Standing Senate Committee on Social Affairs, Science and Technology



OTTAWA, Thursday, March 9, 2017

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 10:30 a.m. to continue its study on the role of robotics, 3D printing and artificial intelligence in our health care system.

Senator Kelvin Kenneth Ogilvie (Chair) in the chair.


The Chair: Welcome to the Standing Senate Committee on Social Affairs, Science and Technology.


I'm Kelvin Ogilvie, from Nova Scotia, chair of the committee. I will start by asking my colleagues to introduce themselves, starting on my right.

Senator Seidman: Judith Seidman, Montreal, Quebec.

Senator Stewart Olsen: Carolyn Stewart Olsen, New Brunswick.

Senator Raine: Nancy Greene Raine, from British Columbia.


Senator Petitclerc: Chantal Petitclerc, from Quebec.


Senator Hartling: Nancy Hartling, New Brunswick.

Senator Merchant: Good morning. Pana Merchant, from Saskatchewan.


Senator Cormier: René Cormier, from New Brunswick.


Senator Meredith: Don Meredith, from Ontario.

The Chair: Today we are continuing our study on the role of robotics, 3-D printing and artificial intelligence in the health care system. So far, the committee has heard from federal research agencies, technology futurists and individual researchers. Today we are going to hear about two of Canada's centres of excellence involved in innovative research in these areas.

Because there was no absolute preference, I will call the witnesses in the order in which they appear on the agenda. That means I will start with Dr. Alex Mihailidis, Scientific Director and Associate Professor, AGE-WELL Network of Centres of Excellence Inc. Please proceed, doctor.

 Alex Mihailidis, Scientific Director and Associate Professor, AGE-WELL Network of Centres of Excellence Inc.: Mr. Chair, honourable senators and other members of the committee, I'm here today as a representative of AGE-WELL, which stands for aging gracefully across environments using technology to support wellness, engagement and long life.

AGE-WELL is Canada's technology and aging network funded by the Canadian government and our partners to ensure Canada remains globally competitive in this field, specifically in the areas of robotics, artificial intelligence and other advanced technologies in the care of our aging population.

AGE-WELL is a network of centres of excellence or NCE, as you just heard. We have over 140 industry, not-for-profit organizations, government, care providers, end users and academic partners. Our network also brings together approximately 150 funded and affiliated researchers from 33 universities and research centres across Canada.

We work closely with older adults and caregivers who over the course of my career and throughout the development of AGE-WELL, have provided invaluable insight, expertise and purpose to our work.

The aim of AGE-WELL is to help current and future generations of older adults in Canada to enjoy the best quality of life possible. We do this by developing technologies and services that increase their safety and security, support their independent living and enhance their social participation.

I commend the Senate for embarking on this study. My remarks today will focus mainly on home health care, but many of these technologies may have implications for direct and indirect patient health care as well.

What is the challenge? This is the key question AGE-WELL has been trying to identify. We know from work with older adults and caregivers that there is a growing expectation for technologies to be integrated seamlessly into our daily lives. Older adults and their caregivers are becoming tech savvy and a computer in everyone's pocket is no longer enough. Technologies like wearable devices, smart homes and mobile robots are entering the marketplace and the community at increasingly rapid rates. These are significant emerging markets on a global scale and Canada is at a critical moment where we often see a gap between the innovation of technologies, practice and decision making. AGE-WELL is actively working to close this gap through transdisciplinary research, training, partnerships, knowledge mobilization and the commercial development of our technologies.

Many older adults face complex health issues and daily challenges that result in their not being able to remain independent in their own homes and communities. These are often referred to as wicked problems that require more complex and personalized solutions that often go beyond the traditional boundaries of health care systems. Keeping people out of expensive hospitals and long-term care as long as possible is win-win scenario with obvious benefits for seniors, caregivers and the health care system.

I will now talk a bit deeper about the role of artificial intelligence or AI. AI-based systems can provide solutions that are personalized to an individual's needs. This is crucial given the diverse population of older adults in Canada, including those experiencing dementia. I have often heard from seniors in our network. They say to me, “Alex, if there is one message to get across it is when you've seen one senior, you've seen one senior.”

Here are three examples of AI-based technologies currently being developed by AGE-WELL investigators. The first is using AI-based systems in smart homes. These are new sophisticated technologies that address various aspects of daily living. These technologies allow Canadians to remain independent longer and age in place at home and in their communities.

As an older adult walks into their smart home, there may be a floor tile that collects vital signs such as heart rate and blood pressure. They may have an intelligent mirror that helps with tasks such as washing their hands and brushing their teeth.

Motion sensors can detect falls and connect the older adult to a family member or emergency services. These sensors can even collect long-term data and provide useful trends on patterns of daily living. For instance, after monitoring a person for three months in one of our projects we can predict the onset of dementia with approximately 85 per cent accuracy using AI technology.

A second example is the use of cognitive computing, a type of AI to create a tool for family members that allows them to better search for the products and services they need. Think of it as a personalized search engine that takes plain language descriptions and finds solutions that take into account the unique needs of older adults and caregivers.

The third example is AGE-WELL's development of intelligent scooters and power wheelchairs. Using intelligent control technologies that will compensate for a user's limitations, individuals can become more mobile in their environment and continue to navigate their environments without harm to themselves or others sharing these spaces.

These are all examples of integrating AI into the lived environments of older adults and their caregivers. We can also introduce robots into these environments.

As the cost of building technologies decreases and the popularity of 3-D printing increases, robots are becoming a more viable solution for supporting older adults. These advances will not only impact individuals who need assistance but will also have implications in the workplace and may be able to address the labour and skills shortages of the future. Older adults and caregivers will need to adapt to new patterns of working and living once these technologies are in place. With advances in the field of robotics, many of which you heard from in previous testimony by Dr. Goldie Nejat, who is part of AGE-WELL, we need to understand the role of robots and what applications will be important to assist older adults while keeping costs down.

Robots that can pick up heavy objects, transfer people on and off the toilet and perform other physically complex tasks are unlikely to be feasible anytime soon. However, robots will be able to provide cognitive and emotional support and help older adults stay healthy, independent and living at home.

AGE-WELL investigators are creating mobile assistive robots that can remind older people who have cognitive impairment of the steps involved in daily tasks like preparing meals, doing exercises and taking medications. These robots will also provide cognitive support through brain training memory games. Telepresence is making remote medical visits possible through robotics as well.

I would like to close by saying that no matter the solution, we need to understand that these new technologies are only tools used by caregivers and others to supplement and support the care they are already providing. They are not replacements. They cannot be seen as replacements for the human touch that is needed in caregiving.

AGE-WELL is studying the needs of older adults and caregivers and the broader policy and regulatory environment for implementing these technologies. Investigating the ethical, cultural and social aspects of introducing new technologies and issues of access are key projects in our network.

Finally, we are also working on the creation of innovation hubs that tackle the complex challenges at the intersection of aging and technology across Canada. These hubs are bringing together local partners in expertise and skills to create solutions to some of the wicked problems facing health care and our seniors.

This is an important moment in history, with an opportunity to push innovation forward and help older adults to age in place. AGE-WELL will continue in our mission to position Canada as a global leader in development of technologies for healthy aging.

The Chair: I will now turn to Dr. Mehran Anvari, Scientific Director for the Centre for Surgical Invention and Innovation.

Dr. Mehran Anvari, Scientific Director, Centre for Surgical Invention and Innovation: Good morning, senators. Thank you for the invitation. My remarks are a bit less formal. I am a professor of surgery at McMaster University and hold a chair in surgical innovation. I have been working in the field of robotics and surgery for over 20 years.

What originally attracted me to the field of robotics was to deal with the primary problem of improving access for Canadians who live in very remote parts of Canada. After a trip to Nunavut I realized that even though on paper people have access, the access for many Canadians comes at the cost of travelling thousands of miles.

We successfully used robotics to perform remote telesurgery almost 12 years. In 2003, my team and I performed a number of very complex surgeries on patients in remote northern communities in Ontario. They needed to undergo surgery but would have otherwise had to travel south to Toronto and Hamilton. This showed that it’s feasible to use robotics to improve access.

What followed after were significant research and the realization that all of our research will not have an impact on Canadians until and unless companies decide that there is a commercial market for it.

That was a hard lesson for a scientist like me to learn. I was really glad when the Government of Canada introduced the CECR program in 2008. Because we were successful in getting that, I have seen many ideas and IP, intellectual property, generated as part of that quite remarkable research. It is still leading in the world and in various science books around the world although it is not in reality because of the commercial thing. We are now able to take some of those ideas.

Our CECR, the Centre for Surgical Invention and Innovation, has the primary aim of developing a novel intelligent generation of medical surgical robotics with the direct aim of improving quality and access to surgical and interventional procedures for Canadians and people around the world.

