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Readings week 5

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  • 1. 1. TRANSCRIPT: It wasn't that many decades ago where to use a computer you had to travel to a large city and in a room much larger than this one the computer took up the entire room. And you had a series of systems operators – these were people who would take your punch cards and put them into this huge machine and out comes 2 plus 2 equals 4, right? And that was the computing power of this entire room size of computers. That was a mainframe computer. And you had to travel there, and you had to have experts help you use the system and you certainly didn't have access to this in your home. It wasn't part of your personal life. You had to have a real good work reason to go there. In many ways this kind of hospital-centric paradigm that we created 200 years ago, and that we continue to continue and keep moving forward in time as if it's some God-given requirement that we have to care for people in hospitals, it's the same model. You're sick, you travel to a large urban center, go to the big shiny hospital on the hill, it's filled with experts and high technologies, none of which you could ever have at home or control yourself. And hopefully the high priests of healthcare put you back together again. And I don't mean to be denigrating of a hospital or healthcare experts. Those are miraculous technologies and amazing people that save people's lives. But it means that we aren't really focused on prevention and quality of life and care for people in the other 99.9 percent of their days when they're not at a hospital. And there's so much useless pain and suffering, needless pain and suffering going on because we aren't applying innovation and the best of our thinking to preventing disease and illness and injury in the first place. So that medical mainframe model needs to change to a personalized model. And much like computing, we couldn't imagine three decades ago that this kind of mainframe computer – you were going to have a smartphone on your hip with your wallet that was going to be thousands of times more powerful than that, and it was going to become a personal tool. Computing is now a personal part of our lives that we use for all kinds of things. I want to drive that same kind of transformation using very similar disruptive technologies that say those technologies, those diagnostic capabilities, those expert systems that are in that mainframe can now be mine and part of my life and I have tools to be part of my own care. And I can author my own existence and pilot my own body when I'm dealing with my own healthcare needs. At the end of the day, the technology is just one piece of it. I'm trying to drive a fundamental new social covenant that says, we as people, as patients sometimes – we're not always patients, but we as people who need health – and the other people, our informal caregivers, our family members and our neighbors, and professionals have to have a new kind of relationship together to really deal with health and wellness so that everybody in the planet can have it. Otherwise, you're going to say, yep, the wealthy can have access to that medical mainframe and they'll get the best of the best. But the vast majority of other people, we can't afford to do that for everyone and you're going to have this ugly, ugly bifurcated system. And there is no doubt that particularly in the United States, but not just here, patients, consumers have to get off of this smorgasbord mentality of healthcare that says, I paid my insurance premium, I don't have to think about my health and wellness at all, and if I'm sick, there'll be a bunch of people to throw millions of dollars to fix me and put me back together again. This is the all-you-can-eat healthcare system that we've grown up with and come to expect. First of all, having every test in the book thrown at you is not safe and not wise for your own health and wellness. And second of all, that kind of smorgasbord mentality of healthcare is not
  • 2. sustainable and scalable in a world of global aging. So there's no doubt you're going to have to have new responsibility. But we can't say suddenly, you're responsible for your own health and wellness and there's no tools, there's no coaching, there's no training and there's no social support for you. And I think information technology – whether it's social networking tools that help you find other patients who are like you, whether it's wearable sensors that are helping you collect data so that you know when you need to talk to a professional versus when you're doing fine just managing things on your own – it's all here. The really sad part to me right now is that most of these technologies are here, and it's not a technology problem. It's an imagination problem and it's a financial problem. That mainframe hospital system that we've had for 200 years wants to protect itself. And I'm here in Washington, D.C., this week like I am every month to work on policy changes that say, stop putting policies in place and payment systems in place that only allow doctors and nurses to be paid for a face-toface visit at the mainframe – in the hospital or in the clinic. Pay for secure messaging between a doctor and a patient if that's the best way the doctor thinks they need to follow up. Pay for a virtual video visit with that patient. Pay a doctor to look at the trend lines of your vital signs that you captured over the last three weeks so we can really see what's going on with you. And in some not-too-distant future, pay for a system that has an implantable device that's looking at the proteins in your body on a