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Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology

Issue 64 - Evidence

OTTAWA, Monday, June 17, 2002

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 9:07 a.m. to examine the state of the health care system in Canada

Senator Michael Kirby (Chairman) in the Chair.

The Chairman: Honourable senators, our witnesses today are from the Government of Denmark, Mr. John Erik Petersen and Dr. Nielsen. These two gentlemen will speak to us about the maximum waiting time concept. Subsequent to that discussion, we will hear from two officials from the government on the issue of the electronic patient record.

First, I ought to offer my condolences to our witnesses in regard to the soccer results of the weekend. Although it would be hockey in this country, and not soccer, we can understand what a traumatic experience that was.

Mr. John Erik Petersen, Head of Department, Ministry of Health and the Interior, Government of Denmark: Honourable senators, I should like to start with a few words of introduction. First, the so-called care guarantee is not really a guarantee, it is an extension of our free choice of hospital. As a background, we have a national health system in Denmark meaning that health care is taken care of mostly by public resources. Health care, and particularly the hospitals, is operated and financed by our county councils in a decentralized structure.

We introduced a free choice of hospitals among the public hospitals 10 years ago. However, we have not yet had free choice for the few Danish private hospitals, nor hospitals abroad.

As of July 1, we are introducing an extended free choice of hospital to include private hospitals and hospitals in other countries in cases where the patient cannot be treated in the public hospitals in his own country or neighbouring counties within two months. That is where the care guarantee comes in. It is not really a guarantee, but it is an extended free choice after two months of waiting time.

We also have a care guarantee, but that is only in a few areas of life-threatening cancer and heart diseases. That has been in effect for a year now. That is a guarantee in the sense that the councils, the hospitals, are obliged to find care opportunities for the patient within the time limits, which are shorter than two months. They are obliged to find care for the patient, which is not the case with the extended free choice. You get a free choice of a private hospital or a hospital abroad if you have waited more than two months, but there is no guarantee that a private hospital will take care of you.

The Chairman: I wish to deal quickly with cancer and heart disease. There you do have, in a sense, a waiting period of shorter than two months. Am I correct in assuming that the waiting time for heart disease cases, for example depends on the severity of the condition?

Thus, it is not a flat, maximum waiting time. You are guaranteed service in that sense. Again, would you use private hospitals to deal with those patients if public hospitals could not?

Mr. Petersen: That is correct, if necessary. They are defined in medical terms as the number of severe cases that require fast-track treatment, so that, two or three weeks after the diagnosis has been established, you will have your heart surgery, bypass surgery, or whatever. Likewise, with all cancer diseases, there are several defined stages of examination and treatment. From the diagnosis of suspected cancer from your general practitioner, you should be referred to a specialist and examined at the hospital within two weeks. When the diagnosis has been established and primary treatment has been decided, there is a two week maximum waiting time until the surgery takes place. After that, there is usually a period of four weeks until the supplementary radiation treatment or chemotherapy are administered.

In those cases, the public hospitals are obliged to find treatment for you in other counties or private hospitals in Denmark. In fact, the counties have set up a clearing house, so to speak, to administer this scheme with regard to cancer. There is no big problem with regard to heart surgery, but for cancer treatment they have established a clearing house to administer this scheme.

The Chairman: Am I correct in saying that, if you are sent to a private hospital, either in Denmark or abroad, that does not cost the patient anything? Is the cost of the treatment paid out of your public system?

Mr. Petersen: Yes, that is correct.

The Chairman: I want to talk about what you call your extended freedom of choice issue. Let us say that I go past the two months' waiting period because I want a hip replacement or something, if I can find a private hospital to perform the procedure faster than I could get it done in my county hospital, will the public pay for that procedure?

Mr. Petersen: Yes, provided the counties have made an agreement with the private hospital specifying conditions, in particular the price, of course. They are negotiating that now with the private hospitals in Denmark.

The counties are obliged to make such an arrangement with those private hospitals that want them. There are arrangements regarding disagreements, which the minister could resolve, which provide that you will get free treatment at the private hospitals, if you cannot get it in the public hospital in two months.

The Chairman: Does Dr. Nielsen want to make any opening comments, in particular, to explain what the Top Management Academy is?

Dr. Steen Friberg Nielsen, CEO, Top Management Academy, Government of Denmark: At the outset, I will comment on what you have just discussed. It seems as if the heart program in Denmark has been such a success that is really what is inspiring us to go into other programming. The cancer program comes after that.

The physicians have felt that their free ride of choosing the place for the patient to go has come under pressure by this government initiative. However, everyone is fighting for results at the moment. We are on a good road.

With regard to the academy, for some years we had the need for continuous education of top managers in the health care arena. A year ago it was decided to finance and establish this academy. In the spring I was appointed. I am now fighting to have something to sell out of the academy to the top managers. We will start up September 1.

The Chairman: How are you funded?

Dr. Nielsen: We are funded by the counties of Denmark who, at this time, are operating the hospitals.

The Chairman: They will contribute and, in return, their management staff will take the short-term courses and seminars that I presume you will be offering. This is not a degree-granting organization of some kind, is it?

Dr. Nielsen: No, you are perfectly right. At this time we are trying to build up our educational program. We have no guarantee as to what will be needed, so currently it is run on a module basis. When we know what will be beneficial, we will run a continuous program, and we will take into account the generation shift that will come in some years.

The Chairman: Is the list of things covered under your extended free choice, or what we call our care guarantee, a fixed list? For example, do you have a list that specifies that hip replacements are included but something very minor is not? Does the two-month limit apply to a fixed list of procedures or treatments?

Dr. Nielsen: It is a general option for the patients. We do not have a list that includes the diagnosis you mentioned. Of course, in Denmark, we have been quite reluctant to offer patients, for example, cosmetic surgery. I would not be able to say whether that is included, but more general procedures are included.

The Chairman: Dr. Nielsen, what is your annual budget likely to be for the adademy?

Dr. Nielsen: We had 5 million kroner to establish the academy. After that, we will have a fee for service. Those who will take advantage of the academy will have to pay the full price.

The Chairman: I will turn first to Senator Morin who was dean of medicine at one of our leading medical schools before he became embroiled in politics.

Senator Morin: I am very much interested in what will be happening after July 1. I understand the liberal party got into power, which is an excellent thing because here on this side we are all Liberals. Am I correct is saying that, after July 1 all waiting times will be less than two months, after the infusion of approximately Can. $300 million into the health budget?

What is difficult for me to understand is how you define various waiting times. I understand Dr. Nielsen is a physician. Conditions are extremely different, one from another. With cancer of the skin you can easily wait for a year and nothing will happen, while other much more malignant types of cancer, for example, certain types of cancer of the breast constitute an emergency and a wait of two months would be too long. The same applies to certain heart conditions. Some patients can wait easily for a year for surgery without endangering their lives, while a delay would cause other patients to be at risk.

Who made the decisions regarding the waiting time? It is a very difficult decision to make.

