MODERN CARE FOR MODERN PATIENTS · use of technology to improve the patient experience, setting the stage for a new framework for patient-centred care. The CQCO would also like to

Signature Events Synthesis

Innovative Models of Care:

Why are we using 19th century medical models

for 21st century patients? December 2009

Using Technology to Improve the Patient

Experience in Cancer Care June 2009

June 2010

MODERN CARE FOR MODERN PATIENTS

Innovating and supporting care for 21st century patients

In partnership with:

MEMBERSCQCO MEMBERS

Chair: Michael Decter, October 2002 to June 2009

Dr. Robert Bell, July 2009 to present

Vice-Chair: Dr. William Evans

Members: Julia Abelson, PhD

Arlene Bierman, PhD

Adalsteinn Brown, DPhil

Virginia Flintoft

Deborah Gillis

Dr. Richard Lewanczuk

Dr. Michael Marcaccio

Rolly Montpellier

Dr. Carol Sawka

Terrence Sullivan, PhD

Acknowledgements

The Cancer Quality Council of Ontario would like to thank the

patients, participants, speakers, and panelists who contributed

to this timely discussion on innovative models of care and the

use of technology to improve the patient experience, setting

the stage for a new framework for patient-centred care.

The CQCO would also like to acknowledge the contributions

of Cancer Care Ontario staff, particularly the clinical leads who

provided feedback on this report.

Disclaimer

The materials in this report are a synthesis of literature reviews

and two Cancer Quality Council of Ontario Signature Events in

2009: Innovative Models of Care - Why are we using 19th century

medical models for 21st century patients? held on December 2

in Toronto and Using Technology to Improve the Patient Experi-

ence in Cancer Care held on June 8, also in Toronto. Questions

regarding the report should be directed to the Cancer Quality

Council of Ontario Secretariat. Cancer Care Ontario does not

make any representation or warranty as to the completeness,

accuracy or currency of the information contained in this

report, including, without limitation, any information derived

from data sources.

Proceedings Documents

For copies of the proceedings documents, please visit our

website www.cancercare.on.ca/signatureevents or contact

the Administrative Assistant at the Cancer Quality Council of

Ontario Secretariat at 416-971-9800 extension 1247.

CONTENTSTABLE OF CONTENTS

Executive Summary............................................................................................2

1.0 Introduction........................................................................................5

2.0 Why does Ontario require innovation in models

of care?....................................................................................................5

2.1 Increasing demand and constrained resources.............5

2.2 Changing patient expectations................................................6

2.3 The opportunity for innovation................................................7

3.0 A system-wide approach to innovation..........................8

4.0 What do we need to support the cancer system’s

ability to implement innovations in a patient-

centred service delivery model?..........................................8

4.1 Encouraging communication and collaboration..........9

4.2 Creating cultures of change.......................................................9

4.3 Facilitating dissemination of innovations........................10

4.4 Providing evidence, measurement and guidelines...11

5. 0 What is technology’s role in facilitating innovation

and improving patient care?................................................11

5.1 Patient-centred communication..........................................12

5.2 Information and education......................................................13

5.3 Self-care................................................................................................13

5.4 Support in the community.......................................................14

6.0 Where can we benefit from different financial

models in the cancer system?..............................................15

6.1 From fee for service to capitation........................................ 15

6.2 Pay for performance.....................................................................17

6. 3 Episode-based funding...............................................................19

7.0 Recommendations......................................................................19

1. Model of Care: Improving quality, maximizing

resources, and using international

leading practices.............................................................................20

2. Support the patient voice.........................................................20

3. Support system change through

performance improvement.....................................................22

4. Improve care delivery and the patient experience

through integration......................................................................22

5. Strengthen the evidence base...............................................23

6. Use e-tools to inform and empower patients...............24

7. Implement tools enabling dissemination

and mentoring.................................................................................24

8. Enable individual-level performance

reporting..............................................................................................25

9. Address financial and reimbursement

challenges...........................................................................................25

References..............................................................................................................27

Appendix A: Definitions of technology tool types........................31

MODERN CARE FOR MODERN PATIENTS innovating and supporting care for 21st century patients 2

SUMMARY

Ontario’s cancer system is in the midst of a perfect storm.

The demand for services is increasing, the supply of resources

is constrained, and a growing number of patients want to

participate more actively in their care. This storm has created

both a need and an opportunity for innovative models for

cancer care delivery in Ontario.

To address the sustainability of the province’s cancer system,

the Cancer Quality Council of Ontario (CQCO) hosted a

Signature Event in December 2009 entitled Innovative Models

of Care: Why are we using 19th century medical models for

21st century patients? This event focused on how innovative

models of care, including funding models, from other

cancer systems and the greater health care system were

being used to address various challenges and constraints,

and to empower patients.

As a complement to this discussion, a Signature Event

entitled Using Technology to Improve the Patient Experience

in Cancer Care was held in June 2009, focusing on how

technology contributes to innovations in models of care.

In particular, this event explored how technology could be

used to transform the care delivery model and to empower

patient connections, navigation of the health care system

and social networking.

Panelists at the two events and reviews of background

literature highlighted the need for a system-wide approach

to innovations. There are numerous isolated pockets of

innovations in Ontario and other jurisdictions, but the province

requires a more concerted effort to bring these innovations

into a cohesive whole. The following enablers have been

identified in facilitating innovations in models of care:

Collaboration of multidisciplinary teams within •

and outside organizations

Creating cultures of change which foster and •

adopt innovations

EXECUTIVE SUMMARY

Assisting with the uptake and dissemination •

of innovations

Providing quantifiable evidence of successful innovations •

and guidelines

Identifying best practices•

Technology is a key enabler of a number of patient experience

innovations. Through the Internet, patients have new and

varied ways to access information and to connect and interact

with other patients and providers. The exponential growth

of the Internet for health information has supported the rise

of empowered, informed patients who seek to be active

participants in their own care. In addition to enabling and

empowering patients, technology provides opportunities

to realize greater efficiencies. Mobile technologies, for example,

can enable patients to send their clinician relevant and timely

data, such as blood pressure readings or symptoms, from the

comfort of their own home. However, current models of

care are not designed to support the empowered patient or

to take advantage of new modes of patient-provider

interaction such as email and mobile interaction.

Financial remuneration is another enabler critical to the

success of innovative models of care. A number of financial

models are examined including fee for service, capitation,

salary, pay for performance and episode-based funding.

Examples of incentive-based funding models in the United

Kingdom, the United States and in surgical oncology in

Ontario highlight some benefits, such as increased productivity

and maximizing efficiencies, but also suggest potential

negative implications such as gaming. The model of financial

remuneration for physicians and specialists was compared

to remuneration of hospitals, and it was determined that

there is a need for hospital funding to align with physician

and specialist funding.

innovating and supporting care for 21st century patients MODERN CARE FOR MODERN PATIENTS 3

Action needs to be taken to make the health care system

more sustainable and to meet patient expectations.

Enabling new models of care to be introduced, adopted

and accepted throughout the cancer system in Ontario is

critical to ensuring the cancer system is efficient and

maximizes all resources. Based on the 2009 Signature Events,

the Cancer Quality Council of Ontario has identified a

framework and a set of supporting recommendations for

Cancer Care Ontario and its partners to facilitate innovations

in models of care that promote a new patient-centred

approach within the Ontario cancer system.

Cancer Quality Council of Ontario Recommendations

1. Model of Care: Improving quality, maximizing resources,

and using international leading practices

Use Cancer Care Ontario’s Models of Care working group, •

tasked with maximizing resources for sustainability, to

research and develop a proposal for a new model of

care delivery learning from international best practicea

to improve the patient experience and enhance provider

satisfaction and quality.

2. Support the patient voice

As a core goal in the Ontario Cancer Plan, Cancer Care •

Ontario should maintain and strengthen efforts

to improve the patient experience. It should increase

its focus on including patient input as an integral part

of all program activities – from program planning

and development to ongoing program activities.

Cancer Care Ontario’s Clinical and Regional Programs •

should embed measures of the patient experience

as part of their performance measurement and

reporting expectations.

Cancer Care Ontario’s Cancer Services and Policy Research •

Unit, in collaboration with research networks such as

the Innovation Cell and Elixir, should identify how existing

patient and survivor peer-to-peer and social media

collaboration can inform Cancer Care Ontario and

the cancer system.


performance improvement

Cancer Care Ontario should engage provincial •

and regional practice leadership in communities of

practice and other mechanisms to share best practices

in areas such as inter-professional communication,

innovative models, e-innovation and leadership training

in change management.


through integration

Cancer Care Ontario should extend the focus on multi-•

disciplinary models beyond the realm of programs and

into the broader corporate-level environment by creating

processes and structures that are explicitly interdisciplinary

and cut across stages of the patient pathways.

Cancer Care Ontario should include as a key priority in •

the Ontario Cancer Plan integration among cancer care

providers and between steps of the patient journey.

