a people-centred, participatory, e-patient model of care.

Consider this: Canada spends more than most developed countries on healthcare but the 2010 Commonwealth Fund International Health Policy Survey concluded that Canada has the least effective, least safe, least co-ordinated, least timely and least patient-centred care amongst the nations surveyed.

The same report noted that 80.3% of Canadians use Internet regularly and 40.7% of Canadians aged 65+ engage in online activity. IPSOS Reid predicts consumer trends will see massive increases in Internet usage (Statistics Canada 2010).

According to the Ivy Centre for Health Innovation and Leadership, “Although Canada ranks
amongst the top 4 OECD nations in knowledge creation, it ranks dead last among OECD
countries in the transfer of new knowledge to innovative health care technologies and solutions”.

As a former CEO in the financial services sector, I know that consumers embrace the
convenience, speed and accessibility of their banking records and funds – wherever in the world they may find themselves. Imagine life without a bankcard that can be swiped to allow fund transfers and payments, or instant cash in local currency when travelling abroad? Stock research and trades from an iphone, bill payments online, mobile flight check-ins to avoid airport line ups, instant messaging to stay connected with loved ones, cloud computing that allows instant syncing of calendars and sharing of information, face-time and social networking for support and emotional connection. These technologies have become de rigueur and have helped to make our lives easier, while keeping us engaged and feeling connected. We are more empowered. Knowledge is at our fingertips.

In everything that is, except healthcare.

The fact is, our 20th century medical worldview did not conceive of 21st century technological realities.

We must now embrace the information technologies that other sectors of the economy have
successfully implemented in order to enhance, at the core, the very patient engagement that will be vital in transforming the system to truly participatory medicine and which in turn will create efficiencies both in delivery and costs while improving quality and outcomes.

People-centred, participatory medicine is a critical paradigm shift that will be instrumental in addressing a system severely strained by the impending demographic and epidemiological convergence of ageing population and multiple chronic conditions.

It’s been said that publicly funded health care is one of the few industries that can ignore – even fail – its customer without risking the collapse of the business. Successful business leaders know their very survival is based on putting customers first. In order to sustain a universal health care system, we must now take the same approach by putting patients first and engaging them to become both active participants and self-managers of their chronic conditions.

A mandated system-wide patient-focused model will effectively inspire innovation, demand
accountability, promote adoption of technology and foster collaboration while improving quality care, outcomes and cost reduction; permitting the shift to a more health-first based system of prevention, wellness, and self-management of chronicity by designing everything around the needs of the patient and providing the tools that support participation.

There is a growing body of research that demonstrates that participatory medicine reduces
hospital admissions, shortens length of stay, reduces primary care visits, improves safety,
promotes self-care and facilitates teamwork.

We must adopt innovation and health technologies along the continuum of care in order to
engage people, create meaningful customer experience, improve quality and outcomes and
create sustainable effective delivery of health care, as well as management of health and
wellness. We must truly empower patients and their families to become active partners in the health care journey rather than helpless observers.

We must design and implement innovative ways to interconnect providers, patients and
services while providing the tools and technologies (i.e. Bluetooth-enabled monitoring) currently held in the exclusive domain of our provider-centred system – only accessible in institutional environments – in order to change the paradigm from dependence to independence.

Imagine a connected platform, powered by technology, that effectively enables data to be
shared in meaningful ways across the spectrum of one’s care and that includes remote heath monitoring, surveillance, electronic health records, coaching and navigation; coordinating and engaging the health ecosystem for the benefit – both physical and psychological – of the patient.

Participatory medicine is a major shift from the prevailing paternalistic attitude that ‘father
knows best’. Adoption requires both engagement and empowerment of health consumers and willingness by providers to embrace active patient involvement for joint decision-making and shared responsibility.

Physicians’ self-view has historically been the all-knowing guardian of information, placing
them safely on a pedestal. This phenomenon is not unlike the clerics of the Dark Ages
who recognized knowledge is power and went to great lengths to reduce the threat to their
powerbase by followers who wanted direct access to this information.

Forward thinking physicians today recognize that the world’s medical literature is already
available to their patients and some find relief in no longer having to appear to know it all – as this is just no longer possible. The amount of medical information doubles every 3 to 5 years (Dr. Daniel Sands, Beth Israel Deaconess Medical Centre). Some physicians are now – perhaps grudgingly – accepting the new paradigm while others openly welcome the active engagement and participation of their patients and the joint decision-making it enables.

My experience in the work I do, is that patients and their health care providers, families and
caregivers often do not have access to a complete record or all the relevant information
necessary to make decisions in line with desired outcomes. This compromises quality, puts
lives at risk, and prevents the engaged and shared decision making that are the cornerstone of a sustainable model.