If we say that no patient should wait longer than two months, the danger is that everyone will wait for two months. You know how bureaucrats operate. Everyone will wait for two months and then, after a month and a half, they will start treating the patient. There must be some flexibility. I am bit worried about rigid bureaucratic decisions as to waiting times.

My next point has to do with private hospitals. If I understand correctly, a patient will now have a choice of hospitals, which he did not have in the past. This does not apply to our country because Canadians have had a choice of hospitals at all times. He will have the option of going to a private, for-profit hospital. Have you any sense of the quality of care at these private, for-profit hospitals? Are they regulated? Do you have any studies of the outcomes of these private for-profit hospitals? Can a patient go there for major surgery with the same confidence he would have if he went to a large, public, teaching hospital?

It is not only a matter of time, of waiting lists; it is also a matter of quality of care. Personally, I would prefer to wait two weeks and ensure that the quality of care will be excellent, rather than having this done in a hurry at an institution where the quality may not be as good.

These are my two questions: first, how to define what is the best waiting time; and, second, what is the quality of care?

Dr. Nielsen: I can assure you that all the arguments that you brought up in introduction to the first point have been in play in Denmark as well. The two-month maximum waiting time offered as an option for the patient has been pressed through. It has not taken into consideration the more fine differentiation that you might see. It may be more beneficial if you look from one diagnosis to the next.

Mr. Petersen: First, for your information, the Liberals came into government in a coalition with the Conservatives.

Senator Morin: We also have Conservative members here.

Mr. Brian Herman, Counsellor, Political and Cultural Affairs, Canadian Embassy in Denmark: The Liberal Party in Denmark is similar to the Conservative Party in Canada, and the Conservative Party in Denmark is similar to the Alliance Party in Canada. You have to move the political spectrum.

Mr. Petersen: With respect to different waiting times and different requirements for urgent care, you are perfectly right that long waiting times may be a big problem or a smal problem, depending on the disease. You mentioned the one cancer disease that is not included in our cancer maximum waiting time: non-melanoma skin cancer.

With regard to the two-month time limit, we do not foresee that all waiting times over two months will disappear in Denmark. We already know from the existing free choice among public hospitals that patients often choose to wait longer to be treated at their local hospitals rather than travelling to Europe and other parts of the country, even though Denmark is a rather small country. Therefore, we do not foresee that many people will take advantage of this offer. One reason is that there are only a few, and rather small, private hospitals in Denmark. Treatment abroad is available, but that brings with it other problems such as language and travelling. We do not foresee a massive travelling of patients and we do not foresee that actual waiting times will drop below two months in all cases.

Senator Morin: You did not specifically comment on quality, but I understand you are satisfied with it. If a patient goes to a private, for-profit hospital, you are satisfied with the quality of the care there. Have you actually measured outcomes, or do you have any evidence to show that the quality of treatment in these private, for-profit hospitals is as good as it is in the other county hospitals?

Mr. Petersen: Yes. Private hospitals are under the same monitoring from the Danish health care authority, our National Board of Health. In many cases, the doctors who work at the private hospitals are the same doctors who work in the public hospitals. The general feeling is that the quality in the private hospitals is on the same level as the public hospitals.

We have not done very much measuring of quality, which is a difficult issue, as you I think you agree.

Senator Morin: If I correctly understand what you are saying, the situation will not change much because patients will not wish to travel outside Denmark, and they will want to wait more than two months to have surgery or take treatment in their local hospital.

Mr. Petersen: You are not correct on the last point. You are right that we do not expect large numbers of patients to take advantage of this offer but, at the same time, other developments are going on. The government has given the counties a good deal of money to extend activities in the public hospitals. We expect that waiting times in the public hospitals will be reduced as well, although, you are right, not in the short run to two months.

The Chairman: Our next questioner will be Senator Robertson who was the Minister of Health in our province of New Brunswick for a number of years.

Senator Robertson: The question that I should like to begin with touches on those questions asked by Dr. Morin. When you were defining the estimated waiting times, were those times developed based on scientific, evidence-based criteria? How did you arrive at those times?

Were the causes of delays the same as those we experience in Canada, such as human resource and diagnostic equipment shortages, and poor management of waiting lists?

You mentioned just a moment ago that the physicians work in both the public and private hospitals. Did I understand you correctly in that statement? If, for example, a surgeon was working in both environments, is that because of the lack of OR time in the public hospital, the lack of sufficient financial resources, the lack of sufficient human resources or the fact that there was more traffic than the facility could accommodate? When a patient goes to a private hospital rather than a public hospital, does the patient participate financially more than in the public hospital?

Mr. Petersen: As to how were these time limits derived, I would say that our maximum waiting time for cancer and heart diseases was based on a professional adjustment that these waiting times, for instance, of two weeks for all life- threatening cancers, was reasonable and, professionally, good enough.

The two-month waiting period, in the general area, is more like a political decision. These are diseases where, from a professional point of view, one could easily wait three, four or six months. It might be unpleasant, but no harm would be done. Therefore, to specify two months, as was done in this case, was a political decision based on the level of service that you would like to offer.

Dr. Nielsen: I will go to the second part of your question which relates to the stress that has been placed upon human resources and equipment in the public sector in order to go to a high level of activity. I will not say that we feel in great need of resources at this time. We have quite a high standard of technological equipment in our hospitals. In the last five or ten years our government has invested some considerable money in equipment, so in that regard, there is no problem.

However, we face a problem with human resources because many young girls do not choose health care as a career. As a matter of fact, some of them are outpacing their main competitors in medical faculties. About 60 per cent of the medical students coming out of the university are women.

Within some years, we might have to find some other hands to take care of health care. Currently, we are looking at bringing some of our immigrants into our health care system.

Senator Morin asked about the quality of care in private hospitals. We have no indications at all that the quality of care in our private hospitals is inferior to the quality in university hospitals. Why do Danish physician specialists go to the private sector? In Denmark, our consultants are employed at the hospitals. Therefore, they are co-workers, so to speak. They have a time schedule that indicates when they will have to serve the public hospital. In their free time, they perform their medical art in the private hospitals. We do not hinder them doing so. They may choose to go there because of, as we have heard, the very satisfying working conditions that they meet in a smaller hospital as opposed to the large, public hospital. The public hospital is considered to be a complicated organization. Private hospitals have 10 or 15 beds and the physician works in a teamwork environment. That is considered to be very satisfying.

Senator Robertson: Have you experienced the problem of the private hospitals co-opting the staff from the public hospitals? That concern is expressed here in Canada, namely, that the private hospitals will take the cream of the crop and the public hospitals will not be serviced as well.

Dr. Nielsen: I would not say that we do not have the same fear. However, we have 165 private hospital beds as compared with 23,000 hospital beds in the public sector. We have a small private sector. Initially, we might see some growth in the private sector. When our physicians have done what they should do in the public hospital, we do not hinder them from doing what they want to do in their free time. We do not see any huge flocks of physicians with the ambition to shift to the private sector. Our public hospitals are still attractive to the physicians and specialists. There is no huge demand to shift sector.

