Latest articles about Primary Care http://www.longwoods.com http://blogs.law.harvard.edu/tech/rss Mon, 17 Nov 2008 13:09:28 -0500 Mon, 17 Nov 2008 13:07:18 -0500 FeedForAll v2.0 (2.0.2.9) http://www.feedforall.com The purposes of this study were to identify the Canadian population's performance priorities for primary care, to ascertain the stability of these priorities over time and to examine variation across priorities among different subgroups of the population. The authors administered a survey of 10 priorities (determined through earlier work) to over 1,000 Canadians in 2001, and again in 2004. Analysis of variance was used to compare the ratings of each priority across the two years. The authors completed a forward stepwise regression analysis to examine the relationships between performance priorities and population characteristics in each year. http://www.longwoods.com/product.php?productid=20170&cat=572&page=1 0B403B22-C5DB-47B8-8A66-E9171B831F5A Mon, 17 Nov 2008 13:07:18 -0500 To ensure an adequate supply of physicians for the future, Canadian faculties of medicine have been expanding and modifying physician training at the undergraduate and postgraduate levels with the intention of producing more physicians and addressing long-standing challenges in the Canadian physician workforce. While these medical education initiatives may partly address these goals, the lack of alignment between health services policy and education policy may well lead to failures and disappointing results. The authors argue that changes in related healthcare policy are required both to support the intended outcomes and to sustain innovations in medical education. From their perspective as medical educators, the authors describe seven key gaps in this alignment, identify those who are in a position to address them and call for ongoing opportunities to identify, discuss and address alignment of policy with other initiatives at the national and provincial levels. http://www.longwoods.com/product.php?productid=20264&cat=572&page=1 F86A8B38-AB1E-4A40-A222-74CE42A67480 Mon, 17 Nov 2008 13:03:46 -0500 Nursing practice in remote northern communities is highly complex, with unique challenges created by isolation, geography and cultural dynamics. This paper, the second of two focusing on the advice offered by nurses interviewed in the national study, The Nature of Nursing Practice in Rural and Remote Canada, considers suggestions from outpost nurses. Their advice to new nurses was: know what you are getting into; consider whether your personal qualities are suited for northern practice; learn to listen and listen to learn; expect a steep learning curve, even if you are experienced; and take action to prevent burnout. Recommendations for educators were to offer programs that prepare nurses for the realities of outpost nursing and provide opportunities for accessible, flexible, relevant continuing education. The outpost nurses in this study counselled administrators to stay in contact with and listen to the perspectives of nurses at the "grassroots," and not merely to fill positions but instead to recruit outpost nurses effectively and remunerate them fairly. The study findings highlighted the multiple interrelated strategies that nurses, educators and administrators can use to optimize practice in remote northern communities. http://www.longwoods.com/product.php?productid=20062&cat=562&page=1 6249794D-F29C-4AA1-BD96-1A5EE8740D9C Fri, 26 Sep 2008 09:25:38 -0400 The sustainability of the rural and remote nursing workforce in Canada is increasingly at issue as the country becomes more urbanized and the nursing workforce ages. In order to support the retention of nurses in rural and remote communities and the recruitment of nurses to these communities, we require a better understanding of what is important to rural and remote nurses themselves. As part of the in-depth interviews conducted within The Nature of Nursing Practice in Rural and Remote Canada, a national research project, registered nurses (RNs) were asked what advice they would have for new nurses, educators, administrators and policy makers. This is the first of two papers describing that advice. It focuses on RNs in acute care, long-term care, home care, community health/public health and primary care roles in rural and remote communities across the country. The RNs were generous with their advice and gave many rich examples. While they were enthusiastic about their nursing practice and encouraging of other nurses to work in rural settings, they were intent that improvements be made in several key areas: education available to new practitioners and themselves, working conditions for rural and remote nurses, leadership, organizational supports and policies that better support rural and remote practice and communities. http://www.longwoods.com/product.php?productid=20060&cat=562&page=1 B7CBD91F-C518-4F96-A1FA-203E418A3879 Fri, 26 Sep 2008 09:25:04 -0400 Homeless persons are numerous, carry a significant burden of illness and face challenges in accessing care. A search of the literature revealed insufficient empirical sources to permit the use of standard systematic review methodology to determine the most effective way to deliver point-of-first-contact healthcare to homeless people. Instead, we used a policy analysis approach. We found that the dominant model of primary care in Canada performs poorly when assessed on 13 evaluation criteria. While there is variable performance on individual measures, the three alternative models - targeted standard facility/clinic site, fixed outreach site and mobile outreach service - all perform well. Our findings suggest that some factor other than performance on the specified measures, such as costs, feasibility, geographical fit or local preferences, should be used to choose a specific model. Our analysis clearly indicates that the status quo model of primary care is inadequate to meet the needs of homeless people. http://longwoods.com/product.php?productid=20012 044EDEE9-DE89-45DC-B54E-38366583551E Fri, 15 Aug 2008 10:33:13 -0400 The 2003 Statistics Canada Health Services Access Survey found that 12% of Canadians polled did not have a family doctor, and 18% reported access problems such as long waiting times and difficulty contacting the doctor. Research has repeatedly shown that where a problem with access exists in the general population, it is considerably more severe in subsets of the population that are most disadvantaged. Statistics at both the national and local levels confirm that although people with disabilities have greater need for health services, including both institutional and community services, they also experience significant disadvantages in attempting to access service. The question explored in this study is how physicians' perceptions of disabled patients and behaviour towards them might affect access to primary care for adults with disabilities. The study used a qualitative interpretive approach to uncover physicians' perspectives on working with people with disabilities. Semi-structured interviews were conducted with a sample of 34 physicians in Eastern Ontario. http://longwoods.com/product.php?productid=19989 BB2C748F-E293-4371-941F-141C565121CE Fri, 15 Aug 2008 10:32:34 -0400 New models of primary healthcare delivery recently implemented in Ontario are designed to improve after-hours accessibility. This study examined whether the six-month prevalence of emergency department and walk-in clinic use differed among patients of eight Family Health Network (FHN), 16 Family Health Group (FHG) and 12 fee-for-service (FFS) physicians in one city. http://longwoods.com/product.php?productid=20009 CD8B3391-8EC6-445C-AA6E-9F275174BEC2 Fri, 15 Aug 2008 10:31:48 -0400 There are strong arguments that national catastrophic drug insurance should be established in Canada with assistance from the federal government. The author of this paper projects the long-run program costs for two proposals for such a program: that of the Kirby Committee and that of the Romanow Commission. He concludes that both the annual program costs to the federal government and the share of the federal government on total prescription drug expenditures in Canada would increase dramatically under either program. Although the Kirby-style program requires less initial expenditure by the federal government than does the Romanow-style program, because of their different designs, over time the Kirby-style program would become more expensive. Moreover, the Kirby-style program would be more sensitive to the growth rate of prescription drug expenditure. The choices relating to the program threshold and federal cost-sharing rate have far-reaching influences on the long-run costs to the federal government. http://www.longwoods.com/product.php?productid=19897 E9484C71-9F80-4DD9-BA2A-0DA17E66FC21 Fri, 20 Jun 2008 09:57:26 -0400 For over 30 years, Canadian provinces have provided universal public insurance for hospital and physician