CIHR Primary Healthcare Summit 2010 Final Report Summary

CIHR Primary Healthcare Summit
Patient-Oriented Primary Healthcare - Scaling Up Innovation
January 18-19, 2010
Toronto, Ontario

To access the full report, Summit programme, and copies of the Summit presentations, please visit the Primary Healthcare Summit website.

Summit Vision

To catalyze innovation in patient-centered delivery models in Canadian primary care settings

Summit Goal

To foster multidisciplinary primary care collaboration among decision makers, administrators, clinicians, researchers and patient representatives in conducting and using research. The Summit will also provide Canadian and international stakeholders with an opportunity to exchange best practices in implementing primary care initiatives.

Summit Objectives

The Summit aimed to achieve its goal by enabling summit participants to:

  • Gain a better understanding of the diversity of primary care research in Canadian and international jurisdictions
  • Engage in dialogue regarding innovation in patient-centric models for chronic disease prevention and management
  • Understand existing barriers and explore solutions for achieving a high performing primary care delivery system
  • Engage with Canadian and international leaders to explore innovative delivery models that can be applied to the Canadian context

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Main Messages

Primary healthcare is the foundation of Canada's healthcare system. It is viewed as the gateway or first point of contact with the healthcare system for all Canadians, who receive a diverse and comprehensive array of services in primary healthcare. The key attributes of a strong primary healthcare system include coordination of care, including an electronic medical records system; long term person focused care; comprehensiveness; and chronic disease prevention and management.

A strong primary healthcare system is vital to health. Strong primary healthcare is linked to better health outcomes, improved equity, and an improved patient experience, and is recognized as the foundational basis for a high-performing, accessible, and sustainable healthcare system. Robust primary healthcare systems are also recognized as contributing to improved access to healthcare, reduced inequities, lower health system costs, improved outcomes, and higher patient and provider satisfaction.

A strong primary healthcare system is also cost-effective. An effective primary healthcare system is also the key to delivering high quality care and improving healthcare outcomes in a cost-effective way by reducing health system costs – a key challenge for many cash-strapped provincial governments.

Canada's primary healthcare system is lagging behind those in other developed countries. Canada has not yet achieved a robust primary healthcare system that provides patient-centred, comprehensive and coordinated primary healthcare, and lags behind several other developed countries in terms of access, quality improvement and management, and the use of electronic medical records. Major primary healthcare issues in Canada include uneven access, fragmentation across the system, lack of communication and information sharing, insufficient use of inter-professional healthcare providers, inadequate chronic disease prevention and management, limited patient involvement and a misalignment of incentives in remuneration models.

Primary healthcare research in Canada is also lagging behind. Comparable nations have also done better than Canada in terms of investments in primary care research and in the translation of research knowledge to practice and policy. Again, Canada is lagging, both in terms of support for and coordination and translation of primary healthcare research. Primary healthcare researchers are isolated, data are difficult to access, and there is limited, meaningful coordination between governments, institutions and researchers. Moreover, local, innovative demonstration projects are not "scaled up."

The path forward for primary healthcare in Canada requires a clear vision. Primary healthcare is an area in critical need of innovative research and transformation. The path forward requires scaling up of innovation. We need collaboration and information sharing among all stakeholders; a patient-centred approach to care; primary healthcare champions at all levels of the system working together; scaling up of primary healthcare research and research support; and a clear vision for the path forward. This will require a three-pronged approach involving research, capacity and infrastructure. Coordinated investment to build a high-quality, skilled and innovative primary healthcare research community in Canada is needed. Probing, pertinent research questions must be asked. Investment in research, knowledge translation, capacity building and infrastructure will help to ensure that the issues discussed at this Summit are addressed and that future challenges are anticipated.

The vision for primary healthcare is for every Canadian to have access to comprehensive, high-quality primary healthcare. It is hoped that by 2020, Canada will be an international leader in the generation of high quality primary healthcare research that will contribute to a high quality primary healthcare system for Canadians.


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Executive Summary

What is Primary Healthcare?

Primary healthcare is the face of the Canadian healthcare system. It is viewed as the gateway or first point of contact with the healthcare system for all Canadians, who receive a diverse and comprehensive array of services in primary healthcare, including prevention, prenatal care, episodic care, chronic disease management, mental health care, post-hospitalization follow up, and rehabilitation. The key attributes of a strong primary healthcare system include coordination of care, including an electronic medical records system; long term person focused care; comprehensiveness; and chronic disease prevention and management.

Why is it Important?

A strong primary healthcare system is vitally important. Strong primary healthcare is linked to better health outcomes, improved equity, and an improved patient experience, and is recognized as the foundational basis for a high-performing, accessible, and sustainable healthcare system. Such systems are also recognized as contributing to improved access to healthcare, reduced inequities, lower health system costs, improved outcomes, and higher patient and provider satisfaction. Indeed, the definitional principles of primary healthcare include accessibility, comprehensiveness, continuity and appropriateness. An effective primary healthcare system is also the key to delivering high quality care and improving healthcare outcomes in a cost-effective way by reducing health system costs – a key challenge for many provincial governments which are now looking at the prospect over the next few years of spending nearly 50% of public expenditures on the healthcare system.

