Health Committee on June 1st, 2006

[The Chair, Conservative, Rob Merrifield]

I will call the meeting to order.

First of all, welcome everyone. This is the sixth meeting of the Standing Committee on Health of the 39th Parliament.

I will start first of all with an announcement to the committee members to let you know we will need to deal with one motion concerning some finances of the committee, which we will do after we're done with the witness portion and questioning portion of our meeting. We will have this later on in the meeting; I just wanted to give you that information.

We have a great selection of witnesses with us today to talk about wait times and success stories right across Canada. We're looking forward to what they have to present to committee and, by doing so, to Canadians. I first of all want to introduce them.

With us today is Mr. Cyril Frank, who is vice-chair of the Alberta Bone and Joint Health Institute. Thank you for being here.

Also, from the Cardiac Care Network of Ontario we have Kevin Glasgow. Thank you for coming.

The Canadian Association of Radiologists is represented by Dr. Martin Reed. Thank you for being here.

And with us also today from Capital Health is Richard Lewanczuk. Thank you for coming, as well as Angela Estey, also from Capital Health. Thank you for being here.

We are looking forward to what you have to share with us, and we'll start right off the bat with Mr. Frank. Would you please start us with your presentation?

[Dr. Cyril Frank, Co Vice-Chair, Alberta Bone and Joint Health Institute]

Mr. Chair, it's a great honour to be here. Thank you for the invitation.

I'm here not to rehash all the problems in health care but to propose some potential solutions, with some preliminary evidence that it is possible. I brought copies of my presentation in both English and French, to be distributed to you.

I would like to start by telling you a little bit about the Alberta Bone and Joint Health Institute, what it is, what we've done with our pilot project and what we're planning to do with our next steps, and tell you where the institute is going in the future.

The institute is a not-for-profit entity, which is a registered charity created by philanthropy in the province of Alberta. It has two key roles. It attempts to be the catalyst for positive change in our health system and to become the objective evaluator of the success of the changed system.

The central operating theme of the institute is to create cooperation between the key players in health that have been operating in relative silos--the health regions; the universities; members of the public; the bone and joint health practitioners, in our case; government; and industry.

The institute was created by Mr. Bud McCaig, a philanthropist in our community who engaged a number of community leaders to serve on a board of directors. Their names are listed for you, including Peter Lougheed, who is a special adviser to our board of directors. We also have an international advisory board of prominent people from the United States and internationally who are advising us on whether we're doing the right things to promote change in our health system and not reinvent the wheel.

The goal of the institute is to create a sustainable system of patient-centred care that efficiently provides the best quality care to all Albertans equally. It meets people's needs as the top priority. It isn't organized for doctors, it's organized for patients and the public.

The problem, as we see it in the institute, is that there are these long waiting times for various elective procedures such as hip and knee replacement, as one example, and the reasons for those long lists are not totally clear. We would propose that we need to be clear on what the problems are in order to solve them, and a systematic solution is possible if we understand what the problems are.

Central to solving the problems, we believe, is that a partnership is required between these various entities that have been operating in silos, and that's the role of the institute--to bring them back together where they're no longer adversarial but cooperate to achieve the right balance of access, quality, and cost control.

The hip and knee project that the institute championed is an example of that. The institute analyzed the problems and began implementing solutions by communicating with all those partners and securing buy-in of all the health regions in Alberta, Alberta Health and Wellness, primary care physicians, and all the orthopedic surgeons in the province. About 100 orthopedic surgeons are behind this project. The institute then worked with those partners to clean up the poor information that existed in the system, starting with the waiting lists. I'll give you some examples in a few minutes of how poor the information is.

The institute analyzed the existing way of doing business and designed a new way of doing business, called a continuum approach, which is not totally unique. There are other examples that we're going to hear about today of reorganizing the system to make it more efficient and effective.

The institute did secure the buy-in of Alberta Health with the commitment of new dollars to be able to do this, and I will talk about that in a few minutes, too. But there was $20 million allocated by the Province of Alberta to make this happen, which was obviously very important for change management, as well as doing the new joint replacements.

