Innovation in the Canadian health system

Introduction

The essence of human ingenuity is creation and novel ideas that result in collective and desired impact. Indeed, innovation is foundational to life in a changing world. In no situation today is this more relevant than in health systems, whether they be challenged to maintain population health, threatened by impending disasters, or expected to respond to the ever-expansive demand and inexorable course of those with chronic diseases.

This article discusses health system innovation and its trajectory. It focuses on clinical innovation as a means of achieving high-level performance within a Learning Health System (LHS) model. Examples of innovation in Canada are used to illustrate successful approaches worthy of broader consideration and pan-Canadian attention.

What is innovation?

Few terms in health and healthcare seem to be used more frequently or differently than “innovation,” a word that suffers from semantic satiation. There are countless definitions and wide-ranging uses of the term. This article offers a simple working definition, with inputs from many sources:

Health system innovation is the phenomenon of developing and/or delivering new or improved health technologies, products, services, policies, or practices.

Technologic innovation in healthcare involves a new invention, technology, or product or a technology-enabled approach or intervention. Some of these innovations have been transformative, such as the introduction of laparoscopic surgery or phacoemulsification in cataract removal.

Non-technologic innovation relates to a novel practice, service, or way of doing or thinking about things that derive a preferred result, such as prone positioning of critically ill patients with hypoxemic respiratory failure in order to improve oxygenation. For the most part, this article deals with non-technologic innovation and, specifically, clinical innovation designed to achieve high performance.

The trajectory of innovation to implementation

Whether an innovation is technical or non-technical, it has to have a start and finish. The ‘starts’ happen with an idea and champion. To have relevance or impact, it must be implemented. The trajectory from idea to completed implementation can be long and tortuous, with well-recognized gaps between scholarly research and uptake by the health system or market. Eventually, and after varying periods of use, the lifecycle of a technologic innovation reaches a point at which it wanes in value or popularity, there is something better to replace it, and disinvestment and obsolescence ensues. ¹

This trajectory may be further disrupted by the reality that appropriate diffusion of technology does not always follow an orderly or predictable course, wherein the right innovation takes place at the right time and is used in the right way for the right purpose. Some innovations diffuse too rapidly yet are of unproven or limited value, such as widespread vitamin D screening. Other potentially beneficial innovations may be slow to achieve uptake or effective use, such as earlier commencement of palliative care in non-cancer patients.

Enabling the trajectory

It is recognized that there are steps and a trajectory for diffusion of technologic innovation, as described in models of innovation and technology adoption. ² In many countries, this has prompted the emergence of structures and processes meant to support and catalyse this technology transfer and trajectory, such as innovation strategies, springboards, accelerators, pipelines, corridors, and hubs; with or without clearly defined goals and actionable outcomes; and with variable degrees of reported success and impact.

On the non-technologic side of innovation, particularly clinical innovation, there is similar emergence of models, structures, and processes. These are similarly meant to inform, support, and catalyse this knowledge transfer and trajectory through practice and policy change aimed at achieving high performance.

Learning health systems to achieve high performance

In this past decade, the LHS model has emerged to offer guidance in achieving high-level system performance. Distinctive structures, processes, and outcomes of LHSs combine with the aim of optimizing health system performance and delivering greater value. ^3,4 High performance is usually judged in relation to measures of achieving the Quadruple Aim of better health, improved healthcare outcomes, and greater value for money, with engaged and fulfilled care providers. ⁵ Notable international examples of systems that accomplish this include Intermountain Health and Birmingham East Primary Care Trust. ^6,7

Learning Health Systems are constructs in which “science, informatics, incentives, and culture are aligned for continuous improvement and innovation, with best practices seamlessly embedded in the delivery process and new knowledge captured as an integral by-product of the delivery experience.” ⁴ This suggests a highly dynamic and iterative approach to the issue, in which each act of care liberates data. From this, continuous and iterative improvement is informed and results, with measurement driving management and management changing and influencing what is measured and how it is used.

