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International Congress on Telehealth and Telecare

Healthcare reform in Quebec:Accountable care organizations and

meaningful use

London

David Levine C.E.O

Montreal Health and Social Services AgencyMarch 2-3, 2011

Establishments: 294Physicians/MD : 16.062

Omni: 7.766Specialist: 8.296

Nurses: 54.896Emergency : 2.532.410ADT : 716.191Imaging:Public: 7.7 million/yearPrivate: 2 million/yearLabs: 152.591.184 (procedures)

Area: 1 542 056 km2

Population: 7 631 552

Province of Quebec

Montreal region

Area: 365 km2 Population: 1.957.345Establishments: 89

with more than 450 points of serviceEmployees: 86.068 FTEPhysicians/MD: 5.686

Omni: 1.955Specialist: 3.731

Nurses: 22.071Emergency : 834.497ADT : 155.129Imaging:

Public: 4.8 million/yearPrivate: 1.6 million/year

Labs: 49.996.604 (procedures)

The Health Reform

Objectives

• Improve the health and well being of the population (specific mandates)

• Bring services to the population• Facilitate the use of services (accessibility,

continuity)• Manage care for vulnerable clientele• Improve the quality of care• Improve the cost of care

Guiding principal

• Populational responsibility– Defined population – Responsible for the health well being of that

population– Responsible for the individuals health and well being

• Hierarchical provision of services– Regrouping primary care responsibility– Clearly refining secondary and tertiary services– Reference protocols and corridors of services

Structural changes - Integration

• A new organization: Health and Social Services Centers (HSSC)

• A new concept of integrated services through the creation of local services networks

• Mergers of hospitals, local community service center, long term care centers into a single institution

• 12 HSSC in Montreal, 95 across Quebec• 18 Regional Authorities across Quebec

The Reform of Health

Mandate of a Health and Social Service Center

• Manage and evaluate the health and well being of the population

• Manage the use of services by the population

• Manage the services offered by each HSSC

• Develop a local network of care

Local territory

Health and Social ServicesCentres :

grouping of one or severalCLSCSs, CHSLD, CHSGSs

Community pharmacies

Community organizations

Non institutional resources

Social economy enterprisesPhysicians

(FMG, AMC, medical clinics)

Youth Centre

Rehabilitation centre Other sectors: education, municipal, justice, etc. Hospitals that provide

specialized services

Montreal’s vision to achieve the objectives

• Managed care model (chronic care model, mental health model, continuum of care for the elderly, etc)

• Multidisciplinary teams for primary care with rostered population

• Unified and computerized medical health records

• Empowerment of the population and the individual to manage and direct their care and needs

Montreal’s vision to achieve the objectives

• Evaluation and measurement of clinical and administrative (eg. financial) outcomes

• A motivated, engaged and empowered work of force

• Leadership and organizational change needed to implant the vision

The Results 2005 – 2010

• Developed a successful system management strategy leading to joint management of health and social services on the Island of Montreal

• Successful implementation of 12 CSSS health and social service networks

• Implementation of 45 primary care groups, 12 local departments of primary care

The Results 2005 – 2010

• Implementation of a city wide IS platform – OASIS in all institutions as well as physician offices

• Implementation of a chronic disease management model. Pilot in each CSSS with a role out to other CSSS –eg. diabetic chronic care management, 12 programs implemented, one in each CSSS

The Results 2005 – 2010 (continued)

• Surgery wait time management by grouping high volume services together and creating new volume capacity and managing wait lists, weekly, biweekly, monthly data updates

The Results 2005-2010 (continued)

• Optimising projects• Bed management model 10% • Home care software 20% • Centralized IS servers• Centralized phone system• Centralized purchasing• Centralized transport

• 6 years balanced budget

TREND Challenges to:

