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Government of Canada is investing $3.7 million to ensure that public health services can be more efficient and effectively delivered in First Nations

January 10, 2008

KENORA - The Honourable Tony Clement, Minister of Health and Minister for the Federal Economic Development Initiative for Northern Ontario, today announced that the Government of Canada is investing $3.7 million to ensure that public health services can be more efficient and effectively delivered in First Nations communities across Ontario.

This new project – the Ontario First Nations Public Health Initiative – is a three-year agreement supported by the Government of Canada, the Province of Ontario, and the Chiefs of Ontario, and will ensure that:

• The public and on-reserve health systems will be better integrated with better coordination of health information systems;
• A new information system will be established which will be used in First Nations communities for sharing on-reserve patient information with provincial public health units;
• Health professionals will be able to share information about communicable diseases with First Nations communities.

This agreement will also include extensive consultations with the more than 130 First Nations communities in Ontario.

"I am pleased to announce that the Government of Canada is providing $3.7 million to support this initiative," said Minister Clement. "This project is the first of its kind to improve the delivery of public health services to Ontario First Nations communities. It will ensure that First Nations people in Ontario have an effective role in the design and delivery of public health services."

"This is a very exciting day for all First Nations in Ontario as we welcome the announcement of the first “Made-in-Ontario” First Nation Public Health Project," said Angus Toulouse, Regional Chief, Chiefs of Ontario. "It should be recognized that almost one-third of all First Nations people in Canada originate from territories in Ontario. The project is aimed at improving public health services on reserve and has been driven by First Nations communities desiring, and entitled, to improved public health services," he added.

Today's announcement builds upon an agreement made in May 2006 at the Ontario First Nations Public Health Dialogue Forum to investigate opportunities for collaboration on First Nations public health information management.

At the event, Minister Clement also noted other initiatives currently underway to help improve the quality of life for First Nations in the Kenora area:

• The Government of Canada has provided $200,000 to the Kenora Chiefs for the development of a local public health pilot project, in cooperation with the Assembly of First Nations.
• The Government of Canada has provided the Kenora Access Centre with $122,156.00 and the Northwestern Health Unit with $152,580 this year for the Children's Oral Health Initiative, which helps to prevent and control tooth decay and other oral diseases in young First Nations and Inuit children. To date, some 1,450 children have benefited from this project in the Kenora area.
• In October 2007, the Government of Canada provided over $1M to the Kenora region to support: broadband infrastructure in four remote First Nations, the local Community Futures Development Corporations, an online bookkeeping system for Shibogama First Nations Council, and to support a feasibility study for the Northern Forest Innovation Centre.

Some Doctors' Oaths Hypocritical, Study Says

By Jesse Stanchak, CQ Staff | taken from Washington Health Policy Week in Review

December 3, 2007 -- Many doctors have trouble living up to their own professional standards, according to a new study published Monday in the Annals of Internal Medicine.

The study, performed by David Blumenthal and Eric Campbell of Massachusetts General Hospital, surveyed 1,600 doctors across a range of specialties and found widespread agreement among doctors on a range of ethical standards, but considerable disparities in how well they live up to those ideals.

According to the study:

• If a colleague was "significantly impaired," by drugs or alcohol or some other problem, 96 percent of doctors felt they should always report the problem, but 45 percent had let it slide at least once.
• Ninety-three percent of doctors felt all serious medical errors should be reported, but 46 percent said they'd failed to report such an error.
• A quarter of doctors would refer a patient to a facility that presented a clear conflict of interest for the doctor, even though 96 percent of physicians said their duty to their patients outweighed financial concerns.
• While 93 percent of doctors felt they should treat anyone regardless of ability to pay, only 69 percent are currently taking patients who cannot pay for their treatment.
• Only 25 percent of doctors have looked for disparities in care based on patient gender or race in the last three years, even though 98 percent of doctors agreed they should be working to minimize these inequalities.

"There is a measurable disconnect between what physicians say they think is the right thing to do and what they actually do," Campbell said in a news release. "This raises serious questions about the ability of the medical profession to regulate itself."

