Health care goes horizontal

Back in the 1970s, U.S. Secretary of State Henry Kissinger, frustrated with the baffling multiplicity of people to consult, grumbled: “When I want to speak to Europe, who do I call?”

A similar state of affairs prevailed in Ontario’s health care sector until recently. Organized in sectoral silos, there was no central entity concerned with common interests. “It wasn’t clear who to call, so everyone would be called,” says Hy Eliasoph, CEO of the Central LHIN (Local Health Integration Network) in northern Toronto. “Things got replicated over and over.”

Moving forward on e-health initiatives across the continuum of health care providers was difficult in this scenario. Decisions made in isolation created fragmented IT environments lacking interoperability, says Eliasoph. As a consequence, Ontario lags other provinces in developing a unified health care system.

“Looking across Canada, there is a high correlation between regional integration and IT systems integration,” says Michael Martineau, e-health practice leader at Branham Group Inc., an Ottawa-based IT research consultancy.

Shifting from a vertical to a horizontal regional model is a major change for Ontario. Now over two years into reorganization along regional lines, the 14 fledgling LHINs must learn to speak with one voice and their systems must talk to one another. Their impact is being felt in many areas and will continue to grow as they integrate disjointed parts into a provincial system.

Financial teething pains

A milestone was reached this month when the 14 LHINs assumed responsibility for funding health care organizations within their regions. Recognizing the province can’t continue to micro-manage this enormous area, the Ontario Ministry of Health and Long-Term Care transferred about $21 billion of the $35.4 billion operation into LHIN hands.

“Just from a financial accountability perspective, this is a huge undertaking,” says Eliasoph, adding that LHINs have been putting financial systems in place for this area of responsibility. These evolving organizations will play a larger strategic role in the future. “Any additional funding that hospitals or other organizations may want will be directed to us.”

But there isn’t much discretionary funding, at least for this first fiscal year, says Matthew Anderson, e-health lead for the Toronto Central LHIN and CIO of the University Health Network. “All that money is already spoken for,” he says.

Agreements were signed with the Ministry last October, specifying the services expected for the funding. “For the most part, it means maintaining last year’s volumes of transplants, cardiac procedures and so on, plus or minus a few things – so we’ll be dealing with the deltas.”

All administrative funding is in that pot, including money for IT projects which are not funded separately by the Ministry. In the past, if hospitals wanted to implement a system, they had to find the money themselves, says Eliasoph. This independent approach to systems development has created the cacophony of systems in Ontario, he says.

“Over time, we’re thinking of a different funding model for hospitals and other organizations. IT funding will come with strings attached, which will be this: you can’t just do whatever you think is right for your organization – there’s a broader health system to consider.”

Ultimately, LHINs are political vehicles to influence their organizations to operate with a more regional rather than local focus, since they have no delivery responsibilities themselves, says Anderson.

LHINs do have the authority to shift money around within their regions based on the priorities of the whole: to close or consolidate health care organizations, start joint programs and so on. But extra funding has not been provided for integration projects, he says.

Cost or investment?

Funding is a central issue. More money would give LHINs more wiggle room to help fulfil their e-health integration mandates, says Anderson. “The Ministry will say, there they go again. But the reality is it doesn’t have to be a lot,” he says, pointing to the successful wait-times program as an example.

In response to citizen pressure, extra funding was provided to help hospitals perform more high-priority procedures within defined timeframes. But to achieve that clinical outcome, a comprehensive information system was developed to support it. “They didn’t say, let’s put in a measuring system; they said, let’s reduce wait-times.”

The lesson learned is that a small percentage of overall funding can be very useful as incentive for systemic IT improvements, says Anderson. “If you look at the actual amount of money the wait-times program controls around doing more cancer procedures, for example, it’s actually a fraction of the overall budget for cancer treatment in Ontario.”

There are other areas where a similar approach can help build the information bridges needed to connect islands of information, he says. Projections of diabetes, for example, are making headlines. With an increasingly aging population, about 10 per cent of Ontarians will be diagnosed with the disease by 2010.

“IT will be the investment required to support diabetes management. We don’t need all of the money for all of the databases required for that – many are already constructed,” he says.

To understand patterns of the disease, a first step is building a population health model aggregating information from all sources: from hospitals to clinics to nursing homes.

But organizations struggling to meet their own IT needs will have a tough time coming up with funds to support broader integration projects. IT budgets in the health care sector are already at bare-bone levels, about half what is typically allocated in other industry sectors, says Martineau.

So extra funding would be useful in getting cash-strapped organizations onside, adds Anderson. “Then we could go to organizations with those diabetes databases and say, ‘We’re not asking you to cough up the dough yourself; we’ve got a bit here to move on the diabetes management agenda.'”

Martineau agrees funding levels and models are a major issue. “The biggest challenge the LHINs face from an IT perspective is dollars: inadequate funds to move on the e-health agenda,” he says.

Other provinces fund IT projects separately from administrative budgets. Ontario alone lumps these together, he says. “You need to spend more money on IT today to get savings down the road.

“But hospitals get their knuckles rapped if they spend too much on administration. There’s a lot of discussion going on at the Ministry to say, no, we should break out the IT budget so we can analyze it separately.” Many such funding and strategic issues are pending before government for decision, says Adalsteinn Brown, Assistant Deputy Minister with Ontario’s Health Ministry.

Eliasoph says: “The Ministry’s view has always been, ‘We’re in the health care business, not the IT business.’ But that’s an archaic view: if you’re in the health care business, then you’re in the IT business.”

Joining the islands

The government’s position is clear. “We want to see systems oriented to patient needs, so it means the systems that support the care people receive in different settings must be able to talk to each other,” says Brown, adding the Ministry isn’t concerned h