Reduce costs Improve quality of care Improve process

efficiencies Telemedicine Remote patient monitoring Deployment of patient

eHealth records

Healthcare IT – The key to transformation

NEED Enhanced a health network

infrastructure Enhanced hospital

infrastructure Enhanced wireless

infrastructure Adoption of data exchange

standards EMR (Electronic Medical

Record) Enhanced security Improved backup and recovery

Technical Immature technology and lack of interoperability Lack or inconsistent use of standards Perceived high acquisition and maintenance cost

Financial Lack of demonstrable ROI Dealing with existing legacy IT investments Concern on total project costs and ongoing support

Educational Current health care culture and organizational resistance Lack of standards (clinical content and relevancy, terminology, interoperability, clinical

practice); Misalignment of incentives for IT adoption from physicians

Policy Concern over privacy, security and confidentiality Lack of incompatibility of rules about who is allowed to see information and why Clarity regarding the role of government

Healthcare IT – Famous barriers to adoption

Objectives of Montreal project Access to results

Anytime, anyplace, anywhere, but not by anyone! Quality of care

Clinicians can make informed clinical decisions about treating patients (proof based decision)

Incorporation of therapeutic advisors to support prescribing physicians

Patient safety Extensive medication history and allergy information Advanced clinical decisions support and alerts Facilitates and reduces adverse clinical events Decrease the risks of medical errors

Reduce costs Eliminate or reduces redundant tests and procedures Reduces costs associated with adverse clinical events Eliminates costs associated with transcriptions and storage of paper records

Montreal Establishments Path to EMR

OACIS

Wave 1 Wave 3

Initiators

Wave 2 Wave 4

Sacré-Cœur

Verdun

Hôpital général juif

CUSM

Sainte-Justine

Institut de Cardiologie

St. Mary’sHospital

Lakeshore

SantaCabrini

JeanTalon

DorvalLasalleLachine

Fleury

MaisonneuveRosemont

MD: 653FTE: 9.388

MD: 619FTE: 8.636

MD: 255FTE: 3.552

MD: 103FTE: 3.367

MD: 299FTE: 4.147

MD: 222FTE: 4.264

MD: 87FTE: 1.427

MD: 147FTE: 1.717

MD: 103FTE: 1.940

MD: 120FTE: 1.544

MD: 81FTE: 1.987

MD: 68FTE: 2.236

MD: 306FTE: 4.557

MD: 93FTE: 2.605

MD: 68FTE: 2.310

MD: 46FTE: 1.301

Montreal Application Platform

Telehealth and surveillance at home

• Context

– Elderly population– 30% or more chronic illness– Increased demand for home care– Poor compliance in management of chronic illness

Objectives

– Improve accessibility and continuity– Keep elderly at home as long as possible– Develop the autonomy and empowerment (self-

management) of the chronically ill person– Reduce the number of home visits– Work as a multidisciplinary team– Use common protocols for chronic care

Objectives

• USER• With one or

more chronic illness linked through a telephone or web connection to a group of professionals

• Professionals• Multidisciplinary

team collecting patient data from their computer

Personalized care plan

Data from the patient

Permanent link

Benefits

– Clinical protocols

– Electronic data acquisition

– Integrated medical record OACIS

– Medication management

Conclusions of 2009 study of Sicotte, Paré, Moreault, Morin and Potvin

1. High satisfaction of patients and professionals

2. New technology easily accepted by patient and staff

3. Allows systematic follow-up

4. Excellent learning tools

5. Increase in patient self management skills demonstrated

The East end telecare home project (Pointe-de-l’Île)

– 120 stations – Telus– 4 months length of stay– Very high satisfaction – Reduced number of home visits (12 to 2.5)– Reduced visits to emergency room– Increased self management – Long term follow-up required

Montreal region future project

– 1000 stations– Island wide coordination– Connection to the OACIS platform

Just a last Message …

Source: Dennis Muntslag – The Art of Implementation

Manage the change

Merci !Thank You, Gracias, Grazie, Obrigado, D anke