1. Policy Issues:
eHealth in Ontario
HLTH 405 / Canadian Health Policy
Winter 2012
School of Kinesiology and Health Studies
Course Instructor:
Alex Mayer, MPA

2. Briefing Notes
Generally, very well done!

3. Briefing Notes
Most Common Mistakes:
• Did not substantiate the problem with statistical evidence!
• Lack of specific information provided
• Saying that there is an ‚increase in rates of drug abuse‛ is not
sufficient
• Using Fallacious Logic to say that there is a problem worth addressing
• Suggesting that ‚Obesity is on the rise, therefore physical activity
must be decreasing‛
• Suggesting that ‚U.S. rates are increasing, therefore there must be a
similar problem in Canada‛

4. Briefing Notes
Most Common Mistakes:
• Did not make evidence-based recommendations!
• Locked in on the ‘common-sense’ option too quickly
• Made a guess as to what would work best, based on intuition rather
than evidence
• Did not try to compare the effectiveness and cost of different
approaches
• Did not present statistical evidence to prove an option’s effectiveness

5. Briefing Notes
Most Common Mistakes:
• Did not understand the purpose of a Communications section!
• This section is used to highlight a messaging strategy
• To allay potential concerns in specific segments of the population
• To promote a policy’s benefits
• Should include specific talking points
E.g. ‚The Liberal government’s introduction of full-day kindergarten is a
hard-won victory for young families in Ontario! It will save parents
money, improve educational outcomes, and prime our province for
continued economic growth in a competitive future.‛

6. Last Week…
Government intervention in the marketplace is
justified when there is
• Market Failure:
The market for a good or service is not resulting in an optimal gain in
societal welfare due to unequal power and/or information between
buyers and sellers, or due to the nature of the good.
• Equity Concerns:
Socially unacceptable outcome where some segment of the population is
going without an essential good or service, due to a lack of resources.

7. Last Week…
5 Instances of Market Failure
o Informational Asymmetry
o Non-Competitive Markets
o Principal-Agent Problem
o Negative Externalities
o Public Goods

8. Last Week…
Net Present Value and Discounting
If you are trying to assess the costs or benefits of your policy
recommendation, be sure that your analysis is making an ‘apples
to apples’ comparison. A $50 savings in 1980 is not worth the same
as a $50 savings in 2012.
The inflation rate (CPI % change) measures the rise in the price of
a basket of goods. If the price of goods rises by 3.3% over 2011-
2012, then the relative value of money has declined by this
amount.
E.g. My grandmother likes to tip people with a couple of quarters
($0.50). This may seem rude, but in 1950, two quarters were worth
the equivalent of $5 in today’s market! So you see, my
grandmother is actually an excellent tipper… Kind of.

9. Last Week…
Net Present Value and Discounting
E.g. My grandmother likes to tip people with a couple of
quarters ($0.50). This may seem rude, but in 1950, two
quarters were worth the equivalent of $5 in today’s market!
So you see, my grandmother is actually an excellent tipper…
Kind of.

10. Last Week…
Net Present Value and Discounting
Try the inflation calculator below to figure out the net
present value of a $50 savings generated in 1980.
Bank of Canada Inflation Calculator:
http://www.bankofcanada.ca/rates/related/inflation-
calculator/

11. Last Week…
Net Present Value and Discounting
Inflation, however, is only one part of the equation. The other is
‘opportunity cost’.
Say I want to buy a TV; I have the option of paying in a lump sum
or paying the same amount but spread out over 12 monthly
payments.
In order to figure out the true cost of each proposition, I have to
calculate the ‘opportunity cost’: The value of the next best
opportunity foregone, say by investing the money and earning
interest. O.C. = $P * (1 + r%)t

12. Last Week…
Net Present Value and Discounting
E.g. Buying a $1000 TV.
Opportunity cost of TV (lump sum): Had I not bought the TV, I could
have invested that money and earned 5% interest instead!
$P (1 + r%)t = O.C.
$1000 (1 + 0.05)1 = $1050
Opportunity Cost = $1050
Opportunity cost of TV (monthly payments): If I buy the TV by making
monthly payments of $83, the opportunity cost is the foregone interest.
Month 1: $83 + $83* IR (5%/12 * 12 months) = $83 + $4.15 Diminishing
Month 2: $83 + $83* IR (5%/12 * 11 months) = $83 + $3.80 O.C. in foregone
interest
Month 3: $83 + $83* IR (5%/12 * 10 months) = $83 + $3.46
Opportunity Cost = $1023

