What could health-care reform look like on P.E.I.?

Attempts to reform Canada's health-care system — particularly when it comes to primary care — are nothing new.

Ten years ago, Dr. Monica Aggarwal, a professor at the Dalla Lana School of Public Health at the University of Toronto, first listed a series of features she believes should characterize high-performing primary health-care systems in Canada and similar countries.

Some points Aggarwal outlined had been in the works for years before she looked into the subject. But she says actual implementation was spotty at best. By 2022, she told CBC News in a recent interview, that was still the case.

"Back in the 2000s, there [were] some federal investments that were made," she said. "But in terms of progress, no jurisdiction really has done a great job in implementing primary-care reform, which is why I think we're facing so many of the problems we are right now."

British Columbia, Alberta, Ontario and Quebec have made the most progress toward reform, according to Aggarwal. And all of them have something in common: they have made the required financial and logistical investments to make the features she pointed out more widespread.

"That is the reason why a lot of them have been able to move in the various different areas," she said. 

For example, she said, "in Ontario we have a long history of investing in interprofessional teams. Although only 25 per cent of our population has access, there has been a lot of effort and initiatives put in place to move reform."

Why teamwork works

Moving toward team-based health care is key when it comes to addressing shortages of physicians, Aggarwal said. 

Essentially, that means health professionals from a wide set of disciplines — think dietitians, nurse practitioners, pharmacists and mental health professionals — work together to provide care for the same patients.

Experts have long pointed out the benefits, including fewer needs for time-consuming referrals, better health outcomes for patients and less spending. In P.E.I., this arrangement has come to be known as "medical homes and neighbourhoods."

"It just allows everyone to practise to their scope and focus on the things that they're trained to do," said Dr. Krista Cassell of the Medical Society of P.E.I.

"We have underused many of our paramedical professions. And we're certainly seeing that that [we've] stepped up during the pandemic," she said, pointing out that pharmacists can now do everything from vaccine administration to treating minor illness.

"So as more and more practitioners practise to their scope, [that's] freeing up everyone to do just exactly what they can — and should — be doing with their time."

P.E.I. has made the transition toward team-based health care one of its main priorities. Ten medical homes are now operating and serving patients on the Island in some capacity, and the province plans to have another four ready by the end of March.

Recently, the government said it had created 90 new positions to ensure the homes are appropriately staffed.

Aggarwal said the expansion is a welcome step forward, but she cautions that governments need to ensure these systems include accountability mechanisms, and that performance is measured.

I don't think we necessarily need more doctors. I think we need interprofessional teams to work together to build capacity.— Dr. Monica Aggarwal

"If we had interprofessional teams, then it would improve capacity for these physicians and allow for patients to have access to other providers," she said. 

"I don't think we necessarily need more doctors. I think we need interprofessional teams to work together to build capacity."

The role of nurse practitioners

Gail Macartney, an assistant professor with the University of Prince Edward Island's faculty of nursing, said she'd like to see the province invest in clinics led by nurse practitioners, which are also based on the team model.

Nurse practitioners, or NPs, are trained to serve similar roles to family doctors. In P.E.I., they have a fuller scope of practice than in most parts of the country, being able to do things such as diagnose issues, order tests and write prescriptions as well as referring clients to other health-care professionals when needed.

The Island has a larger percentage of NPs per capita than any other Canadian jurisdiction except for the territories, and the number has been growing. Close to 90 of them are currently listed with the College of Registered Nurses in P.E.I. According to the Canadian Institute for Health Information (CIHI), there were only 45 NPs working in the province in 2020.

But Macartney says shortages in the broader health-care system are affecting how many nurse practitioners are available to fill gaps in the system.

It takes two and a half years for a registered nurse to finish training as a nurse practitioner at UPEI. The system doesn't have the flexibility to allow many nurses to reduce their hours while they're in school, Macartney said. That means nurses likely have to forgo full-time work — and the income it provides — while they complete the program.

"Being able to stop your nursing career… is very costly," she said. "And typically, we have students that are mid-career, [with] young families." 

Macartney would like to see some funding go toward helping nurses cover training costs so they don't have to worry about losing income.

Going digital

Another relief measure the P.E.I. government has emphasized is telehealth.

Expansion of virtual health-care services became a top priority for governments across Canada during the pandemic. P.E.I. received $3.5 million from Ottawa for that purpose.

In 2020, the province launched a pilot allowing people without family doctors on the Island to use the Maple virtual-care platform for free. More than 16,000 Islanders have been assessed through Maple since then.

Maple was in the spotlight this month as the federal government told provinces their health transfer payments could be at risk if they continued to allow private businesses to charge people for providing essential medical care. 

But the Canadian Medical Society sees online care playing a big role in increasing access, even though patients can get only limited care online. The society  argues that even more doctors could participate if barriers to practise in other provinces were eased.

The move toward an Island-wide electronic medical record (EMR) system has been far more rickety.

It's been over a decade since the province announced it would implement such a system, which would make health-care delivery more efficient by allowing doctors to share information about patients with other health professionals.

The vision: patients wouldn't have to give their medical history every time they saw a different specialist, and the results of bloodwork and other testing could be seen at a keystroke by everyone involved in the patient's care.

But the rollout? It has faced several holdups.

It was put on pause from June to September last year due to usability issues being reported by frustrated doctors, many of whom reported working well into the evening to catch up on filing the electronic information after seeing patients all day.  

As well, at the start of the pause, there were about 100 doctors yet to be connected to the system. And late last year, the government alerted Islanders that data errors in the system led to hundreds of gynecological referrals being delayed.

The transition to EMRs is one of Aggarwal's key strategic points.

According to the 2019 Commonwealth Fund Survey , P.E.I. has been a major laggard, with only a quarter of primary physicians exclusively using EMRs compared to about 85 per cent elsewhere in Canada.

Aggarwal said there's still more work to be done across Canada, particularly in making information move between different record-keeping systems.

"That's where we're pretty behind in the country," she said. "And, you know, collection of data is critical, right? Because that's the only way that we can monitor progress over time, and the only way we can continuously improve patient care."

Improving what data is available on the country's health-care system was one of the commitments tied to the new federal funding agreement hailed this winter.

In the announcement, Ottawa allocated $505 million for data initiatives, including creating common indicators across jurisdictions and refining existing data tools.

Medical Society of P.E.I. president Dr. Krista Cassell said the current data that's available is not extensive enough, particularly when it comes to figuring out which policies actually work to improve patients' lives. Essentially, you need to learn whether the money that's being put into the system is making a difference.

Are we providing value by having these services and is it worthwhile to the patient, or are we just adding yet another layer of cost and care?— Dr. Krista Cassell

"CIHI kind of keeps track of what happens in hospitals and what have you. But outside of that, you know, we don't have a lot of great access to data," the medical society president said. 

"What we really need to know is: Are we providing value by having these services and is it worthwhile to the patient, or are we just adding yet another layer of cost and care?" 

Whether or not the new deal leads to the reforms that are needed? That remains to be seen.

This is the third and last part of an in-depth series by Arturo Chang on how Prince Edward Island could fix its stressed system of providing primary health care.  Read the other parts: 

• Part 1: What does it mean when we talk about doctor shortages?
• Part 2: What can P.E.I. do to recruit more doctors?
• Part 3: What could health-care reform look like on P.E.I.?