Cancer Care Ontario’s Information Management and •

Information Technology division should include, as part

of its strategy, a program to enable integration within the

cancer system as a top priority, aligning with the broader

provincial eHealth agenda and the strategies of other

health system partners such as Infoway.

The Cancer Quality Council of Ontario should work •

with Cancer Care Ontario’s Informatics team in the

Information Management and Information Technology

division, the Cancer Services and Policy Research unit

and/or external health services research units – such as

the Health Policy, Management and Evaluation department

at the University of Toronto and the Centre for Health

Economics, Services, Policy and Ethics Research in Cancer

Control at the Canadian Cancer Society – to identify and

develop key indicators for measuring and reporting on

cancer system integration in an ongoing and sustainable

basis via the Cancer System Quality Index.

a From the broader health sector


5. Strengthen the evidence base

Cancer Care Ontario’s Clinical Programs should engage •

the Program in Evidence-Based Care and other groups

as appropriate, to synthesize evidence and provide

guidance on a number of areas, including the effective-

ness of new models of care, financial remuneration and

the use of technology communicating health care

information in peri-diagnostic and survivorship stages.

Cancer Care Ontario should engage the Models of Care •

working group to develop proposals for alternative

delivery models, including pilot projects maximizing

scopes of practice, expanding the work of the Resource

Modeling group, and implementing demonstration

projects such as group visits.

Cancer Care Ontario should apply lessons learned from •

innovative practice models in other disease sites to pilot

projects focusing on new ways to deliver cancer care.

6. Use e-tools to inform and empower patients

Cancer Care Ontario should incorporate technology •

innovations to improve the patient experience as a core

component of its Information Technology/Information

Management strategy.

Cancer Care Ontario’s Planning and Regional Programs •

should work to establish appropriate incentives or

rewards for technology initiatives aimed at improving the

patient experience.

Cancer Care Ontario, in collaboration with appropriate •

partners such as the Canadian Cancer Society and

the Canadian Partnership Against Cancer, should develop

demonstration projects that identify specific online

resources and tools to serve as an information prescription

for each stage of the cancer journey. Intended to help

meet patient and caregivers’ needs, these pilot projects

should be implemented and evaluated at the Regional

Cancer Program level.

Cancer Care Ontario’s Clinical Programs should work •

with the Information Management and Information

Technology division to pilot an e-tool intervention that

supports the needs of cancer survivors in the follow-up

phase of cancer care.


and mentoring

Cancer Care Ontario should engage its provincial and •

regional clinical networks to enable more systematic

dissemination and uptake of regional best practices for

using technology to improve the patient experience.

Cancer Care Ontario should partner with the de Souza •

Institute, the Canadian Cancer Society, the Canadian

Partnership Against Cancer, or other appropriate organi-

zations to design and develop systematic dissemination

programs that leverage networks and knowledge to

enable collaboration and mentoring.

8. Enable individual-level performance reporting

To drive and support ongoing quality improvement, •

Cancer Care Ontario should explore, together with

provincial and regional clinical leadership, providing

information to individual clinicians.

9. Address financial and reimbursement challenges

Cancer Care Ontario should establish a working group •

with its partners on remuneration and financing of the

cancer system.

Cancer Care Ontario’s Models of Care working group •

should work toward evidence-informed changes to

specialist remuneration within the cancer system.

Cancer Care Ontario should, together with the appropri-•

ate external organizations, propose a harmonized remu-

neration system for physicians and hospitals.

Cancer Care Ontario should work with the appropriate •

external partners to pilot episode-based funding in

regional cancer centres or partner hospitals interested

in testing this funding model.


1.0Introduction

With an aging population, more people surviving cancer,

and continuing advances in clinical practices and

technology, today’s cancer system faces significant changes.

These changes, combined with the current economic

climate, raise questions about the efficiency of the health care

system and its ability to meet the needs of patients who are

more savvy, research-oriented and have higher expectations

when it comes to their care. Health care systems today

are challenged to provide higher quality care in the face of

growing fiscal constraints and the increasing burden

of chronic disease.1

Emerging health care models increasingly focus on patients

across the continuum of care, encouraging them to be more

proactive in managing their care. These patient-centred

models have the potential to create a more efficient, cohesive

cancer system that better serves patients’ needs, strengthens

linkages with the rest of the health care system, and ensures

future sustainability. However, for these models to take hold,

it is necessary to examine what system enablers and levers

are required for different models of care and for facilitating

innovation in the system.

2.0 Why does Ontario require innovation

in models of care?

2.1 Increasing demand and constrained resources

As Ontario’s population ages, the incidence of cancer is

anticipated to rise exponentially, challenging the system’s

ability to provide appropriate and timely care. While advances

in diagnosis and treatment mean more Ontarians are living

longer with cancer and surviving beyond cancer. It is estimated

that, by 2017, there will be 406,000 people living with cancer,

putting greater pressure on the system to manage

follow-up care (Figure 1).2

Trends in newly diagnosed cancers attributed to risk, population, growthand aging, Ontario, 1982 to 2006

CSQI 2010

AgingPopulation GrowthIncrease Cancer RiskBaseline

An

nu

al

Nu

mb

er

of

Ne

wly

Dia

gn

ose

d C

an

cer

Ca

ses 70000

60000

50000

40000

30000

20000

10000

0

Data Source: Ontario Cancer Registry, 2009Prepared by: Cancer Care Ontario, Population Studies & Surveillance

1985 1990 1995 2000 2005

Year

Figure 1: Cancer Incidence Rates - Attributable risk, population growth & aging

At the same time, the cancer system will see a shortage

of human resources. Recent modeling for future projections

shows that Ontario will have a shortage of 40 medical

oncologists by 2011/2012.3 Overlay these factors with the

current economic climate, where governments are

increasingly required to maximize resources and operate

as efficiently as possible, and it becomes clear the current

system is not sustainable.

It should also be asked if the system is providing the right

care. There is concern that some patients are being over-

treated, with potentially adverse consequences. For instance,

excessive imaging is an issue of concern because the effects

of accumulated radiation exposure are not fully understood.

Conversely, some patients being treated for one type of

cancer are not being screened for other cancers relevant to

their age group.4 The question of appropriate care also

applies to the post-treatment phase of the patient journey.

After their treatment is completed, patients follow up

numerous times with multiple providers within the cancer

system. Some of these appointments are, without question,

necessary but others may not be required or could be

handled by another health care provider. The NHS (National

Health Service) Improvement program in the United King-

dom has found that not all patients need to receive follow-up


appointments within the cancer system, particularly if the

cancer patient does not have a long-term condition.5 In the

United Kingdom, it is estimated that following treat-ment, 70

per cent of patients can be appropriately supported outside

the cancer system (Figure 2). In Ontario, there is significant

variation in care for patients coming in for follow-up visits in a

primary care setting.

2.2 Changing patient expectations

In addition to providing the right care, the system must take

into consideration the needs of patients. Organizations should

be reminded that the health care system is a service industry.6

Customer service is the value-add portion of the care package

which could potentially yield the greatest return in benefits

for health care organizations and for the patient’s treatment

experience.7 The Ambulatory Oncology Patient Satisfaction

Survey – Ontario’s cancer-specific patient satisfaction survey –

consistently shows that hospitals and providers are not

meeting patients’ emotional needs (Figure 3). The “patient first”

notion needs to be embedded in organizations and in their

delivery of health care. Patient-centred care focuses on the

patient’s perspective – taking into consideration the entire

care pathway rather than the discrete phases of screening,

diagnosis and treatment. Patient-centred care enables

coordinated and integrated care across the care continuum.8

NHS Improvement, 2009

Following treatment

When significant event occurs either patient orprofessional triggered

On the transition to end of life care

Assessment and care planning - trigger points

Dying and transition to end of life care

END

OF

TR

EAT

MEN

T

Post treatment assessment & care planning

Multi professional

agency complex care (5-10%)

Co-ordinated care (10-20%)

Self management(60-70%)

Long term condition management model

Transition from treatment to survivorship:

Clinical m

anagement of acute effe

cts, building

capability and confid

ence to self m

anage

Living beyond cancer with some risk:May involve surveillance and needs rapid access if symptoms occur

Living with cancer and consequences of treatment

≈ 70%

≈ 30%

CSQI 2010

Pe

rce

nta

ge

Report date: January, 2010Data source: Ambulatory Oncology Patient Survey, 2004 to 2009Prepared by: Cancer Care Ontario

Dimensions of Care

Average cancer patient satisfaction scores for outpatient care, 2006 to 2009

2006200720082009

Emotional Support

Coordination& Continuityof Care

Respect for PatientPreferences

Physical Comfort

InformationCommunication& Education

Access to Care

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Figure 3: Patient Experience - Measures of Satisfaction for Outpatient Care

Figure 2: NHS Improvement: Potential Survivorship Model of Care


As patients take the initiative to be more engaged and active

in the management of their care, there appears to be

growing pressure within health care to meet patients’ needs.