We then went on to test this new way of doing things, the ideal continuum. The top of the next page shows the partners involved in the project: the universities, the health regions, and all the doctors.

I want to again quickly highlight what we believe the problems are.

The system is very confusing; patients are left on their own to try to navigate this complicated system. There is a lot of redundancy, inefficiency, and waste when people are trying to navigate the system on their own, seeking care from multiple providers, recycling through diagnostic testing in a very inefficient manner, and consuming unnecessary resources and time.

There was also a critical lack of good information to fix this problem. The administrative databases do not contain the real information needed to solve this in terms of access, quality, and cost. There is a schematic here of a spaghetti-like system that has been organized around departments and doctors and hospitals. It looks very confusing to people.

Central in our whole argument is that we need accurate information to solve this. A couple of examples of cleaning up the so-called queue or the waiting times occurred when we analyzed 20 surgeons' practices. We discovered that about 15.5% of people who had already signed consent forms to have surgery by those surgeons were not really waiting for surgery at all. Many of them had already had surgery; some of them were dead, had moved away, or didn't want surgery, despite the fact that they had signed a consent form. They had done so just to have their names on the list in hopes of having surgery in the future.

A separate list of people who had been referred to these surgeons was even worse. Fully one-third of them were not really waiting to see that surgeon. Unknown to the surgeon, they had already seen others and had had their surgery. They had actually been working their way through a separate path in the system entirely, consuming unnecessary resources. These surgeons were waiting in good faith for patients to show up in their practice, whereas they had already been treated. That's just an example of poor information driving unnecessary cost, waste, and inefficiency of people's time and effort.

What the institute did was create a continuum approach with some hard guidelines around when the clock starts and stops on different parts of the continuum of care. The system was reorganized from a patient's perspective from beginning to end, from hip pain all the way through to a happy, healthy, educated patient back home again. I'm not going to go through the details of that unless you want to in the questions, but the way the system was re-engineered was through creating focused facilities with central triage clinics, multidisciplinary teams with case managers assigned to every patient and armed with standards and benchmarks of time of access, and appropriate testing. These were implemented in every patient's case.

Central to this was the creation of an accurate database of access quality, which meant satisfaction as well as patient outcomes were being measured in every case--and cost, both direct and indirect, with a costing system that has been agreed to by all three participating health regions. We were able, for the first time, to define accurate case costing of hip and knee replacements with some agreement on what that means, and have the ability, most importantly, to track it prospectively for all cases. We have a benchmark of figuring out cost.

We set this up as a randomized control trial, which is a research design in which the same surgeons send patients either into this new path or into the existing path. Then we measured access, quality, and cost.

A preliminary report released in December talked about their improved access times. Times were dramatically reduced: the waiting time to see a surgeon went down from 35 weeks to 6 weeks, and the waiting time for surgery went from 47 weeks to 4.7 weeks. Again, this was 1,200 patients in a specialized system, just to show proof of the concept that it can be done. This is a kind of best-case scenario, with new resources, new teams, and adequate pathways. It shows what can be done.

The most important part of that is the information being generated for all patients going through the system. There'll be another report coming out from the institute within the next couple of months, with more quality and cost information. That will be more revealing about the cost-benefit ratio of doing it this way.

Patients were very satisfied with this new way of doing things. They said it was better. They felt as if they knew what was required. Somebody was always looking after them in the system. They loved their case managers. So proof of concept shows this new way is better in terms of satisfaction and can provide better access.

However, you might say, “So what? This was done with new money that could have been directed to doing new hips and knees”, which is the solution in some other jurisdictions we're aware of. Well, not only did this provide better access and higher satisfaction, we think there will be better outcomes. There will be a system in place for measuring access, quality, and cost for all the patients in the province, because we're now actually spinning out this model to the entire province. We've engaged all of the orthopedic surgeons doing hip and knee replacements. Using what we've learned from this project, it's now being used for all the doctors in those three regions, and we're educating the others in the other health regions.

This also gives us the chance to now identify how much it really costs to provide care across the continuum, and for the first time ask the providers, “Can we save money and provide better care?”, which I think is critical to creating a sustainable system. They've never been asked before, “Can you imagine saving money, as co-owners of this business?” In hallway discussions I've had, every one of them believes they can.

