Sunshine Sketches of a little LHIN: Thoughts on health care reform in South Eastern Ontario

| 25 May 2015

The South East Local Health Integrated Network and SECHEF (the South East Community Care Access Centre and Hospitals Executive Forum) have launched an initiative called Health Care Tomorrow, which invites comments from the public and professionals to “inform their strategic goals and initiatives (http://healthcaretomorrow.ca/). The goals of Health Care Tomorrow are to simultaneously improve the quality and financial sustainability of health care in Southeastern Ontario.

Warning: This blog offers my personal views on how we should proceed with health care reform. The blog focuses largely on hospital-based care, rather than primary care. While it is written concurrently with Health Care Tomorrow, it does not represent the thoughts of the leadership of the LHIN, members of SECHEF, the consultants for that process (KPMG), or Queen’s University. The LHIN model: A substantial proportion of health care funding in Ontario is provided by the Ministry of Health and Long-term Care (MOHLTC) through 14 local health integrated networks (LHINs). The LHINs were created April 1, 2007 with the mandate to plan, manage, and fund the health care system at the regional level. Bashin and Williams noted, “LHINs are seen to be a mechanism for overcoming existing health care “silos”, and improving integration and coordination of services that will hopefully lead to a more efficient, accountable and sustainable health care system in Ontario.” LHINs were meant to eliminate silos; do you think this has been achieved? Our LHIN faces several challenges: It is geographically large (>200km east-west) and has a low population density with a high proportion of elderly residents, which has implications for the tax base and for health care utilization. The projected 10-year population growth for our SELHIN is slower than larger adjacent LHINs (Figure below). Moreover, a 35 % increase in the proportion of our population who are seniors is anticipated over the coming decade. Figure: Slow population growth in the SEHLIN over the next decade

However, the SELHIN is heterogeneous. There is projected to be population growth in parts of the region (Kingston) and contraction of the population in rural areas (see below). Figure: Heterogeneous population growth in the SEHLIN over the next decade

Let’s take a look at how the SELHIN is currently structured Health care for the over a half-million persons in Southeastern Ontario is governed by the South East Local Health Integrated Network (SELHIN). The SELHIN is a loose affiliation of 7 hospitals (3 in Kingston). Its stated vision is admirable: “Achieving better health through proactive, integrated and responsive health care in partnership with an informed community.” Even the LHIN’s biggest fans will acknowledge that in reality each hospital is largely free to manage their own budget, set their own strategic priorities, and purchase the brands of major infrastructure they prefer (e.g. electronic health records (EHR) and picture archiving and communication systems (PACS)). Each hospital has its own hospital board and their own support systems, such as information technology (IT), human resources and credentialing. Each hospital has its own pharmacy, pharmacy and therapeutics (P&T) committee and medication formulary. Each hospital manages its beds as it sees fit and controls its own hours of operation. If you are wondering how a patient moves through this maze of silos, how much redundancy there is in the system, or how the system will be remain solvent in an era of shrinking global budgets with increasing reliance on targeted funding that requires close in-patient and out-patient care coordination …read on. One MD’s approximation of how the SELHIN is currently structured* (see Figure below)