Patient engagement has been shown to have a positive

impact on outcomes and on the efficient use of resources.

For instance, in chronic disease management, self-manage-

ment is a key component of the treatment and is associated

with better health outcomes.9 Patients with chronic diseases

who are encouraged to monitor their health and get help

early are reducing the need for specialists and emergency

department visits.10 There are also examples of volunteers

or lay people delivering health behaviour counseling in the

primary care setting, reducing resource constraints for practices.11

A major enabler of this change has been the emergence of

technology tools and resources that give patients access to

information and let them connect and interact with other

patients and providers. Searching for medical or health related

information continues to be one of the dominant activities

for Canadian internet users.12 In addition to enabling and em-

powering patients, technology provides opportunities to

realize greater efficiencies. Mobile technologies, for example,

can enable patients to send their clinician relevant and timely

data, such as blood pressure readings, from the comfort of

their homes. However, current models of care are not designed

to support the empowered patient or take advantage of new

modes of patient-provider interaction, such as email and

mobile applications.

2.3 The opportunity for innovation

Given the growing demand for care and the rising cost

of providing it, combined with a more sophisticated and

engaged patient population and the limited amount of

resources available, there is clearly a need as well as an

opportunity for innovation in cancer care delivery in Ontario.

Successful implementation of patient-centred models of care

will likely require changes to the current methods of health

care financing. The absence of payment mechanisms for key

elements of a care model can make providers less inclined

to make the required investments and practice changes.13

It is also important to better understand how to harness

emerging e-tools to support the stronger patient role in care

management that is key to patient-centred, collaborative care.

Cancer Quality Council of Ontario Signature Events

The Cancer Quality Council of Ontario (CQCO) is charged

with a mission to improve the quality of cancer services in

the province while contributing to Cancer Care Ontario’s

vision of “working together to be the best cancer system in

the world.” Accomplishing these goals requires benchmarks

to compare Ontario’s cancer system to other jurisdictions as

well as constant innovation to improve services.

To support innovation and service improvements within

the cancer system, the CQCO regularly organizes Signature

Events where stakeholders and decision-makers work

together to identify system-wide recommendations for

addressing gaps in quality.

In December 2009, the CQCO hosted a Signature Event entitled

Innovative Models of Care – Why are we using 19th century

medical models for 21st century patients?, which focused on

how innovative models of care, including funding models,

from other cancer systems and the greater health care

system were being used to address the challenges of sustain-

ability in health care and heightened patient expectations

(Proceedings from Event available at: www.cancercare.on.ca/

signatureevents).

As a complement to this discussion, a Signature Event

entitled Using Technology to Improve the Patient Experience

in Cancer Care was held in June 2009, focusing on how

technology contributes to innovations in models of care

(Proceedings from Event available at: www.cancercare.on.ca/

signature events). In particular, the event aimed to understand

how technology can be used to transform the care delivery

model, and to empower patient connections, navigation

of the health care system and social networking.


3.0 A system-wide approach to innovation

Numerous innovative models of care currently exist in our

health system and in other jurisdictions. These models

encourage collaboration and set high standards for the quality

of care delivered from the patient perspective. The Canadian

Partnership Against Cancer (CPAC) Service Delivery Models

Project has identified a wide range of innovations across

Canada including examples within Ontario, such as the Regis-

tered Nurse Performed Flexible Sigmoidoscopy Pilot Project,

which improves patient care by decreasing wait times,

and the Healing Beyond the Body Volunteer Program, where

volunteers provide emotional support and help patients

navigate the health care system. However, CPAC has also

stated that a system perspective in innovation is lacking in

the cancer system.14 Innovation in the system tends to remain

isolated to specific hospitals or regions. CPAC’s Service

Delivery Models Project will ultimately engage and collaborate

with health care professionals to bring these innovations to

a cohesive whole. At the same time, the cancer system needs

to break the barrier that inhibits the movement of innovations

in and out of the system14. Models such as group visits,

which have the potential to increase productivity and facilitate

communication among providers, have been adapted

to many sectors.

As administrators look for ways to sustain the cancer system

and improve patient care, there is a need to also examine

ways of working with various new settings and encourage

the sharing of models of care across settings.5

National organizations such as CPAC are creating the system

infrastructure to help provinces, regions and hospitals identify

available innovations and evidence-based practice models

that facilitate broader implementation. There is an opportunity

to examine and gain a better understanding of what else is

needed at the system level to facilitate the introduction and

adoption of new models of care. There are also opportunities

to collaborate with other health care stakeholders to learn

from those working in various settings – from the hospital to

social and community services.

4.0 What do we need to support the

cancer system’s ability to implement

innovations in a patient-centred

service delivery model?

In preparation for the Cancer Quality Council of Ontario’s

December 2009 Signature Event, a literature review was

completed which looked at models of care with a patient-

centred focus. The literature review examined corresponding

enablers and barriers to implementation in the cancer system

as well as in the broader health care system. Reviews of

collected articles also looked at experiences using different

remuneration models and whether incentives resulted in

an improved quality of care. Through these reviews and

the panel discussion at the December 2009 Signature Event,

the following key enablers for successful models of care

were identified:

Encouraging communication and collaboration between •

providers and systems


Creating cultures of change within organizations •

and systems

Facilitating dissemination of innovations system-wide•

Collecting evidence•

Building guidelines and monitoring innovations •

through measurement

4.1 Encouraging communication

and collaboration

Collaborative multidisciplinary teams and effective comm-

unication at all levels – from frontline providers to top

management – are essential to successful models of care.

Collaboration is critical to change, whether that change

is a small-scale project, such as developing comprehensive

interventions in primary care, or a major undertaking such

as the redesign of health care services.11, 15 When adopting

a new model, the involvement of providers in the develop-

ment and planning stages is important to their continued

engagement.16 Models employing new provider positions

to improve the coordination of patient care require clinicians

to have strong relationships with one another.17 For example,

key partnerships and periodic meetings between the clinicians

and policy-makers contributed to the success of the Pivot

Nurse in Oncology initiative.18 When lack of communication

creates challenges, processes should be established to ensure

communication occurs throughout the model and all providers

are engaged in the process.10 For example, in the model for

group visits – where health care providers from various

disciplines see a patient together – strong communication

with patients and other health care providers is embedded

as a primary enabler.

At the system level, partnerships are important to models

of care. Linkages with outside organizations, both locally and

nationally, are critical when implementing new models of

care.19 Bottom-up development commonly occurs when there

are partnerships between the providers, policy-makers and

the research community.20 Partnerships with universities and

the community are valuable because they bring complemen-

tary strengths together.10,19

4.2 Creating cultures of change

Regions, hospitals and clinicians need to embrace and

promote a culture of change. The Quality Improvement

& Innovation Partnership, a provincial organization funded

by the Ministry of Health and Long-Term Care with the

goal of advancing the development of a high-performing

primary health care system, states that improvements are

achieved “when at every level, in every department, discipline

and site, continuous improvement is being made to meet

the patient’s needs and expectations by establishing systems

and cultures to achieve results.”21 Before implementing

a new model of care, there needs to be commitment to a

widely understood change strategy.17 The Ottawa Model for

Smoking Cessation includes a step to assess the environment

to see how best to implement the model into the structure

of the organization.22 Central policies are primary drivers

for change, particularly when changes shift care among and

between different care settings.15 In the Netherlands,

the government established a centralized advisory commit-

tee to identify barriers to adopting a new model of care and

propose policy measures to solve implementation issues.23

Commitment at the institutional level is critical to bringing

forward new models of care.19

Training and education initiatives are central to an institution’s

ability to adapt to new models. When strategies are imple-

mented across the system, continuing educational activities

need to inform providers of the changes.24 Staff should be

encouraged to maintain and further develop their skills,

through such activities as in-house professional development,

conferences and seminars.10


Professional boundaries and scope of practice should

be considered when implementing new models of care.

One example shows that when skills for roles are not

established at the institutional level, it can result in ambiguity

of professional roles.25 The regulation of providers’

roles and competencies should be defined and analyzed.9

Role stereotyping can be a barrier to implementing new

models; for this reason, roles must be communicated

to entire health care teams.26 Many clinicians have limited

knowledge of the competencies and legitimate scopes

of practice of other health care providers. 27 The Ontario gov-

ernment recently passed Bill 179, which revises and clarifies

scopes of practice for a number of professions in health care.

Champions and leaders at the hospital level are necessary

to encourage and assist innovations. Clinicians, who tend to

have great influence on the spread of innovations, can cham-

pion preferred models.15 Champions who push change in

the organization from the bottom-up – from high-level

administration to front-line providers – have common qualities,

including being well regarded in their field and having a

strong commitment to achieving the goal of the model.19

Motivation of individuals on the team affects whether a model

is adopted. It is critical for new models to have commitment

from all providers from front-line to the very top.22

4.3 Facilitating dissemination of innovations

The adoption of an innovation and its implementation across

the health care system are dependent on a number of factors.