Our systems aim to provide improvement for patient care by allowing the skilling of the procedures, allowing more targeted and accurate performance of procedures and by improving access. Every procedure and every system we develop can be teleoperated. A physician from a remote area can operate and perform procedures on patients at a completely different distance.

It will also improve health care by reducing the steps in every aspect of our health car. We cut out the inefficiencies introduced at every step. Our first system that's being commercialized is for early detection and treatment of breast cancer in high-risk women. Anyone who has gone through that will tell you how many steps there are from screening to diagnosis to treatment.

Producing something which can perform a one-stop, see-and-treat procedure both in diagnosis and treatment would save not only a significant wait from the patients’ perspective but would also cut out interventions leading to a potential surgical solution from the assistance perspective.

Our centre is working with MDA, Macdonald, Dettwiler & Associates, Canada's preeminent robotic manufacturer which has been in the field of robotics for almost 30 years, producing space robotics like the iconic Canadarm and others. This has always put Canada on the map. We are using many of the same technologies now in the surgical field of health care. The combination of our CECR with MDA has been successful in developing systems now to a commercial end.

In my presentation I included a little imagine of my own road, realizing that the research we do at universities at TRL 1, 2 and 3 has a long way to go to commercial. Until you get to the market at technology readiness level 9 you will not impact patient care.

The government supports research. It also needs to support all steps necessary to get that research into the market because without that we won't make impact in patient care.

We are hopeful. We have created a start-up with MDA to take our first system to commercial success. We have a number of systems that will tackle early detention and treatment of other cancers, particularly prostate, kidneys, lungs and liver.

I do believe that robotics and cognitive computing are here to stay and will have a significant part to play in improving our health care. Particularly in a country like ours with a vast surface area with remote areas it is almost essential. Without this we will not be able to maintain our precious health care the way we want to.

The Chair: I will now open the floor to questions from my colleagues.

 Senator Stewart Olsen: Thank you, gentlemen, for being here. It's fascinating. I have two questions, one for each of you. I think it is quite a challenge under the AGE-WELL system, but I'm wondering if the provinces are involved in your network and how much of an uptake they are giving you. Do you sense they are willing to pay the money for these innovations?

If you had a top 10 for the smart home, what would be the most useful thing that's being used?

Mr. Mihailidis: In terms of provincial uptake a critical aspect of our AGE-WELL network is to develop partnerships with each and every province to ensure we can leverage our resources as much as possible and to ensure they are willing to look at innovations coming out of our network.

I should mention that our innovations are not just technologies. They are also the services, the policies and the service delivery models required in order to get these technologies into the health care system. This is a key aspect we are working on with the provinces.

A good example, as I mentioned in my opening remarks, are innovation hubs that we are developing across the country. One of our first ones will be launched with the Province of New Brunswick. We're looking specifically at a hub around policy as it applies to technology in the health care system for seniors. This is something the province has significantly come on board with and is working with various partners to ensure that happens. We will do similar models across the country as well.

In terms of the top 10 smart homes, from my own research and the research we are doing in the network we see applications around people with dementia as being very viable and existing right now. We are already seeing technologies that are allowing people with dementia to remain in their own homes longer and safer, because the smart home is providing reminders of the various activities they need to complete. These may be anything from washing hands, brushing teeth, preparing a simple meal to taking medications. We are seeing significant increase in the uptake of technology in that type of application.

Those activities may seem to be simple ones that we are addressing. However, when you talk to family members about the big issues, the wicked problems they are facing and why they are not able to return to their jobs because they are providing constant monitoring care, it often comes down to the basic activities of daily living they are providing, monitoring , prompting or reminding. If we have technology to do that, it will solve that issue.

From a caregiver's perspective of returning to work smart home systems are having a significant impact as well. Individuals are able to return to their workplaces and use the technologies they have set up in their loved one's home to monitor and ensure they are safe and secure and completing activities. We will see an increase in that application as well from the caregiver's perspective.

We have been hearing from workplaces and insurance companies: “How can we provide this technology as part of a benefit package?” No longer are you getting medical and dental but you are also getting access to caregiving technologies that will allow you to become a productive part of the workforce once again.

 Senator Stewart Olsen: Dr. Anvari, you mentioned surgical innovation when doing surgery in remote areas. Can you tell me how that would work? Do you have a robot there or are you instructing via teleconferencing a doctor who is there? How does that actually happen?

Dr. Anvari: You actually have a robot there that is operated by an expert at a distance. To set up the robot, you may have a nurse or a less trained physician who can actually do that.

In the regional surgeries I was actually performing complex surgery with a local surgeon who had not performed any of the operations but could set up the robot and be there. He was being trained in the midst of it. With the current systems it's simpler. We have automated many of the steps so radiologists anywhere can operate it at a distance. We are going to do a demonstration between Hamilton and Quebec City where a patient will undergo a procedure by a physician thousands of miles away.

The next level is autonomy. We are now working with IBM's Watson to incorporate that so that the robot can actually make decisions. Each of these steps will hopefully reduce patient need to travel. Right now patients often have to travel to get to expertise. What we want to do is to be able to bring the expertise to the patient.

To add to what was asked earlier, in my own field provinces are very supportive of the idea because they can see how it can help them. The problem often comes later on when you actually have a company which now has to sell because procurement in medical systems in Canada is very complex. This is an area about which I hear from companies.

We have received an ample amount of support at the provincial and territorial levels in Quebec, Ontario, Northwest Territories and Nunavut. They are all keen to support this early phase of developmental research.

When the company starts they have to go through procurement, which is very complex in the medical field. That's often where they hit roadblocks. We should somehow address this. Frankly, what we have seen is that a lot of the innovative companies that Canada has produced have had to migrate south of the border to become commercially successful, which is an unfortunate reality, because they can sell their products more easily.

Senator Seidman: Thank you both very much for your presentations. I have a question for each of you, if I might.

Mr. Mihailidis, in your presentation you identified AGE-WELL as a network of centres of excellence. It has been our experience at this committee in many studies we have done to hear the challenges associated with centres of excellence, let alone Networks of Centres of Excellence, in terms of many competing demands, silos and other various things.

You say you have over 140 industry, non-profit organizations, government, care providers, end users and academic partners. It is a large number of organizations, groups and people under one umbrella. How do you set priorities for development? Have you been reviewed to assess effectiveness or successes in moving to commercialization?

Mr. Mihailidis: In terms of your first question, all of our priorities are essentially set from the bottom up, and that is from our stakeholders. Even in the preparation of the application that went into the NCE program three years ago, we did what we called cross-Canada knowledge cafes where we invited seniors, caregivers and other stakeholders to come to us and say, “These are our problems and this is what we feel technology can solve.” We continue to do that on a consistent basis. We continue to go back to our stakeholders and advisory groups to ensure we are hitting the right problems.

This has continued to be reviewed throughout our structure, right up to our board of directors. On our board we have several agencies, health care providers and other key stakeholders representing their organizations and their specific interests, not only to our board but to our entire management structure.

We try to maintain the involvement of our stakeholders as much as possible. This is ingrained into the projects themselves. We will not provide any funding to any project unless their stakeholders and partners are involved and have some skin in the game, whether that's industry, government or not-for-profit. Whoever it may be, they are putting something into the project, whether it is money, expertise, their time or whatever it may be.

This has been important for us. Because of this all of our projects have been grounded in real-life problems. We review the projects on a yearly basis. If we see that notion has been lost, funding will be cut to that project or we will work with that project and those investigators to ensure they are getting back on course and listening to the stakeholders themselves.

For example, we also do calls for new projects from time to time. These are small catalyst projects, as we call them. These are new research questions and projects around knowledge translation and commercialization that we fund. When we set the calls for these things, we go back to stakeholders and ask, “What are the key things that are now affecting you?” Last year, the resounding answer that came back from all of our stakeholders, including our industry partners, was technology to help seniors remain in the workforce. We did a specific call asking for projects only in that particular area, and that's what we funded.

Senator Seidman: I would like to follow up on the second part of that question, which I'm not sure you answered, that has to do with how you evaluate for effectiveness and success and if that has actually happened.

Mr. Mihailidis: We are developing a framework. You heard that from my colleague when he mentioned the technology readiness level scales, or the TRLs. We have adopted that and modified it for our own purposes because we are not just developing technology. We have developed an evaluation framework based on that particular scale, plus some additional measures required by the NCE program.

All of our projects are measured on a consistent basis. That includes indicators around commercial success but also around knowledge translation and knowledge mobilization. We are not just about commercializing product but about getting knowledge and information out there as well.

These are requirements of all projects. We are only 18 months in. We are still developing the framework. We are still waiting to see additional commercial successes come out of our network. However, in our first 18 month we have had two start-up companies that AGE-WELL has supported and funded. One was in the area of intelligent wheelchairs, called Braze Mobility, and the other one was in the area of dementia diagnostics using artificial intelligence, called WinterLight Labs.

