Essays October 2016

Open Letters

A Perfect Storm: Get Ready for a Paradigm Shift in Health Services and Policy Research

Robyn Tamblyn

This letter is part of series of Open Letters from Canadian leaders in Healthcare. To see the complete series please click here.  

There are major forces, worldwide, that are shifting the way in which health systems will operate, how health services will be delivered, and the role that health services and policy research will play in this emerging frontier.

First, there is the crushing, and unsustainable escalation in health system costs, exceeding $3.0 trillion in the United States in 2014[i], and $219 billion in Canada in 2015[ii], accounting for 17.5%[iii] of the GDP in the US and 10.9%[iv] in Canada. The escalation in costs is driven by greater consumption of medical technology, including diagnostic imaging and pharmaceuticals, and by increasing prices of these services and products[v]. These financial pressures provide impetus for transformational change and an increasing pull for cutting edge research that can pioneer innovations in health system delivery which can lower costs, improve patient experience, quality of care, and the health of the population.

Second, the greying of the baby boom generation will create a very different kind of consumer of healthcare services. Both the sheer number, estimated to be 20.1%[vi] of the population in 2024, and the unprecedented level of education and wealth of this cohort will create a demand for patient empowerment and partnership in healthcare and in engagement in healthier lifestyles. Indeed, it is not healthcare alone that is being transformed by the demands of this generation but “the silver economy” is emerging to cater to the needs of the “new gen senior.”[vii]

Third, we are finally tipping point on the innovation adoption curve for incorporating health information technologies in healthcare. Widespread digitization of health services, coupled with an explosion in consumer-oriented wearable devices, point-of-care diagnostics, and social media has created the opportunity to deliver services in a very different way—e-consults, tele-homecare, self-care robots, smart homes are all leveraging advances in technology re-purposed to fill needed gaps in providing more accessible, equitable consumer-oriented services. Indeed developing countries have accelerated the pace of innovation in mobile health solutions, using high volume low cost production of smart phones to bypass the costly land-line infrastructure that is gradually being abandoned in the developed world[viii]. Not only will services be delivered differently, so will access to providers, likely spanning national boundaries and demanding changes in our traditional approach to professional regulation and reimbursement. Can you imagine a “trip-advisor” for healthcare organizations and professionals, where those that deliver better outcomes and experience, are compensated for better value?

Fourth, and perhaps the most powerful trend is the emergence and power of “big data.” With the use of digitalized solutions in health, social, and consumer services, we have a daily flood of trillions of bits of structured data that can be used to provide real-time measurement of quality, assess the risk and benefit of new technologies and process innovations, personalize health interventions to incorporate preferences, values, lifestyle and genomics, detect emerging epidemics, and compare outcomes and patient experience with different providers, organizations and jurisdictions. One of the early wins of the “big data revolution” is that it accelerates the data infrastructure needed to shift from paying for “services” to paying for “value and outcomes” in healthcare.  There is nothing more deadly to an agenda of transformation and innovation than being paid no matter what the quality, outcome or experience with the service.  But imagine if a substantial part of the budget for delivering care was a bonus for better outcomes and patient experience, at the same or lower cost. Imagine consumers googling which health delivery organizations achieve the best outcomes for persons with dementia and their caregivers, and that their choices would factor into increments or reductions in annual budgets for providers and delivery organizations. Imagine incentivizing providers and delivery organizations to push the envelope, creating innovative frugal solutions that would improve the way we run the business of healthcare. We have a precious and vastly under-used resource in healthcare—a highly trained health professional workforce involved in day-to-day delivery, and highly motivated consumers who are eager to have a say in making the system better.

Research will play a central role in a system that measures and rewards value. There will be a big pull for basic descriptive and predictive intelligence—how are we doing, who is doing better and why, and what is predicting our successes and failures. There will be a demand for data scientists who can structure and harmonize data for description and prediction, for clinician scientists that lead the teams that generate new solutions and evaluate them, for methodologists who can develop a new set of tools for near real-time evaluation of what is working or not, and why, and for policy researchers who can transform an understanding of the effect of context into policy solutions that will allow effective solutions to be adopted and spread.  We are entering the era of the “learning health system,” where health services and policy research will be the investigative core of the enterprise.


[i] Centres for Medicare and Medicaid Services. National Health Expenditure Data.  (Accessed July 13, 2016)_
[ii] Canadian Institute for Health Information. Spending. (Accessed July 3, 2016)
[iii] Centres for Medicare and Medicaid Services. National Health Expenditure Data.  (Accessed July 13, 2016)_
[iv] Canadian Institute for Health Information. Spending. (Accessed July 3, 2016)
[v] Canadian Institute for Health Information. Health care cost drivers: The facts [Internet]. Ottawa (CA): CIHI; 2011 ISBN 978-1-55465-985-2 (PDF). Available from:
[vi] Canada: When the elderly outnumber the children. (Accessed July 14, 2015)
[vii] (Accessed July 14, 2016)

[viii] (Accessed July 14, 2016) 

About the Author

Robyn Tamblyn is the James McGill Chair, Professor, Department of Medicine, and Department of Epidemiology & Biostatistics McGill University and Scientific Director of the Institute of Health Services and Policy Research, Canadian Institutes of Health Research



Duncan Sinclair wrote:

Posted 2016/10/18 at 02:12 PM EDT

Dr. Tamblyn is, as usual, spot on, although the time line for change will likely be longer than her optimistic article suggests. The power of provider competition based on the quality of outcomes, especially among family health teams also providing home and community care, has great potential when coupled with the health information systems she describes. I will not live long enough to see it in place but hope and trust that my grandchildren will.
Duncan Sinclair


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