The most effective way to improve health care is to make it more collaborative. It is our greatest hope for restoring the lustre of our national pride – our universal health care
system. Moving toward a ‘health’ system supported by participatory medicine and less of an acute health ‘care’ system will make our public system more sustainable and ensure its viability for generations to come.

Fundamental changes in society and economy have happened during periods of upheaval
that caused people to think and behave differently. I believe we are in just such a period of
emerging upheaval; it may be the impetus we need. A demanding, technology-savvy baby
boomer cohort reaching old-age in historic numbers and suffering multiple chronic conditions will combine, not least of all, with the advent and adoption by patients of Web 2.0 and mobile technologies to form the basis for collaborative participatory medicine. This electronic collection and dissemination of information has the ability for mass collaboration – transcending silos, old paradigms and geographic borders and allowing for partnerships.

If we don’t take action, if we don’t urgently move to participatory medicine we risk turning our national dream of world-leading, universally accessible health care into a nightmare of even longer wait times, scarcer resources, crammed, crumbling hospitals and vulnerable to the inevitable human tsunami that threatens our cherished system.

We will end up with a system no one wants. One that is unworthy of this great country.

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Provinces Should be Freer to Experiment in Health Care

November 22nd, 2010 by Maxime Bernier | No Comments

The federal government today intervenes massively in provincial jurisdictions, and in particular in health and education, two areas where it has no constitutional legitimacy whatsoever.

This is not what the Fathers of Confederation had intended. The objective of the 1867 Act was not to subordinate provincial governments to a central authority. But rather to have sovereign provinces within the limits of their powers, dealing with local matters that directly affected citizens; and a sovereign federal government within the limits of its own powers, dealing with matters of general national interest.

During the 20th century however, this fundamental principle was gradually pushed to the wayside. We saw everywhere the growth of the state, the rise of central planning, of command-and-control Keynesianism and of government interventionism.

In Canada, government activism grew both in Ottawa and in the provincial capitals. Predictably, federal planners decided that Ottawa had to have its say on all kinds of social issues, despite the fact that these matters were the responsibility of the provinces in our Constitution.

At first, it was done in the proper manner – by amending the Constitution. This is why after the Privy Council ruling in 1937 which said that Ottawa had no authority to establish an unemployment insurance program, the BNA Act was amended to allow it. In 1951, old age pensions were established in the same way.

However, several other programs, from family allowances to grants to universities and hospital insurance were set up which clearly did not respect the constitutional division of powers. Some of these programs are direct transfers to individuals and tax measures. While others, such as the health and social transfer programs, are money sent by Ottawa to the provinces, to the tune of nearly 40 billion dollars today.

This intrusion into provincial jurisdiction was accomplished by the so-called federal spending power. No constitutional provision to legitimize this federal spending power was ever adopted. The Supreme Court of Canada has never explicitly recognized this power either.

I believe we should bring back the balanced federalism envisioned by the Founders.

This would be done by putting an end to all federal intrusion into areas of provincial jurisdiction. Instead of sending money to the provinces, Ottawa would cut its taxes and let them use the fiscal room that has been vacated. Such a transfer of tax points to the provinces would allow them to fully assume their responsibilities, without federal control.

Since the Séguin Commission, set up a decade ago by the Quebec government, the debate has focused mainly on the fiscal imbalance, the discrepancy between the fiscal resources of the federal government and the growing financial responsibilities of the provinces. This problem was solved in large part by our government when we increased the social and health transfers to provinces in our 2007 budget. But this has not solved the legislative imbalance, which is the heart of the matter.

As we saw last summer during the premiers’ meeting in Winnipeg, the provinces have already started to pressure Ottawa to increase health transfers when the ten-year health agreement expires in 2014. If transfers do not increase as fast as provinces want them to, you can be sure that the debate over the fiscal imbalance will be back in the news three years from now.

This is a recipe for permanent discord. The provinces act like special interest groups who would rather get money from the central government than increase their own taxes. But at the end of the day, the money comes from the pocket of the same taxpayer.

It also guarantees confusion and a lack of accountability. Despite the existence of the Canada Health Act, it is provincial governments that are mainly responsible for managing the health care system. But the debate over federal funding makes it difficult for the average citizen to see who is responsible for what.

Why do we have waiting lines for surgery, overcrowded emergency rooms and not enough family doctors? Is it because of bad provincial management or because of insufficient federal funding? Each level of government can blame the other to score political points.