The way we have essentially measured their success is through the amount of investment they have been able to garner and the amount of leveraging they have been able to do, based on funding we have given them. Both have been quite successful. One company has gone through another series of fundraising from VCs, which we obviously consider a great success. The other one has started to receive orders already, in particular from the U.S. and from Canada. We use that as a measure of success as well.

It is ongoing process. It is evolving. We have been working closely with our other NCE partners and NCE itself to develop these evaluation frameworks. We expect that over the next year or so we will start to see more indicators come out.

Senator Meredith: Thank you both for your presentations. I have a quick supplementary question for you, Dr. Anvari, with respect to the Senator Stewart Olsen's question about operations from a distance and how you eloquently explained that.

How do you deal with the connectivity issues with respect to technology? I think that is very vital in that certain areas do not have connectivity, especially in the North. Please explain that for me, and then talk about commercialization and what it is going to take to get us to the full commercialization of some of your products.

Dr. Anvari: One of the reasons we have moved toward automation and autonomy is that you now need fewer commands. In the telesurgery I did on patients I had to have to triple redundancy in case the line went because I was in control of the robot and performing the procedures. Now that it is automated, you plan the procedure and the system does the procedure based on what you planned. Once that planning is done and the system starts working, pre-planning has already gone into it. Autonomy now allows the system to actually make minor changes to its direction based on findings. Each of these steps will make these capabilities better.

I totally agree that the reason we could not do telesurgery in Nunavut was that they use microwaves for a long portion and anything flying through would affect it. In many places if you use satellites, the time delay or the latency would make it difficult. That's why we moved from teleoperability to automation and are moving toward autonomy.

If I may say, from our centre’s perspective we have a much simpler paradigm because we work with one major Canadian company and a half-dozen related companies. As a clinician, the success I look at is if we actually positively impact patient care. Everything else about economic growth, start-ups and commercialization is important in that road toward patient care at the end of the day. However, what has always allowed our CECR to say what solutions we want to bring to the market? Where can we make the most impact in quality of care in our climate?

You also have to take into account that there are many areas in which you can move forward, but you have to bring the regulatory agencies with you. The FDA, Health Canada and NCE are having a hard time with automation, let alone autonomy. It's a journey that you have to take with these regulatory bodies to understand where you are moving to. They are coming along. I am hoping this paper will allow them to explore these areas because the technology is certainly moving faster than the regulatory requirements. I think we need to be moving as fast.

We could have autonomy right now, frankly; autonomy is not so difficult. The reason we don't have it is not because we can't create an autonomous system. It's the fact that it will not get any regulatory approval at this stage. We have to get there.

In automation with pre-planned procedures the system can actually make a diagnosis based on algorithms, but we allow that to occur by the physician who plans the procedure and the system does it.

Mr. Mihailidis: I want to add one point to the aspect of commercialization in this area. We have two very different fields we're looking at here.

In the area of technology and aging one significant thing we need to look at is the way we commercialize these things and the service delivery models of these technologies. In looking at the technologies that are being developed for seniors and caregivers, not only in AGE-WELL but really around the world, the majority of these are not medical devices. They do not need to go through the traditional health care channels and the typical regulatory aspects that a medical device or surgical robot would have to go through.

A lot of these can be considered consumer products. They should be technologies that you could go to your local big box electronics store to purchase and install for your loved one or for yourself, if you have that capability. We are starting to see that trend more and more. More caregivers are coming to us and saying, “I went to an electronics shop on the weekend and bought some sensors and a little microprocessor and built my own fall detection system.”

This is going to be a growing trend, especially in the area of technology and aging and in the assistive technology field in general. Looking at new ways of commercializing and service delivery, outside of the traditional routes we've been thinking about in this group and others, will be really critical in order to ensure success in our field.

 Senator Meredith: Mr. Mihailidis, you mentioned in the closing part of your presentation investigating the ethical, cultural and social aspects of introducing new technologies and issues.

My question is for both of you. Dr. Anvari, you talked about the autonomous robot doing the operation. How do you deal with the ethical issues related to embracing these new technologies? I would like your comments on that, please.

Mr. Mihailidis: Within AGE-WELL we have a whole theme or module looking at the ethics of introducing these types of technology, in particular introducing robotics and smart home systems with potentially vulnerable users such as people with dementia.

We have researchers, projects and other outreach programs that are looking specifically at those questions and trying to understand how to incorporate these types of things into the work we're doing.

In recent years we've been seeing the example of sex and gender. How do sex and gender play a role in the introduction and the development of these technologies in the first place? That's a key aspect.

In terms of the cultural issues that's another critical one as well. We see very different approaches in the way the technology is being used and in the way caregiving is being provided across various ethnicities and cultural groups.

We heard about the work around surgical robots in the North. That's an issue we're also dealing with. How can technology be used in indigenous communities to provide care to the elders in those communities? We have a few projects out of the University of Saskatchewan and elsewhere that are looking at that issue.

It's amazing how the technology is being shaped differently based on what we are learning from these various cultures and different ethics issues. It is a very critical part. We're really trying to get the message across to our researchers that these aspects and variables need to be ingrained right at the start of the project. They cannot be afterthoughts, as they typically are, especially in technology development.

Dr. Anvari: All of our procedures are with patient consent. I would like to make sure the senators realize that although our systems are teleoperable, 95 per cent or more of their use is in everyday hospitals where the patient is there to improve accuracy and reliability, to reduce pain, and to minimize cosmetic scarring, et cetera.

The majority of the systems we build will be used every day in big hospitals and small hospitals, but you are also allowed access to the remote. In every procedure in the medical field the patient consents. One of the first questions I was asked was, “How would patients accept a robot performing a procedure instead of a physician?” My question was answered. This is something we didn't know 15 years ago. The reality is that patients accept a procedure if it's done at the highest level and improves their quality of health care.

I may daresay that robots often come with the belief that they're going to do it better and faster. A good example is the Da Vinci system, which is used in prostate surgery. The reality is that there is no good evidence that it makes a huge difference compared to laparoscopy. It does make a difference compared to open prostatectomy, but now almost 95 per cent of the procedures in the United States are robotic and Canada is moving that way as well. That's very master-slave; it's not a telerobot or an autonomous robot. It's not automated.

Patients accept robots if they perceive this as improved health care. There is no concern regarding their interactions. With telesurgery, after the first two patients there were patients who realized the benefits and we had no shortage of patients coming in asking for the bionic surgery. The reality is that we need to make sure we don't build up patient expectation too much and appropriately talk about the risks and benefits of the procedure to get informed consent, which is like every procedure. From a patient point of view, they easily accept robots in their health care.

Senator Meredith: When they consent to that, then, in terms of any risks from an ethical standpoint the doctor is not liable and so forth.

Dr. Anvari: Correct, they consent because they understand all of the risks and benefits. The doctor is liable if they don't explain the full extent.

Senator Griffin: I'm filling in for Senator Tony Dean today. I'm not sure what questions he would ask because I think he is having surgery.

Anyway, with regard to anything, the federal government has economic instruments and regulatory instruments. You've mentioned both. In particular, regarding the regulatory agencies, you indicated that they're having trouble keeping up with technology that is evolving so rapidly.

What would be needed in terms of regulatory advances or changes to enable us to make faster progress?

Dr. Anvari: Both jurisdictions understand, and I say “both” because I'm looking at the North American continent. All agencies are looking at improving their structures to deal with the pace of advancement in technology. Often the regulatory requirements include clinical studies and multiple randomized studies, all of which take years to complete and makes the process take longer.

They are looking how they can build on their knowledge and reduce the path toward regulatory advancement without reducing the oversight necessary to prevent a cavalier introduction of technology. This is a fine line. Being very up to date with how technology is evolving in these fields allows them to make that judgment.

I certainly wouldn't want to be in their shoes. I understand the problem they have. One of the things both Health Canada and FDA have done is to have panels such as this one where they actually hear from the experts where technology is moving and how rapidly. How can they make sure that they're ahead of that curve rather than always fall behind?  Autonomy is coming to us in things like the Google Car and Uber. Society is looking at how to introduce autonomous robots into society, and health care is one of the areas.

I would certainly think that Health Canada has to study and look at how they can license this degree of autonomy in health care. It is a gradual learning process.

Mr. Mihailidis: In addition, these regulatory bodies need to understand that there are other ways of collecting the same level of quality of evidence to support the efficacy of these new technologies.

Currently, everyone refers to the RCT or the randomized control trial as the gold standard. You take a control group and an intervention group and randomize them. A lot of times with the new technology being developed, RCTs should not be considered the gold standard. They are very difficult to do sometimes, especially when you introduce new technologies that are expensive to build, et cetera. They need to understand and accept other approaches.

