加拿大作业参考案例：High Cost Low Quality Healthcare in Canada

本文是加拿大作业范例，题目是“High Cost Low Quality Healthcare in Canada（加拿大高成本低质量的医疗保健）”，加拿大的医疗保健费用在增长;然而，护理质量似乎在下降。a)为什么会发生这种情况，并提出了什么解决方案来解决这些问题?b)利用阅读资料、课堂讨论和你自己的研究，讨论你的4个最佳循证解决方案，以解决加拿大高成本低质量的医疗保健。

The costs of healthcare in Canada are growing; however, the quality of care seems to be declining. a) Why this is happening, and what solutions have been proposed to fix these issues? b) Utilizing the readings, class discussions and your own research, discuss your top 4 evidence-informed solutions to address the high-cost low-quality health care in Canada.

The cost of healthcare is a prominent issue in Canada, for it is the single largest budget item for every province. Although the costs of healthcare in Canada are growing, but the quality of care is seen to be declining.

a) The current Canadian system, Medicare, was founded in the 1960s when the needs of the population were vastly different. The focus was on acute care, to match the needs of the population. Now, the needs are vastly different, but the system is not equipped to handle it. The likely reasons for this decline in quality are lack of accountability and citizen participation, disorganization and un-coordination of service delivery and integration, and lack of attention paid to community-based care. The lack of accountability is in large part due to the fact that those that finance care have little say in where that money goes. Furthermore, there is no simple accountability model to reference. The various models present are unclear and inconsistent, and they do not provide goals for what should be accomplished. When patients engaged with the healthcare system, the would feel as if their needs and requirements of a proper healthcare system were not being properly addressed; however, many people feel as if the decisions regarding healthcare should be made by ‘the experts’ instead of them. Even if citizens raised their concerns to officials, they would feel like they were not actually being heard or being taken seriously. This is the original reason Regional Health Authorities were created in response to this, but many citizens do not know about them or their purpose to successfully utilize them. The disorganization and un-coordination of service delivery and integration leads to resources being inappropriately being under or over utilized, as well as inconsistencies within the delivery and availability of services. This often leads to patterns such as increasing wait times. Because of the lack of authority given to RHAs in provinces especially, there is no clear integration across Canada. Attention to integration is often hindered by the fact that it is a goal that needs long-term investment and funding to provide long-term benefits, which is an issue when considering the changing of political parties and their policies and strategies for re-election. The lack of attention paid to community-based care is likely due to the focus on institutional care (e.g., hospitals). Although there have been attempts to increase spending on community-based care, these efforts have had a minimal effect. Furthermore, the cost of healthcare remains increasing, but this rise in spending has not seen proportional advances in quality of care.

b) Solutions to the address the high-cost low-quality healthcare in Canada include: proper allocation of resources, initiatives such as the eShift model of homecare, Accountable Care Organizations, and increased authority given to RHAs.

A huge issue seen within Canada is the misallocation of resources primarily associated with the overuse of hospitals. Hospitals use up a substantial portion of the healthcare expenditure within Canada. This is largely due to the underuse and/or unavailability of primary care. Many people do not use them either because they don’t know they exist, or they don’t know that they should be using these resources instead of the emergency room (e.g., going to the ER for a broken arm instead of an urgent care center). Moreover, the access to this primary care in Canada fares much lower compared to other OECD countries. This lack of access not only leads to more preventable hospital admissions, but also poorer quality of life and bad returns on investment within the healthcare sector. Therefore, increasing access and knowledge about primary care would help use resources appropriately and efficiently.

加拿大国内的一个大问题是资源分配不当，主要与医院的过度使用有关。在加拿大，医院消耗了很大一部分医疗保健支出。这在很大程度上是由于初级保健使用不足和/或无法获得。许多人不使用它们，要么是因为他们不知道它们的存在，要么是因为他们不知道应该使用这些资源而不是去急诊室(例如，去急诊室治疗手臂骨折，而不是去急救中心)。此外，与其他经合发组织国家相比，加拿大获得这种初级保健的费用要低得多。这种准入的缺乏不仅导致更多可预防的住院，而且还导致生活质量下降和医疗保健部门的投资回报率下降。因此，增加获得初级保健的机会和知识将有助于适当和有效地利用资源。

