Regionalization creates organisms from isolated cells
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 how systems are knitted together so long as this end-goal is achieved.
Many integration projects on the table predate LHIN restructuring, so there is tremendous goodwill to get on with the job, says Martineau.
With it comes a major behavioural change. Learning to work in teams across organizations to fulfil system-wide goals is the biggest challenge in the IT community, says Sam Marafioti, CIO at Sunnybrook Health Sciences Centre in the Toronto Central LHIN.
Different LHINs are at different starting points on the road to integration, as are different organizations within them. Most hospitals have advanced IT systems, but community care access centres have virtually no infrastructure. Many LHINs need basic plumbing and wiring such as secure e-mail and health information management networks to achieve a minimum level of interoperability within their own regions.
On top of intra-LHIN integration, there are many cross-LHIN dependencies to be considered in strategic planning. Toronto Central LHIN receives patients for specialized care from across the province at the Hospital for Sick Children and other downtown hospitals. Beyond Ontario, it also contains some of the biggest teaching hospitals in Canada.
One of the top priorities is building a common e-referral system, says Marafioti. Still largely handled by paper and fax, this project will define and digitize the patient information that needs to be transmitted and moved around as one organization refers a patient to another for tests, secondary follow-up care, and so on.
“This will really help people understand wait-times and moving patients based on priority. A referral will either get you immediate attention or get you on a waiting list,” he says.
System integration will need to be done within the context of privacy and security legislation.
“We know how to secure information within our local systems, but how to secure it when it’s moving around dynamically among many partners is very new to all of us,” he says.
Dealing with the tension between local and regional priorities is another major challenge for the IT community, says Anderson. Organizations have their internal strategies to fulfil, but with limited resources.
“These are all committed to moving your organization forward, and now you have to parse off some resources to go over and build an interface,” he says.
These projects are rarely as easy as they sound, as IT folks often run into data quality issues and other time-consuming problems, Anderson adds.
This may delay local projects that clinical staff want to launch. “Then you must tell someone local, ‘I can’t put in your departmental system because I have to shift my resources over to this regional priority,’ which may or may not have great value back to my organization,” he says.
Decisions, decisions
Another major issue is how to create interoperability out of disparate proprietary systems, and how to handle legacy systems.
Decisions will need to be made by LHINs about whether to invest further in extending existing systems or replacing them outright. Most LHINs have inherited multiple systems from different vendors that are not always compatible.
At major hospitals, users have learned how to operate their particular systems and are heavily invested in them, so getting a common system will be tough, says Anderson.
“In our LHIN, we’re not telling our hospitals to get rid of systems and move to new ones. We’ll instead build interfaces – but there’s a cost to that,” says Eliasoph.
Decision-making has been simplified considerably on other fronts. The LHIN structure is effective at giving the rallying cry to move on languishing projects, says Linda Weaver, CIO at Smart Systems for Health.
Charged with providing common infrastructure such as networks and data centres to Ontario’s health care sector, Smart Systems often had difficulties coming to a decision.
“In the past, we had to deal with hundreds of individual end-points. Now when we’re talking about what we have to deliver next year, it’s to a roomful of about 20 people, so we can get some consensus,” she says.
Building a common client registry, for example, so that patients can be identified and tracked as the same person while they move through the health care system, is a straightforward technology problem. But solving it means agreeing on a unique numerical identifier, and most parties have a vested interest in their own: hospital cards, health cards, insurance cards, and so on.
Dealing with parties one at a time stymied this process. Whichever one picked created a problem for another. With 20 people in the room charged with finding the best communal solution, progress can be made on this front, says Weaver. “We can say we have to make a decision to pick one or create something new. But we can’t keep waffling.”
Weaver notes government priorities may not be the same as other players’, and these will ultimately direct decision-making. “The Ministry doesn’t have a provincial strategy in place yet, and most other provinces do,” says Eliasoph, adding this is expected in the near future.
“Until then, we’re working on the assumption that certain things will appear in it. So another challenge is developing our own strategies in the absence of an overarching one.”
Work in progress
To avoid creating 14 new silos, an e-health leads council has been established to provide IT governance for the regionalization effort in Ontario as a whole.
Comprised of a leading CIO from each LHIN, the council meets regularly with the Ministry and Smart Systems. Counterparts in other provinces further along in their regionalization efforts are frequently consulted.
This consolidation of IT leadership will make a huge difference, says Eliasoph. The e-health lead at Central represents 143 organizations and is currently the joint CIO for three hospitals, he says.
Senior IT staff with the big picture view will help foster the standardization and interoperability needed for the next step: developing common electronic health records (EHRs), which are the building blocks for a fully integrated health care system.
At this point, e-health leads have a collegial working relationship with the CIOs in their regions, not a direct reporting relationship, says Anderson.