Senator Robertson: Do you require the staff — that is, the physicians surgeons, and the specialists in particular — to work a particular number of hours in the public system in order to participate in the private system?

Dr. Nielsen: It is expected that, if you are employed in an organization, you will fulfil your contract. Therefore, if we do not see that they slip out of the door before the rest of the group, then we do not put up any barriers to prevent physicians from working in both places.

Of course, there is a control with all our employees — we get out of them what we expect.

Senator Robertson: You have a limited number of beds in the private system. Do you control the number of private beds? Could the 165 beds grow to 1,000 private beds, or do you control those numbers?

Dr. Nielsen: We do not control the numbers. It could grow to 1,000. During the last few years, we have seen some initiatives in order to establish private hospitals. Those have has not been very successful from a financial point of view. Many private hospitals have had financial balancing difficulties. That is been limiting. However, if the patient has a free choice, who knows, maybe the patients would like to be served by liberal doctors and you would see a shift towards that. However, this is not because of any difference in quality, and it is not that we try to regulate the markets.

Senator Robertson: A conservative position is always helpful.

The Chairman: Our next questioner is Senator Cook, who has been a member of a board on what started as a small community hospital that ultimately was amalgamated and, by a series of iterations, it is now a large regional hospital.

Senator Cook: Please assist me in understanding the waiting lines. If, for instance, I were in a waiting line in a county hospital and I ran the time limit of two months, and I now have access to a private hospital, would I be able to I jump the queue in the private facility, or would I join the waiting line there?

Is there one code of conduct for the public hospitals and one for the private hospitals? If so, who establishes those and who is responsible for those regulations?

Mr. Petersen: First of all, we have to bear in mind that this scheme, the choice of private hospitals paid for by the public, is coming into the force on July 1. We have not seen it yet.

The patients going to private hospitals today have chosen to pay for the service themselves, even though they could have gotten it for free at a public hospital. The county will only cover the services if the patient's home county has approved sending the patient to a private hospital. That has not been the practice until now.

From July 1, many patients will have the right to be referred to a private hospital, and the service will be covered by the public plan. Until recently, private hospitals have not had waiting times. How they will cope with that problem, if it turns out to be a problem, we do not know. Unlike public hospitals, they will be free to expand because they will be paid for each patient they treat. They may try to attract more resources and expand activities in an effort to keep waiting times down.

Senator Cook: If I live in Denmark and I require hospital treatment as of July, if I understand you correctly, I would have a right of choice. I could go to a private hospital. Who establishes quality assurance for the care and for the outcome of my procedure in the private hospital? Is it regulated, or is it done in-house by the private hospital system?

Dr. Nielsen: Denmark has a central health authority, the National Board of Health. It monitors the quality of procedures. Within the last year, we introduced accreditation in one hospital setting in Denmark. Now accreditation is required nationwide. Frankly, the quality of care in private hospitals is monitored the same way as in the public hospitals.

Senator Cook: From a human resources perspective, do you see private hospitals having an impact on the skilled worker in your public hospital? Is remuneration the same?

Dr. Nielsen: Nurses in private hospitals earn a higher salary than those in the public hospitals. They also have different working conditions. They are obliged to work late at night; however, they are compensated for doing so. Private hospitals try to recruit those with special competencies. We have not seen the same thing with physicians.

Senator Cook: Are nurses, doctors and allied health professionals unionized in Denmark?

Mr. Nielsen: All are unionized.

Senator Cook: Would there be bargaining units for the private and public sector, or is there only one union?

Mr. Nielsen: There is only one union. The nurses union is very interested in serving both the public sector and private hospital nurses.

The Chairman: May I clarify that? If I am a nurse or a doctor in a private hospital, is my remuneration is the same if I am doing the same job in a public hospital?

Mr. Nielsen: No. The nurses, for example, in the private hospital, have a higher salary, but they also have different terms of employment.

The Chairman: However, the private hospital would have a union contract the same way the public hospital does.

Dr. Nielsen: They negotiate with the union. It seems the private hospitals are obtaining higher salary levels than the public sector.

The Chairman: If I looked surprised, it is because I am. Typically, in a Canadian context, the union would attempt to get a uniform wage rate, regardless of the employer. In this case, it seems the union is prepared to accept different wage rates for roughly the same job with different employers.

Dr. Nielsen: It seems so.

The Chairman: The next questioner is Senator Pépin, who was a nurse for many years before entering politics and government.

Senator Pépin: You said that currently 60 per cent of medical students are women. I was happily surprised to hear that you have more women who are qualified doctors. However, you seem a little bit annoyed by that fact. I am wondering why. Is it because they are less qualified or less efficient?

Dr. Nielsen: I would never, in any company, try to hinder women from entering the room. I expressed myself very poorly. Recently, a high percentage of women have entered the medical field, and they are graduating from university with degrees. They are achieving high standards. They boys are doing less.

Senator Pépin: Is it because of the income? Is it because the income is not high enough to attract more young men into medicine? Are they going into another profession where they can earn a higher income?

Dr. Nielsen: Generally, girls are coming out of high school with higher exam results. Those with higher marks will be admitted to medical school, and those with lower marks will have to look for something else. Sixty per cent of those now graduating are young women.

I am not annoyed, but we have some concern that women actually do something else in their lives other than stay in the work place. They have a family to take care of. We have not found any way to have men give birth, and therefore we see the women leaving their work for three-quarters of a year to have one child, more children and so on. That will dramatically change the culture of the medical work force. We see that now. We do not view that with anger or fear, we just speculate on how can we have both an excellent working place for women and have our patients cared for.

Senator Pépin: I want to be naughty and tell you that, yes, it is true that women have children, but on the other hand, when male doctors get to be 50 years old, you find them on the golf courses and the women work at the hospitals.

You have told us that patients are allowed to choose the hospital, even if it is located outside of the country. Do patients take advantage of that right? How do they select the hospital at which they will receive their treatment? In general, how far are they prepared to travel, and who pays for the extra travel cost?

Mr. Petersen: The last question is the easiest. The patient will pay for any extra travel costs. How many patients will go abroad according to this scheme, we do not know. We have some experience with the existing free choice of public hospitals within Denmark. The experience is that some of the patients, approximately 5 per cent, use that right and usually choose a hospital not too far away. We do not expect many patients to travel a long distance.

How will they find the hospitals? As I mentioned, the private hospitals, or the hospitals abroad that want to get into this scheme, must make an agreement with the Danish county councils. The councils will then prepare a list, which will be on their Web sites, as to the agreements they have made and what patients they offer to treat.

We then expect patients to get some help and counselling from their usual general practitioner or from the hospital to which they were primarily referred.

Senator Pépin: If they choose a hospital on the list, and the doctor, does that mean all the expenses will be paid by your government?