The eShift model consists of collaboration between clinical care nurses, Sensory Technologies, Southwest LHIN, and Southwest Community Care Access Centre. The model was created in response to a growing concern about the lack of nurses in the Southwest Community Care Access Centre, especially during night shifts and in palliative care units. This was largely because of a lack of trained and knowledgeable nurses in the palliative care field. There was too much demand, but too little supply existed of nurses, putting more burden on the families. The eShift model emerged as an interdisciplinary answer to this problem. Nurses would not have to be at the patient’s bedside to help treat and assist them with their care, but rather they could help manage that care remotely via the eShift system. This makes it so that a nurse can treat multiple patients in a shorter amount of time and even simultaneously, thereby utilizing that nurse with the appropriate knowledge so that more people may benefit. Furthermore, eShift decreased the amount of preventable emergency room visits by those seeking end-of-life treatment, as well as those related to inadequately handled symptoms. It also increased the number of hospital discharges for those that did not previously have the resources for care at home.

The system is largely unaccountable to the public, but an exception is the introduction of Accountable Care Organizations (ACOs). These are hospitals and medical groups that have recognized and absorbed the responsibility for both cost and quality of care for specific groups of people by means of a capitated budget between them and a public or private insurer via a legally binding agreement. In this integrated system of healthcare delivery, more services are able to be provided. The groups of physicians are smaller and more specialized, and additionally a hybrid, interdisciplinary group consisting of hospitals, physicians, and health centers offer services. This system has already been implemented in the U.S. These organizations are effectively increasing the accountability in the system and patient satisfaction within it.

该系统在很大程度上对公众不负责，但有一个例外是负责任医疗组织(ACOs)的引入。这些医院和医疗集团通过它们与公共或私人保险公司之间的资本预算，通过具有法律约束力的协议，承认并承担对特定群体的医疗费用和质量的责任。在这个综合医疗服务系统中，可以提供更多的服务。医生群体更小，更专业，此外，由医院、医生和健康中心组成的混合、跨学科小组提供服务。这一系统已经在美国实施。这些组织正在有效地提高该系统的责任性和患者满意度。

The RHAs are underused and underappreciated. Not many citizens know about them and how to use them, and the RHAs themselves are not given enough authority to properly initiate change. Their role and authority need to be more clearly defined. Furthermore, they need to be given the room to act upon their role. This change would help to maintain the continuity and standards of care, as well as validate the RHAs as authorities in their field. Moreover, many people do not know about the RHA or what they do. If the public is informed, then they are more inclined to utilize this resource while also voicing their concerns more often and effectively. This increase in citizen participation will help to make sure that healthcare systems are more patient-centered by including the public in their formation and revisions, effectively progressing quality of care.

Access to quality health is one of the main determinant factors of health disparities in Canada; it seems the current Canada Health Act (CHA) and the universal coverage is unable to address this issue. Unfortunately, health disparities are affecting the minority groups the most, including women, children, seniors, newcomers, LGBTQ, the people living with mental health issues and those living in the rural areas. Please discuss 1 main issue faced by each of the above minority groups, and provide an effective and efficient way to address each of those issues.

The main issue women face in Canada is violence, especially among intimate partners. The health implications that result from violence concern more with mental health; these include: depression, dependencies (e.g., alcoholism), anxiety, as well as sexually transmitted infections. It is important to note that violence can be prevented. So, a way to address this issue is to provide more community supports for women, especially those that are private and discrete, so that they may report the violence. It is also important that they feel comfortable confiding in someone, so the person trained must know how to handle such a sensitive topic. Perhaps just having a widely advertised helpline can help to intervene in these relationships before it becomes too serious.

Children in Canada that have been abused have been shown to subsequently show worse mental health outcomes, especially among women. The abuse paves the way for worse health outcomes later in life (e.g., lung problems, back problems, and chronic fatigue). So reducing the instance of childhood abuse should lower the amount of bad health outcomes later in life. Therefore, a way to address this issue is to provide more supports for children so they may speak up if they are comfortable, as well as training practitioners and communities (e.g., teaching dentists what to look for when examining children) to better recognize the signs of abuse so an intervention can happen sooner than later.