care; however, evidence points to persisting socio-economic inequity in healthcare use. Because provinces hold the responsibility for planning and funding most publicly insured health services, there is some variation in health system characteristics. In the context of such variation, this study systematically investigated equity in healthcare use across the provinces. Drawing on the 2003 Canadian Community Health Survey, the author applied the indirect standardization approach to create an index of needs-adjusted inequity in the probability, total and conditional number of GP, specialist, hospital and dentist visits. http://www.longwoods.com/product.php?productid=19924 F9DB620C-2683-4EAA-8B64-EDE4E274AFB1 Fri, 20 Jun 2008 09:56:40 -0400 Indicators are increasingly being used to monitor and evaluate health system performance. However, although indicators can provide valuable information, they also have limitations. The benefits of indicators are vitiated when they are seriously flawed (unreliable, invalid or easily "gamed"), selected before the right question has been posed or used to the exclusion of other sources of information. This critical assessment of the use and misuse of indicators employs practical examples from a Canadian health authority to illustrate common pitfalls. It concludes with some solutions to optimize the benefits of indicator use. http://www.longwoods.com/product.php?productid=19918 CD9114CE-A9CC-48BF-97DD-08D0074CF069 Fri, 20 Jun 2008 09:54:09 -0400 Sarah Bowen and Sara Kreindler argue that indicators can be valuable, but are also often flawed. They suggest that performance indicators should at best serve as a flag for policy makers but should not drive decisions. We would argue that there is growing evidence of the positive impact of performance indicators. When performance indicators are selected based on sound strategies - and used as part of a clear performance management cycle that balances policy instruments (e.g., accountability agreements) and performance improvement processes (e.g., process redesign) - they can drive valuable performance improvements and help align strategies across all health system partners. http://www.longwoods.com/product.php?productid=19919 DD7D2FA5-4B52-495C-A17F-4B0339D1A686 Fri, 20 Jun 2008 09:53:42 -0400 Adalsteinn Brown and Jeremy Veillard have done an excellent job of outlining the gains that may be achieved from performance measurement, and the context for increased focus on this area. We do not suggest that indicators should not be used, or cannot be useful. We believe, however, that it is important to differentiate between the efficacy of indicators (their potential in ideal situations) and their effectiveness (what we see happening in actuality). The observation that the Veterans' Administration and Institute for Healthcare Improvement are using indicators in appropriate and helpful ways does not imply that every local health authority or hospital is doing the same. There remains a need for caution - not about the fact that indicators are used, but about the way they are used. http://www.longwoods.com/product.php?productid=19920 2B031364-E261-47F2-AD0B-AB6A1AAB2E1D Fri, 20 Jun 2008 09:53:32 -0400 British Columbia focus group participants identified six domains of primary healthcare as important: accessibility, continuity, responsiveness, interpersonal communication, technical quality and whole-person care. http://www.longwoods.com/product.php?productid=19577 1290B414-5905-450D-A55C-230DC9ED356B Wed, 27 Feb 2008 10:20:04 -0500 Just over half of survey respondents reported that their board had approved a management plan to address emergency situations and a process to identify, manage and minimize risks to their hospital's sustainability. http://www.longwoods.com/product.php?productid=19557 F60D9CB5-EBBD-4E9A-ABA2-DA347540DFF4 Wed, 27 Feb 2008 10:19:40 -0500 Objective: This study set out to identify the perspectives of family physicians (FP/GPs) on the quality and capacity of the services they provide and of the system in which they work, to assess their responsiveness to potential changes and to determine their suggestions for future directions to enhance primary care services. Methods: Thematic results from prior focus groups with FP/GPs provided direction for a questionnaire sent to practitioners in the urban study area. Seventy-four questions, most using a five-point Likert scale, were grouped into 10 sections: physician issues (based on themes from the focus groups), access to specialist services, workload, scope of practice, primary care physician networks, interdisciplinary collaborative practice, complexities and challenges of family practice, future directions, comments and demographics. Results: Five hundred and eighty-three FP/GPs were surveyed, and 300 responses (52%) were analyzed for frequencies and comparisons using SPSS. In addition to informative responses to the various survey sections noted above, specific physician suggestions for future directions to improve quality and capacity were identified. These included access to specialists/consultants, teamwork/collaborative practice, access to diagnostics, electronic records/technology, time and remuneration. Conclusions: The identified suggestions by FP/GPs to enhance the quality and capacity of health services contribute to a framework for policy development at national, provincial/territorial and regional levels and can be used as a reference point for the progress of primary care reform initiatives. http://www.longwoods.com/product.php?productid=19365&cat=517 548798B9-30F0-4C18-BF1B-F04C11A82C7C Mon, 19 Nov 2007 10:57:15 -0500 Objective: A 2002 survey of primary healthcare sites found that 51% of rural and 33% of urban primary care patients reported using the hospital emergency room (ER) in the last 12 months. We did a secondary analysis to identify urban-rural differences in accessibility-related organizational features that predicted ER use. Methods: We collected information on clinic organization and physicians' practice profiles from 100 primary healthcare sites across Quebec and 2,725 of their regular patients, who reported on ER use. We used hierarchical logistic regression to identify organizational features that predict the probability of ER use by patients. Results: Patient confidence in rapid access at their clinic decreases ER use (OR=0.73). Rural sites offer fewer walk-in services or on-site medical procedures and less proximity to laboratory and diagnostic services, but paradoxically, rural patients are more confident that their own physician will see them for a sudden illness. Patients from clinics offering a larger range of medical procedures on site have lower ER use (OR=0.92 per procedure). Rural physicians tend to divide their time between hospital and primary care; doing in-patient care increases ER use (OR=1.64). Discussion: Decreased ER use is found in patients of clinics organized to enhance responsiveness to acute needs, especially in rural areas. Although the high rates of ER use in rural areas partly reflect problems with the accessibility of primary care clinics, in a resource-scarce context rural hospital ERs may cover both primary care urgent problems and emergencies. http://www.longwoods.com/product.php?productid=19394&cat=517 7C5A11ED-F98A-4A9E-8302-92D0FD0C03B7 Mon, 19 Nov 2007 10:56:28 -0500 Despite change, uncertainty and disarray in Canada's healthcare system(s), some observations about Canadian medicare still seem beyond challenge: * access to healthcare based solely on need is the core value that gave rise to and sustains medicare; * the advent, through medicare, of universal, publicly funded physician and hospital services substantially reduced disparities in access to, and outcomes of, healthcare based on socio-economic status (Enterline et al. 1973; James et al. 2007); * despite those gains, disparities remain - factors other than need continue to influence access to and use of services. http://www.longwoods.com/product.php?productid=19387&cat=517 39EE56E2-1FBE-4954-BA45-5C788A021A75 Mon, 19 Nov 2007 10:55:11 -0500 It has been suggested that inpatient hospital care has been neglected in our enthusiasm for community- based ambulatory care. Nevertheless, over one-third of our health dollars are spent in hospitals and the majority of people alive today will have received some of their healthcare as hospital inpatients. The current environment of downsizing, restructuring and cost shifting, however, has had a profound effect on the acuity of and expectations for inpatient care and, coupled with a withdrawal of physicians from inpatient care, is forcing us to rethink how we care for this population. What is rapidly emerging is the development of hospitalist models for inpatient care. http://www.longwoods.com/product.php?productid=17433&cat=319 0E3133CF-C469-42F7-BEA6-EBBB0616F89C Fri, 15 Jun 2001 14:32:36 -0400 Recently attention has been focussed on the significance of primary care to the Canadian healthcare system. Nova