Mr. Petersen: The home county will pay for the treatment at the hospital. The only cost the patient will have to pay is the extra transportation costs. They would pay the difference between the transportation cost to the original hospital, or the hospital that the county would refer the patient to, and the actual transportation to the remote, private or foreign hospital.

Senator Pépin: Will patients be entitled to take a family member if they are to have very important surgery or treatment? Will the cost be covered?

Dr. Nielsen: No, those extra costs will also be covered by the patients.

Senator Robertson: Where you have public and private institutions, and there are waiting lists for both, do you allow your citizens to purchase private insurance so that, if they wanted to get into the hospital faster than the waiting line would allow, they would have insurance to pay for the care they get?

Mr. Petersen: Yes, private hospitals are perfectly free to establish themselves and patients are free to go there if they pay themselves, or if they have private insurance that pays for them. If they agree to have private insurance, there still are services covered for free by the public system.

Senator Robertson: Are you suggesting that private insurance would cover processes that are not covered by your state health insurance?

Mr. Petersen: According to the policy agreement, private health insurance in Denmark also covers, in many cases, treatment in the private hospital even though the service could have been had for free in the public hospital. One of the attractions of private health insurance in Denmark is that you can go to a private hospital where there is no waiting list. As I mentioned before, generally speaking, there are no waiting lists in the private hospitals. That is their basic attraction.

Senator Robertson: In the public hospital, are there health services that are deleted? Do you have a roster of processes that are not covered by your public health insurance?

Mr. Petersen: Not really, expect for cosmetic surgery and so on. If we talk about treating diseases, no, all diseases are covered by the public scheme. As to the two months' free choice, there was a question about whether we have a list of services included on the two months ruling which would give a free choice to private hospitals. We do not have an inclusion list, but we have an exclusion list. We have a list of services that are not included in the two months' time limit.

Senator Robertson: What are some of the excluded procedures?

Mr. Petersen: Transplants, where there would be waiting times for obvious reasons other than resources. Fertility treatment, IVF treatment, sterilization and that sort of procedure are not included, and cosmetic surgery, of course.

Senator Robertson: Are abortions covered completely?

Mr. Petersen: Yes, but there are no waiting times in the public hospitals for abortions.

Senator Morin: I would like to come back to the waiting times. As I understand it, in March 2000 a number of targets for waiting times were set. For example, two, three and five weeks for certain conditions and then six weeks for others. Which organization is responsible for setting out these waiting times? Is there any way of appealing or changing these times? Have the times changed with the advance of science, clinical research and so forth? I have the list of cancers that would require surgery — maybe my list is not complete. However, many cancers are not part of the list such as cancer of the kidney and some prostate cancers that are rapidly malignant. The heart conditions can be two, three, five weeks and so forth. These are extremely difficult scientific, clinical decisions to make.

The patient's life is at stake and that worries me. In theory, waiting times are perfect with two weeks here and four weeks there. However, each patient confronts different circumstances. One patient with one condition can wait six months, while another patient cannot wait — depending on the biopsy if we are talking about malignancies, or if we are talking about heart disease it depends on the number of vessels involved and what function of the left ventricle remains, and so forth. I do not want to become too technical. Each patient is so different. I wonder how you can determine waiting times with any sense of equity because one patient may suffer and another may not. Do you have a clinical organization or someone who is constantly reviewing the literature to make sure that these waiting times change with the advances in clinical research?

Mr. Petersen: The list you have is a little obsolete. From September 1 last year, the maximum waiting time for life threatening heart and cancer diseases was extended to include all cancers except for non-melanoma skin cancers. Waiting times are pretty short, two weeks for surgery and four weeks for radiation. Those time limits have been established to ensure that we have the shortest possible waiting times as practicable in our hospitals. Some other waiting times, such as those for heart surgery, have been established by the National Board of Health from professional counsellors and are believed to be in line with professional consent.

However, let me point out that no doctor should disregard his professional evaluation of each individual patient. If a patient is in more urgent need of treatment, then the doctor should treat the most urgent patient first. What he should do with the other patient who has some right on the list is to refer him to a place that can treat him. The professional evaluation of each individual patient is the most important factor.

Senator Morin: My second question deals with those patients who have chosen one of the two types of general practitioners, group 1 and group 2. Would the waiting time for a group 2 patient, the patient who pays for direct access to a specialist, be shorter because he does not have to be referred by his general practitioner? Can he go directly to the cardiologist? Would his waiting time be shorter as he would save on the referral time, which is two weeks on the list I have here?

Mr. Petersen: The two weeks waiting time is defined as the time the referral is received at the hospital until the procedure is offered. It does not matter if the referral comes from a general practitioner or a specialist. You might say that a patient who goes directly to a specialist may not need to go to a hospital in some cases. The practising specialist might be substituting for the hospital in that case.

There are a number of different possibilities. The practitioner may send you to a practising specialist rather than to the hospital, and in that case you could say that the patient who has gone directly to a practising specialist gets into the system faster. However, we think that our system of general practitioners — our gatekeeper system so to speak — is a valuable part of our system. These days, only 1 or 2 per cent of the population is in group 2.

The Chairman: I have two final questions: one of clarification and then a political question. First, is it reasonable for me to assume, given the small size of the private hospitals, that they are only doing relatively simple procedures such as simple orthopaedics and hernias and they are not doing complicated cardiac procedures and so forth? I ask that because I do not know how a small hospital — almost the size of what we would call a clinic — could afford the overhead associated with the more complicated cases.

Dr. Nielsen: A small number of private hospitals in Denmark also take more complicated cases such as coronary bypass operations and hip replacements, if you consider that complicated.

The Chairman: Let us take your hip replacement example. Does that private hospital only deal with joint replacements or orthopaedic procedures? Would the same hospital do a bypass? They focus on doing a limited number of procedures well; is that right?

Dr. Nielsen: They want to have a focused operation. We have one private hospital in Copenhagen that does perform hip replacements, knee replacements and cardiac surgery.

The Chairman: How many beds would it have, roughly?

Mr. Petersen: Approximately 40 or 50 beds.

The Chairman: I am thinking of the amazing overheads you would have in order to operate a 40- or 50-bed hospital with that range of services. Their rates are high, I presume.

Mr. Petersen: It is based on part-time surgeons and physicians who have their full-time job in the public hospitals. They can use different specialists for different cases. They do not have to have a full-time heart surgeon, for instance.

The Chairman: I was thinking more of the capital cost of equipment required. In any event, since it is a free market and they are operating in a big city, their patients would be upper-tier income people for whom an extra few thousand dollars would not be a constraint. Is that a reasonable assumption?

Dr. Nielsen: My comment is maybe that is why we have such a small private sector.

They have experienced great difficulty in finding financial balance. Not many of them are running in balance. They have great deficits. Therefore, we will have to wait some years before we see the booming business of private hospitals in Denmark.

The Chairman: I was intrigued by your observation that the two-month maximum waiting time was a political decision. I had guessed as much

Was whether it should be two months or three months or six months a hotly debated political issue? Was this an election promise that a government put on the table, and therefore, it was implemented without a great debate about the appropriate waiting time?