The Current State of Primary Healthcare and Research in Canada

Despite the recognized contributions that high quality primary healthcare can make to health and health systems, Canada's primary healthcare system is in need of help. Canada has not yet achieved a robust primary healthcare system that provides patient-centred, comprehensive and coordinated primary healthcare, and lags behind several other developed countries in terms of access, quality improvement and management, and the use of electronic medical records. Major primary healthcare issues in Canada include uneven access, fragmentation across the system, lack of communication and information sharing, insufficient use of inter-professional healthcare providers, inadequate chronic disease prevention and management, limited patient involvement and a misalignment of incentives in remuneration models.

Currently, primary healthcare research in Canada mirrors the primary healthcare system itself: uncoordinated and in need of transformation and renewal. Again, Canada is lagging, both in terms of support for, and coordination and translation of primary healthcare research. Primary healthcare researchers are isolated, data are difficult to access, and there is limited, meaningful coordination between governments, institutions and researchers. Moreover, local, innovative demonstration projects are not "scaled up."

The Vision for Primary Healthcare

Despite the current state of primary healthcare and primary healthcare research in Canada, the vision is for every Canadian to have access to comprehensive, high-quality primary healthcare.

It is hoped that by 2020, Canada will be an international leader in the generation of high quality primary healthcare research that will contribute to a high quality primary healthcare system for Canadians. The design, implementation and timely translation of high quality research results will be available to all primary healthcare stakeholders. A broad range of multi-method research and knowledge translation activities will be delivered by a network of highly trained clinician investigators, research scientists and knowledge users, all of whom will be supported by a dedicated research infrastructure. Close connections among researchers, clinicians, policy makers and other stakeholders will ensure that the outputs of the strategy are relevant and responsive to changing community needs.

A Move Towards a Robust Primary Healthcare System in Canada

As discussed at the Summit, it is finally time for primary healthcare. Canadians demand and deserve high-quality care, delivered in the right environment and by the right provider.

Primary healthcare is an area in critical need of innovative research and transformation. The path forward requires scaling up of innovation. We need collaboration and information sharing among all stakeholders; a patient-centred approach to care; primary healthcare champions at all levels of the system working together; scaling up of primary healthcare research and research support; and a clear vision for the path forward. This will require a three-pronged approach involving research, capacity and infrastructure. Coordinated investment to build a high-quality, skilled and innovative primary healthcare research community in Canada is needed. Probing, pertinent research questions must be asked. Canada must also develop the capacity to become internationally-recognized in primary healthcare research, and infrastructure support is needed to foster excellence, optimal collaboration, data sharing and the uptake of results across Canada. Investment in research, knowledge translation, capacity building and infrastructure will help to ensure that the issues discussed at the Summit are addressed and future challenges are anticipated before negative consequences arise.

Outcome of the Summit

The two day Summit brought together primary healthcare researchers, research funders, primary healthcare providers, CEOs, senior leaders and board members of healthcare delivery organizations and regional health authorities, decision makers at the provincial and federal levels, leaders from professional and advocacy organizations, thought leaders in primary healthcare and primary healthcare research, and representatives from national and provincial health organizations and agencies. National and international attention was focused on the issue of primary healthcare reform. The Summit enabled participants to gain a better understanding of the diversity of primary healthcare research in Canadian and international jurisdictions; engage in dialogue regarding innovation in patient-centric models for chronic disease prevention and management; understand existing barriers and explore solutions for achieving a high performing primary healthcare delivery system; and engage with Canadian and international leaders to explore innovative delivery models that can be applied in the Canadian context.

The Summit included plenary talks and panel discussions featuring nationally and internationally renowned speakers who spoke on a variety of primary healthcare topics. Workshops explored in-depth issues raised in the plenary sessions. Significantly, the Summit began with a discussion of individual patient's experiences in the primary healthcare system, highlighting the importance of patient-centred care. The key attributes of primary healthcare and the benefits they provide were shared. Issues around the implementation of chronic disease management models in England and the United States were discussed, including a focus on the factors that led to their respective successes. The reasons for Canada's failure in this area were also explained. The conceptual divide between patient-centered and guideline-driven care was explored, and the quality of some guidelines questioned. The appropriateness of using guidelines in some situations and not others was reviewed, and the risks of applying disease-specific guidelines to patients with co-morbid conditions were highlighted. The elements of primary care important to consider when evaluating performance were also discussed. The importance of aligning provider incentives with health system goals was highlighted. The reasons why Canada is lagging behind in the area of primary healthcare were also candidly discussed. An exploration of the linkages between public health and primary care was given, including a description of the benefits and challenges of community-oriented primary care. The challenges surrounding the functioning of primary care practitioner teams, solutions for enhanced performance, and methods of team evaluation were also shared. One panel discussed the realities of collaborative teamwork, including the challenges and barriers to collaboration. The experience at Kaiser Permanente of the environment and processes required to successfully implement new technology into primary healthcare practices was also shared. The Summit concluded with frank discussions with the Deputy Minister of Health (Saskatchewan) and the Assistant Deputy Minister for Health Human Resources, Ministry of Health and Long-Term Care (Ontario), who synthesized the major themes of the Summit and offered suggestions on ways to achieve successful change and system-wide improvements in primary healthcare.