在加拿大，受到虐待的儿童，特别是妇女，其心理健康状况随之恶化。虐待为以后的健康状况恶化铺平了道路(如肺部问题、背部问题和慢性疲劳)。因此，减少儿童期虐待的案例应该会降低以后生活中不良健康结果的数量。因此,解决这个问题的方法是为儿童提供更多的支持所以他们可能会说如果他们舒适,以及培训从业人员和社区(例如,教学牙医检查时寻找孩子),以更好地认识到虐待的迹象,所以一个干预迟早会发生。

The primary concern with seniors is multi-morbidity, which is when two or more illnesses are occurring at the same time. It is associated with numerous bad health outcomes, including: decreased life expectancy, decrease in daily function and ability, and lower life expectancy. As Canadians age, it is found that their life satisfaction decreases. A possible effective and efficient way to address this is by using a more coordinated and integrated health model so that seniors’ times attaining healthcare is easier, as well as their chronic illnesses are better managed.

Newcomers (e.g., immigrants and refugees) to Canada often face discrimination when trying to attain healthcare. This discrimination results in worth health outcomes, including: worse physical and mental health and more risky health behavior. Newcomers are often made to feel ashamed when trying to attain care that is consistent with their cultural and religious beliefs—which in turn negatively affects their health. Healthcare practitioners need sensitivity training regarding how to treat patients in a way that does not ‘other’ them. Further, it would also be useful to hire staff that are from these backgrounds so that patients feel a connection and are comfortable sharing their health information and experiences.

The Canadian LGBTQ youth population faces a lot of stigma when trying to attain care. These results of fear of being judged harshly, uneasiness when asked about what sex they most identify with, and only being educated in a heteronormative context. School boards have implemented support services for these youth to provide them with the sexual health information as well as community support that they may not receive otherwise. Many times healthcare practitioners find difficulty in relating to LGBTQ youths, so they are unsure how to present and tailor information for them—which then leads these youths further lost and confused.  LGBTQ youth in Canada are not properly educated about issues that relate to them but not those considered “normal” (i.e., cis-gender, heterosexual, etc.), especially in regards to sexual health education. Therefore, the best way to address this issue is perhaps to employ more healthcare professionals into the field that are either LGBTQ or have a deep understanding of their needs so that interventions and education include their needs and ensures that they are comfortable.

People living with mental health issues face complex health needs where the solution is not often easy or clear. The most common barrier found among these people was personal circumstances that hinder their access to care. A way to address this issue would be to give mental health the same level of importance as other chronic conditions, and thus change the stigma against mental. Once treated like any other chronic condition, mental health will be an accepted means to miss work to get treatment for, covered by insurance, and deemed an appropriate reason for having to be absent from obligations for.

Those living in rural areas often get medical attention later and less frequently than those living in urban areas (Silver, 1994), which is largely due to the fact that they do not have the appropriate amount of access (especially to primary care) that is inequitable in comparison to their urban counterparts. A way to address this issue is by recruiting healthcare practitioners into rural areas through incentive measures, which would then subsequently increase access to primary care through being able to open more primary care facilities with this new staff.

As per the readings and class discussions, it appears that Canada requires to expand its universal health coverage to include the pharma care, home/community care and the healthcare services provided by allied healthcare providers to ensure improving the healthcare delivery system for all. Considering the costs of healthcare delivery is not even currently sustainable, please discuss your evidence-informed opinions on how P4 Medicine, Medicine/Health 2.0, and the digital health/virtual healthcare could assist with these challenges (expanding universal health coverage as above, improving healthcare delivery & containing healthcare cost).

Canada needs to expand its universal health coverage to include pharma care, home/community care, and the healthcare services provide by allied healthcare providers to ensure improving the healthcare delivery system for all. Since the cost of healthcare delivery now is not sustainable, the P4 Medicine, Medicine 2.0, and digital and virtual healthcare can assist with the above challenges in order to improve healthcare without also investing more money into the system without adequate results. In other words, these methods can help promote a more sustainable healthcare delivery system that is both cost-efficient and effective.