Mr. Petersen: That is a fair and precise description. The former government had a three-month waiting time goal, you might say. At that time, the opposition in the election campaign promised this two-month time limit and after that you would have free choice to a private hospital.

The Chairman: We got from three months to two months as part of competitive pricing in an election market. Is that a reasonable assumption?

Mr. Petersen: Very precise.

Senator Pépin: There was no study done prior to adopting the policy choosing two months compared with three months? Was it merely an electoral promise?

Mr. Petersen: As I mentioned, all the diseases we are talking about are those where people can in fact wait three, four or six months. It may be unpleasant, but not harmful. Therefore, it is a question of the level of service you want to give your citizens. It is not unfair that it is a political decision, in fact.

Senator Pépin: We will be watching you.

Dr. Nielsen: Before I changed to my current position, I was a medical director of a hospital in a county where it was decided to introduce a three-month-maximum waiting time. We organized and reorganized all the hospitals and all the clinical departments in order to gear up for that level of activity.

This election came along and set the barrier higher, and that caused some frustration. However, everyone is now doing the best that they can to fulfil the objectives of the government. To have changing expectations in a very short period might exhaust even people in the medical profession.

Senator Cook: I am back to the waiting line issue. I have been diagnosed with a problem, and I am on your waiting list. Am I to assume that all the tests and the diagnosis are ready, and I am just waiting for the procedure?

When I come off the public hospital list and into private hospital care, is information shared or must I start at the beginning? Does my file go with me?

Mr. Petersen: Yes. The necessary information will be transferred from the public to the private hospital.

Senator Cook: In effect, that would lessen the need for equipment in a private facility.

Mr. Petersen: We do not want double examinations.

Senator Cook: Would the public and private hospitals share diagnostic equipment?

Mr. Petersen: They would not share equipment. They would share information. For example, the X-ray pictures and MRI scans would be transferred from the public hospitals to the private.

The Chairman: That is a perfect bridge to the next panel, which will deal with electronic health files. Thank you very much for joining us. It has been most helpful.

The next two witnesses are from the National Board of Health, which we just heard is, among other things, responsible for quality evaluation and outcomes research both in the public and private sectors.

Welcome. I know that you will be giving us an overview. However, before you start direct comments on medical informatics and electronic health records, you might give us a brief summary of the role of the National Board of Health in managing the health care system in Denmark.

Please proceed.

Mr. Morten Hjulsager, Head of Department, National Board of Health, Government of Denmark: We have not organized a formal introduction from the National Board of Health. Between the two of us, perhaps we can put it together.

The Chairman: It would be useful if we understood what the National Board of Health does.

Dr. Kverneland, Head of Division of Medical Informatics, National Board of Health, Government of Denmark: We can give a short introduction. The National Board of Health has seven departments of which, Medical Statistics is one department and Medical Informatics is another.

Our role is to collect information from what is going on in health services in Denmark, especially in the hospitals. We collect data and we compile statistics. Informatics' role is to come up with standards about how to collect data, manage that data, and how the registered work in the field occurs.

The National Board of Health also deals with prevention and quality improvement.

Mr. Hjulsager: The board also has departments that deal with health planning in general and departments that deal with the supervision of health personnel.

The Chairman: Are you an arm's length agency from the government? What is your relationship with the ministry?

Dr. Kverneland: We are part of the ministry. However, we have our own registration. We focus on certain areas. We collaborate with the Ministry of Health but we are responsible for the security of patient rights. We have our own legislation to deal with that.

The Chairman: Are you publicly funded out of the ministry's budget?

Dr. Kverneland: Yes.

The Chairman: Please proceed to tell us about your electronic health records.

Dr. Kverneland: I am a medical doctor who has been working in the field of Medical Informatics for five years. The National Board of Health has a department which focuses on standardization, and I will tell you about that. We have come up with a national IT strategy for Danish hospitals and we are on working on a new strategy for 2003-07. I will show you the actual strategy from 2000-02.

In 1996, there was a strategic report action plan for EPR. In 1998, we founded the EPR observatory that looked into what happened in various hospitals. They collected experiences from EPR sites in Denmark.

In 1999, the strategy I told you about came into existence, namely, the strategy for the development of information technology in hospitals, 2000-02. That is what we are working on at the moment. The new strategy will be in for 2003.

As to the main topics in the National Board of Health, in the Department of Medical Informatics, we are working with the classification system, the medical record, the clinical quality databases and communication. We use EDIFACT. We have a huge EDIFACT communication system in Denmark. We have about 2 to 3 million messages a month.

The Chairman: Can you take one second to explain what you mean by EDIFACT? That is an acronym I have not heard before.

Dr. Kverneland: EDIFACT is a technical way of communicating. It is used for prescriptions, referral notes and admissions from the general practitioner to the hospital and from the general participatory to the pharmacy. They communicate on this standard called EDIFACT.

The Chairman: It is the technical standard.

Dr. Kverneland: It is also called EDI.

We are also working on is a national patient registry. I will not go into further details on that.

This is linked together in a parcel where we have the national health classifications systems in the middle and EDI communication, the medical records, the patient register and the quality databases all using that classification system.

We are talking about two generations of medical records. I call the first generation electronic paper where you do not structure the information. You do what you always have done. You write by hand and on the screen. You have the text of a medical record. Of course, we call it the first generation because we went further than that. It is now electronic paper. Of course, with that, you gain a multi-user environment and easy accessibility. You have some compression of the record, and you have the possibility of much more security and access to regulation when this is done electronically.

The second generation is structuring the data. We want a common way of structuring the data and know what has to be done if it is to be used further. If you want to do it as quality monitoring or as professional management, like DRG, you can get help from professional decision support. You have more research opportunities, more possibilities for updated medical statistics and much more possibility to do communication of information, which is understandable on the receiver.

We are working with clinic processes. I apologize for the red circles. These are Danish words, but I can explain them to you. Our model for the EPR, the patient record, is an individual model used when treating patients. The first red circle is for the diagnosis; and the diagnosis is then documented in the blue field. In the next red field in the lower left, you make a plan for the patient's treatment; and in the lower blue field, you document your plan. The treatment plan is carried out and you document your results; and in the next red circle, you record your evaluation. In the middle, you document the patient's treatment goal, and you compare the result with the goal.

That is the process model for the patient record in Denmark. I hope it is not too complicated for you. I tried to make it simple. Of course, if you delve further into each part of the model, it is complicated; however, it is useful from a clinical perspective. This is used as the basis for medical records in Denmark.

What needs to be standardized in this development? We are working with commonly shared terminology and definitions. We are working with a model based on the patient's treatment.

Next is the patient record structure, the data model that I showed you earlier, and then the national health classification system. National standards are needed for using and developing the medical record system.

We then have an example of how we use and change the patient context, which is referred to as ``admission in an outpatient clinic.'' If you link this context together in one informatic unit, you can then use it to compile statistics for DRG and for research. You link it together in an episode-of-care model.

