Integrating Ontario’s Healthcare System: A Point of View

By Paul Sulkers, Healthcare Consultant & former Ontario Executive for IBM Health

Globally, many countries are facing challenges with healthcare services, costs and overall value. The World Economic Forum (WEF) has recognized these challenges which include an unsustainable rise in health and social service expenditures, variability in medical practice, disproportionate acute care infrastructure, and misaligned incentives1. The WEF has leveraged early work by Michael Porter2, positioning integrated care as a cornerstone of healthcare transformation and the delivery of value, specifically, improving outcomes at the same or lower costs.

Some jurisdictions have led the way to transform healthcare by integrating care services, moving to value-based care and population health management strategies, including Spain13, Denmark14, and US providers Geisinger Healthcare10 and Kaiser19. These jurisdictions, averaging populations in the range of 5 million people, have invested in centralized capabilities, scaled across entire populations, and are now reaping the benefits of a seismic shift in the way that health is managed, funded and measured.

Denmark recognized that shifting health expenditures from acute care to community and home-based services was key to value-based care and has reduced the total number of acute care facilities from 98 to 36, shifting this previous acute funding to community and home-based care14. Geisinger utilized centralized clinical leadership and integration capabilities to focus on quality management and consumer engagement, reducing overall costs per patient by 11% over five years, and reducing avoidable readmission rates by over 35%10.

The need for integration is not new to Ontario, as outlined by Leatt et al3. We understand the key policy drivers that need to be in place4, and frequently refer to these international examples as aspirational. However, Ontario is clearly lagging behind any shift to population health management based on integration of care delivery. We can no longer view healthcare transformation as ‘stopping hallway medicine’5 or delisting OHIP fee codes8. We must begin to thoughtfully view transformation through the lens of these aspirational leaders, thoroughly understanding the centralized capabilities that have enabled their journey to value-based care, heavily leveraging their investments and scaling over entire populations.

Establishing Core Capabilities

Social media has been electric over Ontario Health Teams (OHTs)5 and the integration of healthcare in Ontario with a goal to eliminate ‘hallway medicine’. However, prior to leaping to an OHT-based integration model, or focus on treating the symptom of hallway medicine, it is important that we understand the WEF1 recommendations, and international examples, including Spain13, Denmark14, and US references such as Geisinger10, Kaiser19 and Michigan9 who have already initiated a journey to value-based and integrated care. These jurisdictions have clearly defined the problem as the urgent requirement to improve overall population health, supported by integrated care delivery processes. By focusing on population health and process integration, we can begin to assess the core capabilities established by these jurisdictions.

Specifically, based on the WEF recommendations and aspirational international leaders, the following six capabilities are critical to supporting a shift to population health and integrated care, centrally, via significant and rapid parallel investments:

  • Population Segmentation: clearly segment our population, and shape solutions and strategies for each, avoiding a one-size fits all approach, addressing both specific procedures as well as complex cohorts,
  • Funding Innovation: new funding programs to deliver these new care models by segment, with payments aligned with cost structures, incenting integration among organizations,
  • Consumer Partnership: a culture to embrace consumers as full partners in transformation, based on extended reach and community engagement, and leveraging the Health Care Manager in each Ontario resident,
  • Process Integration: positioning process as the key to integration, utilizing an automated process integration platform across Ontario’s disparate digital landscape, allowing our health system to ‘appear’ integrated,
  • Digital Scalability and Productivity: a strategy that places scalability and productivity at the centre of the digital discussion, scaling care and funding innovations, and enabling highly productive primary care and digital case management strategies that allow other clinical resources to focus on high-need populations, and lastly
  • Digital Health Economy: a recognition that our expense in digital must be aligned with a shift to a new digital and AI health economy, leveraging private sector investment to fund Ontario’s digital transformation.

We must understand aspirational jurisdictions and their investments, leveraged across populations of 5 million, establishing these capabilities centrally. We must also understand that investment in these capabilities at an OHT level, leveraged across small population sizes, can be a dilution of resources towards an ineffective outcome, and at best a duplication of effort.

Population Segmentation

We must start with segmentation. Like any complex environment, dissecting the problem into bite size portions can assist, with a solution designed for each portion. We must clearly segment our population, and shape solutions and strategies for each, including segments centred around a specific procedure or clinical ‘line of business’, or heterogenous cohorts such as patients with complex or chronic conditions, eldercare (geriatrics and aging), paediatrics, and women’s health.