At a forum Monday at the National Press Club to discuss the study's findings, James Thompson, CEO of the Federation of State Medical Boards, argued that doctors were penned in by the American the health care system, fighting giant bureaucracies while fearing legal action if they make a mistake.

"We need to replace this system of punitive measures with non-punitive remediation," said Thompson, arguing that fear of punishment, for themselves or other doctors, makes it difficult for doctors to act on problems.

Sara Rosenbaum, head of the Health Policy Department at George Washington University, agreed that the problem was best addressed by state medical boards and other private regulatory groups, not with law suits and legislation.

"The social ideal is to avoid heavy-handed use of the law," said Rosenbaum, "It's too slow. By the time the money or the changes are ready to effect the people who made a complaint, its too late for the individual." She added that doctors and hospitals already have difficulty meeting their regulatory burden, limiting the effectiveness of new rules.

Rep. Michael C. Burgess, R-Texas, a physician, was in the audience but did not speak on the panel. He has long taken an interest in limiting medical liability suits. While he found himself agreeing with Rosenbaum that the medical industry would have to work harder to regulate itself to correct the issues brought up by the study, Burgess said he also knows how hard it can be effect change at a medical practice.

"The trouble is that it's almost impossible to bounce a physician out of a practice, no matter what they've done, even if you think you've got just an iron clad case against them," said Burgess. "Of course no one wants a doctor that's been drinking in an operating room, but what about the guy with the anger management problem? It's trickier."

Burgess cited a particularly extreme example. "I knew a doctor, years ago, who'd killed his wife, strangled her in fact. And everyone who worked with him knew it, absolutely. But it took 10 years for a case to be built against him and for him to be convicted and until then there was nothing anyone could do, because you're innocent until proven guilty."

Reporting the performance of HIT vendors: Smart Pumps

In 2006, the Institute of Medicine (IOM) reported that "when all types of errors are taken into account, a hospital patient can expect on average to be subjected to more than one medication error each day." To help counteract patient safety issues, the IOM report suggested that hospitals "make greater use of information technology in prescribing and dispensing medications … including the adoption of smart infusion pumps."

Recently, KLAS conducted a study on smart pump usage, with extra attention being given to issues such as the functional strengths of the available pumps, missing functionality, pump tracking and quantifiable benefits reported by providers. KLAS found that while there are difficulties in using, tracking and quantifying benefits for smart pumps, 90% of purchasers would buy their smart pump again. However, there are kinks to be worked out in the areas of functional strengths, missing functionality, pump tracking and benefits.

Functional Strengths

While the majority of study participants (92%) are using smart pumps in all areas, the functional strengths of those smart pumps vary. Collectively, the smart pump vendors KLAS studied scored highest in ease of use of the dose error reduction system (DERS), scored weakest in reporting capability and are most alike in preventing medication errors.

When drilling down into specific vendor scores, KLAS found that reporting capability is each vendor's lowest-rated functional capability. In many cases, providers expressed frustration with pulling data from the pumps. A lack of wireless implementation means that each pump must be located, brought to the download station and manually downloaded. Once more hospitals have wireless features implemented, the data pulls will be substantially less difficult.

But for now, much functionality is simply not accessible. One provider stated, "We are not currently pulling alert data from the system. Not having a way to easily pull the alarm data seems to be the missing link for not being able to do a lot of things, such as monitor which nurses are using the software and which alerts are firing."

Another common concern is that the generated reports are not user friendly. Providers say they have difficulty understanding portions of the reports or that the data are almost useless because of the way in which they are presented.

However, not everyone is unhappy. Many providers like the ability to track what caused an alarm to go off. One provider shared, "We like the event history reporting features. We can access the last 1,000 keystrokes when an alarm goes off, print out the data and save the reports for future reference." Another said, "I like that I can go in and see every button that the nurses push. They will often say it was the pump that was the problem, and oftentimes it was the clinician. This functionality was especially nice in times past when the colleague's on/off button was next to the start button and people would turn off the pump instead of starting it."

Missing Functionality

As mentioned above, wireless connectivity and interfaces are considered essential for ease of pulling data. Unfortunately, wireless connectivity (and interfaces to support it) is the functionality most often identified as missing in organizations' current smart pump arsenal (Figure 1).