Learning Health Systems require vision, leadership, and infrastructure to flourish. Such systems are organized to learn at every level of scale, from a single clinician’s practice to a hospital unit or an entire provincial system. They require structure and essential building blocks including:

robust, comprehensive, and accessible data;

The LHS Framework as promulgated by Charles Friedman portrays a model with an identified intent or issue at its core and with phases to address or achieve it arranged around that core—data to knowledge (D2K), knowledge to performance (K2P), performance to data (P2D), and so on. ⁸

OPEN IN VIEWER

Framework for a LHS: Adapted from Charles Friedman et al. ^5,7

A major component of the D2K phase is health and healthcare research, while K2P has formed the basis for the expansive field of knowledge transfer, and P2D continues to evolve into integrated knowledge translation, in which there is a highly iterative relationship between practice performance and the data generated by it. The formation of a learning community, such as a clinical or research network, may occur or be created at any stage in this cycle and act as an enabling vehicle to engender and sustain change.

Clinical innovation in LHSs

The handling of the COVID-19 pandemic in 2020 by governments, public health agencies, other officials, providers, researchers, and countless is an outstanding example of LHS development and approaches in Canada. Measurement has been central to pandemic management provincially and nationally. Management has influenced what has been measured and how it has been used (P2D). Moreover, knowledge gaps have been identified and, in some cases, filled, and there has been a flurry of new research and funding support to stimulate it (D2K). As knowledge has advanced, it has changed public health direction and messaging, as has been the case with asymptomatic transmission and how it has influenced both practices and communications (K2P). What we do know has translated into robust information dissemination and advice, which has been better and more organized in some provinces than others, but Canada-wide, it has been a live demonstration of LHSs in action. Continuous learning from this experience will have indelible effects on Canada. It has acted as a nation-wide preparation to more broadly and deeply drive and improve our health systems through the LHS model.

Even before the pandemic, many favourable features of LHSs were becoming more apparent in Canada, such as the commencement of CIHR’s Canadian Data Platform and several provincial examples discussed later. Moreover, in this past decade in Canada, in alignment with and informed by the LHS model, two phenomena appear to be developing simultaneously, patient engagement and clinical networks. Where these have been harmonized, interesting results are emerging. Both seek to implement evidence-informed, patient-centred innovation designed to maintain health, to fill care needs and gaps, and to achieve best value throughout the patient’s health trajectory.

Patient engagement has been enabled and advanced in this past 5 years by the “Strategy for Patient-Oriented Research” led and funded by the Canadian Institutes for Health Research. This work is supported by matched funding from each province. Simultaneously, clinical networks comprised of physician and non-physician clinicians, patients, and researchers have been forming. Many have been using the LHS model to drive change, with early findings that they are able to achieve the Quadruple Aim at scale. ⁹ Momentum has been enabled by continuing health system integration into fewer regions or single provincial delivery systems.

Promising Canadian examples of LHSs and clinical innovation

Of the current and varied examples across this country, the following are selected and differing LHSs in Western Canada. These are chosen because of their common characteristics as seen in the LHS model. Each is a clinical or research network with demonstrably strong leadership, meaningful patient engagement, and systematic approaches to change and improvement, with each informed by continuous measurement and iterative processes for change.

A maturing and comprehensive example of LHSs in Canada is the Strategic Clinical Networks (SCNs) in Alberta. In June 2012, Alberta Health Services introduced SCNs as engines of innovation to work at provincial scale. ¹⁰ The SCNs are collaborative clinical teams. Each has a provincial and strategic mandate, with defined goals of achieving best outcomes, getting greatest value for money, and engaging clinicians and patients in all aspects of the work. The SCNs are led by clinicians and physicians; involve patients, community partners, researchers, and policy-makers; are driven by demonstrable clinical needs, based on measurement and best evidence; and supported by research expertise, infrastructure, quality improvement, and analytic resources. In short, SCNs are about improving the outcomes and value of the health system in Alberta at scale.

There are now 16 operational SCNs in Alberta at various stages of maturity, with each focusing on demonstrable populations or clinical healthcare issues. Recent publications have shown how the SCNs are advancing the LHS model in Alberta and leveraging the advantage of a single healthcare delivery system that was the first to be established in Canada in 2008. ¹¹

A comprehensive analysis of the SCNs’ collective impact and return on investment showed a direct cost savings of $15.2 M and reduction in bed days of 43,000, for a total saving of $42.3 M from the first nine signature projects carried out, with a reported 2:1 return on investment.

