Health System Funding Reform: Driving Change using Technology Presentation to – Canadian Health Informatics Association

April 2014 Ministry of Health and Long-Term Care

V2.4 (2014-04-28)

Session Objectives

• To provide a high-level overview of Health System Funding Reform

• Highlight the role and importance of technology, communication and information in support of funding reform and the healthcare system as a whole

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Our Vision to Achieving Value

• Our goal is to make Ontario the healthiest place in North America to grow up and grow old

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1. Keeping Ontarians Healthy

2. Faster access and a stronger link to family health care

3. Right care, right time, right place

Our Goals

A focus on standardization, appropriateness, productivity and safety, innovation implemented at scale is essential.

Our Strategy to Achieving Value Health system transformation is about redesigning the system to allow for more flexible delivery models which

promote access, quality and allows for services to be provided in a fiscally sustainable manner.

Transformation will be guided by evidence and co-designed with the sector.

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Funding Reform Right Care, Right Place, Right Time

Wellness & Prevention

Integration & Execution

4 Pillars of Transformation

Empowering people to make healthier

choices and improving health

outcomes for children

Paying for health care services based on the needs of the patient

and on performance to drive quality, efficiency

and effectiveness

Maximizing investments by shifting services to more

appropriate and cost effective settings and

optimizing existing resources

Strengthening coordinated care to improve access to

health care services and maximizing quality

and value

54 Health Links

Population Coverage: 7,723,490

Total Number of High Users:

720,000

Over 1000 multi-sectoral

Partners

• The response to Health Links in year one has exceeded expectation • There is at least one Health Link in every LHIN and some LHINs have full coverage. • Future: 90+ Health Links, providing full coverage across the province – we’re already halfway there! • The impact of other early successes have centred around local and regional innovations in

programming, clinical pathways, and governance.

Health Links: Current State

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Health System Funding Reform

Aligning Incentives and Accountabilities by Funding For High Quality Care and Better Patient Outcomes

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Global Funding

An evidence-based approach with incentives to deliver high quality care based on: • Best available evidence and best practices • Needs of the population served • Services delivered • Number of patients

A historical approach where health service providers received lump sum funding • Hospitals, on average, received 75-90% of their funding

from global budgets • Majority of the funding is in the form of:

o Base annualized funding o New incremental funding o Remaining funding acquired from other sources

(i.e. preferred accommodation, alternative revenue etc. )

We are moving from the global provider-focused funding model to one that revolves around the person

Health System Funding Reform

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Ontario’s Health System Funding Reform (HSFR) approach will draw from over 25 years of international Activity Based Funding experience

• Patient focused funding systems reimburse providers at an established rate, based upon quality care for standard patient groups

• Ontario is one of the last leading jurisdictions

to move down this path

Pat

ient

Foc

used

Fun

ding

Ado

ptio

n Ti

mel

ine

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Activity Based Funding is about Patients

Ambulatory

Nursing

Clinical Laboratories

Peri Operative Services

Health Disciplines

Pharmacy

Medical Imaging

Infrastructure

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Patient care needs the information and accessibility that technology brings…

Health System Funding Reform (HSFR) has two funding components

• HBAM is a ‘made in Ontario' funding model

• QBPs are clusters of patients with clinically related diagnoses/ treatments and functional needs identified by an evidence-based framework

Note: At the culmination of HSFR, HSPs will account for approximately 70% of funding

HSFR

Health-Based Allocation Model

(HBAM)

Global Funding

(Non-HSFR) Quality-Based Procedures

(QBPs)

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1. Health Based Allocation Model (HBAM)

Patient demographics • Age, gender, growth projections,

socio-economic status and geography

Clinical data • Complexity of care and type of care

Financial data

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A funding model that optimizes the allocation of available funding

2. The ‘Quality’ in Quality-Based Procedures • Best practices informed by clinical consensus and best available evidence

• Engage in clinical process improvement/re-design and adopt best practices

• Best practice pricing to strengthen the linkage between quality and funding

• Develop indicators to evaluate and monitor actual practice

• Broaden scope of QBPs to strengthen the continuity of care

• Ensure every patient gets the right care, at the right time, at the right place

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Developing and Implementing QBPs

Acute Inpatient • Entering Year 3 (2014-15) of QBP implementation • To date (2012-13 and 2013-14), QBPs represent 11% of the total

provincial budget

Transition from Acute Inpatient Admissions • Existing QBPs expanded to address transition from inpatient

admission/episode

Community • Concurrent work underway to define community-focused QBPs

Integrated Indicator Scorecard • Provide a starting point for monitoring and evaluating the impact of

the introduction of each QBP 13

Technology and Healthcare Advances

• Technology can play a role in containing costs, improving access, and saving lives

• An electronic medical record system is often touted as the utopian marriage of healthcare and technology savvy, so let’s

• We’re spending more, but are we getting value for our money?