Geisinger has segmented their population, developed new care models aligned with incentives, with clinical leadership supported by centralized innovation and quality support functions, a single digital strategy for consumers, and an enterprise wide data common10. For each segment, value must start with the systematic tracking of health outcomes over time and the end-to-end costs required to deliver those outcomes, including health, social and municipal costs1. The International Consortium for Health Outcomes Measurement (ICHOM) is developing a set of outcome measures that would contribute to Ontario’s ability to measure value1, moving beyond our current state of measuring wait times and compliance to quality measures.

Other industries have used data to ‘know their consumers’, understanding their wants and needs, and shaping offerings or services that drive value for a specific segment. In a similar way, value in healthcare starts with segmentation of our consumers, and definition of improved outcomes for each sub-population. By considering patient needs relative to a group of similar patients, including co-morbidities, risk factors, social determinants of health (SDOH) and accessibility of provider services, specific care models and delivery capabilities can be established tailored to the outcome.

Spain’s Catalonia region, a leader in population health management14, has segmented their population into 320 segments, based on 8 levels of acuity along with age and sex distributions, yielding the ability to tailor care models to each segment with defined outcomes. To become comparable to Spain, we need the data management ability to segment our population by defined cohorts or sub-populations, using data to ‘know our customers’, leveraging the efforts by the Ontario Institute for Clinical Evaluative Sciences (ICES) and the University of Toronto. It is critical that Ontario enable all key stakeholders to access a single Ontario health ‘data common’, based on an integrated view of acute, primary, home care, community health, municipal, social and emergency services to measure the health status of our population.

By establishing an approach to population segmentation using an integrated ‘data common’, similar to Geisinger10 and Spain14, clinical leadership will be able to develop new Ontario-wide care models to address both individual clinical lines of business as well as heterogeneous populations such as paediatrics, women’s health or eldercare. Ontario is not short of clinical expertise and leadership, armed with the knowledge of how to improve outcomes or avoid preventable episode. We are short of the data-driven knowledge that risk profiles our populations and targets patients who may most benefit from interventions to prevent onset, improve outcomes at lower costs, or reduce preventable episodes.

Complementing the formation of the data common, we must also build a focused Ontario data science capability, leveraging AI and the Vector Institute, to derive insights from our digital health and social resources, driving iterative re-design and increasingly precise interventions for each sub-population. We must also build our data science capacity by harnessing our health analytic capability, currently spread across 140 organizations. Although Ontario has completed important work to categorize the top 5% of patients from a cost perspective, we need the ability to use machine learning to derive actionable insights, via predictive models that identify patients in the next 10% who are drifting to become five percenters.

At a second level, we also need to move our new health ‘data common’ so that it is accessible to data scientists in both our research community and the private sector to drive further medical innovation and emerging AI solutions, positioning health data as the fuel to drive an Ontario Health AI economy. Ontario’s ICES and the Vector Institute at the University of Toronto are working to shape a ‘health data common’ to drive Ontario’s AI economy.

Importantly, our new care models tailored to each sub-population will define the required re-alignment of delivery organizations and end-to-end cost structure. These new care models must be aligned with funding innovation.

Funding Innovation

Funding innovation is arguably the most important capability needed to define the payments, specifically bundled payments among delivery organizations involved in new care delivery models. The WEF clearly positions funding innovation as a critical top priority1rapidly attacking key sources of benefit or value, such as avoidable episodes, adverse events and a holistic approach to eldercare, with benefits in the 15% range achieved by several US examples9. We must establish centralized clinical and business leadership to define these new payment models, associated with the anticipated value, and aligned with the total end-to-end costs of the effort required to achieve the outcome.

As outlined above, population segmentation will require centralized clinical leadership in order to define segments that are actionable relative to defined value. Some key segments will be groups of complex patients, or patients with multiple co-morbidities, while other segments will be more homogenous associated with procedures, such as total hip replacements. For each segment, using centralized clinical leadership, we need to define the area of benefit/value and then devise a care model and team structure to deliver, similar to Ontario’s centralized development of Quality-Based Procedures (QBPs).