For example, a policy “push” at the early stage of an innova-

tion can increase the chance of successfully spreading the

model of care,28 while the perception of the innovation is a

key factor in its dissemination and the rate at which it spreads

throughout an organization or system.29 Innovations tend

to have higher chances of being adopted when they are

perceived as being less complex, compatible with the values

of the organization, demonstrate visible improvements,

and can be launched as a pilot. 28,29

Innovations that can be modified to suit an organization’s

needs are also more likely to be adopted.28,29 For example,

inventors of the Ottawa Model for Smoking Cessation

encourage the “bastardization” of their model to meet

the population needs of organizations and to increase the

chance it will become a routine of the organization.22

Innovations can also be more effective when the organiz-

ation hires staff who are familiar with the local environment

and who have a greater understanding of what resources

are available and how to access them.10 The Pivot Nurse

Oncology model, for example, was designed to adapt to

rural areas where health care providers may not have the

same qualifications as their counterparts in urban areas.18

Models of care should remain flexible to accommodate

geographic and cultural variations between regions

and organizations.19


4.4 Providing evidence, measurement

and guidelines

Evidence-based practice in the health care system is

becoming the status quo.30 A lack of scientific evidence

can result in the overuse of unhelpful care and the underuse

of effective care.29,30 Often, implementing new models of

care involves developing processes that minimize the gap

between research evidence and research practice.30

The Institute of Medicine’s framework identifies two areas

of “translation blocks” – one which impedes movement

of science to clinical studies and another which impedes

the translation of those studies into the health system.20

In the United Kingdom, the NHS (National Health Service)

Improvement program stresses the importance of develop-

ing evidence that demonstrates that a model of care

is beneficial, of high quality and meets safety standards.5

Accurate and timely information about the dissemination

process can increase the chances of the innovation becoming

an integral component in an organization’s model of care.28

A key component of the Ottawa Model for Smoking Cessation

is providing feedback to clinicians using the model to keep

them motivated, as well as providing quantifiable results that

compare current outcomes to outcomes in prior practice.22

Guidelines are another important aspect of disseminating

models of care. Furthermore, the enforcement of guidelines

is a vital step in developing an organization’s quality improve-

ment strategy. After guidelines are implemented, health

systems develop outcome measure indicators to see if the

specific intervention was successful.24 For example, the Cancer

System Quality Index, published each year by the Cancer

Quality Council of Ontario in partnership with Cancer Care

Ontario, measures adherence to guidelines and reports on

the progress cancer centres and hospitals have made

towards standards and targets to ensure patients receive

the highest quality care.

5. 0 What is technology’s role in

facilitating innovation and improving

patient care?

Across Ontario, technology has been a key enabler in a number

of patient experience innovations. At Princess Margaret

Hospital, Caring Voices [www.CaringVoices.ca] provides cancer

patients with a way to connect virtually with each other

and with clinicians. The MyHealth Passport at Sick Kids Hospital

(www.sickkids.ca/good2go) enables youth with chronic

conditions to create a wallet-sized health information card

they can use to facilitate their transition from paediatric

care. Tele-oncology through the Ontario Telemedicine Net-

work allows patients to consult with their care team

via web-conferencing technology rather than having to

travel long distances for a face-to-face meeting.

However, while examples of technological innovation exist

across the province, they are largely known at the local level,

limiting the potential for system-wide application. Identifying

system-wide implementation priorities and investments is

also limited by lack of an evidence base.


To support discussions at the June 2009 Signature Event,

the Cancer Quality Council of Ontario collaborated with

the Information Management and Information Technology

division of Cancer Care Ontario and the Educational

Informatics team at Princess Margaret Hospital on a com-

prehensive environmental scan on the role of technology

in improving patient-centred care. This scan was completed

through two parallel phases.

In Phase One, the collaborators completed a review of research

related to the patient experience and existing innovations in

models of care. Of particular interest were models, frameworks

and delivery systems that:

focus on cancer control and/or care between •

the diagnosis and survivorship phases;

are used with other chronic illness populations;•

are designed to maintain or improve patient care, •

for example with a particular focus on approaches to

increase ‘patient empowerment’ in the health system; and

incorporate a new approach or an improvement relative •

to more traditional approaches.

Models of care considered for inclusion also had to meet two

or more of the following requirements:

have been tested and evaluated formally or informally•

have not been evaluated, but could be assessed •

and replicated

focuses on empowering the patient •

A number of common characteristics emerged in the

models identified, including patient-centered communication,

information and education, self-care and support in the

community. These characteristics provided a framework for

understanding the findings from the second phase of the

environmental scan. In Phase Two, collaborators completed

a review of the evidence base related to the implementation

of various electronic tools and technological applications.

The literature search identified 16 types of technology

(See definition table in Appendix A). The key findings were

then mapped to the common characteristics identified

in Phase One.

5.1 Patient-centred communication Effective communication is one of the most important

components of the physician-patient relationship,

particularly when the goal is to achieve patient activation.


Effective physician-patient communication can be defined

as interactions that give both parties sufficient information

to come to the right conclusion or decision.31 For doctors,

this means getting the information they need to make the

correct diagnosis and to suggest one or more evidence-

based treatment plans. For patients, it means getting the facts

they need to make an informed decision. Effective physician-

patient communication – whether it’s about cancer or other

conditions – not only includes health information but also

takes into account beliefs, attitudes and values that may

influence a patient’s preferences for outcomes and risks of

treatment. Good communication is also vital to ensuring

effective shared care between cancer treatment centres and

health care teams. Technology such as secure email and Web

messaging between patients and providers have been found

to have a positive impact on patient satisfaction levels.32,33

Email or Web messaging appears to be used for non-urgent,

non-sensitive matters, including test results, prescription re-

newals, updates and questions related to medications.34,35,36,37,38

Enabling such options for timely patient-provider interactions

may contribute to patient satisfaction.

5.2 Information and education

Consumer awareness and education play an important role

in cancer care. Providing information has been found to

empower cancer patients by helping them gain control and

promote self-care and particpation.39,40,41 Education about

cancer diagnosis, treatments, current health status including

complications, and recommendations for medical monitoring

and wellness are some of the ways to help patients make

informed decisions on their health care. Efforts are being

made to empower patients through access and control of

their medical records by maintaining Personal Health Records

(PHR). While there is limited empirical evidence supporting

the benefits of PHRs,42 studies have shown that access to

PHRs may educate patients about their medical condition43

and improve their communication with physicians.44,45

Patients using patient portals have been found to experience

an enhanced sense of security about their health and health

care.46 Studies found the majority of patients used a patient

portal to access their laboratory and test results.46,47

5.3 Self-care

Activated and engaged patients are more likely to monitor

and manage their own health status outside of traditional

care settings. Effective self-management requires realistic

goal-setting and devising ways of achieving those goals

with the necessary supports. Patients’ use of technological

applications such as mobile health tools and online disease

and lifestyle management programs have shown a range

of positive impacts, including patients feeling actively

engaged in their care and management,48 and improved

ability and motivation to look after their health. 49 In some

instances patients have also experienced decreased

symptoms and improvements in their health behaviours

and satisfaction levels.49,50

Patients who want to assume a more active role in their

care can do so by taking certain steps that give them

more control over their health and care. These steps include

getting a second – or even a third – medical opinion,

working to improve their health and lifestyle by adopting

better habits and accessing complementary therapies

such as psychotherapy, spiritual healing and self-help groups.

These activities may help patients accept their diagnosis.


5.4 Support in the community

Clinical care and social support are recognized as priorities

for the survival and quality of life of cancer patients.

Especially after treatment is complete, cancer survivors must

cope with emotions, uncertainty, as well as practical and

financial challenges. From diagnosis to long-term survivorship,

cancer survivors, their families, and their health care providers

depend on community-based resources to meet their

psychosocial needs. In order to ensure comprehensive care

for cancer survivors, new approaches for increasing awareness

and use of community resources are essential for improving

survival and quality of life. Emerging Web-based collaboration

tools, such as online communities, blogs and wikis, offer

the potential to drive a major shift from traditional resource

directories and printed pamphlets.51,52 These collaborative

technologies can give patients, survivors, families and care-

givers better access to emotional support and improve their

ability to share and exchange information and experiences

across time and distance. 53,54,55

While the evidence base for e-tools is promising, it is still

under development. Deficiencies in research methodologies –

such as small sample size, specific study population, selection

criteria, and self-reported data – limit the ability to generalize

findings. However, despite such limitations, the emerging

theme overall is that e-tools, including social media, do provide

opportunities to engage patients and caregivers more

directly in care management. Such direct patient engagement

not only empowers patients but enables a more patient-

centric, collaborative model of care with the potential to deliver

much needed system efficiencies. From a system perspective,

further evidence is still needed to assess the impact of

patient engagement on actual care outcomes as well as on

the cost-effectiveness of developing technological solutions.

However, from the patient perspective, the lack of a rigorous

evidence base is not slowing the pace at which they are

embracing technology innovation. Consensus appears to

be building among providers and planners that this is not just

a populist trend but a new reality and, despite the lack of evi-

dence, there should not be delays in movement on this front.


