final report of the globalization and the eworld task force

Final Report of the Globalization and the eWorld Task Force Report to the Planning and Priorities Council

April 12, 2001

Executive Summary

Globalization is the process of closer interaction of human activity across a range

of spheres, including the economic, social, political, and cultural, experienced

along three dimensions: spatial, temporal and cognitive. Globalization is an

international phenomenon that is not only affecting the way in which people work,

live and think worldwide – it is a trend that is changing the way health services

are organized and health care is delivered in Canada and beyond.

Health care organizations have lagged behind industry in the adoption of

information technology and in the transition into the information age. This is

illustrated by the poor information and communication connectivity across the

system, missed opportunities to use technology to improve health care delivery,

the entrenchment of an industrial age model of health care delivery, and public

frustration that the system is not adapting fast enough to meet their needs.

The Task Force on Globalization and the eWorld was created to assess the

impact of globalization trends on the healthcare system over the next ten years

and to develop strategies in response. Despite the many challenges present in

the current system, the Task Force is optimistic about the future use of

knowledge, information and communications technology and strengthening

UHN’s commitment to the global community it serves, and in revolutionizing the

health care experience in Canada. Steps already undertaken at UHN which will

facilitate this leap are investments in community and multicultural health

programs, the Workplace Diversity Program, the International Patient Program

and the five-year Information Management Strategy (care@uhn). The newly

created eHealth Innovation Program, a partnership with the University of Toronto,

also represents an initiative that is an enabler of change.

mailto:care@uhn)

Pursing such globalization and eHealth initiatives at UHN will encourage the

building of a true healthcare system that is equitable, accessible, caring and

supportive, accountable, responsive, convenient and efficient, and geared toward

high quality and continuous improvement.

This type of system can be created, if UHN commits to the following

recommendations:

��The Planning and Priorities Council must create and participate in a corporate

policy and forum on globalization.

��UHN must develop a strategy to ensure that it monitors the trends and

changes in the globalization of health services and eHealth innovations,

within and without UHN, and that it evaluates the impact that such trends and

changes could have on the provision of existing services or on the need for

new services.

��The Toronto General Hospital, Toronto Western Hospital, and Princess

Margaret Hospital must provide better “globalized” services at home, with key

investments in:

��Enhancing the infrastructure to ensure cultural competence within all UHN

programs

��Improving eHealth competence to increase self-care and improve care

delivery

��Using technology to enhance the public-UHN relationship.

��UHN must support the globalization of professional services, teaching, and

research by facilitating provider communication around the globe, and

improving research and education networks, while ensuring maximum benefit

to the local community

Table of Contents

EXECUTIVE SUMMARY................................................................................................ 2

1 INTRODUCTION ....................................................................................................... 5

2 PROCESS OVERVIEW............................................................................................. 7

3 TREND ANALYSIS ................................................................................................... 9

3.1 EXTERNAL ENVIRONMENT ...................................................................................... 9 3.2 INTERNAL ENVIRONMENT ..................................................................................... 15

4 OPTIONS FOR UHN POSITIONING ....................................................................... 19

5 VISION 2011 ........................................................................................................... 21

6 RECOMMENDATIONS ........................................................................................... 26

6.1 CORPORATE POLICY ON GLOBALIZATION.............................................................. 26 6.2 PROVIDING BETTER “GLOBALIZED” SERVICE AT HOME ......................................... 27 6.3 GLOBALIZATION OF PROFESSIONAL SERVICES, TEACHING AND RESEARCH............ 31 6.4 RESOURCES........................................................................................................ 33

7 CONCLUSION ........................................................................................................ 34

8 BIBLIOGRAPHY ..................................................................................................... 35

9 APPENDICES ......................................................................................................... 38

APPENDIX A: GLOBALIZATION AND THE EWORLD TERMS OF REFERENCE ......................... 38 APPENDIX B: CONCEPTUAL FRAMEWORK ....................................................................... 40 APPENDIX C: THE IDEAL HEALTH SYSTEM ...................................................................... 57

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Globalization and the eWorld Submission to PPC April 12, 2001

1 Introduction

The Task Force on Globalization and the eWorld discussed issues related to the

globalization of health and health care, and its implications and opportunities for

UHN.

There are four terms that had to be defined at the outset, to facilitate the work of

the Task force. These terms, which will also be useful during the review of this

report, are:

Globalization

This is defined as “the process of closer interaction of human activity across a

range of spheres, including the economic, social, political, and cultural,

experienced along three dimensions: spatial, temporal and cognitive.” (Walt

2000)

eWorld

The network that makes it possible to exchange data around the world using

electronic means.

eHealth

Any activity that involves the transmission or exchange of data related to health

using information and communication technology (ICT).

eHealth Innovation

The conceptualization, design, development, evaluation and application of new

ways to use existing or emerging information and communication technology to

enhance health or the provision of health care services. eHealth innovation goes

beyond technology, to promote the integration of technology with multimedia,

knowledge and the culture of health and health care to make the health system

more accessible, efficient, effective, and equitable.

The creation of this Task Force was motivated by the expectation that in the next

ten years health care organizations will need to evolve to maximize the benefits

and minimize the problems associated with the globalization of health services

fuelled by the information age.

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The Task Force drew together representatives from industry, academia, the

public sector, providers, and administrators from within and outside UHN. The

task force terms of reference outlining the group membership objectives can be

found in Appendix A. Together, using face-to-face meetings and virtual

communication, these individuals with diverse backgrounds and experiences

discussed the issues facing UHN over the next decade with regards to its

multicultural population, growing trends in the globalization of health care and the

enabling ability of technology to bring it all together

All members of the Task Force, regardless of their background, shared the view

that there is a clear opportunity for University Health Network (UHN) to develop a

strategy that would ensure that it benefits from globalization. UHN must consider

some of the scenarios in which globalization of health care services may occur

and the opportunities that exist for large teaching hospitals in a rapidly changing

global environment, not only to benefit from these changes directly, but also to

contribute to the equitable and efficient provision of health care services world-

wide.

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2 Process Overview

The objectives of the Globalization and the eWorld Task Force were to:

��identify, project, and analyze the impact of globalization and the eWorld on

UHN

��define the enablers, possible threats and expected benefits for UHN

associated with the delivery of health services in a global environment;

��recommend options and strategies for positioning UHN's programs and

services into the global health services environment.

These objectives were met through several strategies. The Task Force held

three meetings. The first meeting had an internal focus at which the eHealth

Innovation Program and the Information Management Strategy were presented

to provide context regarding UHN’s current strategies and structure. The second

meeting, coined “The View From Outside”, brought the task force members

together to discuss what would happen if UHN did nothing to address issues of

globalization and their advice to UHN as it considers moving forward with global

strategies. The final meeting focused on the elements of an ideal health system

from a community perspective (Appendix C), and concrete strategies that UHN

could use to facilitate the achievement of this vision.

Through the course of the task force process, a conceptual framework was

developed that outlined the barriers, enablers and strategies for addressing

globalization and the eworld. The framework was used as a basis for discussions

at the meetings and is attached in Appendix B. The framework broke out the

strategies into 3 separate but closely related sections:

��“Globalization at home”: UHN employs a diverse staff and serves such

diverse communities (e.g., people from over 150 countries) that it could be

considered as a mini-model of the world, an ideal living laboratory where the

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impact of “global” services and eHealth innovations could be evaluated

efficiently. On the other hand, any aspiration of the UHN to become a world

player would be unrealistic unless it meets the “global” needs of the

multicultural population it is meant to serve, coupled with the technical

infrastructure to study how to satisfy such needs effectively and efficiently.

��UHN as a change agent in Canada: UHN must act as an agent of change

within Canada (e.g., vis à vis government, provider groups), leading by

example and following other leaders when necessary, to ensure that the

Canadian health system evolves in a way that is consistent with the

information age and the rapid growth of global health services.