Scotia, like other provinces, is seeking ways to improve the healthcare that it provides within a financially constrained publicly funded system. The Strengthening Primary Care Initiative in Nova Scotia (SPCI) was a primary care demonstration project to evaluate specific goals related to primary care. Although the provincial government conceived the SPCI, the approach to its planning and implementation was participatory and consultative. Funded through the federal Health Transition Fund (HTF) (Health Canada 2002) and the government of Nova Scotia, the SPCI involved changes in four communities over a three-year period (2000-2002). These changes included the introduction of a primary healthcare nurse practitioner in collaborative practice with one or more family physicians; remuneration of the family physician(s) with methods other than a solely fee-for-service (FFS)arrangement; and the introduction and utilization of a computerized patient medical record. http://www.longwoods.com/product.php?productid=16345 41099FC8-34F7-474B-9158-FE0167C9833D Sat, 15 May 2004 14:31:19 -0400 In his 1995 article "Big Bang Health Reform - Does It Work? The Case of Britain's 1991 National Health Service Reforms," Rudolf Klein described health reform as one of the worldwide epidemics of the 1990s. Klein's description of the new National Health Service model as a self-inventing institution, coupled with the powerful images on Canadian television in October 1998 of the Calgary General Hospital's implosion, make his article an apt starting point for a preliminary assessment of the impact of health restructuring in Calgary. In describing Britain's health reform, Klein noted the Thatcher government intentionally resisted formal evaluation of the impact of the changes. The creation of internal markets within the NHS was implemented in a way that frustrated attempts at evaluation. http://www.longwoods.com/product.php?productid=16739 78769EE8-4F2F-4B4F-B45A-2AB9C871BC56 Tue, 15 Dec 1998 14:28:01 -0400 More than half of all Canadians use some form of complementary and alternative medicine (CAM) every year. The way CAM is being used, the magnitude of its use and the lack of clarity on standards of evidence make CAM a rising healthcare issue. A recent research priority-setting exercise by the Canadian Interdisciplinary Network for CAM Research (IN-CAM) identified three research priority areas: (1) healthcare delivery and policy research, including (a) exploring if and how CAM should be regulated, (b) defining what constitutes acceptable evidence of safety and efficacy, (c) investigating the organization and delivery of integrative healthcare; (2) methodological research, including exploring how best to assess whole systems of care and how to choose patient-, practitioner- and policy-relevant outcome measures; and (3) knowledge transfer, including formal education strategies, the provision of information and dialogue with those who use information in decision-making. The high use of CAM products and therapies leads to many questions from patients, practitioners and policy makers. The research agenda presented here provides a guide to begin programs of research that will answer these questions. http://www.longwoods.com/product.php?productid=18120 4C58D9FD-09C6-4146-BE0E-96B396220F8B Sat, 15 Apr 2006 14:27:09 -0400 A study commissioned by Canada Health Infoway provides a comparative analysis of automation in general practice in 10 countries. The most common clinical application is the automation of medication prescriptions - even if it is not a mandatory requirement as it is in Norway. It is the clinical application that provides one of the biggest benefits to general practitioners as it addresses legibility concerns, can be a significant time saver (particularly for repeat prescriptions) and offers the potential to make use of decision-support capabilities. The transmission of laboratory results is the most common electronic clinical communication application. http://www.longwoods.com/product.php?productid=18833 00441F6B-FCF3-4F49-AB0D-DC76593D525A Sun, 15 Apr 2007 14:25:32 -0400 The premise of Leatt, Pink, and Guerriere's paper is that international experience with integrated healthcare can inform strategies for the establishment of integrated healthcare in Canada. The authors propose that based on international reforms, development of an integrated system of healthcare delivery for Canada can better meet the needs of consumers, improve quality of care and outcomes and decrease costs of service provision. A cynic might suggest that the most important global lessons to be learned are that consumers, when asked, cannot readily agree on the services they want or need (Robinson 1999); that purchasers have difficulty defining what will be purchased in terms that ensure quality outcomes (Maynard 1994; Propper 1995; Robinson 1999); and that the level of competition, the amount of central control and the financing methods may have a greater impact on cost control than integrated service delivery (Berwick 1996). Although integration and coordination of care delivery has logical appeal, as highlighted by Leatt et al. there is limited empirical evidence on the impact of integrated healthcare on either individual or community health outcomes or value for money in healthcare delivery. http://www.longwoods.com/product.php?productid=17217&cat=333 53C48C87-9282-40FB-B4FF-BC46169A251E Wed, 15 Mar 2000 14:24:38 -0400 There is general consensus across Canada that to be able to cope with rising costs in healthcare and improve the status of health of the population a move must be made towards more primary care, chronic disease management, home-care services for the elderly, health prevention and better health education. More money has to be invested in our healthcare system, and universal coverage must be maintained. The use of costly hospital services must be focused on those patients that can be served nowhere else, and those hospital services must be provided in the most efficient and economical way possible. http://www.longwoods.com/product.php?productid=17118&cat=343 5AED05FE-F0DA-4633-AF05-DD73BFCA9BD6 Sat, 15 Feb 2003 14:21:11 -0400 In this study, we identify the significant factors associated with having difficulties accessing first-contact healthcare services. Population-based data from two national health surveys, the Health Services Access Survey and the Canadian Community Health Survey, were used to identify respondents who required first-contact services for themselves or for a family member during 2003. Fifteen percent of Canadians reported difficulty accessing routine care, and 23% reported difficulties with immediate care. Physician/service availability was the chief reason cited for difficulties accessing routine care, while for urgent care, it was long wait times. Women, younger respondents and residents of eastern Canada and Quebec were consistently more likely to report difficulties accessing both types of these first-contact services, whereas less educated Canadians were less likely to report problems. Canadians without a regular family doctor were more than twice as likely to report difficulties accessing routine care compared to those who had a regular doctor. New immigrants were almost two and a half times more likely to report difficulties accessing immediate care than were Canadian-born respondents. Household income was not associated with difficulties accessing either type of care. The relatively low level of reporting of difficulties by older and less educated Canadians may be related, in part, to more modest expectations about the healthcare system. http://www.longwoods.com/product.php?productid=17882&cat=412 49F8D685-C18E-4D75-B048-71E145F8E29E Sun, 15 Jan 2006 14:20:08 -0400 A Briefing Paper from the U.K. National Coordinating Centre for NHS Service Delivery and Organization Research and Development http://www.longwoods.com/product.php?productid=18130&cat=439 2B078CD5-25AE-491A-9A2C-9A4C7278A2B1 Wed, 15 Mar 2006 14:17:45 -0400 Broad re-examinations of the healthcare industry are the order of the day. Recent federal and provincial commissions have put forward volumes of recommendations for strategies they believe will ensure the sustainability of the industry and better equip it to achieve improved international standards of health for our citizens. Where to from here? This paper reflects on this pivotal question, drawing from recommendations put forward by selected national and provincial commissions. The discussion addresses (1) federal/provincial/national relations; (2) fiscal sustainability; (3) accountabilities and health information; (4) primary care reform; (5) extended coverage of insured services; and (6) customer expectations. http://www.longwoods.com/product.php?productid=17120&cat=343 261AB7AA-968A-406C-991F-7216BB854C57 Sat, 15 Feb 2003 14:15:38 -0400 England is the world leader in moving the health information agenda forward at a national level. Many healthcare organizations around the world