Key heterogenous segments are Ontario’s elderly and chronic populations. The aging Ontario population and rise of chronic conditions, not only within elder populations but also adolescent cohorts, forces special attention to the problem. Elderly populations represent the highest cost cohort of our populations, via frequent use of emergency and acute services. As Ontarians age, they seek to live longer in their homes, with major implications for municipal planners. Health, municipal and community planning must understand the integrated or coordinated capabilities and environment required for a healthy community18, leading to healthy aging at home and battling the rising issue related to loneliness20.

Based on clinical leadership and the value sought for each segment of the population, we require the ability to rapidly launch new payment models designed to drive value – improved outcomes at the same or lower costs, or neutral outcome change at lower costs. For each segment, including various complex segments, we need to start by defining value including lower costs (e.g. reduced readmissions or acute LOS) and/or better outcome (avoidance of acute care episodes or better quality of life).

By measuring the gap between current value and desired value, we will be in a better position to assess a potential payment model. Specifically, we must have several centrally organized clinical and business capabilities to:

  • size the total annual value or benefit (reduced costs and/or improved outcomes) accrued to the Province, and therefore, determine the order of magnitude of the bundled payment on a per patient basis,
  • design Province-wide care models to achieve the value improvement, including the cost of multi-discipline resources across acute care, home care (including long term care), primary, community and municipal services,
  • based on the cost of resources, determine a bundled payment structure comprised of a ‘base’ that covers the cost of resources, and an incentive or ‘up-side’ element attributed to the achievement of KPIs related to each population segment,
  • ensure that the payment structure, including the ‘base’ and ‘up-side’ elements, is greater than the costs of delivery and less than the desired benefit accrued to the Province,
  • incorporate teaming agreements, including service level agreements (SLAs), associated with each bundled payment that defines the multi-organizational commitments supporting each care model,
  • complete a transition period whereby both the Province and the delivery teams jointly assess actual cost structures and adjust the payment model, and
  • conduct annual reviews where new payments are adjusted to better align with value, including removal or reverting to current funding models if value is not being achieved.

Clearly, funding innovation is not going to be a simple process. The capability required to define funding models for procedural (homogeneous) population segments, such as total hip replacements (TPRs), is well understood. In contrast, the effort or roadmap to define the care model and payment structure for heterogenous segments, including patients with complex needs or patients with multiple chronic conditions, will have greater complexity related to both care model definition as well as payment definition. For example, efforts by the Ontario MOHLTC to introduce payment bundles have been more successful at reducing LOS in patients having surgical interventions rather than admissions for exacerbation of chronic condition like CHF.

We must be prepared to address this complexity head on, designing funding or payment models for procedural as well as chronic or complex segments, in parallel. We must also consider funding innovation for each segment that targets both ‘down-stream’ cost as well as ‘up-stream’ preventive programs1. As outlined below under digital health, we may not be able to significantly impact the top 5% of patients, but it will be critical to establish care models and bundled payments to prevent the next 10% of patients from becoming a ‘top 5%er’. We must also be prepared to remain with status quo funding for some segments where the cost to deliver value far exceeds the anticipated value.

Michigan’s Blue Cross Blue Shield, focused on specific segments of their population, has reduced avoidable ER episodes by 18% and achieved a 21% reduction of inpatient days9. Others in the US according to the Primary Care Collaborative, have outlined substantial reductions in avoidable ER episodes in the 10%-18% range by focusing on sub-populations9. Spain recognized primary care’s critical role to be consumer-facing and leader of population health management, and established an enterprise primary care capability, incorporating multi-disciplinary teams and shared resources14.

We must also understand that funding innovation must be executed in concert with consumer partnerships, process integration, and digital health, as outlined below. Funding innovation must not be executed in isolation. Process integration and digital health will be key to enable the new integrated care models and therefore drive value. For some complex or heterogenous population segments, funding innovation must be closely linked to remote patient monitoring, digital case management, coaches and digital reach to family and carers. We are not short of technology innovation; however, we are short of funding innovation.

Clearly, funding innovation must be based on strong central clinical leadership and business acumen to understand our segmented population and define funded care models that deliver value. We must avoid diluting efforts across OHTs, or duplicating infrastructure critical to deliver the model.  We must also define payment models that leverage Provincial capability, including a strong provincial primary care enterprise capability, teamed with home care, case management and engaged with family and careers.

From a funding innovation perspective, the whole is greater than the sum of the parts. We must adopt a ‘fail fast’ attitude, based on the need to ‘spend money to make money’, recognizing that we will not get this right up-front, and will need to evolve funding innovation through an iterative process.