6.0

Where can we benefit from different

financial models in the cancer system?

Financial models are key enablers in implementing new

models of care. Having remuneration models which encourage

key aspects of a model of care – for instance multidisciplinary

collaboration – can facilitate implementation. As described

in Table 1 on the following page, hospitals are funded through

a global budget with a trend in volume-based funding. But

there are a number of remuneration models to fund physicians

and specialists, including salary, billing for services, incentives

and blended models that incorporate multiple methods of

remuneration. An expert panel at the December 2009

Signature Event addressed a number of financial models,

including fee for service, capitation, salary, pay for performance

and episode-based funding.

6.1 From fee for service to capitation

Fee for service and capitation are viewed as opposite ends

of the funding spectrum (Figure 4).56 These two remuneration

models work toward the same goal of keeping populations

healthy, but use diametrically opposed approaches. A fee

for service payment model, where pay is based on services

provided to each patient, gives physicians the incentive to

increase productivity and the intensity of their services. In

comparison, a capitation model, which consists of salaries

adjusted for the population served, creates an incentive for

physicians to provide less treatment and reduce costs.

Each model yields positive outcomes and drawbacks. 56,57

The fee for service model provides good access to care, but

may lead to shortened appointment times and over-servicing

of patients.57 Fee for service is considered the primary cause

for unnecessary care.58 Organizations should ensure there

is no over servicing, for example, in the area of follow-up

appointments.5 A study of fee for service and capitation

models for physicians in Ontario showed physicians in the

blended capitation model had fewer patients and their

patients had lower morbidity and co-morbidity incidences

as well as more visits to the emergency department.59

In between fee for service and capitation are the salary-based

and case-based models. A salary-based model pays providers

for time spent and is seen to be closer to the spectrum

of fee for service. Salary remuneration models do not provide

incentives to ensure that time is used well or spent on required

or essential services.57 One method of paying medical

oncologists in Ontario uses a blended remuneration model

where a base salary is combined with fee for service to incent

certain types of behaviour. Currently, wait times for systemic

therapy may be partially related to perverse incentives in

the existing remuneration model. Using blended models can

help ensure that medical oncologists’ care achieves the right

balance between well-patient follow-up and treatment for

new patients waiting for care. Financial renumeration should

be part of policy and funding discussions to reduce wait

times while maintaining high quality care.

Tim Doran, MPH, 2009

Increasing incentives to increase productivity & intensity

Increasing incentives toavoid treatment & reduce costs

Cost FFS Salary Case rates Capitation

Figure 4: Objectives of Financial Renumeration Models


Case-based models, which pay providers for each case they

treat, are closer to the capitation model on the remuneration

scale. Depending on the “resource intensity weights” applied

to cases, physicians may have an incentive to treat the least

complicated cases, potentially under-serving patients with

more complicated needs.57 Conversely, incentives can also be

given for more complex cases, leaving easier cases untreated.57

South Eastern Ontario Health Science Centre replaced fee

for service with an Alternate Funding Program, a type of case-

based model with a base salary and fee for service component.

The Alternate Funding Program was found to have no impact

on the overall volume at South Eastern Ontario Health

Science Centre, and led to only minimal changes in the case

mix specialists.60 However, radiation oncologists in Ontario use

an Alternate Funding Program and wait times in radiation have

been decreasing.2 Organizations should be careful to ensure

that the plan adequately compensates for different priorities

which could potentially result in clinicians favouring particular

types of cases.

ROLE FUNDING MODEL(S)

Hospitals

Primary CarePhysicians

Medical Oncologists

RadiationOncologists

SurgicalOncologists

- Global budget funded by the Ministry of Health and Long-Term Care through the Local Health Integration Networks (LHIN) to allocate funding to each hospital within the LHIN

- Capitation - Fee for service- Incentives to form teams, and also for programs such as ordering Fecal Occult Blood Test (FOBT) kits.

Alternate Funding Plan with a blended model of:- Salary - Incentive related to “shadow billing” (>80%) Fee for service is used by a small number of medical oncologists and a subset of these receive some salary support

Model is based on billing fee for service but has additional remuneration methods and incentives: - Specialty Repair Fund (for academic Surgical Oncologists only)- Incremental volume fund as part of the Cancer Surgery Agreement, which results in increasing surgical volumes and surgeon remuneration in a fee for service arrangement- Regional Program Stipends to support surgical leadership and administration- A billing code for Multidisciplinary Cancer Conferences (MCCs) is being created to provide incentive to implement the MCC Guideline. This likely will be directed toward community-based surgeons as well as pathologists and radiologists.

Alternative Funding Plan with a blended model of:- Base salary and - Fee for service

Table 1: Funding Models in Ontario’s Cancer System


The cancer system in Ontario employs a number of remu-

neration models which have demonstrated some benefit

and posed some challenges. But no serious attempt has

been made to relate them to hospital funding and budget

allocations. Unlike primary care where physicians practice

on their own or with a team of other health care providers,

specialists work out of hospitals, which have a separate

means of allocating funds. Tension can arise from models

where incentives are not harmonized. For example, hospitals

have incentives to have high volumes and discharge

patients quickly, while physicians have incentives to decrease

volumes when paid on a capitation system.57

The current financial remuneration model in Ontario’s cancer

system does not align providers to work together towards

common goals, and does not aim to serve the models of care

desired by the 21st century patient.

Models for patient-centred care require financial redesiging

to align with care delivery.8 For example, problems arise

when there are no billing mechanisms for the care model or

for key elements from collaborative care.13 Models which

seek to correct some of these issues are pay for performance

and episode-based funding.

6.2 Pay for performance

In pay for performance models, payments are based on

outcomes achieved for a set of quality indicators.61

Physicians working for Kaiser Permanente, for example,

are paid a salary in a capitation model with a bonus

for performance and administrative duties. A portion

of the capitation amount paid to the group of physicians

or medical group is withheld, and is paid only if the

financial results meet the forecasted ones. 62 It is suggested

that withholding money may be more effective than

bonuses when it comes to driving performance improve-

ment because the provider is no worse off if they don’t

change their behaviour; they just forgo an extra payment.63

A pay for performance model was introduced for all family

practices in 2004 in the United Kingdom. The performance

incentives were given in addition to the physicians’ salary,

based on 146 quality indicators, and resulted in a 25 per cent

increase in the physicians’ income. Outcomes of the indicators


were shown to vary; for some, the rate of providing care

significantly increased, although this could be the result of

physicians taking greater care to record the services they

were providing.64 Other indicators were not affected by

the incentive and continued as projected. Finally, for some

of the indicators, once the incentive was taken away there

was a decline in the number of physicians providing care,

contrary to projections without the incentive. For these

reasons, attention needs to be paid to how incentives are

chosen, the repercussions of their removal, and their impact

on the physician’s perception of how much the system

values a particular aspect of care.64

The pay for performance model can also affect behaviour

negatively by resulting in ”gaming” and other changes

in behaviours. Gaming occurs when providers find ways

to maximize the desired outcome without actually

accomplishing the objective.57 63 For instance, the pay for

performance model for family physicians in the United

Kingdom had an exception reporting system which

allowed physicians to exclude certain patients from indica-

tors.56 Behaviour can also be altered in other negative ways,

by concentrating on measured items that offer incentives

or by not trying innovative approaches for fear that it

will affect performance measures.63 Indicators should be

carefully analyzed before selection.

Surgical oncologists in Ontario are compensated using a fee

for service base with additional performance incentives.

The incentives are for volumes as well as surgical leadership

within regions. This funding method has been successful

in lowering wait times over the last few years.2 However, the

example from the United Kingdom demonstrates the need

to continuously re-evaluate the effectiveness of pay for perfor-

mance schemes in driving providers to meet their goals.

Public reporting is used in some cases in pay for performance

models. Leapfrog Group is a consortium of health care

purchasers in the United States who advocate for a pay for

performance model with a focus on public reporting

to improve overall quality and safety in health care.65 They

measure hospital performance, with incentives and rewards

for high quality care. Kaiser Permanente has common

reporting measures for physicians in their pay for perfor-

mance models – developed collaboratively by health plans,

physicians researchers and other industry experts – where

bonus payments are provided to medical groups that

meet targets.62

In Ontario, the Cancer System Quality Index (CSQI) measures

a number of quality indicators at the Local Health Integration

Network (LHIN) level. Public reporting of results has been

shown to drive poorly performing LHINs to take actions

to improve.2 The CSQI is an important tool for ensuring all

regions offer a similar level of care, leading to an equitable

standard of care across the province. However, hospitals

subject to both public reporting and financial incentives

improved quality more than hospitals engaged only in public

reporting.63 The CSQI is currently not attached to financial in-

centives and there is no public reporting at the provider level.


6.3 Episode-based funding

Episode-based funding can be described as a system of

payment where payments are organized through a medical

condition or ‘care cycle’ rather than different specialties,

on a carefully defined set of integrated services and practices.