have more advanced information technology applications, but in terms of a national strategy, plan and commitment, the English are second to none. We can learn the most from the English in the areas of planning, funding, primary care, the Internet, standards, and electronic records. http://www.longwoods.com/product.php?productid=16206 61F92637-FF96-44F5-894B-1B9F5483CF51 Tue, 15 May 2001 14:13:30 -0400 Shared mental healthcare, defined as a process of collaboration between psychiatrist and primary care physician, has recently been pushed into the forefront through a position statement by the College of Family Physicians of Canada and the Canadian Psychiatric Association. However, the question of how to foster and implement such a process has not been addressed. We set out to answer this question. In an examination of an innovative service delivery program at North York General Hospital (NYGH), in North York Ontario, between psychiatry and primary care, we compared and contrasted our experiences with traditional consultation models. We also performed a review of the literature, broadening our scope to include the areas of anthropology/sociology, relational theory, education and business management. http://www.longwoods.com/product.php?productid=16725&cat=313 0B09DB5A-421E-4829-9C58-83161810004A Wed, 15 Dec 1999 14:11:37 -0400 Although this article could be applied to physicians across all specialties, our focus is on the engagement of Canadian primary care physicians in the use of Electronic Medical Record (EMR) systems. The objective of our article is to suggest a methodology that can be followed in order to assist in the physician's adoption of EMR. It would be presumptuous to state that we have all the answers when it comes to an issue as complex as the adoption of EMR by physicians; however, there are broad principles that can provide an organized and logical approach towards the implementation of these systems. http://www.longwoods.com/product.php?productid=16188&cat=257 EC8ACFE8-5116-43AF-911A-59B8E0CF0EF1 Tue, 28 Aug 2007 14:10:34 -0400 We begin this paper by highlighting some of the facts behind this inconvenient truth. We then review and provide examples of several best practices in CDPM. We suggest that these best practices provide the foundation for a national CDPM strategy and argue that the FPT mandate for wait times be expanded to encompass CDPM and result in "care guarantees." We conclude with a high-level preliminary analysis of costs and benefits of this strategy to transform CDPM in Canada. http://www.longwoods.com/product.php?productid=18992&cat=495 6C08EECC-9218-4A59-978E-E52867D8B654 Fri, 15 Jun 2007 14:09:34 -0400 In this issue, Pineault and colleagues (2006) report on a Quebec-based research collective, a process aimed at rapidly synthesizing results from ongoing or recently completed research and releasing them to decision-makers. The process outlined differs markedly from Cochrane-based formal systematic reviews, and the authors claim a number of benefits that make the results more relevant to decision-makers, including enhanced timeliness of results, increased triangulation among emerging research findings, and more in-depth understanding of the impact of contextual environments on research results. This approach may offer opportunities to both advance and enrich existing synthesis tools. The research community should learn more from this process. http://www.longwoods.com/product.php?productid=18246&cat=446 DC146E66-7C06-4D05-9423-73F16ACE2B84 Mon, 15 May 2006 14:08:37 -0400 Leatt, Pink and Guerriere provide a comprehensive paper that describes the nature of integrated healthcare, the rationale for it, the Canadian state of the art with respect to integrated healthcare, lessons learned and where we go from here. The reader might conclude from this paper that an integrated delivery system (IDS) is the natural next step that we have to undertake in developing the future of the Canadian healthcare system. The authors of this commentary challenge the supposition that an IDS is the next phase of our health system evolution. Furthermore, we raise some questions regarding the value that IDSs in Canada would provide beyond what could already be attained under regional health authorities (RHAs).We will argue that the next decade needs to be a period of information integration, and of primary health care reform, where organizational structure and corporate decision-making are reformed to reflect partnerships between healthcare providers and managers. http://www.longwoods.com/product.php?productid=17220 62849EC9-CDCC-417E-A3CB-414AF0FD087D Wed, 15 Mar 2000 13:55:04 -0400 Building upon some key discussion points in the Brown et al. paper, we explore the key elements driving performance measurement and quality improvement strategies in the Veterans Affairs healthcare system in the United States and the national primary-care trusts in England, both of which offer important insights into understanding the factors that affect rapid, large-scale change. In the context of these "extreme makeover" examples, our commentary discusses the currently evolving performance measurement culture in the Canadian primary healthcare reform setting. We specifically highlight the experiences in Saskatchewan, a province that has been acknowledged recently by CIHI as a leader in primary healthcare evaluation. Although Saskatchewan has attempted to overcome the methodological and conceptual challenges in evaluation that Brown et al. outline in their paper, a stable performance measurement culture has yet to emerge and systematically utilize performance measurement reports for purposes of facilitating change. Although there is a growing recognition that measures by themselves will not be able to spur improvement, it is yet to be seen to what extent these performance reports can speak compellingly to policymakers, primary healthcare providers and managers to serve as catalysts to a major leap forward in overall quality improvement. http://www.longwoods.com/product.php?productid=17750&cat=406 A9C6D337-AC91-4050-85A2-6792C293BAD7 Tue, 15 Nov 2005 13:54:15 -0400 The purpose of this descriptive study was to examine the implementation of the nurse practitioner role in primary care settings. Nurse practitioners who were certified by the College of Nurses of Ontario as Extended Class were surveyed. The questionnaire inquired about the nurse practitioners' professional characteristics, employment settings, scope of practice, practice pattern, and satisfaction with their role. The majority of the 166 respondents working as nurse practitioners were Baccalaureate prepared; has been in the role for a relatively short period of time; were employed in community health centers; and were able to practice to their full potential, within the expanded scope of practice. They saw patients who are primarily healthy or presenting with acute minor illness, and provided care with an emphasis on wellness. They were satisfied with their role. Directions for future research are presented. http://www.longwoods.com/product.php?productid=16302&cat=269 8DF73C88-53E7-4C57-B399-DB703D1D8D58 Fri, 15 Sep 2000 13:53:38 -0400 Lewis and Kouri provide an excellent review of the status of regionalization across Canada. Their paper examines the potential benefits of regionalization and the factors increasing or decreasing potential impact, the state of regionalization in each province and regionalization's contribution to health reforms. Of the six goals mentioned in the potential benefits of regionalization, four focus on effectiveness and efficiency and two on accountability and public input. The political nature of healthcare is mentioned often, and the negative impact of end-runs to political authority if patients or providers are not satisfied is underlined. http://www.longwoods.com/product.php?productid=16838&cat=349 31A7B0BA-BE49-4F26-85AA-554C06BB924C Thu, 15 Jul 2004 13:52:48 -0400 Healthcare issues continue to occupy a major place on the public agenda in 1997. This is not surprising given the high value that Canadians place on high-quality, comprehensive and accessible healthcare. http://www.longwoods.com/product.php?productid=16596&cat=305 09783B5D-5225-498D-A40C-9D602FC6046A Mon, 15 Dec 1997 13:51:45 -0400 A closer relationship between Academic Health Sciences Centres and governments will benefit the overall agenda of health system reform, contribute to the focus and immediacy of the future vision of AHSCs and give governments a deep pool of expertise from which to draw in facing significant policy challenges. Jointly established priorities in health between federal, provincial and territorial governments correspond closely to the interests and expertise of AHSCs. A mutual commitment to evidence as the basis for making decisions in health policy, in education, and in patient care, will find expression in closer interaction between these two institutions. http://www.longwoods.com/product.php?productid=17209&cat=338 