From the IT point of view, the National Board of Health is working with the EPR structure, with a continuity-of- care model, with technology, with the episode-based patient register as well as patient intake and security.

You asked how EPR worked in Denmark and whether there were barriers using medical records. I found a picture from 1998 and 1999, from the EPR observatory, with respect to the record project in Denmark. It shows the results. The blue one is 1998 and the red one is 1999. I think the barrier is funding. There is insufficient funding and an unsatisfactory EPR system. There is little resistance to change in this result.

Finally, IT is a means, not a goal. The means should be used for the support process and problem solving. It should present the necessary information to the correct person, allow for the possibility of real-time registration and presentation, simple documentation, and we should make use of the data for all purposes.

That is my presentation.

The Chairman: Before I turn to questions, would you expand as much as you can on the privacy issue? One resistance to an electronic patient record in Canada is concern about the privacy of information. People are concerned that their employers will be able to access the information. Will their life insurance company, for example, be able to access the information? How have you ensured the security of the system? I would also like to know the extent to which that is a public issue. If it is a public issue, how have you allayed peoples' fears about the loss of privacy on what is clearly the most private information?

Dr. Kverneland: Insurance companies do not have access to this information. Some information may be forthcoming if the insurance companies ask the general practitioner for it. They have no access to this, and they will never get it in Denmark.

When we collect information from the patient, we tell the patient that we will be using it for quality purposes and for statistics. They can say ``no'' if they do not want you to collect it. However, usually they consent. They trust that the information is being used for their benefit.

The Chairman: Was there no fear of ``Big Brother''? I am not exaggerating to make a point. I am using the kind of language that opponents to electronic records have used. Is it just that the Danes are more trusting of their government or the government is more deserving of trust, or did you do something specific to deal with the issue?

Dr. Kverneland: If some information reaches the wrong hands, the press or someone else, then a case might arise out of that. Then, I am sure, there would be some discussion. However, that has not happened. The law is very clear: You ask a patient, the patient can say no, and that is accepted.

Mr. Hjulsager: Perhaps I can add to what Dr. Kverneland has already said. It is important to realize that there is a long tradition of public registers containing individual data on the public. We originally had this discussion, and there has been intense discussion in the public concerning the ``Big Brother'' view. However, we have managed for many years now to create confidence in the public. I will show you later on how we have dealt with confidentiality issues in regards to health information systems.

The Chairman: Would you now care to comment specifically on how you dealt with the confidentiality question? How do you ensure that only authorized people have access to the system?

Dr. Kverneland: The counties are running the hospital system to a large degree. We told them that they have to take a hand in the security of and access to the system by using PIN codes or another system for security. We gave them rules, and some information about how they can do it. However, they have to do it themselves.

Some counties are better than others in making these systems acceptable from our point of view. We have worked on it, and we have made some very strict guidelines during the last two or three months which precisely describe how they must work. We hope it will work and that it will get better, so that the security is good enough that we do not risk having data getting into the wrong hands.

The Chairman: Are there severe penalties for someone violating your guidelines?

Dr. Kverneland: No, I think you have to rely on civil rights, and then you go to court if you are seeking to levy penalties.

Senator LeBreton: On the same issue of the security and accessibility of patient records, are those records held in a public institution? Am I correct that individual, private patients do not hold them?

Dr. Kverneland: Some hospitals get help from private companies to run their IT systems. The county has that responsibility. It is not private.

Senator LeBreton: Can the individual, private patient access at all times what is being held in the public registry on their file?

Dr. Kverneland: Not at the moment. We are working intensely on that question. Of course, the patient should know what is collected about them. If we reach the point that the patient can do that, then they will not be afraid of the system. It is an important point.

Mr. Hjulsager: I might add that a part of the patient record is submitted to the National Board of Health and is entered into the National Patient Registry. Citizens contact us on a daily basis and ask for access to information held within the National Patient Registry. They are given this information within 20 days.

Senator LeBreton: Is that the individual patient?

Mr. Hjulsager: Yes.

Senator LeBreton: You can have occasions where you want patients to participate in a research study and, of course, some may not want to do that. Do they have the right to deny their records going into research projects?

Mr. Hjulsager: It is complicated. We have general laws that describe how you must take care of individuals' information. In general, the patients cannot, and will not, be asked whether or not they want to enter a research project. That is the general issue. In some projects, where the researcher has to collect additional information further to what is within the register, he must ask the patient, and the patient has to give permission to access this information.

At the general level, we have a data inspection board that keeps records, and monitors and accepts all projects, stating all the current projects that contain the individual data. Every research project or administration has to be notified and accepted by the data board.

Senator Robertson: There is a lot of information here. As you may know, we have had considerable difficulty with our public regarding their concern for privacy.

If I were a patient in your country and my file were gathered and stored, who would have access to my file besides myself?

Mr. Hjulsager: The general answer is that everyone who is carrying out the job and needs access to the information has access.

Senator Robertson: Everyone associated with the job. Does that mean everyone who stores and gathers information, in addition to your physicians and the hospitals or whatever, has access to your file?

Mr. Hjulsager: If they need the access to carry out their jobs, they are given access to the information.

Senator Robertson: Could you please define what you mean by that? I can understand physicians needing the information. However, I am having trouble understanding why those who work in this division storing information and that sort of thing would require access. Why would they need the information?

Mr. Hjulsager: One purpose would be to develop a health information system to be used in quality control or quality development of the health sector. It could be as simple as giving information to politicians in parliament.

Senator Robertson: I do not want a politician looking at my private information. Let me just digest that for a moment.

Mr. Hjulsager: I would add that, when the information is given out further in the system, it is delivered at an aggregated level.

Senator Robertson: You are giving out blind information, are you? My name would not be attached to the information given.

Dr. Kverneland: No.

Mr. Hjulsager: The statistics that are used in health quality and health planning, is not based on individual information. The information must be anonymous for it to go further.

Senator Robertson: That is comforting.

Do drug companies ask to raid your files, for instance? We have heard here that certain drug companies will find out from computer files in a public pharmacy, a drugstore, who is using their product and who is not using their product for a medical condition. They often get the list of the doctors who do not prescribe their products. Then the drug company can target those physicians and encourage them to use the product. Some of us find that is, perhaps, not an ethical practice. Do you encounter problems like that? We have had many examples pointed out to us of where the system goes astray. Our public is very nervous about this.

Dr. Kverneland: If that happened in Denmark, it would be breaking the law. There is a law against the use of information for such a purpose. The closest you can come to that is that they gather statistics in each county that is a part of Denmark. Denmark has 14 counties with some 300,000 to 400,000 people in each county. Some statistics are gathered about which medicines are used in a particular county. Therefore, one can find out if there are 20, 40 or 50 doctors in that area. If they do not use some products, then the industry can go to those doctors and ask them why they are not using their product, and advise them that they should use it. That is a type of marketing with statistics. It is not individual patient data. That is the closest they can come. If they used personal data for such a purpose, they would be punished. That cannot be done.