In the classic example that's relevant here in terms of assisted technology you don't need to do an RCT to show that a power wheelchair helps someone who is paralyzed to get from point A to B. You do not need that level of scientific rigour, so to speak, that people consider an RCT to be part of.

We have to continue to educate our regulatory bodies, whether it's Health Canada or others, in terms of other ways that data can be collected and presented that will show the same level of rigour that an RCT or other approach would have.

Senator Griffin: The second part comes back to the economic instruments or the financial power of the government. One reference was made that government needs to support research to get technology into the market.

I assume there is some support currently. What additional support would you see being needed?

Dr. Anvari: The CECR program has been very positive. CECRs have seen their research often from various NCEs evolve to a commercial end. I also see a closer collaboration with the government’s body of experts in financing and all the commercial aspects to help these start-ups to not only start in Canada but remain in Canada. As I said, part of that is the difficulty in my field of procurement and how they remain competitive in the world if they stay in Canada.

Those are the steps that are important. Canada is doing a wonderful job. We rank very high in the amount of research we generate from the funding we get. We also rank reasonably well in innovation, helping it get to the market. Where we fall is actually creating wealth from all those innovative industries because so many go south.

How do we actually ensure that they succeed in Canada supplying the rest of the world? That certainly is a step that will be beneficial.

The Chair: On that note, I asked other witnesses, after they finished, if they would provide me, through the clerk, with any ideas they have gleaned with regard to how to make our systems more effective and how to assist evolving entrepreneurs with these areas. Perhaps you could follow up on that because it's too complex for us to get into a full discussion at these meetings. It's an important part of this discussion.

The overwhelming majority of our witnesses are Canadian. They are moving into commercial activity and they are all experiencing some difficulties. If you could provide the clerk with your thoughts after you leave, we would welcome them.

Senator Petitclerc: Thank you for your presentations. I found it very interesting and at the same time very hopeful, especially since you are talking about the group that I am going to be part of in 40 years, let’s say.

I would like you to expand on access. I'm interested in learning about all the things that you mentioned in the home: monitoring, health, safety, help and entertainment, whether it is robots or artificial intelligence.

I would like to have an image or an idea of this is accessed now. To me, it seems like it's very high technology. It is probably expensive and sometimes you need experts to actually deliver it from where it is to the individual.

What is the situation now? How do you see it in 10 years or 40 years when I'm there?

Mr. Mihailidis: That's a very good question. If you asked me that question five years ago, I would have said that access was very poor and still far away because things were too expensive. Things have dramatically changed in this area. In the past five years we're seen robots go from hundreds of thousands of dollars, to tens of thousands, thousands and to hundreds of dollars now.

If we focus on the issue around robots, we're starting to see this whole new class of robots being available.  I like to refer to them as appliance-type robots. Just like your refrigerator, stove and dishwasher, everyone seems to also have a little robot on their counter, whether it's a product like the Amazon Echo, the Google Home, or new things such as the Jibo that’s come out. These robots are only costing hundreds of dollars and they are actually quite sophisticated. They're not robots in the traditional sense. They don't move around. They don’t walk up and down stairs. They don’t carry things, but they're using many aspects that we use in robotics and other aspects of artificial intelligence.

These devices are incorporating a lot of things that they have been trying to be put into use for several years to care for seniors such as speech recognition, sensing and helping to control various aspects of their environment whether it's environmental controls or other issues. Because these platforms are now available and several of these companies are making the platforms more open so that we can develop our application on top of them, we're starting to see this rapid influx of new technologies such as smart home systems that are being applied in the support of seniors.

The access is there. As I mentioned before, it's really fascinating to see that the access is being opened beyond the traditional developers. It's not just the researchers, the engineers like me, or the computer scientists that are doing this. Caregivers and family members are purchasing these systems and developing their own systems on top of them to provide the care that's required for the specific situation in their own home.

In the next five years this is going to continue. We're going to see an influx of these new applications and new technologies that can be used in the home, not only for seniors but for everyone. That's kind of our Holy Grail of a smart home. It's not just something that gets installed once you turn 65 or 85. As I grow it's a home that grows with me. It changes and it adapts. We all experience points of disability in our lives, whether it's long term or acute. As we age and decline cognitively or physically, the home should recognize this and change.

These are the types of technologies we are trying to focus on now. It's not so much about the standoff device or the single robot or the single sensor. It's more looking at integrating these systems into a living environment that adapts to you as you need it.

Senator Raine: Many of the questions I was going to ask have already been asked.

I find it quite intriguing that in the use of robots to assist in home care the evolution, as you say, will come through consumer products. There will be lots of back and forth. These will be designed as the caregivers themselves see them becoming increasingly helpful.

I'm above the baby boom era. We're all looking at more people becoming seniors and wanting to stay in their homes. There is a big market. To me, one of the things that's really interesting is I consider myself to be a bit technologically challenged, yet I know that people 10, 20 or 30 years younger than me have no problem at all. If you look at children in the schools today, there are classes and clubs for kids involved in robotics and robotic development.

I'm wondering if there's a way at the research level, maybe in university or in your network, to harness that youthful free-thinking and have them work directly with care facilities and get that experience so that they understand the needs of seniors and maybe can be part of that transfer of knowledge and technology.

Mr. Mihailidis: Absolutely. That's a very good point and something we're trying to do more and more through community events.

We've all heard of hackathons and other events where the public gets together for 36 hours. They're given a challenge and essentially sit there and build something for two or three days straight. These have been very good events in terms of bringing these various generations together. We've gone to events where I've seen families with small children participating and seniors and people from industry all getting together in this area.

The issue with these kinds of hackathons community events is typically nothing useful comes out of them in terms of commercially viable product because they are done so quickly. At AGE-WELL we're running, in collaboration with an organization called Hacking Health our ideathons.

Across the country we're holding one-day events where we bring the general public together. Anyone can enter, whether you're a child, adolescent, adult or older adult. They work directly with our stakeholders. We bring in caregivers and older adults. They hear directly from them and deal directly with the individuals in terms of what their issues are.

At the end of the day, they formulate their teams, come up with an idea or a solution to care for a senior. They have one month to put a video together and submit it to us. Then we go through a judging process. We're doing it across four cities: Toronto, Montreal, Halifax and Vancouver. Our grand finale will be at our national conference in Winnipeg this October. We've held the one in Montreal already where about 180 people attend, again a wide variety in terms of age ranges.

We find these kinds of events and others we put on really useful for doing intergenerational design of the technologies. We also find that they really love getting together. We've seen several models of these working outside the technology space. For example, in the U.S. there are models of Montessori schools where children plus older adults with dementia are sharing in the same space, in the same classroom. If we can bring those types of models to the technology development world even more, we will see a significant impact on the types of technology that are coming out, the usefulness of these technologies and what future generations should be looking at.

I'll give one quick story and then I'll close off my remarks. When I started as a graduate student many years ago in biomedical engineering, the first thing my supervisor did at that point was made me volunteer for two months in the long-term care facility at Sunnybrook Hospital where we house many of our veterans. The whole point was to get me involved. I was part of those were changing them, feeding them and getting them dressed.

That experience as an engineer at that point kind of seemed to me like: Why is he making me do this? If he's watching, thank you very much. It gave me insights that I continue to have to this day. I also make my graduate students go through the same experience. Having that hands-on experience is invaluable to understand the problems, these wicked problems I mentioned that we really need to solve. It has impacted the research of my own group and hopefully the research within AGE-WELL too.

Dr. Anvari: Definitely the outreach programs at each of our centres are key in helping stimulate young scientists of the future. They also bring them into touch with what are the needs in society. In our last robotic competition the winner was someone who produced a voice-activated wheelchair at a very low cost. It's incredible.

Every robotic manufacturer struggles with making the system easy to use. The simplicity of use will lead to its commercial success. If you need a PhD in computer engineering to use a robot, that robot is not going to be used. That's part and parcel of why companies need to be engaged with researchers. I can tell you as a researcher you always want to find a solution which does many things.

The first system I patented was a sophisticated robot with six arms which could do many different surgeries. This was instead of doing one procedure extremely well. As for the commercial side let's walk before you run. Let's make it simple, safe, reproducible, and something that every radiologist and every technician can use.

 To your point, I don't know what Alex does, but whatever system they commercialize at the end should not be something that seniors can't use. It has to be easy to use by the user; otherwise it won't be commercially successful.

Mr. Mihailidis: You raise an important point. That's where artificial intelligence is having its largest impact. A very complex system can be made to seem very simple on the front end. The power of AI is allowing us to make our technologies more usable but still keep the sophistication and the customization required.


Senator Cormier: Thank you, gentlemen, for your statements. I live in a small region in northern New Brunswick, and I fully understand the positive impact of the arrival of new technologies such as yours for many people like us who have to travel for work, for instance. We are hearing a lot of experts on this topic. I was discussing this with my mother, who is 93. She uses new technologies like Skype at home, in her house. She is independent. As I discussed these matters with her, I felt a lot of hesitation on her part.

Here is my question: in your research, do you examine the psychological impact of the new technology? In areas like the one I come from, how will these new technologies be integrated? How will the users of these technologies integrate them with confidence? My mother seemed to think this was akin to Big Brother. She wondered if she would be constantly watched. This research does raise that question.

The second part of my question is about the training needs in our hospitals and other institutions; training will have to be provided so that people can access these technologies. Are you in contact with the various teaching establishments regarding the integration of new technologies? Thank you; I’m sorry about the length of my question.


Dr. Anvari: Thank you, senator, for that interesting question. My own experience is that in a hospital setting people accept technologies quite easily. They're used to going to a hospital. The more technologies there are, the more they say, “Oh, I'm in a great spot.”

In my world patients look at new technology as their friend because there is this recognition that people are not going to buy technology if it doesn't have benefit for the patient. They're not going to pay hundreds of thousands or millions of dollars to buy something if it's not going to benefit the patient. There is that trust. When they see technology they accept it. Technology is not threatening in a medical hospital setting.

In a home setting, and Alex can discuss it, that's a different issue. You are now entering their space. A friend of mine, Yulun Wang, produced one of the first robots. It was initially for hospitals but then he moved it to home. His company, InTouch, was American. The robot was threatening so he reduced the size and made it friendlier.

There are other considerations when it comes to their own home environment as compared to a hospital. I want to make that distinction. In a hospital setting we don't find that at all. Patients don't find it threatening. In fact, they find it reassuring that the hospital has the latest technology. In a home setting it's a slightly different challenge because you want to make sure they don't feel threatened by the equipment. Size matters. How it appears and the cosmetic aspect of it are crucial.

Mr. Mihailidis: That point is absolutely right. We face a different challenge in the home and with seniors. This goes back to our whole idea of co-creation of the technologies and ensuring that we understand right upfront what seniors want from technology. What do they want it to look like? What do they want it to do?

We have several projects in our network that are focusing on those issues from an older adult perspective and from the caregiver perspective. We have several technologies you can look it. You can look at the user interface to see what it looks like. It looks like it does because we can probably show you a drawing that seniors did themselves and gave to us as part of the co-creation approaches that we insist on and promote within our network and within the field in general. We always have to be very careful with that particular aspect of understanding what their needs are. If we incorporate that we find the level of acceptance significantly increases.

It is interesting in the technology and aging field that often we find the resistance doesn't come from the senior. It comes from the caregivers or family members who say that their moms or dads will not want to have cameras or robots in their homes. When we speak to the seniors themselves we often get this response: “If this lets me stay in my home, I'll take it as long as I understand what it is.” Education is part of it.

Another issue is that these technologies are not for everyone. We have not done well in the technology and aging field to come up with some kind of approach to determine who would benefit the most from technology beyond what their own self-reports are telling us. There must be a better way to develop to understand who will benefit from a robot or from smart home systems and who will not, based on their characteristics, personalities, desires, medical conditions, et cetera. That's important as well.

To address the question on training, this is a significant part of any NC. You probably know, but I should clarify that in the NCE program, there are several different types of networks. Mehran is running a commercialization NCE and I run a classic NCE, so we cover from research and development right through to commercialization.

Training is a significant aspect. We have a training program in AGE-WELL called EPIC, which is Early Professionals, Inspired Careers. We have approximately 300 trainees going through our program. We are training individuals not to become the future academics but to become the future leaders whether they choose to be an academic, an industry leader, choose to work for government in policy or whatever the case may be. We have a wide range of activities, workshops, online courses and mentorship opportunities to train individuals throughout our network across all of our institutions.

We are preparing to open our EPIC program to people outside of your classic person, the graduate students and undergraduates, by offering an opportunity for seniors and caregivers to join. This goes back to the intergenerational approach in education. If a company has an employee who wishes to gain further skills and knowledge in their technology and aging, they can also become an affiliate member of our program.

We are slowly building up the training aspect. We feel that is critical. It's not only the skills required to develop the technology to do the research. It’s also understanding how to implement the technology, how to use it and when to use it appropriately.

This goes back to my initial remarks: These are just tools; these are not replacements for caregivers or services that can be provided. They are additional tools that caregivers in the health care system should be using at appropriate times and in the appropriate places.

Senator Hartling: Your presentations will help me prepare for my old age. I have a couple of questions. You spoke, Dr. Anvari, about breast cancer and early detection, especially for those at high risk. Breast cancer is probably one the things that most women are most terrified of. How does technology work to detect it and how far away are we from it?

Dr. Anvari: Right now most women over the age of 50 undergo screening. High-risk women need to have a mammogram plus MRI on an annual basis. The problem with many screenings is that either the lesion is too large when they diagnose or often when they are finding lesions that are small and less determinant. Then they go from one screening to a second screening, to a biopsy, to a potential lumpectomy and are often negative.

We are trying to make it a one-stop. In some procedures you will reach that. If you go for a colonoscopy, you are sedated. You have the colonoscopy. They find a polyp. They do a biopsy and they remove it. It's the same with the angiogram. If they find an obstruction they stent it.

We are moving to the same principle of see and treat. In breasts it's a long way from that. The systems we are developing are early detection in screening. Right then and there at the moment, in the automation under the guidance of the radiologist they can decide to biopsy and if appropriate ablate. In future autonomously using Watson, which is using millions and millions of interactions to make accurate diagnosis, can make those decisions.

Basically, our systems allow a patient to undergo screening if something is detected.  With needlescopic we have an accurate biopsy with minimal pain or almost no pain because the system freezes it beautifully, gets to the point and targets it accurately. The next step is within certain parameters. Right now we are working with a couple of companies toward early detection and having a biopsy and diagnosis right on the spot. That's not that far away. We can ablate using cryotherapy. Actually the patients come for a screening and they leave. If it is detected that something has to be dealt with, they don't have the wait that goes into that step.

Eventually health care will save money from robotics by reducing the steps built into the ways we deliver care. By making it more efficient these systems not only pay for themselves but, from a patient perspective, they reduce the wait, the worry and the benefits of having something that is minimally invasive or less invasive. That's why it's a natural progression in any health care but particularly in ours.

Senator Hartling: I have a question for Alex. We talked about smart homes. I'm concerned about my mother because she's aging. She's almost 90. She has vision loss. Otherwise she can live on her own, but it's a concern for my siblings who live nearer to her than I do.

Will there be some technology that can help her? She can see in one eye but not that well. Are there things coming in the technology area that will help her remain in her home?

Mr. Mihailidis: In a lot of work is being done in the vision area and in hearing loss as well. It all depends on the severity of her impairment and what aspects of task completion she is having difficulty with in interacting with her environment.

Often for that kind of situation it's not a high-tech solution. It's maybe a series of low-tech solutions but environmental modification.

Senator Hartling: Such as what?

Mr. Mihailidis: Changing the layout of the room, changing contrasts of various objects, or simple things like placing reflective tape on the edges of furniture. They're simple solutions that anyone can implement. If you talk to good occupational therapists they can also help implement these types of solutions.

My point as part of this answer is that it's not all about high tech. I understand we are here to talk about robotics and artificial intelligence, but often a lot of people jump right to the high-tech solutions, especially when it comes to seniors, when often it's the low-tech environmental and behavioural changes.

Talk with your mother about different ways she can do things in order to take into account her visual loss or other impairments. These are all critical aspects. It’s part and parcel of the high-tech solution. It's a combination of everything we need to be looking at.

Senator Hartling: It is trying to figure it out in the best interests of seniors. They are happier staying in their own homes. Sometimes when they go into homes they fail quicker and their happiness is lower. To your point, you can find ways and if it's not technology it's other ways.

The Chair: Before I go to second round, I would like to pursue a couple of issues that have come up.

Dr. Anvari, you talked about current applications of these areas in the surgical field. Can you give us a bit of a sense of the near future with regard to developing technologies?

For example, you mentioned prostate issues. It's my understanding that recent developments at the research level in your kind of operation have shown that the spectrographic/radiological combination, with the information from deep learning applied to robotic surgical capabilities, is projecting the possibility of dramatically reducing the invasiveness of testing and so on in that area. The whole prostate can be screened and looked at before doing a biopsy. It can be done much more accurately with much less impact and lowering the risk of infections and so on. Can you give us a few examples of those things you see on the horizon?

Dr. Anvari: Absolutely, thank you. As a surgeon I often laugh at what I am doing in a way will put many surgeons out of work because it will reduce the need for many surgeries. With this technology we are moving the diagnosis earlier and earlier in its phase and often treating it at an earlier molecular level. We are getting close, as you said, as is the case with mastectomies, to prostatectomies and even lumpectomies being things of the past.