* The electronic health record brands are not those in place in our LHIN and are used simply to illustrate the lack of a shared system). In addition, some hospitals do share PACS, some share labs and some share electronic health records. There is however no standardization of these services across the region. What are the consequences of this model, from a patient perspective? Patients observe that while most health care workers and facilities are well-intentioned the patient experience is fragmented. Our current model (despite the “I” in LHIN-which is supposed to mean integrated) is comprised of hospitals that are siloed (meaning they exist as isolated units with their own administration, mandate and budget). A patient’s health records and images often do not move with them (there are exceptions with some hospitals partnering and sharing some services). As a result, each new practitioner tends to ask the same questions. Often, when radiology or lab tests are not readily available, repeat testing is performed. This is not patient friendly, is not Choosing Wisely®, and is also expensive. This is allowed to occur (in part) because of the siloed leadership and budgetary model. I must emphasize, the problem is the organization model; not the people who run the organizations. As evident in the figure above, each hospital has a CEO and an independent board and budget. These hospitals have a fiduciary responsibility to manage their budget (not the global SELHIN budget). This leads to decisions that are responsible and wise when seen from the hospital board’s local perspective, but are manifestly suboptimal, if seen from the patient perspective or a “system” perspective. Patients (and many physicians) get to experience the full breadth of the system: primary care, outpatient facilities, emergency departments and in-patient care - and the siloed organization chart does not work for them. Some hospitals in the SELHIN are purpose-specific, focused on outpatient care or chronic care; however most are general hospitals. While there is little competition and much good will amongst hospitals, there is little coordination and what coordination exists is voluntary. The hospitals do not share common electronic health records (EHR), pharmacy systems, PACS systems (the electronic repositories of medical images) or laboratory services; nor are they required to do so by the SELHIN or the Ministry of Health. Moreover, the region does not have common credentialing or shared finance or human resources systems. There is no single point of entry for consultation amongst physicians and functions like medication reconciliation or the conduct of Pharmacy and Therapeutic Committees are the exclusive mandate of the individual centres. The organizational structure is passively permissive of redundancy and waste. Thus there is opportunity that reform could not only improve the patient experience but also save money. Dr. Chris Simpson, our Head of Cardiology at Queen’s and the current President of the Canadian Medical Association, has been travelling the country this year advocating for a national seniors strategy. He argues that patients with chronic and complex disease need integrated care – and that creating a system that delivers that will actually save money. “At some point, we’re going to get our heads around the fact that quality care saves money”, he says, “but we won’t be able to generate action on this until we change our governance and operational structures in a very fundamental way.” Questions for patients: As we consider what results we would like from reform of the SELHIN it is helpful to ask a few questions of patients (and we are all potentially patients).

Would you like to have your personal health care record available to all providers in the SELHIN, regardless the setting in which your care is delivered?
Would you like to have timely, local, access state of the art surgery, a trauma centre and critical care unit that is open 24-7, stroke care, Moh’s surgery, neurosurgery, hip resurfacing, renal transplantation and STEMI care?
Do you think the care and the people that provide it make our local economy more robust and vibrant?
Do you think that faculty (who can work anywhere in Canada and the USA) would prefer to work in the SELHIN if they are permitted to implement advanced medical and surgical therapies to treat common health problems like congestive heart failure, cancer, epilepsy, Parkinsonism, coronary artery disease and respiratory diseases?
If you need a kidney transplant would you not expect that you could have a live donor transplantation within your region-just like your friends in Ottawa and Toronto?

I could go on with the rhetorical questions. There are many reasons to change the SELHIN model of care: 1) Provide better access to high end (tertiary-quaternary) care and prevent loss of service (and resources) to other LHINs: Approximately 44% of hospital care in our LHIN is provided in Kingston: Kingston General Hospital (KGH, tertiary-quaternary care), Hotel Dieu Hospital (HDH, outpatient care), and Providence Care (chronic care, geriatrics, rehabilitation). In addition, 25% of care is provided in Quinte (Belleville General Hospital), 10% in Brockville (Brockville General Hospital), 7% in Perth-Smith Falls and 3% in Lennox and Addington. Note these totals do not add up to 100%. Approximately 13% of all hospital care for SELHIN residents is provided outside the region. Ottawa is just 2 hours from Kingston. Toronto is likewise 3 hours away. The reality in a provincially-funded system is that patients who can (usually younger and richer) will travel to other LHINs to access advanced health care if it is not available at home. This creates a vicious cycle that lowers the SELHIN’s capacity for quaternary care. Outmigration of high complexity cases that could have been provided within the LHIN results in a regression of overall care quality to a lower mean. For example, 2 years ago there were only 2 dermatologists in a region with 500,000 people; a far cry from the nationally recommended number of eight for a population this size. There was no reason for this Dermatology deficiency other than apathy and a false sense that the care could be provided elsewhere. While Dermatology in the SELHIN is now well on the road to recovery (we have 5 dermatologists, including a Moh’s surgeon (See a recent blog, Skin in the Game) you get the idea. If a LHIN delegates high-end care to other regions the quality of all levels of care suffers. The uncoordinated leakage of patients is also bad for patients, most of whom cannot or will not travel to Toronto and Ottawa. Perception also becomes reality and sadly many patients who chose to travel are unaware of the high quality of care provided within their own LHIN. Many residents who have their life saved through procedures in Kingston, such as primary angioplasty to treat STEMI (heart attack) or thrombolysis for stroke, make donations to the Ottawa Heart Institute! CHEO and Sick Kids fund raise in Kingston – even though many children with cancer and other complex illnesses are successfully treated here.