Consumer Partnerships

Population health by definition is a lifetime process and depends heavily on consumer engagement to promote healthy behaviours and compliance with care plans; however, Ontario consumers remain a significant untapped resource in the transformation journey. We must establish a partnership culture with consumers related to both care management as well as community engagement, and not merely selective participation on planning committees. Partnership must mean an end-to-end relationship, using the concept of extended reach, moving knowledge to the consumer rather than moving the consumer to the ‘point of knowledge’.

Other jurisdictions have forged strong partnerships with consumers10 13 14 19, based on ‘extended reach’ in order to maintain a connection between the clinical team, the patient and family. This partnership and extended reach are supported in many ways including coaches or navigators, home nursing support or community champions, as well as through partnerships with both private sector and public organizations under a ‘team sport model’. We need consumer partnerships to reinforce care plan compliance for patients managing chronic conditions, or patients in high cost segments such as complex care or eldercare. We also need consumer partnerships in order to rapidly introduce preventive programs designed around behaviour change. This partnership goes hand-and-glove with funding innovation, since we need consumer compliance with care plans in order for the health system to deliver value!

In the UK, Bradford’s Bangladeshi community has established a ”seniors show the way” project to train champions in the community, via the NHS Altogether Better Program5. In a similar way, the Shropshire Health Authority established a network of 150 young champions to extend to the community using social media6. The Netherlands Buurtzorg Neighbourhood model of care has received international recognition by partnering home nursing with the family and patient7. Other jurisdictions have also recognized that resources beyond the health care system are required, defining partnership and extended reach as a ‘team sport’, as demonstrated by Jersey Health Call and Check Program15 in partnership with Jersey Post, or via potential private partnerships such as Best Buy’s transformation of their Geek Squad to support home monitoring devices and security in a growing elderly market.

In addition, unlike other industries who have focused on the ‘end consumer’, the health system has not embraced the ‘health care manager’ or HCM in each Ontario household, as the ‘end consumer’. The HCM typically manages the health of their spouse, children and aging parents, as well as their own health. Frequently referred to as the ‘sandwich’ generation, we must leverage the HCM, engaging them on family health schedule management, education-based behaviour change, and care plan compliance tools. We must do this at scale across Ontario in order to enable consumers to see a seamless view of Ontario’s health system, regardless of their place of residence or OHT relationship.

HCMs, of course, can be patients as well as carers for patients in their family circle. Through the same digital channel that enables clinical-administrative processes, healthcare content can be served up directly to patients who opt to this digital channel, supporting critical processes such as behaviour change, care plan compliance, e-consults, and remote monitoring or virtual care, tailored by segment. More important, this extended reach is not local or regional, since HCMs can support aging parents from anywhere in Ontario, other Provinces, or in fact globally.

Again, by framing the problem as improving the health of the population, and given the 13 million in Ontario, we have no choice but to embrace a stronger partnership with consumers, supported by extended reach. This scale of consumer engagement, supporting self-management at home as well as behaviour change and compliance, can only be enabled by digital process integration, tailored to each population segment. This must not be defined at an OHT level!

Process Integration and Organizational Change

We must recognize that process integration is the key to integration, enabling the ability to implement new care delivery models for a specific set of outcomes, based on innovative funding models. Process integration is also the key to becoming patient-centred, recognizing patient wants and needs. Four processes are cornerstones of health transformation, specifically behaviour change, care plan compliance, remote monitoring or virtual care, and case management, all supported by extended reach to consumers. These processes are key to designing new integrated care models across primary, home and acute services, and the basis for shifting care closer to home, tailored by segment, aligned with funding, and based on patient “wants and needs” for that segment. By focusing on these key processes Provincially, and engaging consumers as partners, we will achieve greater levels of ‘health system integration’ based on patient-centred design.

Patient-centred design means designing integrated processes that connect consumers at all key steps and decision points through extended reach. To be clear, using consumer-centricity in other industries as proof-points, patient-centricity is not about being in the centre. Patient-centred is a culture statement that integrates consumers, via Design Thinking11 and Service Design12. Each clinical line of business and segment of our population needs to define their view of consumer engagement and process integration. These integrated processes are based on the care delivery model and define the required cost structure underlying the payment model, ensuring that value is created for a sub-population.