It is argued that value-based competition would focus on

the value of service being improved for the patient and

provider through improved quality and efficiency.66 However,

there is not a significant amount of research that evaluates

episode-based funding in practice.

One documented model is the Prometheus payment model,

which is currently being piloted in select hospitals in the

United States. The model bundles services for all the care a

patient requires over a defined clinical episode or a set period

of managing a medical condition.67 The budget provided

for the bundle is an evidence-informed base payment with

patient-specific severity adjustments, plus an allowance

for potentially avoidable complications.67 The opportunity

for financial gain or loss lies in providing high quality, safe care

by eliminating or minimizing potentially avoidable complica-

tions. The model is not appropriate for all reimbursements

because you need highly specific guidelines or standards

to determine the budget of the care package. However, the

model does seek to improve quality and encourage collabora-

tion across the larger portion of the patient pathway.

Current hospital funding models in Ontario are not well

aligned to physician remuneration. Neither the salary-based

nor the fee for service model of remuneration of oncology

specialists encourages collaboration of physicians with other

health care providers. For salary-based care, there is no

incentive to delegate less complicated tasks to other health

care providers because the level of the work is not evaluated.

The same barriers to collaboration can be seen in fee for

service models. But in the case of billing for services, if the

task is not completed by the specialist then there is no

compensation for the task.

In Ontario, oncology specialists have a variety of funding

models, which strive to correct the basic issues of using

one financial remuneration model. However, the result is an

extremely complex system that may fail to take into account

the entire patient journey, including transitions through care,

and the overall efficiency and sustainability of a system

where all providers at a hospital are performing tasks that

maximize their scopes of practice.

7.0

Recommendations

As Vice President of Clinical Programs & Quality Initiatives,

Dr. Carol Sawka, highlighted, there is a burning platform;

demand and resources are being maximized and patients

have higher expectations for how they receive and partici-

pate in their care. Innovations in models of care are required

if the cancer system is to become more sustainable. From the

discussion at the two events and from research undertaken

prior to the events, the Cancer Quality Council of Ontario

proposes the following recommendations to Cancer Care

Ontario and its partners as a framework for facilitating

innovations in models of care and working towards a new,

patient-centred model of care.


1. Model of care: Improving quality, maximizing

resources, and using international leading practices

Cancer Care Ontario needs to look at new models of care

in this resource-constrained environment. Patient-centred

models with more direct patient and provider engage-

ment can improve the quality and safety of care and

increase access. They can also enable much needed

system efficiencies and improve on the sustainability of

the system. In developing new patient-centred models

of care, Cancer Care Ontario can leverage leading practices

from the literature, experiences with other disease sites

and other jurisdictions. Patients with cancer are treated

in a number of settings and share many of the same

issues as other patients accessing health care. The Cancer

Quality Council of Ontario has renewed its emphasis

on looking at international best practices to take

advantage of global expertise from within and outside

the cancer system.

To guide this work, the CQCO proposes a new Patient-

Centred Model of Care Framework (Figure 5). This frame-

work articulates eight enablers that will be critical to

the success and sustainability of new models of care

for the cancer system. The framework is dependent on

robust patient engagement and is anchored by appropri-

ate financial models and remuneration schemes that

align within the key elements of the model of care.

The other six enablers extend from the system level to

the individual level.

At a system-wide level, models of care will be enabled

by a corporate-wide focus on integration to create insti-

tutionalized structures that facilitate transitions across

the patient journey and as patients use health services

outside the cancer system. The implementation of

the performance improvement cycle will be extended

at a system level beyond clinical care. At a regional level

through Cancer Care Ontario, models of care will be

enabled by e-tools and a stronger evidence base that

removes regional barriers to the transfer and adoption

of knowledge and practices across the system.

Finally, at the individual provider level the new models

will be enabled by improvements to supports for health

care providers and through performance reporting that

breaks down regional information to highlight

where best practices are exemplified in individual work.

For each of the eight enablers, there are specific

recommendations highlighted.

Recommendation

Use Cancer Care Ontario’s Models of Care working group, •

tasked with maximizing resources for sustainability, to

research and develop a proposal for a new model of care

delivery learning from international best practiceb to

improve the patient experience and enhance provider

satisfaction and quality.

2. Support the patient voice

Cancer Care Ontario has a robust model for engaging

clinicians at multiple points along the cancer journey and

through multiple methods such as provincial and region-

al clinical networks, communities of practice, mentoring

and academic detailing processes and workshop events.

This participation is essential for ensuring clinical rele-

vance and adoption of Cancer Care Ontario initiatives.

However, although engagement is key to improving

the patient experience, Cancer Care Ontario lacks a similar

model for patients.

Cancer Care Ontario needs to have an institutionalized

means for including the patient voice in all initiatives –

from development to ongoing implementation – based

on best practices. All programs and projects should

have clear methods for consulting with patients on new

and current initiatives that are based on principles of

equal voice and meaningful input. There are many ways

of doing this, including patient and family advisory

bodies, patient and caregiver surveys, town hall-style

consultations, focus groups, and online social net-

working sites.

b From the broader health sector


Prior to the June 2009 Signature Event , Cancer Care

Ontario’s Vice President of Clinical Programs & Quality

Initiatives, Dr. Carol Sawka, moderated a scheduled

online chat with patients and caregivers using Princess

Margaret Hospital’s Caring Voices social networking site

(www.caringvoices.ca). More than 25 people participated

in the chat – higher than the general rate of participation

in chats, which ranges from one to 15 people. This pre-

event online discussion demonstrated the ability of social

media to provide Cancer Care Ontario with new ways to

engage with patients across the province and across the

patient journey. At the same time, Cancer Care Ontario’s

ability to leverage the value of social media does not

have to be limited to direct participation. Much can be

learned from patients and survivors’ use of Web 2.0

by using approaches such as “data mining” what is

discussed online.

Recommendations

As a core goal in the Ontario Cancer Plan, Cancer Care •

Ontario should maintain and strengthen efforts to

improve the patient experience. It should increase its

focus on including patient input as an integral part

of all program activities – from program planning and

development to ongoing program activities.

– Cancer Care Ontario’s Clinical Programs division

should be encouraged to leverage, as appropriate,

social networking and existing patient/survivor

networks and communities, such as Caring Voices,

as tools for gaining patient input.

Cancer Care Ontario’s Clinical and Regional Programs •

should embed measures of the patient experience

as part of their performance measurement and

reporting expectations.

Patient engagement

Financial Supports

Support for system-wide performance improvement

Individual-levelperformance

reporting

Support for individual-levelimprovement

Corporate-widefocus on integration

Strongerevidence base

Model of Careensuring:

quality, access, efficiencyand safety

E-tools

Figure 5: Patient-Centred Model of Care Framework


Cancer Care Ontario’s Cancer Services & Policy Research •

Unit, in collaboration with research networks such as

the Innovation Cell and Elixir, should identify how existing

patient and survivor peer-to-peer and social media

collaboration can inform Cancer Care Ontario and the

cancer system.


performance improvement

Cancer Care Ontario has seen its improvement cycle

advance innovations in clinical practice, but the same

cycle needs to be applied to developing, implementing,

disseminating and maintaining internationally recognized

best practice models of care. Recommendations put

forward to strengthen the evidence base, increase the

output of best practice guidelines, and establish more

integration in the system all work towards utilizing the

performance improvement cycle to innovate

models of care.

Recommendation

Cancer Care Ontario should engage provincial and •

regional practice leadership in communities of practice

and other mechanisms to share best practices in areas

such as interprofessional communication, innovative

models, e-innovation and leadership training in

change management.


through integration

Although there is a role for individual health care

organizations to foster and implement innovation across

the patient journey, there is also a role for Cancer Care

Ontario to facilitate this process. However, it is challenging

to have models of care that span the patient journey

without processes and structures that follow the patient

pathway to ensure that the information and collaboration

needed to support these models are available. Currently,

Cancer Care Ontario’s Disease Pathway Management

program is looking at the entire journey for one disease

site, but more programs need to have structures spanning

across the continuum of care to facilitate transitions

between care for patients and to lessen the appearance

and feeling of discrete treatment phases for the patient.

Recommendations

Cancer Care Ontario should extend the focus on multi-•

disciplinary models beyond the realm of programs and

into the broader corporate-level environment by creating

processes and structures that are explicitly interdisciplinary

and cut across stages of the patient pathways.

Cancer Care Ontario should include as a key priority in •

the Ontario Cancer Plan integration among cancer care

providers and between steps of the patient journey.

Cancer Care Ontario’s Information Management and •

Information Technology division should include, as part

of its strategy, a program to enable integration within

the cancer system as a top priority, aligning with the

broader provincial eHealth agenda and the strategies of

other health system partners such as Infoway.