The lack of recognition for the excellence we have is bad for patients, bad for philanthropy and could render the SELHIN irrelevant, positioning it for amalgamation with one or more adjacent LHINs. This would hurt the academic medical centre and further reduce the quality of care available to our residents. Lack of “programs of distinction” is also bad for the educational and research missions of our regional academic health care enterprise. The impact of Queen’s University, one of Canada’s top research intensive universities, is huge. The best and brightest (and their talented significant others) will only relocate to South Eastern Ontario if they can ply their craft (i.e. perform neurosurgery, implant ventricular assist devices, or perform deep brain stimulation and epilepsy surgery, POEMS procedures, stroke thrombectomy, percutaneous aortic valve replacement, allogeneic bone marrow transplantation, living related renal donor transplantation, Moh’s surgery, bariatric surgery, or atrial fibrillation ablation. The medical school is not only an economic engine, it also trains most of the physicians in our region. We need a strong LHIN to attract and retain the talented people who train our nurses, pharmacists, physiotherapists, technologists and physicians. The dial is starting to move toward high-tech medicine, at least at Queen’s. New programs are being created and quaternary care programs are becoming more available. With the improved care comes an influx of specialized physicians, pharmacists, nurses, technologists and others that enrich the region in many ways outside health care. A reformed LHIN in addition to being cost-effective and patient-centred should be a bit more braggadocios and self-promoting with a can-do attitude. It should be unapologetic in its pursuit of excellence, remembering the adage that “It’s a poor dog that doesn’t wag its own tail”! 2) Improve patient-centred care by making a fully integrated system where patient information and images move electronically throughout the region both between hospitals and to and from primary care providers. You will intuit the benefits of this reform if you have been repeatedly re-questioned about your prior medical illnesses or medication list, had your blood tests redrawn because the physician shouldn’t see your prior test results or been concerned about having a second echocardiogram because the images from the first study are unavailable. A patient-centred system would also be a system that would be much more enjoyable for MDs, RNs, pharmacists, technologists and others. 3) Save money and make the health care system sustainable by consolidating hospital services and avoiding redundancy: Currently our LHIN is in the 75^th percentile in terms of expenditure per capita on inpatient services. If nothing changed, it is estimated we would need to spend an additional $122 million/year by 2023 just to maintain the status quo (See Figure below). Its unlikely this increased funding will be available in a province where the MOHLTC has “flat-lined” hospital budgets as labour costs rise, creating structural funding deficits. Figure: Re-organization is necessary to approximate financial neutrality by 2023 4) Support our academic medical centre (Queen’s University): Queen’s University trains most of our health care professionals, performs research.

Grant Hall, Queen’s University

Queen’s is also a huge economic engine for the SELHIN. I would argue that formal creation of a unified Academic Health Sciences program with multiple campuses is required to ensure our University remains competitive. This is precisely what was done in Toronto, where 4 hospitals are linked as the University Health Network. Queen’s and its community of faculty, staff, and students contribute to the economic vibrancy of the city. The local impact of Queen’s amounts to $1.5 billion per year in economic activity (http://www.queensu.ca/discover/queenskingston). A fragmented health care system which loses patients to other LHINs and allows high technology to migrate to Ottawa and Toronto (and with it high tech faculty) is bad for trainees, who need a critical mass of patients to master their professions, bad for the University, who need to be able to compete globally for talent and for grants, and bad for the people of the SELHIN, who would receive reduced access to care and lower quality care. I must also add that all these high-tech procedures (deep brain stimulation, transplantation, percutaneous aortic valves, bariatric surgery etc.) are provincially funded. Failure to perform the procedure would simply consigns us to provide the poorly-funded, post-procedural, care while other centres perform the lucrative, rewarding procedural care. The Vision: Since we are considering how to create a practical vision for health care in an era where budgets are flat lined we will need to consider solutions that make sense but also save dollars. One could tinker with the current system but that is unlikely to deal with our lack of coordination and dispersed geography. A new, bold vision of the hospitals in Kingston in particular and the SELHIN in general is required. This would involve a new unified leadership structure and a common budget, so that hospitals cannot opt out of the region’s health care plans (which to date has led to variable health care records and imaging platforms and lab systems that don’t communicate with one another). As we create “the SELHIN 2.0”, I, Like Sir John A MacDonald (Canada’s first prime minister, for those of you south of the border), call for a bold vision.