13. Last Week…
Net Present Value and Discounting
Combining these two concepts: the time value of money and
opportunity cost… We can come up with there following
equation.
$FV = $PV * (1 + r%)t
Where real rate of return, r:
r% = interest% - inflation%

14. Last Week…
Net Present Value and Discounting
$FV = $PV * (1 + r%)t or $PV = $FV / (1 + r%)t
Where ‘real rate of return’ or ‘discount rate’, r:
r% = interest% - inflation% and t = years
The Government of Ontario plans to spend $5M per year over 5 years to
build new bike lanes once Toronto finalizes its new transit investment
strategy. The Bank of Canada website says that the 3-year moving
average for inflation is 3% and the government’s next best alternative is
not to incur debt, thereby eliminating interest on long-term bonds of 6%
per annum?
What is the net present value of this investment?

15. Last Week…
Net Present Value and Discounting
$PV [Year 4] = $5M/ (1 + 3%)4 = $4.44M
$PV [Year 3] = $5M/ (1 + 3%)3 = $4.58M
$PV [Year 2] = $5M/ (1 + 3%)2 = $4.71M
$PV [Year 1] = $5M/ (1 + 3%)1 = $4.85M
$PV [Year 0] = $5M/ (1 + 3%)0 = $5.00M
$PV of Project Outlays $23.58M
So in comparing the cost of the bike lane project to the cost
of, say, building a dedicated street for cyclists for $25M this year, the bike
lane project is actually $1.42M less expensive in an apples-to-apples
comparison.
If they provided equivalent benefits, the bike lane project would be
the more cost-effective option!

16. eHealth Applications

17. Topics for today’s lecture:
Policy Issue #3: eHealth
• What is it?
• eHealth Ontario
o The strategy
o The scandal
o Signs of progress
• Future applications
o EMR
o RM&R
o ePrescribing

18. eHealth: What is it?

19. Definition
eHealth: (n)
‚A consumer-centered model of health care where
stakeholders collaborate utilizing information and
communications technologies (ICTs), including
Internet technologies, to manage health; arrange,
deliver and account for care; and manage the health
care system.

20. Canada Health Infoway
Canada’s eHealth Story
• In 2000, the First Minister’s agreement on health sees the
forging of a federal-provincial-territorial agreement to
build up ‚infostructure‛ in Canada’s health care system.
• ‚Canada E-Health 2000‛ conference sees 400
stakeholders meet to discuss progress on a national
action plan for eHealth.
• In 2001, Canada’s Health Infoway is operational.

21. Canada Health Infoway
• Introduction to eHealth in Canada
http://www.youtube.com/watch?feature=player_em
bedded&v=3SYtv5jh4tQ#!

22. eHealth Consultations
Obstacles to better health care in Ontario
o Paper-based information management
o Limited integration of local applications and data
o Limited information-sharing across providers
o Varying technological capacity across the health system
o Fragmented and incomparable data
o Lack of common data and technical standards
o Underinvestment in technology
o No provincially coordinated strategy for eHealth funding and
planning!

23. eHealth in Ontario
• 2002: Creation of the Smart Systems for Health Agency
(SSH)
• 2003: SSH begins its operations with 6 key priorities
• Develop a common unique patient identifier in Ontario
• Establish privacy and security requirements for eHealth
• Design an Ontario EHR starting with Hospital-to-Primacy Care
Physician information exchange
• Initiate an ePharmacy Initiative for Ontario
• Expand on Telehealth’s success and capabilities
• Evolve a Wait List Management Initiative for key health services

24. eHealth in Ontario
• 2006: Deloitte is hired to conduct an operational review
of SSH’s activities.
• The final report finds that SSH has not delivered
sufficient value-for-money for the $650M invested thus
far. It recommends an aggressive agency-turnaround
plan.
• Smart Systems for Health (SSH) is reborn as eHealth
Ontario in 2008, with heavy-hitting CEO Sarah Kramer
at its helm.

25. eHealth in Ontario
• In 2008, Ontario’s new eHealth Strategy is developed.