The Cancer Quality Council of Ontario should work •

with Cancer Care Ontario’s Informatics team in the Infor-

mation Management and Information Technology

division, the Cancer Services and Policy Research unit

and/or external health services research units –

such as the Health Policy, Management and Evaluation

department at the University of Toronto Centre for

Health Economics, Services, Policy and Ethics Research

in Cancer Control at the Canadian Cancer Society –

to identify and develop key indicators for measuring

and reporting on the cancer system integration in an

ongoing and sustainable basis via the Cancer System

Quality Index.


5. Strengthen the evidence base

Working together with its Program in Evidence-Based

Care (PEBC), Cancer Care Ontario develops a significant

number of evidence-based guidelines and standards.

It is just as important to have this practice applied to

models of care. Evidence is critical to disseminating in-

novations to organizations, which take considerable time

and effort to implement a new model. Evidence is also

critical to motivating health professionals to continue

with the model post-implementation.

An important aspect of efficiency when establishing

best practices is to ensure health care providers

are maximizing their skill sets. Planning and Regional

Programs at Cancer Care Ontario is currently working

on resource modeling for systemic treatment. By looking

at which health care providers are administering which

type of care or treatment, they are identifying the most

efficient team practice.

As best practices are identified, Cancer Care Ontario

partnerships also need to be strengthened to facilitate

information sharing of evidence-based care from outside

of the cancer system, since several aspects of delivering

cancer care intersect with other health sectors.

Recommendations

Cancer Care Ontario’s Clinical Programs should engage •

the PEBC, and others groups as appropriate, to:

– Synthesize evidence on effectiveness – including cost-

effectiveness – of new models of care and provide

guidance around best practices.

– Synthesize evidence and articulate best practices

for funding/remuneration alternatives, including pay

for performance models.

– Synthesize evidence and articulate best practices for

the use of technology in communicating health care

information, beginning with the peri-diagnostic and

survivorship stages and including the provision of

clinical information to the patient. For example: what

test results should be released to patients and when

should these results be released.

Cancer Care Ontario should engage the Models of Care •

working group to develop proposals for alternative

delivery models, including:

– Exploring innovative pilots that maximize existing

scopes of practice within cancer care and seeking

support for implementation from the Ministry

of Health and Long-Term Care’s Health Human

Resources group.

– The Models of Care working group should expand the

work of the Resource Modeling group to treatment

areas other than systemic, and to other phases of the

patient journey, in a unified and coordinated way.

– Developing and implementing demonstration

projects on group visits for the peri-diagnostic and

survivorship phases in collaboration with the

Survivorship working group.

Cancer Care Ontario should apply lessons learned from •

innovative practice models in other disease sites to pilot

projects focusing on new ways of delivering cancer care.

6. Use e-tools to inform and empower patients

Despite the rapidly growing use of online tools and

resources by patients and caregivers, health care provid-

ers lack the necessary supports to enable them to appro-

priately guide and support patients and caregivers in the

use of online tools and resources as they support

models of care.

Providers and organizations require mechanisms to

support the use of technology for innovative models of

care, particularly in the area of follow-up – a phase of

the patient pathway with processes that can vary from

one patient to another.

Recommendations

Cancer Care Ontario should incorporate technology •

innovations to improve the patient experience as a core

component of its Information Technology/Information

Management strategy.


Cancer Care Ontario’s Planning and Regional Programs •

should work to establish appropriate incentives or

rewards for technology initiatives aimed at improving

the patient experience.

Cancer Care Ontario, in collaboration with appropriate •

partners such as the Canadian Cancer Society and

the Canadian Partnership Against Cancer, should develop

demonstration projects that identify specific online

resources and tools to serve as an information prescription

for each stage of the cancer journey. Intended to help

meet patient and caregivers’ needs, these pilot projects

should be implemented and evaluated at the Regional

Cancer Program level.

– Resources from trusted Ontario or Canadian sources

should be identified. For example, the Canadian Part-

nership Against Cancer’s Cancer View Canada website.

Cancer Care Ontario’s Clinical Programs should work •

with the Information Management and Information

Technology division to pilot an e-tool intervention that

supports the needs of cancer survivors in the follow-up

phase of cancer care.

– As appropriate, the e-tool intervention should

incorporate social media.

– The implementation should include a robust

evaluation framework that looks at not only the impact

to survivors, caregivers and health care providers,

but also identifies the organizational supports needed

to enable successful implementation.


and mentoring

While documentation is a valuable tool to enable the

transfer of successful practice, many of the key factors

that contribute to the widespread adoption of innovative

models of care are not captured. Instead, they remain

embedded within the creator and early adopters of the

model. Such individuals can serve as mentors for newer

implementation teams. Mentoring and learning from

leading practices of other organizations can be enhanced

through use of e-tools, which enable teams to connect

with less regard to time and space.

Recommendations

Cancer Care Ontario should engage its provincial and •

regional clinical networks to enable more systematic

dissemination and uptake of regional best practices for

using technology to improve the patient experience.

Cancer Care Ontario should partner with de Souza Insti-•

tute, the Canadian Cancer Society, the Canadian Partner-

ship Against Cancer, or other appropriate organizations

to design and develop systematic dissemination programs

that leverage networks and knowledge to enable

collaboration and mentoring.

8. Enable individual-level performance reporting

The Cancer Quality Council of Ontario has focused on

reporting at the regional or Local Health Integration Net-

work level to affect performance improvement at the

system level. While system-level performance management

will continue to play a role in supporting new models

of care, individual-level performance reporting warrants

consideration. Individual-level performance reporting

supports pay for performance financial models and helps

identify areas for ongoing quality improvements.

Cancer Care Ontario’s ColonCancerCheck program will

make progress reports available to providers which

will enable them to identify which of their patients are

due for screening or at risk for an incomplete screening.

These reports will also let providers track their progress

towards screening incentives.


Recommendation

To drive and support ongoing quality improvement, •

Cancer Care Ontario should explore, together with

provincial and regional clinical leadership, providing

information to individual clinicians.

9. Address financial and reimbursement challenges

It is clear that the cancer system and health care system

as a whole do not have aligned financial models.

Remuneration of physicians and hospital global budgets

have different incentive processes and do not act as

proponents for new collaborative models of care that

take into account the patient journey. Cancer Care

Ontario needs to examine other financial models such as

episode-based funding, which rely on providing care

in a multidisciplinary team over a larger portion of the

patient journey, as opposed to separate discrete visits to

clinicians and hospitals.

As Cancer Care Ontario closely examines financial

models that could be beneficial to the cancer system,

the Ministry of Health and Long-Term Care (MOHLTC)

could gain valuable insights from analysis within the

cancer system which likely correlate to experiences by

other disease sites in primary and tertiary care.

Since financial models affect the overall health care sys-

tem, Cancer Care Ontario needs to conduct this analysis

with partners who have complementary perspectives on

this issue, and who can contribute additional insights to

the evaluation process.

Recommendations

Cancer Care Ontario should establish a working group •

with its partners on remuneration and financing of the

cancer system.

– A provincial working group, together with Cancer

Care Ontario’s Models of Care working group,

should provide input and advice regarding the

alignment of physician and hospital incentives

and payment models.

Cancer Care Ontario’s Models of Care working group •

should work on evidence-informed changes to specialist

remuneration within the cancer system.

Cancer Care Ontario should, together with the appropriate •

external organizations, propose a harmonized remunera-

tion system for physicians and hospitals.

Cancer Care Ontario should work with the appropriate •

external partners to pilot episode-based funding in

regional cancer centres or partner hospitals interested

in testing this funding model.


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Appendix A: Definition of Technology Tool Types

CATEGORY TOOL TYPE DEFINITION

H

ea

lth

fro

m a

Dis

tan

ce

Co

lla

bo

rati

ve &

Ad

ap

tive

Te

chn

olo

gie

s

Pe

rso

na

l H

ea

lth

In

form

ati

on Patient Portals

Personal Health Records (PHRs)

Wikis

Blogs

Microblogging

Online Communities

Online Patient-Provider Communication

Home-telehealth

Patient portals are websites that offer patients online access to health information, services, and clinical care.1

Consumer health information is information that empowers consumers to make informed decisions about their health and health care.17 Online consumer health information may include flat files, databases, videos or interactive technologies/sites.

Consumer Health Information or Online Sources of Health Information

A personal health record (PHR) is a universally available2 electronic application that allows people to access, manage, and share3 their lifelong health information4 and that of others for whom they are authorized, in a private, secure, and confidential environment.