Recognizing that unity was required to build something remarkable, he said: “If I had influence over the minds of the people of Canada, any power over their intellect, I would leave them this legacy: ‘Whatever you do, adhere to the Union. We are a great country, and shall become one of the greatest in the universe if we preserve it; we shall sink into insignificance and adversity if we suffer it to be broken. .” There are barriers to the movement to reform our LHIN. I would summarize these as The Four “F”s: of Failure: They include: Familiarity, Fatigue, Futility and Fear. Familiarity: The chief barrier to a re-envisioned LHIN is a sense of adequacy and comfort with the status quo (i.e. our system is not perfect but its not horrible). It is human nature to become comfortable with daily life. The narcotizing effect of familiarity is best described by Stephen Leacock, once Canada’s leading satirist. Stephen Leacock used his pen to slay parochialism and point out how failure to dream and the comfort of the quotidian can gradually erode standards… Southern Ontario gave Leacock a rich body of material for his craft. Born in Swanmore, England (1869) he grew up on a farm in Ontario (near Lake Simcoe) and studied at Upper Canada College (where he later taught) and the University of Chicago (I missed him by 104 years). Leacock’s signature piece Sunshine Sketches of a Little Town (1912) skewers the complacency and the inertia of a status quo that leads to complacent mediocrity. Sunshine Sketches is set in the mythical Mariposa (modeled on the real town, Orillia, Ontario).

