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What is the most pressing issue for primary care not just in Ontario but across the country?

“What’s most exciting to me is the challenge of managing the 6.5 million unattached patients in Canada – that’s not going away,” says Dr. Onil Bhattacharyya, lead of the Canadian Primary Care Research Network (CPCRN), a national network focused on building a strong primary care foundation through research and learning. “Every province is dealing with this, and federal money is going to this area. That’s the use case I’m most excited about.”

The goal of the Canadian Primary Care Research Network is to establish provincial and territorial practice-based research and learning networks to allow spread and scale of primary care solutions across the country. With 13 different health systems, there may be local innovations at family practices across Canada but the challenge is knowing about these and implementing them on a larger scale.

He sees enormous opportunity for the network and related groups to be systematic about channeling the benefits of research at the national level. Dr. Bhattacharyya, a family physician-researcher and member of the Office of Spread and Scale at Women’s College Hospital, an OSSU Research Centre, is energized by the challenge.

“We set up the network because primary care research is often done on a small scale, it’s hard to have impact and we want to facilitate scale and spread,” says Dr. Bhattacharyya. “We want to study primary care and develop solutions that will be applicable in multiple provinces and help the country. How do we organize and deliver primary care for people?”

“Most care is in primary care; it’s the most efficient way to deliver health care in general but we don’t always know how best to do that.”

With a bird’s eye view of the challenges and opportunities facing Canada’s health system, he sees CPCRN’s role as a synthesizer of best practices at the provincial and territorial level, with research and data  a key component.

“This infrastructure will allow us to systematically learn from the variation across the country; it’s a learning opportunity that has never been really exploited,” he says.

To ensure relevancy of primary care research, the network involves researchers, policy-makers, patients and others in all stages of research and dissemination.

Practice-based learning networks

There are a range of groups and stakeholders working with CPCRN who are all equally passionate about improving primary care with research, sharing best practices and engaging patients throughout. Provinces are creating Practice-Based Learning and Research Networks (PBLRN) to share de-identified data from individual practice electronic medical records (EMRs) in a common database for health research and quality improvement. In Ontario, POPLAR is leading this work, with 6 departments of family medicine and the Alliance for Healthier Communities involved and supported by the Ministry of Health and OSSU.

The team envisions a true learning health system, in which the researchers and policymakers can learn from other jurisdictions and can effect change relatively quickly. They are trying to leverage skills and experience from other provinces and territories to improve care across the country.

“We want to ultimately take what we have in our hands now, such as data, patient and caregiver experience and outcomes, to improve care tomorrow,” says Dr. Jennifer Rayner, Director of Research and Policy, Alliance for Healthier Communities and the Ontario lead of the CPCRN. “This also means access to care – patient-centred, equity-driven, accessible, all the dimensions of high-quality care.”

“Often research takes so long to get down to the patient level of care. Research shows it can take 17 years but that’s no longer okay. We want to get research into practice quickly.”

OSSU’s Primary Care Roundtable was particularly valuable for her, as there was open dialogue with policy-makers at the event.

“After the policy table, we heard what policy-makers needed from us – that kind of dialogue is amazing because you want your work to matter,” says Dr. Rayner. “Primary care is a big priority for policy makers – they want to understand health equity, impact of the [health] team and how to design care based on the population’s needs beyond a sole health care provider. How do we design the right [health care] team so that communities get the right care? Health human resources and health equity are significant concerns at the policy level.”

Patient perspective

As a member of CPCRN’s Pan-Canadian Patient Council, Steve Wolinsky is excited to contribute the patient perspective to improve primary care. He came to the network through his local hospital, North York General, and because of his wife, Dr. Michelle Greiver, a primary care researcher leading POPLAR. A retired chemical engineer with a varied career, he now finds himself involved in an important role – bringing the patient voice to this transformational work. At the CPCRN launch, the council met in-real-life for team building, networking with researchers and getting to know each other. An overarching theme was equity, diversity and inclusion.

“I never thought research can be harmful but it can be if framed in the wrong way or excludes a group,” says Steve. “That’s the type of thing we’ll look at as the patient council. Is it inclusive? Is there harm being done?”

The 10-person patient council represents a diverse group of people with varied experiences in the health system, and insights valuable for CPCRN’s work. They will ensure a 360-degree lens in research across the network.

“Are there common themes at council? One of the members doesn’t have a family doctor and she should; that’s one theme – that there’s a shortage of primary care,” says Steve. “It’s an obvious one. Also, Indigenous groups are not supported the way they should be. The whole idea of inclusiveness is important. Someone who is part of the trans community and not well understood, that’s a comment that came up.”  

Data in primary care

Another partner in the primary care landscape is Innovations Strengthening Primary Health Care through Research (INSPIRE-PHC), an OSSU Research Centre led by Dr. Michael Green that is looking at virtual care, health human resource challenges and linking primary care data from across the province. A major focus of his work is harmonizing EMR data and connecting individual doctor’s offices to input data into a centralized, standardized platform to be used for research studies. The goal? Primary care for Ontarians, ideally through a family health team.

“We’re focused also on understanding what’s happening in primary care and how this impacts health outcomes for patients in Ontario,” says Dr. Michael Green. “For example, we look at who’s attached to a primary care clinician, whether your cancer screening is up to date, did you get vaccinated for COVID, how often do you go to emergency, whether there are differences for people who have trouble accessing health care. Those are the types of questions we’re trying to answer.”

“The biggest thing is attachment to a source of primary care, and attachment to a team within that,” he says. “We know it makes a big difference. It’s been deteriorating over time and it’s now unfair, inequitable, that people don’t have a primary care physician.”

He acknowledges there is much work to be done to understand what types of patients lack care, who are the priority groups, and whether these patients need a family doctor or broader team-based care.

“We don’t have any magic wands to create family doctors or teams out of the air but the data is useful for understanding gaps and planning for needs in a particular region,” says Dr. Green.

What should the province do?

“They do need to prioritize primary care; they should commit to the goal that everybody who wants one – that’s almost everyone – should have a source of primary care. To make it happen, make sure there is fair population-based funding across the province, and this should be funding for teams as we don’t have enough doctors. There needs to be enough funding to make it attractive for people to work in primary care. The paperwork is too much; digital can help with this.”

Where does virtual care fit in this vision? Virtual care was widely adopted during the COVID-19 pandemic, but it is not yet known whether it improves the quality of care. As Dr. Bhattacharyya notes, patients love emailing doctors – asynchronous messaging – but in most provinces it is not billable and in the US (where it is widely used) it has been correlated with physician burnout.

“How do we understand what’s going on in other provinces and roll it out so it improves quality and reduces burnout,” asks Dr. Bhattacharyya. “We can learn from 13 different strategies on how to do it best. Asynchronous messaging has the greatest potential in primary care and is the most widely used because it’s comprehensive – patients can ask questions. There are lots of pros and some cons so we need systems and networks to figure out how do this well.”

And key to this work is patient partnership. At the patient council in-person meeting, the group had a talking circle where they talked about their journeys through primary care, which highlighted for Steve the vital role of patient partners.

“It was quite moving and meaningful as people had a chance to talk uninterrupted, and it worked very well in that people realized that what they said was important and they were being listened to.

Read more about the primary care research landscape in Canada and the various groups involved.