38B77655-1E3A-468F-95C5-C4B194892383 Fri, 15 Feb 2002 13:50:53 -0400 Physician reimbursement in Canada has been dominated by pay-for-volume which leads to high utilization. The concern is that this does not promote attention to quality issues that are known to affect health services. However, the evidence that pay-for-quality works is weak, despite the logic of the approach. Also, pay-for-quality methods that seem to work in primary care may not be appropriate in specialties such as surgery. Canada offers opportunities to assess the effect of pay-for-performance in several areas. Developing primary care networks are attractive locations to study the effect of pay-for-quality, perhaps even in a randomized trial. Specialized high-volume surgical programs, such as the Alberta arthroplasty pilot project, might be study of pay-for-participation, in a partnership of providers and sponsors. http://www.longwoods.com/product.php?productid=18435 F916A0CE-AD02-4103-A259-EAC85A7620AA Sun, 15 Oct 2006 13:49:07 -0400 Anne Rogers and her colleagues from the National Primary Care Research and Development Center at the University of Manchester, England, present a somewhat unusual perspective in Demanding Patients by focusing on patients and their families and their experiences with the National Health Services in Britain. As a result, the outstanding contribution of the book is the authors' analysis of the meaning of "demand" for health services as opposed to the concept of healthcare "need." The implications of this analysis have relevance for healthcare providers across the spectrum. http://www.longwoods.com/product.php?productid=16714&cat=314 84720C58-9616-4675-B0F2-D6B459FC4E06 Sat, 15 Mar 2003 13:48:23 -0400 Primary care is widely acknowledged by politicians, pundits, policy makers and healthcare providers to be the foundation of Canada's healthcare system. A recent Commonwealth Fund survey of primary care physicians in seven countries - Australia, Canada, Germany, New Zealand, the Netherlands, the United Kingdom and the United States - has vividly illustrated the sorry state of that foundation's underpinnings (Shoen et al. 2006). The survey examined information technology, clinical information systems, care coordination, use of teams, participation in quality initiatives and financial incentives. http://www.longwoods.com/product.php?productid=18837&cat=485 C555AF1D-D51C-4EFC-A3A9-00D4C6A0463C Sun, 15 Apr 2007 13:46:47 -0400 Baker and Norton offer an analysis for tackling medical error that, while not wrong, is very traditional in the policy solutions it recommends. The research priority should not be better measurement of error, but instead increased international cooperation to find solutions to existing problems. For instance, rather than developing new databases for mapping errors, existing databases should be utilized to create a learning culture that addresses existing problems. Within this, understanding errors in primary care is essential, and thus research should not restrict the study of errors to clinical situations. Changing the culture of medicine is difficult. A model of governance that emphasizes quality and accountability may be a mechanism for developing a culture within medicine that reduces error and improves patient safety. http://www.longwoods.com/product.php?productid=16927 3539F04B-4DCA-41F8-9FEC-71ACAED67014 Sun, 15 Apr 2001 13:46:04 -0400 Federal policies and state legislation in the United States encourage the use of physician assistants (PAs) and nurse practitioners (NPs) in primary care, although the nature of their work has not been fully analyzed. This article analyzes primary care physician office-encounter data from the 1995-1999 National Ambulatory Medical Care Surveys. About one-quarter of primary care office-based physicians used PAs and/or NPs for an average of 11% of visits. The mean age of patients seen by physicians was greater than that for PAs or NPs. NPs provided counselling/education during a higher proportion of visits than did PAs or physicians. Overall, this study suggests that PAs and NPs are providing primary care in a way that is similar to physician care. http://www.longwoods.com/product.php?productid=16693&cat=320 26CA0C47-022D-45D6-9AE6-5698031D6B9B Sat, 15 Sep 2001 13:44:58 -0400 Although boasting may be foreign to our character, we Canadians can be proud of many things. Central among them is our decision to share collectively the financial risks of disease and injury that before medicare were borne alone by those affected, their families or those who would extend them charity. But before we get too puffed up, listen to Tommy Douglas in 1982. "When we began to plan medicare, we pointed out that it would be in two phases. The first phase would be to remove the financial barrier between those giving the service and those receiving it. The second phase would be to reorganize and revamp the delivery system - and, of course, that's the big item. It's the big thing we haven't done yet" (Decter 1994). http://www.longwoods.com/product.php?productid=16692&cat=320 C47A13E1-C813-4729-B2B9-93BAAF04F7B2 Sat, 15 Sep 2001 13:44:24 -0400 In the Canadian context, primary healthcare providers include physicians, nurses, nurse practitioners, mental health workers, dieticians, pharmacists, midwives and others. Some PHC organizations include public health, social workers, chiropractors, physiotherapists and acupuncturists. Increasing numbers of the population are utilizing naturopathy, homeopathy, traditional Chinese medicine, massage, ayurvedic medicine and other disciplines for PHC. http://www.longwoods.com/product.php?productid=16697&cat=320 FCC2DB77-FFB9-4F67-A45D-133E1DB44C13 Sat, 15 Sep 2001 13:43:34 -0400 The structure of the Canadian healthcare system, particularly in Ontario, has remained remarkably stable over the past 25 years. No other private sector industry employing hundreds of thousands of people, spending tens of billions of dollars annually and serving millions of consumers every day has survived for 30 years without the need to reinvent itself in quite fundamental ways. How then has the healthcare sector in Canada avoided the pressure to "reinvent itself?" http://www.longwoods.com/product.php?productid=17223 8A7211C9-ABC6-4C7A-B98A-E13D743B6E31 Wed, 15 Mar 2000 13:42:45 -0400 Developing a culture to sustain Ontario's Wait Time Strategy is a complex process that can benefit from a thorough analysis of the Strategy's strengths and weaknesses. The commentaries have made a significant contribution to this endeavour, by directly reflecting on the Strategy as well as offering relevant experiences as food for thought. We thank the authors for reviewing the lead paper and for generously providing their thoughtful and useful commentaries. Without a doubt, Ontario's Strategy has benefited enormously from the experiences of individuals such as these, as well as other provinces and countries that have already launched access and wait time initiatives. As Collins-Nakai et al. note, "in a relatively short period of time, Ontario has moved from being a laggard to being a leader in the field of wait time management." http://www.longwoods.com/product.php?productid=18610&cat=478 EB577D0E-B57F-4993-9212-DE2B2675E670 Mon, 15 Jan 2007 13:41:24 -0400 Little is known about the extent to which adverse events compromise the quality of community care. This article describes the results of a consensus workshop in which 31 healthcare professionals were asked to identify and rank common adverse events and important research questions relating to community care. Workshop participants were decision-makers and healthcare providers with areas of expertise that included community and home care; acute and primary care; patient safety; medical errors; and health services policy, administration and research. Results include prioritized lists of adverse events, research questions and contributing factors associated with adverse events. Further study should be aimed at defining and implementing research priorities and developing standardized definitions of common adverse events associated with community care. http://www.longwoods.com/product.php?productid=18926&cat=492 857DE692-DD19-4934-BD24-CFFBC1721CBF Tue, 15 May 2007 13:39:36 -0400 The Ontario healthcare sector can be described as an intricate system of bureaucratic processes where fragmentation and duplication are endemic to its structure. The sector lacks an overarching vision that articulates a clear direction; roles, responsibilities and accountabilities are not adequately defined or aligned and there are few formal relationships or clearly established expectation levels between the different components of the system. http://www.longwoods.com/product.php?productid=17940 4C2EA0B3-BC74-4EBD-BD43-8C08CC93F681 Mon, 15 Dec 2003 12:15:05 -0400 This international literature review did not find substantial evidence to support the development of hospital at home services as a cheaper substitute for in-patient care within health care