Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 5 - Evidence - October 27, 2011
OTTAWA, Thursday, October 27, 2011
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 10:26 a.m. to examine the progress in implementing the 2004 10-Year Plan to Strengthen Health Care.
Senator Kelvin Kenneth Ogilvie (Chair) in the chair.
[English]
The Chair: We have a quorum, so I will call the meeting to order. Before I go to the full committee and our witnesses, I want to go over the agenda with my colleagues to remind them that we have two panels this morning. The first one is scheduled from 10:30 a.m. to 11:30 a.m. Is that agreed?
Hon. Senators: Agreed.
The Chair: Then we have a second panel from 11:30 a.m. to 12:30 p.m. Is that agreed?
Hon. Senators: Agreed.
The Chair: Thank you.
[Translation]
I wish to welcome you to the Senate Standing Committee on Social Affairs, Science and Technology.
[English]
I want to especially welcome our guests. I will start by having us identify ourselves to them. I am Kelvin Ogilvie from Nova Scotia. I will ask my colleagues to introduce themselves, starting on my right.
Senator Seidman: Judith Seidman from Montreal, Quebec.
Senator Eaton: Nicole Eaton from Toronto, Ontario.
[Translation]
Senator Demers: Jacques Demers from Hudson, Quebec.
[English]
Senator Braley: David Braley from Ontario.
Senator Cordy: Jane Cordy. I am a senator from Nova Scotia. Welcome.
Senator Martin: Good morning. I am Yonah Martin from Vancouver, B.C.
Senator Merchant: Good morning. I am Pana Merchant from Regina, Saskatchewan.
Senator Eggleton: Art Eggleton from Toronto, and I am deputy chair of the committee.
The Chair: Thank you.
I will remind us all that this meeting is on the 10-Year Plan to Strengthen Health Care. This is the review of that accord. This is a meeting on health innovation and electronic records. We have two panels, the first one on health innovations.
I want to remind colleagues that we need to proceed through our two panels very efficiently this morning.
Now I welcome our distinguished witnesses. I will introduce them as they are called to present. In that regard, I will start with Genome Canada and Dr. Pierre Meulien, President and CEO.
[Translation]
Dr. Pierre Meulien, President and CEO, Genome Canada: Thank you, Mr. Chair. I will present in English but I will be happy to answer questions in French.
[English]
On behalf of Genome Canada, I am pleased to participate in your review of the 10-Year Plan to Strengthen Health Care and provide you with some insight on the topic of health innovation as it relates to genomics.
In support of the critical role of genomics in Canadian science and medicine, the federal government supported the establishment of Genome Canada a decade ago. Genomics is an enabling technology that has enormous potential to translate pure science from the laboratory into innovative medical treatments, more resilient agricultural products, alternate energy sources and more environmentally stable supplies of everything from bees to trees.
Our goals are to invest in large-scale science and technology projects necessary to advance innovation; connect ideas and people across the public and private sectors to find new uses and applications for genomics; and translate discoveries into applications that create valuable products and services that directly benefit Canadians.
In the past 10 years, Genome Canada has built a broad and highly successful Canadian genomics enterprise. We have delivered real return on investment, leveraging the $915 million received from the Government of Canada into $2 billion in research through agreements with international partners, the private sector, universities, provincial governments and other funders.
Five world-class science and technology innovation centres have been created in Canada that are on the cutting edge of genomics technologies and provide access to researchers across Canada. Six regional Genome Centres have been created to raise co-funding, manage large-scale science and understand regional economic sectors capable of integrating genomics for social and economic gain.
More than 20 private sector companies have been created or enhanced through Genome Canada investments. 10,000 highly skilled people have been employed and trained because of our research investments. Our strong focus on commercialization has led to more than 350 patent applications and awards, as well as 24 commercial licence agreements with the private sector.
New pressures on Canada's health care system are coming from a new reality in medicine and science. The economic burden of chronic disease and an aging population are forcing Canadian policy-makers to look differently at how to manage a sustainable health care system. This system should be open to receive fresh opportunities and innovation.
New approaches that demonstrate cost-effectiveness and are evidence-based need to be integrated to contribute to health maintenance and early diagnosis of disease.
Genomics are the underlying catalyst for a shift from a disease-oriented health care system to one that is more personalized, predictive, preventive and cost-effective. Since the year 2000, Genome Canada has invested over $400 million in around 80 large-scale innovative projects in the health care sector. Partnerships with provincial governments, the private sector, universities and research hospitals have leveraged our investments by a further $700 million plus. In total, we have invested around $1.2 billion in genomics-based research that is shaping the changes in health and medical care.
Genome Canada helps translate discovery into medical applications through important partnerships. These include the Canadian Cancer Stem Cell Consortium, which we helped found, along with our partners at the Canadian Institutes of Health Research. Indeed, CIHR is a valued partner.
In yet another partnership with CIHR, we have embarked on two major genomics-based research projects to investigate and seek the underlying genetic causes of childhood cancers as well as other rare diseases in children.
A further example is the Atlantic Medical Genetics and Genomics Initiative, which we fund and which has identified a genetic mutation that was leading to early deaths from heart failure among men under the age of 50. The province of Newfoundland and Labrador now makes genetic screening and diagnosis for this more widely available and offers heart defibrillators to those diagnosed with this mutation.
Research funded by Genome Canada has led to a test that can identify those people who have a heightened risk of developing colon cancer, and a new company has been created around this technology.
Nursing mothers are now being warned that people with a particular genotype convert codeine to morphine more rapidly, placing their infants at risk of toxicity following breast feeding. This investigation has led to labelling changes for codeine use in Canada and the United States.
Genomics brings ever closer the role of personalized health care so that therapies and treatments can be tailored to the patient, avoiding adverse drug reactions, allowing physicians to quickly identify hereditary diseases based on genetics and rapidly identifying pathogens to efficiently manage a disease outbreak. Indeed, the SARS virus was sequenced for the first time in Canada and in the world, in one of our centres. Learning to understand human genetics in the overall function of disease and stratifying patient groups accordingly is another quest.
Canada's genomics enterprise has just developed a new five-year plan. To continue the process of generating discoveries and translating them to societal benefit, we have been in ongoing discussions with senior government officials in request of stable multi-year funding of $500 million over five years, $100 million per year, which we would leverage to a net investment for Canada of $1.5 billion over the next five years.
In addition, we have recently presented to the pre-budget consultations of the House of Commons Standing Committee on Finance for their support. We therefore make the same request of this committee.
The benefits related to health we have reported to you today are only the first steps in an entirely new approach to health care. I look forward to answering your questions.
The Chair: Thank you.
We will now move to the Canadian Academy of Health Sciences, Dr. Paul Armstrong, Founding and Former President.
Dr. Paul Armstrong, Founding and Former President, Canadian Academy of Health Sciences: Thank you. It is a privilege to present on behalf of the academy. In my presentation, I would like to make five points. First, the academy is a relatively new organization founded seven years ago and is one of the three founding academies of the Council of Canadian Academies, along with the Canadian Academy of Engineering and the Royal Society.
The objectives of the academy are to serve as a credible and expert independent assessor of science and technology issues relative to health in this country, support the development of timely and informed strategic advice that reflects on health care and create an informative dialogue on health public policy.
The composition of the academy is on a volunteer basis. We now have over 400 fellows who are committed and have a covenant to serve the best interests of the country. They are volunteers, and they represent the full spectrum of health disciplines, six in all, ranging from pharmacy to medicine to nursing to rehabilitation medicine, dentistry and veterinary medicine. We are neutral, we are non-vested and we are able, therefore, to conduct arm's length independent assessments. Two that I think would be of interest to the committee relate to the performance of chronic disease assessment for Canadians with these conditions and evaluating return on health investment. I will leave this report with your committee.
Essentially, in this evaluation, we have created a document that envelopes five domains and over 82 metrics. It is now part of the strategic planning exercise of our partners in CIHR. It is engaged in the science and technology of the Government of Canada planning, and it has also been taken up internationally to a substantial degree.
Our enthusiasm for participating in the dialogue relative to your charge — that is, the future of health care as it relates to the accord — had led us to conduct a forum in this city about a month ago entitled "Smarter Caring for a Healthier Canada: Embracing System Innovation." Emerging from this was a prospectus, which I have provided you, and I will very briefly refer to it.
