Value-based Healthcare by Design Webinar: February 15, 2019

good afternoon ladies and gentlemen welcome to today's webinar I would like to remind you that this conference is being recorded at this time all participants are in a listen-only mode those connected by telephone require operator assistance during a call please press star 0 web participants requiring support should use a chat feature on your screen I would now like to turn the meeting over to your moderator Jennifer Zellmer president at the Canadian Foundation for Healthcare Improvement please go ahead thanks so much Val and hello and welcome to everyone on today's webinar about value-based healthcare by design identifying promising innovations in a Canadian context we'll begin the webinar today by acknowledging that we're meeting on land that has been inhabited by indigenous peoples from the beginning in particular we acknowledge that we're broadcasting this webinar from the traditional unceded territory of the Algonquin and initiative egg people we recognize and deeply appreciate their historic connection to this place as well as the opportunity to gather here today we also recognize the contributions that First Nations made T in UE and other indigenous peoples have made in this community and all those from which people are participating in today's webinar we invite you to participate in this webinar and either in English or in French and we're providing simultaneous interpretation to make this possible gave me or webinar Viveca feminine and lay a do prefer le français n'est hypotenuse on a for me I led de la boîte to dialogue it's great to see everybody introducing themselves to see some people I know and some new friends introducing themselves in the chatbox and I encourage you to do the same so that everyone gets a sense of who's on the webinar today we have more than 300 people registered so we're delighted to have participants from coast to coast to coast in Canada and beyond my name again is Jennifer Zellmer I'm today's host for the webinar here at CFA chai and it's part one in a series of webinars we plan to focus on value-based healthcare before we get started there's a few very exciting housekeeping mental health keeping items that I'd like to mention I'll be introducing our speaker shortly but as I said feel free to introduce yourself in the chat box throughout the webinar you can also use the chat box to send in your questions in English you are flossing will stop between presentations to respond and have also reserved some time at the end of the webinar for Q&A please also this is an all teach all learned process one of our true beliefs here at CFA chai so please feel free to share links and resources you might think you think might be of interest to others in the chat box as well and finally for those who are on Twitter we have a hashtag for you you can join the conversation with us by using hashtag vb HC so for value-based healthcare webinars so for those who have just joined us today welcome to this webinar on value-based healthcare by design and I'm going to provide an introduction to value-based healthcare just to get a started have a common understanding what it is what it isn't some key enablers some examples from Canada and then afterwards all focus on a set of assessment criteria that can be used for selecting or developing evaluates healthcare initiatives but I'm super excited to be joined by co-presenters Neal Fraser and Deb Klein who I have the pleasure of introducing Neal is the president of Medtronic Canada and regional vice president of camp for Canada for Medtronic he's also the chair of medic a board member of Baycrest Health Sciences and a member of the federal government helped in Biosciences economic strategy table which is the primary hat that he'll be wearing on the webinar today because in his presentation he'll be sharing some highlights from his role and the government's health and Biosciences economic strategy table including their fall 2018 report recommendations around value-based procurement kneels at frequent speaker and the topics of value-based procurement and outcomes based healthcare and in 2014 he was a member of the Federal Advisory Panel on healthcare innovation and the Ontario Health innovation Council he'll be followed by Deb Klein who's the VP of innovation and strategic partnerships at plexus a not-for-profit shared healthcare services organization in this role Deb works as a wide array of stakeholders to enable plexus hospitals to acquire products and solutions to support patients through value-based healthcare innovation procurement and the development of new business models and partnerships previously Deb was a director in PwC's healthcare practice and was the anterior Hospital Association's program leader for financial management Deb received his MBA from Rotman his Ahmed's from Boise with a focus on policy leadership diversity and change and his presentation today will cover Ontario's recent procurement initiative for cardiac devices and how it was shaped through a patient engagement strategy welcome to kneel to Dove and to everyone who's on the line with us today so getting started just a couple of seconds on who C FHI is so we're a national not-for-profit organization and funded by the federal government with a focus really on how do we provide and how do we help our partners to provide more improvement for more people right across the country and improvement at last we do that in in four main ways the first is to for areas where there are no one problems but not knowing solutions to identify innovators connect them with each other and help to raise the profile of their work the second area which is where a lot of our activity happens is focused on where there are proven innovations helping to spread and scale them so that more people can benefit the third area where we work is supporting improvement capable health systems so we support extra fellowships for health leaders and teams we work with patient and family advisory network across the country and many other activities that hopefully help to be the tide that lifts all boats and improvement and last but not least our fourth area focuses on the policy and system enablers and barriers to healthcare transformation how can we make the right thing to do the easier thing to do and work with our many partners across the country and so doing and that's where much of our work on value-based healthcare comes in so what is value-based healthcare anyway there are whole PhD theses that have been written on the definition of what is value so there's a number of ways that it can be defined for the purposes of today's conversation were boring some work by Porter from Harvard really focusing on that relationship between outcomes that matter to patients and the resources that are used over the patient's journey so it's not about the numbers of services provided or specific products or processes that may or may not achieve those outcomes it really is that focus on outcomes that matter and so it's one way of instantiating patient preferences expectations into a broader health policy approach and to funding and procurement I think it's important to sort of hold in our minds that this is about how can we use our resources both money and other resources the most effectively it's not about the specific dollar amounts that are spent on a particular product or service it's about that relationship between overall outcomes and resources used just as important is what value-based healthcare is is what it isn't so it is not about driving down the lowest-cost if that doesn't improve outcomes it's not about taking a narrow slice of an individual component of an episode of care and isolation rather it's usually about looking across an entire episode of care or population group a more holistic view if you like it's not the same as a straight pay-for-performance model that rewards the delivery of specific care processes so did you do X type of screaming for example and it may actually go broader than only the health sector so it may include interventions for instance from the social sector or from other areas in in broader types of interventions that improve outcomes that matter to patients bottom line value increases when the total cost of achieving the same or better outcomes fall this is a summary that the World Economic Forum put together a couple of years ago now and they're there a sort of conception of a focus on a patient-centric way to design and manage health systems that really focuses us on the full outcomes the trajectory of care there's been a number of studies over the past couple years around value-based healthcare and and what it really takes to make this work and we did some analysis last year to basically line these various reports up against each other and this is a summary across some of the common characteristics that were identified so key enabler in terms of the context of policy in the institutions so we need to have the mechanisms in place to make it easier to implement value-based healthcare so for instance to be looking and understanding what matters to patients what are the outcomes that matter how do we look at those how do we embed some of these actions in a policy environment how do we ensure that our procurement capacities or our funding mechanisms are well aligned at the second measurement of costs and outcomes and obviously these are measurement of cost and outcomes that match with the perspective of value-based healthcare so that match for instance with the full episode of care not just a piece of it another key enabler of value-based healthcare is looking at care pathways and integration so it's much easier to be able to achieve value across an episode of care if there are mechanisms to support individuals through that journey and last but not least the reports also identified outcome-based payment approaches as a key enabler value-based healthcare a mechanism not the only one but an important mechanism that can help us to drive forward with that last as a caveat though an important caveat from Steve Morgan and his colleagues that of course no financial mechanism no payment model is a silver bullet this obviously has to take into account the broader organizational arrangements clinical arrangements engagement with patients and Families and other processes as well as the legislative and regulatory environment in which we're working one of the things that we did last year is that we have a summit around value-based healthcare and then a follow up with a smaller group to help us really navigate what do we know from a Canadian context in terms of what helps and this series of sort of advice we challenge participants to say what could we start doing what could we stop doing and we gave them extra bonus points for stop doings that would help to accelerate value-based healthcare and their impact and I won't go through and read them all for you here you'll you'll see the broad perspective but you can also see that this brings together a number of different aspects of success so that there's a proactivity a leadership but also some technical questions around for instance value-based procurement capacity that we need to accelerate progress as well as we were starting down this journey there's some well-publicized examples of value-based healthcare internationally there aren't as many that have been shared in a Canadian context so we wanted to draw together what do we know about Canadian experiences in value-based healthcare to date what are some of the lessons learned and so that hopefully we can build on those experiences as we go forward and I'll share a link for you in a minute we have done a series of profiles of different kinds of value-based healthcare initiatives in the country and there are links there as well if you want more information just before I dive in I've been asked to remind everyone that if you've just joined the webinar please introduce yourself in the chat box so that everyone knows who's on the line and who's joining us today and feel free at any point during the webinar to add questions into the chat box or if you've got suggestions for resources or tools that may be useful to others on the webinar please feel free to add them there as well bills just added a link to the FBI's work on value-based healthcare including the case profiles that we've done and we've got actually more under development as well so you can keep coming back to that space for more information so the first set of profiles we did looked at outcome linked funding where the amount of resources that a healthcare provider could be an individual provider it could be an organization receives depends on the extent to which predefined health outcomes are achieved and there's been a number of examples of this in Canada one of the ones that we profiled with some work that had been done around telehomecare for individuals with serious chronic conditions such as CHF or chronic obstructive pulmonary disease where resources were dependent on progress in terms of health outcomes as well as in terms of things like avoiding potentially avoidable visits to emergency departments and hospitalizations there's those have been a series of work that's been done more on the public health and population health side that's been exploring social impact bonds although there's an additional development on the healthcare side now underway in this area as well social impact bonds are a relatively new tool globally and they reflect a pay for success model one of the largest ones in Canada in the health sector is the community hypertension prevention initiative involving a whole range of partners that is intended to really focus on individuals who are at cardiac risk and the ability to reduce their risk over time focusing on the management of risk factors and self-management and then a number of initiatives as well that we identified in profiles that include risking risk or gain sharing contracts organized in a variety of different ways and you'll hear a little bit about some of that work on the webinar today and more in an upcoming webinar that we're planning as well so if you're interested in these kind of areas there's also more to come in the webinar series so with that Whistlestop tour through value-based healthcare and some of the resources and work that's been done in Canada if you're interested in more information you can follow up at the link on your screen or the one that bill typed into the chat box I wanted to make sure that we had good time on this webinar as well to talk about the broader context both the broader policy context and then a specific example of the use of value-based healthcare in Canada so to start us off I'll just pause here and see if there are specific questions that have come up already I'm not seeing any at this point so we'll just dive right in and I'll turn things over to Neal Fraser president of Medtronic Canada seemed to talk a bit about some of the federal policy environment and the work that he and colleagues have been doing as part of the health and Biosciences economic strategy table so Neal I'll be turning it over to you yes good afternoon everybody I'm here at Mars actually in Toronto and I'm just going to be highlighting some of the key recommendations coming out of the health and Biosciences economic strategy table that relate to the specific area value-based healthcare we can probably go to the next slide sorry is someone changing the slides yep should be up in just a sec there you go okay good so basically the economic strategy tables were created and largely identified by the consulting firm McKinsey who who basically identified that in Canada although we're enjoying some good economic growth at the moment it's anticipated that the GDP will actually start to decline in the next five years and so the focus is really to identify sectors that we see tremendous growth potential in and you see the six that they focused on there but I'm only going to focus on health and Biosciences so we can we can maybe flip to the next page so we we were a group of about 15 people chaired by Korea asked the bar of quark Ventures from Vancouver and the specific focus that we had was to look at how could we double the exports and double the number of companies of innovative companies in the healthcare sector in Canada and then within that we identified specific objectives and I was charged actually with the first two of these but I'm only going to focus on the first one which was specifically we called ourselves I pack and we focused on innovative procurement adoption and commercialization and just to bring this into focus a little bit one of our colleagues on the table the fellow named Armen the curt's Ian of intelligent in Waterloo he's an entrepreneur and inventor I invented a very interesting tool for use in knee surgery and hip surgery that allows you to orient the device very accurately to reduce the number of revision surgeries unfortunately though he's been a great success everywhere else but Canada and so what you know he really brought home the issue that he cannot have his product procured in Canada for a variety of sort of structural and procurement reasons and so he was a constant reminder to us of some of the shortcomings of our processes in Canada also I would just add that we did consultations with folks across Canada and interestingly the next speaker Dov Klein was part of one of our consultations because he's such an expert in this area so just to focus then we to focus on accelerating innovation adoption you know one of the key things that we identified was the need to use value-based procurement across the Canadian health systems and really to establish expertise and one one thought was to create an agency that would fund sandboxes where all of the resources could be pooled to solve important problems in the healthcare system we can go to the next slide so why why do we feel that that the procurement is is a challenge is that you know procurement today in Canada I'm sure Dave will talk about this largely focuses on procuring things that might perhaps come in a box and yet the focus of health technology is really to improve the patient's journey and to focus on the quadruple aim you know that was composed coined by Donald Berwick of the the IHI which is to focus on the patient's experience the cost of delivering care you know the health of the population and also on the experience of the caregiver so basically what we are recommending is that value-based procurement needs to be spread and scaled much like the model of dfhi that we've just heard from Jennifer's Elmer and we are going to be focusing in our implementation phase on identifying will call them sandboxes but areas that address the most important problems in healthcare across the country and finding willing partners at the provincial level to participate in this initiative so with that I'll turn it over actually I'll open it up for questions thanks Neil we've got the first question that's come in and could you just give people a little background on who the health and Biosciences economic strategy table reported to little more context yes this this was part of the I said ministry the the innovation science and economic development ministry which is led by Navdeep Bane's Minister as well as John nobly who's the Deputy Minister and we actually had David govern the ADM directly involved we also pulled in Simon Kennedy who's the Deputy Minister of Health for this specific table great thank you very much and just a reminder to everyone that at any point during the webinar you can include questions either in English or in French in the chat box and we will direct them appropriately and Neal will have a chance to come back to you if there are additional questions when we do the Q&A at the end thank you so much so moving from the broad federal policy landscape to a specific example from Ontario it's my pleasure to turn the webinar over to Deb Klein VP of innovation and strategic partnerships at plexus gov over to you thanks so much Jennifer and and yell thank you for an introduction so just in terms of what I thought would be helpful to cover today is a bit of a background to the provincial initiative that we undertook with the support of the Ministry of Health in Ontario and core health Ontario how we want to talk a little bit about how we define value how we brought the patient perspective into it the goals of patient engagement and how those linked into the ultimate procurement goals for this category and while this is still a project in motion we we do have some value that we think we've created to date that we'd like to share with you and obviously chat about and obviously take any questions that you might have so uh just provide you a little bit of background of kind of where we've been and how we got to today plexus has taken out of the ICD in CRT category two markets or several times over the last decade or so you know in largely traditional ways to be honest and over that time you know stop price and come down quite significantly but over that time you know I think as an organization we recognized that there was more to be done from from our perspective and the value that we could create both for our hospitals and for patients and we we knew that kind of beyond just simple price there was a lot of gaps in the system that patients in particular we're experiencing just from talking to our hospitals we knew that how patients transverse the system you know they may get an ICD implanted at a particular implanting Center but seek care and other parts of the system yet popular maybe civilian ambulance or sitting in a car for hours to then go back to the rack implanting Center to receive care we knew that wasn't good for cost of the system nor for patient experience or outcomes we knew that there are patients throughout the system still receiving shocks at end of life when their palliative and at home and we also knew from from just a pure Hospital perspective that the demand on volumes and growth and on funding was just continuing unabated and so we recognized that there was something more that we could do in this sector and so we approached the Ministry of Health and and court helping tario and said listen maybe there's an opportunity to do something here there's only 12 hospitals in the province that employs ICD so it's not like it's 50 or 70 or 100 if we want to try something and see if it works this is probably the right amount of hospitals to do it with there's great data so we have an Ontario registry that tracks and follows every single patient who receives the device in the province we know for many parts of the patient journey or episode of care what the costs are for those patients and we also know that there's just been a general trend particularly in Ontario and in Canada more as large to really start looking at what neil refer to as more solution based approaches to some of these challenges that that patients face and we thought that if there was ever a time to do this it was now and it also didn't hurt that all 12 hospitals happens to be the end of their contracted the exact same period of time but but beyond that we just felt that this was an opportunity to do something different and with the support of the Ministry of Health and with core health we went about our work and so very early on in the process we really wanted to make sure this was really rooted in the patient experience and how the patient experiences value obviously taking to account also obviously the cost to achieve that value and this is a slide taken straight out of Porter and Kaplan's Harvard Business School course on the topic a Jennifer referred to the equation earlier on but one of the the just to be honest one of the big challenges that that we had with icy DS is that when you look at the equation in terms of looking at the outcomes for a patient over the full cycle of care that works pretty well for kind of an acute episodic type of patient who the entry types criteria are clearly Nolen ap hum a patient we know when they leave being a patient for something like CDs and for heart failure rotations this is something where they experience their disease over years or even decades so one of the big challenges we've had in this is really being able to look at the funding model that exists in the province this really is just about the implantation of the device and some limited follow-up afterwards versus a patient who needs to now experience and live with that device as they transverse this quite complicated healthcare system that we have and and and quite frankly the funding model also sort of set it up so that there was quite a high price for an ICD but that money is used not just the implant ICD this used to implant all sorts of other things in other cardiac surgeries and really subsidized we're not I shouldn't say subsidized really support the entire cardiac portfolio across across the hospital and so that's just again a challenging place to start from and we knew this wasn't gonna be perfect so we're not suggesting this was the perfect strategy what we call more of a best-fit approach where we try to take all the different constraints that we had to come up with something that we thought could better a new patient needs and outcomes at the end of the day and it's anna ministries credit they were a big partner in this and ensuring that hospitals would have the ability to take any savings or value that was created from this process and reinvested back in the cardiac program so it didn't go to orthopedics it wouldn't go to di or maybe other parts of the hospital had to stay within the cardiac program with the idea that would be reinvested in the episode of care so that's how we sort of started the process really focused on patients and focused on what we were paying for as part of the process in terms of patient engagement again relatively early on we we worked with Karen Harkness from core health Ontario who is a nurse who cared for these patients who lived with them through their disease to really come up a framework for how we were gonna go about doing patient engagement so we certainly weren't starting from scratch and we really believe that if we can understand why or how patients experience their care and where the gaps are we could actually reflect both patient needs within the procurement but also wait their needs properly within the permanent so every procurement has different weightings of points we wanted to make sure that the things that mattered to patients were weighed obviously the highest versus other things that might not may not be as important so specifically we want to understand what it was like to live with a device the impact on families and personal the personal life of the family and the patient we wanted to understand the gaps in supporting patients living with the device the elements of care and support the patient's value we wanted to make sure that also we gave a supplier as an opportunity to respond to those needs identified by patients you know Neil mentioned earlier about sort of the movement of the med tech industry towards solutions we know that 7 I think seven of the ten largest med medical device companies by revenue don't call themselves device companies anymore they call themselves solution companies they want to go with the hospital or the care provider to actually achieve an outcome and so by understanding what these challenges were we could give the far as those those opportunities to do that and so these were some of their overarching goals that we entered the process in I won't go into the next slide on in much detail but you know that we also what didn't want to just start from scratch there's been a lot of research qualitative research in particular on on patient experience living with devices the challenges that they face and so we also spent quite a bit of time grounding ourselves in some of the core literature in the area so that we made sure that you understood what we were going into we could design those in questions and that we really were focusing on a local Ontario perspective in our patient engagement activities so working with both core health and can Matt's we went out and tries to recruit patients for one-hour interviews and we had a very very broad inclusion criteria so you know if we did this again we may have changed this up a little bit but we really went out and a quite a broad way to make sure that we were getting patients from across the province different parts of the province and really trying to understand all the different types of patients that exist so I recently had an ICD if you had a replacement procedure you know these experienced remote monitoring hot shocks travel long distances and also have experienced both treatment in an academic center and/or a community center those were all kind of things that we really really wanted to understand from a patient perspective and we we didn't want to make it sherman focus as procurement professionals can find kind of tend to do but really focus on patient focused questions and we really looked trying to try to help patients to describe to us what are sort of the trade-offs in your own care that that you could help us understand better so for example longer-lasting devices versus devices with the latest technology right would you be willing to have another procedure to get the device with that newest technology is that trade-off it's acceptable acceptable to you all things being equal so on and so forth really trying to just understand again from the patient's perspective where we were going from and where we're trying to get to it's just to give you one example of kind of one of the patients that we spoke to and kind of the feedback that we got this is Patricia obviously her name has been changed but this is a 39 year old nurse who had had a sudden cardiac arrest had three children and was living with a device Bert not you know for very very very long period of time is expected to live with advice for many decades and really diving into her her experience was really quite shocking and enlightening just understand kind of the impact of living with a device on her family on herself on her ability to work under the ability to to transverse the system things like the impact of Education I'm really understanding you know what was being implanted inside for the size and comfort of that device and really being able to say hey listen I would have maybe preferred a smaller device all things being equal if I had that choice really being disappointed that remote monitoring although it was available was not turned on in her case and also just the general challenges moving through the system and experiencing care in different ways and I think it was just really really grounded us and really lived experience of patients in terms of how that all rolled up into our provincial strategy basically there were five key that were really clear pretty much across every patient as we went through this so some of them were things like consideration of device characteristics so patients were invariably interested in longer-lasting devices they pretty much would do anything they could to not come back into hospital if they didn't ask me but impact of device die the unphysical experience analogical enhance enhancements remote monitoring and the need for MRI compatibility patients did not appreciate the fact that that in many cases they were receiving devices that would preclude them from having an MRI later in life and that particularly for younger patients was a really really big concern and something that really stuck in our mind as we went about our approach education our awareness obviously a big big issue in terms of the impact on their daily living lives with their families and also from any patients on what that meant for end of life on on whether they were getting the right education about device deactivation so that they wouldn't receive shocks at end of life that was a big thing that we heard and we know at least in Ontario core health has worked on a strategy around improving some of those those outcomes in that area patient experience again was with a another big thing we focused on so the pain of having a replacement procedure of having the initial procedure a physical toll that it takes on them and their families clinician contacting support was a big area we heard about as well so being able to talk to their their care team afterwards be in touch with Eric your team and really being able to feel supported post implementation and then another big area which which we really kept top of mind with device assurance so patients are really anxious and a lot of anxiety when they receive these devices particularly around getting shocked inappropriate shocks device failures or potential for lead failures these were things that really really worried them and when remote monitoring was not turned on and they couldn't sort of have that assurance when they went to sleep that someone somewhere was watching over them that was the big disappointment to them is something that they really thought was important as long as security of their personal information could be to be guaranteed and so again these are just some of the the big things that came up as part of our conversations and while we weren't trying to be statistically significant we were trying to be directionally correct and really trying to create a a framework of how to create value for patients as part of this process so in terms of how we then work that into a provisional procurement we really tried to look at it from four distinct areas the patient the providers to the hospitals and physicians the broader health system and also the vendors or suppliers or in this case medical medical device companies we want to make sure that we could find elements of value that touched on all of them but again all rooted in the patient experience so for patients you know some of the obvious ones we've already talked about things like minimizing lifetime device replacements you know a traditional procurement would take a four thousand device a four thousand dollar device that last four years and weighed it much tighter financially than a thousand dollar device that last eight years and that's really a silly way to look at pricing if there's such a big difference in how long a device actually lasts and all the significant cost that would come with a patient would come in earlier for a device replacement looking to improve outcomes for heart failure patients ensuring the latest technologies ensuring that there was either follow-up and improvement in quality of life and making sure that patients could get access to care closer to home those are some of the big things that we focused on from a provider perspective you know ensuring that we can manage their financial pressures was top of mind in Ontario a big big issue as you all know they wanted to be able to be able to reinvest the news the newest technologies as we know completions having access to those technologies is important they also want to make sure that there was equity and service delivery we know we have a quite a large province as you know with many different distinct areas and I think there was a feeling that service will depend a lot on where you are and so what we wanted to do is basically create a standard level of service that wouldn't matter whether you were in downtown Toronto or Ottawa or London but it would also be if you're in Sudbury or the patients showed up in Thunder Bay that there was a certain standard level of service and support or warranty that could be expected as part of that patient experience also explore mechanisms for partnerships with vendors was really important and from a physician perspective really being able to maximize clinical flexibility and choice for somebody give the right patient the right device at the right time now system I think there's pretty self-explanatory things like transparency inputs ensuring value for money increasing capacity we're all of inch to our our our health system and then from the vendor's perspective we really wanted to focus on making sure that they also would be able to get value out of this and on most basic level we stopped you know putting you know five thousand requirements on RFP and we really tried to focus on what are the real things that matter in the device from the physician from the patient perspective and give it the medical device companies real opportunity to highlight their innovation in that particular area so we weren't just looking at things that we know everyone's the same at what we're can you really be distinguished as a company the other thing that we looked at was and back that goes goes back to my comment earlier about solutions we wanted to give the opportunity for vendors to become more deeply ingrained in the episode of care so if we could actually provide the vendors with challenge statements and things that were problems within the system that they could help us solve them that could be the basis of some of the elements of the procurement and then finally you know a sustained opportunity for open access to the market we were we weren't interested in a you know a 95 percent commitment to one vendor we wanted to make sure that that every single vendor had a sustainable business in the province increasingly you know particularly for plexus as we as we look at more provincial opportunities we are very concerned about creating unintended consequences both for vendors or sort of supply chain risk and we wanted to make sure that the outcome allowed all vendors to have meaningful business moving forward in terms of the project scope you'll get these slides after the presentation so I won't go through this in detail but we looked at sort of four categories the first was devices and leaves and this was I think one of the biggest deals of the whole the whole process we're the first jurisdiction that I'm aware of that's made a commitment for both devices and leaves to the same vendor so there was a primary commitment at a minimum of 50% for one vendor and the reason why we made that joint commitment to the same vendor is that it would ensure MRI compatibility for that patient many jurisdictions sort of do a 100 percent open share for leaves but we wanted to make sure we got all the physicians at the provincial working group table to agree that moving forward we would only be implanting MRI compatible devices so really that's what we've heard from patients that's what we knew we're important and that's what at a provincial level we were to move forward on my compatibility so that was a really big deal service as I mentioned making sure that there was equity and service in terms of how that worked across the province and ensuring that a patient who does have a device problem or issue outside of their implanting Center could experience a standard level of meaningful support from from some from the vendor or from the hospital and finally remote device monitoring was another big area there's no Kadett and otac recommendations around funding a remote device monitoring is not funded in Ontario right now the expectation is that hopefully over time that will be the case but even without funding many are out seen most Ontario hospitals are starting to ramp up the remote device monitoring programs and so we wanted to make sure that not only were we supporting that we could support hospitals who are trying to move to scale on remote device monitoring but also allow the vendors to help scale up a brand new program or some of our hospitals who hadn't actually set up any type of remote device monitoring program to date and then the last area was around the value-add solutions which means we've talked about which was really to to provide the challenge statements for all the vendors to see of what are the biggest problems in Ontario and are there additional warranties risks or structures programs or services or other ways for us to go into partnership with the vendor community in achieving some of these outcomes and so that there were ten challenge statements that were in the RFP I know I'm running short on time so I'll just start to wrap up but these were the kind of the big ten areas that were there were massive issues across the sector and in very great detail in the RFP we detailed all of these different challenges that the system was facing and that's vendors to propose how they would work closely with hospitals and with the province to address these areas on them so to wrap up while the the RFP is still in process many of the hospitals are still going through their evaluation approaches or their valuation processes I should say there are some tangible takeaways the things that we've been able to create through this process which which we're proud of and we're hoping we'll be to start to other things like this in the future so the first one from a patient's perspective is we've enabled it we've heard them and we're enabling the consistent use of MRI compatible devices across the province as long as the patient's appropriate for it expectation is that began an MRI compatible device from the device warranty and service perspective we've now really removed the certainty that contracts from being a vendor or device company to hospital relationships are really a patient perspective or patient relationship so what if that patient shows up with the lead fracture or device failure in other parts of the province not there implanting Center we basically standardized what that looks like from a care perspective from the patient from hospitals perspective we've been able to really support and create some transparency around the mote device martyr's to all 12 centers they now know what the cost is how to scale up and what it looks like for for that cost of a patient's entire lifespan not just the budget cycle so that's a big area and we've been able to give them a sense of what's the total cost of care using the core health registry using other registries they know what the care for that patient cost across that lifespan for that patient some of these other ones I spoke of spoken about from the assistant perspective we've also been able to ensure some vendor specific physical interrogation technology existed all implanting sites so there's been for example some challenges where patients would show up but see for cancer treatment at a hospital that wasn't there implanting sensor and that vendors physical technology didn't exist so that patient then have to sit and then go back and there they didn't have remote device monitoring turned on so that patient would then have to go back maybe travel for hours or spend potentially an ambulance to get their device interrogated at their implanting Center and and what we basically made as a mentor a requirement is that the physical technology for all five vendors has to be at all 12 sites at a minimum so patients won't have to transfer between sites we've also as I mentioned developed a ten system level problems that the vendors have all responded to and we're hoping to see how those work out and then from the vendor perspective at this point all five vendors have qualified they're all likely to retain a significant market share and the problem is moving forward and we've also given a metaphore opportunity to be more ingrained in the episodes of care so with that you know open to questions again we're not suggesting that this was the perfect approach but it was I think I thought small approach with a lot of partnerships and really trying to move the needle on some of the stuff in Ontario and hope we've achieved thanks so much to uh really appreciate that overview and understanding of something that is still a very alive initiative as you go we do have a couple questions that have come in for you and as a reminder if others have got questions please feel free to type them into the chat box the first question is maybe just can you talk a little bit about how you made the transition from the work that you did in focus groups and in interviews with individual patients into the requirements that you then put out through either the challenge statements or the other requirements in the procurement yeah sure that's a great question so so we had a provincial working group where all 12 centres of physicians administrators all sat on the table and essentially we we facilitated the process we brought the information to the table we brought all the different sort of requirements from the various hospitals also to the table and basically basically match them up to say cut know guys like this is what you're asking for these are what patients are saying these are the clinical needs from the physician community how do we match these up and how do we bounce these off in a meaningful way and they're an era trade-off certainly in all of that but at the end of the day it was the twelve centers ultimately making that that decision and again we tried to link up every single question we asked back to a core patient need as part of the process and if took months and months just to be honest yeah that's actually not a bad segue into our next comment actually because this is still a relatively new process and so there are other areas like critical care or other end of life situations that may also be candidates for outcome based access to appropriate devices may be based on some of your lessons learned you know are there are the things that you see is future opportunities what would you see is the ways that you might be able to look ahead whether it's within the province or even maybe nationally and looking at really that participation of patient partners more actively so I think there are tons and tons of opportunities I think there are also some fundamental challenges and so ultimately when you're looking at caring for patients outside the four walls of the hospital and and to be clear in Ontario that's the hospitals are funded they're essentially funded for a you know a patient who enters there for their four walls and until they leave their four walls and there's very little ability for a peek for a hospital to invest and then realize the benefits of those investments in either the primary care sector or post acute sector or in other sectors and that makes a really really really challenging to have hospitals make the investment getting and I'm sometimes questioned this again investments get not see some of the benefits so I mean there are so many you know whether it's in cardiac or Reno you know I could go on and on where if we were able to match up the funding model to the actual patient journey through the healthcare system seeing the hospital as an important but not necessarily central to that to that patient care journey we could take many many things out to market in a very very outcomes-based ways I mean you know even you know you look at heart failure or COPD I mean the fact that the patient's showing up in the hospital is is essentially you know failure of the system yet back to where the funding model starts in many cases when that patient is in there keeps an acute setting and now two transverse again an ICD maybe and then go back into the regular population without Negreanu monitoring without other technologies to support them so really anything that moves across sectors and that is supporting particularly chronic patients would have a massive payback by doing it in this way great thanks so much dove and great to see all the questions coming in I'm doing my best to take them in the order in which they came in and where there is sort of related questions to combine them so that we get as many questions as possible in there's one more specific one for you dove and then there's a few general questions that we may save for the Q&A at the end so the specific one can you just remind us how many patients you included in the qualitative interviews and the other processes to garner perspectives and requirements yeah so in terms of just the pure requirements that vacuum from the 12 hospitals and physicians represented that those 12 hospitals so they were the ones who were making the case at the end of the day in terms of the patient population was was smaller than we hoped one of the challenges that we had in terms of recruiting patients is that a lot of the patient registries of patients who would be happy to participate we can't actually we may know that they have COPD slash CHF but we don't not know that they actually have an ICD and so we weren't able to use sort of the big leverage some of the big big registries or other support systems and so we we brought tentation at the table for these 1-hour interviews not what we hoped for in terms of a sample size but we did you know we had our qualitative researchers from core Hoffman from Kenya who reassured us that the information we were getting with meaningful and relevant to helping us around grounds the procurement in a patient centric focus we also had obviously all the hospitals and doctors and nurses around the table who could also validate those those the concerns of the patients and also bring their own experiences from dealing with patients at the table but certainly if we did this again we would expand the sample size great thanks so much Deb so we're gonna keep a couple of the general questions for the general Q&A that will be coming up just before we do that I wanted to introduce you to one other resource and set of work that's gone on and get some of your feedback on it as well so one of the questions that came up as we have been going down this path from partners we've been working with across the country was okay so I'm interested in value-based healthcare I see the potential on a variety of fronts but where can I start and how do i if I'm considering a couple of options how do I assess the readiness to go ahead and the risks so we actually brought together a group for people from across the country including both Neil and Devon and a whole range of others over the summer and asked them based on their experience what are the key characteristics that need to be taken into account in assessing the opportunities for moving forward and the top four that were identified were having meaningful metrics things that you could leverage preferably that were already developed and tested and harmonized not necessarily that they had to be absolutely perfect but that they needed to be fit for purpose for the initiative that they were moving forward with the second was for those metrics to have both outcome and cost data available so much easier where those data already exists where there's an existing mechanism to collect and standardize those data but to be able to understand more broadly what would if those data don't exist what would be required to achieve that patient based data collected at a level and in a way that aligns with the scope of the scope of the initiative that's going forward number three on our top four list was having a clear scope so clearly defined target for the work so which patients which outcomes matter who would you reach out to for things like the work that dub described in terms of interviews with individuals and recognizing also that we may need to consider timing in that context so in some cases particularly with chronic conditions you may have individuals who are part of a group for a long period of time in other cases you may have people who move into or out of a population group so for example if you were focused on a group of individuals who might live in a particular geographic area and last but not least at the top for material impact so this was sort of lessons hard learned by some folks who've been going down this path in terms of understanding upfront the probability that you can actually move that mountain and of influencing value for individuals so the scope that you're able to focus on and then the impact that that would have and in addition to those top four there was a series of other issues identified so to be able to understand the potential and existence of clinical leadership in an area the ability to focus resources on a particular challenge permeability between silos a fancy way of saying if individuals are receiving care for instance across geographies or across silos in the Health System can we actually join those up move resources as necessary supportive policies and structures not just on the funding front but also you know examples came up of areas where they were existing really well established patient communities it might be easier to tap into to understand what mattered and what outcomes would matter then there might be in some other areas well aligned payment models also recognizing that this is a relatively new area and so understanding the capacity and skills for value-based healthcare where that was possible to leverage it situations where there were proven solutions in place so are you going out hoping that somebody can solve a problem that you're trying to address or do you know that there's proven solutions out there and last but not least how long would it take you to achieve that value so different approaches that might be relevant in context where you might be intervening on a preventative basis and expecting to see things change maybe 2025 years down the track versus something that might have a much more immediate reflection in terms of outcomes let's give you a sense of some of the things that came up when we had our design day in the summer and we would love to have your view on those and feel free to type into the chat box as well if you think were missing anything along the way so to get things going as we invite you to add your comments into the chat box in terms of other things you may have seen or things that are important from a value-based healthcare perspective we've got a quick poll for you to what extent do these factors fit with your experience of what drives successful value-based healthcare initiatives either because you've already embarked on several or because you've observed ones that others may have embarked on so how does this fit with your perspective and you'll see the the votes coming in and if this doesn't fit with your perspective we would love to hear about what's missing or what's there that frankly you haven't seen to be of value so it didn't really matter in your experience at the end of the day so you can rate it everything from greatly to moderately to somewhat to very little to not at all and I see the early votes are coming in suggesting that these factors are resonating for you but I also do continue to invite you to contribute in the chat box to other things that may not be there this is an ongoing exercise for us we're planning to use the criteria that we identify here as a jumping-off point for a self-assessment tool as you're doing that want to get in one last question that came across the line and this is a question that will go to dove so don't get ready and question was with language and culture considered in value-based healthcare by design or in the examples that you've discussed so I'll give you an opportunity to respond specifically on that front and then we'll have a bit of a more general conversation around that yes so so from a language perspective we just tried to get a diversity on that on that front but as you know from her sample size it was hard we did we did also touch on in our in our interview some of the cultural elements to living with a device experiences device how that impacted that patient probably it's something that we were too focused on more in the future but yes definitely it's something that we touched on great thanks Jeff and then slipping in a couple of other comments just as we're closing out the webinar for today so the first is Neil was only able to present a couple of slides of his full presentation on the H best recommendation so if you're interested in more there's a link that's been put into the chat box in terms of more information on the slides and Neil's blog about value-based procurement we will also be sharing the recording from today's webinar within a couple of business days so you'll get access to that as well and then there were also there was also just a question couple questions on the last information that I presented in terms of does this exist somewhere and indeed it does there was a summary of the design day that was the genesis of these criteria that's available at the link that Bill shared earlier that's also in the slides in terms of resources that are available coming from this work and we will also be sharing as its tested because we're in the testing mode right now in a way the self assessment tool that comes out of that and then the other question that came up a couple of comments actually in terms of the criteria the where the patient foundations of value super important question and actually that Flags for me that maybe some of these labels aren't as descriptive as they might be because certainly the the whole point of having meaningful metrics with meaningful metrics for patients based on the outcomes that matter to them from their experience and so we probably need to do a better job of describing how that is driven by the patient and family experience and how central that is we've had a few other comments and questions but we I'm getting the signal that we are right at 1 o'clock and so if you didn't have a chance to get your question on today's live session we will be following up after this webinar and sharing the answers to questions within the session that came in within the session within two business days and you also hopefully know where we are and how to get a hold of us you've received a question you've received emails reminding you of this webinar and so if there are other ways that you wish to interact with us over time please do and I'll just conclude today by a big thank you to Neil and Doug for their terrific presentations and sharing their experiences today and to everyone on the webinar for participating in this process for your great questions your feedback your insights we look forward to continuing to connect with you including if you're interested in joining us at our next webinar one month one month from now on February 3 on Friday March 15th this would be February next month would be March and that that webinar will be highlighting some of the innovative work happening in value-based healthcare in both Quebec and New Brunswick I hope that you can join us then goodbye for now and for those of you who are shortly heading into your weekend depending on your time zone have a wonderful weekend thank you very much this concludes today's call thank you for your participation you may now disconnect

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