systems with developed primary care services. On the other hand, there was no evidence found to recommend discontinuation of existing hospital at home programs for patients with terminal illness, elderly medical patients, or following elective surgery. http://www.longwoods.com/product.php?productid=17944 3E960B75-3460-4F50-B8E4-8FC8688C8358 Mon, 15 May 2006 12:14:08 -0400 In many Canadian rural and urban areas, the role of the family physician within hospitals has gradually diminished over the past 30 years. In Canada, approximately 34.5% of family physicians provide in-hospital care for their patients (College of Family Physicians of Canada 2003). This corresponds with 29% of Ontario respondents (College of Family Physicians of Canada 2003). While the availability of family physicians to meet demands to provide hospital in-patient care is one main issue, choosing a more flexible lifestyle and increasingly busy community practices are also reasons that keep family physicians from this aspect of care. Family physicians define their individual scope of practice on the basis of community needs and their own interests in medicine (Rosser 2002). This may not include hospital in-patient care. If provision of this care is the only formal connection between family physicians and hospitals, the opportunity for rich partnerships, community leadership and innovative activity will be lost. Whether or not family physicians feel that their methods of practice can include participating in hospital in-patient care, community-based family physicians and hospitals would benefit from mutual support and collaboration in our changing healthcare system. Hospitals, as social pillars and hubs of medical activity, can be a great influence and supporter of family physicians and primary healthcare, which will in turn improve the health of their communities. This paper will discuss general linkages between family physicians and hospitals and the development of a specific program to enhance these linkages created at a large community hospital in Ontario. http://www.longwoods.com/product.php?productid=18177&cat=443 150C89DC-4881-4632-B55D-D506AFEDB6BA Mon, 15 May 2006 12:13:11 -0400 The Veterans Health Administration in the United States has wrought a miracle. After 10 years of transformation and strategic reinvestment, their healthcare system has become more community-oriented, provides more services overall and costs less per patient. In this commentary, the systems of the Veterans Health Administration and of Canada are compared and contrasted with regard to three key issues: community orientation, patient-centredness and the role of information technology. http://www.longwoods.com/product.php?productid=17387&cat=374 1A701A93-9C56-44CC-B3AF-25399AFFDFA9 Sun, 15 May 2005 12:08:31 -0400 It is encouraging to see that the first phase of planning by the LHINs has been done with a lot of enthusiasm and collaboration. The task of integrating healthcare services is not an easy one, and it is made more complicated in Ontario as the key areas that must be well interconnected lie outside the mandate of the LHINs. This being said, I will try to add value to the present article by referring to the integrated planning that is being carried out by the Health and Social Agencies in Quebec. http://www.longwoods.com/product.php?productid=18939&cat=493 A6A8B01E-A0A7-4A30-A388-25B16AE7A58C Tue, 15 May 2007 12:07:21 -0400 In the May 4, 1999 issue of the Medical Post I hypothesized that the prevailing debate around primary care reform (PCR) in Ontario raised two questions: Is PCR part of an overall strategy to "bureaucratize" medicine by the bureaucratic/pseudo-academic conspiracy that manages health? Or is PCR a Machiavellian plot by the OMA to preserve the status quo for yet another three years? http://www.longwoods.com/product.php?productid=16523&cat=321 9DC10E7A-9F4E-4B06-9022-73158A4E8076 Sat, 15 Dec 2001 12:05:18 -0400 Direct-to-consumer advertising is but one example of a process called disintermediation that is directly affecting primary-care physicians and their patients. This paper examines the trends and the actors involved in disintermediation, which threatens the traditional patient-physician relationship. The paper outlines the social forces behind these threats and illustrates the resulting challenges and opportunities. A rationale and strategies are presented to rebuild, maintain and strengthen the patient-physician relationship in an era of growing disintermediation and anticipated advancements in cost-effective office-based information systems. Primary care - as we know it - is under siege from a number of trends in healthcare delivery, resulting in loss of physician autonomy, disrupted continuity of care and potential erosion of professional values (Rastegar 2004; Future of Family Medicine Project Leadership Committee 2004). The halcyon days of medicine as a craft guild with a monopoly on (1) technical knowledge and (2) the means of implementation, reached its zenith in the mid-twentieth century and has been under pressure ever since (Starr 1982; Schlesinger 2002). While this is a trend within the US health system, it is likely to affect other delivery systems in the years ahead. http://www.longwoods.com/product.php?productid=17097&cat=357 64ADD457-6634-4E93-AB3E-9EED2CF5ADFD Tue, 15 Mar 2005 12:04:38 -0400 In previous issues, we have been exposed to what the Danes have been able to accomplish with physician office computing and the electronic medical record (EMR). Here is another success story from another small country that has managed to maximize physician use of computers and the use of electronic medical records to improve the health status of its population. http://www.longwoods.com/product.php?productid=16154&cat=262 E41641E2-CC00-4E53-8044-C69B7E81243A Fri, 15 Aug 2003 12:03:54 -0400 A principal goal in enhancing primary care in Canada is to increase emphasis on health promotion, disease prevention and the management of chronic diseases in the primary care setting. To achieve this goal in Nova Scotia, collaborative practice teams with a nurse practitioner and at least one physician were established, and both alternative funding arrangements for physicians and an information system were implemented. This study reports on the impact of this primary healthcare reform initiative on the quality of process-of-care, self-care and proxy measures for specific health outcomes for patients with diabetes and hypertension. http://www.longwoods.com/product.php?productid=18105 8FEB5198-F78B-419C-876D-73FEEE952528 Wed, 15 Mar 2006 12:02:38 -0400 Initiatives aimed at reducing wait times for surgical and diagnostic procedures and comprehensive chronic disease management programs focus, respectively, on the supply and demand aspects of access to healthcare. Addressing either in isolation can have a salutary health effect for segments of the population and produce system improvement. Approaching healthcare access issues even more broadly, in the context of population health and with a patient-centred perspective, carries the promise of sustainability, the potential for superior health outcomes across a continuum of patient care and the possibility of enhanced system competency through true integration of multiple sectors. A model for comprehensive access to health services includes a plan for a network of primary care providers, appropriate capacity and flow efficiency for the provision of unplanned (emergency) services, operationalization of wait times initiatives to sustain planned services (most surgeries and diagnostic procedures) and a strategy for decreasing demand for care by engaging primary and community care capabilities and a robust chronic disease management strategy. http://www.longwoods.com/product.php?productid=18995&cat=495 F8467627-F5B5-4F89-AE02-7203AE2BE622 Fri, 15 Jun 2007 12:02:05 -0400 Capital Health in Edmonton, Alberta, implemented a system-wide chronic disease management model to support people with chronic disease and their primary care physicians. Groups of family physicians, in partnership with the health region, developed primary care networks to provide services that are customized to meet the priorities of the local community. Management of chronic disease is a cornerstone service, and diabetes management is the most fully developed program. Key to its success are standardized protocols, consistent follow-up and patient education by trained primary care nurses. This model will be used as a template for the management of other chronic diseases. http://www.longwoods.com/product.php?productid=18927 67F3EAF1-C755-4D0D-AF3A-60A8A31340A3 Tue, 15 May 2007 12:01:32 -0400 Both the Romanow and Kirby reports urge provinces to reform the delivery of primary medical care. Romanow recommends billions of new federal dollars to continue and extend recent initiatives. Kirby proposes very little new funding but recommends that regional health authorities assume much of the responsibility for paying physicians. Only