real-time basis to see how that drug is affecting you and whether it's working or not. And you know what? We're going to customize that drug just for you and your biology and your body. That world is here technically and technologically. There's some new science that we need to do and some improvements. It's policy and imagination and our financial frameworks that are keeping us from getting there. So strangely enough, I've become a policy guru because I had to and I got curious about policy as well. And I've moved from creating great prototypes to trying to figure out how do I create great policies that will let this kind of innovation happen? God forbid that we actually apply some common sense to healthcare. Who doesn't want the choice to say, I can go through my chemotherapy round at home, where there's no flu bug that's going to wipe me out from all the other patients that are there, or no hospital-borne infections, and I can sit in the comfort of my own bed, and I can have a machine that's going to infuse my chemotherapy into me at home? And my cell phone can look at my vital signs and alert if there's a problem. Who doesn't want to be treated at home or in an environment that they're comfortable with and wants to travel to that mainframe? It's not that the hospitals will go away. They should be smaller. There should be fewer of them over a period of time and they should be used for extreme circumstances. You've been in a car wreck, you need major surgery, no one's saying that we're going to say hey, here's a knife, here's a scalpel, open yourself up and do surgery on yourself. No one's saying that. We're saying for the vast majority of care – chronic conditions that all of us are dealing with, which are the bulk of the cost of healthcare around the world, and seniors are the biggest burden for that in terms of the economic burden – most of that care, if not all of it, can be done at home, at work, on the go with smart, intelligent IT systems that are hooking you up with other patients, with family members, and with clinicians who are acting in a team-based way to care for yourself.
  • 3. Ontario health-care agency tries virtualization Rafael Ruffolo The Ontario Association of Community Care Access Centres seeks higher availability from its IT infrastructure without having to buy a lot more machines. How to turn servers into a service An Ontario government health-care agency said it has been maintaining a high availability and cost effective server infrastructure through virtualization technology. In a roundtable discussion, hosted by Microsoft Canada with customers and partners at IDC Canada’s Virtualization Forum in Toronto on Wednesday, executives outlined the benefits and challenges in moving to virtualized environments. Ken Sutcliffe, director of IT services for the Ontario Association of Community Care Access Centres (OACCAC), manages 14 care centres around the province as well as over 250 offices. Servicing 8,000 members, Community Care Access Centres (CCACs) provide a governmentfunded, local point of access to health-care services. Sutcliffe said that one of the reasons the OACCAC moved toward a virtualized infrastructure was to manage its budgets and keep total cost of ownership down. “Traditionally, if we needed more server power, we’d buy another server,” Sutcliffe said. “But, as we’ve grown, especially in needing application delivery, it just wasn’t cutting it anymore. So, we looked at being able to turn servers into a service as opposed to into a piece of hardware.” And according to Sutcliffe, this “server as a service” approach is especially vital when dealing with such a scattered IT environment. He said that spread across the 250 CCAC offices, the organization has many of its servers situated in concentrated pockets. “Maybe 70 of those offices are main offices where you’ll find a decent server presence,” Sutcliffe said. “If we need to add another server for the CCACs to run a particular application, we’d effectively have to buy 70 new servers. But with virtualization, we’re able to rapidly, and for really the cost of licensing, provision the same computing power that they would have gotten bringing in the full price of hardware.” Sutcliffe also said that because the local CCACs manage sensitive personal health information, the issue of high availability is a crucial one. “We wanted to make sure that in the virtual environment that we had the high availability characteristic that we’re used to building in our data centres,” Sutcliffe said. “So, we’re able to buy good high-end servers to host and then we’re able to build virtual machines just the same as if we were using physical servers.” And this is where Microsoft hopes its virtualization offerings will gain traction with customers looking to manage their virtual servers in the same way they always have. Recent news out of Redmond has the production version of Windows Server 2008, which ships next February, including the beta of Windows Server virtualization technology; code-named Viridian. Microsoft has also been pushing its System Center line of server products, which includes its System Center Virtual Machine Manager 2007. The software is Microsoft’s first specifically designed to manage VMs on a network, and tweaked licensing for its system-management products to take into account virtualization. It will be generally available in October as part of Microsoft’s System Server Management Center suite of products. According to John Oxley, director of community evangelism at Microsoft Canada, the software is designed to give IT managers a clear picture of how their environment looks, in much the same way that they would manage physical servers. “When companies move to virtualization they are really putting something into the clouds where it’s unknown,” Oxley, said. “When people look at management in a physical world, they don’t want to look at it any differently in the virtual world. They want the same representation and