http://www.thecanadianencyclopedia.ca/en/article/stephen-leacock/

As you read this passage (edited for brevity), replace Mariposa with the name of your local hospital. To the careless eye the scene on Main Street of a summer afternoon is one of deep and unbroken peace. … But this quiet is mere appearance. In reality, and to those who know it the place is a perfect hive of activity. … Busy-well I should think so! Ask any of the inhabitants if Mariposa isn’t a bust, hustling thriving town… Of course if you come to the place fresh from New York, you are deceived. Your standard of vision is all astray. You do think the place is quiet. You imagine that Mr. Smith is asleep merely because he closes his eyes as he stands. But live in Mariposa for six months or a year and you will begin to understand it better. The buildings get higher and higher; the Mariposa House grows more and more luxurious; McCarthy’s block towers to the sky; the buses roar and hum to the station; trains shriek; the traffic multiplies; people move faster and faster; a dense crowd swirls to and fro…” Leacock recognized that we get used to the local standard and soon pretty good becomes good enough. If we don’t leave town periodically and see Mariposa through fresh eyes, Main Street remains chic and comfortable long after it is actually dated and hollowed out. If we are to re-envision health care we need to see ourselves through new eyes. Mariposa’s hospital may be close by and friendly but it lacks modern testing facilities, is not open 24 hours a day and lacks tertiary care services. Fatigue: Physicians have busy full time jobs without reforming health care. Long hours of work, and prior failed attempts at reform, lead to fatigue that erodes the enthusiasm for engaging in the politics of reforming health care. However, we are key leaders in health care and need to put this fatigue aside. It is our responsibility to contribute to improving the system and I am pleased that many of my colleagues (in Pharmacy, Nursing, Surgery, Pediatrics, Family Medicine, Obstetrics and Medicine) from around the SELHIN, have given of their time to provide input into the Health Care Tomorrow project. Futility: This LHIN has previously attempted a reformatting of its hospital structure to enhance function in the recent past. While there is difference of opinion about the impact of the Clinical Services Roadmap exercise, most believe it involved many hours of volunteer time and led to only modest change in the essence of the SELHIN’s functioning. Naysayers of the current initiative cite the prior Roadmap exercise as a basis for skepticism. I view it more like smoking cessation counseling…it takes many efforts at behavior modification before the average smoker stops smoking. There is no shame in the failure of a single attempt at reform; the shame would be failing to try again. Fear: Fear is a big enemy of change. Fear your hospital will close (it won’t), fear the local CEO and Board structure might lose some power (they might), fear that choice will be reduced by introduction of common electronic health record, PACS, regional P&T committee (it likely will be modestly reduced but with many benefits resulting from enhanced communication compensating for the loss). What we are doing now is unsustainably expensive and at the same time is not providing patients with the ease of access or the quality of care they deserve. Placating all hospitals and essentially maintaining them in the current nonintegrated system would not support patient-centered care, would not save money and would perpetuate the relative lack of high tech medicine in our region. Guiding principles for LHIN reform: Volumes matter: Patients and administrators need to understand a fundamental truth in Medicine - repetition is the key to quality, at least for procedural skills. This means with a population of ~500,000 we need to ensure that our tertiary and quaternary care hospitals, those where high-tech surgery and interventions are performed focus on what only they can do. This implies that all the centres in the SELHIN should have designated functions and perform these with pride. Currently for example all stroke reperfusion and primary coronary angioplasty for myocardial infarction (PCI for STEMI or angioplasty for heart attack, depending on your bent) are performed at KGH. This ensures that these complex, lifesaving procedures are done by high volume operators who do them well and this yields optimal results. The benefits to patients accrued by receiving care at high volume centres is not just opinion. For example, a look at the effect of case volume on outcomes from coronary angioplasty reveals, “Mortality and major adverse cardiac events increase as operator volumes decrease …”. Circulation. 2014;130:1343-1345. In our LHIN, we know that stroke outcomes are best if patients are cared for in a specialized stroke program. This focused care has been recognized by Distinction in Stroke Services Award from Accreditation Canada. These tertiary quaternary services not only improve outcomes but drive the recruitment of talented individuals and their talented partners to our region. The importance of volume to outcome is true for virtually all procedures, both open surgical and minimally invasive. The clustering of high volume Programs of Distinction at the tertiary care centre (Kingston General Hospital) does not exclude tertiary care activities occurring in other sites (in our LHIN this would be Belleville). In addition, certain services can still be provided locally, like Satellite Hemodialysis in communities across the SEHLIN, or cancer chemotherapy, some of which can now be safely delivered “closer to home” using a distributed model in appropriately designated, high quality centres across the LHIN Hospitals should be branded: For one centre to offer better access to programs of distinction other services will need to move elsewhere. Some sites might retain general services (emergency medicine, general medicine) and in addition specialize in restorative medicine for the elderly, rehabilitation, secondary-level surgery (hernias, appendectomies etc.). Thus, designation of hospital function could support institutional pride and retain institutional function while ensuring sufficient case volume at all sites to optimize outcomes for our patients. Vision requires direction: A good leader can overcome a poor organizational model but why not create a model that will help the leader succeed. I would submit that a unified leadership structure would be helpful. Perhaps like Canada itself, we can have each hospital run by a high level Vice-President, analogous to a Provincial Premier-but for coordination of vision and direction we would likely fare better with a single CEO, analogous to a Prime Minister. Reassurance in this model would come from clear term limits and performance metrics. What is certain is that a system with multiple CEOs, CFOs, Boards, brands and budgets is unlikely to ever permit vector, velocity or vision. An effective union requires shared means of sharing information: In both the Christian and Jewish faiths the story of the Tower of Babel reminds us of the power of clear communication.