the Kirby approach will lead to comprehensive primary care reform, and only if meaningful accountability is introduced into the business relationship between payers and physicians. http://www.longwoods.com/product.php?productid=17123&cat=343 E4FD5E56-075D-4A47-94B5-7FED83F4E38C Sat, 15 Feb 2003 11:59:46 -0400 Can we improve access in primary care without compromising the quality of care? The purpose of this article is to demonstrate how timely access to primary care can be achieved without compromising the quality of the care being delivered. The Veterans Health Administration (VHA) is an integrated healthcare system that has implemented change to improve primary care access to the veterans it serves, while not only maintaining but also actually improving the quality of care. http://www.longwoods.com/product.php?productid=18108&cat=436 281767C3-1700-44B0-9134-2731F4D485A9 Wed, 15 Mar 2006 11:59:09 -0400 A new telephone health advice service implemented in September 2000 is integral to the Capital Health (Edmonton) Region's strategy to build a comprehensive approach to primary healthcare. Capital Health Link operates 24 hours a day, seven days a week and was the first comprehensive nurse-based health advice phone line in Alberta. Callers to Capital Health Link ("Link") can talk to experienced and specially trained registered nurses for health advice, information about programs and services, and to register in selected Capital Health programs. Satisfaction ratings have been high from the outset as Link supports people to manage their health through informed choice and decision-making. Evaluation results indicate the service is helping the public access the most appropriate level of care. This has led to a reduction in the number of visits to emergency departments, drop-in medical clinics and family physicians' offices. Innovations for the future include linkages with a new electronic health record system and an expanded role in chronic disease management that will further support an integrated primary care strategy for the region. http://www.longwoods.com/product.php?productid=16639 468BD451-90BB-4353-82F9-3A7DB4A7B5B1 Sun, 15 Dec 2002 11:55:35 -0400 The essence of primary care reform is the creation of a formal relationship between a physician provider and a patient. The idea is that a patient will sign on with a particular provider who will then take medical responsibility for accessibility, quality of care and continuity of care. However, various aspects of physician remuneration, specifically negation, are perceived as a disincentive for physicians. Negation refers to the deduction of a specified amount from the contracted physician if a patient sees another family physician or general practitioner not associated with their practice. How often and to what extent patients see different family physicians or general practitioners (FPs/GPs) becomes an important question in the debate. http://www.longwoods.com/product.php?productid=16531&cat=320 188A3EBD-D30C-4EF9-9CD1-293259F3D370 Sat, 15 Sep 2001 11:55:08 -0400 This commentary reviews the content of the lead papers through the lens of primary healthcare renewal (PHCR). Although PHCR has been on the national agenda for decades, only since the turn of the century has real progress been made with emerging new practice models based on inter-professional team care. While much is expected, relatively little is known of the function and effectiveness of such teams in Canada. As well, information regarding healthy workplaces has focused on individual professional groups rather than an inter-professional workforce. Much of the knowledge currently available regarding team effectiveness and healthy workplaces comes from the hospital sector and may not be completely transferable. The work of the Interprofessional Education for Collaborative Patient-Centred Practice initiative and the results of the Health Transition Fund and Primary Health Care Transition Fund are additional key sources of research and knowledge transfer to guide the education, function and evaluation of inter-professional teamwork in these new primary healthcare practice models. http://www.longwoods.com/product.php?productid=18685&cat=467 2A9926A4-B8AC-44B2-8DB6-05250D0A7600 Mon, 15 Jan 2007 11:54:42 -0400 In contemplating this column on primary care reform, many things came to mind. First was an anecdote from a friend of mine who comes from a small town where people frequently greet each other with the salutation, "What do you know for sure?" The standard response is, "Pretty quiet." I think that anecdote probably best sums up how the public generally responds to primary care reform at the present time. http://www.longwoods.com/product.php?productid=16530&cat=320 7AF54F32-169C-4789-9184-87952663992E Sat, 15 Sep 2001 11:54:02 -0400 In 1998 health care legislation in Ontario changed and allowed Primary Health Care Nurse Practitioners the possibility to expand their practice. At a rehabilitation centre, where spinal cord injured patients would seek primary health care services, a new amalgamated role was implemented to meet those needs. This article will described the advanced practice role that was developed, define the scope of practice, and demonstrate an innovative approach to service delivery. The role serves as a concrete link between primary health care services and tertiary care patients needs. http://www.longwoods.com/product.php?productid=16294&cat=266 EBC382B4-91E5-457B-8B46-3DB84F59F3D4 Mon, 15 Nov 1999 11:53:29 -0400 Primary healthcare offers significant benefits to Canadians and to the healthcare system as a whole. The Taber Integrated Primary Healthcare Project (TIPHP) was a three-year primary healthcare renewal initiative involving rural physicians and the Chinook Health Region in Taber, Alberta, Canada. The goal of the project was to improve healthcare services delivery through integration of the services provided by the physician group and the health region in one rural community. Four main enablers emerged as fundamental to the integration process: community assessment and shared planning; evidence-based, interdisciplinary care; an integrated electronic information system; and investment in processes and structures that support change. The outcome of the project has been the implementation of a new model of healthcare delivery that embraces an integrated collaborative team approach in delivering population-based, primary healthcare. Importantly, the TIPHP has influenced regional healthcare policy related to primary healthcare renewal strategies and partnerships. http://www.longwoods.com/product.php?productid=19175&cat=499 A6A66280-A9D4-4388-9897-565DCEA54151 Wed, 15 Aug 2007 11:52:58 -0400 The quality gap in the management of chronic disease is an issue which must be addressed if we are to achieve sustainability of our health system and optimal health outcomes for Canadians. The delivery of quality care needs to be a fundamental expectation of providers, professional regulators, institutional leaders and senior government leaders. Success in the arena of quality improvement comes from clarity of accountability, "obsessive" tracking and action on key performance indicators, and results-based teamwork. Strong leadership, identification of shared priorities across the country, full transparency, and an engaged public are all key to moving ahead in this critical area of Canadian healthcare. http://www.longwoods.com/product.php?productid=19000&cat=495 699C812E-6FB9-40F1-8E0D-55DCAAD6637F Fri, 15 Jun 2007 11:52:26 -0400 The Minimizing Errors Maximizing Outcomes Study is designed to examine the effect of workplace conditions on quality of care and medical errors. In the first phase of the study, patients were asked to "tell their stories" via focus groups. http://www.longwoods.com/product.php?productid=17230&cat=371 66AE23A0-0093-44EA-80A8-6DEDB032ECEA Tue, 15 Mar 2005 11:51:47 -0400 This response to the essay is a "view from the trenches" by two doctors who have worked over 23 years at the Group Health Centre in Sault Ste. Marie, Ontario. We would agree wholeheartedly that reducing wait times for selected procedures will not transform our health system, although they are a start that does provide improved quality of life for a relatively small number of people. We have struggled with the care gap between known best practices and the reality of care provided, from the perspectives of both prevention and chronic disease management. This has resulted in an acute awareness of the need for an across-the-system, "bottom-up" approach to the prevention of disease and management of healthcare. Limited resources must be carefully leveraged in innovative ways if we are to eliminate this care gap, decrease morbidity and minimize expensive "rescue" procedures that make our system increasingly unaffordable. http://www.longwoods.com/product.php?productid=18993&cat=495 CF99A870-2512-419E-A57F-DF5DB1F29A6E Fri, 15 Jun 2007 11:41:56 -0400 How primary care physicians are