Wireless communications needs are varied and range from updating drug libraries, dose guard protection ranges and medication flow rates - which need to be done manually to each machine if not connected - to communicating with the pharmacy. Future anticipated functions involve five rights protection, bar-coding, electronic medication administration record (eMAR) documentation, electronic medical record (EMR) nursing content and other point-of-care functions.

At this point, only 30% of respondents have wireless communication with their pharmacy, and most also do not have wireless access to pump data. For those who do have wireless capabilities, the story is positive. One such provider stated, "The reporting capabilities are great for those who have the server. Without the server, it takes a bit of effort to get the data. I love it with wireless. I can log onto the server in the morning and discover that there has been a reprogramming event, or three or four reprogramming events, during the night on a certain patient, and I can find the patient and see if the changes were appropriate. I can also see if there has been an override on a guardrail that worries me."

In addition to wireless issues, 17% of providers mentioned bar-coding functionality as a missing element in their smart pumps. Most agree that being able to tie data to a specific patient through bar-coding is a desired functionality. One respondent explained, "I can take a look at how many times a user has overridden a particular alert in the guardrails. I can't tie this data to a particular patient or nurse, but I can see general trends around when the alerts are happening, for which drugs and what the corrective actions are. In order to tie this to a particular patient, I would need bar-code scanning technology. This would allow me to scan the patient's wrist and tie the pump to that patient."

However, currently only 6% of respondents indicate that patient medication orders are entered using bar codes. This finding is consistent with other bar-code and nurse findings in KLAS surveys, namely computerized physician order entry (CPOE), where the use of bar-code scanning at the patient bedside for positive patient and medication identification (closed-loop medication administration) was still in its infancy, with 84% of respondents showing none to very low adoption (0-15%).

Pump Tracking

Pump tracking also appears to be its infancy. Users of Hospira pumps were the most successful at tracking the physical location of pumps via radio frequency identification (RFID) or other technology with 53% reporting in the affirmative. This is compared with 19% reported by users of Cardinal Health pumps and 0% reported by users of B. Braun and Baxter pumps. As to the technology used to track the pumps, approximately one-third of study participants reported using RFID, while others reported tracking by noting which wireless hub a group of pumps is transmitting to, and determining general location in this manner.

For those who do not have RFID or other tracking methods (which is the vast majority of users), various manual tracking methods are employed. One provider explained, "Nobody really understands how the pumps move throughout the hospital. For a time, we tried a serial number check-in/checkout process for the pumps, but that failed. Nurses wouldn't trust the fact that they would get clean pumps back if they would just turn in those they were using. Even if the pumps needed repairs, they were hesitant to turn them in. Now, until we get RFID or something like it, we just do the best we can at trying to keep tabs on all the pumps."

Another provider stated, "Right now, we have a system where each pump has a bar code on it, and every day a central service-person goes around the hospital and scans each device to make sure they are all accounted for. The scanner then talks to our ADT [admissions, discharge and transfer] system and makes sure it is on the right patient. Some pumps are kept on standby in departments, but most are assigned to a particular patient. When the patient is discharged, the pump is returned to central services for cleaning."

Nurses are reported to guard their pumps carefully - too carefully in some cases. For instance, one organization reported, "Tracking the pumps is a major issue. We can locate about 95% of the pumps, but there is always a group of them that we just cannot find. We aren't able to really make timely delivery of the pumps, so nursing does hoard them in dropped ceilings or anywhere else they can find."

Quantifiable Benefits

Nurses aren't the only ones who value their smart pumps. Study respondents were asked if they had achieved any quantifiable benefits from their smart pumps purchase, and many answered in the affirmative. Their responses are grouped by category in Figure 2.

As one would expect, reducing errors/patient safety is the top benefit reported, though it is surprising that more respondents did not respond in a like manner. Also surprising is that the number two benefit reported was "too soon to tell." This response suggests that there is more than meets the eye regarding successful implementation and usage of smart pumps. Interestingly, the majority of study participants were seasoned smart pump users who reported that they have used their solutions for more than one year. One would expect that, with such use, the benefits would be realized by now - unless implementation and usage are more difficult than previously suspected.