We often reference Catalonia or Kaiser as appropriate targets but fail to realize that the IT systems in these jurisdictions enable integration of processes that are closed loop and standardized, in other words, hardened12 19. We have to realize that trying to replicate the best practice of these jurisdictions is virtually impossible at scale without using a digital process integration platform or PAP that integrates process across our disparate IT systems and enables Ontario to ‘appear’ integrated.

Before designing new integrated processes, it is also important to understand that our current processes among provider organizations as well as between providers and consumers are highly variable and open loop, caused by open communication technologies – fax, paging or voice. Open loop and highly variable process are the single greatest barrier to integrating the Ontario health system and achieving population health at scale. We will fail if we design new processes but implement using ‘open communication technology’. We will fail if we assume that each OHT will have the skills to deploy integrated processes.

We must learn from other industries who have used a digital process automation platform (PAP) to design and manage integrated process across a variety of backend IT systems, shifting to digitally defined processes that are hardened, closed loop, and measured – if you can’t measure it, you can’t manage it! A digital PAP also provides a high degree of visibility into each step, allowing consumers and care teams to be alerted to variance, and allow action to be taken in time. Other industries have also learned that it is imperative to ensure consistency across multiple channels including both the ‘in person’ channel as well as any new digital channels, via equivalent content and decision-steps. Healthcare is not immune from this requirement!

Recognizing that we are not going to unravel 40 years of IT decision making any time soon, we must leverage a digital PAP to allow the fragmented Ontario IT landscape to ‘appear’ integrated. The PAP must be complemented by regional organizational change management capacity, shared across acute, community, primary and home care, using Design Thinking and the PAP to deploy integrated processes that reduce variability, establish closed loop collaboration, and allow the health system to act as a system – under a design once and replicate many model. The result will be a culture that designs processes with consumers at the centre, supported by a digital process automation platform, whether supported by phone calls, email or self-serve digital capabilities. This is not a capability of an OHT!

Digital Scale and Productivity

Globally, the new digital channel based on mobile devices, the ‘cloud’, and the Internet of Things (IOT) – sensors, wearables and other in-home devices – has fueled an exploding range of digital solutions, creating a fire storm of options for virtual care, remote consultations, consumer self-management and behaviour change. This new digital channel with the IOT represents a new channel that enables behaviour change and care plan compliance among an empowered consumer. This all adds up to digital extended reach and digital process automation, supporting a shift to closed loop and integrated process. Digital has become a critical ingredient of health care transformation and population health management.

In combination with funding innovation, consumers and providers are being incented to adopt these new digital solutions, scaling new therapeutic management approaches, achieving increased productivity and improving outcomes, in other words, value! For example, the US Centers for Medicare and Medicaid Services (CMS) now reimburses for digital therapeutics for diabetes prevention and management, and millions across the US have downloaded digital therapeutics apps for medication adherence16 17. The potential of digital solutions to improve outcomes over traditional in-person channels is increasingly promising, and will be validated over time, with solutions yet to be developed superseding early entrées to this growing market.

However, the key aspect of a new Ontario digital strategy must focus on scalability and productivity. We know that other leading jurisdictions have seized this new digital channel under a single digital framework, meaning the selection of a starter set of digital solutions under a single digital architecture. This framework will be key to allow the Ontario health system to appear as a system across 13 million residents, avoiding one hundred plus OHTs re-defining digital content and care models, and confusing consumers living on the “edges”. Rather than only assessing clinical value of any particular digital solution, it is important that Ontario considers two key dimensions of a digital strategy, specifically:

  • rapid scalability of new integrated care models to 13 million residents, aligned with funding innovation, engaging consumers (and the HCM) via extended reach, and
  • increased productivity of primary care, case managers and health coaches, via extended reach to consumers, managing the vast majority of Ontario residents digitally, reserving the in-person channel for high need populations.

Blue Cross Blue Shield Nebraska uses digital reach to not only improve effectiveness but also reach high levels of productivity for case managers16. Post-hospitalization costs were 41% lower for patients under digital case management versus patients not enrolled in case management, compared to only 17% reduction in post-hospitalization costs when telephonic reach was utilized. Care manager productivity also increased, with a 65% reduction in time spent with patients versus a telephonic channel17. Based on a digital platform for extended reach the US DVA has established a case management model that allows a case manager to manage 300 patients while achieving better therapeutic measures. Based on this 300:1 ratio, applied to Ontario’s highest need or 5% of patients, we would require 2,200 dedicated case managers, a tiny investment in the context of our total workforce.