  • 4. they want to manage it in the same environment because they don’t want to introduce any more costs or complexities.” Andy Papadopoulos, president of IT solution consultant LegendCorp and a Microsoft partner, echoed Oxley and said that one of the biggest concerns for his clients interested in virtualization is with keeping things simple. “People don’t want to own 27 different tools and 15 different vendors because they don’t want to increase the complexity of their infrastructure,” Papadopoulos said. “Because companies have concerns out there with even finding decent IT staff out there and getting them trained, they really don’t want to move to an environment that brings more complications. Every Microsoft partner out there should be looking at the virtualization aspect because it’s something that their clients want to talk about as well as something that’s going to be in the CIO’s top 10 list.” Papadopoulos said that with Virtual Machine Manager, Microsoft’s virtualization support has gone from “good to great” and could allow the company to become formidable competition for virtualization giant VMware. Read more: http://www.itworldcanada.com/article/ontario-health-care-agency-triesvirtualization/9288#ixzz2sMaGbD4M or visit http://www.itworldcanada.com for more Canadian IT News
  • 5. What is the Population Health Approach? Production of this resource has been made possible through a financial contribution by Health Canada prior to the announcement of the establishment of the Public Health Agency of Canada on September 24, 2004. Any reference to Health Canada should be assumed to be to the Public Health Agency of Canada. The population health approach is positioned in the Public Health Agency of Canada as a unifying force for the entire spectrum of health system interventions -- from prevention and promotion to health protection, diagnosis, treatment and care -- and integrates and balances action between them. The approach is integral to the Department's broader role of improving the health of Canadians. In January 1997, the Federal, Provincial and Territorial Advisory Committee on Population Health (ACPH) defined population health as follows: Population health refers to the health of a population as measured by health status indicators and as influenced by social, economic and physical environments, personal health practices, individual capacity and coping skills, human biology, early childhood development, and health services. As an approach, population health focuses on the interrelated conditions and factors that influence the health of populations over the life course, identifies systematic variations in their patterns of occurrence, and applies the resulting knowledge to develop and implement policies and actions to improve the health and well-being of those populations. -from Toward a Healthy Future, Second Report on the Health of Canadians, What is Population Health? Population health is an approach to health that aims to improve the health of the entire population and to reduce health inequities among population groups. In order to reach these objectives, it looks at and acts upon the broad range of factors and conditions that have a strong influence on our health. See also Focus on the Health of Populations. Population Health: Defining Health A population health approach reflects a shift in our thinking about how health is defined. The notion of health as a positive concept, signifying more than the absence of disease, led initially to identifying it as a state of complete physical, mental and social well-being. However, making health synonymous with well-being, human development and quality of life confused health with its determinants and made it unmeasurable as the outcome of action addressing those determinants. Moreover, it became impossible to talk about the contribution of health to social well-being and quality of life - yet their relationship should be seen as reciprocal and (potentially) mutually reinforcing. The population health approach recognizes that health is a capacity or resource rather than a state, a definition which corresponds more to the notion of being able to pursue one's goals, to acquire skills and education, and to grow. This broader notion of health recognizes the range of social, economic and physical environmental factors that contribute to health. The best articulation of this concept of health is "the capacity of people to adapt to, respond to, or control life's challenges and changes" (Frankish et al., 1996). - Health Impact Assessment as a Tool for Population Health Promotion and Public Policy by C.J. Frankish et al., Institute of Health Promotion Research, University of British Columbia, Vancouver: 1996 See also What is health? This question was prepared by the Canadian Council on Social Development. The Population Health Template: Key Elements and Actions That Define A Population Health Approach (PDF document 599.01 KB - 46 pages) organizes and consolidates current understandings of population health. The template outlines the procedures and processes required to implement a population health approach. It provides guideposts that help to assess preparedness and capacity to implement population health initiatives. Building on advances in health promotion and public health, the Population Health Template is a resource for people in health and other sectors who strive to improve the health of populations.