Senator Robertson: Commercial interests can gather collective information on a county basis?

Dr. Kverneland: Yes, but not on that type of data. They can compile statistics about which products they sell in which area. That is the information they get, not which patient has used that product. I think it is more like a marketing analysis.

Senator Robertson: I was not talking about which patient was using a product, I was talking about the pharmacies giving information to commercial companies which would indicate what doctors are not using a particular product, and the companies putting pressure on that group. When someone asks for access to a file are they refused that access? Are my rights protected by legislation that is so strict and the penalties so severe that the abuse is limited?

Dr. Kverneland: Something like that, yes.

Senator Keon: I want to ask you some specifics about the way the system functions, how the data is entered, where it is stored, where your repositories are, who has access to the repositories along the way before it get up to the central government repository, and how you can tap a local repository to retrieve the data. Could you describe for me the situation where a patient goes into a small clinic or hospital, the medical information is entered, and where that information is lodged in transit? Is there a repository in each hospital, or does the data go directly to the central repository?

Dr. Kverneland: I would point out that most of the clinical information in Denmark is still paper-based. In clinics where paper-based records are used, some registration in the IT system is made. It is typical for the secretary of the department to register that information in the system on behalf of the medical doctor. That registered information goes to the national level each month. That is the usual way that is done.

Some medical records are kept in some of the hospitals. They collect all the data in the local system and send the same information once a month to the national level.

Different IT companies are involved. In some counties, the IT company runs the IT system. Of course, technicians working with that IT system could take data out of the system, but that would be against the law. Of course, there are criminals everywhere, so there is a risk. I have not heard about problems with this.

Senator Keon: Fundamentally, you are saying that at the institutional level, you have trained abstractors who take the relevant data off the chart and send it up the line into the central repository. Do you have any institutions with what we would call in North America TMR, total medical records, that contain detailed information? What are the rules about that information being released to researchers and so forth?

Dr. Kverneland: No, we do not have that at all.

Senator Morin: The privacy issue is very important to Canadians. Polls in various provinces have shown that up to 25 per cent of the population would not want to have their records transferred to an electronic form. People have much more concern about an electronic health record than they would have with a paper record. People have no objection to a paper record going all over the place in the hospital, with many people handling it, but they have a strong objection to the electronic health record, which is probably due to their fears about possible hacking, slip-ups or accidents occurring. I would say that this is a major impediment to the establishment of electronic health records in this country.

We also have privacy commissioners in this country, which you probably do not have in Denmark, who also, with reason of course, ensure that privacy is well preserved. It is a major issue here.

You already have an information system, although it is not a complete electronic health record. What clinical information would be transferred from a hospital to the central department? Would it be only the diagnosis or more than that?

I also see that there is a transfer of prescriptions. Does that mean that the individual general practitioner will transfer prescriptions to the pharmacies, or is that purely for administrative purposes — for example, for payment of the pharmacy and so forth?

I see that there has been recent funding for information technology. Can you give me an idea of how expensive that has been? I know you are planning your information system. You are far more advanced than many other countries in the planning of your system. How expensive is your system?

Dr. Kverneland: First, I will talk about the information transferred from the clinic to the national level. The prescriptions go to the pharmacy only, not to the national level. Typically, we collect information on the diagnosis of a patient and the surgical procedures performed on the patient, as well as some other administrative information.

Mr. Hjulsager: We have the basic information concerning the patient — personal security number, address, et cetera.

I can tell from your questions that you have a lot of concern about the privacy issue. I would like to underline that this is very important, and suggest that you take this issue very seriously.

In Denmark there is a long tradition, going back to the mid-1970s,when every person was given a personal security number. To some degree, the Danish population has learned to live with being monitored on an individual basis. This also occurs in the health area.

Our laws are set up to handle the rather specific and detailed information on the patients. We have some general bodies within the state that monitor every registry that contains information at the personal level, whether it is in the area of health or any other area. This is a duty that lies both in the private area, but also for those in the public area. We must report to this body any registries that we are maintaining.

As to the costing question, it is difficult for me to give you good information on that on the spot. I could provide that information by letter, if that would be agreeable.

Senator Morin: Yes. Thank you.

Dr. Kverneland: You asked about the economy of the evelopment of IT in the hospitals. The County of Copenhagen, which is about 600,000 people, is working on a strategy which they will implement over the next four or five years. They have planned to use 1.2 billion kroner for the EPR and for whatever is needed for a working clinical IT system. That will be approximately 200 million kroner per year for that 600,000-person area.

The Chairman: That is approximately $100 million Canadian a year, to put it in perspective.

Senator Pépin: One of you said that the insurance companies have no access to the data. Please explain something to me. If a patient has surgery as part of the treatment for breast cancer, and the bill is sent to the insurance company, how is it possible that the insurance company does not know what condition the patient has? How does the billing work between the insurance company and the hospital or doctor?

Dr. Kverneland: In Denmark, all treatment is free. You do not pay for treatment. You pay your taxes, and you get all the treatment free at the hospital. There will be no bill.

Senator Pépin: No one needs private insurance then?

Dr. Kverneland: No.

Mr. Hjulsager: However, you can see that there is a lot of growth in the area of private insurance. The number of people who are insured is increasing rapidly. There has been a lot of growth in that area.

In cases where the insurance company does need information in order to pay a bill, the bill must be it must be for a private hospital where a patient has received treatment. The bill is then paid by the insurance company.

There has to be supplementary flow of information in order to have an insurance company make a payment. This is not based directly on the medical record. Additional information has to be given to the insurance company.

Dr. Kverneland: As it works in Denmark, the county that is running the public hospitals goes to the private hospitals and says, ``We cannot treat all our patients. Can we have some patients treated at your private hospital?'' They define what treatment the patient needs.

It is customary in the case of a standard procedure such as a hip replacement or heart surgery that that is paid at a fixed price. They have no direct access to setting the medical fee. It is a pegged payment.

Senator Pépin: Perhaps you will be facing that situation after July 1, 2002.

To go back to the information on a patient file, let us assume that a patient comes to the hospital or to the clinic for a blood test. You told us that everything is written on the file. When the patient is in the hospital, one only needs to push a button to find out the disease of the patient. It must show on the file. If a patient comes to the hospital for a blood test, the same hospital where he or she had surgery, the patient gives his or her medicare card, and after that the hospital card number. They must have access or do they not have access? What is your system?

Dr. Kverneland: They do not have access, of course. When you are required to have a blood test, the medical doctor fills out a requisition for the test and the result goes to the medical doctor. The laboratory does not see anything other than the requisition with an X in the system, which is on the requisition form.

If a patient is taking lithium, which is a medical treatment for depression, and it is monitored in a laboratory, of course the laboratory would know that the patient is being treated.

Senator Pépin: If I go to the same hospital where I had surgery and I need, let us say, a blood count, even if the hospital has my card number, they would not find my diagnosis on my file.