加拿大需要扩大其全民健康覆盖范围，包括医药护理、家庭/社区护理和联合医疗保健提供者提供的医疗保健服务，以确保改善所有人的医疗保健提供系统。由于目前的医疗保健服务成本不可持续，P4医学、医学2.0以及数字和虚拟医疗保健可以帮助解决上述挑战，从而改善医疗保健，而无需向系统投入更多资金，也不会产生足够的结果。换句话说，这些方法可以帮助促进更可持续的医疗保健提供系统，这是成本效益和有效的。

P4 Medicine is that which is predictive, personalized, preventative, and participatory. Predictive refers to how this model can be used to predict the needs and wants of a population, as well as their subjective view of health and disease in a manner similar to preventative care. The medicine is personalized in that it will hold all information concerning an individual’s health and body in a personal data cloud. This will allow people to have and access their information in an easier and more accessible manner. Preventative medicine aims to analyze the root of a disease to combat it before it even begins to exist. Preventative medicine does not end once outside health facilities, for it needs to extend into everyday life, thus requiring population engagement. Participatory medicine refers to how the population’s everyday life and their actions and behaviors during it is important to their health. Populations must participate in their own health. This ideology leads to people becoming more active health delivery that is more tailored to them and current population needs. In this way, it ensures that investment goes to incentives and facilities that are more effective in promoting good health and positive change.

Medicine 2.0 refers to the use of social networking, participation, collaboration, openness, and epomediation in the processes of disintermediation, apomediation, and intermediation. Disintermediation refers to eliminating a step to make the population’s efforts to receive information easier and faster (e.g., websites such as WebMD). Apomediation refers to how Medicine 2.0 do the work for you but rather lead you to the answer through your own research. Intermediation refers to the traditional relationship between patient and physician in which a mediating agent curates the information to the patient. This is better for those patients that do not possess the necessary level of health literacy to engage in apomediation; this also relevant when considering patients’ capacities to evaluate information as accurate and credible. Through these different channels, information dissemination can be more efficiently used so that patients are not always required to go to the doctor to receive the health information they need, if they are capable. This decreases the amount of heavy investment in clinics and especially hospitals, for it allows patients to receive information at home easier and faster at no cost to the government.

Canada has not kept other with other countries in their access to and distribution of virtual care, which is largely because of a lack of appropriate infrastructure and payment models (Reid, 2017). Virtual visits to the clinic, as already being piloted in Ontario (Reid, 2017), are becoming more popular and are predicted to become the standard in the future (Topol, 2015). The virtual healthcare environment can be analogized to an air-traffic control center. It would be a room full of computers that contain patient information. A healthcare practitioner would monitor a couple patients on these computers dependent on their current condition. The amount of surveillance this entails may not be feasible. Rather, the ‘hospital at home’ would be full of monitoring devices and home checkpoints, with sensors being embedded into everyday items that can provide analytics to inform and possible change someone’s health behavior. This integration of health into the patient’s everyday life allows them to have more control but also put more of the burden on them to monitor their own health. The information the patient passively supplies allows healthcare professionals to monitor patients and bypass performing more tests in-office and wait for results. This type of healthcare delivery system reduces patient admissions and decreases wait times. However, this type of information-gathering can cause a disparity in access, as the initial investment can be high. This can be alleviated by government subsidies. The implementation of this system could also result in a more cost effective national healthcare system. It promotes public participation as well, which is currently shown to be lacking within the Canadian healthcare system and its governance.

The principal way these models would benefit the healthcare system is by alleviating the current financial burden many practices hold (e.g., patients going to the doctor for potentially simple questions they could’ve found online). Therefore, this change to the primary care practices of patients and healthcare practitioners could lead to cost savings, which in turn could then be used to fund expanding universal health coverage to things such as pharma care. Further, these methods also enhanced the healthcare delivery system by allowing patients faster access to answers, allows doctors faster access to patient information and test results, and easier access for patients to see their own health information. Integrating these would lead to more seamless care and effective preventative medicine to respond to chronic conditions (e.g., through tracking measures and physicians instant feedback on patient behavior and vitals) as well, which are currently costing the Canadian healthcare a large portion of spending.