  • 6. The Population Health Template can be used by multiple groups for various purposes: Policy makers and program planners can use the template to guide and direct policy and program development so that initiatives reflect population health key elements. The template supports health educators in the development of training curriculum and materials that reinforce and promote population health approaches. The template can offer evaluators a set of criteria for evaluating health-related programs against population health key elements. Grant reviewers and writers can use the template to assess the degree to which funding proposals align with population health concepts. Among researchers and academics, the template can serve as a testing field for populationhealth related assumptions and hypotheses (and thereby, advance theory), as well as support the development of population health models and instruments. The Public Health Agency of Canada has identified population health as a key concept and approach for policy and program development aimed at improving the health of Canadians. The concepts and ideas presented in this paper support the Public Health Agency of Canada's initiative to promote a population health approach in Canada. The overarching aim of this paper is to develop and advance our understanding of a population health approach and to spark debate and discussion about the nature of a population health approach and how it can be implemented. Because the paper sets forth the outside parameters of a population health approach, it is detailed and comprehensive. To support operationalization of a population health approach, an application tool, which summarizes the key concepts of this paper,has also been developed. History Population health builds on a long tradition of public health and health promotion. In 1974, the federal government's White Paper, A New Perspective on the Health of Canadians (Lalonde Report), proposed that changes in lifestyles or social and physical environments would likely lead to more improvements in health than would be achieved by spending more money on existing health care delivery systems. The Lalonde Report gave rise to a number of highly successful, proactive health promotion programs which increased awareness of the health risks associated with certain personal behaviours and lifestyles (e.g., smoking, alcohol, nutrition, fitness). More information is available on the history of population health. What is the impact of poverty on health? Which drug would better treat a patient? What is the impact of contaminants on cancer? What is the best length of hospital stay for certain surgeries? What is the usefulness of some medical screening practices? Why are teenagers so attracted to smoking? What intervention strategies are best to address particular health issues? All of these questions require the best information possible to help us address these very difficult health issues. The federal government recognizes that the national health research infrastructure needs to be reorganized in order to be able to answer these questions. The infrastructure should support collaborative research ventures involving researchers working in different fields and in different parts of the country. seePopulation Health Evidence Program The federal government also recognizes that spending more on health research is only part of the solution. We can also address health issues by broadening our approach to health interventions. We've learned a lot in the past several decades about what determines health and where we should be concentrating our efforts. Much of the research is telling us that we need to look at the big picture of health to examine factors both inside and outside the health care system that affect our health. At every stage of life, health is determined by complex interactions between social and economic factors, the physical environment and individual behavior. These factors are referred to as 'determinants of health'. They do not exist in isolation from each other. It is the combined influence of the determinants of health that determines health status. seeDeterminants of Health The challenge we face is how to use what we know about the determinants of health to: focus our research agenda so we can increase our understanding of how the basic determinants of health influence collective and personal well-being adopt strategies that improve health for Canadians
  • 7. That's where a population health approach comes in. In a population health approach, taking action on the complex interactions between factors that contribute to health requires: a focus on the root causes of a problem, with evidence to support the strategy to address the problem efforts to prevent the problem improving aggregate health status of the whole society, while considering the special needs and vulnerabilities of sub-populations a focus on partnerships and intersectoral cooperation finding flexible and multidimensional solutions for complex problems public involvement and community participation for more information, see Key Elements of a Population Health Approach Determinants of Health What Makes Canadians Healthy or Unhealthy? This deceptively simple story speaks to the complex set of factors or conditions that determine the level of health of every Canadian. "Why is Jason in the hospital? Because he has a bad infection in his leg. But why does he have an infection? Because he has a cut on his leg and it got infected. But why does he have a cut on his leg? Because he was playing in the junk yard next to his apartment building and there was some sharp, jagged steel there that he fell on. But why was he playing in a junk yard? Because his neighbourhood is kind of run down. A lot of kids play there and there is no one to supervise them. But why does he live in that neighbourhood? Because his parents can't afford a nicer place to live. But why can't his parents afford a nicer place to live? Because his Dad is unemployed and his Mom is sick. But why is his Dad unemployed? Because he doesn't have much education and he can't find a job. But why ...?" – from Toward a Healthy Future: Second Report on the Health of Canadians More detailed information on the determinants of health and What Makes Canadians Healthy or Unhealthy is available. Key Determinants 1. Income and Social Status 2. Social Support Networks 3. Education and Literacy 4. Employment/Working Conditions 5. Social Environments 6. Physical Environments 7. Personal Health Practices and Coping Skills 8. Healthy Child Development 9. Biology and Genetic Endowment 10. Health Services 11. Gender 12. Culture Research & Evidence Base Defining Evidence-Based Decision Making The aim of evidence-based decision making (EBDM) is to ensure that decisions about health and health care are based on the best available knowledge. To use EBDM one must first assess what constitutes evidence, both in relation to health-enhancing interventions and to organizational or