The plenary talks, panel discussions and workshops were very well received by participants. The vast majority of participants who completed the post-Summit evaluation form felt that the Summit achieved its goals and provided them with new knowledge and ideas that would help them with their work in their respective fields.

This Summit has succeeded in its vision and goal of fostering multidisciplinary collaboration among primary healthcare stakeholders and catalyzing new collaborations and innovative thinking in patient-centered delivery models in Canadian primary healthcare settings, primary healthcare research, knowledge translation and system transformation. The Summit also provided Canadian and international stakeholders with an opportunity to exchange best practices in implementing primary healthcare initiatives, and reinvigorated discussion and innovation on primary healthcare research and system transformation reform. May this collaboration and sharing of ideas continue.


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Moving Forward

The CIHR Primary Healthcare Summit produced many useful recommendations and action items to improve primary healthcare and primary healthcare research in Canada, including:

  1. Create an electronic medical records system (and train healthcare providers to use it) to improve communication, information sharing and coordination of care. This would avoid duplication and wasted efforts that currently result from a lack of computerized records. An electronic medical records system should support patients and providers by allowing instant access to medical records for physicians and patients, providing standardized data and linkages across data sets, and providing clinical content such as decision-support tools that enhance quality and patient safety, including drug interaction and allergy alerts.
  2. Educate primary healthcare providers and policy makers on the importance of providing a patient-centred approach to care. All processes must be examined through a value lens as defined by the patient, and the best interests of patients must be the primary driver of policy decisions, priority setting and resource allocation decisions. This could include using a persona as a starting point to improve patient flow and coordination.
  3. Develop a chronic disease management model to improve chronic disease prevention and management in primary healthcare. The model should include community resources, decision support tools, case and disease management, supported self care, the promotion of better health, and social care. Such a model should also include financial incentives to improve the quality of chronic care.
  4. Encourage patients to make better use of self care support through information support. This includes educating primary healthcare professionals to provide better self care support through changed behaviors and treating self care as a priority. In Ontario, the Ontario Patient Self Management Network could take on this task with the creation of a mandate and the provision of funding.
  5. Educate physicians about the appropriate use of guidelines. The use of guideline-based care is certainly appropriate in some circumstances; however, it is also highly inappropriate in others. As guidelines are not appropriate for all populations and individuals, physicians should be educated to use guidelines in combination with expert opinion, patient values and circumstances.
  6. Improve Aboriginal primary healthcare and decrease health inequities. In doing so the challenges to indigenous wellness, Aboriginal determinants of health and Aboriginal health solutions must all be taken into account. Efforts to reduce the health inequities of Aboriginal peoples must involve the engagement of indigenous communities by the mainstream, including researchers, health professionals and decision-makers.
  7. Develop and implement a rigorous and quality primary healthcare evaluation for primary healthcare team functioning. One example of an emerging issue resulting from a current lack of teamwork is the opening of a private clinic in Winnipeg staffed by nurse practitioners. If team functioning is found to impact positively on outcomes, collaboration with inter-professional healthcare providers in primary healthcare should be increased and strengthened.
  8. Improve performance measurement of primary healthcare. Care providers and policy and decision-makers need high-quality information to aid in decision-making, resource allocation, and to mobilize efforts for improvement. As many dimensions as possible must be measured, or else the performance picture will be incomplete.
  9. Align incentives in remuneration models with health system goals and remove reimbursements and incentives with perverse outcomes. This could include reconfiguring the fee for service model and making a percentage of primary healthcare providers' income contingent on performance. Physicians could also be rewarded for coordinated care and quality versus quantity. Any such incentive system would need to be flexible and evaluated for future improvement.

Invest in a high-quality, skilled and innovative primary healthcare research community in Canada. Investment in research, knowledge translation, capacity building and a dedicated research infrastructure to support clinician investigators, research scientists and knowledge users is needed. Universities and healthcare institutions also need to step up efforts to recruit and retain high level researchers. Increased support for and coordination and translation of innovative primary healthcare research is also required, including better communication and more meaningful coordination and collaboration between governments, institutions and primary healthcare researchers, as well as processes to "scale up" innovative demonstration projects.

Partners

The CIHR Institute of Health Services and Policy Research would like to thank the following partners for helping to make the CIHR Primary Healthcare Summit a success:

CIHR Institutes

External Organizations

Inquiries pertaining to the CIHR Primary Healthcare Summit can be addressed to:

Stephanie Soo
CIHR Institute of Health Services and Policy Research
Tel: 416-978-8402
Email: stephanie.soo@utoronto.ca