Pieter Bruegel the Elder - The Tower of Babel (Vienna) - Google Art It is said that humans built a city, Babel, and within it a tower, reaching toward the heavens Genesis 11:1-9. They perceived that with a common language nothing would be out of their reach. Interestingly, God fully agreed with the consequences of a common language-greater achievement; however, he felt it would make humans less attuned to him. This displeased God, and so he confounded their speech, creating multiple languages and thwarting their communication and growing ambition. Unable to communicate, the people of Babel were scattered across the earth, and the rest is history. Arguably, the SELHIN is in a post Babel state-we are unable to easily communicate (not clinic notes, not medication lists, not health records, and not medical images). The ancient residents of Babel and God agreed upon one thing-a common language is key to power and achievement; perhaps the people of the SELHIN should likewise have a common electronic health record, PACS and Pharmacy Health Information systems. Benefits of an electronically unified LHIN include:

A unified LHIN will smooth the patient’s transitions in care. A doctor in Belleville would see your discharge summary from Kingston and be able to directly view your CT scan. The Med reconciliation done when you leave Napanee Hospital would be available to your primary care doctor or the Emergency Department at KGH.

A unified LHIN could support single point of entry consultation: in which your family physician could readily find and refer to specialists (who would see your electronic health record, prior lab testing and medications).
A unified LHIN could support common credentialing: Ideally, the common communication would allow common credentialing of practitioners across the LHIN, a step toward ensuring uniform quality of care.
A unified LHIN would support real-time, regional bed maps: Hospitals could begin to share their call schedules and bed maps in real time, allowing more dynamic management of in-patient beds easing access to acute care beds and accelerating both urgent transfers to the tertiary care centre for specialized care as well as repatriation of patients who are stable back to their local hospital.
A unified LHIN would support a common budget and accountability model: Money talks! A LHIN that has a vision will need to have a common budget, at least for capital purchases of key systems that support integrated communication. Hospitals should not have the latitude to depart from a LHIN-selected electronic health record or PACS vendor. If the funding is coming from the LHIN, a shared product just makes sense. The benefits of a shared infrastructure planning and funding model would include consistency of the patient’s and professional’s experiences, avoidance of redundant testing and a true ability to fully take advantage of the regions resources.
A unified LHIN would better interact with our partners: A new LHIN model needs to include an optimal role for primary care, long term care facilities, paramedics and transportation services which may not be directly funded via the LHIN but which are nonetheless crucial to a high performing regional health care system.
A unified LHIN would enhance patient centered care: This is our zeitgeist but, like all things that are trending, the definition of patient centred care should be considered critically. Patient-centered care is often oversimplified as meaning “near to home” or “friendly”, while forgetting that this is an incomplete description; however, proximity is not always quality. Patient-centered care is not just convenient, seamless, respectful and timely. It is also provided by the best and brightest health care professionals (MDs, RNs, Pharmacists, Technologists and others) who work in well-equipped hospitals and perform the procedure with sufficient frequency to have optimal outcomes. If you have an invasive basal cell carcinoma on your nose you may want close and convenient care, but what you really need is a Moh’s surgeon (http://deptmed.queensu.ca/faculty/moran_benvon). This means the 1-hour drive from Brockville to Kingston is justified. In a reformed LHIN we would of course reserve patient travel for services that are performed at a regional centre of excellence. Local care could continue to be provided by our outstanding family physicians and nurse practitioners. For patients who are too elderly and frail to travel we can and should reinforce and enhance the model of primary care and in-home care which is provided by the Community Care Access Centre (CCAC).

Conclusion: The new SELHIN might look like this (Figure below), a far cry from the Current State, as shown in the Figure at the beginning of this blog. Note in orange the reduced and centralized administrative structure and the shared information systems and shared support services that encircle the system, serving all centres.

As health care professionals, we have a unique lens through which to view our challenges and our opportunities. Are we ready to broaden our view of professionalism from one that, nobly, advocates for our individual patients, into one that also advocates for a better system? Let’s close with some thoughts from a few distinguished gentlemen who had experience transforming systems. The best way to predict your future is to create it. Abraham Lincoln Change will not come if we wait for some other person or some other time. We are the ones we've been waiting for. We are the change that we seek. Barack Obama Everyone admits that Union must take place sometime. I say now is the time. Sir John A McDonald, at the Charlottetown Conference 1864. Acknowledgements: I would like to thank the many colleagues who proofed this blog