Ontario needs to position scalability and productivity at centre stage in the digital discussion. Scalability will be critical to rapidly deploy (scale) Provincially defined care models, aligned with payment models, to all regions in Ontario. We must avoid care innovation trapped within an OHT or duplication of effort leading to identical care strategies. However, in order to scale rapidly, Ontario’s new digital strategy must provide a seamless digital view for consumers regardless of their residence or employment location, integrated across all processes, and supported by extended reach, coach interaction and system navigation. We must also use digital in support of managing complex care or eldercare, enabling the ‘daughter in Winnipeg’ to be actively connected and engaged with an elder parent in Ontario, supporting care plan compliance. If we are to truly curb the high costs of chronic conditions and eldercare, we need to establish a digital partnership with the patient, local carers, as well as the extended family.

By scaling new innovation across Ontario, digital will also increase the productivity of our health workforce, specifically primary care, home care, coaches, navigators and case managers, and at the same time, reduce the cost of patient scheduling and administration, similar to the impact of digital on airline passenger administration.

By increasing the productivity of a digitally-enabled case manager by a factor of 3 times compared with non-digital case managers for populations where case management is appropriate,16 17 we will open the way to assign more clinical resources to high value, in-person contact for those populations where this is crucial, specifically to manage the five percenters or importantly to manage those drifting to become five percenters. In addition to general productivity increases, a digital platform can also reach new levels of population health management via case management, supported by virtual coaching and virtual care, predictive risk or early warning models, as well as self-care alerts to patients and families.

Although there is great debate over the effectiveness of case managers, it is safe to state that digital does offer an effective way to deploy case managers, coaches or navigators for populations where case management works. As we see from others, it does make economic sense to engage consumers through case management and coaches, and from their experience, it makes more sense to do it digitally16 17.

Digital Health Economy

Digital is not the core competency of our Ontario health system. Historically, digital has been further plagued by local technology decisions that now propagate barriers to process integration, scalability and productivity. Although there is long standing debate on private sector’s role in Canadian healthcare delivery, there must not be debate over private sector’s role to digitally enable Ontario’s health transformation and create a Canadian digital health economy. We must leverage the Canadian private sector, both in terms of their ability to provide the massive infusion of capital needed to pull Ontario in to the 21st century, catching up to Kaiser and Catalonia, but also in terms of their know-how gained from other industries successfully addressing similar integration problems.

Ontario’s private sector has the capacity to invest and build new digital tools based on integrated process, including self-management, virtual care, coaching, care plan compliance dashboards, e-consults, and in the future chatbots and personal assistants. We need to foster wide-spread funding innovation under a single Ontario framework, that will draw in Ontario private sector investment and digital innovation all designed to scale health innovations, dramatically increase productivity and engage the consumer towards overall population health.

AI must be a specific focus of private sector in partnership with our University research community, as a number of issues intersect that demand the investment capacity of the private sector.

Healthcare needs data to segment populations and risk profile populations and our Ontario AI economy needs healthcare real world use cases. AI and machine learning needs large data sets to be trained and evolve commercial solutions, and therefore, we need to allow Canadian private sector access to our health ‘data common’ driving further medical innovation and emerging AI solutions. The goal is to position health data as the fuel to drive an Ontario Health AI economy. Ontario’s Institute for Clinical Evaluative Sciences (ICES) and the Vector Institute at the University of Toronto are working to shape a ‘health data common’ to drive Ontario’s AI economy.

Private sector is also the key to create digitally enabled healthier communities focused on healthy aging, based on new skills to drive connected communities, as researched by Bolzano, Italy18 or exhibited by early use of personalized robots interacting with the elderly in Japan20. We must leverage the final cohort of boomers – all digitally powered and now reaching their 70s – and all planning to age gracefully in their homes! We will need new community health skills, merged with smart municipal programs and infrastructure. This takes investment and new jobs!

Lastly, we must view the health industry not merely as a ‘cost’ to the Province, but as a $60 billion industry that can be a catalyst for a new Digital Health & Health AI economy in Ontario, driving “jobs for our children”. We must view Ontario’s health digital expenditures as an investment in our private sector, with a goal to position Canada as a net exporter of digital health solutions, methodologies and practices. We have a $60 billion burning platform that will require enormous investments in order to transform. We have to create a culture of ‘spending money to make money’. We can and must do this!

