A digital healthcare pathway
The Digital Care Pathway optimizes staffing by reducing waste across the full care cycle of the patient’s care. These will be measurable savings.
The Halton Digital Health Care Pathway will create an interoperable system for patient/client flow across hospitals, community-based providers and physician practitioners for people accessing mental health, substance use and addiction services.
Health Providers in Halton understand that the real innovation in Halton is our willingness to partner to create systems solutions that cut across sectors and organizations to serve people in our community.
Two Ontario Health Teams (Burlington and Oakville), together with insight from the MH&A Alliance, procured “Calian Digital Solutions” to build the Halton Digital Health Care Pathway, which will allow local providers to graduate from independent and siloed digital health attempts to a systems approach - implementing a holistic digital health solution. Calian is a known integration platform employed to create digital virtual solutions for as broad a scale as Health Authorities and as specific as Wellness Hub.
The Halton Digital Health Care Pathway is a critical site for the Ministry of Health (MOH) and Ontario Health (OH) to broadly incubate and test the Digital Health Strategy under design for the province. The effort will build on provincial goals in provincial data collection, data-defined decision making and digital communication alternatives (i.e., Patients before Paperwork, Pb4P).
Halton is the ideal site for innovation and incubation of new models because its health providers collectively serve a diverse community of 625,000 youth and adults through two hospitals, six community-based mental health providers, and over 450 primary care physicians.
Halton’s health partners have successfully built integrated pathways for clients in the areas of centralized access to community-based services, step-down paths from acute care hospitals, step-up services for physicians, and cross-agency models which are responsive to clients with increasingly complex clinical treatment needs (i.e. unhoused individuals in encampments, substance use disorders, etc.).
At its core, the Digital Health Care Pathway is an exercise in creating value in the healthcare system by creating cost savings in client care (i.e., the elimination of duplication) as well as creating value from the patient/client’s perspective (i.e., patient-reported outcomes). The area of “value-enhancing IT platforms” is an evidence-based approach that is:
Centred on patients. “The system follows patients across services, sites and time for the full cycle of care. Data are aggregated around patients, not departments, units or locations.”
Encompasses all types of patient data.
Accessible to all parties involved in care. In a value-enhancing system, “the system architecture makes it easy to extract information (i.e., the data needed to measure outcomes, track patient-centred cost, and control for patient risk factors). Such systems enable patients to report outcomes on their care, not only after it is completed but also during care, to enable better clinical decisions.”[1], [2]
In Halton, reasonable outcomes of deploying the Digital Health Care Pathway for mental health and addictions will be:
An Integrated Pathway: Provide seamless care for patients/clients with mental health and addictions (MHA) needs by integrating approved EMR systems across sectors. The minimal required outcome will be a vertically integrated virtual EMR pathway (i.e., hospital care – community care –primary care) and a horizontal care solution (i.e., across community-based mental health providers).
Validated Learnings from Clients | Client Voice: Be a genuine incubator that validates learnings with clients, informing patient preferences and creating care pathways.
Equitable Access to care for people facing barriers to care and who have alternate access points.
A Governance Framework: The community is aware that this audacious plan will require excellence in governance regarding digital integration, shared information, and information and communication protocols.
Provincial Strategy: Propel aspects of the MOH/OH Digital Health Strategy forward and produce actionable learnings on the ground and in practice.
Innovation Health Care Principles
The use of Information Technology alone may not seem that innovative. However, as Michael Porter outlines in The Strategy That Will Fix Health Care (HBR, October 2013), building an enabling Information technology platform is central to building a value-based healthcare system.
In the study of Good To Great companies, the relationship between technology and innovation was a central driver in companies that created sustained value over decades. They articulate that “good to great companies used technology as an accelerator of momentum, not a creator of it” (p.164). Eric Reis, in The Lean Start Up, identifies that innovation is an evidence-based practice for those whose work it is to disrupt the norm. It is a replicable process that builds from an ‘a-ha moment’ to a scientific implementation process.