I don't want to over-promise and under-deliver, but I'm thinking that a minimum of 10% in costs could be saved in every case, which could be reinvested in doing 10% more. It could probably be more than that with a little bit of pushing.

So the bottom line is that this gives us better information to drive change. We can drive this out with evidence-based decision-making on access, quality, and--I emphasize--cost, and create a new business model with incentives for providers, for the first time, to participate in fixing the system.

We've set up a case rate for funding hip and knee replacements that is flowing into physician groups to manage the continuum of care. I believe that will change how the physicians are actually incented to help fix access, quality, and cost with real information, knowing that somebody is paying attention and getting the right information that's going to improve their quality of care, but also incenting them to be more efficient and cost-effective.

This will allow us to project what's really needed in the future, so there will be no more hysteria about how many patients require care and how much it is going to cost. We will know accurately within the next few months what it will cost to fix this problem, for all time and eternity, for the province.

Our stepwise approach to solving this is to optimize what we have and make it as cost-effective as we possibly can by asking the providers to participate in the solution. We believe that if we don't do that as the first step, it'll never happen. We believe people will continue to order unnecessary tests and drive unnecessary cost, unless they're incented to fix it first.

Then we can transparently define what we need, discuss the options on how to fix it by stopping to do things of marginal benefit that are evidence-based--diagnostic tests, rehabilitation, and whatever is unnecessary--and reinvest that value. That's the bottom line. We propose that as a tactic going forward.

Thank you.

[The Chair, Conservative, Rob Merrifield]

Thank you very much for your presentation.

Just before we go on to the next presentation, I would ask that you send the committee the results of the report that is coming. I'm sure there are going to be some questions on where the $20 million was spent, how many extra physicians it took, and so on. Nonetheless, we'll wait for the questioning part to get into that.

We'll go to our next presenter right now, Mr. Glasgow.

[Dr. Kevin Glasgow, Chief Executive Officer, Cardiac Care Network of Ontario]

Standing committee members, mesdames et messieurs, thank you for this opportunity to discuss monitoring, management, and reduction of wait times for cardiac procedures.

My name is Kevin Glasgow. I am chief executive officer of the Cardiac Care Network of Ontario.

By way of background, CCN is funded by the Ontario Ministry of Health. We operate North America's largest population-based cardiac registry and integrated wait list monitoring and management system. Our pioneering wait time registry work has been adapted by several other provinces, including the Saskatchewan surgical wait list system and the Quebec cardiac surgery registry. We are also an advisory body to the Ontario ministry on cardiac matters, and are well known in our field for expert consensus panel reports on cardiac issues.These are publicly available on our website.

CCN is a national and international leader in facilitating timely and equitable access to quality cardiac care. We do this on a province-wide basis for selected cardiac procedures--specifically cardiac surgery; coronary artery bypass graft and valve surgery; coronary angioplasty, or balloon stents to open up blockages in the arteries of the heart; and cardiac catheterization, also known as coronary angiogram, dye injected to take a look at the blockages of the arteries of the heart.

In conjunction with our 18 member hospitals—every hospital in Ontario that has a cardiac catheterization, or “cath”, lab—and our regionally based cardiac care coordinators, more than 85,000 patients a year benefit from the following from CCN: clinical urgency rankings, urgent, semi-urgent, and elective, based on standardized clinical criteria; maximum wait time guidelines; monitoring while on the wait list; and patient management, to ensure that the most urgent patients receive priority access to care.

We have achieved 100% participation in the provincial cardiac registry with cardiac surgeons, interventional cardiologists, and cathing cardiologists. Essentially, we have taken wait lists out of the desk drawers of doctors, consolidated them on a hospital basis, and then consolidated them on a pan-provincial basis. One of our key success factors has been the engagement of multidisciplinary stakeholders in CCN's committee structure, where clinicians are actively engaged--with nurses, hospital officials, and ministry officials--to continually improve the cardiac system. Accountability agreements are also signed between CCN and each of our member institutions.

In your information packages, I have included background literature on how CCN works and what our procedural monitoring shows over time. Additional materials have been left with the clerk for translation.