Essentially, the proposal that the academy wishes to undertake, which we think speaks directly to our multi- disciplinary complexion and our neutral space, is how we can contribute to the creation of a newly integrated sustainable health care system that optimizes quality, access and expenditures specifically related to the issue of human health resources, which was highlighted in the 2004 accord but unfortunately for which there has been limited progress. We propose, then, to explore and redesign the scopes of practice of health professionals across the country as it relates to a team approach that is patient and individual centred and that has not, up until this point, been possible.
In addition to bringing about a cultural change in the professions, we also propose to undertake a suggested plan for modification of the education and training of the next generation of health professionals in order to properly equip them for the challenges of the future.
The panel will be created according to a work plan that is outlined in the prospectus. I am pleased to report that as of last week, we have identified the key co-chairs of this panel, which will be international in scope and complete its work before the end of 2012. One of the co-chairs is Jeffrey Turnbull, known well to this city, former President of the CMA and Professor Chair of the Department of Medicine here at the University of Ottawa. The other person is Professor Nelson, the Dean of Nursing at the University of Toronto. These two individuals are to begin their work shortly relating to this specific area where we believe the academy can make genuine progress that will contribute to the dialogue around the future of health care.
The Chair: Thank you.
I will now move to the Canadian Institutes of Health Research. We have two representatives who I understand will share their time. We have with us Dr. Alain Beaudet, President, and Dr. Robyn Tamblyn, Scientific Director.
Dr. Alain Beaudet, President, Canadian Institutes of Health Research: I would like to thank the Standing Senate Committee on Social Affairs, Science and Technology for this opportunity to report on the Canadian Institutes of Health Research's contribution to the 10-Year Plan to Strengthen Health Care.
In 2004, the first ministers recognized that investments in science and technology were intrinsic to the development of improved health outcomes and cost-effective health services. In this context, the Government of Canada committed to continued investments to sustain activities in support of health innovation.
CIHR plays a key role in delivering on this mandate. Indeed, its mission is to support the creation of new knowledge and its translation into improved health for Canadians, more effective health services and products and a strengthened health care system.
[Translation]
As you know, provinces and territories are responsible for health services provided to Canadians. The Government of Canada has to assist provincial and territorial governments in establishing an efficient health system and in promoting, through research and innovation, excellence in healthcare and access to state-of-the-art services.
This role is at the heart of CIHR's mission: supporting a high level of research, contributing to the training of health professionals to the most stringent scientific standards and promoting innovation in our health system.
We are talking here not only of the discovery and marketing of new drugs, diagnostic tests and technological tools, but also of putting in place more efficient care practices, developing new preventive approaches and improving the organizational management of our health system.
[English]
As an example of these accomplishments, I would cite the work of CIHR funded researcher Dr. Cyril Frank and his team at the Alberta Bone and Joint Health Institute, who developed a new and more cost-effective model of care for hip and knee replacement. This model has markedly improved outcomes while decreasing hospital stays and wait times for surgery. For governments, the cost savings from a nationwide implementation of this model of care is estimated at approximately $228 million per year.
CIHR funded research by Dr. Lisa Dolovich of McMaster University showed that having pharmacists in family physicians' offices helps optimize medication regimes and improve monitoring of medications. The project actually prevented 241 potential adverse events amongst seniors participating in the study. As a result of this study, Ontario's and Saskatchewan's Ministries of Health now fund full-time pharmacist positions within primary health care teams.
[Translation]
A clinical trial supported by CIHR has shown that Aprotinin, a drug commonly used to prevent hemorrhaging during heart surgery was responsible for a 50 per cent increase in the risk of mortality while costing much more than other safer drugs of the same class. This drug is now banned from our operating rooms.
[English]
The challenge is to ensure that research results are rapidly disseminated and integrated into practice. To this aim, CIHR has developed and implemented programs to help translate research results into decisions that improve the health care system. The process brings together researchers and knowledge users from different levels of government to help provide answers to their most pressing questions. Pauline Rousseau, Executive Director for Saskatchewan's Health Policy and Planning Branch, commented on one of these programs as follows:
This is the most important research initiative targeted at bringing together the research and policy communities that I have seen in decades.
A recent international review of CIHR confirmed that we are making progress towards a better integration of research and care and expressed support for future strategic directions being taken by the organization. They commended us, in particular, for the development, in collaboration with the provinces and territories, health charities, academic health care organizations and industry representatives of a comprehensive strategy for patient-oriented research. This strategy aims at strengthening our clinical research enterprise and improving the transfer of research evidence into evidence-based practice so that the right patient receives the right treatment at the right time.
In launching the strategy earlier this year, the Minister of Health, the Honourable Leona Agluukaq, stated:
By putting patients first, we are making sure that research will have a greater impact on treatments and services provided in clinics, hospitals and doctors' offices throughout Canada. Better integration of research evidence and clinical practice means improved health outcomes and a better health care system in Canada.
We feel that this patient-oriented research strategy, along with our ongoing investments in research and knowledge translation, will help transform clinical practice in this country for better health outcomes and a stronger health care system.
[Translation]
Dr. Robyn Tamblyn, Scientific Director, Canadian Institutes of Health Research: I welcome the opportunity to discuss with you the important contribution of research to health services in Canada. Innovation in this area improves the health of Canadians and promotes a better use of our healthcare expenditures.
[English]
For decades, Canada has been recognized internationally for its health care system. We have been known to provide equitable, high-quality and efficient health care for an entire population, but times have changed, and we are falling behind. You may wonder why.
Canada, like other nations, has an aging population, and that aging population has an increasing burden of chronic disease. We have not yet made fundamental changes in how we deliver care. We have not moved beyond a rather antiquated, hospital-centric model of care. That is what we need to do.
There is consensus that we need, and I want to underline this, a new generation of community-based primary health care models to address the urgent needs of health care in this century. To improve health and then chronic disease management, we need new approaches to patient- and family-centred care through interprovincial and community- based teams in partnership with the community.
Second, we need to carve out innovations at the interface between public health interventions and community-based service delivery models if we want to develop innovative approaches to chronic disease prevention that relate to lifestyle, work and environmental circumstances, thereby reducing inequities in the health outcomes that are experienced by our population, particularly our most vulnerable.
Third, we need to use new information technologies and other innovations to improve timely access to essential health care, particularly in rural and Northern communities.
The challenge that needs to be boldly addressed is that there really is no right answer and there is no best approach to improving health care. If transformative change is to occur, the ground work needs to be laid to promote innovation, to rapidly identify success and to implement the conditions required to scale up innovations into transformative change.
Research is at the core of innovation. It can be a very efficient means of producing rapid improvements in care delivery. This is particularly true in Canada, where research funded by CIHR, the national health research funding agency, can take advantage of the natural experiments that are occurring day after day in Canada's 13 health care systems, one in each province and territory.
For example, investment in an interprovincial network to study the quality and outcomes of care for premature infants who go to neonatal intensive care units identified preventable causes of hospital infections and chronic lung disease in these little kids. The network identified the interventions that actually reduced these problems by 42 per cent for hospital- acquired infections and by 15 per cent for chronic lung disease. The cost savings from this research alone is approximately $70 million per year in Canada.
Building on successes such as this, CIHR, in partnership with the provinces, universities, disease charities and the private sector, will be investing in a 10-year initiative to transform community-based primary health care.
This is part of its strategy for patient-oriented research. It will be the largest scale initiative ever undertaken in Canada. Within five years, it will involve 30 per cent of Canadians from coast to coast, testing new innovative models of care, monitoring success and engaging a national and international network of senior policy-makers to investigate the conditions that will be necessary to scale up successful models of care. We will no longer be a country of pilot projects.
We can and will reposition Canada as a leader in developing a new generation of health care. We thank the federal government for investing in CIHR and the Senate for providing us with the opportunity to present today.
The Chair: Thank you very much.
Colleagues, I will limit each of you to one question in the first round, so if you would please focus the question and identify a responder. Witnesses, I would ask you not to add more unless you have a substantial change or addition to make.
I will attempt to get all the questions on the record before we end in 35 minutes. We would ask you to follow up with written answers to the questions that we do not have time to ask today. The important thing for us is to get the questions on the record and to get the incredible knowledge base you all represent to respond to us in some detail.
Senator Eaton: Dr. Armstrong, you talked about redesigning the cadre of care, I think. What was your term? Could you elaborate?
