Meeting Summaries of the CSA Expert Group on Health Systems

As part of the response to the COVID-19 pandemic, at the request of Health Canada, Canada’s Chief Science Advisor (CSA) assembled the Expert Group on Health Systems to obtain practical opinion from domain experts in order to inform her advice to the federal government regarding health services needs and innovation.

On this page:

• Meeting #1 of the Expert Group on Health Systems
• Meeting #2 of the Expert Group on Health Systems
• Meeting #3 of the Expert Group on Health Systems
• Meeting #4 of the Expert Group on Health Systems
• Meeting #5 of the Expert Group on Health Systems

The following discussion reflects evidence and scientific knowledge up to March 24.

Participants

• Mona Nemer PhD, Chief Science Advisor of Canada (co-chair)
• Stephen Lucas PhD, Deputy Minister of Health Canada (co-chair)
• David Buckeridge MD PhD, McGill University
• Irfan Dhalla MD, Unity Health Toronto, University of Toronto
• Alan Forster MD, Ottawa Hospital, University of Ottawa
• William Ghali MD, University of Calgary
• Joanne Langley MD, Dalhousie University
• Joanne Liu MD, Université de Montréal
• Louis-Martin Rousseau PhD, École Polytechnique de Montréal
• Allison McGeer MD, Mount Sinai Hospital, University of Toronto
• Robyn Tamblyn PhD, McGill University
• Cara Tannenbaum MD, Université de Montréal, Health Canada Departmental Science Advisor
• Abby Hoffman, Health Canada (observer)
• Supriya Sharma MD, Health Canada (observer)
• Alexandre Bourque-Viens PhD, Office of the Chief Science Advisor (support)

Introduction

• This Expert Group is a sub-committee of the COVID19 Expert Panel.

Initial Questions for the Expert Group

From the Government perspective, health systems questions that could benefit from expert discussion include:

• What are the key data needed to inform decisions and how to best make that data available to potential users including how to reduce the delays between data collection and sharing?
• How to deal with the surge in demand. For instance, dealing with increased human resources needs, and need to ramp up testing capabilities?
• How to accelerate procurement of innovative health technologies such as virtual care?
• What broader health systems management, innovative practices and solutions would help with the pandemic response, for instance mechanisms for optimizing governance and coordination between actors?
• Where can the federal government intervention be most effective (e.g. procurement, support pan-Canadian coordination of assets and resources, equity issues and federal, provincial, and territorial (FPT) distribution in front of different capacity or timing, enable key supplies of equipment and pharmaceutics)?

Data Sharing

Standards for data collection and definition

• Key data to support planning and coordination include: number of cases at different stages (under investigation, confirmed cases, in hospital, in ICU) and available resources (HR and protective equipment, testing capacity, beds, intensive care equipment, etc.).
• A way to identify hot spots where people are reporting symptoms could help anticipate where resources will be needed within the coming days.
• Data on infected medical staff, as this could have large effects on staff availability. It could also help adjust protection measures as the epidemic progresses.
• The lack of uniformity across provinces in data collection and reporting presents great challenges for modellers. For instance, different policies on who gets tested influence the number of cases reported.
• Federal, provincial, and territorial (FPT) public health officials are working on guidance about testing and data collection. If made public, modellers could take the differences into account.

Follow-up:

• When available, FPT guidelines for data collection will be shared with members.

Data sharing framework

• Experts are looking for a framework for sharing data that will lead to more reliable and impactful predictions. How can external experts, especially modellers, access the data in a way that will help reuse?
• Johns Hopkins Dashboard: https://coronavirus.jhu.edu/map.html was highlighted as a good platform. Some examples of data gathering and sharing in Quebec and Eastern Ontario were also mentioned.

Follow-up:

• At the next meeting, discuss existing frameworks on data sharing so that it is most useful to inform the expert group proposals for Canada.

Testing

Priority to health care practitioners

• The experts agreed on the importance of making testing available to health workers even without symptoms. This could help deal with asymptomatic infected medical staff that are not being tested.
• Efforts should be deployed, where there is a need, to further support healthcare workers, to protect them, maintain motivation and avoid future absenteeism.
• The importance of Serological testing was raised.