  • 8. policy level decision making. One also needs to explore the availability and accessibility of reliable information and knowledge that identifies how interventions, practices and programs affect health outcomes. More detailed information on the determinants of health and What Makes Canadians Healthy or Unhealthy is available. Population Health Evidence Program Over the last five years, the need for better evidence has become manifest in the health sector. Forward-looking discussions on population health research needs have taken place at the National Forum on Health and the Federal, Provincial and Territorial Advisory Committee on Population Health. These discussions have lead to the creation of various projects and infrastructures to support the development of population health evidence. The National Forum on Health Among the multiple benefits gained through the National Forum on Health in 1997, a national consensus emerged to support the need for evidence-based policy development and decision making. The Forum dedicated one of its reports to describing how health professionals and administrators can use the most solid information available to make their decisions, and to ensure that these decisions reflect the values and principles of Canadians regarding health and health care. Just released in September 1999, the Second Report on the Health of Canadians contains a wealth of information and is a good starting point for a reflection on evidence. More detailed information on the determinants of health and What Makes Canadians Healthy or Unhealthy is available. Health Status Indicators A population health approach recognizes that any analysis of the health of the population must extend beyond an assessment of traditional health status indicators like death, disease and disability. A population health approach establishes indicators related to mental and social wellbeing, quality of life, life satisfaction, income, employment and working conditions, education and other factors known to influence health. More detailed information on the determinants of health and What Makes Canadians Healthy or Unhealthy is available. Collaboration/Partnerships: Intersectoral Action Involving Canadians: Public Involvement A key element of a population health approach is the recognition that improving health is a shared responsibility. "Intersectoral collaboration" is the joint action among health and other groups to improve health outcomes. A population health approach calls for shared responsibility and accountability for health outcomes with health groups and groups not normally associated with health, but whose activities may have an impact on health or the factors known to influence it. Intersectoral collaboration in a population health approach includes the horizontal management of health issues. Horizontal management identifies common goals among sectoral partners. It then ensures coordinated planning, development and implementation of their related policies, programs and services. Collaboration/Partnerships Another key element of a population health approach is the participation of Canadians in developing strategies to improve health. The approach ensures appropriate opportunities for Canadians to have meaningful input into the development of health priorities, strategies and the review of outcomes. A benefit of public involvement is that public confidence in decision making and information sharing is increased, as those Canadians who are most affected by a health issue contribute to possible solutions early in the planning process. See Involving Canadians What Can You Do? At the federal level, our job is to create a climate for improving health by providing coordination and leadership; encouraging federal, provincial and territorial collaboration; providing the public and other stakeholders with the information and tools they need;
  • 9. collaborating on an international level to share information; and developing the infrastructure to institutionalize the population health approach At the provincial and territorial level, the challenges include collaborating across ministries and levels of government to develop healthy public policies; developing health goals and accountability frameworks that reflect the population health approach; balancing investments across the health system; and providing regular information to members of the public about health status The private sector can do its part by ensuring that it provides a safe and healthy working environment that has opportunities for continuous learning; that it takes into account its responsibilities for protecting the environment; and that it contributes to the overall well-being of the community At the local level, communities can focus their energies on developing partnerships that address the determinants of health; planning and providing high-quality services; sharing information and resources designed to maximize health impacts; and involving citizens in setting priorities and implementing programs As individuals, we can all contribute by taking responsibility for our own health and well-being; actively seeking out the information we need to make informed health decisions; building supportive communities; and participating in community activities that have an impact on health. Implementing the Population Health Approach Putting population health theory and policy into practice means acting on health issues in a way that is consistent with the key elements of a population health approach. Implementation Strategies A population health approach plans and executes programs, policies, and interventions along the entire spectrum of health action, including: health promotion disease (and injury) prevention risk management policy coordination medical treatment rehabilitation palliative care The population health approach is a unifying force for the entire spectrum of health system interventions - from prevention and promotion to health protection, diagnosis, treatment and care - which integrates and balances action between them. Health Promotion Health promotion is one of the ways to take action on population health. It has long been recognized as a way of taking action on the social, physical, economic and political factors that affect health. It also emphasizes the need to work with other sectors to ensure that the collective policy environment becomes one that supports health. Health promotion is a concept that has been endorsed within Health Canada's Health Promotion and Programs Branch (now the Population and Public Health Branch) to assist in the development of programs and policies that support healthy living. Risk Management An upcoming Health Canada guidance document, Integrating Population Health and Risk Management Decision-Making, describes the general concepts of population health and risk management, explains the linkage between the two, and provides an example illustrating how a population health approach may be integrated into the risk management decision-making process. Prevention Prevention of health problems (e.g., disease, injury) occurs at three levels: Primary prevention involves activities aimed at reducing factors leading to health problems. Secondary prevention activities involve early detection of and intervention in the potential development or occurrence of a health problem.