We are very good at diagnosis. We have technology where we can almost detect cancer cells. The problem is you still have a very blunt instrument to get that cancer out; you still have to remove the organ. We are combining or coupling our incredible increasing capacity to diagnose diseases at a very early stage with treating. We are allowing the patient to benefit from treatment, not by going to centres of excellence down south but having it closer to home.

You are absolutely right. We are skilling it to the point that technology can in all forms of cancer diagnosis and neurospinal diagnosis. In the future very few people will have craniotomies to deal with various issues. Things are changing. If I were in front of your panel 10 years ago, I would have been talking about the incredible number of cardiac surgeries we do: open heart surgeries, off pump and on pump. That number has diminished substantially in the last 10 years. Many people are getting stenting.

Surgery and many interventions are moving that way. They are becoming less invasive. There is going to be points of diagnosis and they are going to be better targeted. This will help not only with longevity but will eventually cut our health care. It doesn't seem so because every technology is expensive but it is by making a difference in how many stops patients have to make.

To your point, absolutely in the near future certain diseases will be more targeted. The more common cancers are the ones that companies will say “I can,” but in the future it will be across many illnesses where you will see technology make a big difference.

We talk about tremors. There are now robotics systems that can target areas of the brain with high-intensity ultrasound which prevents tremors. This is one of the things the elderly suffer from. This has been a big issue.

You will actually be addressing many of these things using targeted, minimally invasive technology. A robot is a tool that enables us to do something that frankly humans, surgeons or physicians cannot do. It can do things better than we can.

The Chair: You have introduced with a direct example the combination of diagnosis with treatment. You mentioned cancer. We have the Pollock centre in British Columbia which is now able to identify individual cancers and look for treatments of the basic cause of the genetic problem. It's not 100 per cent successful because not all cancers lend themselves to that treatment. The earlier you can diagnose, the better. I appreciate your answers in a number of ways, but having included the combination of diagnostics with treatment and prevention has a big impact.

Mr. Mihailidis, you answered part of this in your comments, but I want to come back to health care delivery, which is a provincial responsibility. We have been talking about innovations in the treatment of patients, diagnostics and/or treatment of patients. Innovations in the actual delivery of that health care are a different thing. It involves people different from you in terms of your affinity and natural instinct to use innovation and adapt it.

 I'd like to get a sense from each of you from the two perspectives you bring. Specifically, do you see provincial health care systems moving with appropriate approaches to prepare themselves to employ these emerging advances for the population in their provinces?

Dr. Anvari: I can answer from my world, which is a medical world. I met a number of health ministers from different provinces. Invariably all of them see the benefits that the technologies I have discussed can bring. However, there is a degree of separation from people understanding the benefits to procurement and the bureaucracy that health care procurement is in this country.

Frankly, the United States is a lot simpler. It may seem like a complex system, but you will sell if you provide a benefit to a patient to the point where they say, “I am going to go to this hospital because they have this latest technology.” In Canada it's not that simple. Often problems arise because of the provincial procurement systems.

No doubt they all see the benefits that technology brings and can improve. Sometimes the minister pushes something. We have been dealing with Quebec and Ontario right now. There seems to be a big buy-in from high up. I will let you know, senator, how much will go down.

It is definitely in how medical health care dollars are spent at the provincial level procuring these technologies. You have to have a high level of evidence, as Alex said. For example, the cancer agencies want a number of RCTs. All of that takes time. Eventually they will get there. It's a slower process, whereas if you show the benefits in the United States and other customer-driven countries the hospitals will buy it because that's where the patients will come to.  

Mr. Mihailidis: I completely agree with the response so far. In terms of our area of technology and aging, I do not feel that collectively the provinces have been preparing us properly for the delivery and the use of these technologies to support our seniors in their homes and communities.

Some provinces are doing better than others. Alberta is doing significant work in this area. Ontario is trying to do more. New Brunswick is doing quite a bit as well. The problem we see at the provincial level is incentivizing the health care systems to use these technologies and their power right at the front lines with the family physicians.

I have heard from several family physicians who say, “This is nice and all but I don't want my patients coming to my office with the data being collected by their smart home showing changes in their cognition. They don't know what that data is telling them. They are coming to me saying that their home is telling them they may have dementia but there is nothing I can do about it at this point.” They're not incentivized, obviously, through our current health care system, to make use of that technology in their practice.

We were working with a start-up company that made a nice technology to help connect family caregivers with each other and with family physicians. The physician could enter information into this app that could be shared among the care circle.

We hear from family physicians saying, “I don't have time in my practice to go to this app and fill in the information. If the caregivers want to hear what is wrong with their loved one then they should come to the appointment.”

There is some truth to that, but if you have caregivers living in Toronto, Montreal and Vancouver, all caring for their parent in Winnipeg, as is often the case, that's not possible to do.

Our health care systems at the provincial level need to provide that incentive. They need to understand the benefit of the data we can collect from our sensors, whether environmental, wearable or robotics based. Our health care systems need to know how it truly can drive down the costs of providing care to these individuals and not just focus so much on the direct health care costs but on the indirect ones as well.

If you look at the indirect cost of caregiving, it's in the billions of dollars in Canada. A significant amount of money is being lost because we are not embracing these new models.

The Chair: Dr. Anvari, you used one word that is basic to the issues we face in health care in Canada, and that is choice. We are the only one of 35 countries that does not have a choice. We are the only country where citizens do not have a choice in our health care in terms of provider. Competition is one the major drivers of innovation in most other areas of human activity so maybe there is some aspect in there.

I will turn to the second round now.

 Senator Stewart Olsen: You mentioned a dementia predictor. Would you elaborate on that, please?

Mr. Mihailidis: I will preface this by saying it is still research based. We have conducted a project and there are others happening at AGE-WELL now showing that monitoring changes in the patterns of living of an individual can be a predictor of change in cognitive impairment with that person.

In the first example of the system we developed we used data from colleagues in the U.S. They put motion sensors in each room of the homes of 300 seniors over a period of three years. During those three years, many of the individuals went from cognitive intact to cognitive impaired.

We built models using predictive analysis and other aspects of machine learning that are able to build models of the sensor firing to know how much time they spend in the bedroom, in the bathroom and out of the house. We built models that showed typical sleeping patterns and things like that of someone who is cognitively intact versus someone who is cognitively impaired or may have dementia.

Based on those models we can build in predictive aspects to show that a person, in terms of the data collected on their living patterns in their home, is trending toward what a cognitively impaired person may look like.

In the particular study we found we only needed three months of data to have a number of around 85 per cent. We increased that to close to 90 to 92 per cent when we took into account other factors. Very simple data can be collected. It is motion sensor data that all of us probably have in our homes already if you have a home security system.

In terms of analytics and machine learning with things like IBM Watson and cognitive computing, at the end of the day these models are becoming more accurate and more easily implemented.

Dr. Anvari: We are going to hear the word prediction more and more. When we talk about prevention generally we look at the macro level at healthy living, exercise, et cetera. We are now going to be seeing prevention at the micro level. With the science of genomics as it is advancing and with the various algorithms that were mentioned and with cloud computing, we are going to be able to predict based on your current trends the types of diseases you will have and prevent them before they get to that point. Prediction will be a big part of how we offer health care because we are hopefully preventing diseases that will cost a lot more to treat.

Diabetes is a big issue. Now we know some of the factors that lead to diabetes. It is going to double in our population over the next few years. It reduces the life expectancy of many communities in Canada, particularly Inuit and First Nations. With these predictive algorithms that we talk about there will be a major change in the next decade.

Senator Seidman: A lot of my questions have been answered already but I did have one for you, Dr. Anvari, which has not. I would like to preface it by saying congratulations to both of you on the major contribution that your centres are making to the future of health care and obviously on many different levels. I'm pleased to hear that you use the input of users, whether they are patient families or ordinary Canadians, in the development of everything that you are doing. That is very hopeful.

Dr. Anvari, I would like to ask you a couple of specific questions about CSii and its funding. You have had funding from NCE from 2009 to 2017. Is that correct?

Dr. Anvari: Correct.

Senator Seidman: That was $14.8 million.

Dr. Anvari: Correct.

Senator Seidman: Then you had $28.4 million in contribution from 16 partners. I have three fairly quick questions. Has your centre requested federal funding beyond 2017?

Dr. Anvari: Yes, there was a new round for present CECRs to apply so we applied for funding. The aim is for our accelerators to become self-sufficient. Although we have already reached some degree of self-sufficiency, in order to continue to fund robotic R&D at the pace we have in the last seven years we need a level of funding beyond what we already have.

With the creation of start-ups and the royalty streams coming back to our centre it will take a few years. The government realizes that it is almost impossible in the provision of health care to expect a CECR to lead to commercial success and receive royalties in seven years. We are hopeful the government will continue to provide support for the next five years, by which time we will be fully self-sufficient with respect to royalties coming back from the start-ups.