Ramping up testing/bottlenecks and alternatives

• Taking full advantage of the current lab capacity could allow to significantly increase the number of daily tests. Securing access to reagents may be a bottleneck.
• Some rapid testing methods have been going through approval at Health Canada.
• Experts were not convinced of the usefulness of at-home tests such as the one currently developed in the UK (IgM/IgG measurement). There may be challenges for instance with low sensitivity at early stages of the illness.
• Alternate approaches to PCR & diagnostic testing may be symptom-based. For instance, a lack of smell has been identified as a predominant feature in asymptomatics. This could speed up screening.

Space and Alternative Facilities

Freeing some beds

• Providing alternatives for people waiting for long-term care placements by partnering with supported-living private sector could be an option. There is a Toronto initiative to support patients staying in the long-term care facilities that may serve as an example.
• Mental health patients present special challenges that will need to be taken into account.

Dedicated facilities

• COVID-19-dedicated facilities: further avoid mixing between infected and non infected individuals which could protect non-COVID patients. A dedicated structure will result in less need for PPE because there is no need to change as often.
• Self-isolation at home puts other family members at risk.
• Various alternatives to hospital locations could be explored, e.g. using hotels as an intermediary step before hospital as in Israel (dedicated hospital and dedicated ICUs). Federal government could be especially helpful to create field hospitals.

Virtual Care

• Virtual care can unload some of the pressure on facilities. It could also provide a personal protective function as assessments may be done outside the room away from the patient.

Follow-up:

• Experts will look at alternative facilities options most relevant for different contexts.

Advance Care Plans and Ethics

• Advanced care planning may require additional attention in the current context.
• A clear framework on how to address shortage of ventilators in an ethical way could help medical teams make difficult decisions. Pandemic influenza planning had a framework on prioritization of vaccines that may be worth checking.

Follow-up:

• Will check where FPT partners are at in developing ethical frameworks.

Health Systems Management and Innovation

• Taking advantage of opportunities for adopting more innovative solutions could be a question of getting them in time and may require attention to privacy, regulatory issues, intra-institutional processes.
• Putting out requests for proposals (RFPs) for key issues/technologies sought by the health system and running quick assessments may help accelerate things. Provincial touch-point for implementing infrastructure should be involved early on. More specific RFPs would be much easier to judge than general ones.
• One area for innovative solutions could be frameworks and tools for the provinces to keep capturing and exchanging information. For instance, infrastructure that can support rapid data capture.
• Another area could be finding ways to deal with the huge logistics puzzle. People working for Oxfam, UNICEF and other emergency relief organization and military are efficient at organizing resources in harsh conditions.

Follow-up:

• Experts could help identify key issues or health technology opportunities that could be the object of a quick RFP

Personal Protective Equipement and Federal Role

• For the past 6-8 weeks the federal government has focused on procuring stocks on provincial requests, coordinating demand from provinces (masks, face shields, gloves, gowns etc.) and ventilators to meet near-term need and longer-term needs.
• A program was launched to encourage Canadian manufacturing to re-tool.

Next Steps

• At this stage of the situation the Group is expected to meet regularly.
• As a first step, the panel is to organize subgroups on data analytics, digital innovation, and facilities and governance; to prepare focused proposals for the entire group to review.

The following discussion reflects evidence and scientific knowledge up to March 29.