  • 10. Tertiary prevention is focused on treatment of a health problem to lessen its effects and to prevent further deterioration and recurrence. Measuring Results Politicians, public servants and organizations at all levels are increasingly called upon to be transparent, open to comment and scrutiny, and accountable for the short- and long-term impact of their decisions. The desired outcome of our work depends on the role that we are fulfilling, how we are working, with whom we are working and what we are working on. If we are the intermediary or the facilitator and catalyst, then our desired outcomes are different than if we are the program deliverer. The population health approach calls for an increased focus on health outcomes (as opposed to inputs, processes and products) and on determining the degree of change that can actually be attributed to our work. This emphasis will have an impact on planning and goal-setting processes as well as on the choice of interventions or strategies employed. In making decisions on the best investment of resources, strategies that have the potential to produce the greatest health gains will be given priority. Outcome evaluation is essential in a population health approach. It examines long-term changes in both health and the determinants of health. These include changes in knowledge, awareness and behavior, shifts in social, economic and environmental conditions, as well as changes to public policy and health infrastructure. Outcome evaluation also seeks to measure reduction in health status inequities between population sub-groups. Longer-term outcome evaluation is essential to a comprehensive evaluation program, which also includes process evaluation (to determine whether a policy or program is meeting its goal and reaching its target population) and impact evaluation (to measure immediate results of a program or policy). The importance of both process evaluation and outcome evaluation can be seen in Health Canada's Community Action Program for Children. Defining Accountability & Evaluation Accountability is the obligation to answer for responsibilities conferred. It involves providing detailed information about how responsibilities have been carried out and what outcomes have or have not been achieved. A key element of accountability is transparency, which results from conducting one's activities in a manner that can be easily observed and understood by the public. This includes responding appropriately to requests for information and reporting to the public. For example, Toward a Healthy Future: Second Report on the Health of Canadians by the Federal, Provincial and Territorial Advisory Committee on Population Health (ACPH) reports and comments on the state of the nation's health. It alerts policy makers, practitioners and the public to current and future challenges in health. Accountability at Health Canada Increasingly, the federal government is emphasizing and taking measures to inform Canadians about the achievements and results of public spending. To provide Canadians with relevant information and report on program investments and results, the federal government is developing and implementing practices for accountability. These practices require that all policy documents to Cabinet and submissions to Treasury Board Ministers feature, first of all, a performance measurement and reporting strategy and, secondly, a performance and accountability framework. Actions and Considerations Health Impact Assessment Assessing the health and social impact of programs and policies is an important aspect of population health. Health impact assessment can be defined as any combination of procedures or methods by which a proposed policy or program may be judged as to the effect(s) it may have on the health of a population. Policies or programs of any nature may directly affect the health of a population, or may indirectly affect their health by altering, influencing, or affecting the determinants of health. Health Goals
  • 11. Health goals provide a framework to better understand the relationship between the health outcomes we want and our efforts to achieve them. When health goals are expressed in measurable objectives and quantified targets, they provide the yardstick to measure population health improvements (or lack thereof). Without specific targets to guide health actions, expectations for health gains remain vague. Targets specify the amount and timing of desired change expected on a health status indicator and set forth the parameters of success in a population health approach. Policy Development Policy development in population health has built on the shoulders of a series of prior policy initiatives with a similar purpose, namely to maintain and improve the health of Canadians. While various characterizations of the population health policy can be made, it is most fruitful to see population health as a framework for thinking about the social and economic forces that shape the health of citizens. As such, it builds on a long tradition of public health and health promotion, and goes beyond the more traditional focus on the individual as the medical, biological or lifestyle problem. The Canadian Institute for Advanced Research has played a leadership role in building this framework, starting with a series of seminars led by Fraser Mustard