remunerated is an important component of healthcare reform debates in Canada. This paper contributes to the policy debate by drawing together the theoretical insights gained from existing economic theory and evidence on how payment schemes affect physicians' behaviour. Several policy implications for the efficient and effective remuneration of physicians emerge from the analysis, as do directions for future research. http://www.longwoods.com/product.php?productid=18547 BFD06BED-3BBB-4802-986B-52558FDA7A64 Fri, 15 Dec 2006 11:41:07 -0400 I read, with interest, the paper by Rosser and Kasperski. I was struck by how similar and applicable the problems and issues identified for family physicians are to those pharmacists face today in Canada's health system. There is a need for a coordinated and systematic approach to address infrastructure support for all primary-care providers. In this companion article, I will provide evidence to support the Ontario College of Family Physicians' position on strengthening family physicians' abilities to provide excellent primary care. In addition, I will make a case for support of greater involvement of pharmacists in community- based primary-care teams. http://www.longwoods.com/product.php?productid=17450&cat=332 3A760700-3A90-41B3-A217-FD999668BF6B Wed, 15 Dec 1999 11:40:32 -0400 The paper by Rosser and Kasperski represents the positions of the Ontario College of Family Physicians. Their rostering proposal has been taken up by the Ministry of Health and the Ontario Medical Association. My comments will be largely on the ideas as seen in the light of their planned implementation. http://www.longwoods.com/product.php?productid=17228&cat=332 5853FA1F-76A2-4FD8-8659-15B8CE20DBBD Wed, 15 Dec 1999 11:40:09 -0400 In "Organizing Primary Care for an Integrated System" Rosser and Kasperski propose changing the way family physicians practice to address deficiencies in the current primary-care delivery system in Canada. These deficiencies include... http://www.longwoods.com/product.php?productid=17449&cat=332 5B36CCBC-65D6-4483-9DE4-A65E4908E319 Wed, 15 Dec 1999 11:39:46 -0400 It is distressing to an observer from south of Canada to read the paper from the Ontario College of Family Physicians (Rosser and Kasperski). It indicates disruption and confusion within an admirable healthcare system - a system with a reputation of getting things right when it comes to family practice and primary care. Apparently, all is not well. http://www.longwoods.com/product.php?productid=17448&cat=332 8E513F03-2847-4377-8DF5-F7DB633292DB Wed, 15 Dec 1999 11:39:16 -0400 I ought to start by giving my credentials for writing this commentary. I have a marked aversion to outsiders with limited first-hand experience telling me about the British National Health Service. This is especially so when their questions and comments raise issues that make me feel uncomfortable. My credentials are all those that I normally abhor. I spent a week in Toronto in May 1999. I visited the medical school and three teaching hospitals. I spoke with many family physicians and some "patients." I interpreted what I heard in the light of my experience and prejudices. Some of the latter will appear in this commentary. http://www.longwoods.com/product.php?productid=17447&cat=332 A6DB60D5-8621-4EEF-87CE-8E8B0588246A Wed, 15 Dec 1999 11:38:46 -0400 As a long-time advocate of primarycare reform and a participant in the present implementation of the Ontario Primary Care Reform (PCR) pilot projects, I am sympathetic to the perspectives of Rosser and Kasperski. The model for reform that they propose has added fuel to the debate on PCR initiatives. However, the future strategic direction for primary care will be determined at the conclusion of the implementation and testing period for the pilot sites and after evaluating models in other provincial jurisdictions. Although the investment of resources over the past four years by government and the profession has clearly been significant, the methodical planning and breadth of consultation and review on many issues may not be apparent to observers. http://www.longwoods.com/product.php?productid=17446&cat=332 9F59FD19-9148-44FE-AFBA-D840C179BC98 Wed, 15 Dec 1999 11:38:21 -0400 The article by Rosser and Kasperski, "Organizing Primary Care for an Integrated System," provides an important stimulus for examining issues surrounding healthcare reform in Canada. As the "Guidelines for Commentary" of HealthcarePapers indicate, healthy debate can foster "constructive change." The Canadian Nurses Association welcomes the opportunity to engage in such a debate and it is within this spirit that we offer a number of challenges, both at a theoretical/conceptual as well as a factual level, to the ideas presented by Rosser and Kasperski. Although there are a number of points in the article that warrant attention, this commentary will address only a selected few. http://www.longwoods.com/product.php?productid=17227&cat=332 FC47C584-D15D-4C75-966C-A8ECB521166C Tue, 28 Aug 2007 11:37:57 -0400 Rosser and Kasperski build upon and consolidate several earlier reports to put forward a "bottom-up" model for the integration of health services for Ontario that establishes the family physician as the focal point of entry to the healthcare system. The essential features of this model are as follows... http://www.longwoods.com/product.php?productid=17445&cat=332 D5A5DF7E-F1C4-4DEC-AFCF-436F0D7AC701 Wed, 15 Dec 1999 11:37:23 -0400 During the past decade, many changes have occurred in the Canadian healthcare delivery system but few, if any, of these changes have specifically addressed the role of the family physician. This paper proposes a number of changes to the infrastructure that supports the role of family physicians, including family physician accountability for delivering twenty-four-hour, seven-days-per-week services to a defined population of patients. The infrastructure needed to support family physicians as the coordinators of care across the continuum of healthcare services includes family-medicine group practices or practice networks linked by electronic networks. Family medicine is the key to health-system integration. Systems to integrate family medicine with other primary healthcare providers and with secondary- and tertiary-care systems are proposed, as well as quality-improvement systems for family medicine. Implementation of these strategies is essential in the transition to a fully integrated healthcare system and is an important part of making the Canadian system of healthcare sustainable. http://www.longwoods.com/product.php?productid=17444&cat=332 C310AB37-3EF5-4FC6-81D7-B47449C9F9FB Wed, 15 Dec 1999 11:36:50 -0400 In April 2004, the United Kingdom introduced a new General Medical Services (GMS) contract that provided new governance and incentive arrangements for general practice. In particular, the new Quality and Outcomes Framework is a points-based system that sets targets for clinical, organizational and practice-related standards with financial payments for achieving set levels of performance. This paper describes the new contract arrangements and their impact on general practice - focusing on the experience in England, where wider policy changes are also having an important impact on practices - and drawing out potential lessons that will be of interest to Canadian practitioners and policy makers. http://www.longwoods.com/product.php?productid=18873 7971C812-808F-4C61-9B4D-6C0092EF6F84 Tue, 15 May 2007 11:36:12 -0400 Improved health and social outcomes would be possible with better coordination and collaboration between public health and primary care. The purpose of this study is to identify linkages between these health sectors with the aim of informing a forward-looking policy approach to integrate public health functions in primary care. http://www.longwoods.com/product.php?productid=19144 D2CE794B-F587-4949-8445-A147A62CE68B Wed, 15 Aug 2007 11:35:29 -0400 This article follows on from part 1 on the history of medical computing in Alberta and Denmark (Protti et al. 2007). It provides background to the driving forces for automation in primary care physician offices in Denmark and Alberta. It also summarizes the functionality of electronic medical records (EMRs) in both jurisdictions and compares the status of primary care physician office computing in Alberta to that of Denmark. The scoring system used is based on data gathered from publicly available sources on the Internet, databases held by the respective jurisdictional programs (MedCom and Physician Office System Program [POSP]) and interviews with individuals involved in the deployment of systems. The article offers a novel method of scoring the adoption of computerized advances in the office setting that may be applicable to other health jurisdictions, at country, state or provincial levels. http://www.longwoods.com/product.php?productid=18936&cat=487 38EAB877-262D-436F-AF4B-148143C34006 Tue, 15 May 2007 11:14:46 -0400