Porter’s observation that “historically, healthcare IT systems have been siloed by department, location, type of service, and type of data” remains true today. This is the norm this initiative aims to disrupt! Porter further describes that “often IT systems complicate rather than support integrated, multidisciplinary care. That’s because IT is just a tool; automating broken services-delivery processes only gets you more efficient broken processes.”
There are three pillars in building the Digital Care Pathway:
Integrated Care Pathways across Sectors: This effort will map the key EMRs in each of the sectors to design a new ecosystem across sectors without changing native EMR systems. As such, a step-up and step-down pathway will be created for mental health, substance use and addictions.
Integrated Practice Teams: Cross-functional teams which operate across sectors/organizations are becoming the norm in meeting the needs of clients with complex mental health and substance use needs. Achieving true inter-professional care in these contexts requires " providing front-line clinicians with seamless and digitally connected systems” [1] to achieve a ‘full cycle of care’ for patients as they travel across services and sites.
Person-Centred Care: Person-centred care begins with the understanding that the patient’s perspective differs from the provider’s. Key design features include enabling technology that facilitates the patient’s experience by removing duplications, providing clarity as to the next step of service, and ensuring that patient risk concerns are not lost in the system. Furthermore, patient-reported assessments are collected early in the patient’s journey to inform service throughout their care. Embedded assessments (level of care tool and clinical measures) can help track improvement across agencies.
A Progressive Digital Health Journey in Halton
There have been progressive efforts across healthcare providers in Halton to respond to presenting issues via a digital solution. As such, across Ontario Health Teams, community-based MHA organizations, and primary care providers, at least five proposals, many of them OH-funded, explored Halton's patient and provider pressures and proposed creative solutions.
The Halton Digital Care Pathway builds on these validated efforts which have occurred locally and which respond to specific practice needs. The following diagram highlights steps in our journey and positions the task ahead.
Key design elements will remain central in our model of care, including:
Unified Care Plan (2020): This CC-OHT (Oakville) )-led effort procured a digital solution to create patient care plans that could serve across sectors. This multi-year program has built relationship consistency across partnerships and helped create an initial IT Governance Framework.
Integrated Virtual Care (2022): This CMHA-led effort received funds to purchase technology with installed intake tools. This creates equitable access for clients facing mental health and addiction services barriers.
Clinical System Renewal (2022): This CC-OHT (Oakville) supported an initiative with the Halton Physician’s Association (HPA) that explored the communication needs of physicians. Although not funded, it provided a valuable understanding of the scope of primary care needs that remains relevant today. Defined physician communication needs and tools to optimize primary care workflow for over 450 physicians.
Community Wellness Hub |Calian Procurement I: Burlington OHT commissioned this procurement effort with the support of the Joseph Brant Hospital. This effort resulted in selecting Calian Digital Solutions to serve their Community Wellness Hub by allowing for integration within the hospital and across agencies.
Integrated EMR Solution - Procurement II (2023): Building on the above procurement effort, Oakville OHT and CMHA Halton led a process to select a digital integration solution. The procurement company (Shared Services West) validated that Calian met the design needs for integration and endorsed the solution. SSW ensures that procurement aligns with the Broader Public Sector procurement directives.
Validation with Ontario Health & Centre of Excellence (2023+): As the strategic plan of OH (Digital Health) and the Centre of Excellence (CoE) unfolds, the system has greater clarity on both the provincial goals and the EMR systems that they will continue to support. Clarity with OH/CoE has ensured the use of Calian to facilitate integrations that will serve the needs of OH and provide feedback on key metrics of interest.
An interoperable system
Through respective digital journeys and in combination with Health Standard Organization’s key design principles, the following innovations in care have been identified for implementation [2]:
Coordinated Continuum of Care & Services: A collaborative platform that is capable of bringing in EMR systems across sectors to support the ‘full care cycle’ of clients across sites and organizations.
An Interoperable Information System: An interoperable digital platform and information communication tools, with one real-time health record.
People-Centred Teams: People are prioritized as members of the care team and, more importantly, given tools to access their healthcare records, communicate with providers, monitor their appointments and more.
Digital Tools to Facilitate Primary Care: Communication and connection.
Elimination of Waste: Reduction of paper in patient care.