at McMaster University in 1983. The population health framework is a work in progress. While many elements are clear, others are yet to be fully developed. It is not yet a fully detailed model that identifies the specific causes of good health, nor does it enable us yet to predict the effects on health of specific social and economic conditions. Nevertheless the population health policy provides, at the most general level, an approach which can increasingly set out the elements that are key to maintaining and improving the health of Canadians. Examples/Case Studies Health Canada supports initiatives that incorporate a population health approach in many areas, such as activities in the Population Health Regional Mobilization Strategy and the Population Health Fund. However, it will take time before these efforts yield meaningful results. As outcomes of current population health activities are compiled, Health Canada will develop case studies to fully examine and document applications of a population health approach to policy, research and practice. Meanwhile, the Department is aware that there are projects not just in health but in other sectors, which (deliberately or otherwise) are using at least some elements of a population health approach. We are gathering information on these initiatives, which we believe will provide useful interim success stories and examples of population health in action. These examples will help stimulate discussion and increase knowledge of critical concepts in the population health approach. Keep in mind that examples of initiatives to date do not illustrate or even contain every element of a population health approach. The Dufferin Mall Story is recognized internationally as a successful experiment in community development achieved by a unique partnership between business and government. Tools The Population Health Template Working Tool organizes and consolidates current understandings of population health. Health Canada has identified population health as a key concept and approach for program and policy development aimed at improving the health of Canadians. The working tool outlines the procedures and processes required to implement a population health approach and provides guideposts that help to assess preparedness and capacity to implement population health initiatives. The tool draws on the detailed and comprehensive discussion paper, The Population HealthTemplate: Key Elements and Actions that Define a Population Health Approach. Considering Issues in a Population Health Approach The linked table highlights the elements and issues that need to be considered in a population health approach.
  • 12. Entry Points to Health Health can be approached from many different perspectives and health concerns can manifest themselves in a wide variety of ways. None of these "entry points" is unique to the population health approach and all are valid places to begin in considering health and interventions to improve health. An essential feature of the population health approach is understanding health in terms of its broad determinants. Because determinants interact, pursuing a population health approach beginning with any given entry point will typically lead to consideration of an array of inter related perspectives and concerns, many of which could equally well have served as the entry point. Entry points include: demographic groups (e.g., children, women, Aboriginal peoples, persons with low income); diseases or causes of death (e.g., AIDS, cancer, influenza, heart disease, diabetes); hazards to health (e.g., radiation, contaminated water, unsafe products, environmental tobacco smoke, violence); settings (e.g., homes, schools, workplaces, municipalities, recreational facilities); behaviours/lifestyle (e.g., tobacco use, alcohol or drug abuse, nutrition, exercise); and determinants of health (e.g., income and social status, education, employment and working conditions, social support). Checkpoints for Applying the Population Health Approach As part of a 1998 pilot session to involve Health Canada staff in developing a population health approach, the BC Regional Office of the Health Promotion and Programs Branch produced a tool entitled Checkpoints for Applying the Population Health Approach. A New Approach to the Population Health Fund The Population Health Fund (PHF) was created in 1998 to increase community capacity for action on or across the determinants of health. In order to fill gaps in addressing key public health issues and to strengthen the emphasis on meeting the needs of Canadians, the PHF has been refocused on innovation in population health interventions to reduce inequalities. To highlight this shift in approach, the program has been renamed the Innovation Strategy. The Innovation Strategy supports the development, adaptation, implementation and rigorous evaluation of promising population health interventions to increase and strengthen population health action in Canada. The Innovation Strategy puts a strong focus on the exchange and use of practical knowledge — based on the results of these interventions — and sharing of best or promising practices across the country to reduce health inequalities and deal with public health issues of a complex nature. Each Innovation Strategy solicitation addresses a specific priority public health issue.