Participants

• Mona Nemer PhD, Chief Science Advisor of Canada (co-chair)
• Stephen Lucas PhD, Deputy Minister of Health Canada (co-chair)
• David Buckeridge MD PhD, McGill University
• Irfan Dhalla MD, Unity Health Toronto, University of Toronto
• Alan Forster MD, Ottawa Hospital, University of Ottawa
• William Ghali MD, University of Calgary
• Joanne Langley MD, Dalhousie University
• Joanne Liu MD, Université de Montréal
• Louis-Martin Rousseau PhD, École Polytechnique de Montréal
• Allison McGeer MD, Mount Sinai Hospital, University of Toronto
• Tom Noseworthy MD, University of Calgary
• Robyn Tamblyn PhD, McGill University
• Cara Tannenbaum MD, Université de Montréal, Health Canada Departmental Science Advisor
• Gavin Brown, Health Canada (observer)
• Abby Hoffman, Health Canada (observer)
• Supriya Sharma MD, Health Canada (observer)
• Alexandre Bourque-Viens PhD, Office of the Chief Science Advisor (support)

Update on Government Perspective

• Tools used to make data available to researchers have been updated, which speeds up access and enables better mapping of data^{Footnote 1}.
• Daily testing has ramped up. All involved are looking at further increasing testing capacity before the arrival of test kits.
• Assessing potential test kits and protocols for serological testing is underway.

Areas where quick proposals of specific approaches and tools from this expert group could be helpful include:

• Increasing capacity (HR, beds, etc.);
• Making allocation of protective equipment and intensive care unit (ICU) equipment;
• Ensuring provinces have the tools in terms of data management and virtual care to move patients to alternate facilities.

Discussion

• The federal government may need a decision framework for the distribution of federal procured resources between provinces rather than for ethical decisions about care itself, which is a discussion with the provinces.
• There may be a need for a curation role when it comes to clinical innovations, ensuring consistency among hospitals, including teaching hospitals (e.g. how we use oxygen?).
• The Canadian military may have the expertise to play a role in transportation and logistics, support in the North, facilities management, etc.

Subgroups

After the first meeting, expert group members split into three subgroups to deal with data analytics, digital innovation, and health system capacity and governance.

Data Analytics

• The subgroup is working on a list of items for standard reporting.

Follow-up:

• Subgroup will continue work, recognizing the short window of opportunity for providing advice.

Digital Innovation

• The subgroup had a meeting and is coming forward with three proposals for keeping COVID-19 patients at home as much as possible and keeping front line practitioners out of danger:

1. Make COVID-19 support app available to citizens to help provide them with the latest information on the ongoing pandemic. The app could include a self-assessment tool to help decide when to seek coronavirus testing (as per BC or UK examples);
2. Allow a large proportion of citizens to access a virtual telehealth platform (such as eVisits) to protect health professionals;
3. Implement remote monitoring to keep people safe at home using wearables or other devices. Also, applying remote monitoring in hospitals where virtual visits to patient rooms could reduce the use of protective equipment.
4. Investing in these technologies now could create a strong legacy for Canada. It could demonstrate the effectiveness of telehealth and help move towards more virtual service delivery.

Follow-up:

• Proposals will be finalized and distributed to the group for review at the next meeting.

Capacity and Governance

Experts discussed some of the challenges for this subgroup:

• The approach to the health systems may be divided into three parts: urban, rural and identified vulnerable communities (first nations, long-term care homes, homeless, etc). The group may want to divide its attention between these.
• The priority for the subgroup is to provide immediate concrete advice. Some of the immediate needs have been identified at the beginning of the meeting.

Short-term vs medium-term perspectives

• The current surge could lead to a situation where the health system would need to deal with mass casualty medicine.
• Beyond the current crisis, the health care system may need to transform as we may live with COVID-19 for a number of years before a vaccine is available.
• The fact that we are pulling all beds for COVID may have an impact on non-COVID patients. We are cancelling surgery, cancer-care, etc. These decisions could have medium-term impacts and result in an increase in non-COVID19 deaths.
• Focus could be split between immediate needs and planning for the next stage.

About the possibility to immediately establish COVID-specific hospitals

• At this time, based on available information, it may not be possible to make some existing hospitals COVID-19-specific because most available ICU beds and respirators (from all hospitals) could be needed to deal with the peak in COVID-19 cases. Most hospitals will rather be separating COVID-19 and non-COVID-19 cohorts.
• Adding old hospitals as locations could be done, depending on ventilators and staff availability, but is not necessary in the short term if we are cohorting within hospitals.
• Patient to patient transmission does not seem to be a risk as high as the infection via staff. Even if we specialize hospitals, there could be COVID-19 outbreaks in non-COVID-19 hospitals because of introduction from the healthcare workers.