Eliasoph expects the CIO’s role will evolve in the future. “We used to have directors of IT; now we have CIOs. I think the next iteration will be moving to Chief Integration Officer roles.”
Different regions are taking different approaches. Many e-health leads are CIOs with day jobs who chair a regional committee, while others are looking to appoint formal regional CIOs as a dedicated full-time position.
The North Simcoe Muskoka LHIN, for example, has only about a dozen IT staff at its community hospitals, and a lot of work to do across a large geographic region. “We aren’t even at the starting gate without a CIO,” says CEO Jean Trimnell.
While larger LHINs may be in a position to assign staff to the e-health lead role, this may create a conflict of interest. These leaders are co-opted from the provider sector that the LHIN will be funding, instead of LHIN staff or leadership, says Neil Stuart, health care leader at IBM Canada.
“You’re asking for direction to be set by the people the LHINs are supposed to be directing. It’s an odd inversion and raises challenges in the long run about accountability.” But he points out this is part of a larger issue: the LHINs themselves are small organizations from a staffing point of view.
There are also questions about LHINs receiving funding to develop their own operations. “They’re start-up organizations at this point and their mandates are still being rolled out,” says Stuart.
Whether LHINs will remain as they’re currently structured is an open question. Most provinces have full-blown regional health authorities who are responsible for health care service delivery and operations, not just planning and coordination.
Martineau points out other provinces that have regionalized have restructured at least once, some several times. “Whatever they came out of the starting gate with is not what they have today. You learn as you go along, about what works and what doesn’t.”
Anderson agrees time will tell how effective the LHIN model will be. “But the regional focus is here to stay, and I don’t think the model matters very much. One way or another, regional integration is coming.”
The market’s response
LHIN restructuring is also having an impact on another IT community that is eyeing developments closely: vendors.
The private sector is also responding to the call for interoperability, says Smart Systems CIO Weaver. “Over the past few years, vendors have realized the health care sector isn’t going to remain proprietary forever, and they must deploy standard tools and products.
“Rather than seeing how much they can sell, they are now helping solve some fundamental problems.”
There are some areas of uncertainty for vendors. The procurement process is not well established, as the LHINs don’t have the administrative infrastructure for it yet, says Stuart.
“We can safely assume the government and LHINs will be looking for IT consolidation, and you only get that through planning and effective procurement,” adds David Brown, a senior associate at the Ottawa-based Public Policy Forum.
The larger projects that come with regionalization give LHINs greater purchasing power and a market influence in areas that have been overlooked in the past, suggests David Thomas, vice-president of Montreal-based Emergis Inc.
Historically, hospitals have been the biggest purchasers of health care IT products and services, so vendors catered to these key customers, he explains.
“The market wasn’t nursing homes, access clinics and so on. Although these are major components of the health care system, they were too small individually to warrant attention. This left them bereft of choices and competition.”
Folding them into larger structures like LHINs gives them more purchasing clout, and they are now getting more attention and product options, he says. “So the market is responding to this change; and not just in Canada, as it’s happening worldwide.”
Thomas believes dealing with legacy systems is a major challenge for LHINs. “Ontario has far too many different systems, so some of the smaller systems won’t make it,” he says, noting these will likely be replaced with systems that comply with service-oriented architecture (SOA) standards.
But a recent survey of 150 health care CIOs reveals interest in SOA is low, says Branham’s Martineau. About half said they weren’t interested, 18 per cent were interested but had no plans, and 32 per cent said they had SOA projects planned.
Martineau says he was surprised by the result, as Canada Health Infoway has embraced SOA in its EHR reference architecture and the Ontario government has adopted SOA to develop interoperable systems.
“There’s a chicken-and-egg problem around standards,” he suggests. “Health care CIOs say they feel vendors are driving the SOA agenda, while vendors say they’re waiting for users.”
Infoway is aware of the need to increase SOA awareness in the sector, adds Martineau.
So what’s next?
Health care system reform has a checkered history. In the U.K., disastrous failures of several massive IT projects undertaken by the National Health Service made headlines recently.
The big-bang approach to systems development doesn’t work, says Anderson. “It’s a real danger and we’ve seen this before: You can’t go on the ‘if you build it, they will come’ philosophy.”
Conversely, Denmark’s health care system is a poster child in this area, says Stuart. “They came at it modestly, step by step, in a very incremental approach over time. This is arguably Ontario’s approach.”
Some critics say the creation of LHINs just adds an extra layer of bureaucracy and a new area to blame if things go wrong.
“I think the feeling is LHINs offer the potential for more rational use of public resources, and there’s a lot of good leader-ship and followership in this area,” says Brown.
“But it’s true that if it’s not done well, if we make a mess of integration on the technology side and things get worse, then it does become another layer of bureaucracy.”
Rosie Lombardi is a freelance writer based in Toronto. She can be reached at [email protected]
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