Need to Know: Public, Provider & Policy Perspectives on Priorities for Information about Primary Health Care in Canada Diane Watson PhD MBA Vancouver Canada October 2006

Overview What is PHC like up there in Canada? Why do we need “new” information systems (IS) that build on “old” ones How to build PHC information systems –What do we need to know –Who needs to know what –How should we build new IS When should we start?

Canada 32,400,000 people 30,000 GP/FPs 25,000 PHC RNs 32,000 whales 2 nd largest country

Health Care in Canada Canadian constitution –Federal government NO jurisdiction for health care (except Aboriginal/ armed forces), only lever is taxation equalization & transfer payments –Provinces/ territorial governments responsible for health care 10 provinces & 3 territories

Canada Health Act (1984) established uniform requirements for federal transfer payments based on 5 principles: 1. Public administration 2. Universality bans private insurance & user fees for medically necessary physician and hospital services 3. Comprehensiveness all medically necessary physician (98% public financed) and hospital (93% public financed) 4. Portability between jurisdictions 5. Accessibility – reasonable access

Health Care Expenditure per Capita by Source of Funding in 2004 Adjusted for Differences in Cost of Living b Source: OECD Health Data 2006 a 2003 b 2002 (Out-of-Pocket) *Out-of-Pocket data not available aa

$130B in 2004

Apr 2001: Prime Minister establishes Royal Commission & Senate Committee Oct 2002: Final Report of Senate Nov 2002 Final Report of Commission Feb 2003 First Ministers’ Health Accord Sept 2004: First Ministers’ 10-Year Plan to Renew Health Care in Canada 3-Year Health Transition Fund 5-Year Primary Health Care Transition Fund

Citizen Priorities: Health Care Renewal In 2002, when asked to deliberate about various options to sustain their health care system, Canadians suggested: –reforms to PHC top priority –physician-led interdisciplinary PHC teams as the centre piece of the health care system –they need to be supported by a central information system –greater focus on wellness, prevention and patient education (Maxwell et al, 2002) 72% of Canadians still agree (National PHC Awareness Strategy, August 2006)

Citizen Concerns: Access to Health Care 30% not confident they can access needed health care services

Access to Doctor When Sick or Need Medical Attention (%), 2005 AUS CAN GER NZ UK US 2005 Commonwealth Fund International Health Policy SurveyAdults with Health Problems

Average Annual Number of Physician Visits per Capita, 2004 a Source: OECD Health Data 2006 a

Relationship with Regular Doctor, 2005 Percent:AUSCANGERNZUKUS Has Regular Doctor years or more NO Regular Doctor Commonwealth Fund International Health Policy SurveyAdults with Health Problems

Citizen Concerns: Access and Quality Over time, Canadians have increasingly become concerned about quality, to the point that access and quality are now viewed as equally important by Canadians (Ekos, 2002, 2003, 2004)

Deficiencies in Care Coordination, 2005 Adults with Health Problems (%) saying in the past 2 years: AUS CA N GERNZUKUS Test results or records not available at time of appointment Duplicate tests: doctor ordered test that had already been done Percent who experienced either coordination problem Commonwealth Fund International Health Policy SurveyAdults with Health Problems

Received Recommended Care for Chronic Health Conditions (%), 2005 AUSCANGERNZUKUS Hypertension* Diabetes** *Blood pressure and cholesterol checked **Hemoglobin A1C and cholesterol checked, and feet and eyes examined 2005 Commonwealth Fund International Health Policy SurveyAdults with Health Problems

Citizens: Needs for High Quality PHC Now and Into the Future 30% of adults and 70% of seniors have one or more select chronic health conditions, 2005 Health Council of Canada, forthcoming

Provider & Policy-Maker Concerns … Whereas 50% of physician workforce is GP/FPs; fewer students (26%) now choose a future in family medicine GP/FP increasingly restrict access to new patients (60%) “Don’t you have any regular doctors?”

GP/FP increasingly reduce the array of office services offered GP/FP report that they work long hours and are unhappy with workloads Provider & Policy-Maker Concerns …

Workloads and work volume –More women are choosing a future in family medicine –Older doctors doing more, younger (<55 years) working hard but less than predecessors … “The coming wave of physician retirements could cause unprecedented annual rates of shrinkage in GP/FP service volumes” (Watson, Slade et al, 2006) Only 10% of nurses work in PHC, 40% of nurse/physician supply (Wong, Watson et al, 2005) Only 7% of GP/FP work in teams (CIHI, 2005)

Overview What is PHC like up there in Canada? Why do we need “new” information systems (IS) that build on “old” ones How to build PHC information systems –What do we need to know –Who needs to know what –How should we build new IS When should we start?