这些模型对医疗保健系统有益的主要方式是减轻目前许多做法所带来的经济负担(例如，病人去看医生，可能是一些简单的问题，他们可以在网上找到)。因此，这种对病人和医疗保健从业人员的初级保健实践的改变可以节省成本，这些成本反过来又可以用于资助扩大全民健康覆盖范围，包括制药保健等。此外，这些方法还通过让患者更快地访问答案，让医生更快地访问患者信息和检测结果，以及让患者更容易地查看自己的健康信息，增强了医疗保健服务系统。将这些结合起来，将会带来更无缝的护理和有效的预防药物，以应对慢性疾病(例如，通过跟踪措施和医生对患者行为和生命体征的即时反馈)，这也将花费加拿大医疗保健部门很大一部分的开支。

The health and wellbeing of every individual in the society are among the core governments’ responsibility. Utilizing the ‘Triple Aim’, ‘Health in All Policies’ and ‘The Whole of Government Approach’, please research, develop and explain a new Canadian (health) governance structure (with one, two or three-tier structure of your choice) to address the future health and wellbeing of individual.

The Canada Health Act has performed well in maintaining funding for services through taxes, but this vary feature is what is likely holding Canada back in innovation. The restriction it places blocks further advancement through its rigid criteria. In the last 40 years, there have not been essential changes to the healthcare system. It is argued that nothing will happen most likely until a catastrophic event or paradigm shift occurs. This results in restricted focus on hospitals and doctors, as well as Canada falling behind relative to other OECD countries. There has been limited attempts at changing health policy in Canada, and many of these attempts were just to procrastinate making meaningful changes and innovations to the system. Therefore, without reviewing and updating Medicare, change is unlikely to occur in the Canadian healthcare system (Adams, 2015). For these reasons, it is clear that the structure of the Canadian health governance structure must be transformed to a three-tier structure through examining the ‘Triple Aim’ approach, ‘Health in All Policies’ approach, the ‘Whole of Governance’ approach, hybridization, and the role of Canadian federal government.

The Triple Aim approach to health in Canada “is the simultaneous pursuit of improved population health, care experience and per capita cost of care” (830). This approach incorporates the organization of populations, thus providing improved services that have been scaled to the whole country while also engaging in a system that advances and adjusts to challenges appropriately. The triple aim approaches require a high degree of integration among the healthcare sector as well as those that fall outside of it, which is often accomplished through means such as the “integrator” role. This role is aimed to improve and maintain the healthcare sector while simultaneously connecting and communicating with other sectors, both on a micro and macro level. The micro-level ensures that the system itself is operating efficiently and correctly while also maintaining that the intended population is reached. The macro-level integrator ensures that the confines in which the system operates is learned and kept up-to-date with recent advances, as well as help to standardize the process. The Triple Aim approach will thus also lead healthcare within Canada to steer more towards a value-based approach (Farmanova et al., 2016). Because this approach happens in such an integrated and multi-level manner, evaluation is difficult. This is already a problem that plagues Canada’s system, and so having a method that further complexes it may not be the best solution at this moment. However, as will be elaborated on later, a larger role of the federal government may aid this.

加拿大的保健三重目标方针"是同时追求改善人口健康、保健经验和人均保健费用"(830)。这种方法结合了人口的组织，从而提供了已扩大到全国的改进服务，同时也参与了一个进步和适当调整以应对挑战的系统。三重目标方法要求医疗保健部门之间以及医疗保健部门之外的部门之间进行高度的整合，这通常通过诸如“整合者”角色等手段来实现。这一角色的目的是改善和维持医疗保健部门，同时在微观和宏观层面上与其他部门进行联系和沟通。微观层面确保系统本身有效和正确地运行，同时还保持达到预期的人口。宏观层面的集成商确保了解系统运行的范围，并跟上最新的进展，同时帮助标准化过程。因此，三重目标方法也将引导加拿大的医疗保健更多地转向基于价值的方法(Farmanova等人，2016年)。由于这种方法是一种综合性、多层次的方式，因此评价比较困难。这已经是困扰加拿大系统的一个问题，因此，在这个时候，有一个进一步复杂化的方法可能不是最好的解决方案。然而，联邦政府发挥更大的作用可能有助于这一点，稍后将详细说明。

The Triple Aim approach was shown to be beneficial in increasing performance and use of primary care methods, predict those patients that may need preventative care, learning from previous mistakes to improve future performance, integrating with the community, decreasing unnecessary use of emergency rooms, and integrating the approach within other frameworks and reforms. However, with all of these advances, there have been some areas of improvement that have arose. There is a larger need for team-based models of primary care, customization of healthcare plans for patients (i.e., more patient-centered care), more support for population health, more emphasis on public health, approaching privacy issues in a way that ensures patients’ privacy while also allowing collaboration among teams, more evaluation measures, a move away from volume-based to value-based care, and scaling of improvements (Farmanova et al., 2016). However, in order to adopt the Triple Aim approach, Canada must first alleviate existing problems (e.g., weak evaluation measures, misallocation of resources, underuse of primary care, and lack of population level interventions) in order to implement new interventions and approaches. With this in mind, I do think that the Triple Aim approach will make a significant impact, as it aims to fix many of the problems that plague Canada’s healthcare sector as well as set Canada up to be more prepared in the future and have a more sustainable and meaningful healthcare framework.