Follow-up:

• The Capacity/governance sub-group will further discuss the short and medium term-groups approach and practical considerations.

Proposal for Recruiting Additional People to Address HR Needs

Members discussed ways to mobilize additional resources and increase capacity to deal with tasks such as screening and contact tracing, pre-acute care (moderate symptoms), acute care, and post-acute care:

• Screening and contact tracing: any university student, public service individuals (good on the phone), 1st and 2nd year medical students, teachers, law enforcement, etc.;
• Patients with mild/moderate symptoms: health apps, telehealth;
• Acute patients: all medical residents in any training program, deployed to COVID-19 response, surgeons;
• Post-acute care: personal care assistants, care aids, 3rd and 4th year medical students, dieticians, dentists, orthodontists, veterinarians.

Comments

• Suggest addition of a category: mental health support as it could accelerate recovery. Graduate students in clinical psychology programs may be candidates for this task.
• Foreign credentials, royal college of physicians and surgeons: there may be an opportunity to offer a short refresher/training/online certification as a requirement for a temporary license to practice under supervision of other licensed healthcare workers.
• What staff are we running low on? Maybe, more than physicians, personal support workers at homes and long-term care homes.

The following discussion reflects evidence and scientific knowledge up to April 1st.

Participants

• Mona Nemer PhD, Chief Science Advisor of Canada (co-chair)
• David Buckeridge MD PhD, McGill University
• Irfan Dhalla MD, Unity Health Toronto, University of Toronto
• Alan Forster MD, Ottawa Hospital, University of Ottawa
• William Ghali MD, University of Calgary
• Joanne Langley MD, Dalhousie University
• Joanne Liu MD, Université de Montréal
• Louis-Martin Rousseau PhD, École Polytechnique de Montréal
• Allison McGeer MD, Mount Sinai Hospital, University of Toronto
• Tom Noseworthy MD, University of Calgary
• Robyn Tamblyn PhD, McGill University
• Gavin Brown, Health Canada (observer)
• Abby Hoffman, Health Canada (observer)
• Supriya Sharma MD, Health Canada (observer)
• Alexandre Bourque-Viens PhD, Office of the Chief Science Advisor (support)

Update on Government Perspective

• Needs for advice previously outlined are still relevant.
• Advice around decision making on the allocation of federal procured resources that will be kept for distribution to meet urgent needs could be helpful.
• As information from clinical trials trickles in, there could be challenges for regular users with maintaining or preserving access to drugs under trial.

Data

• The subgroup’s first three proposals found overall support:
  1. The creation of data standards to support local efforts to capture data consistently so they can be aggregated and used for regional, provincial, and national responses to the COVID-19 pandemic;
  2. That the Government of Canada mandates (through provincial ministries of health) the application of data standards by hospitals, long-term care homes and health units;
  3. That the Government of Canada support provinces in the development of their own data platforms to ensure effective and consistent reporting and planning across the nation.
• Dealing with issues at the national scale requires valid and timely information, which is consistent at that scale to inform decisions.
• Achieving consistency across provinces on resource data may be complex because of the different systems in place (e.g. different product names, tracking numbers).
• Case data consistency may be easier to achieve.
• Availability of data could depend on the extent of the data we want to collect and the resources available in provinces to collect data. There may be an opportunity to provide data entry and curation capacity where it is most needed. For surge capacity, there may be volunteers we can call upon in federal and academic labs across the country that know how to handle data.