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$$$$

• Encourage hospitals and doctors’ offices to digitize health care records

$$$$

• Get better at crunching data to offer a better diagnosis and treatment

$$$$

• Help doctors communicate with patients and their peers

Data (System) Requirements for Healthcare Funding

• MIS, HBAM, QBPs, Forecasting and Budgeting Financial Data

• EMR, HBAM, QBPs, CPOE, Order Sets Clinical Data

• QBPs, Human Resources, Materials and Supplies, Medical Technology Case Costing Data

• Capacity Planning Utilization Management Data

• Indicators/Scorecards/Dashboards Performance Measurement Data

Workload Measurement Data

Business Intelligence

Impact Analysis

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The Trouble with Data

Data not understood is bad data

No matter how much data we have, we always want more No matter how good and validated the data is,

we always want it to be better

No matter how quick it is, it could always be available quicker Everyone else has better information systems than we do

The darn data never answers the questions it should

The data doesn’t always prove what we know is right

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Data Quality Culture

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Understanding

Components of a ‘Good Culture’

Multiple Data Inputs into HSFR Modelling

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Clinical •Acute Inpatient (DAD) •Day Surgery (NACRS) •Emergency Room (NACRS) • Inpatient Rehab (NRS) •Complex Continuing Care (CCRS) • Inpatient Mental Health (OMHRS) •Home Care (HCD)

Financial •Ontario Cost Distribution Methodology (OCDM)

•Management Information Systems (MIS)

HBAM Modelling

Case Costing •Ontario Case Costing Initiative

QBP Calculation

HBAM Adjustments

Population •Statistics Canada census data and Ministry of Finance population projection updates

Socio-economic Status •From Statistics Canada

Rurality

Medical Trainee Days

Coding and Data Quality: Raising the Bar

It’s not the Ministry’s data: it’s the organization’s • Overt and transparent link between coded patient data and funding • Improved data quality benefits everyone • Documentation (physician and departmental) challenges need to be

resolved, need for issues to be escalated • Likely need new data elements; keeping abreast of standards even

more important

Patient Assignment to all QBPs based on coded data • Funds to be paid for different QBPs will vary • Not all patients fit a QBP criteria • Capacity planning…it’s not just about volume reconciliation

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• Complete, clear, and accurate documentation is the foundation for complete and accurate coding of all types of medical records

• Normal scapegoat for any performance results is coding

• What role does Computer Assisted Coding have?

• Education sessions held by Medical Records departments for physicians and clinicians usually result in improved quality of charted data

• Main concern is getting physicians to consistently and accurately ensure highest quality of charted data

• Data review process

• Optimizing processes

Clinical (Patient) Coding and Data Quality

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Deficiencies in the documentation result from:

• Failure of health care provider to record information

• Lack of detail or specificity

• Conflicting or inconsistent information

• Illegible documents

• Missing documents

Deficiencies in Documentation

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• Process of entering medication orders or other physician instructions electronically instead of on paper charts

• The use of a CPOE system can help reduce errors related to poor handwriting or transcription of medication orders

• Although CPOE systems are designed to mimic the workflow of the paper chart, their adoption has been slow, largely because of: • Disruption to existing care settings • Cost of implementation which includes training

Computerized Physician Order Entry (CPOE)

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• Helps organizations facilitate widespread CPOE physician adoption with streamlined order entry pathways, interactive worklists, and evidence-based order sets

• CPOE Reduces: • Misinterpretations and transcription errors by eliminating

handwritten medication orders

• Callbacks to physicians for clarification of ambiguous, incomplete, or illegible orders

• Medication order turnaround time: from ordering to dispensing to administration

CPOE Benefits

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• Conveniently grouped medical orders that work to standardize diagnosis and treatment following pre-established clinical guidelines

• Step-by-step, evidence-based checklists that are used by clinicians to order treatments for patients

• Interacts with many hospital processes and support structures such as: • Drug formulary • Medication policy manual • Approved abbreviations • Method of undertaking diagnostic procedures

• Allow a physician to stop the practice of treating patients completely from memory

What are Order Sets?

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If technology helps facilitate cost-effective care, it is providing value

Summarizing

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Provides (and operationalizes) innovation Is not the panacea for all of our healthcare woes But it is essential to help us move forward

Technology

Raising Awareness

Public website: www.ontario.ca/healthfunding • Targeted to general public and includes presentations, videos, and

frequently asked questions

Private website: www.hsimi.on.ca (password required)

• Targeted to health service providers and includes HSFR memorandums, education materials, and archived webinars

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Keeping you informed of HSFR-related communication and education opportunities

New users can create an account by clicking on “Create new account” from the main homepage.

Contact our helpline for questions!

Email or direct your enquires related to HSFR to the ministry health system funding Helpline:

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HSF@ontario.ca

or call

416-327-8379

Questions and Comments

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Appendix

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QBP Multi-Year Roll-out Plan

Year QBPs

Year 1 (2012-13)

1. Primary hip replacement* 2. Primary knee replacement*

3. Cataract 4. Chronic kidney disease

Year 2 (2013-14)

5. Chronic obstructive pulmonary disease* 6. Stroke* 7. Congestive heart failure*

8. Non-cardiac vascular 9. Chemotherapy 10. Gastrointestinal endoscopy

Year 3 (2014-15)

Wave 1 11. Hip fracture* 12. Pneumonia 13. Tonsillectomy 14. Neonatal jaundice

Wave 2 15. Coronary artery disease 16. Aortic valve replacement 17. Cancer Surgery 18. Colposcopy 19. Knee Arthroscopy 20. Retinal Disease 21. Short-Stay Post-hospital Discharge Homecare:

Medical Discharge 22. Short-Stay Post-hospital Discharge Homecare:

Surgical Discharge *These QBPs have or are being further developed and expanded to address transition to post-acute phase in Year 3 (2014-15).