The ‘Health in all Policies’ approach ensures that health implications are incorporated in all policy implementations from every sector, for many factors that determine health are not directly controlled by the healthcare sector. Success in reforming healthcare can seldom be accomplished without collaboration between all sectors. Gase, Pennotti, and Smith (2013) found seven “interrelated strategies for incorporating health considerations into decisions and systems: (1) developing and structuring cross-sector relationships; (2) incorporating health into decision-making processes; (3) enhancing workforce capacity; (4) coordinating funding and investments; (5) integrating research, evaluation and data systems; (6) synchronizing communications and messaging; and (7) implementing accountability structures” (p. 529). This approach allows a form of integration and communication between healthcare practitioners and other sectors that may have not be possible before. Health in all policies entails an influence not only on the policy aspect, but also in every aspect of development, implementation, evaluation, and communication. It also allows the burden to not only be placed on those operating within the healthcare sector to maintain a healthy population, for now it is the responsibility of all sectors equally and shared. Moreover, more attention must be placed on the social determinants of health and equity. According to the Health in all Policies approach, all of these concerns will be addressed and have intersectoral actors. Because it involves all sectors of government and beyond, it better coordinates activities in a way that is cost-effective and decreases duplicates of similar policies (Gase et al., 2013).

Whole of governance occurs when different professionals from different sectors work towards the same goal(s). When applying this in a healthcare setting, it streamlines care in a way that is more integrated, organized, and efficient. Interprofessional teams aim to provide a multitude of services while ensuring they are backed by up-to-date technology and protocols in a way that is sufficient to connect the public to their environment and healthcare practitioners in a meaningful manner. This intersectoral collaboration also entails that the financial burden is not placed on only the healthcare sector. Most physicians are capable and ready to help innovate the current healthcare system in Canada, and their participation is crucial to implementing and designing change. However, with all of these sectors coming together to collaborate, it is important to maintain transparency while also establishing clear objective and roles for each member (Naylor et al, 2015). The Conference Board of Canada (2017) found that individual-level barriers (e.g., confusion which function should be performed by whom and who, if anyone, has more power or voice in decisions), practice-level barriers (e.g., difficulties in establishing a governance model in which everyone has comparable contributions and tools), and system-level barriers (e.g., inadequate accountability measures) can all thwart the progress of interprofessional teams that aim to use a whole of governance approach.

Hybridization occurs when governing bodies and professional communities come together to collaborate towards their best solution. In the United Kingdom hybridization between public and private delivery of services was used in an attempt to introduce competition as a means to improve the whole sector (Turner, Lourenço, & Allen, 2016). An assigned reading outlined “communities of practice” in which states that change occurs through interactions. This entails that the result of hybridization is unique to the situation and stake holders present. Every player becomes a resource for information and change. These communities of practice become experts and tools of change through their “knowledge use, social interaction, organizational structure, and innovation” (Turner, Lourenço, & Allen, 2016, p. 703). The shift within the NHS in the early 1990s led to increased autonomy that led to greater competition and a more ‘business-like’ mentality. The addition of competition was seen as a way to increase performance, effectiveness, and change. This shift also prompted professional communities to engage with and learn new forms of necessary knowledge (e.g., market tendencies). The effect of competition stretched to how providers interacted with each other. They were less likely to share ideas to maintain a competitive advantage; however, this also led to a hindrance of wide-spread innovation and decrease in cooperation. Within the NHS there was resistance to change via the private sector entering the public. Professional communities are most likely to accept and participate in gradual rather than sudden changes. The collaboration between different communities can lead to novel and more effective interventions (Turner, Lourenço, & Allen, 2016). Therefore, it is clear that hybridization is essential to advancing the healthcare system within Canada. The benefits seen in the U.K. could also be seen in Canada. However, the single-payer model and its bilateral monopoly act as a barrier to this type of hybridization from occurring. In other words, the one-tier system is hindering the progression of the healthcare system. Canada does not have a good holding on the regulation of private services; it is limited to basic functions. It is argued that the Canadian government has too much control over the healthcare system and its proponents for meaningful change to occur (e.g., that in the U.K.) (Touhy, 2012). Thus, Canada must enable entrepreneurs to have the opportunity to implement innovation in the private sector to influence and accommodate the public sector (Banting & Myles, 2013). The recommended incremental implementation by the articles would help Canadians accept a new norm within healthcare.