There would no longer be any ambiguity if each province stopped depending on federal transfers and raised the amount of money necessary to manage its own programs.

A one-size-fits-all solution imposed on everyone from the centre precludes experimentation, kills innovation and makes it awfully difficult to extricate oneself from failed policies.

On the contrary, the genius of federalism is that we can try more than one type of solution to solve public policy problems. Freed from federal conditions and unable to shift the blame to another government, provinces would be more inclined to experiment. Especially in finding better ways to deliver health care services.

Maxime Bernier is the MP for Beauce.

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Will mental illness cost us our health care system?

July 4th, 2010 by Dr. Zul Merali | No Comments

When we talk about the financial sustainability of Canada’s health care system, we tend to focus on the needs of an aging population, the increasing costs of prescription drugs, and the impact of new high-priced technologies. But there is another, less discussed, factor that will have an important impact on health care in the future: the financial and human cost of mental illness, depression in particular.

Mental health is a greater disease burden on our health care system than all cancers combined. Depression is the fastest growing source of employee disability in the labour force. It has already surpassed heart disease as the leading cause of lost work year around the world.

In Canada, we lose 35 million workdays every year to the disease, and many people who remain in the workplace are less productive because they are battling depression. The cost to the Canadian economy for mental illness in general and for depression-related issues, in particular in terms of health care, child abuse and neglect, addictions, criminal justice services, lost income and productivity is estimated to be over $50 billion a year.

The human costs are just as catastrophic. About one in six people will experience depression in their lifetime. It affects men and women of all ages, but it often occurs in people in their prime working years. Only a third of cases of depression are effectively diagnosed and treated, in part because depression lies in the long shadow of the stigma attached to mental illness. Ten to fifteen per cent of people who are hospitalized for depression will eventually commit suicide.

Depression also plays an important role in other serious illnesses. There are strong links between depression and heart disease, Parkinson’s disease and diabetes, and depression often co-exists with other psychiatric illnesses such as addictions, anxiety and post-traumatic stress disorder.

While there are many factors that lead to depression, genetics and stressors are important contributors. Researchers like to say that genetics load the gun, while stressors pull the trigger. For those with a genetic predisposition to depression, many stressors can come from today’s high-pressure workplace with its instant-on technologies and blurred line between work and home.

Like other industrialized countries, Canada has moved from a resource-based economy where physical strength determined success in the workplace to a brain-based economy where mental well-being and intelligence determine success in the global marketplace. In our brain-based economy, a brain-based illness like depression has a particularly devastating effect.

Yet in spite of the economic and human impact of depression, Canada spends less than five per cent of its health research budget on mental health research. As we look ahead to the health care system of the future, we will need to invest more in research, diagnosis and treatment to begin to change the outcomes for patients with depression and to lessen the impact on our economy.

At the new Depression Research Centre at The Royal, we are beginning to see the positive results from an intense dedicated focus on depression. As a specialized care facility that treats the most resistant and complex cases of depression, the Centre is using research-informed clinical practice to accurately diagnose and treat depression more quickly and effectively. Studies at the Centre have already shown double the remission rates in six weeks in patients with treatment resistant depression.

By using imaging technologies such magnetic resonance spectroscopy, we are able to see how the brain functions in depression and to develop reliable brain-based diagnostic markers to do more individualized diagnosis and to recommend the most effective treatments for a specific patient.

Research is also guiding new treatment plans with prescription drugs. Instead of the long and painful method of trying first one, then another drug for depression, physicians are now using more than one drug at once and changing treatment often to find the most effective medication for each person.

The Centre is also looking at the impact of treating depression where it co-exists with other illnesses. Patients with cardiac disease, Parkinson’s disease or substance abuse will frequently also have depression – for example, half of the patients with Parkinson’s will suffer from depression, and in cardiac disease, patients whose co-existing depression is untreated present up to four times increased rate of mortality.

Usually patients receive treatment first for the heart disease or Parkinson’s, but the depression may go untreated. By treating both illnesses at the same time, there are far better outcomes for patients and significant cost savings to the health care system.

Specialized centres like the Depression Research Centre are one important part of turning the tide in diagnosis and care of depression. To be effective, these centres need appropriate long-term funding to purchase and operate the technologies as well as attract and hold researchers to do the important studies that will change outcomes for patients.

To make our valued health care system sustainable for the future, Canada will have to invest in mental health. We can no longer manage the devastating impact of depression on human lives and our economy. The good news is that the investment will pay off in successful outcomes for patients and in financial returns. Statistics indicate that for every dollar we invest in diagnosing and treating depression, we will save another $7 in further health costs and $30 in lost productivity in our businesses.

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