organized curiosity

Improving health care through research

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Canada’s Health System: Are We Making the Grade?

Canada’s Health System: Are We Making the Grade?

In the past week, I read three different items that suggested both hope and concern about progress in the extremely complex world of health care in Canada and in Nova Scotia.  I am immersed in the running of health care and am always interested in how others evaluate how we are doing.

In the first piece titled “The Commonwealth Fund”, a distinguished U.S. Foundation just released a report on how the U.S. health care system compares internationally.  The U.S. was the worst in a comparison with 10 other countries: Australia, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and Canada. But the real message for Canadians is that the Canadian system was the second worst.

Let’s be clear on a couple of things. It is not because Canadian’s don’t spend enough money. Many countries with better health systems spend less than we do. It is not because our doctors, nurses, other health professionals and administrators don’t work hard enough. They do work hard. But often, it is the system itself that holds us back and hinders our ability to make smarter choices.

As you can see from the figure below, Canada was not very good at any of the categories.

Health Study for Pat's blog

There are no areas where we are near the top. Our highest ranking – which still left us in the middle of the pack were: effective care (7th) and cost-related care (5th). In everything else we are under-performing.

One can quarrel with the methodology of the study. The data is drawn from three surveys; two are from patients and one from family physicians. The surveys are meticulously done, but suffer from all the limitations of surveys that ask people ‘what do you do’ instead of hard data on actual behavior. Regardless, I think we can all agree that they are still highlighting the major issues Canada faces.

If you drill down on individual questions, the results start to give us a clear indication of what we need to do in order to have a better health system for all Canadians.

While there are many opportunities for improvement suggested by the Fund’s report, in my opinion, many issues could be helped by a “smart” electronic health record with the notion of “one patient, one record.”  By “smart” I mean a system that would monitor if things that should be done, were done, and had reminders and algorithms that would help the doctor do their job more efficiently and consistently.

The “one patient, one record” means that each of us has just one set of records that could be linked across all of the provinces’ health systems. It could ensure continuity of care across doctors and improve communication amongst all of our health providers. It would also empower patients to become more involved in their own health and health care. I firmly believe we have the right to all of our own health information.

Two Nova Scotia physicians, Micheal Graven and Noni MacDonald, have implemented a “smart,” “one patient, one record” system in Belize. The system covers the entire health system including pharmacies, and has built in algorithms that prompt doctors and other health professions with timely information and reminders. In Belize, this system has reduced deaths and stabilized health care costs. And it only cost a few dollars per patient.

The second two pieces were about Nova Scotia. FairWarning, Inc., a patient privacy monitoring solutions company, announced that Health Information Technology Services – Nova Scotia (HITS-NS) won the “Best Healthcare Provider, Canada” Award for the 2014 Privacy Excellence Awards. This award was judged by an independent panel. The final was an announcement from the 9th Annual Canadian Health Informatics Awards that Nova Scotia and McKesson Canada, a Canadian unit of an international company, had won the Project Team Patient Care Innovation Award for a pilot project involving 5,000 patients in which the patients had access to their medical records.

We should not sweep the Commonwealth report under the carpet. This report needs to be listened to. We need to have a province-wide, functional electronic health record that contains all of our health information. We need a system that helps prompt good practice and can be readily accessed by all of our health professionals and ourselves. Of course we need the privacy protections to go along with such a record. The two awards given to Nova Scotia give hope that we are going in the right direction.

Let’s hope the progress evidenced by these two awards is transformed into a province wide, privacy protected, system.  Nova Scotians and Canadians deserve a first-rate health system, not a health system that is only one step from the bottom of the heap.

~ Dr. Patrick McGrath


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Is More Always Better in Health Care?

Nearly 25 years ago, my family and I moved to Nova Scotia from Ontario. I had worked for 10 years at the Children’s Hospital of Eastern Ontario in Ottawa as a clinician and as a scientist.  I came to Dalhousie University to start the Clinical Psychology PhD program.

I have observed health care over this time and a few issues have dominated the discussion. Timely access to care is the issue we all care about.  Access to emergency, mental health, diagnostic imaging, and acute care beds are the most common concerns. Most of the time there are no complaints about the quality of care.

The proposed solution is usually more health care. Sometimes the solution is more long-term beds to free up acute beds, sometimes it is more surgical time, more nurses, or more of some speciality medical equipment or test.  Most of the time these solutions are short-sighted.

‘More’ does not always mean ‘better’.   Many doctors in Nova Scotia already understand this and are looking for ‘smarter’ health care solutions rather than just ‘more’ health care.  One recently launched idea by the Canadian Medical Association is Choosing Wisely, a research-based campaign to get rid of unnecessary medical care.

Choosing Wisely identifies care that is not necessary.  For example, most of the time x-rays, MRIs or CT scans do not offer a lot of help for resolving back pain. People don’t get better any faster when they receive these tests. And the tests have two types of risks. The first risk is the radiation you are exposed to. The second risk is that many of these unnecessary tests often find quirky things that don’t mean ‘disease’, but have to be followed up by more tests that bring more risk. Unless there are other reasons to validate the need for the test, this circle will continue.  Unnecessary tests can also cause unnecessary angst and worry for patients and families.

We all have quirky things in our bodies, that don’t mean anything. These quirky things can be abnormal values on a blood test, or small abnormalities in our bones. After all, each of us has a body that is not average – we are all unique.

Each and every test also has a cost: a cost to the patient, a cost to other patients and a cost to the system. The cost to the patient is more radiation or pain, extra worry, and even dollars from time off work or travel to the hospital. The cost to other patients is those that need the test can’t get it if someone is taking their spot in line. The cost to the system is the additional dollars spent on more equipment and more staff.

That doesn’t mean that imaging for back pain is always bad. The website does describe “red flags” where imaging should be considered.

In the USA where Choosing Wisely began, over 55 medical specialist societies have joined and typically designated five different things for each medical specialty that doctors and patients should question.

Choosing Wisely uses research evidence to help you and your doctor, together, make smarter decisions about your health care.

I am disappointed that no one appears to have done research to see if the Choosing Wisely campaign works to reduce unnecessary care. Does it work?  Will it work in Nova Scotia?

I encourage you to look at the Choosing Wisely list. It may surprise you.  It just started in Nova Scotia and more things are going to be added. If everyone chooses a little more wisely, we can make a difference.

~ Dr. Patrick McGrath