Public, Provider and Policy-Maker Concerns … Creates Need for Information to Drive, Monitor and Account for PHC Renewal Concerns Regarding Accessibility and Quality: Quality Improvement Concerns Regarding Technical Quality of Clinical Care: Clinical Accountability New Investments and Dedicated Transfer Payments: Sector Accountability Concerns Regarding Supply and Future Availability: Policy and Planning

Why do we need new IS? Old IS: Need to know about hospitals and how dollars followed doctors New IS: Need to know about –access and quality, not just price and volume –investments in/ across sectors (PHC) not disciplines (doctors) –provider networks that are superimposed geographically, not discrete locations (group practice, hospitals) –patterns of population morbidity to plan supply and deliver based on need –topical issues (e.g. patient safety) that cross sectors (e.g. pharma & PHC)

Overview What is PHC like up there in Canada? Why do we need “new” information systems (IS) that build on “old” ones How to build PHC information systems –What do we need to know – framework –Who needs to know what – priorities –How should we build – leverage old & create new When should we start?

Institute of Medicine, 2006 As recently observed by the Institute of Medicine in the United States, “the lack of connections and conceptual links among performance measures put forth by different groups has created an administrative burden for providers, and is a significant barrier to moving the quality initiative forward to a new stage of development”. Institute of Medicine. Performance measurement: Accelerating improvement. Washington, DC: Author, 2006, p. ix.

B uilding a PHC information system Performance Measurement and Accountability Framework Administrative data- based PHC information system PHC surveys validated for Canadian context PHC sector information system to measure key aspects of PHC over time and place, from both population and provider perspectives Public, Policy, Provider Priorities

B uilding a PHC information system Performance Measurement and Accountability Framework Administrative data- based PHC information system PHC surveys validated for Canadian context PHC sector information system to measure key aspects of PHC over time and place, from both population and provider perspectives Public, Policy, Practice Priorities

Methods Used to Develop a Performance Measurement/ Accountability Framework Diane Watson, Anne-Marie Broemeling et al Objective: Develop a performance measurement and accountability framework for PHC Methods: Used Treasury Board of Canada’s Results-Based Management Accountability Framework, reviewed existing PHC conceptual models & health system performance frameworks, literature and policy review on linkages between PHC outputs and outcomes, feedback/ validated through stakeholder consultation (n= 650 people) Result: Results-Based Logic Model for PHC

Available in English, French and Spanish Has been used/is being used in Australia, Canada, New Zealand and Latin America

Source: Treasury Board of Canada, 2000 Treasury Board of Canada Approach to the Design of Results-Based Logic Models

Results-Based Logic Model for Primary Health Care

PHC Inputs, Activities, Outputs

Group, Network or Provincial Levels of Analysis and Comparison

PHC Outputs and Outcomes

Indicator Zone vs. Attribution Zone

Operational Definitions of Attributes of PHC to be Evaluated: Consensus Among Canadian Experts Jeannie Haggerty, Fred Burge et al (2005) Objective: Develop a common lexicon of operational definitions of attributes to be evaluated in predominant and emerging models of PHC. Methods: Delphi process started with 20 experts (clinicians, academics and decision-makers) from all regions of the country Result: Operational definitions for 8 attributes, 4 person-oriented dimensions, 3 community dimensions, 5 structural dimensions and 3 system performance dimensions.

B uilding a PHC information system Performance Measurement and Accountability Framework Administrative data- based PHC information system PHC surveys validated for Canadian context PHC sector information system to measure key aspects of PHC over time and place, from both population and provider perspectives Public, Policy, Provider Priorities

Public Priorities for Information: Sabrina Wong, Diane Watson et al 2006 Objectives: To examine the nature of the publics’ experiences, as well as domains considered priority for PHC and relevant to satisfaction. Methods: Eleven focus groups (n=75). Thematic content analysis using a coding scheme based on the Results-Based Logic Model for PHC. Results: Analysis revealed six domains in the following rank order of priority: accessibility (geographic accessibility to and timeliness of services), continuity (informational, relational and management), responsiveness, interpersonal communication, technical quality, and whole-person care.