当治理机构和专业团体走到一起，为他们的最佳解决方案进行合作时，就会出现杂交。在英国，公共和私人提供服务的混合使用试图引入竞争作为改善整个部门的手段(Turner, Lourenço， & Allen, 2016)。一份指定的阅读材料概述了“实践社区”，其中陈述了通过互动而发生的变化。这需要杂交的结果是独特的情况和利益相关者目前。每个玩家都是获取信息和改变的资源。这些实践社区通过其“知识使用、社会互动、组织结构和创新”成为变革的专家和工具(Turner, Lourenço， & Allen, 2016, p. 703)。20世纪90年代初，NHS内部的转变带来了更多的自主权，这导致了更大的竞争和更“商业化”的心态。加入竞争被视为提高绩效、效率和改变的一种方式。这种转变也促使专业团体参与和学习新的必要知识形式(例如，市场趋势)。竞争的影响延伸到供应商之间的互动方式。他们不太可能为了保持竞争优势而分享想法;但这也阻碍了创新的广泛传播，减少了合作。在NHS内部，对通过私营部门进入公共部门进行改革存在阻力。专业团体最有可能接受和参与渐进而不是突然的变化。不同社区之间的合作可以导致新的和更有效的干预(Turner, Lourenço， & Allen, 2016)。因此，很明显，杂交是推进加拿大医疗保健系统的必要条件。在英国看到的好处也可以在加拿大看到。然而，单一支付者模式及其双边垄断阻碍了这种杂交的发生。换句话说，单层医疗体系正在阻碍医疗体系的发展。加拿大对私营服务业的监管力度不够;它仅限于基本功能。有人认为，加拿大政府对医疗保健系统及其支持者有太多的控制，以至于无法发生有意义的改变(例如，在英国)(Touhy, 2012)。因此，加拿大必须使企业家有机会在私营部门实施创新，以影响和适应公共部门(Banting & Myles, 2013年)。该条款建议的增量实施将帮助加拿大人接受医疗保健领域的新规范。

In the Adams (2015) article, the author argues that, in order to change healthcare policy within Canada, three things must be accomplished: a way of “policy governance,” stopping “policy inertia,” and long-term planning. It is important for healthcare to stop being thought of as reactive (e.g., focused on acute care in primarily in hospitals by health practitioners) but rather as proactive (e.g., focused on prevention and chronic diseases in settings including hospitals as well as outside of them). This is especially true when considering the rising concern and prevalence of chronic and complex conditions within Canada that cannot be properly treated and monitored through the traditional measures that worked for acute conditions. Now, the main role of the federal government in healthcare is essentially funding it through the provisions set in the Canada Health Act and Canada Health Transfer. The Federal government having more control and accountability in the healthcare system will also lead to more consistency across Canada in terms of access, quality, collaboration, coordination, and ability to scale noteworthy interventions on a national scale. This increase in federal control would also likely decrease the amount of fragmentation that now plagues the Canadian healthcare system, thus aiding the lack of appropriate coordination and evaluation measures.

One proposed solution to the lack of innovation within the Canadian healthcare system is the Healthcare Innovation Fund, which aims to “enhance the quality and value of healthcare provided to Canadians, while improving the performance of Canada’s healthcare systems as measured against their international peers” (Naylor et al., 2015, p. 39). This would aim to provide long-term funding for interdisciplinary initiatives from actors from multiple sectors. The Fund aims to both address and alleviate fragmentation, as well as aid in scaling up of noteworthy interventions in an effort to promote innovation and prevent many of the limitations seen today in the health system as detailed above. Furthermore, the funding would only be given to those who clearly state their intentions. Those who receive funding must also report when they meet goals to the Healthcare Innovation Agency of Canada, and this information will be made public (Naylor et al., 2015). This would effectively increase the accountability of the healthcare system as well. The federal government must establish and guarantee that the health infrastructure and health human resources teams are appropriately equipped to handle these new changes within the community.