Another possible explanation is that return on investment (ROI) and other analyses have simply not been conducted yet. As one provider stated, "The data we get from the pumps are only gathered when there is a problem, so it has pieces of data here and there but nothing consistent. It is way too early for us to even try to determine an ROI. I know that we are reporting more errors than before, so that is a good thing. However, for us to get a consistent stream of data from the pumps, either we need them to have a wireless interface to the pharmacy or we need a lot of people to go out and pull the data out of them. We just do not have the personnel to do this."

However, some organizations have done quantifying based upon the cost of an adverse drug event. One provider stated, "We have had a lot of what we call 'great catches,' where a programming error was stopped by a hard limit. We have calculated the average cost of an adverse drug event at $4,500. We had 11 of those last month from the patient-controlled analgesia units alone."

Again, not all organizations have conducted studies to see the rate at which errors have been reduced, and there are difficulties with such an effort (e.g., it is hard to find an accurate baseline since errors often went unreported previous to smart pump implementation); however, those who have conducted basic research generally estimate they are experiencing fewer errors.

One such provider reported, "We have had some good cost avoidance through medication error prevention. We see about four or five medication error preventions every month." Another stated, "I know that in the last year, we have gotten between 30 and 50 calls from nurses who got warnings from the pumps, which prevented medication errors. I do not know the value of these saves."

Complicating matters is the fact that a drug error can be defined in different ways. Should one count a "safe error" as an error? One provider explained this difficulty: "We are constantly looking at drug errors, and I would like to say we are preventing them with the pumps, but I do not know. It is hard to say if going slightly outside the limit would have any kind of effect on the patient, so I do not know what to count as a prevented medicine error."

However, 90% of those who have purchased smart pumps say they would buy them again. Clearly, while each organization's pump data are not all in (or downloaded!), smart pump purchasers are finding enough benefits to warrant continued use and purchase.

For further information on the smart pump study or other KLAS findings, go to www.healthcomputing.com. Providers receive free access to KLAS Online, where one can access ratings on hundreds of medical equipment and HIT vendors and products.

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About KLAS

KLAS , founded in 1996, is the only research and consulting firm specializing in monitoring and reporting the performance of healthcare's information technology ( HIT ) vendors and products. Our senior management staff and advisory board average 25 years of healthcare information technology experience.

How We Serve the Healthcare Industry: KLAS , in concert with thousands of healthcare executives, CIO s, directors, managers and clinicians, has created a dynamic database of information about the performance of HIT vendors. The KLAS database represents the opinions of healthcare executives, managers and clinicians from over 4,500 hospitals and 2,500 clinics on more than 750 different products. The information is continually refreshed with new performance evaluations and interviews daily.

The KLAS database is dynamically and effectively used by:

• Healthcare organizations, to align expectations with a vendor's actual performance, to assist in strategic planning and contract negotiations and to validate decision processes


• Vendors, to monitor their performance in comparison with competitors


• Consultants, for current performance information on a specific company or product


• Healthcare investment firms, to evaluate publicly traded HIT company performance and trends or the competition for a new entrant.

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About the Author
Stacilee Whiting is the manager of corporate publishing for KLAS, Orem, Utah.

Jason Hess is research director of Clinical Ancillary Systems for KLAS, Orem, Utah.

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References
The Institute of Medicine. July 20, 2006. Preventing Medication Errors. Washington, DC. Author. < http://www.iom.edu/Object.File/Master/35 /943/medication%20errors%20new.pdf >.

Ontario's Doctors Applaud Move to Reduce Junk Food in Schools

Ontario's doctors support the action taken by theprovincial government today to remove trans-fats and junk food from schools.In 2005, The Ontario Medical Association (OMA) called for a restriction onnutrient-poor foods for students while under the care of school boards inorder to help curb the rate of childhood obesity. Doctors have also beencalling on the provincial government to mandate one hour per day of structuredaerobic physical activity and exercise for elementary and secondary schoolstudents in order to help reverse this dangerous trend.

"The evidence is clear, obesity rates in children can be siginificantlydecreased with appropriate physical activity and healthy food options," said Dr. Janice Willett, President of the OMA. "It is essential that school be ahealthy environment for children, where they can experience healthy behavioursthat will continue into adulthood."