Policy and Provider Priorities for Information: Evaluating PHC - The Right Questions to Ask Jeannie Haggerty and Carmel Martin, 2005 Objectives: To identify core evaluation questions that are most pertinent to the Canadian Context Methods: Conduct an environmental scan of questions that guide evaluation of national and international initiatives to transform delivery. Validated against Results-Based Logic Model for PHC and with key experts in Canada and in the UK. Results: Provide a framework for the identification and development of PHC performance indicators by the Canadian Institute for Health Information.

Policy and Provider Priorities for Information: Pan-Canadian PHC Indicators Initiative CIHI (lead), national experts, primary health care providers, stakeholders, Federal/ Provincial/ Territorial (F/P/T) governments, and others Objective: (1) To identify and seek consensus on a core set of indicators (clinical and non-clinical) based on an agreed set of evaluation questions renewal; (2) To provide advice on a future data collection infrastructure that could supply the high quality data required for reporting across Canada Results: 105 indicators (access, comprehensive, continuity, integration, coordination, patient- centered, population orientation, technical quality, inputs and supports) of which 18 can be reported using existing IS in Canada

CEQM: Continuous Enhancement of Quality Measurement in Primary Mental Health Care Paul Waraich et al Objective is to help address the care gap by: –Building consensus regarding a set of quality measures that are evidence-informed. –Enhance uptake, promote implementation and support inter-provincial coherence of indicators Methods: 3-stage consensus process with over 500 people from across Canada including consumers/ advocates, clinicians, academics and government decision-makers. Results: 30 consensus measures (access, availability, responsive, comprehensive, continuity, technical quality, equity).

B uilding a PHC information system Performance Measurement and Accountability Framework Administrative data- based PHC information system PHC surveys validated for Canadian context PHC sector information system to measure key aspects of PHC over time and place, from both population and provider perspectives Public, Policy, Provider Priorities

Measuring the performance of PHC: Existing capacity & future information needs AM Broemeling, DE Watson, C Black, RJ Reid 2006 Objectives:to describe how existing population- based data sources, identify gaps and make recommendations as to how these gaps in data might be filled Methods: Conduct a scan of PHC constructs measurable with population-based administrative (MCHP, ICES, CHSPR) or survey data in Canada, as identified in the Results-Based Logic Model for PHC Results: New IS are required in many domains, priorities should be to measure outputs and immediate outcomes

Development of a PHC Information System to Support Research, Evaluation and Monitoring in British Columbia Diane Watson, Charlyn Black et al Special Supplement of Healthcare Policy (forthcoming) –Development of a Population-Based PHC Information System Using Existing Administrative Data In Canada –Development/ Validation of Population Registry –Describing the PHC Physician Workforce –Describing the PHC Nursing Workforce –Measuring Inputs, Activities, Outputs and Outcomes –PHC Information Systems Now and Into the Future: Squandering the Canadian Advantage

B uilding a PHC information system Performance Measurement and Accountability Framework Administrative data- based PHC information system PHC surveys validated for Canadian context PHC sector information system to measure key aspects of PHC over time and place, from both population and provider perspectives Public, Policy, Provider Priorities

Measuring the Performance of PHC: Population Surveys Now and Into the Future Canadian’s Experiences with PHC –Statistics Canada (now) linkable to administrative data –Health Care in Canada Survey (now) –Commonwealth Fund (now) –Survey development, validation, implemented and validation (into the future) Quebec (Jeannie Haggerty et al. 2006) British Columbia (Sabrina Wong, Diane Watson et al. 2006) Nation-wide (Health Council of Canada)

B uilding a PHC information system Performance Measurement and Accountability Framework Administrative data- based PHC information system PHC surveys validated for Canadian context PHC sector information system to measure key aspects of PHC over time and place, from both population and provider perspectives Public, Policy, Practice Priorities

Overview What is PHC like up there in Canada? Why do we need “new” information systems (IS) that build on “old” ones How to build PHC information systems –What do we need to know –Who needs to know what –How should we build new IS When should we start?

Thinkers and/or Doers?

“ “The objective of moving ahead with primary care reform is nothing short of transforming Canada’s health care system.” Roy Romanow, Commissioner Commission on the Future of Health Care in Canada