  • 13. A recent report describes how Canada’s healthcare system performs compared to 13 other countries. Canada ranked at the bottom in access to care and use of electronic health records, and in the middle regarding costs and health outcomes. Thirty-eight percent of Canadians felt the system works well, 51% thought it needs fundamental change, and 10% believed it needs to be completely rebuilt. A recent report from the American organization The Commonwealth Fund provides information about how Canada’s health care system compares to those in thirteen different high-income countries. Some of the findings are summarized here. Access to Care Canada consistently ranked poorly on access to care. In Canada, wait times were longer than in any of the other country for specialist appointments and elective surgeries. For example, 41% of Canadians waited two months or more to see a specialist, compared to just 5% of Swiss and 7% of Germans. One in four Canadians waited four months or more for elective surgery, compared to none in Germany and 5% in the Netherlands. Canada was the second worst country for accessing health care after hours. Sixty-five percent of Canadians report that it is very or somewhat difficult to find care after regular business hours, compared to 33% of people in the Netherlands. This poor performance has occurred even after the federal government commited $4.5 billion to reduce wait times in 2004, as well as major investments by the provinces. Stephen Duckett, an Australian health economist and former CEO of Alberta Health Services says that “the waiting list money was highly targeted at specific services, such as hip replacements” and that other countries like the United Kingdom have been able to reduce wait times by setting up aggressive targets for providers and penalties if the targets were not met. At the same time, funding for health care was markedly increased in the UK. Electronic Medical Records While significant investments have been made to increase the number of primary care providers, Canadian primary care doctors had the lowest use of electronic medical records in their practices – 37% in Canada, 46% in the United States, and above 90% in seven countries. The poor uptake of electronic medical records in primary care has occurred despite considerable investments in eHealthprovincially and nationally. Tom Noseworthy, a Professor of Community Health Sciences at University of Calgary argues that there was “an insufficient investment in [electronic medical records] Canada-wide that did not operate from a careful blue print on how to achieve gains in every province” leading to a situation where “there are little pockets of doctors using electronic medical records that do not connect as a whole”. Duckett believes that “the introduction of electronic health records is much more complicated in primary care because of the disorganized nature of primary care, as opposed to the hospital sector. Hospitals The report also includes measures related to hospitals. Canada had the fewest acute care beds per population and the highest average length of stay (7.7 days). This information suggests that few Canadians are being admitted to hospitals unnecessarily, which is a good thing. However, the lack of hospital beds for acutely ill patients is a major cause of emergency department overcrowding, and our long wait times for some surgical procedures suggest that more hospital beds are needed to accommodate these procedures.
  • 14. However, this may not require the construction of more hospital beds, because about 14% of hospital days in Canada are currently taken up by patients who no longer need acute care. Investments in community and long-term care might help the hospital sector. Noseworthy believes that “it is a good thing that Canada has been able to get by with so few acute care beds” and that in spite of the low numbers of beds, they are still “not being used optimally.” He suggests that “we do not have good substitutive services, leaving acute care beds as the only port in the storm for sick patients who could receive care in less acute, sub-acute or intensive home care environments.” Costs of Health Care All countries in the report had some form of publicly funded health care paid by government revenues from taxes. However, the amount spent on health care varied markedly. Canada was in the middle of the pack when it comes to the percentage of gross domestic product (GDP) spent on health care. The United States spent by far the most at 17.4%, and Japan spent the least at 8.5%. Canada was similar to countries like Denmark, France, Germany and Switzerland, and spent 11.4% of annual GDP on health care in 2009. Canada’s proximity to the United States means that we often compare our health care system with our neighbour to the south. However, as mentioned above, the United States spent by far the most on health care of any country, and its measures of quality were frequently among the worst and rarely among the best (except for access to specialists and surgeries). We might gain valuable insghts by carefully looking at the health care systems of other countries. Public Satisfaction with Health Care While performing poorly in terms of access to care and the use of electronic health records, Canada was average in survival after a heart attack and was in the top two performing countries in survival after the diagnosis of breast cancer and the frequency of a lower-limb amputation in persons with diabetes. Given this mixed picture in performance, it is not surprising that Canadians were far from unanimous in their views about the need for change in the health care system – 38% felt the system worked well with only minor changes needed; 51% felt that fundamental changes were needed, and 10% felt that the health care system needed to be totally rebuilt. These numbers are similar to most of the other countries. The greatest desire for change was expressed by citizens in Australia and the United States, with 20 and 27% respectively saying that their health care system needed to be totally rebuilt. The United Kingdom was on the other extreme, with 62% of citizens feeling that the system worked well, and only 3% indicating that the system needed to be totally rebuilt.

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