The OMA report, An Ounce of Prevention or a Ton of Trouble: Is there anepidemic of obesity in children? showed that from 1981 to 1996, the proportionof overweight boys increased from 15 to 28.8 per cent and overweight girlsfrom 15 to 23.6 per cent. The report also highlighted the severe andpotentially life-threatening consequences of obesity. Obese children face anincreased risk of heart disease, high blood pressure, Type 2 diabetes,breathing problems (such as obstructive sleep apnea) and orthopediccomplications.

"The provincial government has shown that health prevention is a priorityand tackling junk food in schools shows they are committed to improving thehealth of our children," said Dr. Willett. "This action, in combination withmore physical activity and public education, will help address this growingpublic health issue."

Disparities in Healthcare Access and Use: Yackety-yack, Yackety-yack

Healthcare Policy / Politiques de Santé, 3(2) 2007: 10-18

Despite change, uncertainty and disarray in Canada's healthcare system(s), some observations about Canadian medicare still seem beyond challenge:

access to healthcare based solely on need is the core value that gave rise to and sustains medicare; the advent, through medicare, of universal, publicly funded physician and hospital services substantially reduced disparities in access to, and outcomes of, healthcare based on socio-economic status (Enterline et al. 1973; James et al. 2007); despite those gains, disparities remain - factors other than need continue to influence access to and use of services. The last point deserves elaboration. A growing body of research evidence indicates that use of hospital services in Canada is generally consistent with relative need across income groups (e.g., Manga et al. 1987; van Doorslaer and Masseria 2004; Allin 2006). Some studies (van Doorslaer and Masseria 2004; Allin 2006) show greater use of hospital services by those with lower income after controlling for healthcare need - perhaps calling into question the adequacy of existing measures of need. On the other hand, studies of specialist services have demonstrated a direct relationship between use and income, education or both (McIsaac et al. 1993, 1997; Roos and Mustard 1997; Dunlop et al. 2000; Finkelstein 2001; van Doorslaer et al. 2006; Allin 2006) - wealthier and better-educated Canadians use more specialist services independent of need. The picture with respect to primary care physicians' services is less clear. Some studies show an equitable (i.e., needs-based) distribution across education and income groups (McIsaac et al. 1993, 1997; Roos and Mustard 1997; Dunlop et al. 2000), while others do not. For example, Birch et al. (1993) found the use of family physician services to be positively associated with level of education (and extent of contact with friends and relatives). Based on data from the 2001 Canadian Community Health Survey (CCHS), van Doorslaer et al. (2006) found that, after standardizing for healthcare need, higher income was associated with a greater likelihood of seeing a primary care physician but a lower number of visits. Using 2003 CCHS data and a similar methodology, Allin (2006) observed a pro-rich inequity in the probability of visiting a family physician, a finding that was inconsistent among the provinces and territories. In the 2002/03 Joint Canada/US Survey of Health, Canadians with low income were less likely to have a regular doctor and more likely to report unmet healthcare needs than those with high income (Lasser et al. 2006). In an earlier international population survey, Canadian respondents with below-average income were more likely than those with above-average income to report having difficulty getting needed care (Shoen et al. 2000). Data from the 1994/95 National Population Health Survey showed that the likelihood of women in the appropriate age groups having either a Pap smear or a mammogram was associated with higher education level and being born in Canada (Gentleman and Lee 1997; Lee et al. 1998). Income level was also independently associated with having a Pap test (Lee et al. 1998). In the 2005 CCHS, respondents in the highest two (of four) income categories were more likely than those in the lowest income category to report having a flu shot in the previous 12 months (Kwong et al. 2007). Ontario-based studies have shown a positive association between income and access to coronary angiography and revascularization (Alter et al. 1999) and to in-hospital occupational therapy, physiotherapy and speech pathology following a stroke (Kapral et al. 2002). Patients from the lowest-income neighbourhoods waited much longer for coronary angiography (Alter et al. 1999) and carotid artery surgery (Kapral et al. 2002) than those from the highest-income neighbourhoods. Recently published studies in Healthcare Policy/Politiques de Santé point to inequities in access to radiation therapy for breast cancer based on income level (Fortin et al. 2006) and to mental health services for anxiety or depression provided by both family physicians and psychiatrists based on education level (Steele et al. 2007). This summary, reflecting a brief and unsystematic scan of the literature, describes only the tip of a much larger evidence iceberg. Clearly, Canadian medicare has failed to achieve healthcare access (and use) based on need, even for those services within the purview of the Canada Health Act: hospital and physicians' services. Being poor, poorly educated or both impairs access to specialist and (probably) family physician services, to preventive care (e.g., Pap tests, mammograms and flu shots) and to services for specific health problems (e.g., cardiovascular and mental health). But income and education are not only associated with access to services; they are themselves determinants of health, and often cluster together with other determinants such as Aboriginal status, early life experiences, employment and working conditions, food security, housing, social exclusion, social safety net, unemployment and employment security (Raphael 2004). The very people who need care the most are the least likely to get the care they need. Evidence of the continuing relationship between socio-economic characteristics and access to health services under medicare is abundant, long-standing and persistent. This evidence is without doubt well known (at least in part) to health system decision-makers. Why, then, is there so little sign of concerted heath policy or health system design and management initiatives at the federal or provincial/territorial levels to address this violation of the fundamental rationale for Canadian medicare? It may be more than coincidence that those on the receiving end of inequitable access are among the least politically and economically powerful members of Canadian society. Although many Canadians are passionately committed to the principle that access to essential health services should be based only on need, they may, given a lack of media and political attention to the issue, assume that the elimination through medicare of (most) financial barriers to obtaining hospital and physicians' services has solved the access problem. Under these circumstances, politicians and governments at the federal and provincial/territorial levels are under little or no pressure to mount a response. As a result, current policy complacency seems likely to continue unless equity of access emerges as a public issue that resonates with Canadians who support the core principles of medicare and mobilizes civil society. Now, there's a challenge for knowledge translation. Meanwhile, there will undoubtedly be lots of talk (research on access inequities and acknowledgment - out of public view - of their existence), but little policy action.