A tethered PHR is a patient-accessible health record that contains individualized health information which can be accessed, maintained and shared by the patient. A standalone PHR is software that allows health information to be entered by the patient but that has no connection to

provider electronic medical records.5

A Wiki is a collaborative website6 designed to allow the contribution and modification of content by viewers.7 As documents evolve, changes are tracked as “histories” in an underlying database.8

Microblogging is a new form of online communication from individuals to many12 where users can describe their current status in short posts. These are distributed by instant messages, mobile phones, email or the Web.13

A blog (the contraction of “web log”) is an online journal.9 Blogs are published chronologically, with links and commentary on various issues of interest.10 The term blogosphere refers to all blogs and their linkages.11

An online community is a social network formed or facilitated through electronic media,14 where communication can be asynchronous (e.g., online message boards) or synchronous (e.g., chat), and may or may not be moderated or facilitated.15,16

Online patient-provider communication refers to asynchronous communication between patients and their health care provider (i.e., email or Web messaging). Web messaging systems are accessed by logging into a secure website via common browsers (e.g., Internet Explorer).18,19 While generally referring to communication between patients and their current health care provider, communication can occur without any pre-existing doctor-patient relationship.20

Teleconsultation can be defined as a clinical consultation between health care providers and patients that involves the use of real time interactive video.21

Home tele-health describes the use of telemedicine techniques in non-institutional settings (e.g., at home or in an assisted living facility)22 to exchange health information and provide health care services across geographic time, social and cultural barriers.23

Mobile Health (mHealth)

Teleconsultation

Mobile health, or mHealth, is the use of mobile computing, medical sensor and communication technologies for health care.24


1 Weingart SN, Rind D, Tofias Z, Sands DZ. Who uses the patient internet portal? The PatientSite experience.Journal of the American Medical

Informatics Association. 2006; 13(1): 91-5.

2 AHIMA e-HIM Personal Health Record Work Group. Practice brief. The role of the personal health record in the EHR. Journal of the American Health

Infromation Management Association. 2005; 76(7): 64A-64D.

3 Tang PC, Bates, DW, Overhage JM, Sands DZ. Personal health records: definitions, benefits, and strategies for overcoming barriers to adoption.

Journal of the American Medical Informatics Association. 2006; 13(2): 121-6.

4 Markle Foundation. Connecting for Health: A Public-Private Collaborative. Markle Foundation. 2003.

5 Wiljer D, Urowitz S, Apatu E, DeLenardo C, Eysenbach G, Harth T, Pai H, Leonard, K J, Canadian Committee for Patient Accessible Health Records.

Patient accessible electronic health records: exploring recommendations for successful implementation strategies. Journal of Medical Internet Re

search. 2008; 10(4): e34.

6 Seeman, N. Web 2.0 and Chronic Illness: New Horizons, New Opportunities. ElectronicHealthcare. 2008; 6(3).

7 Briceno, AC, Gospodarowicz, M, Jadad, AR. Fighting cancer with the internet and social networking. Lancet Oncology. 2008; 9(11): 1037-8.

8 Barsky, E, Dean, G. Introducing Web 2.0 wikis for Health Librarians. JCHLA/JABSC. 2007; 28: 147-150.

9 Boulos MN, Maramba I, Wheeler S. Wikis, blogs and podcasts: a new generation of Web-based tools for virtual collaborative clinical practice

and edu cation. BMC Medical Education. 2006; 6: 41.

10 Boulos MNK, Wheeler S. The emerging Web 2.0 social software: an enabling suite of sociable technologies in health and health care education.

Health Information and Libraries Journal. 2007; 24(1): 2-23.

S

elf

-ca

re/

Se

lf-m

an

ag

em

en

t to

ols

Personal Status Web Pages

Patient Decision Aids

Disease and LifestyleManagement tools

Disease management interventions are health care programs that focus on preventing any deterioration in health status and/or complications for populations in which patientself-care efforts are significant. In the context of consumer empowerment, this model can be extended to general health or lifestyle management, where the focus lies with the maintenance or improvement of an individual’s health status.29

Rating sites are online tools that allow consumers to rate physicians or facilities on a selected set of characteristics (e.g., punctuality, usefulness or knowledge). Ratings reflect the collective intelligence regarding the rated physician or facility.6

Health Rating Sites / Health Care Performance Indicators

Personal status Web pages are Web pages that individuals can set up for themselves, or that can be set up by friends or family. Through stories, photos and information on these pages, members can update friends and family who can send messages of support. The pages can be used for a specific health event (e.g., hospitalization) or by patients with chronic conditions.25

Patient decision aids are intervention tools that are designed to assist the treatment decisions of patients with life-threatening diseases such as cancer,26 by informing them about the benefits and drawbacks of different treatment options (or other care) without advocating a particular choice.27,28

Patient navigation tools are resources that are intended to expedite patient access to services and resources, and improve continuity and coordination of care throughout the cancer continuum.30 Patient navigation targets a defined set of health services that are required to complete an episode of cancer-related care.31

Patient Navigation Tools


11 Seeman N. Inside the health blogosphere: quality, governance and the new innovation leaders. Healthcare Quarterly. 2009; 12(1): 99-106, 4.

12 Hawn C. Take two aspirin and tweet me in the morning: how Twitter, Facebook, and other social media are reshaping health care. Health Affairs.

(Millwood). 2009; 28(2): 361-8.

13 Java A. Why we Twitter: Understanding Microbiology Usage and Communitees. Joint 9th WEBKDD and 1st SNA-KDD Workshop. 2007.

14 Wellman, B. An Electronic Group is Virtually a Social Network’, in S. Kiesler (ed.) Culture of the Internet. Mahwah, NJ: Lawrence Erlbaum. 1997; 179–205.

15 Demiris G. The diffusion of virtual communities in health care: concepts and challenges. Patient Education and Counseling. 2006; 62(2): 178-88.

16 Lieberman MA, Golant M, Giese-Davis J, Winzlenberg A, Benjamin H, Humphreys K, Kronenwetter C, Russo S, Spiegel D. Electronic support groups

for breast carcinoma: a clinical trial of effectiveness. Cancer. 2003; 97(4): 920-5.

17 Burkell J and Campbell DG. What does this mean? How Web-based consumer health information fails to support information seeking

in the pursuit of informed consent for screening test decisions. Journal of the Medical Library Association. 2005; 93(3): 363-73.

18 Liederman, EM, Lee JC, Baquero VH, Seites PG. Patient-physician web messaging. The impact on message volume and satisfaction.

Journal of General Internal Medicine. 2005; 20(1): 52-7.

19 McGeady D, Kujala J, Ilvonen K. The impact of patient-physician web messaging on healthcare service provision.

International Journal of Medical Informatics. 2008; 77(1): 17-23.

20 Umefjord G, Hamberg K, Malker H, Petersson G. The use of an Internet-based Ask the Doctor Service involving family physicians:

evaluation by a web survey. Family Practice. 2006; 23(2): 159-66.

21 Mair F, Whitten P, May C, Doolittle GC. Patients’ perceptions of a telemedicine specialty clinic. Journal of Telemedicine and Telecare. 2000; 6(1): 36-40.

22 Wootton R, Dimmick SL, Kvedar JC. Home Telehealth: connecting care within the community. Royal Society of Medicine Press. 2006.

23 Reid J. A Telemedicine Primer: Understanding the Issues. Billings, MT, Innovative Medical Communications. 1996.

24 Istepanian R, Jovanov E, Zhang YT. Introduction to the special section on M-Health: beyond seamless mobility and global wireless

health-care connectivity. IEEE Transactions on Information Technology in Biomedicine. 2004; 8(4): 405-14.

25 CarePages [Internet]. Retrieved May 7, 2009, from http://www.carepages.com/.

26 Molenaar SS, Sprangers M, Postma-Schuit F, Rutgers E, Noorlander J, Hendriks J, De Haes H. Interpretive Review : Feasibility and Effects of Decision Aids.

Medical Decision Making. 2000; 20(1): 112-127.

27 Williams L, Jones W, Elwyn G, Edwards A. Interactive patient decision aids for women facing genetic testing for familial breast cancer:

a systematic web and literature review. Journal of Evaluation in Clinical Practice. 2008; 14(1): 70-4.

28 Barnato AE, Llewellyn-Thomas HA, Peters EM, Simnioff L, Collins ED, Barry MJ. Communication and decision making in cancer care:

setting research priorities for decision support/patients’ decision aids. Medical Decision Making.2007; 27(5): 626-34.

29 Demiris G, Afrin LB, Speedie S, Courtney KL, Sondhi M, Vimarlund V, Lovis C, Goossen W, Lynch C. Patient-centered applications:

use of information technology to promote disease management and wellness. A white paper by the AMIA knowledge in motion working group.

Journal of the American Medical Informatics Association. 2008; 15(1): 8-13.

30 Brebner C, Jones R, Krisjanous K, Marshall W, Parry G, Holt A. Electronic Medical Consultation: A New Zealand Perspective.

Journal of Medical Internet Research. 2001; 3(1): e13.

31 Wells KJ, Battaglia TA, Dudley DJ, Garcia R, Greene A, Calhoun E, Mandelblatt JS, Paskett ED, Raich PC, Patient Navigation Research Program.

Patient navigation: state of the art or is it science? Cancer. 2008; 113(8): 1999-2010.

Cancer Quality Council of Ontario 620 University AvenueToronto, ON M5G 2L7

Phone: 416-971-9800 extension 1247Fax: 416-971-6888

Email: [email protected]

In partnership with: