Key Informants Session on E-health and Primary Health Care Renewal

Organized and hosted by:
Primary and Continuing Health Care Division
Health and the Information Highway Division, Health Canada
April 20-21, 2004

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Table of Contents

Introduction

Themes and Highlights

Meeting Summary

Background and Context-Setting

E-Health & Primary Health Care Renewal

Change Management Issues

Enabling Primary Health Care Renewal

Conclusions and Next Steps

Appendix A - List of Participants

Appendix B - Agenda

Introduction

On April 20-21, 2004, Health Canada held a key informants session to explore the potential of e-health to support primary health care renewal. The meeting developed from the observation that primary health care renewal and the application of e-health solutions in the health care sector are both prominent themes in recent and current discussions concerning health care reform, yet to date there has been relatively little exploration of the linkages between them. Attendees included health care professionals and representatives of regional health authorities, provider organizations, and federal and provincial governments (see Appendix A for participant list).

The discussion over the 1-1/2 day session was lively and dynamic, ranging beyond the original agenda (Appendix B) to offer rich insights into broad health care system issues as the context for e-health applications in primary health care. Underlying the discussion was a sense of the critical role of primary health care renewal in the improvement and sustainability of the health care system and the importance of information technology to support these developments. As such, the meeting organizers believe that this report will be pertinent and useful to those interested in health care system issues.

The report is divided into two parts. Themes and Highlights summarizes the substantive themes which emerged from the session and highlights points on which there was significant consensus and emphasis. Meeting Summary offers a factual summary of the session.

Themes and Highlights

Urgency of primary health care renewal

Although the original intention was to focus on the integration of e-health applications in primary health care settings, participants felt strongly that the overall project of primary health care renewal urgently requires greater attention and support. This emphasis includes both:

• A greater focus on the primary health care sector within the health care system; and

• Within the sector, greater visibility of and support for team-based primary health care models focussing on population-based health, health promotion, chronic disease management, and continuity of care.

Progress in these areas is urgently required, but participants felt that there is little public understanding of the need for primary health care renewal and few supports or incentives for providers to participate in new models.

Interdependence of primary health care renewal and e-health

E-health applications are highly desirable, if not absolutely necessary, for comprehensive primary health care practice. At minimum, a team-based approach to service delivery requires effective information-sharing among team members, especially if they are not co-located. In addition, e-health applications have enormous potential to support population-based approaches to health care delivery as well as chronic disease management programs and health promotion initiatives. They are also key to evaluation and accountability activities.

Short-term and long-term focus

There was general agreement on the potential of a comprehensive electronic health record (EHR) to support quality and continuity in health care delivery. However, full EHR capabilities are still under development. In the meantime, the first stages of EHRs are now available, as are electronic medical records (EMRs) which are more limited but which offer valuable and immediate support to primary health care practice. (The main distinction between EHRs and EMRs is the ability of the former to link across institutions and sectors to provide a comprehensive health history, while the latter pertains to a more limited practice setting.) A balance is required between encouraging the uptake of EMRs in the short-term (itself a challenging task requiring much planning and support) and maintaining the focus on development of interoperable EHRs.

Importance of change management support

Both in the realm of overall primary health care delivery and the more specific question of integrating e-health applications into primary health care practice, participants strongly identified the need for change management support (see below for specific issues in each area). Introducing changes on this scale will require incentives, supports, facilitation, "champions," education, and training. The more systematically and consciously this is done, the greater the rewards will be. For example, the fact of forming multidisciplinary teams does not automatically result in teamwork, which must be developed and nurtured with explicit attention to roles and responsibilities.

Supports for both primary health care renewal and uptake of e-health

Many issues and recommendations were common to primary health care renewal in general and the uptake of e-health applications in particular. These included the need for:

• National leadership;
• Adequate funding as well as financial/non-financial incentives for engaging in innovative models;
• Development and marketing of a compelling case for change, including identifying successes across the country and how to replicate them; and
• Removal of regulatory barriers.

Supports specific to primary health care renewal

Health care delivery is a provincial jurisdiction and decisions regarding primary health care renewal will occur within individual provinces and territories. Nonetheless, participants felt that there is a pressing need and important role for national activity to support provincial and regional decision-making and implementation.

• Primary health care lacks a national "presence." At the level of public engagement, Canadians generally do not understand the potential of primary health care renewal to address health care sustainability issues. Similarly, a compelling case has not been made for health care providers to engage in primary health care renewal. The evidence base for primary health care renewal must be developed and shared to address these challenges.
• Even those who are interested in participating in new models are unlikely to do so before issues such as liability in team-based settings are resolved. Similarly, regulatory changes are required to support and encourage teamwork. Practice guidelines for team-based care would also be helpful.
• All of these considerations support the creation of a national "forum" on primary health care which could provide a focal point for functions such as ongoing dialogue of primary health care issues with national scope; development of a research agenda to address evaluation/evidence needs; dissemination of best practices and other knowledge-sharing activities; and support for the on-going evolution of the sector beyond the Primary Health Care Transition Fund (which will sunset in March 2006).

This approach was summarized by one participant as "thinking and sharing nationally; acting and organizing locally."

Supports specific to e-health applications

• In order to maximize the benefits of e-health applications, a deliberate and thoughtful approach to change management is required. For example, optimal use of EMRs requires workflow assessments and re-configuration of office settings and procedures. These needs must be anticipated and supports and incentives must be offered to providers contemplating such changes.
• A dual focus is required between educational changes to prepare new health care professionals to work with information and communications technology, and change management activities for existing providers.
• Although fully interoperable and networked EHRs are not yet available, current activities should be undertaken with this longer-term view in mind.
• Conformity testing and development of standards for vendors of software products would facilitate the selection and installation of e-health applications in practice settings and help to ensure interoperability as EHR building blocks are implemented by P/Ts.
• Systems that are user-friendly and meet providers' needs will demonstrate value and facilitate uptake.
• Health care system reform itself is a complex process involving multiple stakeholders and numerous change management activities. Sequencing issues regarding the introduction of e-health applications amidst numerous other innovations are a major consideration.

Privacy, security, and confidentiality

Participants discussed various e-health applications with respect to their potential to support primary health care practice, but underlying all of these considerations was the importance of privacy, security, and confidentiality. Public confidence in these critical areas is a necessary condition for progress in implementing e-health applications in any setting (not limited to primary health care).

Meeting Summary

Background and Context-Setting

Background

On April 20-21, 2004, Health Canada's Health Care Policy Directorate and Office of Health and the Information Highway held a key informants meeting to explore the potential of e-health to support primary health care renewal. The intention was to bring together a small group of subject experts for initial discussion of the issue. A high proportion of invitees agreed to participate. The key informants included health care professionals and representatives of regional health authorities, provider organizations, and federal and provincial governments. Please see Appendix A for the final list of participants.

The meeting developed from the observation that primary health care renewal and the application of e-health solutions in the health care sector are both prominent themes in recent discussions and initiatives concerning health care reform, yet to date there has been relatively little exploration of the linkages between them. Accordingly, the objectives of the meeting were:

• to explore the potential of e-heath as an enabler of primary health care renewal, focussing on pragmatic challenges and opportunities within the current environment;
• to identify key change management issues related to the implementation of e-health applications in primary health care settings; and
• to identify potential strategies to address these issues.

Context-setting

The meeting was jointly opened by Marie Williams of the Office of Health and the Information Highway and Nancy Milroy-Swainson of the Health Care Policy Directorate who welcomed participants and thanked them for giving of their time and, in some cases, travelling long distances in order to attend. Several presentations provided background and context for the session. Summaries of these presentations follow.

Primary Health Care Renewal (Nancy Milroy-Swainson, Primary and Continuing Health Care Division, Health Canada)

Canada's health care system generally works well to provide Canadians with access to primary medical care (primarily family physicians and general practitioners) when they need diagnostic and treatment services. However, relatively few Canadians have access to comprehensive primary health care, which includes a broad range of services emphasizing health promotion and illness/injury prevention, improved management of chronic diseases, and integration of services within the continuum of care. There is a growing consensus that a team approach to delivering primary health care has far-reaching implications for the health care system, including improvements to access, health outcomes, resource utilization, and provider and patient satisfaction.

This orientation is reflected in many provincial and national-level health system analyses in recent years, and in the First Ministers' Meetings of September 2000 and February 2003, both of which emphasized the role of primary health care renewal in health system reform and targeted the creation of multidisciplinary teams. The $800M Primary Health Care Transition Fund was created by the federal government following the September 2000 First Ministers' Meeting and primary health care renewal is a key feature of health system reform in most jurisdictions.

While there is general consensus among governments on the importance of primary health care renewal, there is also recognition of the need for flexibility and responsiveness within jurisdictions. Accordingly, there is no "one size fits all" model for primary health care renewal. The size and composition of the primary health care team will vary according to factors such as geography and the needs of target populations. However, there is general agreement among governments on the principles of primary health care renewal, as articulated in the five common objectives of the Primary Health Care Transition Fund:

• increase the proportion of the population having access to primary health care organizations accountable for the planned provision of a defined set of comprehensive services to a defined population;
• increase emphasis on health promotion, disease and injury prevention, and management of chronic diseases;
• expand 24/7 access to essential services;
• establish interdisciplinary primary health care teams of providers, so that the most appropriate care is provided by the most appropriate providers; and
• facilitate coordination and integration with other health services, i.e. in institutions and in communities.

The use of e-health applications will be integral to achieving these objectives. By improving access to high-quality primary health care services, e-health applications will help to improve the health status of Canadians which, in turn, will help to address concerns about the sustainability/cost-effectiveness of the health care system.

Mainstreaming e-health (Michel Léger, Office of Health and the Information Highway, Health Canada)

There is growing recognition that e-health solutions can have a significant impact on patient safety, quality of care, access to services and efficiency. Reports by Romanow, Kirby, Fyke and others point out that electronic health records are one of the keys to modernizing Canada's health care system. An important step came in 2000 and 2003 when First Ministers agreed to support the adoption of modern systems of health information and communications technology. In response to those agreements, the federal government invested $1.2 billion in Canada Health Infoway (Infoway), an independent, not-for-profit corporation working in collaboration with provinces, territories and other key stakeholders to foster and accelerate the development and adoption of electronic health information systems on a pan-Canadian basis. Infoway has developed a Business Plan, endorsed by the provincial, territorial and federal governments, which is currently focused on electronic health record building blocks, telehealth applications and health surveillance systems. Collaborative planning between Infoway and the jurisdictions is ongoing to ensure the alignment of Infoway and jurisdictional strategies and action plans.

From its founding in 1997 to the spring of 2004, Health Canada's Office of Health and the Information Highway (OHIH) supported the development and adoption of electronic health information systems in Canada. Successful initiatives included The Health Infostructure Support Program (HISP) and Canada Health Infostructure Partnerships Program (CHIPP). In the spring of 2004, Health Canada created the Health and the Information Highway Division which continues to build a strong knowledge base on e-health matters, provide leadership and direction in policy and program development, and foster stakeholder collaboration. The goal is widespread use and integration of e-health within the mainstream health system. E-health technologies will be key enablers and contributors to health system renewal efforts in primary health care, home care, public health, patient safety and so on.

Group Health Centre - "The Road Less Travelled" (Dave Murray and Cathy McCullough, Sault Ste Marie & District Group Health Association)

This overview of Sault Ste Marie's Group Health Centre focussed on its use of e-health applications to support comprehensive primary health care delivery. A electronic medical record has been in place for six years, and through the use of this and other technologies the Group Health Centre has developed and evaluated evidence-based outcomes management programs in areas such as diabetes, congestive heart failure, mammography/breast health, anticoagulation, asthma, immunizations, and cervical screening. These programs have produced measurable results in reducing the burden of disease and improving resource utilization. For example, the congestive heart failure discharge transition program has reduced hospital readmission rates by 44% over the past two years. Aggressive management of diabetic patients at an estimated cost of $130 per patient per year has resulted in estimated benefits of five years of additional life, eight years of sight, and six years of freedom from kidney disease.

There was keen interest in this model and it served as a point of reference for much of the discussion over the remainder of the session.

E-Health & Primary Care Renewal

Participants were asked to identify how e-health solutions could act as enablers of primary health care renewal. They examined the potential impact of five broad categories of e-health solutions, namely electronic health records, telehealth, secure electronic linkages, electronic health information, and other e-health applications such as surveillance and practice management systems. They then ranked the importance of these solutions and identified ways that they contribute to the objectives of primary health care renewal.

Although participants found it somewhat difficult to rank the identified e-health solutions and felt that there was significant overlap between them, the five categories of e-health solutions were ranked in the following order of importance to primary health care renewal: electronic health records, secure electronic linkages, electronic health information, telehealth, and other e-health solutions.

The following is a summary of ways that e-health solutions contribute to the objectives of primary health care renewal. Participants were asked to focus on the following five objectives of the Primary Health Care Transition Fund. Participants did not attempt to examine the potential impact of e-health on other goals of primary health care such as improved patient safety, quality of care and efficiency of service delivery.

1. Creation of primary health care organizations accountable for the planned provision of a defined set of comprehensive services to a defined population

E-health solutions have the potential to:

• Provide communication links to facilitate the establishment and functioning of primary health care teams/organizations collaborating within the same site, from different sites, or across large distances in rural and remote communities
• Save time and money

2. Increased emphasis on health promotion, disease and injury prevention, and management of chronic disease

E-health solutions have the potential to:

• Identify target groups (e.g. diabetes patients) for early interventions
• Help track how interventions impact patient outcomes
• Identify trends
• Help patients become more involved in their own health care by giving them access to their own health record and trusted electronic sources of health information
• Generate system reminders (e.g. for required tests or vaccinations)
• Assist in managing chronic disease by monitoring patients in the home and offering efficient new opportunities for communication between health care provider and patient
• Provide new methods for delivering patient education, lifestyle counselling and follow-up
• Help multidisciplinary teams improve care planning

3. Expanded 24/7 access to essential services

E-health solutions have the potential to:

• Allow health care providers to access patient records 24/7 from different locations (e.g. the provider's home) to facilitate 24/7 service delivery
• Provide 24/7 triage nurses with access to trusted electronic health information, practice guidelines and so on
• Enhance communication between 24/7 triage nurses and the patient's primary health care team, giving them access to the same up-to-date patient record
• Give patients in rural and remote communities improved access to health services
• Provide 24/7 home monitoring capabilities

4. Service provision through interdisciplinary teams of providers, so that the most appropriate care is provided by the most appropriate provider

E-health solutions have the potential to:

• Provide a standardized and legible patient record for team use
• Provide each team member with quick access to the patient's record whenever it is needed
• Improve communications among team members
• Reduce the need for patients to give the same information to multiple members of the team
• Facilitate performance measurement planning and evaluation among teams

5. Facilitated coordination and integration with other health services, i.e., in institutions and in communities

E-health solutions have the potential to:

• Connect the different sectors of the health care system electronically, breaking down the silos
• Facilitate health planning across sectors and continuity of care
• Link primary health care providers to health care organizations and institutions, specialists, subject experts in teaching hospitals and so on
• Facilitate sharing of information at the population level
• Reduce scanning and faxing

Change Management Issues

The next portion of the key informants session examined change management issues. Although the original intention was to focus on change management issues for the adoption of e-health in primary health care settings, the scope was expanded to look at general issues in primary health care renewal as well.

After an initial review of issues, participants felt it made sense to organize their discussions around the following broad topics: Leadership and Funding, Data Policy and Standards, Primary Health Care Models, Reengineering, and Accountability, Professional and Regulatory Issues. Although participants did not explicitly define these topics, the following descriptions are based on examples cited and the overall discussion:

• Leadership and Funding - involves setting the overall direction, making key decisions, energizing people to work towards common goals, and providing the necessary resources to achieve those goals
• Data Policy and Standards - includes policy relating to data definitions, standards, capture, ownership, privacy, security, retention, access, and reporting; as well as broader standards issues relating to electronic messaging, electronic health records architecture, and so on
• Primary Health Care Models - relates to the organization, governance and operation of primary health care models
• Reengineering - involves incorporating fundamental new approaches to business processes, workflow, organization, use of technology and so on to improve results and client satisfaction
• Accountability, Professional and Regulatory Issues - accountability involves being answerable to someone, particularly for use of time and resources and outcomes; participants examined accountability of primary health care providers to governments, professional bodies, the public and so on, as well as professional and regulatory issues

Participants split into sub-groups to examine each of these topics. The following is a summary of the results. For the Leadership and Funding topic, participants identified change management issues relating to both the adoption of e-health in primary health care settings and primary health care renewal, with many of the issues being very similar. For the Data Policy and Standards and Reengineering topics, most of the issues related e-health, and for Primary Health Care Models and Accountability, Professional and Regulatory Issues, most of the issues related to primary health care renewal.

Leadership and Funding

For the most part, participants felt that the following issues apply to both e-health in primary health care settings and primary health care renewal:

• Lack of leadership and direction
• Lack of clarity on roles and responsibilities in bringing about change
• High cost to implement change
• Lack of funding
• Lack of a compelling case for change for the public and providers
• Challenges with implementing two major initiatives at the same time - comprehensive e-health solutions and primary health care reform
• Challenges with multiple health care systems and complex health care governance, e.g. makes it difficult to replicate best practices across the country
• Duplication of work
• Multiple fragmented stakeholders
• Lack of communications infrastructure, particularly in rural and remote areas

Data Policy and Standards

The following issues relate to the definition and use of data, the need for standards and interoperability, and the importance of privacy, confidentiality and security:

• Lack of standards (data is defined differently by different disciplines; much of the work to date has been related to billing and not provision of care and outcomes; significant investments are being in made in primary health care systems that use different standards)
• Significant privacy issues
• Lack of clarity on ownership, storage, governance and access
• Integration of legacy systems
• Lack of integration between primary health care applications and the rest of the health care system
• Risk that independently developed First Nations e-health systems will contribute to additional fragmentation

Primary Health Care Models

Given the linkages and sequencing issues in using e-health as an enabler of primary health care renewal, there was considerable discussion of the need for general momentum in primary health care and new models of service delivery as the context of e-health applications and other innovations. In particular, issues to be addressed when contemplating new models of primary health care delivery included:

• The need to address governance and business issues
• Amalgamation and merger of practices
• Lack of policies and procedures for a team environment
• Scope of practice
• Integration of disciplines that currently tend to work on their own
• Acceptance by health care providers of responsibilities associated with team care and outcomes of team care

Reengineering

The most significant benefits of automation are typically not achieved by simply automating a paper process. Usually, the true benefits come from reengineering -- using the new possibilities that automation can offer to fundamentally improve business processes, workflow and so on. However, this involves significant change and with it, significant change management issues. Participants identified the following issues:

• Cost
• Resistance to technology and reluctance to give up the paper record
• Potential increased workload
• Complexity of applications
• Lack of keyboarding skills and information technology (IT) capacity in general by health care providers
• Data capture of historical records
• Integration of legacy systems
• Effort required to reengineer business processes and workflows
• Time required to learn and implement new systems
• Staff training
• Lack of policy and procedures for e-health in primary care settings

Accountability, Professional and Regulatory Issues

Relating to primary health care renewal in general, these issues addressed concerns about accountability requirements in new delivery models as well as professional and regulatory barriers to team-based care:

• General lack of accountability in Canada between the providers, the payer and the public
• Rising expectations by consumers, providers and payers
• Fear of primary health care restructuring, especially following the results of hospital restructuring
• Fear of lower remuneration in new primary health care models
• Fear of reduced autonomy, power and control in new primary health care models
• Outdated regulations impeding positive change, e.g. regulations prohibiting electronic prescriptions and regulations requiring face-to-face visits
• Resistance to obligatory reporting
• Resistance to performance evaluation
• Liability issues in a shared care setting

Enabling Primary Health Care Renewal

Participants split into new sub-groups and examined the same five change management topics, focussing on practical strategies that could be undertaken in the short and medium term to facilitate change. The results are presented below.

Leadership and Funding

This sub-group's key proposal related primarily to primary health care renewal. The sub-group proposed the establishment of a national umbrella organization to provide leadership by bringing key stakeholders together (including representatives from governments, provider organizations, Canada Health Infoway, the research community, and others). The organization would develop a vision and strategy to advance primary health care renewal, including appropriate incentives, and would engage the public and health care providers at the grass roots level.

In addition, the following strategies were identified in relation to e-health in primary health care settings and primary health care renewal:

• Improve leadership at the national level re e-health in primary health care settings
• Increase funding to support both e-health in primary health care settings and primary health care renewal
• Provide financial and non-financial incentives and eliminate disincentives
• Develop a compelling case for change based on research and evidence and communicate the case to health care providers and the public
• Ensure interoperability of e-health systems
• Ensure that IT solutions are expandable and scalable to accommodate evolving primary health care system requirements
• Address health human resources change management issues
• Enhance health educational programs by addressing gaps in curriculum and faculty capacity related to e-health
• Facilitate knowledge transfer to enhance IT capacity among health care providers
• Ensure IT meets the needs of health care providers and provides value
• Encourage interim steps to move health care providers towards e-health even as the electronic health record is being developed
• Encourage communication and collaboration and create opportunities to bring people together

Data Policy and Standards

Strategies included:

• Establish common data definitions and standards for primary health care; build on protocols that currently exist and consider beginning with a common data set for those chronic diseases that have a huge impact on the health of Canadians (such as cardiovascular disease)
• Consider the Alberta example where the province sets standards for provider software products and performs conformance testing
• Increase funding for connectivity of primary health care providers
• Establish standards for obligatory reporting
• Create a patient bill of rights, including provisions for sharing of information, access and consent
• Ensure that systems incorporate multiple levels of access to personal health information, and audit trails to track access
• Ensure that depersonalized data will be available to provide information for research and accountability

Primary Health Care Models

Strategies included:

• Develop a compelling case, e.g. highlighting primary health care models that have the potential to improve quality of care and enjoyment of the workplace; then, deliver the message
• Provide financial and non-financial incentives
• Allow flexibility - a single model is unrealistic; for example, a legitimate model could involve a network of individuals operating under defined rules of engagement caring for a defined population with ongoing monitoring of outcomes
• Investigate different models and assess the determinants of success, e.g. assess the impact of co-location on achieving economies of scale, continuity of care and team expertise
• Through use of incentives and other means, encourage steady movement along the continuum towards a fully integrated model such as the Sault Ste Marie Group Health Centre, where information technology is an enabler and connected teams of health care providers offer enhanced service to a defined population
• Develop a broad vision for primary health care renewal including long term care, home care, public health, mental health and so on
• Develop professional standards of care for team-based models
• Improve clarity around issues of shared governance, shared resources, scope of work, shared care, shared information, shared accountability and so on
• Resolve liability and insurance issues for team care
• Provide change management resources to help with transitional activities, e.g. funding and peer-based coaching/education

Reengineering

Strategies included:

• Establish the business case for e-health solutions in primary health care settings and demonstrate value to health care providers and their office staff (evidence that e-health makes a difference financially and in the quality of care)
• Provide funding for e-health in primary health care
• Improve leadership at the national level for e-health in primary health care settings
• Develop integrated and comprehensive electronic health records as quickly as possible - access to lab results and other components will encourage health care providers to adopt e-health solutions
• Replicate successes across the country; Canada Health Infoway should have a role
• Establish standards for e-health applications in primary health care settings and perform conformance testing to ensure that they meet standards
• Involve clinicians in applications development
• Use a common interface for all applications
• Offer change management support including financial assistance, assistance with reengineering and administrative issues, and a help desk
• Reward individuals who implement systems that meet standards
• Keep demands on health care providers low, e.g. consider voice recognition and minimize administrative requirements
• Ensure that educational programs for health care providers address e-health
• Address IT capacity building for existing health care providers
• Create "super-users" to provide leadership
• Ensure that duties and responsibilities in a reengineered environment are clear
• Deliver benefits
• Develop accreditation of reliable sources of electronic health information

Accountability, Professional and Regulatory Issues

Strategies included:

• Develop a strategy to manage physicians' perceptions of risk - loss of autonomy, power and remuneration - and build their trust
• Provide incentives
• Publicize successes
• Show payers and the public value for money; demonstrate how inter-professional collaboration and adoption of e-health improve efficiency, compliance with best practices, outcomes and management information, and enrich the experience for patients and providers
• Establish a legislative framework, remove regulatory barriers to e-health, and review/revise regulations to accommodate a team environment, e.g. regulations relating to risk, liability and insurance
• Develop tools and protocols for a team environment such as collaborative practice agreements and inter-professional accountability; clarify scope of practice
• Provide education on working collaboratively
• Establish models that minimize the loss of income and promote positive change

Conclusions and Next Steps

Conclusions

As the session neared an end, participants were asked in plenary to re-cap the day-and-a-half by identifying conclusions and expressing any final thoughts. The results were as follows:

• Canada Health Infoway should pay attention to primary health care; the Health Council could also be an important facilitator
• A national organization or clearing centre is needed for primary health care renewal to facilitate, provide guidance, reduce duplication and keep the issues front and centre
• Bring primary health care out of the shadows and into the spotlight; establish more ways to share information
• Think and share nationally, and act and organize locally
• There is an important link between e-health and primary health care renewal
• The discussions on both of these major change initiatives have to be grounded in reality and the users need to be present
• These are complex issues with complex solutions; it will take time
• The compelling case for change has not been made; there are tremendous benefits if it is done right; examine what hard data should be collected, and collect the evidence to convince policy and decision-makers; professionals need to hear real-life success stories and the public needs to hear the possibilities
• These change initiatives are not an option for our health care system; as a society, we can't afford not to do them

Next Steps

Participants agreed on the following next steps and identified Health Canada as the responsible party:

• Distribute copies of presentations to participants
• Develop and disseminate a report summarizing the findings of the key informants session
• Identify ways to use the ideas and suggestions from this key informants session to keep the momentum going

Concluding Remarks

Several participants commented that it had been an excellent session, bringing together some of the best thinking in the field.

Marnee Manson, on behalf of Primary and Continuing Health Care Division, thanked participants for their participation and valuable ideas. She said that the key informants session had met its objectives with an excellent discussion of e-health in primary health care settings, primary health care renewal and the linkages between the two. She assured participants that the effort would not stop here. She said that she would be looking at ways to keep the momentum going.

Michel Léger, on behalf of the Office of Health and the Information Highway, also thanked participants for their valuable input. He stressed the importance of e-health as a foundation for health system renewal and the need for collaboration in moving the agenda forward. He looked forward to the day when e-health would be widely used and integrated in the mainstream health system.

Appendix A - List of Participants

HEALTH CANADA:

First Nations and Inuit Health Branch
Debra Gillis

Health Care Policy Directorate
Ghyslaine Jalbert
Marnee Manson
Nancy Milroy-Swainson
Sandra Tomkins

Office of Health and the Information Highway
Brian Foran
Tim Hunt
Michel Léger
Jeannine Simard
Marie Williams

Appendix B - Agenda

DAY 1

08:30  CONTINENTAL BREAKFAST

09:00  INTRODUCTION

Welcome/Purpose.....Health Canada

Agenda/Process.....Facilitator

Round Table.....Introductions

Participant introductions and interest in the topic (1 min. each).....All

09:40  CONTEXT

E-health in primary health care settings

Context on e-health and primary health care renewal, Q's and A's (30 min.)
.....Health Canada

Experience in the field, Q's and A's (20 min.)
.....Sault Ste Marie Group Health Centre

10:30  HEALTH BREAK

10:45  E-HEALTH & PRIMARY HEALTH CARE RENEWAL

#  Present and discuss various e-health applications such as electronic health records and telehealth (15 min.).....All

#  Prioritize the applications in terms of potential impact on primary health care renewal (15 min.).....Sub-groups

#  Discuss the potential of each solution to support the achievement of primary health care renewal goals (60 min.).....Sub-groups

12:15  LUNCH

13:15  E-HEALTH & PRIMARY HEALTH CARE RENEWAL (Continued)

#  Present and discuss sub-group reports.....Plenary

14:15  CHANGE MANAGEMENT ISSUES

#  Identify change management issues (15 min.).....All

#  Discuss change management issues, including barriers and facilitators (50 min.).....Sub-groups

15:30  HEALTH BREAK

15:45  CHANGE MANAGEMENT ISSUES (Continued)

#  Present and discuss sub-group reports.....Plenary

16:45  ADJOURNMENT

DAY 2

08:00  CONTINENTAL BREAKFAST

08:30  RECAPITULATION.....Facilitator

08:45  ENABLING PRIMARY HEALTH CARE RENEWAL

#  Identify practical strategies that could be undertaken in the short and medium term to address change management issues (addressing the barriers & enhancing the facilitators)

#  Identify suggestions for further study of this issue.....Sub-groups

10:00  HEALTH BREAK

10:15  ENABLING PRIMARY HEALTH CARE RENEWAL (Continued)

#  Present and discuss sub-group reports.....Plenary

11:15  CONCLUSIONS AND NEXT STEPS

#  Key observations and follow-up items.....All

11:45  CLOSING REMARKS.....Health Canada

12:00  ADJOURNMENT