Digital Innovation

• The subgroup proposals found overall support.
  1. Make COVID-19 support app directly available to citizens to help provide them with the latest information on the pandemic. The app could include a self-assessment tool to help decide when to seek coronavirus testing (as per BC or UK examples);
  2. Allow a large proportion of the people to go to a virtual telehealth platform (such as eVisits) to protect health professionals;
     1. This may be a self-directed platform or, for patients with low digital literacy, connects to a nurse/doctor through homecare agencies equipped with technology.
  3. Implement remote monitoring to keep people safe at home using wearables or other devices. Applying remote monitoring in hospitals allowing virtual visits to patient rooms, could reduce the use of protective equipment.
• A Canada COVID-19 app has been launched (https://ca.thrive.health/)
• It is important to ensure virtual care is documented in the patient’s medical record and accessible to other practitioners.
• There may be an opportunity to better organize as more people are adopting virtual care through necessity. There could also an opportunity to think of how this could leave a long-term legacy.
• If there are specific wearables to support proposal 3, they could fall under the medical devices category and should be brought to Health Canada’s attention.

Capacity and Governance

• A set of subgroup proposals on dedicated staff and structure for COVID-19 patients, received overall support:
  1. Have COVID-19-dedicated staff, not swapping from COVID-19 positive to negative;
  2. have a clear closed circuit for COVID-19 patients (example X-Rays) to avoid amplification of COVID-19 through structures;
  3. allow development of staff expertise to work under PPE, decrease usage of PPE and, increase protection of staff as well;
  4. provide support to medical staff for self-isolation to not infect family and vice versa:
     1. Given the elevated risk of acquiring COVID-19 in health care settings, governments prepare for alternate accommodation for health care workers (HCW) to prevent transmission to HCW households.
• Further discussions from this group may be necessary on additional ideas pertaining to long-term care homes.
• The subgroup also discussed topics it may want to further explore like what would be the approaches to managing vulnerable elements of the general population, such as those located in remote areas of the country?

Follow-up:

• The subgroup will devote more time to discuss ideas pertaining to long-term care homes.
• Add public health unit – tracing capacity and monitoring isolation to the topics that could be further explored.

Surge Strategy for Federally Procured Resources – Ventilators

• The Expert Group believes there could be a need for a science-informed surge strategy for the distribution of federally procured resources, especially for mechanical ventilators.
• The Group would like to see equipment being distributed effectively.

Follow-up:

• A task force will be assembled to provide ideas within the next the 24-36 hrs.

The following discussion reflects evidence and scientific knowledge up to April 6.

Participants

• Mona Nemer PhD, Chief Science Advisor of Canada (co-chair)
• Stephen Lucas PhD, Deputy Minister of Health Canada (co-chair)
• David Buckeridge MD PhD, McGill University
• Irfan Dhalla MD, Unity Health Toronto, University of Toronto
• Alan Forster MD, Ottawa Hospital, University of Ottawa
• William Ghali MD, University of Calgary
• Joanne Langley MD, Dalhousie University
• Joanne Liu MD, Université de Montréal
• Louis-Martin Rousseau PhD, École Polytechnique de Montréal
• Allison McGeer MD, Mount Sinai Hospital, University of Toronto
• Tom Noseworthy MD, University of Calgary
• Cara Tannenbaum MD, Université de Montréal, Health Canada Departmental Science Advisor
• Gavin Brown, Health Canada (observer)
• Abby Hoffman, Health Canada (observer)
• Supriya Sharma MD, Health Canada (observer)
• Alexandre Bourque-Viens PhD, Office of the Chief Science Advisor (support)

Update on Government Perspective

• Topics identified in previous meetings are still relevant. The Expert Group is welcome to provide advice for topics that are still pending.

Disease Modelling

• A number of modelling approaches are in use across Canada to inform action.
• Challenges:
  • Ability to do proper calibration (e.g. lack of data) limits the validity of modelling results.
  • Communication of results in terms of potential scenarios.
• Soon to be published by Canadian Medical Association Journal are 2 papers on an assessment of Ontario modelling and agent-based modelling for Canada.

Mechanical Ventilators

The proposal on mechanical ventilators developed by the task force was circulated before the meeting.