��UHN as a team player in the world scene: By drawing lessons from the local

and national settings, and through partnerships with institutions in other

countries, UHN should position itself as a model for the world.

In addition to the group meetings, each Task Force member was invited to

participate in a one-on-one interview to discuss further options for UHN and to

have the ability to provide more input to the overall process. These views were

summarized and incorporated into this report. Consultation with other key groups

within UHN also provided useful feedback. These groups included The Planning

and Priorities Council, Operations Committee, Managers, Community Advisory

Committee, Medical Staff Association, and front line staff.

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3 Trend Analysis

3.1 External Environment

Globalization Trends

TTHHEE RREEVVOOLLUUTTIIOONN

Globalization is shaping and rapidly changing the way we live, work, play and

think. For the first time in history, information can be exchanged simultaneously

and interactively all around the world, with the potential to be available equally to

health care professionals, decision-makers and the public. Economies, cultures

and nations are becoming integrated and this integration is already having

profound effects on individuals, corporations, communities and societies.

Corporations are becoming more knowledge-based and acutely aware that to

thrive, they must focus on branding, reputation and relationships, all of which

depend on close connection with and trust from their customers. The physical

aspects of the workplace are changing, being “deconstructed”, and will no longer

be geographically dependent. As a result of globalization, increasing numbers of

people are expecting more from the health system and faster. The new media

and tools to which we all are being exposed are changing the way in which we

communicate, learn and think.

We can no more foresee the shape or extent of their effects on health care than

our 16th century ancestors could have predicted the blossoming of science that

followed the Gutenberg revolution. What we can see now is that we are going

through a period of rapid transition that is creating unprecedented opportunities

and challenges to large traditional health care institutions like UHN.

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TTHHEE BBAACCKKLLAASSHH

In an ideal world, globalization should not be about status, control or hierarchy

but about enabling and empowering people (Fiorina, 2001). The main driving

force in a globalized world should be innovation, knowledge, ideas and fairness,

not the pursuit of economic dominance by a small group of individuals or

organizations.

In reality, there is much concern and debate over the benefits and harms of

globalization. Advocates of globalization say it is a means to bridge the gap

between rich and poor nations. They argue that through technology, the

economies of developing countries can become efficient and functional and

share in the wealth of industrialized nations.

On the other side of the coin, is the anti-globalization camp. In January, 2001

while the world was tuned into the World Economic Forum in Davos, Switzerland,

there was the anti-Davos forum being held in Porto Alegre, Brazil called the

World Social Forum. This forum was the culmination of anti-globalization forces

that were organized around the riots in Seattle during the summit of the World

Trade Organization. The anti-Davos movement challenges the motives of the

World Economic Forum and calls for the “democratization” of the process of

globalization. They claim groups like the WTO, IMF and World Bank have more

power than many nations and that need to become democratized, accountable

and more transparent. The World Social Forum indicated that thus far,

globalization has been a process of exclusion rather than inclusion and the rich-

poor divide is growing, especially with the increased incidence of poverty and

disease in the third world. What is needed more than anything in developing

countries is direct investment with a social conscience. This view was shared by

the United Nations Human Development Report of 1999, which was called

'Globalization with a human face’ [http://www.undp.org/hdro]

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Trends in Globalization and Healthcare

Although it is impossible to predict its evolution, it is clear that globalization will

have a profound effect on the way in which health services are planned,

organized, provided and funded. One of the most likely effects of globalization on

the health care system will be the elimination of geographical barriers for the

provision of health-related services. Even though we are just at the dawn of the

information age, there are already some clear examples of organizations that are

starting to provide services to a global ‘market’ over the Internet.

Many of these organizations are mostly virtual. The clearest example of this

group is WebMD, the most powerful health-oriented Internet-based company in

the world. WebMD has recently entered Canada, through WebMD Canada,

establishing partnership with the Royal College of Physicians and Surgeons of

Canada and the College of Family Physicians of Canada [http://www.webmd.ca/].

The objective of WebMD, in Canada and elsewhere, is to provide “connectivity

and a full suite of services to the healthcare industry that improve administrative

efficiencies and clinical effectiveness enabling high-quality patient care. The

company's products and services facilitate information exchange, communication

and transactions between the consumer, physician and healthcare institutions”

There is also an increasing number of Canada-based start up companies that are

hoping to fill many of the gaps that the traditional health system, with its industrial

age model, has left wide open in Canada and world wide.

Traditional “bricks-and-mortar” health care institutions are also evolving to deliver

global services with strong brands, such as The Mayo Clinic, Harvard Pilgrim

Healthcare, Kaiser Permanente, and MD Anderson (http://www.mayoclinic.com/,

http://www.harvardpilgrim.org/, http://www.kaiserpermanente.org/,

http://www.mdanderson.org/ ). These organizations have started to address

trends in the changing hierarchy of health care. They have opened up

communication with the public in an effort to decrease episodic care and

http://www.mayoclinic.com/

http://www.harvardpilgrim.org/

http://www.kaiserpermanente.org/

http://www.mdanderson.org/

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increase constant interaction with the health system. They have helped place

decisions in the hands of the patients and give them greater control and support

in maintaining their day to day health or illnesses. For example Harvard Pilgrim

Online has a system that helps diabetics manage their disease through

monitoring devices and online information and interaction with clinicians.

This trend toward increased self-care is likely to continue at least over the next

10 years. Most people want to be empowered with the tools and information to

make appropriate decisions about their own health. Smith, in the British Medical

Journal suggests a renewed model for the health system in the information age

as shown below:

Figure 4.1 Information Age Model of the Health System (Smith;BMJ, 2000)

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Smith displays the traditional industrial age model which places tertiary and

quaternary care at the top. People seek primary care, secondary care and

tertiary care in a bureaucratic and episodic system. Smith suggests this system

will be turned on its head as people demand and the system encourages the

movement towards increased self-care, family care and care from other people

through support groups and networks. Professionals will become facilitators and

partners in a system that empowers patients and allows them to navigate and

make informed decisions. eHealth innovation will be one of the key factors in this

transition.

In Canada, Internet access by the public has been increasing progressively, with

some groups estimating that the proportion of people with has reached 70%.

(Angus Reid, 2000). Preliminary data from the ‘UHN e1000 Project’, conducted

by the Program in eHealth Innovation at UHN, suggest that, in April of 2001, 56%

of patients coming to the UHN have access to the Internet. Of them, 69% use it

as a source of health information and 75% would like to communicate with health

professionals and the UHN through e-mail and Web sites. This trend will certainly

continue.

Increase use of information and communication technology is also occurring from

the health care providers’ side. A recent survey by Deloitte and Touche and

Cyber dialogue aimed at physicians in the US, cited that more than 70 percent of

the respondents believe they will rely more on the Internet for their day to day

activities in five years. Data from Canada show that 88% to 100% of physicians,

and more than 75% of nurses have access to the Internet, with more than 90% in

each group reporting that they have interacted with at least one patient who has

brought information from the Internet to their attention

[http://www.cma.ca/cmaj/vol-163/issue-5/prq/index.htm ; Jadad et al, 2001]

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Enablers of online communication over vast distances are being developed and

expanded at a time when health care is becoming increasingly specialized.

“Specialization in medicine has been a virtually inexorable trend for many years.”

(Barondess, 2000) Increased specialization will drive the need to communicate

across specialties and between generalists and specialists. The need for

increased communication between these groups will not stop at organizational

boundaries but will require health professionals to collaborate across institutional

boundaries and even geographic and international boundaries. Organizations

cannot expect to house specialists in all areas but instead house few specialists

in a few areas of excellence and institutional priority, who should be equipped

with the tools and given the incentives to apply their knowledge and skills to the

broadest possible population. This will increase the need for collaboration and

communication.

Globalization will also bring with it global reaching diseases carried by world

travellers as the world ‘gets smaller and smaller’. It will also continue to create

opportunities for the exchange of professionals from country to country as the

global network expands, especially in specialized services such as those focused

on genetic disorders.

While the trends in globalization can provide health care organizations with an

expanded population base, there is some debate on the impacts this will have on

the principles of the Canada Health Act. With decreasing autonomy of nation

governments in the global economy, the trend for governments is towards

decreasing taxes to remain competitive. The majority of Canada’s health care

system is provided through taxpayer dollars. Globalization can provide the

opportunity to decrease this reliance on the Canadian tax dollar but will also

throw open the gates to Canadian patients seeking health care from other

countries, as well as to major international groups to target Canadians as clients

for their health services. The prevention of a second private tier is what is said to

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have kept the health care system in Canada so healthy, by making every

Canadian an advocate for its maintenance. Once the walls come down to

globalization there is a risk that the principles of the Canada Health Act will

erode.

3.2 Internal Environment

Patient Care Services

UHN serves a diverse group of patients who represent more than 170 languages

and many cultures. The small formal structure around multicultural health is

situated in the “Healthy Connections Program” which is based at the Toronto

Western Hospital. They offer culture-specific programs (e.g., Portuguese Mental

Health); coordinate the cultural interpreter program for UHN; and have made

progress in linking with several multicultural communities. All clinical programs

across UHN serve a multicultural population and make attempts to meet their

needs for service.

UHN also has an International Patient Program. The program is designed to

coordinate health care services for international patients who have the resources

to pay for such treatments. Unlike the Hospital for Sick Children, there is no

private fund to support the provision of services at UHN to those who cannot

afford to pay.

Patient education has been improved with computers at Princess Margaret

Hospital. Patients can access computer-based interactive learning tools on

treatment options, health information and information about their cancer in fifteen

patient and family resource centres including a library throughout the hospital.

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Human Resources

UHN, which employs more than 10,000 people, has a very diversified workforce. The Program in

Workplace Diversity was established to encourage cultural competency and to increase

awareness and sensitivity of international and diversity issues throughout the organization. The

office’s mandate is to ensure inclusive staff recruitment and retention strategies. The tools used

by the Workplace Diversity Program for ensuring equitable hiring and retention practices are:

policy reviews, sensitivity awareness training, tracking systems, benchmarking, cross-cultural

mediation and equity seeking intervention.

Information Systems and Technology

UHN is very well positioned in terms of technology.

The organization has developed an information

technology infrastructure that supports excellence in

patient care, teaching and research. This

infrastructure is currently being enhanced through the

Information Management Strategy (called care@uhn)

that will take the organization through to the year

2005.

The investment in information technology and systems at UHN is 4.5% of its

operating budget, and calls for the investment of $50M in capital over the five-

year period of the strategy. In 2005, UHN will be one of the most advanced

health care organizations in Canada and the world in terms of IT infrastructure,

including electronic patient records, enterprise-wide schedule and clinical

decision-support tools for providers and patients.

Research

To augment future strategies within the organization as well as outside the

organization, the UHN joined forces with the University of Toronto (U of T) to

create, in 2000, the Program in eHealth Innovation. This Program has a mandate

to study how technology and knowledge can benefit patients, providers and

mailto:care@uhn

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improve access and equity to the health system. This Program will foster the

development of a ‘mini-model of the world’ in Toronto, building on the

multicultural population served by UHN and its multicultural workforce, with the

capacity to recreate any health decision-making environment in any region of the

world, bring research to the point of care, promote input from all groups of

decision-makers, and accelerate the rigorous evaluation of eHealth innovations.

Currently, the Program has identified over 100 individuals affiliated with UHN and

each of the other major teaching hospitals in Toronto, who are interested in

joining forces to study eHealth innovation and its impact on the Canadian and

global health system. The Program is currently leading, on behalf of UHN, an

ambitious proposal for the creation of unique infrastructure to study eHealth

innovations and their impact in the health system and society. The infrastructure

includes the following elements:

��The Centre for Global eHealth Innovation: This will include approximately

10,000 sq. ft. of renovated space, which will enable economies of scale to

support eHealth innovation research. It will host physical, human and virtual

resources to support five core functions (idea/knowledge exchange; research

and development; education and training; business development; and

research administration). It will also include the first standard usability

laboratory dedicated to support research in eHealth innovations in Canada.

��The Health-oriented Flexible Simulation Environment: This will be a

unique multitasking laboratory designed like a movie set in an area of

approximately 5,000 sq. ft. to simulate real world settings, such as consulting

offices, nursing stations, classrooms, boardrooms, waiting rooms, homes, and

other decision-making environments to allow controlled experiments and

economies of scale for the efficient pre-testing, refinement and development

of new information technologies, human-computer interaction, evidence-

based decision-making and computer-assisted learning tools.

��Living Laboratories: This will be a series of networked environments in

health care institutions (institutional laboratories in hospital wards, consulting

rooms, waiting areas and libraries) and the community (non-institutional

18


laboratories in family physician offices, waiting rooms, community centres,

schools and homes) to support research and development activities in real-

world decision-making settings.

The large number of people who are willing to participate in activities of the

Program, together with this infrastructure, will form a unique engine for trans-

disciplinary research on the transformative effects of information and

communication technologies on health systems, positioning Canada as a leader

in eHealth innovation and UHN at the forefront of the information age.

The View From the Outside

The Task Force drew members from outside UHN to assist in developing

recommendations around globalization the eWorld. They offered advice that is

critical for UHN to heed if it is to be a credible player in the local, national, and

international communities. The messages can be summarized as follows:

��UHN must learn to follow and lead. UHN is known in the community for

attempting to be a leader in all areas. This has sometimes made partnerships

difficult to create and maintain, and is an unsustainable position to maintain in

a global world. In many areas, UHN can show leadership by following others.

��Branding the “University Health Network” name will be critical to a successful

global strategy. The name of the organization implies a number of factors

that can be developed further: academia; health – not just illness; and

partnerships in a “network”.

��“Digitize, globalize, or die”. Many lessons are being learned in the private

sector that are important for public sector organizations to consider. Though

a passive approach to globalization might result in short term savings and one

less thing to worry about, the results could be disastrous. UHN could find

itself in a position of progressive isolation and inefficiency; vulnerable to rules

defined by others; not involved in decision-making by the public and funders;

and unable to recruit and retain highly qualified and experienced care

providers.

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4 Options for UHN Positioning

While industry has moved quickly, traditional health care institutions have been

slow in reacting to the information age. The rapid developments in information

technology are outpacing the ability of the traditional institutions to keep up. Most

institutions continue to provide health care services following a model that was

developed in the industrial age. Health-related programs and health care

systems in traditional health care institutions were built for the pre-Internet era

and to satisfy the needs of the health care providers and managers who work

within their own walls. In industry terms, Canadian health care is a seller-driven

business, not a buyer-driver business. As a result, there is poor connectivity and

compatibility of computer systems across organizations, and between

organizations and the community. This is compounded by the fact that most

policy makers and managers are unable to monitor the impact of technology on

health-related issues or to respond to the opportunities to improve health

services created by new technology. Health professionals are feeling

overwhelmed by clinical work and do not have the time or the incentives to re-

tool and adapt their practices to the information age. Patients and other members

of the public are using the Internet increasingly, but find that the system is not

adapting fast enough to meet their needs. To our knowledge, for instance, not a

single hospital in Canada is asking patients for their e-mail addresses.

Against this background it could be argued that only those institutions that evolve

and adapt to the changing needs and expectations of the people they hope to

serve will avoid becoming out of touch and even obsolete.

In response to this description of the current environment, the Task Force

described the key elements of an ideal health system (see details in Appendix

C). The Task Force advised that UHN should pursue globalization and eHealth

initiatives in order to create a system that is:

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��equitable

��accessible

��caring and supportive

��of highest quality and continually improving

��responsive, convenient, accountable and efficient.

The vision and recommendations that follow were developed with this vision of

the ideal health system in mind.

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5 Vision 2011

April 12, 2011: Ten years ago, UHN decided to implement a systematic approach

to assess and position the organization within the global and eHealth world. Its

key investments were to improve consumer-consumer, consumer-provider, and

provider-provider relations using technology and the eHealth innovations.

The primary focus was to improve access to services for UHN’s local community,

ensuring that members of the public and health care providers had access to the

people, information and services they need, when and where they need them,

regardless of who they are. The next focus was to build on the success of this

improved service to the local population to ensure UHN’s position in the ever-

changing global environment. The following events of today illustrate the

improvement in service that has been possible because of this investment and

vision.

7 A.M.

As Mary Jones stands in front of the bathroom mirror, she feels a lump on her

breast. Startled, she quickly heads for her computer and links up the University

Health Network public Web site. She’s nervous and wants to look up instructions

for what to do. Through a virtual coaching system developed by her family

physician, Dr. Phil Ellison at the Toronto Western Hospital, she books an

appointment at 2:00 PM, gets step-by-step guidance on how to describe the lump

and on encouragement to select and ask questions important to her during the

consultation. Hours before she shows up, Dr. Ellison has already been alerted,

checked her medical records, reviewed the questions that Mary wanted to ask

during the consultation and sent additional information to Mary to prepare for the

appointment. That same day, a biopsy is taken, which confirms within minutes

that the lump represents a benign condition that just requires observation.

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8:30 A.M.

Jarib Mohammed isn’t feeling well as he wrestles with the blankets. While he

tries to go back to sleep, he hears a loud sound. It is the alarm on his wristwatch

which is informing the groggy 32-year-old diabetic that his blood sugar levels are

high. His physician has already been informed over the Internet and has

suggested an adjustment in the dose of insulin delivered by his recently

implanted system. Once he approves the suggestion given by his physician, the

system is activated through Jarib’s home wireless network and the dose of

insulin is increased accordingly. His watch asks him if he would like to see his

physician at noon, or if he prefers to wait and see how the dose adjustment

process evolves from home. He decides to stay at home. A message is sent to

his supervisor at work, notifying her that Jarib will not be going to work today.

10 A.M.

Eighty-five-year-old Paulo Silva steps out of the cab in front Toronto Western

Hospital’s Emergency Department. Inside, Mr. Silva, who has difficulties

communicating in English, is welcomed by the Portuguese-speaking nurse with

whom he has kept in touch through the cab’s information system. She introduces

him to the physician with whom she has been following his symptoms since he

left home. His grand-son, the closest relative available in Toronto has been

informed of the situation and is on his way. Mr. Silva receives the latest

treatment to dissolve the clot that is causing a small stroke and is taken to a ward

to recover for a few days. During that time, Portuguese-speaking staff teach him

how to use a hand-held device to record any new symptoms after discharge and

transmit them to the hospital. Through the community planner program, on a

nearby desktop computer, a discharge nurse arranges for Mr. Silva’s care to be

continued back in the community by a network of people with expertise in

managing Portuguese patients.

11 A.M.

For 24 hours, a team of UHN researchers and physicians have been working

closely with several laboratories to figure out what’s wrong with a sick woman

from Uganda visiting her family in Toronto. There’s a possibility that she is

23


carrying a new type of bacteria known as I-coca 3 which is quickly compromising

her lung function. Using his desktop, one of the physicians looks up a teaching

hospital in Kampala through the Virtual Library. A videoconference is quickly

arranged and the physicians confirm from experts back in Uganda that their

diagnoses is most likely correct. The patient is quarantined and quickly treated

with a combination of antibiotics with which impressive results have been

obtained by a study that was completed last week in the hospital in Kampala.

12:00 noon

Dr. Brenda Gallie, an internationally known expert in the diagnosis and treatment

of retinoblastoma, an eye cancer, is participating in global teaching rounds,

broadcast over the web, exchanging information with colleagues from 32 medical

schools around the world. A group of parents of children with this type of cancer

is holding parallel live discussions about a new form of treatment and trying to

decide what questions they should ask to the physicians at the end of the

session.

5:15 P.M.

Dr. Josef Penninger, very excited about the findings of a recent experiment

accesses the Multimedia Group Interaction Centre on his laptop and sets up a

five-way videoconference call with colleagues from AMGEN, Acme Proteomics,

Massachusetts General Hospital Research Centre and The National Centre for

Genetics Research in Stockholm. Dr. Penninger shares his findings with the

group and gets very valuable feedback. Three of the participants (one of whom

is at home) agree to repeat the study in their own laboratories. They conduct a

live search of the international database of tissue banks and proteomics from

their stations and confirm that they have enough tissue samples in their local

back to try to reproduce Dr. Penninger’s findings.

6:00 P.M.

24


Maria Contreras, a 32-year old Colombian woman, has been diagnosed with

breast cancer in Bogota. She is very distressed and asks Dr. Gomez, her

oncologist at the Colombian Cancer Institute to help her get a second opinion.

Dr. Gomez links up from Bogota to the International eHealth Program at UHN

and contacts Dr. Carlos Rizo, a Colombian physician who heads the program.

Dr. Rizo agrees to take the case, assesses Maria’s files over the Internet and

distributes it to the IPP’s breast cancer specialist team on call. Twelve hours

later, the diagnosis has been confirmed. Dr. Rizo holds a videoconference with

Maria and Dr. Gomez in Spanish. After reassuring Maria, Dr. Rizo receives

verification that UHN’s financial system has been credited with the revenue from

the consultations.

7:00 P.M.

An engineer on the Hibernia oil rig is bent over with sharp pains slicing through

his abdomen. The rig’s nurse practitioner links up in Toronto with Dr. John

Wright, a gastorenterologist at UHN. From his own computer, Dr. Wright guides

the nurse practitioner in performing an endoscopic procedure using a

swallowable camera as he watches. He manipulates the scope using commands

on his computer and diagnoses the engineer. After recommending treatment, he

signs off. One hour later, he receives a multimedia message from the nurse, with

attached greetings from the engineer, indicating that the pain is under control.

UHN has been automatically reimbursed for the transaction, part of which will go

directly to Dr. Wright (equivalent to what he would have received for the same

procedure locally), part to SIMS and part to the Underserved Assistant Program.

This is a self-funding program that has been set to support tele-health services to

people in Toronto with no insurance.

2:00 A.M.

Ian Smith, the nurse on call at the International eHealth Program receives a

request from Dr. Alex Chekov, from UHN Emergency Room, to link him up with

one of 3 leading experts on treatment-resistant seizures. Given the time, Roman

searches the database of the Program and verifies that Dr. Mansukh Anand in

25


Bombay, one of the experts, is available. He sets up the consultation and Dr.

Chekov learns about a new technique being developed in India by Dr. Anand’s

team. He links up to the tutorial developed by this team of specialists and follows

step-to-step guidance on how to treat the patient. The outcome is excellent. Dr.

Chekov and Ian send a message thanking Dr. Anand. The data from the patient

are contributed to an international study on the new technique and the Bombay

hospital that supports Dr. Anand’s work is credited the revenue from the

consultation.

9 A.M.

Tom Closson, the CEO of UHN, is the keynote speaker at the World Social

Forum in Porto Allegre, Brazil presenting the paper “UHN and globalization: from

Toronto to the world” in which he will share with audiences in 25 countries how

efforts to meet the needs of the multicultural community in Toronto 10 years

before, led to the creation of the Global eHealth Innovation Network, the largest

network of people and research infrastructure in the world working on the

transformation of health systems through eHealth innovation. The audience

found particularly interesting experiences with the EGALITE project, the

successful initiative that worked with underserved communities in Toronto in

collaboration with 12 developing countries to use technology to improve their

health. He decided to fly to Brazil instead of delivering his lecture by satellite,

because he wanted to take a well-deserved break with his wife on a computer-

free cruise through the Amazon.

26


6 Recommendations

6.1 Corporate Policy on Globalization

6.1.1 Create a forum with a mandate to assess and make recommendations on globalization and eHealth issues that reports directly to the Planning and Priorities Council.

If UHN is to be successful in a global health care environment, the Planning and

Priorities Council must create a forum which uses a systematic approach to

assess and make recommendations about globalization and eHealth. This

group, will build on the activities, expertise and partnerships of the Program in

eHealth Innovation and various clinical programs across all three hospitals. ,

The group must have a direct reporting relationship to PPC, with representation

from UHN and the key sectors involved in and affected by globalization:

government, media, health care providers, private sector, community members,

research, academia. They will be charged with:

��Monitoring trends and changes in the globalization of health services and

eHealth innovations, within and without UHN.

��Evaluating the impact that such trends and changes could have on the

provision of existing services or on the need for new services.

��Identifying and overcoming barriers to changes in the structure and

services of UHN that could help it thrive in its local community and in a

global environment.

��Evaluating the impact that any of the above changes will have on the staff,

patients, services, teaching, research, financial status and image of the

organization.

��Mitigating the risks of any business venture on a global scale including the

effects to our image as a global organization and any negative

connotations with globalization.

27


6.1.2 Implementation Plan ��A member of PPC will be appointed to be the liaison of the group

��The group will be charged with the mandate outlined above

��The group will be given a regular schedule for reporting to PPC

The critical success of this recommendation depends upon the commitment of

the Planning and Priorities Council with funding and a true desire to build a

consumer-focused organization.

6.2 Providing better “Globalized” Service at Home

6.2.1 Develop an infrastructure that supports and builds the organization’s cultural competence in providing health care.

The University Health Network serves a city which boasts a rich diversity in its

people, communities and institutions. That diversity is reflected in its patient and

staff populations. UHN embraces the importance of cultural competency in

maintaining a vibrant workforce and an effective response to patients at all three

hospitals. At the present time, the UHN centres its efforts in two key areas:

Workplace Diversity and Community and Multicultural Health. These areas of

focus have made strong contributions to the effectiveness of the organization.

This recommendation supports extending our current initiatives by building a

strong infrastructure to move the organization to excellence in this critical area of

health care and customer service.

��Key investments in the Workplace Diversity and Community and Multicultural

Health programs to build a stronger infrastructure are needed to ensure that

the organization is able to make the necessary gains to meet current and

future needs. This would include additional staffing to reflect the importance

28


of both education and research in cultural competency, as well as the

personnel to improve front-line service delivery to a diverse client population

and staff.

��One of the critical areas that must be addressed is educating all UHN staff

regarding the impact of socio-cultural factors on the overall health of our

patients and staff. A broad-based educational and research initiative should

be launched in order to move the organization in a phased approach towards

achieving cultural health care competence across all disciplines and sites.

��Ongoing data collection is needed to ensure that UHN is nimble in responding

to changing socio-demographic and other trends. Monitoring the

effectiveness of our efforts, and meeting staff and patient needs should be

carried out through the administration of survey instruments which have been

developed to address socio-cultural barriers. Indicators which measure

success in addressing socio-cultural barriers should be regularly reported to

three Hospital Executive Committees and to the Planning and Priorities

Council.

��Service provision in diverse languages and with an understanding of diverse

cultures should be addressed with a proactive hiring and training policy for

staff. Interpreter services should be augmented and training should be

offered to staff to ensure that interpreters are used effectively in patient

interactions. Patient education materials, signage and other modes of

communication in the organization should be translated into key languages

and strengthened by the use of symbols that are accessible across diverse

cultural constructs, and information technology and multimedia to facilitate

knowledge uptake, reduce production costs and promote wide coverage.

6.2.2 Implementation Plan

��Support the increased efforts of the Workplace Diversity Program in the

development of a diversity strategy.

29


��Support Healthy Connections in expanding efforts to improve Community and

Multicultural Health programs.

��Develop and implement survey methods and data collection systems to allow

better measurement of improvements in reducing socio-cultural barriers to

UHN services.

6.2.3 Develop an eHealth strategy to improve the ability of consumers to manage their own health by increasing access to health information, facilitating contact with other consumers (e.g., chat-groups), and providing them with decision-support tools.

UHN should become the premier source of Internet-based information for the

population it serves. This recommendation supports the use of Internet-based

applications to promote self-care, support the development of communities with

common interests and the use of interactive tools to allow consumers to monitor,

maintain and make decisions about their health.

The promotion of self-care through interactive tools and relevant health

information via the Internet is crucial to allow individuals managing chronic

diseases to live more productive lives and for health promotion of the general

population. Access to support chat-groups will also help distill the “iceberg of

illness”. (Jones 2000)

6.2.2 Implementation Plan ��PPC must make investments that build on UHN’s current Internet

infrastructure to allow the development and support of ongoing tools on the

Internet site.

30


��Undertake an analysis of the needs and expectations of people from its

catchment area, to monitor and determine the appropriate strategy for UHN in

this area in a longitudinal fashion.

��PPC and the three hospitals must develop and implement a philosophy that

encourages self-care, equitable access to technology and knowledge, and a

stronger relationship between the public and UHN.

6.2.3 Enhance the patient-provider relationship through improved electronic access to the system and improved efficiency in a way that responds to the patient’s needs.

In an attempt to become an efficient organization, UHN will need to respond to

the needs of the public and the workforce that interacts with them. Enhanced

patient provider relationships will become a priority. UHN will achieve this goal

through increased electronic communication with patients; online appointment

scheduling, clinicians accessible through chat and email, personal, accessible,

health records and home-based telemedicine visits.

These resources will allow seamless communication with patients when and

where they need it the most. This continual relationship between patients and

providers will also end episodic care and create a relationship of “travel

companions”. (Jadad 2001b)

Considerable efforts need to be made to ensure that developers create

applications that do not disrupt busy clinical environments and that are perceived

by clinicians as help, not hindrance. In additions, incentives for physicians and

other care providers to use technology (e.g. teleconsults) to enhance the patient-

provider relationship must be evaluated and implemented.

To facilitate telemedicine visits, UHN should partner will established telemedicine

networks (e.g., NORTH Network, eCHN etc.) to develop a system that works well

with patients. The Network will also build on its information management

strategy (Care@UHN), in close collaboration with the Program in eHealth

mailto:Care@UHN

31


Innovation, to implement new developments in technology in a way that will

maximize the limited resources available.

6.2.4 Implementation Plan ��Provide funding to create economies of scale at the Program in eHealth

Innovation and Healthy Connections, to support pilot projects in collaboration

with their partners, with support from SIMS and Research Information

Systems, and strong links to the clinical settings.

��Undertake research to determine what information these consumers would

like on their health/disease

��Identify priorities for the assessment of needs of UHN’s patient and provider

population and the demand for services that will be created by unmet needs

and technological developments.

��From that research, develop a strategy in SIMS to respond to the needs of

those stakeholders.

��Build on the current information management strategy to give it the flexibility it

needs to accommodate the pace of innovation and the changes in the

population we serve.

��Develop and hire staff to build and support the required tools to support online

services.

��Constantly monitor changes in the environment, changing technology and

changing stakeholder needs and demands.

6.3 Globalization of Professional Services, Teaching and Research

6.3.1 Develop a strategy that supports knowledge sharing between specialists at UHN and specialists from around the world that includes plans for a supportive infrastructure, partnerships, promotion and branding.

32


UHN will develop a strategy to facilitate knowledge sharing among specialists

within UHN and between specialists inside and outside the organization. This

will require the development of an information technology infrastructure that

supports physician interaction over the Intranet and through the Internet for

external communications. Relationships with international organizations and

specialists and a culture of collaboration will have to be established.

6.3.2 Develop a strategy to support the collaboration with leading Research and Education networks.

UHN will develop a strategy to support collaboration in the fields of research and

education. The UHN community would benefit immensely by connecting to

prominent networks around the world.

Technology will be an enabler to future efforts to promote interactive web-

enabled Continuing Education (CE) as well as current education activities. Staff

and students at UHN would benefit immensely from being connected to leading

experts from around the world through interactive learning technologies.

6.3.3 Implementation Plan ��Research into the need and desire of UHN clinicians and researchers to

collaborate with peers inside and outside the organization through

technology.

��Based on the results of this research, a strategy will be developed on the

establishment of an infrastructure to support collaboration and communication

for research and education. This strategy will include an economic model,

information technology requirement and interested partners.

��Build on the success of the Ontario Medical Education Network to expand

education activities to other centres in the world.

33


6.4 Resources The successful implementation of initiatives of these globalization and eHealth

strategies will require investments in the following:

��full implementation of the Program in eHealth Innovation

��expansion of the Healthy Connections program to increase the Community

and Multicultural health programs (e.g., translation support; improved survey

tools and methods; community outreach)

��recruitment and training of additional cultural interpreters to support all three

hospitals

��development and implementation of a Workplace Diversity Strategy

��staff to support the Globalization and eHealth Forum

��Website improvement and expansion (e.g. chat groups)

��protected and funded care provider time to provide services over the Internet

The exact figures of investments are unknown at this time. Investments will

depend on the success of pilot projects and an assessment of their applicability

to UHN

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7 Conclusion

UHN should adopt global and eHealth strategies that enable the provision of

better care to our local diverse communities, make use of eHealth innovations to

improve self-care and enhance the patient-provider relationship, and promote

collaborative efforts by its providers, researchers, teachers, and students with

counterparts around the world for the improvement of health for all.

The Task Force on Globalization and the eWorld feels optimistic about the future

of health care. Though the trend towards globalization will require significant and

continuous efforts by UHN to analyze and adapt to its impact, the benefits to

UHN’s local population can be tremendous. UHN needs to be fully committed to

a health system that is:

��equitable

��accessible

��caring and supportive

��of highest quality and continually improving

��responsive, accountable, convenient and efficient

The global and eHealth activities in which UHN will engage must aim to bring the

organization closer to this vision.

35


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10) Foss, Krista; Deadly Virus Still Puzzles MDs, Globe and Mail, Friday February 9, 2001.

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13) Jadad AR, Sigouin C, Cocking L, Booker L, Whelan T, Browman GP. Use of

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9 Appendices

Appendix A: Globalization and the eWorld Terms of Reference Purpose

The Task Force will provide the University Health Network with an analysis of the trend towards globalization and the eWorld of health care delivery. The Task Force will make recommendations on strategies for UHN to address these trends. The strategies will consider the patient services, teaching and research roles of UHN.

Objectives

•= To identify, project, and analyze the impact of globalization and the eWorld on UHN.

•= To define the enablers of globalization in health care (e.g., clinical telemedicine; internet; hospital branding)

•= To identify the implications and benefits for delivering global health care services (e.g., investments; revenues; research opportunities; etc.)

•= To recommend options and strategies for moving University Health Network's programs and services into the global marketplace.

Membership

Chair: Dr. Alex Jadad, Director, Program in eHealth Innovation, UHN and University of Toronto

Membership •= Matt Anderson, Chief Information Officer, UHN

•= Dr. Ed Brown, Director, NORTH Network

•= Irene Cameron, Representative from the Community Advisory Committee, UHN

•= Dr. Derrick DeKerckhove, Director, McLuhan Program in Culture & Technology, University of Toronto, Faculty of Information Studies

•= Hy Eliasoph, Senior Manager, Health Care Solution Group, Deloitte & Touche

•= Dr. Murray Enkin, Professor Emeritus, McMaster University

•= Tom Goldthorpe, Director, Research Informatics, UHN

•= Dr. Michael Guerriere, Chairman & CEO, HealthLink

39


•= Dr. Richard Heinzl, Founder, Doctors Without Borders Canada

•= Jean Holden, Director, International Patient Services, UHN

•= Jeanne Jabanoski, Director, Healthy Connections, UHN

•= Brenda Laurie-Shaw, Director, Nursing Informatics, UHN

•= Dr. Alan Mease, Chief Medical Officer, Telemedica Group

•= Steve Orsini, Ontario Hospital Association

•= Dr. Carlos Rizo, eHealth Innovation Program, UHN

•= Jordan Sullivan, UHN Board of Trustees

•= Nick Tidd, Managing Director 3Com Canada

•= Dr. Paul Walker, Vice President, Toronto General Hospital, UHN

Process Coordinators:

•= Sarah Downey, Director Corporate Planning and Drew Baillie, Analyst, Corporate Planning

40


Appendix B: Conceptual Framework Framing the Debate In order to facilitate the task force’s thinking and discussions, we propose that the discussions be focussed on the following: EEFFFFEECCTTSS OOFF TTHHEE GGLLOOBBAALLIIZZAATTIIOONN OOFF HHEEAALLTTHH CCAARREE AANNDD TTHHEE EEWWOORRLLDD OONN UUHHNN:: If UHN is to thrive in a global health care environment, it must develop efficient strategies to:

�� Monitor trends and changes in the globalization of health services and eHealth innovations.

�� Evaluate the impact that such trends and changes could have on the provision of existing services or on the need for new services.

�� Identify and overcome barriers to changes in the structure and services of the UHN that could help it thrive in its local community and in a global environment.

�� Evaluate the impact that any of the above changes will have on the staff, patients, services, financial status and image of the organization.

�� Mitigate the risks of any business venture on a global scale including the effects to our image as a global organization and any negative connotations with globalization.

IIMMPPAACCTT OOFF UUHHNN OONN TTHHEE GGLLOOBBAALLIIZZAATTIIOONN OOFF HHEEAALLTTHH SSEERRVVIICCEESS IINN TTHHEE EEWWOORRLLDD:: UHN is in a unique position to play a leadership role in the globalization of health care and the promotion of eHealth innovation in Canada and around the world. The following are three sequential steps that the task force could use to guide its discussions around strategies to enable the UHN become an important world player in the delivery of health care services in a global/international context. These steps are as follows:

1. “Globalization at home”. UHN employs a diverse staff and serves such diverse communities (e.g., people from over 150 countries) that it could be considered as a mini-model of the world, an ideal living laboratory where the impact of “global” services and eHealth innovations could be evaluated efficiently. On the other hand, any aspiration of the UHN to become a world player would be unrealistic unless it meets the “global” needs of its multicultural clients coupled with the technical infrastructure to support globalization.

2. UHN as the Canadian change agent for global services. UHN must act as an agent of change within Canada (e.g., vis à vis government, provider groups) in order to be able to deliver its services in a global setting.

3. UHN as a team player in the world scene in the delivery of global services. UHN must establish partnerships in order to provide and sustain the delivery of global health care services.

Various stakeholders are required to facilitate the achievement of the above-noted steps. They can be broadly organized into the following groupings:

•= National/Provincial Governments Canadian national and provincial governments and national governments of foreign countries.

•= Health Service Providers Both the Organizations and the professions that deliver health care services.

41


•= Academia (teaching and research) The institutions contributing to the education of health care professionals and conducting health services research (Universities and Colleges)

•= Industry Private sector companies competing in the development, marketing and sales of products and services in health care.

•= Public/Patients Current and potential/future consumers of health care services.

•= Media The role of each group in preventing and/or enabling the delivery of global services must be carefully assessed in order to define a strategy for UHN to achieve its goal of globalization.

42


Barriers, Enablers and Strategies of Globalization The following tables refer to each of the 3 steps identified above, highlighting examples of barriers and enablers for each of the stakeholder groups. These tables were used as tools in the development of enablers barriers and strategies in globalization.

SSTTEEPP 11: “Globalization at home”. Developing a mini-model of the world in Toronto.

PPLLAAYYEERR BBAARRRRIIEERR EENNAABBLLEERR SSTTRRAATTEEGGIIEESS Service National & Provincial

Government •= Globalization of health care is not a political or funding priority for governments

•= Restrictive/non-existent legislation (e.g., privacy laws; licensing issues, payment for internet consultations)

•= New funding available for projects that promote Canada’s global presence (e.g., Canadian Foundation for Innovation, Ontario R& D Challenge Fund)

•= Beginning to address privacy issues with legislation

•= Federal government funds institutional change strategies with the outcome of better service to diverse populations

•= Lobby for funding changes that reflect the current realities

•= Apply for Canadian Immigration Centre for funds to provide culturally sensitive programs

•= Lobby funding sources to provide funding to serve vulnerable groups with access barriers

Electronic

43


PPLLAAYYEERR BBAARRRRIIEERR EENNAABBLLEERR SSTTRRAATTEEGGIIEESS Service Health Service Providers

•= Globalization and eHealth not a current priority

•= Staff shortages (no staff available to deliver more services)

•= Conflicting incentives between provider groups and health care organizations (no economic benefit for delivering better/global services)

•= Limited co-ordination across continuum of care (integration) to optimize opportunities for globalization

•= Large population of health professionals in Toronto with diverse ethno-cultural background but unable to work in Canada because of their foreign degrees

•= Recent high-profile clinical cases that underscore the need to think globally (african woman in Hamilton with unknown disease)

•= Link with Community agencies for innovative programming

•= Hire skilled staff with the appropriate language skills to serve UHNs multicultural population

Electronic •= Low levels of awareness

about eWorld/eHealth •= Lack of resources and skills

to facilitate communication with diverse cultural groups and across large distances

•= High levels of internet access

44


PPLLAAYYEERR BBAARRRRIIEERR EENNAABBLLEERR SSTTRRAATTEEGGIIEESS Service Academia (Teaching

and Research) •= Lack of formal collaboration among groups interested in globalization and eWorld

•= Healthy Connections Program at TWH

•= Industry interested in partnerships

•= Recognition of the need for collaboration and joint efforts

•= New funding opportunities (Canadian Foundation for Innovation, Ontario Challenge Fund)

•= Several research groups with global reputation for excellence

•= Apply for funding to study cultural sensitivity issues

•= Apply for funding to educate our staff and patient’s on the issues

•= Bring together the research community involved and interested in study global health issues on a collaborative basis

Electronic

•= Lack of infrastructure and economies of scale to study eHealth innovations

•= Program in eHealth Innovation at UHN and U of T

•=

45


PPLLAAYYEERR BBAARRRRIIEERR EENNAABBLLEERR SSTTRRAATTEEGGIIEESS Service UHN

•= Same issues as “providers”

•= Lack of will and momentum to respond to the needs and wants of our customers.

•= Large multicultural patient population and staff

•= Healthy Connections •= Senior leadership interested in

further investigating global opportunities

•= Linkages established in Saudi Arabia, South America, Africa and China.

•= Strong community of hospitals and other health service organizations who can enhance UHN’s offering through partnerships

•= Organizational values that build on our customer relationships and a mission to be an internationally recognized health science centre.

•= Experience merging corporate cross cultures and functions in the mergers of TWH, TGH, PMH.

•= Vibrant community advisory committees at all three sites with diverse representation and interest in client service

•= Implement Board policy statements on serving diverse populations and procedures that flow from that.

•= Implement hiring practices that reflect the need to recruit with the skills, including language, to serve diverse populations

•= Interpreter services, in the absence of staff who speak key languages, should be a routine tool in delivering health care to patients

46


PPLLAAYYEERR BBAARRRRIIEERR EENNAABBLLEERR SSTTRRAATTEEGGIIEESS Electronic UHN cont’d

•=

•= Program in eHealth Innovation

•= Large technology investment •= A strong technical

infrastructure that can serve as a base for global eHealth at home or abroad.

•= Improve patient access and satisfaction through technology (Internet and email)

Service Industry

•= Low profit margins in the delivery of global health care service in and from Canada

•= Market volatility a barrier to risking significant investment for local services

•= Organizations are required to work within the Canada Health Act which can limit the offering of services for profit.

•= Barriers to market entry are high.

•= Willingness to compete on a global scale, a mini-model in Toronto can act as a testing ground and launching pad for ideas world-wide.

•= Experience implementing and conducting business across cultures and boundaries.

•=

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PPLLAAYYEERR BBAARRRRIIEERR EENNAABBLLEERR SSTTRRAATTEEGGIIEESS Electronic

•= •= Strong international technical infrastructures and skilled trained staff readily available.

•=

Service Public/ Patients

•= Low socio-economic or health literacy status of many multicultural patient populations in downtown Toronto

•= Diverse cultural and linguistic groups not organized to advocate for better/more global services

•= Perception that health care organizations are not responsive to community needs

•= A growing, knowledgeable consumer that demands service and access to the system 24/7.

•= Evidence that other health care organizations (i.e., camh) are moving to address these needs

•=

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PPLLAAYYEERR BBAARRRRIIEERR EENNAABBLLEERR SSTTRRAATTEEGGIIEESS Electronic

•= Limited access to technology to facilitate delivery of global services

•= The growing computer literacy rate of the local population (50% have access to the internet).

•= Growing multiculturalism on the Internet. (English no longer the dominant language).

•=

Service Media •= No media awareness or interest in

reporting on UHN delivering global services locally

•= Growing trends in anti-Davos philosophy, including reactions to Seattle WTO summit can provide controversial, high rating stories.

•= The need to educate the public on the real issues and benefits/risks of globalization due to public interest.

•= “Good news” globalization stories.

•=

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SSTTEEPP 2 & 3: UHN as a change agent in Canada and a Team Player on the world scene. PPLLAAYYEERR BBAARRRRIIEERR EENNAABBLLEERR SSTTRRAATTEEGGIIEESS

Service National & Provincial Government •= Concern that global focus may

detract from local service •= Tight controls on private markets in

Canadian health care •= Concern with financial risk of

publicly-funded organizations pursuing global opportunities

•= Won’t support creating two tier health care (one tier for Canadians in a publicly funded, universal system and a second tier for global patients)

•= Political risks with changes in governments in other countries or international disagreements

•= Diminished role for the Canadian government as they are dominated by more powerful states/unions/private organizations

•= The need to decrease Health care’s reliance on tax dollars: with increased globalization, governments are losing autonomy. There is a trend toward lower taxation. The globalization of health services will decrease Healthcare’s reliance on the Canadian tax dollar.

•= Global governments desire to participate in the global community and the new economy.

•= View that Canadian healthcare organizations can compete well on an international scale – huge export potential (increase balance of payments)

•= View that globalization of Healthcare can potentially increase the reputation of Canadian scene and attract worldwide talent to use Canada as their base.

•= Lobby/educate provincial and federal governments to change funding measures to make them reflect reality (telemedicine, physician email)

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PPLLAAYYEERR BBAARRRRIIEERR EENNAABBLLEERR SSTTRRAATTEEGGIIEESS Service Health Service

Providers •= Staff shortages (no staff available to deliver more services)

•= Conflicting incentives between provider groups and health care organizations (no economic benefit for delivering better/global services)

•= Limited co-ordination across continuum of care (integration) to optimize opportunities for globalization

•= Unions perception of globalization as a threat to their members

•= Providers who are only interested in serving a local English speaking customer.

•= Balancing global vs. local service priorities, particularly if global service is more remunerative than local

•= Unions perceive globalization as a threat to their members

•= Collaborate with others who are already working in this field

•= Support knowledge sharing between specialists on an international csale

Electronic •= Low levels of awareness about

eWorld/eHealth •= Globalization and eHealth not a

current priority •= Lack of resources and skills to

facilitate communication with diverse cultural groups and across large distances

•= Canadian Medical Association interested in using information technology and improving its global profile.

•= Pursue international eHealth opportunities and strategic alliances with sister health care enterprises.

•= Provide physicians with access to collaborative networks that will facilitate telemedicine visits

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PPLLAAYYEERR BBAARRRRIIEERR EENNAABBLLEERR SSTTRRAATTEEGGIIEESS Service Academia (Teaching and

Research)

•= Significant brain drain to industry and the US of an important proportion of interested people

•= New funding opportunity (Canadian Foundation for Innovation)

•= Develop collaborative relationships with research networks around the world

Electronic

•= Lack for formal programs in eHealth at academic institutions

•= Few academics interested in research and education on eHealth, Informatics, and globalization

•= Lack for formal partnerships worldwide to study eHealth and globalization

•= Link into international research databases

•= Provide an infrastructure that makes research more streamlined and dissemination more efficient

•= Develop an infrastructure that allows electronic continuing education and current education over distances

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PPLLAAYYEERR BBAARRRRIIEERR EENNAABBLLEERR SSTTRRAATTEEGGIIEESS Service UHN

•= Organization and priorities not focused on delivering global services (some involvement with international patients at UHN)

•= Lack of partnerships and contacts with provider organizations at local and international levels

•= Lack of partnerships with organizations/ industry with global perspective/ experience.

•= Current focus on providing “Western Medicine”, not necessarily focused on providing medicine the global consumer wants.

•= Balancing global vs. local service priorities (e.g., access; type of care)

•= New/better competitors entering the marketplace

•= Risks of competition in a global market place – barriers to market entrance are declining, the need to agility is great and the need to always out innovate the innovators.

•= Large multicultural patient population

•= Healthy Connections •= Linkages established in

Saudi Arabia, South America, Africa and China.

•= Strong community of hospitals and other health service organizations that can enhance UHN’s offering through partnerships.

•= A workforce with a large multicultural mix.

•= Organizational values that build on our customer relationships and a mission to be an internationally recognized health science centre.

•= Experience merging corporate cross cultures and functions in the mergers of TWH, TGH, PMH and Doctor’s Hospital.

•= Nationally/internationally recognized programs and services

•= Recognize the importance of branding

•= Consolidate horizontally to gain efficiencies and integrate vertically

•= Position products for emerging consumerism trends

•= Stimulate direct to consumer demand with consumer decision support tools

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PPLLAAYYEERR BBAARRRRIIEERR EENNAABBLLEERR SSTTRRAATTEEGGIIEESS Electronic UHN cont’d

•= •= Program in eHealth Innovation

•= Large technology investment •= Senior leadership interested

in further investigating global opportunities

•= A strong technical infrastructure that can serve as a base for global eHealth at home or abroad.

•= Strong, knowledgeable, technical savvy staff who can provide service to a global community with the required technical tools (information/communication technology, Internet, PACS, EPR etc.)

•= Improve on current IT infrastructure

•= Digitize or die •= Stimulate direct to consumer

demand with consumer decision support tools

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PPLLAAYYEERR BBAARRRRIIEERR EENNAABBLLEERR SSTTRRAATTEEGGIIEESS Service Industry

•= Market vulnerability, particularly with third world countries

•= Competitive disadvantage (experience, market size) with the United States or Europe

•= Decreasing barriers to market entry increase the level of competition and the need constantly change and innovate.

•= May be difficult to get Canadian business to compete with large multinational companies

•= Risks of competition in a global market place – barriers to market entrance are declining, the need to agility is great and the need to always out innovate the innovators.

•= Having UHN (a knowledgeable body on health care) as a partner will help them compete on a global scale.

•= Experience of delivering service internationally, across cultures and across borders.

•= Desire to compete globally or else risk being taken over by a bigger global player

•= Partner with Industry to gain insight and knowledge from global opportunities

Electronic

•= Volatile marketplace for small companies and fast turnover in new technologies and treatments

•= Established technical infrastructures

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PPLLAAYYEERR BBAARRRRIIEERR EENNAABBLLEERR SSTTRRAATTEEGGIIEESS Service Public/ Patients

•= Socio-economic differences between the developed and developing worlds

•= Concern that our current system is in crisis, so why focus attention on international programs/services?

•= Concern that globalization is happening TO them and not WITH them. The feeling that they have no control or say in the process of globalization, that they are being excluded while the rest of the world integrates.

•= Risk to delivery of local service at the expense of global service

•= Extensive globalization may result in the dilution of the values in the Canadian health care system (e.g., public insurance, accessibility, comprehensiveness)

•= Increasing gap between middle/upper class who can navigate the global health care system and the lower class

•= Desire to be a participant in the new global economy and not sit idly by as the world outside develops and changes. – WEF Senegal Rep “we’re making headway”

•= A developing active voice on the “democratization” of the globalization process.

•= Provide supports for patient self-care

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PPLLAAYYEERR BBAARRRRIIEERR EENNAABBLLEERR SSTTRRAATTEEGGIIEESS Electronic Public/Patients cont’d

•= Limited access to information and health care technology in most countries to share/exchange services

•= •= Develop a strategy that lets patients email their physicians or other clinician

•= Develop patient support chat groups

•= Provide patients with access to health information on the UHN website

•= Provide patients with the ability to book appointments online

•= Provide patients with the ability to access their own person medical record electronically

Service Media •= Reporting that the Canadian health

care system is in crisis so how could we organize the system to provide global service?

•= Negative reporting of globalization in the press (e.g., Seattle)

•= Healthcare number one concern of Canadians. (election issue polls)

Electronic

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Appendix C: The Ideal Health System At the final task force meeting on March 23rd, task force members were asked to describe the characteristics of an ideal health system. The participants cited an ideal health system as having the following improvements: ��Increased accessibility to providers over the Internet including online scheduling, access to physicians through email

and access to health information sanctioned by hospitals and physicians. ��Increased access to personal health information over the Internet with control of that central health record residing in

patient’s hands. ��Increased ability of physicians to exchange my health information as the patient sees fit, electronically and

instantaneously. ��Increased access to preventative health information that is widely disseminated and easily accessible for all. ��Increased access to self-diagnostic tools on the Internet and increased access to knowledge on personal health

issues. ��Increased access to care where it is needed the most, in the patient’s home.

��Increased supports for self-care and support chat groups ��Increased supports for family supportive care ��Increased access to home care

��Increased human touch by care providers that have time to listen to me ��Increased equity, fairness, trust, respect and accountability throughout the system ��Increased ease of access to the system in general with efficient tools to help patients navigate through the system ��Increased integration of the system where each provider and player in the system is truly part of the patient’s health

care “team” ��Streamlined process to improve inefficiencies ��Increased access to specialists around the world and the assurance that patients are getting the best health care in

the world. �� Increased involvement by consumers in developing and building the system, to know that the system is constantly

adapting and changing according to consumers’ needs.

final report of the globalization and the eworld task force

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