We are fortunate in having MDA being a big investor in not only our CECR but now in our start-up. This shows that a multi-billion dollar iconic Canadian company believes that Canada can be a leader not only in space robotics but in medical robotics. That is an important area for Canada to consider as it looks at what niche we can have in the future of health care.

A significant investment as a nation was made for the space program and we created space robotics. If you can translate that know-how into creating a major niche in the field of medical robotics, whether for home or hospital care, they are not that different because it is the same intelligence.

Remember, we build robots in space that last for 30 years. They have to be as reliable as the day they were built. We have built things for which most countries still don't have the capacity. Translating that into medical is an important part of our heritage in the future.

Senator Seidman: Does your centre provide commercialization support only for innovation developed within the centre or can other innovators on the outside ask for your assistance?

Dr. Anvari: We are not a distributor. We welcome innovators coming and working with our centre. We have a number of inventors working within the framework of what we are producing, but we don't give out grants if that was the question. Our model is to incubate systems within our own environment but we welcome inventors from outside. We have collaboration with a number of individuals and centres across the country very much focused on the field of medical robotics. We are a national entity for them but we don't give our grants or money.

Senator Seidman: I understand that. I think you answered the question by saying you welcome people coming in.

Dr. Anvari: We rely on Canadian innovation.

Senator Seidman: Can I ask a similar question in terms of funding of Mr. Mihailidis?

Mr. Mihailidis: In response to your question on our funding model, we were funded in the most recent round of the classic NCE program. We have been in existence about 18 months. In our first five-year cycle we received $36.6 million from the NCE program and we raised about $22 million from our partners.

Obviously, we should hopefully be renewed two more times. We have a shelf life with federal funding of 15 years. Like the CECR programs, though, we are expected to become self-sustaining over that time. We are already trying to develop what our business model may look like.

The one difference in terms of the commercialization aspect is that we provide funding to start-up companies or other innovators and entrepreneurs who wish to develop a product in this area. We also provide them with business support as well. It is probably not to the same level of depth as a CECR would, but we have a business development person and others within our network to help not only with the commercialization but with the knowledge translation and mobilization aspects as well.

Senator Meredith: I have a follow-up question with respect to funding. How are you reporting to the government in that you are getting so much taxpayer monies and so on? How is that allocated for?

The Chair: Before you answer perhaps you take this question. How are the networks of centres of excellence set up? Don't go into how you get the group together, but tell us how the first application gives you funding, what is the review point, and then go to the senator’s question.

Dr. Anvari: The CECRs work very differently than classic NCEs. We are very much focused. We have a very close relationship with NCE. We have individuals from NCE at our board meetings which occur three to four times. We provide not only annual reports but regular input. It has been very good, collaborative work.

I recently gave feedback that one of the things we would have benefited from early on was a commercialization panel to assist the CECRs. In the medical field it took us a couple of years to find our feet. For most scientists this is a really different world. It's something where advice has been taken on how to actually support CECRs in that commercialization. The Government of Canada has access to some of the best minds in commerce and I think to have had that collaborative support would have resulted in something actually being built.

In talking to other CECRs' scientific officers, they are all finding their own way. Yes, we now have a strong commercialization committee with experts and panels but it took a few years and would probably have allowed for our timelines.

CECRs have very different patterns but I think they have accepted input. Some actually give out money. Some are incubators that look at ideas and say, “I am going to put $300,000 toward this idea to see how much we can commercialize it.” Others, like us are very focused on one area of actually developing systems within their own environments. How to gauge them and how to measure success has been a learning process.

The time span required in the medical field to take an innovation from a drawing to the market is a lot longer than if the gadget were for the home where you don't have to go through the regulatory process. In my field that adds a significant amount of time to bringing that product to market. The CECR program understands that when they fund programs in health care, especially if they have to go through the regulatory process, because that timeline is necessary. I found their support and their access very good.

Mr. Mihailidis: It is a very rigorous process we had to go through to be funded. It was pretty much a 2.5-year process, starting with a letter of intent to a full application and two reviews in person here in Ottawa.

Another interesting aspect of the NCE program is you're not submitting a research proposal. We submitted an 80-page business plan. NCE typically responds with: “We know your science is going to be excellent. We now you will have the best and brightest scientists out there, but how are you to manage them? How are you to govern this and actually change the culture of your scientists in the academic field to understand that NCEs are more than just the publication?”

It's more than just the presentation. It's about what impact we are going to have and what outcome we are going to see. That’s significant. That's something that NCE continuously asks us to report on. Beyond the formal yearly report, which is a fairly sizeable document, we also have continuous contact with our NCE person who sits on many of our committees and our board.

Another interesting aspect about an NCE is that we are required to be a not-for-profit incorporated entity run by a board of directors. That gives it a whole different flavour when we're being run by a board. Our chair is Michael Harcourt, who many of you will know is a former premier of B.C. and Mayor of Vancouver. He has a critical eye from the policy side. Our vice-chair is Barb Stymiest, who used to be an executive with RBC and chair of BlackBerry. She is chair of CIFAR right now and brings a very critical business eye.

We have various aspects we're always looking at in terms of how we report. When we look at our metrics and how we report on those metrics, both our board and the NCE take that businesslike approach. What is the return on your investment? We're not handing out research grants. We're investing in different projects and portfolios to ensure that we have the ultimate outcome and impact.

Senator Meredith: Mr. Mihailidis, with respect to dementia, you mentioned embracing technologies around that in the homes. We're looking at those individuals who have to be put into a residence for seniors and embracing technologies that will minimize isolation and depression.

Talk to us about that in terms of not only the embracing of it by staff but by those clinicians whose are working with individuals separated from family members and relatives due to distance.

Mr. Mihailidis: The use of technology to minimize mental health, social isolation and depression in seniors is a relatively new aspect of technology in the aging field. It is one that is obviously growing significantly not only within AGE-WELL but in the field in general.

We're starting to see the use of relatively simple technologies. Even things like Skype or current online tools that exist can actually have a strong impact on the health and well-being of seniors by allowing them to remain in touch with their families, their friends and their communities.

We have a wonderful project happening in AGE-WELL that's looking at the use of online storytelling and digital tools such as virtual bowling leagues. Connecting people in nursing homes through these virtual leagues is showing a significant impact on their own health and well-being. That's a critical aspect. The other side of things is using technology in education around mental health issues for seniors and others, obviously.

Those are a couple of other projects we're looking at in terms of how technology, whether a smartphone, an app or an online community, can help not only with specific interventions in mental health but by educating people so they understand the symptoms of mental health issues. What is the difference between depression and dementia which often get confused? How can technology be used to reduce the use of medications and other prescription drugs that may not be needed because the issue may be one of dementia and not depression? The social connection aspect of reducing isolation can actually help overcome some of those aspects so you don't have to medicate that particular person.

You mentioned the role of care facilities and nursing homes in long-term care. Technology has not really penetrated much in those facilities. We're talking about in the home, but we need to use the word home a bit more loosely. Someone's home may be the nursing home or long-term care facility that they have been in for the past 10 years. If that's their home and their community, technology must play a role there as well.

 Senator Raine: I'll follow up on that last topic with Mr. Mihailidis. Obviously it is very important that nursing homes and senior facilities are equipped with Internet connectivity. Even the caregivers who come to visit their loved ones in those homes will import some of this connectivity with them.

Mr. Mihailidis: Yes, absolutely.

Senator Raine: That isn't really the case right now.

Mr. Mihailidis: We find it's growing. We have many partners in AGE-WELL that are care facilities or are running various types of care agencies. We're starting to find that they are as much on the leading edge as they can be in order to provide the best health care and support possible. It is a competitive advantage, to be honest with you. It's still a big business out there that everyone is competing in.

We have several care organizations that are part of AGE-WELL. They recognize they can provide the best care possible if they can show they're at the leading edge and are starting to implement some of the new technologies we or others are developing in this field. They can show competitively that they are at the forefront of providing care to their residents and providing better work conditions for their staff.

We are looking at a couple of projects where we're trying to predict aggressive behaviour by residents in dementia care units. We've heard many news stories of resident on staff violence and resident on resident violence. If technology can play a role to reduce that circumstance and those episodes from happening that provides a safer workplace.  It’s important that we always talk to these facilities as well and that their employees are talked to about them as well.

Senator Raine: Dr. Anvari, I’m following up on Senator Ogilvie's question about how in Canada we have we think a great health care system but it doesn't allow for choice.

When you talk about the difficulty of bringing some of this technology to our system, is it not possible to have private/public facilities in our future? I think of the Shouldice clinic which has done cutting edge work on hernias. We have private clinics that specialize in certain things.