The Rural Coordination Centre of British Columbia (RCCbc) is a provincial, rural, and physician-led clinical network. It includes physicians, patients, and other members of the primary healthcare team. ¹² Its intended purpose is improving the health and healthcare of rural patients and their communities. This network started in 2005 to advance interprofessional and collaborative practice. It has strong and committed leadership, measurement and research support, and a core oversight body (governance). This network has shaped rural health system innovation and change. It has done so in a socially accountable manner, with a focus on health equity and narrowing the gaps in care in rural and remote British Columbia (BC). The Network is data-driven and depends on knowledge synthesis and the wisdom of the learning community to choose priorities for change.

As an innovative approach to maximizing the advantages of digital infrastructure, information, and communications technologies, and prompted by COVID-19 pandemic in early 2020, RCCbc supported and championed the implementation of a provincial virtual care platform and a shared electronic medical record to enable virtual access to care and services. This included novel care and exchange, such as with the First Nations Doctor of the Day, and creation of a provincial virtual emergency room.

These programs occurred through an unyielding commitment to partnerships. They used a rapid cycle innovation and acceleration approach in testing and iterating the options and subsequent selection of a best fit. Implementation occurred in 2 weeks from finalization of a funding agreement to activation of accounts for over half of the rural physicians in BC (as of May 2020). The platform is driven from a clinical interface, with utilization across BC and adoption by multiple agencies.

Canada is in demonstrable need of a major and positive transformation in how we think about and care for older adults and their families and the experience of nursing homes. This has been made starkly apparent from the COVID-19 pandemic. Learning Health Systems in nursing homes have been developing and have been enabled and informed by Translating Research in Elder Care (TREC). Operating since 2007, this is the only large-scale, multi-disciplinary research network working longitudinally in the residential long-term care (nursing home) sector in Canada. The TREC has completed studies and clinical trials that have made immense contributions to how health authorities and nursing homes can translate and implement innovation and improvement.

This network has long-term and notably strong scientific leadership. It receives international expert advice and has a core multi-disciplinary and multi-provincial/state membership, with an oversight body that influences course and direction (governance). It is grounded in strong metrics, data acquisition, standardization, and analytics. It has made novel discoveries across the long-term care sector related to symptom burden at the end of life, reducing burnout among frontline workers, documenting increased complexity among residents, uncovering the extent of social isolation and the associated care challenges among adults with no friends or family, documenting the severe under-detection of health issues, developing a system-level composite indicator of quality, and establishing the importance of the care unit in nursing homes. ^13,14

Considerations for health leaders

What are the implications for those responsible for the outcomes of health systems? Why address issues and challenges through the LHS approach? As Henry Ford said, “if you always do what you always did, you will always get what you have always got.” Hence, if the current practice is not getting the results one seeks, this is the time and the argument for new and innovative ways of thinking about issues and doing things differently to achieve improved outcomes and value for resources used. This is unachievable without central involvement of clinicians. Moreover, in consideration of everything we have learned in these past years, the patient voice and that of their family/friend caregivers must be fully integrated into decision-making.

Innovations may be implemented if the essential components of the LHS model are assembled. This requires the common characteristics of strong and sustained leadership, clear vision and goals, a core team with team-based approaches to decision-making, a backbone of supports, and a continuing and iterative process of change based on input from measurement and evidence. Health system managers and leaders can enable such an environment for learning if they encourage top-down, bottom-up decision-making to flourish. This requires a culture of co-operation and collaboration, wherein there is an expectation to achieve alignment between the executive/senior leadership, clinical leaders and practitioners, and patient voices around common goals, measurement, and management of the measures. While there is no single recipe for achieving success in the trajectory of innovation to implementation, there must be a clear line of sight and a navigable plan between the innovation and achieving one or more goals of the Quadruple Aim.

Paths forward

Innovation in health is alive and well in Canada. At no point has this ever been more important. This is an ideal opportunity to learn about innovations coming from others, near and far. While there is no single solution for structure or process, the examples demonstrate the features and components of LHSs in Western Canada. Each has had collective impact at scale.

The components for LHSs are present in many parts of Canada. The successful assembly of these components in some places demonstrates that system-level change of this sort can and should be taking place across and throughout Canada.