Dr. Armstrong: What we propose in our assessment is to redesign the way the health professions work with each other. As opposed to solo practitioners, we believe they should be integrated, and we believe this requires a substantial cultural change because the historical divisions around scopes of practice have led to a silo mentality, and the future is clearly an integration one. This change will require a redesign of the health care system, both from the standpoint of where individuals are seen, how health professionals are funded and how they work together.
When I began my practice in the 1970s, I was a solo practitioner. Next Tuesday, I will be doing a clinic on complex heart failure, and there will be nurses, pharmacists, dieticians, social workers and psychologists present to support that. This is where I believe we need to go, and this is why this prospectus is aimed towards that.
It is not enough, of course, to change the culture currently; we need to change the education of young people who are still being educated in individual schools as opposed to in a more integrated system, which is the way they should think and act in the future.
Senator Eggleton: This is a question to all of you. The 2004 accord put $41 billion on the table. Much of it transferred to the provinces, but some of it was used as incentive to the provinces for collaborative efforts, such as reduction of wait times, in buying diagnostic medical equipment or in advancing further electronic health records.
Assuming we have an accord in 2014 to succeed this one, and assuming similar funding methods are used, what are the main proposals or incentives you think should be put to the provinces? Last time, as I said, it was wait times and the others. What do you think it should be this time in order to bring about further collaboration and improvements in the system for patients?
Dr. Beaudet: As I said, it is very clear to us that it should be support for the patient-oriented research strategy, which I briefly mentioned in my remarks. This is unique. It is a coalition of the provinces and territories, the federal government, but also representatives of the charitable sector, health care organizations, academic health sciences centres, patient representatives, of course, and representatives of the private sector.
What we are aiming to do is to break down the silos and work together to establish country-wide means, infrastructure and support of health professionals to ensure that we have better integration of research and care and to ensure that we truly practice evidence-based medicine.
To do that, we are working on several fronts. We are building infrastructure in terms of support units for clinical research in each province. We want to ensure that researchers and clinical investigators across the country work together. We also will be creating networks across specific themes. The first two networks have actually already been determined: mental health and primary health care. This is to ensure that we can rapidly access patients for clinical research across the country and mobilize the collective efforts of all our researchers across the land. These networks will hinge upon the infrastructure of the support units.
We also want to set up mechanisms whereby health professionals are trained for research, have protected time for research, and can better obtain the qualifications to carry out that research. We want to become more competitive internationally in terms of clinical research, particularly in terms of attracting this industry in Canada, because we are losing this sector, as you know, to other countries. We have an excellent environment and a perfect niche for unique clinical trials in this country, but we have to be able to provide the infrastructure.
Foremost is to ensure better mechanisms in order to include decision makers in the development of research protocols and the generation of ideas to ensure that we can rapidly disseminate the research results and ingrate them into practice.
The Chair: Dr. Armstrong, do you have a quick rejoiner here?
Dr. Armstrong: I believe we need to establish national standards and make our system accountable. We need to measure those standards. We need to get return on our investment that is more meaningful than we have in the past, and we need to emphasize innovative transformative change, then publish the results on an annual basis.
Dr. Meulien: There are two key elements here. One that is not yet implemented correctly in Canada is the electronic health record, which I know is very challenging but very important. The second thing is to ensure an open system that is open to quickly integrating new innovations. That as well is a challenge for the system.
Senator Merchant: We have a high incidence of MS in Western Canada. I am from Saskatchewan. You have spoken about clinical trials. There has been a lot of anxiety currently because there is an MS therapy that has received a lot of publicity. There seems to be an exodus of people who can afford that therapy and some who cannot and go to different countries to receive it.
I would like to hear from you as to whether, with the clinical trials we are doing in Saskatchewan, that money is being spent in Canada. Is that research being done in Canada? Are you involved or do you have opinions, using this particular MS therapy as an example, as to how we deal with these issues in Canada today?
Dr. Beaudet: Certainly. As you know, Minister Agluukaq has announced that CIHR will be launching, before the end of November, a call for proposals for phase 1 and 2 clinical trials on the therapy you are referring to, which is the Zamboni procedure, or CCSVI. This procedure consists of expanding veins in the neck to try to improve some of the symptoms of MS.
As you know, there has been a lot of discrepancy in the scientific literature regarding the efficacy and the safety of the procedure. Therefore, the phase 1 and 2 trials will look at safety and establish the proper diagnostic parameters and the proper outcomes to be measured. It will verify whether the opening of the vein through angioplasty improves blood flow and will determine how long any improvement may last. If the ongoing research continues to hint at an association between CCSVI and MS, which is still in question, that could potentially lead to a much larger trial in the future. This much larger trial would therefore be based on solid evidence from phase 1 and 2 trials, which is the normal way things are done. Yes, Canada is moving in that direction.
Senator Martin: I feel we are getting to the key language or details that we need to put on record. My question is regarding this linkage of transferring knowledge to practice. Everyone says there are silos and that the problem is the gap. There needs to be a bridge to ensure more effective knowledge transfer between researchers and clinicians. Clearly, we are making investments and there is innovation, but how do we actually transfer it and link it?
In that space, that gap, I heard some of you talk about the mechanisms we need, whether it is the e-records and/or establishing certain national standards.
Would any one of you speak to the importance of a trans-disciplinary model in that if we have an interdisciplinary model wherein each specialized group is doing their thing, there could still be a gap? There has to be some sort of crossover to clearly integrate.
What mechanisms would we need in order for a trans-disciplinary model to work and what language needs to be in the accord to allow this to be a clear target going forward?
Dr. Tamblyn: I would love to answer that question. It is a critical one. Here is the scope: What you really want is to prevent disease, improve outcomes, reduce disparities and improve efficiencies. Those are the four things you want to do. You do not want to tie people's hands behind their backs and say that you need to do it with an electronic health record or you need to do it with such and such. You want that very smart workforce at the front line to be engaged in that innovation. If you said that this is what we want to accomplish and we want to monitor that and we want to even pay for that — that would be revolutionary, right — then, in fact, you will see the most creative things happen on the front line. That is really where the innovation is and it will produce exactly what you want, without tying people's hands as to how they get there. They will get there. If you benchmark the right outcomes then they will get there.
I have complete confidence in the creativity, dedication and intelligence of the health professional workforce in Canada. We just need to liberate them to get going.
Dr. Meulien: I will add a point from more of a technology piece. I believe one of the gaps you are referring to is the lack of a robust, country wide technology assessment system that would say that this technology is going to bring value to this part of the system. I think the onus is placed across the divide; I think the onus is on funders of research like ourselves, who should demand of multidisciplinary project teams to come with solid economic analyses around some of these new innovations that provide health authorities from the provincial standpoint justification for deciding, decision making on clear evidence that yes, this will bring value.
I do not think we have done that properly and I think we should be able to improve that and it is partly to do with — this is Genome Canada speaking — the way we design our programs. We can make improvements to include some of these pieces of the puzzle. Paul Armstrong just talked about the multidisciplinary team kind of thing and I believe that applies to the way we fund our research as well. Those kinds of things will make a difference.
Senator Seidman: In a way, we have all been tackling the same issue; perhaps in slightly different ways. If I could just go back again to the importance of knowledge transfer; you have all referred to it and we have heard it in previous sessions, there is no question about that.
There are obviously difficulties in translating innovations into research, into clinical practice, and part of it appears to be a lack of integration. You have referred to it at levels of governments and among health professionals, both between and among those groups.
In the name of cost effectiveness in health care, should we and how can we build in knowledge translation in future accords?
Dr. Armstrong: I would like to comment on the information technology that is so critical to knowledge transfer and try and consolidate the previous and the current question, if I may, Mr. Chair.
We all should electronically possess our own record and our health information. Although I am from Alberta, if I experience loss of consciousness on the way to the airport this afternoon and arrive in an emergency room my information should be immediately available to the emergency room nurse who sees me at the first point of care.
If a Newfoundland oil sands worker with heart failure in the tar sands sees us in our clinic, we should be able to remind him to stop smoking and take his medication through cell phone and electronic record on a regular basis through a shared opportunity amongst health care professionals.
We are now caring for patients with heart attack, reading their electrocardiograms over cell phone technology in the field with devolution of care to paramedics in northern Alberta.
The sharing of care, the information technology, the collaboration and paying for quality, rather than for the number of services we provide, is clearly the way we need to get to where we need to be in the future.
Dr. Beaudet: It is a challenge because we are talking about a change in culture. We take it for granted that we practice evidence-based medicine, but in fact we do that only in part. We have to realize that excellence in care is totally linked to health innovation and to research, not only research that will compare new, innovative techniques or procedures with what we are already doing, but also research on comparative effectiveness, which will look at what we are doing and ensuring that we are doing more good than harm.
It means a whole new culture of evaluating everything we are doing — accountability, as Dr. Armstrong said. It means ensuring that, as a matter of culture, we know that constant evaluation will ensure that we are employing the best and most up-to-date practice, and this is what will bring excellence in care. That culture has to be standardized across the nation.
The Chair: Thank you.
I have a list here. We will get additional questions, and I indicated that we would like follow-up responses from you in more detail. I would like to get my colleagues' questions on the record with you present.
Senator Cordy: My first question requires a yes or no.
Dr. Beaudet, Senator Merchant asked about MS CCSVI. I know you published a report in June for the minister. May the committee have a copy of that report?
Dr. Beaudet: Certainly.
Senator Cordy: I would like to go to the issue of human health resources, which of course was in the previous accord, the one we are currently using, but we still find in Nova Scotia shortages of medical personnel. I guess I have been on this committee a long time because we studied the health care system in the early 2000s and this was a big issue then and it still seems to be an issue. Are we using our health care personnel effectively? How will we train to ensure we do not have shortages so the Canadian people we are talking about have individualized programs and people have access to medical personnel?
Dr. Armstrong: No, we are not using our health professionals appropriately. In relation to the collaborative research of which Dr. Beaudet speaks, we need to do this better. Our emergency rooms are clogged with people with complaints that should be dealt with by a nurse navigator in the community. We talk about 5 million Canadians not having access to a family doctor, but they should have access to an integrated health care team where the first point of care would not necessarily be a physician.
In the disposition of our practitioners, in whatever discipline, and failure to be integrated, with some substantial exemptions, there are islands of excellence across the country but we need to make this a full-scale geographic map where all have access to an integrated health care system. Then I think we can make much better use of the current professionals we have and get value for investment.
Senator Hubley: I believe it was Dr. Tamblyn who mentioned a new generation of community based health care systems. That is somewhat exciting because I sense that that will bring in family responsibilities. We are looking at childhood situations and I wonder if you might elaborate on that for us, how you envision that happening?
Dr. Tamblyn: There are probably three things we could actually focus on that would produce massive innovation. We can look at some of the most prevalent problems, conditions in our society such as obesity. Clearly you will not solve obesity by increasing the number of ORs providing stomach stapling services. That will not be the way to go. Public health interventions aimed at improving quality of lifestyle, food security and tax reforms with respect to sales tax on foods will be a way forward.
We did so well with smoking. We are a model for smoking. We can tackle this, but it means the same kind of foresight of saying that we have some public health interventions and population health interventions, and we will combine that with an inter-professional service delivery model that will be aimed at improving healthy lifestyles and so on.
What is really interesting is that for two decades at least people have said they want to manage their conditions better themselves. They want to manage their health better themselves. We have not empowered people to do that.
Dr. Armstrong's point about information technology will be important. People want to have access to their records. They want to have access to information about what will make them better. They want to know what the evidence says about what they should do better and how to do it. We should organize to give it to them. They are the power behind the behaviour change that individuals and families will make.
We have the smarts and the tools, we just need to try out some things and see what will work and make sure we scale it up this time and set up the conditions to do so.
Senator Braley: My question is an extension of the two previous questions. I believe the clinical approach is absolutely correct. McMaster is now in the process of evaluating to move all their general practitioners being trained in the clinical environment and also looking at the scope of work at each station, whether the nurse or the nurse practitioners can do things, or what person takes on the task, and the scope of the work of the doctor being reduced and putting them in the clinical situation as they are being trained. This is so they become much more useful and they have the culture now.
Should we not be taking a look at how we train them? I do not think any general practitioner today gets one course on eldercare in their curriculum. There are so many things that should be looked at in this area. Am I assessing this correctly?
Dr. Armstrong: You are spot on, senator, and many of us received our initial training basically in a hospital-based system around acute disease. We were not trained adequately in primary or secondary prevention, and we had little experience in the outpatient care which is where, of course, prevention must occur.
The other point to make is that it is highly likely that we should be having, in the first few years of training, dentists, pharmacists, physicians and nurses working together in the same educational milieu because of the cross-fertilization that occurs. Not all physicians should be trained the same way and, indeed, for many the training is too long. There needs to be a culture shift here, both in terms of the collective training of the health professionals and where they are trained. As you point out, much of this should be done outside of the critical care institutions.
Senator Braley: Should public health be forced to be part of and joined together with the training of the doctors?
Dr. Armstrong: Absolutely, sir.
The Chair: Now I will go to two senators on a second round and then I will end by asking a question.
Senator Eggleton: I was kind of anxious to hear Dr. Tamblyn's response.
The Chair: We can do that and then have you put your question on the record.
Senator Eggleton: I will put my question on the record then. I am following notes from my researchers on this, but I am interested in the answer you gave, Dr. Beaudet, about Canada's strategy for patient-oriented research, which is a report you did. It aims, as I understand, is to introduce innovative diagnostic and therapeutic approaches into clinical care.
According to the strategy, Canada faces two "death valleys" in terms of knowledge translation. First, Canada lacks the capacity to translate discoveries in biomedical laboratories into clinical practice while commercializing those discoveries. We know that old story. Second, Canada is limited in capacity to synthesize and disseminate existing research into clinical practice settings and health care policy making. How do you address these two issues?
Dr. Beaudet: As I said, we want to address these issues by acting on a number of elements — by providing better infrastructure and by providing better support to train and foster health professionals who are involved in research and particularly in clinical research. We also want to provide more support for clinical trials and clinical research broadly, but also for research synthesis and for the writing of guidelines aimed at the uptake of research results. That is the real challenge.
Senator Eggleton: What is the federal role in that though?
Dr. Beaudet: The federal role in that is really its role in supporting research, and in the case of CIHR, its role in delivering on its full mandate. Its full mandate is not only basic biomedical research, as you know, it is also clinical research and also public and population health research and it is also health services and policy research. In doing that, we can ensure standardization and excellence of care across the provinces, but we cannot do it alone. If we do not do it with the provinces, this uptake we are talking about will not happen.
Moreover, we really need to get the decision makers and the heads of the academic health centres, fully integrated and fully involved in this project. We have to modify the way we are evaluating this kind of research to ensure that not only have the results been obtained and published, but that in fact they have locally and nationally changed the practice.
Dr. Meulien: Dr. Beaudet said there was a culture change necessary and going back to the knowledge transfer piece. This is crucial for our own field in genomics. For each of our projects we integrate social science and humanities research within the program to try and foresee what will be the barriers going down the line in terms of technology transfer. What infrastructure changes would there need to be? Is it a clinical lab change, the human resource issues, the regulatory issues? All of these are integrated into our projects and I think that is a theme that will recur. Once again, some of what we can do in terms of actors is in terms of program design to ensure that the deliverables are most likely there at the end of the project.
Senator Eaton: This is for Dr. Meulien. What is Genome Canada's relationship to universities, or to things like the newly opened Lee Ka Shing Institute, to coordinate and help transfer, translate medical research to the big wide world?
Dr. Meulien: When we fund programs we fund academically driven programs traditionally. Our relationship with the university is we contract through our regional genome centres with the universities so it is a contract-based model, and accountability from the universities in terms of the milestones, et cetera, that we deliver. This applies as well to any research institutes that may well be involved in the projects.
Senator Eaton: Do you then take the results of that research and do you translate it?
Dr. Meulien: This comes back to the program design. The translation should be part of the program design, and we do milestone-driven types of programs which are followed very carefully because we are dealing with large-scale science. One of our projects is about $10 million. Therefore we carefully monitor these, so translation is part of the program design.
The Chair: Obviously you have all covered really exciting and important areas. I would like to ask one question. I will start with Dr. Meulien and then I think the others may want to comment.
One of the issues we have seen among the many difficulties we have is with the use of pharmaceuticals. We know there are a great number of issues there, much of which has to do with the lack of information immediately available to a given patient at a given time. However, there is another aspect, and that is there is normally a subset of the population that will react severely to almost any new compound. We have seen in the recent past one of the most promising pain relief medicines removed from general use because of exceptional problems in a subset of the population.
Dr. Meulien, do you see the advances in genetic understanding as translating soon into a practical way to determine when an individual may be subject to a severe reaction as opposed to having a clean opportunity to benefit from a modern miracle of science?
Dr. Meulien: Adverse drug reactions account for about $15 billion of cost to the Canadian health system. Probably over 90 per cent of these are genetically determined. The proof of concept is already there. I explained the codeine story. We are saving lives through this new label change for codeine, which was responsible for some unexplained infant mortality.
Absolutely yes, our knowledge of what genes are now involved in this different drug metabolism that goes on that gives rise to these adverse drug reactions is escalating to a point where we will now be progressively able to understand clearly the genetic basis of these and, by simple testing pre-administration, hopefully a lot of these cases will be avoidable.
Dr. Tamblyn: I think you heard from Dr. Peterson yesterday, from the Drug Safety and Effectiveness Network, and one of the platforms in that network is to look at the pharmaco-genomic determinants of drug response. That is definitely what needs to happen. We spend $500 billion worldwide on drugs and a lot of the time they do not work or they work badly. This is such a promising area of innovation.
Dr. Beaudet: Genome Canada and CIHR are working together on a major initiative on personalized medicine — stratified medicine, if you will — to address just these issues which are absolutely key. It is not only a question of side effects; it is also a question of non-responders that totally dilute the effect. In some cases the net result is having patients taking drugs they do not need.
The Chair: Dr. Tamblyn, will you be that efficient in answering Senator Eggleton's earlier question where I did not give you an additional chance on his question? Would you focus in on your question?
Senator Eggleton: If the federal government is going to put incentives on the table again, as it did in 2004, what are the areas you think it should provide incentives to entice the provinces?
The Chair: You indicated you wanted to comment, so you must have the answer ready.
Dr. Tamblyn: I think you need to focus on the outcomes you are wanting to achieve in accordance with basic principles that we have been known for internationally, which is equitable access, appropriate care and so on, but you need to focus on preventing disease, reducing disparities and improving outcomes, and then you need to put something in an innovation fund to actually make that happen. That would be exciting because then people would be goal- oriented in trying to get that done. In fact, when you look at what has happened in Israel, there they have been effective at trying to produce wonderful innovations and it is because they have been very goal-oriented, they want to get this done and want to actually fund getting it done and then ramping it up. That would be very exciting.
The Chair: Thank you very much. As I mentioned earlier, we have had an exceptional panel here today dealing not only with the practical application but the basic understanding and the development of the issues for the future. We would really like you to think about the questions that have been put today, to follow up with us with regard to additional information that you may think of with regard to the questions, and in particular we would invite you to put forward examples. You have given several examples in different areas during your presentations. If you could identify specific examples where advances in science and technology can be implemented more broadly, that would be most welcome.
Furthermore, your comments with regard to the issue of integrating knowledge in the health care activity directly with the individual patient, any further thoughts you have with regard to how that might roll out even faster than it does currently would be most appreciated.
We have our second panel, which will deal with electronic health records. It is something we have been hearing a great deal about. We are looking forward to this presentation.
I will remind our colleagues we will be finishing this session at 12:30. Our questions need to be sharp and focused.
I will now call on Canada Health Infoway, which is represented by two people, Richard Alvarez, President and Chief Executive Officer; and Mike Sheridan, Chief Operating Officer.
Richard Alvarez, President and Chief Executive Officer, Canada Health Infoway: Thank you for this opportunity to appear in front of you today. I will start with the 2004 accord, since it is your primary mission.
In that accord, the first ministers agreed to accelerate the development and implementation of electronic health records and telehealth systems. They did that to improve the quality, access and productivity of our health care system. At the time of Canada Health Infoway's creation a couple of years earlier, there was not an agreement on what an electronic health record was, how it would operate or what the priorities would be. There were no common frameworks and no agreed upon national standards. Privacy and security approaches and practices varied considerably across the country. Much of this is now in place.
I get ahead of myself. Let me speak to how our investments are used to incent the progress towards the vision of the first ministers. Infoway's investments in these areas flow differently from most federal health spending. Canada Health Infoway invests in capital costs of health IT with the provinces and territories. The jurisdictions are responsible for the development of their overall strategies, proposing projects that align with the agreed blueprint, standards and eligibility criteria, and implementing the projects. However, as jurisdictions control the pace of progress, we only pay when deliverables are achieved.
Following the 2004 accord, Infoway, the provinces and territories agreed to two ambitious goals. First, that every jurisdiction would see benefits from new health information investments by 2010. Second, that the core elements of the electronic health record would be available for 50 per cent of Canadians by 2010. Where are we today?
As the Auditor General said in their 2009 and 2010 reports, much has been accomplished. The first goal was met well before the deadline. Every jurisdiction had at least one system in place, and many had more. The second goal of passing 50 per cent to make the information available was achieved in March of this year.
The ultimate goal is not just about availability of information. Rather, it is about delivering the tools and providing value to Canadians and their clinicians, helping to transform health care. Where are we in that regard?
In the interest of time, I will concentrate on three areas of focus from the 2004 accord, with recent independent evaluations. Let us start with access to care in the North.
Telehealth, which is a way of providing services when patients and clinicians are not in the same place, is already reducing wait times and increasing access to care, particularly in the North. A recent study found that Canada has the world's largest video conferencing network, with 5,700 telehealth sites in 1,200 communities, including 423 sites in northern, remote First Nations and Inuit communities. The result is that a 250,000 sessions were delivered last year, saving patients time, money and eliminating nearly 47 million kilometres on the road.
The second example is in regard to reducing wait times and improving access. The best example here is probably digital diagnostic imaging, which collects, stores, manages and shares patient X-rays, CT scans, MRIs and other images and reports. As the result of our investments, nearly 90 per cent of most common radiology examinations in Canada's hospitals are now digital. That is up from 38 per cent six years ago. Research shows radiologist and technician productivity increased by 25 per cent, enabling as many as 11 million more exams annually. When fully implemented, we expect annual benefits valued at $1 billion.
The third example is drug information systems, which allow authorized clinicians to access, manage and share patient medication histories, thus avoiding harmful drug interactions. Used by one in three community pharmacists and half of hospital emergency rooms, they help avoid harmful drug interactions and manage medications. Research shows the benefits are valued at $436 million per year. Pharmacists surveyed as part of the study rated improved access to patient information, increased patient safety, reduction in fraudulent medication, and a reported nine per cent productivity gain as the top benefits.
As you can see, progress has been made, but much work remains. Putting key components of the electronic health records in place remains a focal point to ensure connections and tools are available at the point of care.
To advance that goal, Canada Health Infoway and the jurisdictions are investing in efforts to enrol 12,000 physicians and nurse practitioners in electronic medical records programs. That will take us to about 60 per cent of Canadian physicians with EMRs. It is a major improvement from the 37 per cent measured in 2009. It is a huge change management task, and we will continue to work with clinicians to provide them the support they need.
We are also beginning to invest in consumer health projects that will help Canadians book appointments online, renew prescriptions, communicate with clinicians and access their own health information. Through specific innovation investments, we are exploring the best ways to support home care and long-term care.
There is a lot of work to do in these areas and others. Handwritten health records — once described as tradition, unsullied by progress — have been around since before Hippocrates. Moving to modern IT is a big cultural change in health care. You do not get there in one step.
Getting there and harvesting the potential benefits in doing so will require ongoing commitment to practice improvements from thousands of dedicated clinicians across the country, continued investments and strong alignments of legislations, regulations and policies. While we need to look back occasionally and celebrate how far we have come since the 2004 accord was signed, we also need to recognize how much there is to do in the future. That concludes my comments. I would be happy to take questions.
Neil Maxwell, Assistant Auditor General, Office of the Auditor General of Canada: Thank you for this opportunity to present the results of two audit reports on electronic health records.
Electronic health records, or EHRs, are intended to offer solutions to a number of persistent problems in Canada's health care. Some may be attributed to the use of paper-based health records. It is expected that EHRs will allow health care professionals to be better able to share patient information, resulting in reduced costs and improved quality of care.
[Translation]
In November 2009, we reported the results of an EHR audit of Canada Health Infoway and Health Canada, based on audit work completed in April 2009. Concurrent with our audit, six provincial audit offices looked at how electronic health records funded by Infoway and/or provincial governments were being implemented in their respective provinces. Each office reported the results of its audit to its own legislature between October 2009 and April 2010. We presented an overview of the federal and provincial reports on electronic health records in April 2010. We have not audited actions taken since these reports were completed.
As of March 31, 2009, Infoway had committed to spending or had spent $1.2 billion on this initiative. We examined how Infoway managed the funds from the federal government to achieve its goal of making compatible electronic health records available across Canada.
[English]
Overall, we found that Infoway had accomplished a lot since its inception. It managed its $1.2 billion in funds well, which were granted by the federal government to achieve that goal. Canada Health Infoway has developed an approach for moving to electronic health records. It developed the key requirements and components of an electronic health record, as well as a blueprint or architecture for the design of the systems. Infoway worked collaboratively with its partners and stakeholders. It obtained agreement with them, which is critical for the success of the initiative.
We reported that Canada Health Infoway needed to report more information on results, in particular information on progress achieved towards its 2010 goal. At the time of our audit, Infoway only reported if systems were completed, but not whether they were being used by health care professionals or if completed systems met the requirements for compatibility. This information on system use and compatibility would help Parliament and Canadians better understand progress to date.
[Translation]
Turning now to the overview report, the provincial audits found that every audited jurisdiction had at least one core electronic health record system in place, and some provinces have almost finished implementing their EHR systems.
However, provincial auditors general found that public reporting on progress was limited. Provinces lack comprehensive information such as costs to date, baselines, and performance measures necessary to report progress more completely.
We highlighted several significant challenges in fully implementing the blueprint. First, there is a need to increase the number of primary care doctors using computerized record systems or electronic medical records, which is low compared to other countries.
[English]
Second, completed EHR projects that do not meet all the standards for national compatibility need to be upgraded, given that the focus for provinces to date has been to ensure compatibility within their respective jurisdictions.
Third, there is a need to address the implications of differences in provincial and territorial laws regarding the collection, use, protection and disclosure of personal health information. This is a concern in situations where Canadians move from one part of the country to another or travel often. Finally, funding is needed to complete the initiative, which some have estimated at as much as $10 billion.
Your committee may wish to ask Health Canada as the policy setter, and Canada Health Infoway as the strategic investor, what progress they are making to address these challenges. I wish the committee success in its deliberations on the renewal of the 10-Year Plan to Strengthen Health Care. This concludes my opening remarks and we would be pleased to answer any questions.
Senator Eggleton: I thought up until now that EHR and EMR were the same thing. However, I am told by our researchers that an electronic medical record is electronic but it is kept in physicians' offices in one location. The electronic health record is intended for access across a wide range of health providers and systems in different parts of the country.
Mr. Alvarez, your statement said that you had the aim that electronic health records would be available for 50 per cent of Canadians by 2010. You said it was completed in March of this year. Towards the end you say, "It will take us to about 60 per cent of Canadian physicians with EMRs, a major improvement from the 37 per cent measured in 2009." I want to be clear that we are not mixing apples and oranges. Is the 60 per cent intended to have people on the EHR systems, or is that lower than the figure for EMRs?
Mr. Alvarez: First let us go back to the earlier clarification you were seeking. There is a big difference between EMR and EHR. We get compared internationally around EMRs, which are siloed systems that are in a doctor's office or hospital. What Canada set out to do was an EHR, which is a longitudinal record for an individual with data being available — medication histories, lab tests, no matter where they were performed — to whoever needed to access them.
The first number I provided is the availability of the data. The data for the EHR comes in the flavour of medication histories, lab results, diagnostic imaging, immunizations, et cetera, and being available. There was 50 per cent of that data available across the Canada. In some cases, there was 100 per cent, with P.E.I. being an example as well as Alberta. It was less in some larger provinces.
The EMR, on the other hand, was in the last tranche of money we got from the government. The vast proportion went towards the ramping up of the EMR in community physicians' offices and ambulatory care systems. When we get compared internationally — the Commonwealth fund out of Washington does this study on a biannual basis — they measure us in terms of EMRs across the world. We were about 37 per cent in 2009. That is the number we hope to take up to about 60 per cent by next year.
Senator Eggleton: What do you hope to take the EHR up to?
Mr. Alvarez: Our next goal is basically 100 per cent availability by 2016. Basically, we will have these repositories in place. As Mr. Maxwell pointed out, and as I said in my speech, it is not a matter of making the databases available. It is a matter of making use of them. You can make medical histories available, but if clinicians are not using them it is a different kettle of fish.
When you look at the continuum of electronic health records, it goes like this: As most of us walk into our doctors' offices, we see shelves of paper. You have to digitize that. If you do not do so, you cannot share it. When you digitize that, you have to provide connectivity next. Canada is doing well with connectivity. Then comes the difficult parts on the continuum, which is the sharing of the data. The data is shared between clinicians and practicing physicians. The other part is knowledge, such as decision support systems, looking at adverse drug events, clinical guidelines and how information is used.
We are well along in terms of the first part of digitization and connectivity. We are starting to share, but we are still a long way away.
Senator Eggleton: At the moment the number of people on EHR is further along than the EMR?
Mr. Alvarez: Yes. If you start to count EMRs in hospital settings, Canada is doing extraordinarily well. The numbers are high.
Senator Eaton: I will go in a different direction. My question is about the North, or in communities such as Parry Sound, who do not have tertiary care hospitals. In a medical study we did last year, we talked about how you get a patient from one of those areas in an emergency, such as after hitting a deer on the road and crashing their car. Are you going into those areas with telehealth? If a patient cannot get to a tertiary care hospital within an hour or two, can you provide them what they need to know on a computer screen?
Mr. Alvarez: We have live examples of what you were talking about. People have written up stories. Lives have been saved, mainly because of federal investments together with jurisdictions. The answer is yes. We have concentrated our efforts in rural and remote locations in terms of telehealth and diagnostic imaging.
The story is about an individual up in the Far North who fell off his motorcycle and was injured. He had a phone with him. He knew where he was because he had a GPS. He was able to call an ambulance. The ambulance got him to a local clinic that had aspects of diagnostic imaging. They were able to do the X-rays and show them to the tertiary centre at the Stanton Territorial Hospital.
From there, they were able to say how they should move this individual when they got him to Stanton hospital. There was further work done, with Edmonton or Vancouver looking at those X-rays and advising them what they should do.
Remote care has been advanced quite dramatically. In fact, there has been a 35 per cent increase in tele-consultation in the last few years.
Senator Eaton: I am sure we are making great strides in the Far North. My concern is closer to home, not the big centres, but places like Parry Sound and Owen Sound, which are 150 miles from a major care centre. Have you started going into those smaller centres that cannot afford a helicopter or do not have tertiary care hospitals?
Mr. Alvarez: Yes. In fact, I believe Ontario has one of the most advanced telehealth networks in the world. There is no question.
Senator Eaton: Are there others?
Mr. Alvarez: Yes, Manitoba and British Columbia.
Senator Eaton: Quebec?
Mr. Alvarez: Absolutely. Through our investments, there is a lot happening in Quebec. There is tele-wound care. People are being treated in their homes, in many cases by clinicians who are remote. We just started a pilot project among three provinces — Ontario, Manitoba and Newfoundland — where they are doing tele-pathology. They are now doing quality assurance on reading the pathology slides. It is really starting to improve things in relation to work flow and backup.
In terms of reading some of these images, pathology was a big issue. We have had this problem in Canada. This is an example of technology being used to solve that type of issue.
Senator Merchant: Thank you very much for your presentations. I am puzzled by the reported lack of acceptance on the part of the professionals regarding the sharing of information. I believe that a challenge facing the EHRs is the low adoption rate by health care professionals. In 2009, the Auditor General of Canada mentioned that Canada Health Infoway does not report on the adoption or use of completed systems by health care professionals.
Will Canada Health Infoway report on the adoption and use of EHRs by health care professionals? Do you see the low adoption rate of EHRs by health care professionals as a potential risk to the initiative? What incentives or strategies could Canada Health Infoway develop to increase the adoption rate of EHRs by health care professionals?
Mr. Alvarez: Those are excellent questions. In terms of publishing adoption rates, we started doing that in 2010-11. It is in our annual report. We can tell you today that we have 19,000 users of EMRs. We have 43,000 users of diagnostic imaging. We have 30,000 users of drug information systems. We have about 35,000 users of EHR systems. We are publishing that information.
Your next question is a question about low adoption rates. Again, you can take horses to water but sometimes it is difficult to get them to drink. We are seeing the early adopters and clinician leaders embracing these systems, but it is somewhat worrying and I will tell you why. Alberta started with their EMR program years ago. After seven or eight years, they hit a wall. Between 57 and 60 per cent have adopted it. The rest have not. It is not a matter of money. I assure you of that. It is a matter of culture. It is about changing what you have learned in medicine school many years ago. You are used to using paper and all of a sudden your workflow changes, your productivity drops until you get the new system, and there is a fear of learning new things. Occasionally I hear from clinicians, "I will retire in five years, six years, seven years time; I cannot wait for this to pass, I will not switch." That is a concern.
Your last question is about incentives. The first incentive is to get clinician leaders to work with others in a peer to peer group. We are doing that across the country. Provide as much support as you can to clinicians to adopt this, showing them the value it will bring to them and their patients. You cannot do enough of that.
Ontario was later than Alberta in getting their EMR program started. They caught up to them. Why? They changed the structure. They created family teams and they had requirements that could not be done without a computer. The family teams had nurse practitioners and everyone had to be singing from the same hymn sheet. There is a lot for solo practitioners out there who do not need to share their information.
There is a whole host of cultural and structural issues of why adoption could continue to be a struggle for a while. We are continuing to go up stream. We are funding and working with medical, nursing and pharmacy colleges to put this into their curriculum. The students coming out will not have problems with technologies but, they need to know how to work with medical records, decision support systems, et cetera. When they come into practice, they will not practice any other way.
Senator Cordy: This is very interesting. We know there are some EHR projects that have been completed, but they are not up to the standards for national dissemination of information. You spoke about it from a national perspective, Mr. Maxwell. We have heard on this committee that it is from province to province, but we have also heard it is within provinces. We also heard one doctor who said he could not communicate on his computer from one part of the hospital to another to send something. In Nova Scotia, I had an X-ray done on Monday morning. By the time I had gotten home from the hospital, my doctor phoned, said she already received the email copy of my X-ray, and I was to do X, Y and Z. It is working and from a cost and time management perspective, it is much more effective.
The cost of maintenance and operation of the electronic health record system is provincial and territorial. Is this having an effect on why provinces and territories may not be upgrading? What is the reason?
Mr. Alvarez: I just want to deal with this question on a more fulsome basis in terms of standards. A lot of the issues were also raised by my colleague in his opening remarks.
You are right. Not long before we got started, they could not communicate between floors in a hospital, and patients had to repeat their history over and over. Generally that has gone away and is happening now. Hospitals across the street could not communicate with each other.
Canada Health Infoway's mandate was pan-Canadian standards. You have to start where you bring the most value, which is where patients are going for their treatments and areas they are moving around.
What we have done is developed a series of standards, including messaging and data. We will not fund anything unless they use our standards. You can then start to connect the many points of care at a local level. If those standards are used in many parts of the jurisdiction, you will be able to connect them, just like your diagnostic imaging in Nova Scotia.
Today in Nova Scotia, you can have your X-ray done in Cape Breton, be done in the QE the next day, and they will be able to pull up your image because of the standardization.
Once those standards are used in different jurisdictions, there is no reason why you should not connect. However, it is not as easy as that. Alberta had their lab systems in place and we did not fund those lab systems. They did not use our standards because they were not in place. At some stage they will need to get around to upgrading the systems. When they do that, they will upgrade the standards.
It is not absolutely perfect but where there is a real practical need — like sharing telehealth images or diagnostic images we are talking about — we seem to have gotten over that and provinces have come together to share that data.
While it is not perfect, we will start to see that coming.
We are looking at new strategic plan between now and 2018. We will take into consideration some of the joins we have to make and the lowest cost alternative. The next thing on the horizon is consumer health records. Many of you are from out of town, and there is no reason why you cannot have your histories if your clinician has them.
Right now in B.C. clinicians are getting lab results and they are being sent to the patients at the same time. There is no reason you should not have that. If you have that, you can make it available with full access to whoever you want. It is not a matter of two clinicians having to work about how their systems communicate. You can basically make it happen. That is the direction I see us going.
Senator Seidman: I would like to continue to pursue this particular line of questioning, particularly the lack of progress being made in national compatibility. At this moment, I am looking at a CMHA piece that came out as recently as October 18. It seriously criticizes Canada's efforts in making any headway in a nationwide electronic health records scheme.
I think all of us are very aware, and hear almost daily criticisms within our provinces. How do you see headway being made in overcoming issues related to compatibility across the country?
Mr. Alvarez: As I said earlier, whilst compatibility across the country is important, what is more important is compatibility at local levels and within a jurisdiction. Clearly, progress is being made. We have got life examples of children being injured in the North — where they do not have a radiologist or neurologist — and images are being read in Nova Scotia. Then, in a conference, neurologists in Edmonton also reading the images they are able to advise attending physicians in Whitehorse or Yellowknife. I gave you the example of tele-pathology happening within three provinces. There are many aspects of compatibility happening across the country.
Is there compatibility when someone from Toronto goes skiing in Whistler and breaks their leg? The answer is no. We have not gotten to that stage. Ontario has not finished their program, and B.C. is still working on some of the aspects of theirs. However, that will come as well. Will it come from the point of view of connecting these two clinicians? Perhaps, but my sense is it will come with empowering the patient to have access to their own record, probably via the Internet, and making it available to the attending physician.
Senator Seidman: I am not sure we are getting at the answer. There has been serious criticism that we are spending all our money on IT development, and to information technology companies developing software. We are not spending money on facilitating a system for physicians and patients. Would you try to address that question?
Mr. Alvarez: Thirty per cent of the funding we provide to jurisdictions goes to change management. As I said before, there is a huge change management issue. We have many peer to peer groups, clinician reference groups, clinician peer groups and a clinical council. A lot of effort is going into the change management effort. It is not a matter of technology. A lot of the areas that have failed in the world have looked at this as a technology problem. It is not a technology issue, but a people issue.
Senator Seidman: That was the point I was making. Are we giving too much money to IT companies and not on trying to understand what we need in Canada for the sake of a patient-centred system?
Mr. Alvarez: Our priority is basically on change management, but you do need the tools, hardware, and software. It is a world market in terms of hardware and software. As they go out, every single jurisdiction goes to a major RFP. They have clinicians involved in the selection. A lot of tools and the take-up of the tools will be based on usability. Will clinicians use it? Will their work flow change and how will it change? Will it be easy to use the tools? A lot goes into usability rather than, "Here is piece of software. Go figure out how to use it." That is not the case.
[Translation]
Senator Verner: According to information provided to us, there are significant differences between Canadian jurisdictions in the implementation of electronic health records. In your opinion, is this due to a lack of funds in some provinces, to technological reasons or to a lukewarm support by the medical profession?
We have heard many things up to now, but it seems to be difficult to accurately pinpoint the reason for this situation. According to available data, Alberta and Prince Edward Island, for instance, are well ahead while Quebec is a long way behind the others.
[English]
Mr. Alvarez: Let me answer this question this way: All provinces started from a different point since 2004. Alberta was already further ahead in the journey. There are a few reasons why the country is at different levels. Number one is political will. Is this a priority for the province or not? Ralph Klein said that by the end of 2008 all Albertans will have technological records. It happened in 2009. Keeping this on the front burner is important when there are other raging fires in health care. Number two is the size. The larger the province, the more difficult it is. If you are not structured in some sort of regional basis, the tougher it is. The more points of care and providers you have, the more difficult it is to get them all on the same page.
Ontario and Quebec are making progress, but are not as advanced as Alberta. In many cases it is because of size and because of the structure.
Senator Martin: I feel very passionate about this topic because, as a daughter to ailing parents with a father who is in between two health authorities, I directly experience the challenges of trying to ensure that information was properly passed on to the next health authority. I live between two authorities within Vancouver. I live closer to this hospital but I know if I go here, when my father gets transferred here, it will be an uphill battle to try to get that information transferred. In my opinion, I have not seen the sharing of information and medical histories conducted as effectively as I would like in this day and age.
My first question is regarding the technology. Technology is effective when it is user friendly, when there is good training of the individuals who will be using it and when there is follow-up from the producer or the creators of the technology. It might take too long to explain, but when you work with clinicians or institutions, can you talk about the kind of thorough follow-up you do or how you implement this system to make it user friendly and effective and what challenges you have been met with? Surely with $2.1 billion, like you say, it is not an issue of funding. There has been plenty of investment. How user friendly has this technology been to the health professionals using it and what thorough follow-up is done through your organization?
Mr. Alvarez: Let me start by being clear about our role in life. Our role in life is not to go into hospitals. We basically fund and have some requirements. If you are in B.C., the work will be done in B.C. They will basically fund the project. They will contract for the project, and they will do the implementation.
That said, let me take electronic medical records as an example. Because of the kind of work that needs to get done with clinicians to get them on side, get them trained and supported, we will not fund a project unless the government has come together with the medical association and created a program that basically shepherds how physicians get trained, how they select the product and what the follow-up care is. It is a dedicated program. Right now, we have about six or seven in the country. We have not provided the rest with any money because we are still waiting for them to form that program providing that support, and I can speak for my jurisdictional partners, whether electronic medical records and drug information system or diagnostic imagining.
Let me give you an example of diagnostic imaging. I know this for a fact. There was a clinician, a specialist, who liked his X-rays and did not want to move to the computer and digital because he said he can put his X-rays in a light box and then draw on that light box. They said, "Here is the screen. Your digital image will come up. We will give you a clear plastic and you can draw on the clear plastic." He did that for about two weeks, then threw the clear plastic away and started using the computer. It goes back to the aspect of change management. Canada has learned from others who have gone before us that this is not a technology issue. This is a people issue. If you do not work and support clinicians in using this, and many times that is support by other clinicians, you will not get that level of adoption.
Senator Martin: That you for that clarity. I do not want to use the word "enforcement," but in order to ensure the accountability of the users when a program is funded, are you able to look at whether standards are being met? If a system is already in place, you said that is something beyond your control or that you are not looking at it because it is already in place. For those things that are in place, is it just those jurisdictions? Who would be tasked with ensuring that those standards can be equal to or closer to bridging with the system or the EHR that has been implemented? How do we bring those standards up? Who measures the other existing systems?
Mr. Alvarez: Everyone is now aware of what systems are compatible and which ones are not. We publish it in our annual reports in terms of which ones conform to the national standards and which ones do not. Typically, the few that do not are systems that have gone before. Jurisdictions are aware of that. They are committed to meeting national standards, but it is a matter for them of priorities.
Going back to your earlier question, Mr. Chair, I talked about a bit about aspects of our funding and that it flows differently to federal funding. Our worst nightmare is the line basically that we build it and nobody comes. As we do not have control in terms of getting the adoption, we give them 20 per cent of the funding up front once the contract is assigned, we give them 30 per cent when the hardware and software is in, but we hold back 50 per cent based on targets of usability and adoption. Jurisdictions have to work hard in getting that level of adoption, because from where we sit at the centre, we cannot do that. It has to be done at the local level. If you do not get the adoption, we do not spend the dollars until they do get the adoption.
The Chair: This is a significant question. Senator Martin is getting at the example of existing technologies and compatible technologies and so on. Perhaps you could follow up by giving a couple of examples and show the challenges you face in this area and the authorities you have to move that forward, and perhaps an example or two of how it has worked and a good practice example. If you can think about that a bit, could you follow up after our meeting some time with a written submission on that?
Mr. Alvarez: I will do that.
The Chair: I want to follow up on this general aspect. A number of my colleagues have been asking about this, and I think we are finding the answers just a little bit difficult to jive with some of the witnesses and testimony we have heard to this point. If I have heard you clearly, I think there may be a meshing issue that we have not brought out clearly enough to explain the discrepancies between the reporting of practitioners and what you are presenting to us today. For example, I will go back to the example one of my colleagues used, where we heard from one practitioner who very clearly stated that if he could only get the medical record evidence from other areas of his own hospital system, he would consider that a major victory, forget about getting it from Calgary to his centre. Yet, we have heard from you how a radiologist can get access to a record that occurred in Cape Breton this morning in Halifax this evening. It strikes me there are two different things here. The digitalization of X-rays is a straightforward technology. I am not saying it is simple to do it, but it is. The transmission of that is very much like getting an email with an attachment, and away we go. The medical record of a patient is not so simple. It is the document that is carried perhaps on a computer by an individual doctor or even a specialist in a given hospital. Now, it may be that that the next specialist who needs to look at the radiogram can get that quickly by pressing a button on his or her computer, but how that relates to the underlying medical condition of patient, the record of which is housed over here in a completely different set of software and on a completely different computer, is not occurring as fast as we would like it.
Very clearly, there is a discrepancy between the percentage of adoption that you are reporting to us today and what the actual practitioners are telling us. I wonder if it is not this issue of the difference between the individual patient's medical record versus the ability to transmit, on the one hand, and the actual transmission of things like X-rays, and so on, which is more specialized. Could you help us there?
Mr. Alvarez: The issue here is who you are speaking to and where they come from.
If you speak to a clinician in Alberta or in P.E.I. or a pharmacist in B.C., you might get a completely different answer than if you speak to a physician in Ontario. In Alberta, no matter where you are, they can pull up your electronic health record, which would be your diagnostic imagining, your medication histories and your lab results, at a minimum. There are reports attached with that as well, which is basically the basics of an electronic health record.
If you go to B.C., and we have had it for many years, no matter which pharmacy you go to, they will have your entire medication history. They will not have your lab results, but they will have your entire medication history. B.C. is now in the throes of making lab results and diagnostic available as well. If you go to Ontario, they have drugs available in emergency rooms for seniors. They have not got all drugs or all people as yet. That will be a little while coming. They are making tremendous progress on diagnostic imagining and being able to share that around, and they are certainly starting to make a lot of progress on laboratory results and bringing that in as well.
It really depends on which part of the country you talk about. When I talk about a 50 per cent figure of available data, I am talking about the systems that have lab results, diagnostic imagining, medication histories, client and provider registries, because you have to identify the individual uniquely and the provider uniquely. I am talking about 50 per cent of those data repositories being available across the country. As I say, in some parts, 100 per cent are available. In others, there is a lot less.
The Chair: I will leave it at that. I do think what we are hearing is that this is an issue of the next accord that is of considerable importance.
I would like to get the questions from the second round on the record. I will ask my colleagues to pose their questions and to have you follow up with the answer. The clerk will provide you with the question so you do not have to write it down. Would you agree to do that?
Mr. Alvarez: Sure.
Senator Eggleton: Picking up on your comment, Mr. Chair, what would you suggest the federal government should put on the table for the next accord as an incentive to move this agenda along in terms of electronic health records, and what are the roadblocks to electronic prescriptions and how do we move that along too?
Senator Cordy: Mr. Maxwell, you spoke about the differences not just in technology but the differences of provincial and territorial laws that we have specifically regarding privacy. Of course, you have talked about people moving from one part of the country to another. Certainly from Atlantic Canada we have a lot of people working in Alberta and flying home every two or three weeks. Going back to Senator Eggleton's point, you said it was $10 billion to get a national plan. Should that be part of the next health accord, or does an accountant answer that kind of question?
Mr. Maxwell: I will be glad to respond to that in due course.
Senator Braley: I see a lot of information on the big picture. I see a lot of information on the items that are part of it from the top down. I do not see very much in solving a lot of the problems in manufacturing. You start with the gathering of the live data, and hopefully there are no mistakes in it. You deal with it going up the chain. Has lots of work been done in that area with simple systems?
[Translation]
Senator Verner: Going back to the question I asked which colleagues here answered, I want to ask the same question but more specifically to the Office of the Auditor General. What is your view on this matter? What do you think of the differences between jurisdictions in the implementation of electronic health records?
[English]
The Chair: We will certainly look forward to your response to these specific questions. On reflecting on the issues you have encountered today, if you have additional input, we would most welcome that.
My observation from what we have heard here today and earlier, repeating my earlier comment, is that this is seen increasingly as an exceedingly important part of delivery of health care in the modern context, and particularly to the patient's preferred location for receiving health care, which is often in the home. The direction we are moving in is in order to be able to give complete patient care in one visit as opposed to multiple visits. All of these are extremely important factors in terms of not only the perceived degree and responsible treatment on the part of the patient but the actual, real delivery of just-in-time medical practice across the country.
If you have further reflections on this general aspect, we believe that this is likely to be a very important issue going forward, and I am sure you do too, since that is where you are, and we would certainly welcome additional insights that either group may have with regard to those issues.
With that, I again want to thank you for responding so clearly to my colleagues. I thank my colleagues for their questions.
(The committee adjourned.)