Is this not a field for our system to encourage private clinics that would innovate? Perhaps we could get you out from underneath that huge bureaucratic resistance to change. I think in any system there is a built-in resistance to change.

Dr. Anvari: In any system there is. At the moment different provinces have slightly different rules about what they allow private clinics to do. I'm not necessarily a proponent of private care but Shouldice is grandfathered. Certainly in most of the provinces, if the services you provide are already insured, even though you may be able to provide them in a better way and more comfortably for the patient, it's not necessarily allowed. If you are offering a service which is already insured, it's not.

We need to make the system more responsive to innovation. That is a challenge. Once the system has shown its worth, and particularly if it can reduce the cost of the care, it will be adopted very quickly.

What Canada does well is provide high-quality availability to those who don't have the same access. The proponents of private care talk about being able to get better access, but what we do is provide high quality.

The system needs somehow to be responsive. Whether it's when things are in the early phase that you allow patients to take advantage and pay some of that cost, that's for the government to decide.

I certainly don't believe right now that private clinics can offer, for example, robotic breasts. In the United States they can, but in Canada it’s not going to be because it is available under insurance unless you pull out of insurance completely and just offer private.

Senator Raine: I was thinking about where it's not private pay. It's still insured. It is still paid under our medicare system, but it is delivered and developed privately.

Dr. Anvari: I think provinces are experimenting with that. For example, private clinics in Ontario are experimenting with offering publicly paid endoscopy. Health care jurisdictions are looking at that type of model. Maybe that's the future. At the moment it's very early to make a decision on whether they want to look at the expansion of such a program.

Cancer care isn't at the moment but it may be one of the things that can come. Definitely colon screening is already in Ontario. You are seeing it in British Columbia and in Quebec, I think. That may be certainly a model where innovations such as this can be introduced.

Senator Raine: When I look at the diagnostics of these kinds of systems, we don't have enough diagnostic imaging facilities. We get backed up before we even start.

What is incredibly interesting in what you're saying is that if you have the right system you could do the diagnostic and the actual all at once. That would be wonderful, but it would be expensive. As a private investor I would love to invest in the capital side and the government would invest in the cost delivery.

Dr. Anvari: It would not be expensive to the system. It is expensive because we have partition. The hospitals buy the systems. Somebody else pays the physician costs. Somebody else pays for the patients to travel.

At the moment the cost of care is divided, so everyone looks at their own budget. The hospital asks, “Do I have to buy a million dollar system?” The fact is that it reduces patient travel and the number of physician visits. If OHIP or some other insurance is not paying for these physicians, the cost of the care of the patient is reduced. The system at the moment is budgeted or funded everyone is responsible for their own pocket of funding. By buying or offering this, somebody may take a hit, but actually the system could save in many different areas.

We should be looking at the holistic care of a patient as a model to how much it costs. You actually save money. When you look at each element of it, one element may be a bit higher than what you're saving.

I’ve been to the Northwest Territories. We spend over probably $150 million to $200 million transporting patients in the Northwest Territories. If you have a hemoptysis or cough up a bit of blood in the remote north, you are transported to Yellowknife to undergo a five-minute endoscopy at a cost of $17,000. That comes from a different budget. My concern is that the people who are responsible for buying a piece of equipment don't see the rest of the benefits.

Senator Petitclerc: That was a very interesting question and answer.

My question is quite brief, but I'm interested, Dr. Anvari, because you mentioned from the patient perspective how the new robotics and technology are well perceived. People are even impressed and they trust it.

From the medical side, the doctors, nurses and technicians, is there any sort of social resistance to it or is it also welcomed?

Dr. Anvari: That's a very good question. Let's put it this way. No physician thinks that a robot can do a better job than they can. No nurse would do the same. It's our egos. However, when people come to use it they see it brings benefits to them. It will make them better. It will make their quality better. Once they use it they decide that this is a tool.

I use a communication tool because it improves me. Some people may use an iPad or a computer or a telephone. It's their decision to use it or not. However, does it displace jobs? Yes, eventually it will impact certain jobs. There's going to be some resistance. As I said, 10 years ago cardiac surgery was a fantastic specialty to be in. The numbers of those going into it have now reduced because of what has evolved.

We are seeing evolution of medical practice and medical practitioners. We need to change with the changing technology. Yes, there will be some resentment because there will be displacement of professionals in how they do things, but I think that's progress.

Senator Petitclerc: You say it's displacing. Is it displacing jobs and not really lowering the number of jobs? Are we preparing people in universities that their jobs may not be there in 5 or 10 years? Do you know what I mean?

Dr. Anvari: I do. No, we're not really all that well prepared because we deal with medicine which has been practised the last 10 or 15 years. We look at evidence-based medicine and evidence-based medicine looking backward. It doesn't look necessarily forward to what is coming around the corner.  

In 10 years, if we take out a single prostate, I will be very surprised. In 10 years, if we remove a lump from a breast, I will be very surprised. Those are things of the past. Is urology and breast surgery looking at that and saying do we really need to train in this? No.


Senator Mégie: Thank you for your presentations. My question is about the ethical aspect and is addressed to Mr. Mihailidis. The sensors installed in rooms to detect dementia, as a first step, are very interesting. However, I’d like to know who authorizes you to install these sensors? Is it the family or the patient? After having detected certain symptoms, certain behaviours or other such things, to whom do you provide the results? To the family physician, or to the family itself?


Mr. Mihailidis: That's a very good question and one that we continue to struggle with in all aspects of technology and aging, in particular when we're dealing with an individual who may have a cognitive impairment.

In terms of who consents or who provides permission to use the technologies, it comes down to the individual circumstance of the family. If the parent or loved one has cognitive impairment that's already noted and aspects have already been taken into account in terms of legal authority and decision making being given to the family, obviously the family will be more involved in terms of deciding what interventions to be used.

However, we are trying to target older adults well before that happens, well before that person has full-blown Alzheimer's disease and to the point where they can no longer legally make their own decisions. We're very much into the prevention side of using these technologies.

When you look at the prediction technology I described, the goal there is to help predict that a person may develop dementia. The technology is not saying you have dementia or you will have dementia. It's saying there are symptoms or signs here that may indicate that something is changing with you.

The goal is for the individual then to work with their family members, their family physician and whoever else may be necessary in order to start to put interventions in place that may slow down the progression. It may be further testing to confirm what is happening with the person or really just to prepare if the person is well along.

When we talk about that particular technology it is interesting the resistance comes a lot from the family physicians who ask, “Why would I want them coming to my office to say they have dementia if I can't do anything about it?”

It's a very different story from the individual and families who say to us, “If we would have known that my father was going to develop dementia several months in advance, it would have helped us to prepare better.”

That's the kind of approach we want to have with these technologies. They are not diagnostic tools. They are tools that allow them to understand what's happening in their own lives with respect to their health, whether it is cognitive, medical, physical or sensory and then be able to put the right interventions in place as soon as possible.

Around the ethics aspect of it, the decision ultimately should remain in the hands of the individual where the technology is being used, not only whether they want to use the technology but who has access to that data.

Many times we have found it comes down to a group decision. It's the families and the individuals sitting down together and saying this is the type of thing that we can do. These are the types of interventions or technologies we can do to help alleviate some of the burden on the caregivers but also support the older adult as well.

The Chair: This has been a very thorough discussion on the focused areas that you have brought before us.

I'd like to point out to the committee that the Networks of Centres of Excellence are quite a remarkable development in Canadian research history.  Many, if not most, of the NCEs involve experts in the area from across the country. It gives us capability in this vast country. We are the second largest land mass of countries in the world with only 36 million people. Our expertise is spread across Canada, so it's very difficult to have a critical mass of all related areas to research development, application and cross-pollination of areas that can benefit. Today, just as we're hearing in every example, there are many different disciplines that relate to major advances in the area.

The NCEs that started somewhere around 1989-1990 or in that vicinity have evolved in terms of the experience of how you apply and get authorized to set up a NCE, how they are managed and reviewed, and the changes in the years of guaranteed funding followed by possibilities of renewal and so on.

I'd like the committee to know that our witnesses today are leaders and representatives of a remarkable Canadian research concept that bringing together people with a focus can benefit Canadians in many ways. They have led enormously to the development of knowledge and, as the mandates have grown over time, to the requirement to translate that into social and economic benefit.

The maturing of the experience in these areas is critical for us. As we've seen today, the possibilities, the social and economic benefit from the work that your networks are doing, are almost unlimited if the infrastructure is there to allow you to go into those next steps.

I come back to the request that if there are specific ideas that you have in that regard, I'd ask you to get them either directly to me or through the clerk to me. I'm going to collect a bit of knowledge from the experts that come before us in this area to see if something might emerge there.

With that, I thank the committee and I thank you very much for being with us today and for the information and insights that you've given us.

I declare the meeting adjourned.

(The committee adjourned.)