In a three tier system, tier 1 consists of items that are medically necessary and thus covered by the government; tier 2 items are those that are not required to live but enhance quality of life; and, tier 3 refers to items that are used for cosmetic reasons or for comfort (Montgomery, 2017). Through this system tier 2 procedures and items would be covered by private insurance, while those that lie in the tier 3 would be completely out-of-pocket. This structure of organization of different procedures based on necessity helps to alleviate the financial burden on the healthcare system by allowing others to access procedures on a private basis. This would also help to decrease wait times for those that want to access procedures faster and have the means to do so. In conclusion, it is clear that more integration and collaboration is needed in the Canadian health governance structure, and, given the current state, it needs to implement initiatives and structures that promote sustainability by decreasing the financial responsibility of the government while also increasing the control and oversight of the federal government.

The introduction of health information technologies (HIT) in recent years has provided the health care systems in Canada and around the globe with a great hope and potential to address many of the challenges they face with, including providing better health, better care, better value and empowering patient/public to actively engage in their health. With examples, please discuss your evidence-informed critical analysis on how HIT could assist with each of the above (better health, better care, better value and patient/public empowerment).

近年来，卫生信息技术(HIT)的引入给加拿大和全球的卫生保健系统带来了巨大的希望和潜力，以解决他们面临的许多挑战，包括提供更好的健康，更好的护理，更重视病人/公众的健康，并让他们更积极地参与健康。请举例说明您关于HIT如何帮助实现上述每一项(更好的健康、更好的护理、更好的价值和增强患者/公众的能力)的循证批判性分析。

Before elaborating on how Health information technologies (HIT) can assist better health, care, value and patient/public empowerment through its ability to provide more seamless integration of care, as well as provide quicker, more efficient access to patient information, it is important to understand the state of it right now in Canada. Firstly, the primary mode of HIT is electronic health records (EHR): health information that is compiled and saved in electronic mediums. Development and innovations are occurring very slowly in Canada compared to other OECD countries, and most Canadian doctors do not use it. However, the use of it is increasing (Canadian Foundation for Healthcare Improvement, 2014). Many of the EHR methods used today are outdated and incapable of providing the functions that healthcare practitioners need. Like the Internet used today, EHR needs to be able to quickly adapt to changes and incorporate new information and methods. This is largely attributed to the leaders in EHR development that insist on having full private control of all the data contained in their respective programs (Mandl & Kohane, 2012). The advances that have prompted the existence evolution of EHR were in response to needs of healthcare practitioners, so now a change is happening where, although it is still suggested to change to accommodate healthcare practitioners better (Mandl & Kohane, 2012), it is also beginning to conform to the requests and needs of the public as well. However, it is difficult to modify a system that was never made with the intention of being able to support rapid innovations. The inability of the multiple EHR systems to communicate and integrate with one another, as well as other systems, does not foster the integrated care that is being promoted, but rather limits its own advancement (Mandl & Kohane, 2012).

HIT can give patients access to their own records, which allows them to become more informed players in their own healthcare process. EHR can allow markers for strengths and weaknesses within each system so that evaluation measures are more easily attained, as well as determination of what needs improvement versus what needs to be scaled-up is more easily identified. By making the system more public to advancement and incorporating more of patient needs into the software, the Triple Aim approach can be used, which calls for more integration of key players to improve health, care, and value in an effort to increase patient empowerment. It effectively breaks a barrier to care that was previously decreasing the quality and amount of care the public has.

HIT可以让患者访问自己的记录，这让他们在自己的医疗流程中成为更知情的玩家。EHR可以对每个系统的优缺点进行标记，以便更容易获得评估措施，以及更容易确定哪些需要改进，哪些需要扩大规模。通过使系统更加公开化，并在软件中纳入更多的患者需求，可以使用三重目标方法，它要求更多地整合关键参与者，以改善健康、护理和价值，努力提高患者的能力。它有效地打破了先前降低公众医疗质量和数量的障碍。

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