CCN has standardized wait time definitions between hospitals and between clinicians, thereby permitting apples-to-apples comparisons. In our recent data definition review process, our expert panel included representatives from the provinces of Nova Scotia, Quebec, and Alberta, in addition to representatives from the Canadian Cardiovascular Society. Thus, a significant step was taken toward achieving common data definitions to facilitate interprovincial comparisons. CCN also has close ties with the Winnipeg Regional Health Authority and the B.C. cardiac registries.

For over a decade, CCN has publicly reported wait times by cardiac hospital. We provide, on a monthly basis, very detailed reports that go back to clinicians, hospitals, and ministry officials. Through our collective efforts, and with the support of successive governments since 1990, cardiac procedure wait times have been substantially reduced and equity in access improved. But translation of wait time data into useful information and associated monitoring of wait times can only improve patient access so far. Active system management is required to achieve the next level of wait time reductions and the next level of improvement in equity to access.

I am pleased to report that a year ago, CCN was given an enhanced mandate from the Ontario Ministry of Health to further reduce regional variations in wait times through active system management. We are achieving success in altering referral patterns and reducing waiting list bottlenecks to increase the percentage of patients receiving their procedures within recommended maximum wait times. I wish to acknowledge the conceptual and financial support of the Ontario wait time and access to care strategy in this regard.

The key action items in CCN's 10-point plan for action in reducing regional disparities are included in your package, on these two sheets, in both official languages. Our detailed 10-point plan for action is available on our website at www.ccn.on.ca.

I also wish to thank both the provincial and federal governments for their financial support for improved information technology. By the end of 2006, CCN will have a modern web-based real-time information system that will much improve the timeliness of information availability for active system management.

Now I wish to highlight some of the positive trends that have occurred in Ontario over the past year in cardiac wait times. Please refer to the handout entitled, “10 Point Plan for Action in Reducing Regional Disparities to Care”.

The first slide in this handout, which is a very important slide, shows substantial improvements in the percentage of patients receiving their procedure within the recommended maximum wait time. For example, if we look at CABG, coronary artery bypass graph elective—and this is where the federal-provincial benchmark was set at six months—we've seen an improvement from fiscal year 2004-05, with 86% of patients in Ontario receiving the procedure within the recommended maximum wait time, to the fourth quarter of the 2005-06 fiscal year—so very recently—when it's up to 98%. Similar improvements are seen across other urgency categories for cardiac surgery and cardiac catheterization.

The remaining slides in this particular handout show marked reductions in wait time disparities between high and low wait time hospitals.

On slide 2, I'll draw your attention to the schematic for elective catheterization. In the colour version, the blue top line represents a high wait time hospital, and the pink line stands for a low wait time hospital. Over the past year, they've essentially converged, which means that the percentage of patients getting the procedure within the recommended maximum wait time has improved. It's less important where you live in the province of Ontario, in terms of where you're receiving your procedure within the recommended maximum wait time.

So why has Ontario succeeded in reducing cardiac wait times and improving equity? Success has been built on several things: first, monitoring and anticipating demand; second, investing in capacity; third, coordinating and facilitating access across the system, with specific addressing of wait-time hot spots; and fourth, ensuring that physicians, surgeons, administrators, and ministry officials participate in planning for the common good.

In my invitation to meet with the standing committee, I was asked to comment on ways of dealing with wait times to the satisfaction of patients, within an environment of limited human and financial resources. I will do so by making reference to listening to patients, assisting patients, increasing throughput, utilizing capacity, planning ahead, and linking utilization to quality outcomes.

First, one must listen to patients and the public. Last year, CCN surveyed more than 2,000 patients waiting at home for elective or semi-urgent procedures, plus providers and members of the public. Some highlights of our survey—the details of which will soon be posted to our website—were as follows:

First, wait time was not then a major consideration in most physicians' decision about where to refer patients.

Second, only a minority of patients and providers were discussing wait times and options of care.

Third, we posed a theoretical question to patients and said, if you had been provided with full information on your options, would you be prepared to travel a farther distance to get your care in a shorter period of time? Twenty percent of non-urgent patients said yes, they would consider this. It is important that patients be fully informed.