Transforming Healthcare Organizations

Imagine you are a member of a hospital's executive team, having just left a meeting in which you and other members discussed the possible introduction of an ambitious Computerized Physician Order Entry (CPOE) system. Around the conference table you and others questioned whether CPOE would be the most effective way to realize your hospital's commitment to patient safety. Other issues that were raised included whether clinicians would support or resist the change, whether staff would have sufficient skills, where to begin, affordability and whether to proceed incrementally or with a "big bang." While there was much disagreement with respect to each of the issues, there was near unanimity around two important decisions - CPOE would be implemented and you would be the executive responsible for the system's design and implementation. This article, based on the experiences of a multi-site hospital, and drawing on past research on organizational change, provides a Four-Stage model to help change leaders in healthcare. Although relying on Toronto's University Health Network to illustrate the change model, the model is intended to speak to change leaders implementing various types of complex changes in all healthcare organizations. [from Healthcare Quarterly, 10(Sp) 2006: 10-19. Author:Brian Golden]. For the full article go here.

Transforming Healthcare Organizations

Imagine you are a member of a hospital's executive team, having just left a meeting in which you and other members discussed the possible introduction of an ambitious Computerized Physician Order Entry (CPOE) system. Around the conference table you and others questioned whether CPOE would be the most effective way to realize your hospital's commitment to patient safety. Other issues that were raised included whether clinicians would support or resist the change, whether staff would have sufficient skills, where to begin, affordability and whether to proceed incrementally or with a "big bang." While there was much disagreement with respect to each of the issues, there was near unanimity around two important decisions - CPOE would be implemented and you would be the executive responsible for the system's design and implementation. This article, based on the experiences of a multi-site hospital, and drawing on past research on organizational change, provides a Four-Stage model to help change leaders in healthcare. Although relying on Toronto's University Health Network to illustrate the change model, the model is intended to speak to change leaders implementing various types of complex changes in all healthcare organizations. [from Healthcare Quarterly, 10(Sp) 2006: 10-19. Author:Brian Golden]

It's time to balance fight for life with ballooning health costs. Robert Cushman

By Andrew Thomson, Ottawa Citizen
Published: Wednesday, October 31, 2007

With acute-care beds being filled at area hospitals with chronically ill seniors, the time for a serious public discussion on the collision of rising medical costs and the "death with dignity" debate is now, says the man charged with co-ordinating health care in Eastern Ontario.