26. eHealth in Ontario – A Shift
No dedicated provincial
Funded, Cabinet approved Strategy
eHealth Strategy
Government as stewards; eHealth
Government responsible for
Ontario responsible for
Strategy eHealth
eHealth Strategy
Diffuse/competing/confusing Single point of accountability at
accountability eHealth Ontario
Provincial strategy delivered
Duplication, fragmentation and
through local, regional and
Proliferation of eHealth efforts
province-wide solutions
Health System
Technology plan
Transformation Strategy
26

27. 3 Clinical Priorities
Diabetes Management Medication Management Wait Times
Enable online prescriptions and Enable public reporting and
Monitor patientcompliance with
medication History performance management
evidence-based interventions
Provide decision support for Expedite patient referrals out
Alert physicianswhen best practices
physicians of acute care where appropriate
not being followed
ordering drugs
Divert ER visits to more appropriate
Report on care gaps
Alert of potential adverse drug events community care settings
ER length of stay
To Reduce
Wait times
 Blindness
 Adverse drug events  Focus of ERs on
 Heart attacks urgent patients
To Reduce To Reduce  Physician office visits
 Amputations To Increase
 Hospitalizations  Access to community
 Renal failure services
 Deaths
 Deaths
 % prescriptions ordered
 % patients receiving  ER length of stay
Measure Measure online Measure
best practice care  Wait for post acute
 % reduction in adverse
drug events care

28. Ontario eHealth Solutions
Diabetes Management Medication Management Wait Times
• Baseline Dataset  ePrescribing Demonstration Project • eReferral and Resource Matching
• Diabetes Registry • Drug Information System (DIS) • Emergency Department Reporting
• EMR interoperability with Diabetes • Drug Profile Viewer (DPV) System (EDRS)
Registry • Systemic Treatment Computerized • Wait Time Information System
• OLIS interoperability with Diabetes Physician Order Entry (CPOE) (WTIS)
Registry
28

29. eHealth Scandal
• 2009: The ‚eHealth Scandal‛
A loosening of managerial policies around hiring
private-sector consultants, meant to make eHealth
Ontario more efficient, actually leads to more problems
after the AG’s report finds that $1B had been spent with
little to show for it.
Oct 7, 2009. News Report (Global TV)
http://www.youtube.com/watch?v=txkoB8s5qZ8&feature=
results_video&playnext=1&list=PL9EFAFB182DCE4C29

31. Doctors Use Electronic
Patient Medical Records
99 97 97 96 95
100 94 94
72
75 68
50
46
37
25
0
NET NZ NOR UK AUS ITA SWE GER FR US CAN
* Not including billing systems.
31
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

32. Third Time’s A Charm?
eHealth Reboot (Feb 24, 2012)
http://www.youtube.com/watch?v=F7kYDCtuTnQ
32

33. Diabetes Management
•Baseline Dataset • Provides primary care MDs with a Diabetes
Patient List
• Testing reports inform MDs of most recent dates
for 3 key tests for diabetes patients (blood
glucose, cholesterol, retinal eye exam)
• Reports give MDs %patients whose tests were
within recommended guidelines so they can
identify care gaps
•Diabetes Registry • Fancier version of the baseline dataset
• Will connect to OLIS give to notify MDs when
patients are due for tests or when lab results are
higher than normal
• Will connect to EMRs so that a new diagnosis
instantaneously gets added to a patient’s
medical record and generates a care plan
• Will eventually provide patients with self-
management tools

34. Medication Management
 ePrescribing  MDs can electronically ‘push’ prescription
Demonstration directly to a local pharmacist
Project  Prescriptions can be printed in order to
avoid deciphering MD’s handwriting
•Drug Information •Will allow multiple health practitioners to
System (DIS) ePrescribe
•Will produce comprehensive medication
profiles and tools for predicting allergic
reactions, drug-to-drug interactions and
accurate dosages
•Drug Profile Viewer •Will give health providers connected to
(DPV) eHealth Ontario access to ODB claims
records so that all pharmaceuticals
consumed by elderly and welfare patients
will be visible at the point-of-care

35. Wait Times
•eReferral and Resource •Hospitals to plan post-discharge care for
Matching patients at the time of intervention
•RM&R Solution will communicate with
community care providers to flag a patient’s
discharge date to ensure that someone is
tasked with, and accountable for, providing
follow-up care
•Emergency Department
Reporting System •Will record and publicly report ED wait
(EDRS) times online, for both high and low acuity
patients
•Wait Time Information
System (WTIS) •Will record and publicly report wait times
for many types of surgeries and diagnostic
imaging, and for both adult and children.

36. A Bit of A Winding Road

38. What Would You Have
Done Differently?

39. Have a great week!