Dr. Kverneland: The reason for the test must be defined. If a medical doctor request a blood analysis, then there must be some clinical information accompanying that request. The doctor asking for the examination would tell the patient that the physician who will deal with the blood analysis will require some clinical information in order to do his job properly. However, that would be specific.

Senator Pépin: We have a lot to learn about that.

Senator Cordy: The information you are giving is most helpful.

I would like to get back to the issue of funding which Senator Morin raised. As you explained to us, to set up such a system is very expensive. It is also very expensive to maintain it. One must have long-term funding, which you told us your government is willing to provide.

The systems in all of your counties must be compatible. Who paid to set up and maintain the systems? Did that money come from the federal government or was it co-shared with the counties? How were the funding arrangements set up?

Dr. Kverneland: There are two questions. The first one involves the standards that are developed in collaboration in Europe and also in the ISO — International Standardization Organization. Then there is a national standardization paid for by the national government. We in the National Board of Health are working on that.

However, the implementation of the standards is work done by the IT specifically in the counties. It is a very good question because we are currently discussing how far the government shall follow the standards in the systems. We have not really finished discussing that. Some say we must follow the standard much more out in the field because, if they implement it in the way they want to implement it, then we cannot communicate. It is a good question. I cannot answer precisely but we are working on going further out in the field with the implementation.

Senator Cordy: My next question was regarding implementation in doctors' offices and in hospitals. How much influence would you have in terms of their implementation of the patient health record systems in private hospitals?

Mr. Hjulsager: I can give you some insight into the National Patient Registry. Both private and public hospitals send patient information to the National Board of Health for the National Patient Registry and information on the activity in a hospital. At the moment, we have not been very successful in receiving information from the private hospitals. I would expect that we have asked a handful — maybe five hospitals — for information, and one or two are now giving the information to us.

Dr. Kverneland: You should know that less than 1 per cent of the hospital beds in Denmark are in the private sector. We have very few private hospitals. I think there are only two or three. There are also a handful of private clinics.

Senator Cordy: I wonder whether or not in the long term you would have a patient card that the patient could carry around with them to have access to their records, not only within Denmark but, if they were to travel to Canada, for example, and needed medical attention, they would be able to access their health information.

Dr. Kverneland: I have heard about it and we have discussed it, but I do not think we have made decisions on that. If we issued a chip or a card containing the medical record, when the patient goes to the hospital she or he may have forgotten that card or it may have been lost or destroyed. We do not trust that way of transferring information. We have to have it within the hospital and within the county.

Senator Robertson: I have several questions on how you use the system from the practical point of view of the patient, the doctor's office, or the pharmacy on a daily basis. One of the concerns that we have in Canada is that some patients go shopping for family practitioners. They collect prescriptions from them and then they go to different pharmacies to fill their prescriptions.

Let me put myself in the position of the patient. If I go to my family practitioner, then does he or she have access to my total medical file? If I go into the pharmacy to have a prescription filled, does that pharmacist have access to all of the medications I have collected in whatever period of time or framework you are using? Do dental surgeons have access to a patient's total file?

Dr. Kverneland: You are asking many questions. The pharmacy only knows about medicines that are paid for by the government. If the government should pay for some part of the medication, then that information is in a central registry.

With certain narcotics, physicians must send a copy of the prescription to the national government. That information will be gathered so that, if a person gets many prescriptions from different doctors or a doctor prescribes too many narcotics, some pain relief medications or morphine, then the authorities will ;contact the doctor and advise him not to prescribe such medication.

If a patient goes to different doctors and gets different prescriptions, there is no system for collecting that information. However, most medical doctors will not prescribe narcotics to a patient with whom they are not familiar. There is no system for collecting information other than the information related to prescriptions for heavy drugs.

The Chairman: What is your estimated length of time for full national implementation? You said that Copenhagen was planning on 300 million kroners a year for a period of four or five years.

Mr. Kverneland: I could say, with some polemic, ``When will you be finished with this job?'' However, we are very close to achieving our mission of having the medical records for a patient's episode of care electronically connected, with the possibility of communicating between different departments in six or seven years time, if the counties want to pay for it, because I do not know that they all have committed to that sort of long-term budgeting. I do not think they have done that, but if they do, we will be there in six or seven years.

The Chairman: The issue is the same issue we have here, which is: Who will pay for it? To that extent, if the national government believes it is useful, it is more inclined to make a significant contribution.

Mr. Kverneland: I hope so.

The Chairman: In your response to the question from Senator Keon, I got the impression that the data is input into the system by experts who are trained to read a doctor's paper record and abstract it into your system. Is that how it is done? If one goes to an individual family practitioner, does that individual family practitioner input the data or does someone in her office do it? I think this is a huge human resource education and training problem.

Mr. Kverneland: In Denmark, in general, most of the practising GPs have an electronic patient record. They enter the data themselves.

The Chairman: How difficult was it to educate the family practitioners to do that?

Mr. Kverneland: It is a process that they themselves have adopted. It was cheap and smart.

The Chairman: They did it as good business practice for themselves as opposed to you having to impose it.

Mr. Kverneland: Yes.

The Chairman: The National Board of Health does the quality evaluation of various institutions, hospitals and so on.

Does that mean that the information in the electronic record is being used for outcomes research, that is to say analysing the quality of service? I presume it is an integral part of the data that anyone doing proper outcomes research would require. Is that correct?

Mr. Hjulsager: That is correct. It is an integrated process of quality development and control. Some of it takes place within the National Board of Health, or with the National Board of Health as the central figure. There is much activity in the local clinical units. A specified part of the patient record is recorded monthly to the National Board of Health.

We keep a total register concerning both in-patient and out-patient activity in somatic and psychiatric departments in the hospitals. This is kept as a national register. This register is used in many ways in quality control and development, both within the National Board of Health and in many research projects. We process and submit data to those projects, and the outcomes of the projects are used in quality control and planning.

In general, we try to stimulate a high degree of self-control in the clinical departments.

The Chairman: How critical is the electronic patient record to being able to do effective or competent outcomes research?

Mr. Kverneland: It is not critical at the moment, but we are thinking of the medical record as the most important part of the quality improvement process.

The Chairman: It is not now, as the system is not yet operating, but do you see it as we do, that is, down the road, quality improvement, monitoring of outcomes and outcomes research will all require the electronic patient records as the cornerstone of input?

Mr. Kverneland: I agree with the structuring of information because, if you structure your information in a way that you can make those analyses, you have to structure it in the same way to make other analyses.

The Chairman: May I thank both of you for coming and being with us this morning. We are delighted that the technology is working so well.

We would ask that you e-mail to us the power-point presentation you did because then we could distribute it to members of the committee.

I would also like to thank Brian Herman who is from the Canadian embassy in Denmark, and also ambassador Neilsen who is the Danish ambassador to Canada. Thank you. You have been very helpful.

The committee adjourned.