Essays

Essays January 2017
Open Letter

Challenging the Orthodoxies of Health System Design and Management

Dr. Graham D. Sher

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

As healthcare leaders, we see firsthand the multiple challenges health systems face in this country. From reorienting services around patients and finding ways to address waitlists, to optimizing use of expensive diagnostics and therapeutics and implementing better technologies — there is a multitude of ways in which progress must be made. We also run the risk of tackling these critical symptoms in isolation and as point solutions, rather than addressing some of the underlying causes of what ails Canadian health systems.

As we look to the future of healthcare through these open letters, let’s take a few minutes to dig deeper. I believe a great deal of the friction we see now within health systems stems from the fact that they are designed to fund and deliver commodity services in bulk rather than at the individual level. This structural design has not evolved in keeping with innovative therapies and is a significant factor contributing to the growing system unsustainability we face today.

This dynamic is coming into greater focus of late, in part because patients are demanding more customized approaches that reflect their experience in the consumer marketplace. And while the delivery of care is starting down the path of increasingly precise (and often expensive) treatments, the pace of change can be painfully slow without a wide-spread culture shift to transform systems and better meet patients’ needs. As health leaders, we also know we need integrated systems that leverage data and technology much more effectively than they do today. As leaders, it behooves us to be forward looking and to challenge some of the orthodoxies of our health systems’ governance, structure and funding models.

One path forward is to leverage more broadly some key lessons from the commercial sector. (I’m not talking about privatization, but rather about the transformative potential of system design principles such as personalization and scalability of services, technological innovation and the power of big data, and a relentless focus on exceptional user experience.) Many healthcare organizations and governments are beginning to learn from and apply these principles in a variety of ways, but understanding the effect they’ll have on the health systems of the future is challenging. Canadian Blood Services’ experience in organ donation and transplantation (ODT) is a small example that may help illustrate their potential.

In 2008, understanding the significance of scale in addressing certain transplant patients’ needs, Canadian Blood Services was able to leverage its existing pan-Canadian expertise and begin work on a national approach to ODT. Together with funding governments and ODT partners across the country, we coordinated something unusual within the country’s healthcare arena: the scaling up and operation of three national programs supporting ODT in Canada. These include:

  • The Kidney Paired Donation program for patients with a mismatched living donor.
  • The Highly Sensitized Patient program for kidney patients whose physiology makes them exceptionally hard to match, therefore requiring an even more specialized approach.
  • The web-based National Organ Waitlist, a continuously updated listing of patients who are waiting for major organ transplants of all types.

The Kidney Paired Donation and Highly Sensitized Patient programs use algorithms to facilitate transplants for more specialized groups of patients struggling to find a matching kidney within the more limited donor pools of their provincial systems. The National Organ Waitlist replaced a paper and fax system that often missed transplant opportunities due to the lack of real-time data. All three are accessed through and supported by a common data engine managed by Canadian Blood Services, which provides critical real-time information on organ listing and sharing for the entire country: the Canadian Transplant Registry.

Since their inception, the kidney programs have facilitated a total of 752 transplants for patients who otherwise would have languished on wait lists within health systems designed to churn out expensive, commodity services like dialysis. Instead, via a collaborative innovation that links ODT health-system partners across the country, these patients received a more targeted, data-enabled, and ultimately life-changing solution: an organ transplant, which also, in the long term, is significantly more cost-effective and offers greatly improved quality of life.

For me, these national (interprovincial) registries demonstrate the transformative potential of integrated systems that leverage data and technology to improve both patient outcomes and health-system performance. And to be clear, they are only one of the steps required to more fully address the number of Canadian patients still waiting for organ transplants (a critical symptom that we continue to work on).

That these registries have succeeded at all, however, is due in part to the fact that they were able to stimulate a shift in culture around the sharing of organs and data, both within and across health systems. And while these programs continue to see progress, I will acknowledge that discussions are often still challenging in areas where mindset is harder to shift. Not surprisingly, these tend to centre around governance, funding and accountability on a national basis, in a system designed to think and operate on a siloed jurisdictional foundation.

The Canadian Transplant Registry is only one small window into where health systems could go in the future if we can better leverage approaches like the personalization of services, scalability, technological innovation, data sharing, and more creative approaches to governing and funding new products and services. Indeed, we need many more successful shifts from commodity service delivery to more individualized, precise care — and on a much greater scale — if we are to come to terms with the underlying unsustainability of our health systems. Perhaps in doing so, we’ll also be able to find appropriate treatments for more of the critical symptoms that continue to shape our lives today as healthcare leaders, and as citizens and patients.

About the Author

Dr. Graham D. Sher is Chief Executive Officer of Canadian Blood Services

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