The complex problem of system fragmentation will be addressed by bringing the right enabling technology together with people and partners. Calian will be central to engineering solutions that will help bring innovation in design in patient and provider collaboration. With over 20 years of helping healthcare institutions transform, Calian will support us in achieving excellence in Virtual Care and collaboration, Data Integration and interoperability, and Cloud Services.
Reducing redundancy
Implementation of the Digital Health Pathways system will help providers understand where we have duplicated efforts and costs in the system. Currently, there are independent organizations purchasing solutions that partially meet our needs. Implementation of this digital pathway will improve flow and reduce costs over time.
In addition, our approach to the Digital Care Pathway will be to understand specifically the use case (e.g. which programs and people we mean to include) and determine which IT features are used by patients and providers. Most costs faced in the next two years will be integration and testing. Anticipating and tracking cost savings across the system is led by a Solutions Analyst who will conduct User Application Testing to reveal where there are cost savings and allow us to repurpose existing dollars for any future identified ongoing costs. Finally, for an effort like this, there are grants available for private-public partnerships for which we become eligible.
The Digital Care Pathway optimizes staffing by reducing waste across the full care cycle of the patient’s care. Efficiency is gained in HHR by streamlining pathways and eliminating redundancy in the system. Building intake, triage, and pathway-streaming into the process allows staff to work to the scope of their practice. These will be measurable savings.
A Measurable Solution
The virtue of this virtual platform allows for data extraction for ongoing analysis. Patients/clients utilizing the Digital Health Pathway will provide valuable understanding. We believe that this effort will provide measurable data in the following domains:
System-level (Region & Province)
Emergency department visits – i.e., reducing ALC by reducing admissions and facilitating discharges
Understanding Patient Pathway utilization across the hospital, community-based and primary care (e.g. Step-up and Step-down)
Understand the impact of diversion, admission and discharge patterns in the community.
Wait times for community-based mental health care
Digital Health (Efficient & Effective)
Determination & Reduction of Paper-driven Pathways
Common assessments completed at key milestones (e.g. Level of Care Tool, clinical assessments, assessments related to social determinants of health)
Risk of Harm – elevate understanding of client involvement for clients in the system facing risk of harm
Client Tools & Patient Reported Outcome(s)
Introduction of Client tools such as access to records, secure chat and a shared appointment calendar across multiple organizations
Client access to referrals, summary documents and client visit history
CMHA Halton will act as the lead partner and be responsible for all contracts and deliverables. They will also lead the consultation and support with Calian Digital Services. As required, CMHA Halton will purchase staff participation in the model from partner organizations where their capacity is required.
CMHA Halton and members of the MH&A Alliance have a strong history of successful partnerships and delivering on projects of similar scope. This includes the implementation of such programs as Justice SafeBeds (provincial initiative), Integrated Virtual Care (provincial), the Ontario Structured Psychotherapy program (provincial in two OH Regions), and the 988 Suicide Prevention Implementation (National Providers with CAMH).
A range of partnership agreements support the work:
Data Sharing Agreement (DSA) has been developed by the Collaborative Committee of CCHOHT, Halton Healthcare, Acclaim Health, Halton Region and Home and Community Care Support Services to ensure privacy and security mechanisms are in place as new digital projects are developed and implemented.
Memorandum of Understanding with cross-agency programs such as SafeBeds, PHAST (Joseph Brant), Court Support Services and numerous other service provisions.
Memorandum of Agreement (beta) with the Mental Health & Addictions Alliance (i.e., all adult MHA care providers in the region).
The Oversight Structure of the Digital Health Care Pathway will match the innovation that we hope to design in the domains of Client Access, Flow and Transitions, and IT Solutions. The proposed structure visualizes the importance of clinical input & an IT networking team to achieve success.
References
[1] The Strategy that Will Fix Health Care, M. Porter, Harvard Business Review, October 2013
[2] Redefining Health Care, Porter and Teisberg, 2006
[3] Ontario Health Bulletin – Digital Excellence In Health Update, Email communication of Susan deRyk dated July 31, 2023
[4] Health Standards Organization’s “Integrated People-Centred Health Systems” – 10 Key Design Principles for Integration (p.IX)