• It focuses on avoiding inappropriately placed resources, either because they are not needed, cannot be used (lack of capacity) or are used disparately.
• It proposes that the large majority of federally procured ventilators be allocated based on demonstrated needs and capacity to use.
• The expert group unanimously supported the task force proposal.
• The task force agreed to provide additional suggestions on implementation of the proposed principles.

Follow-up:

• The task force will reconvene to provide further guidance on implementation of the proposed principles.

Digital Innovation – Virtual Care

• It was agreed that the digital innovation subgroup would be consulted on a short document on virtual care in preparation for discussion with provinces and territories.

Capacity/Governance

Long-term care:

• Expert group members discussed how COVID-19 challenges in long-term care are currently being addressed, and the potential impacts to the whole system.
• Some elements to consider as part of potential proposals:
  • Quickly putting in place a lead authority over long-term care homes in each province.
  • Setting up a mechanism to compile lessons learnt from the first outbreaks, so informing disease epidemiology as it happens.

Follow-up:

The following discussion reflects evidence and scientific knowledge up to April 19.

Participants

• Mona Nemer PhD, Chief Science Advisor of Canada (co-chair)
• David Buckeridge MD PhD, McGill University
• Irfan Dhalla MD, Unity Health Toronto, University of Toronto
• Alan Forster MD, Ottawa Hospital, University of Ottawa
• Joanne Langley MD, Dalhousie University
• Joanne Liu MD, Université de Montréal
• Louis-Martin Rousseau PhD, École Polytechnique de Montréal
• Allison McGeer MD, Mount Sinai Hospital, University of Toronto
• Tom Noseworthy MD, University of Calgary
• Robyn Tamblyn PhD, McGill University
• Cara Tannenbaum MD, Université de Montréal, Health Canada Departmental Science Advisor
• Gavin Brown, Health Canada (observer)
• Abby Hoffman, Health Canada (observer)
• Supriya Sharma MD, Health Canada (observer)
• Alexandre Bourque-Viens PhD, Office of the Chief Science Advisor (support)

Update on Government Perspective

• The Expert Group proposals are appreciated and used.
• Institutional thinking is moving beyond containment and mitigation towards next stages. The timing is good for a conversation on how to prepare for the medium-term.

Mechanical Ventilators

The final proposals on mechanical ventilator allocation were circulated before the meeting.

• The work of the Task Force has been helpful in real time and in many ways has been used and implemented.
• Thanks to the Task Force chair for a great job on short timelines and bringing together a great group to advise on this question.

Virtual Care

• Since the last meeting, the Subgroup provided feedback on a virtual care paper.
• Virtual care could be very helpful in the next steps, and there is interest in its sustainability.
• The opportunity to identify outcome indicators seems to make consensus.

Follow-up:

• A new Task Force will be convened to identify virtual care outcome indicators.

Long-Term Care

The draft proposals developed by the Task Force on long-term care were circulated before the meeting.

• The Task Force chair, recognized the high quality of task force membership. He gave an overview of the ideas that came forward.
• There is overall consensus among Expert Group members on the proposed ideas.
• The opportunity for mandatory testing of all people who enter long-term care homes, like we do in airports, was discussed.
• Challenges remain in defining the role of the federal government in dealing with many of the Task Force proposals.

Long-Term Care, Next Phase

• The Task Force discussions have revealed systemic issues that could benefit from post-crisis attention.
• Beyond older adults, there may be a need for a broader look at vulnerable populations such as homeless persons and foreign agriculture workers. How do we protect people when their life situation does not easily allow them to be protected?

Follow-up:

• Identify the systemic LTC issues that could benefit from post-crisis attention.
• There may be an opportunity for a scoping discussion on the broader vulnerable population.

Medium Term Planning

A scoping one-pager for a Task Force on medium-term planning was circulated before the meeting.

• During the containment phase, many non life-threatening cases were delayed. In restarting regular activities, planners and people who are on the ground could benefit from support on how to manage the trade-offs.
• What tools and guidelines could help impede overprotecting and overreacting to COVID-19 cases? How do we deal with the collective effects when we are making patient-by-patient decisions?

Follow-up:

• A Task Force will be initiated shortly.