Symptoms versus the Diagnosis

In summary, business acumen and system theory, as well as sound medical practice, teaches the importance of root cause analysis and applying the correct level of problem solving that focuses on the eco-system and not a symptom. Hallway medicine is a symptom, not the problem. Integration is not the destination but a means to an end. Clearly, we can and must ‘address’ symptoms, and deliver early value via defined solutions, but in the end, we must look beyond. The real problem is the need to achieve a healthier population, reducing the demand side of healthcare and managing care closer to home, via preventive measures and behaviour change across an entire population.

To achieve higher levels of population health, Ontario must transform via significant investments in all six capabilities, in parallel and at scale. We must establish a health data common to derive new insights for each segment of our population, designing new models of care and end-to-end cost structures, aligned with new funding incentives or bundled payments. We must embrace consumer partnerships and HCMs, tailored by segment, through digital extended reach, regardless of their OHT relationship. Similar to aspirational examples, Ontario’s fragmented health system must reach the ‘appearance’ of integration via a single digital process integration platform. We must form a digital strategy that rapidly scales care innovation to 13 million and enables high levels of productivity for a large percentage of the population, allowing increased resources to be applied to the in-person channel for high needs populations.

High health expenditures reduce Canada’s competitiveness relative to countries with advanced population health strategies that reduce the demand side of health services. The more we spend on health, the less we have to invest in job creation and new innovation. We are also on the brink of a global workforce shortage by 2025, across the G15, fueling a competition for skills. Our most skilled physicians and nurses will retire from the Ontario workforce in the near term. From our millennials, we must replace these skills while concurrently reshaping a workforce from acute to community and home care resources, creating healthier communities, fostering healthy aging, and caring for the elderly closer to home. We must view the health industry not merely as a ‘cost’ to the Province, but as a $60 billion industry that can be a catalyst for a new digital economy in Canada, driving “jobs for our children”. We have a $60 billion burning platform that will require enormous investments in order to transform. We have to create a culture of ‘spending money to make money’.

We must ensure significant additional funding in a ‘spend money to make money’ view, and position Ontario’s $60 billion health industry as an economic driver of a new health digital economy, leveraging our Canadian private sector, and creating ‘jobs for our children’.

And lastly, we must establish these capabilities once, centrally at scale, and not duplicated in multiple OHTs, or at worst, diluted and ineffective in each OHT.  We must avoid trapping care innovation at an OHT level with no ability to scale. We must ensure consumers see a seamless view of Ontario healthcare, and not only an OHT-defined relationship. We must clearly position the health leadership across Ontario, specifically within each OHT, as a critical delivery channel. We must innovate once and replicate at scale leveraging the ‘on-the-ground’ capabilities of each OHT – rapidly!

Image Credit: ©frender – Can Stock Photo Inc.


  1. World Economic Forum; Value in Healthcare project session held at the World Economic Forum Annual Meeting 2017.
  2. Michael E. Porter and Thomas H. Lee; The Strategy That Will Fix Health Care, October 2013.
  3. Peggy Leatt, George H Pink, Michael Guierre, Towards a Canadian Model of Integrated Healthcare, March 2000.
  4. Dr Robert Bell, August 2019,
  6. NHS Altogether Better Program:
  7. Netherland’s Buurtzorg Neighbourhood Care
  8. Delisting Services
  9. Primary Care Patient Centred Collaborative
  10. Geisinger …. D Maeng et al. “Can Telemonitoring Reduce Hospitalization and Cost of Care? A Health Plan’s Experience in Managing Patients with Heart Failure”. Journal of Population Health May 2014
  11. Design Thinking:
  12. Service Design.
  13. Catalonia Spain:
  14. Denmark: Australian Financial Review,
  15. Jersey Post Call and Check Program:
  16. Case Management: Mobiheatlh News, David Muoio, January 4, 2018
  17. Productivity of Case Management: AHIP blog, Darcy Lewis, January 25, 2018.
  18. IBM Research, Comune di Bolzano, ASSB, Geriatric Dept.
  19. Kaiser Permanente Integrated Care Models
  20. IBM Research on Loneliness