It's the ethical responsibility of doctors to encourage discussion regardless of the painful moral, ethical, and political questions that arise, said Dr. Robert Cushman, CEO of the Champlain Local Health Integration Network, who added that the demand for such health care is likely to rise.

"Do I have personal opinions on this? Yes I do," he told the Citizen editorial board this week during a wide-ranging, candid meeting.

"But my professional and my public opinion is that we need to have this healthy debate."

Legislatures and courts across North America and Europe have long grappled with the right to die.

For Dr. Cushman, it's a matter of money and higher levels of respect and care for seniors. The strain on acute care resources has to be addressed as Canada's population ages and pressure mounts on health services, said the former medical officer of health for the City of Ottawa.

Dr. Cushman described a number of 80- or 90-year-olds on ventilators being sent to intensive care units, some of whom have Do Not Resuscitate orders lost in the system. His own 87-year-old mother "would not be happy" with such a scenario, he said.

"It's bad enough with our parents' (generation) but when we get these it's going to really burst the bubble," he said of himself and fellow baby boomers.

Health care administrators now face a zero-sum ethical game where dollars are used for chronic patients in "high-end" acute-care facilities instead of community programs and home care, Dr. Cushman argued, reminding his interviewers that bottom lines aren't his only motivation for seeking public dialogue.

"What kind of heroics can you do in the last six months or two or three years of a life?" he asked. "For someone who's over the age of 80, a hospital is a pretty scary place, and a pretty dangerous place.

"We're talking about the frail elderly. And we have too much of an emphasis on the cure when the returns for the cure can be very low. I think we need to respect seniors' independence and their dignity."

Dr. Cushman, who oversees health care funding and delivery for more than a million residents between Cornwall and Algonquin Park, hopes the growing popularity of living wills is one solution.

He also wants to stop seniors from bouncing around the health care system like a "ping-pong ball." That includes improving "ordinary" procedures such as basic nursing care, home support, and meal delivery.

For more on this story go here

Hospital Standardized Mortality Ratio (HSMR) in Canada

The hospital standardized mortality ratio (HSMR) is an important new measure of patient safety that compares a hospital's mortality rate with the average Canadian rate. It examines observed versus expected deaths and is adjusted for various factors such as the age, sex, diagnoses and admission status of patients. The ratio provides a starting point to assess mortality rates and identify areas for improvement, which may help to reduce preventable deaths.

Developed in the United Kingdom in the mid 1990s, the HSMR has also been used in hospitals in Holland and the United States. When tracked over time, the ratio can be a motivator for change, by indicating how successful hospitals or health regions have been in reducing inpatient deaths - leading to improved patient care. CIHI has led the effort in calculating HSMRs for Canada and later in 2007, will be releasing its first public report on results for facilities in all provinces outside Quebec. To learn more about the HSMR, see the documents below: What is HSMR? Saving More Lives Understanding the Report The HSMR Public Release Technical Notes Getting Started Resources Frequently Asked Questions New! HSMR Cases Validation Tool. To download the tool, click here. To see the instructions, click here . To learn more about the public release: Targeted information sessions (via WebEx) are being held prior to the public release. Each topic will be presented twice at the dates and times that follow: For analysts: Session 1: September 18, 2007, 10:00-11:00 EST Session 2: September 18, 2007, 15:30-16:30 EST Objective: To review methodology changes and ask questions of HSMR analytical staff Click here for presentation slides To listen to a recording of the session, you can stream the presentation from the CIHI site or download the WebEx player (http://www.webex.com/downloadplayer.html) and then click here (offline option). For senior leadership audiences (part 1 of 2): Session 1: September 20, 2007, 10:00-11:00 EST Session 2: September 24, 2007, 13:00-14:00 EST Objective: To give a high-level overview of HSMR and outline strategy for public release Click here for presentation slides To listen to a recording of the session, you can stream the presentation from the CIHI site or download the WebEx player (http://www.webex.com/downloadplayer.html) and then click here (offline option). Source: http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=hsmr_e