As a result of this survey and other data and information, and the liaison we've done, we're in the process of further improving access to care in Ontario. We have strengthened our partnership with the Heart and Stroke Foundation of Ontario to make sure that what we do is patient focused.

A second key point is that one must assist patients and the public. So our hospital-based regional cardiac care coordinators serve as patient navigators to navigate that confusing pathway. Wait time information is also available on our website, and in our package you have examples of patient information brochures, which are given to 85,000 patients a year in the province of Ontario.

Third, one must increase throughput. CCN is currently engaged in operational efficiency benchmarking and sharing of best practices across our 18 member institutions. We're also reaching out to community hospitals that refer into the specialty hospitals. The Ontario provincial wait time strategy has also initiated improvements to surgical throughput across therapeutic areas.

Fourth, one must utilize present capacity to benefit the maximum number of patients--hence CCN's 10-point plan for action, which essentially equates to better use of current health care resources.

Fifth, one must plan for the future. CCN engages in procedural volume target-setting, looking into the future, to assist the Ontario ministry in making decisions regarding future capacity investment. We are also currently engaged in scenario planning for cardiac surgery--the volume is essentially stable--given rapid changes in that field associated with the growth of angioplasty.

Sixth--and I'll reinforce Dr. Frank's comments--one must link wait time information, utilization, to outcomes and quality. CCN and the Institute of Clinical Evaluative Sciences have collaborated on cardiac surgery report cards for a number of years. They are publicly reported on our website, and reports compare patient results by hospital. By the end of this calendar year we'll be producing an angioplasty report card, which we believe will be a Canadian first.

This brings me to my final point. A truly patient-focused wait time reduction strategy needs to address both upstream and downstream waits, in addition to wait times once the patient has been accepted to specialists' procedure lists. This means addressing the wait time to see a family physician; the wait time from the family physician referral to the specialist; and then after one's procedure, the referral time for cardiac rehabilitation. It also means reducing the need for procedures in the first place--primary prevention, and the need for repeat procedures and re-entry into the acute care system--secondary and tertiary prevention.

The recent federal and provincial initiatives directed at reducing wait times are a great start. In Ontario, we have seen substantial reductions in wait times and improvements in equity in cardiac care. This momentum needs to be sustained and applied more broadly.

I thank you for your attention and look forward to addressing your questions.

[The Chair, Conservative, Rob Merrifield]

Thank you, Dr. Glasgow.

We'll now hear from the radiologist, Dr. Martin Reed, for 10 minutes.

[Dr. Martin Reed, Executive Member, Canadian Association of Radiologists]

Good morning.

Thank you very much for inviting me to this meeting.

Diagnostic imaging plays a very important role in the diagnosis of clinical conditions in many clinical areas, and we know that you cannot treat patients properly without having an accurate diagnosis. Therefore, wait times in diagnostic imaging create major bottlenecks in many other areas of clinical care.

I just want to share a few figures with you to give you some idea of the problem. In 2003, there were 35 million diagnostic imaging studies performed in Canada. That's 17,000 exams per radiologist, about 2,000 more than we feel are optimum, and more than one diagnostic imaging exam per Canadian.

In 2004, there were approximately 2,000 radiologists in Canada. This was, we feel, about 500 short of the number of radiologists we actually needed, and that situation has not changed substantially a year or two later.

If current trends continue, we expect that diagnostic imaging volumes will increase by 30% over the next six years, whereas the net supply of radiologists will increase by less than 5%. So the situation is not going to get better; it's going to get worse unless we can do something about it.

In the past we have advocated for more diagnostic imaging equipment, and we certainly appreciate the response of the federal and provincial governments in providing money for more equipment. But we also know that the solution does not lie just in providing more equipment. We have to become more efficient and more productive.

The Canadian Association of Radiologists is working on four projects that we feel will increase our efficiency and productivity. The first of these is advocating for more PACS and RIS systems in Canada. PACS are picture archiving and communications systems. RIS refers to radiology information management systems. These are electronic systems, and you can view these as the diagnostic imaging part of an electronic health record. These will increase our efficiency, and we appreciate the support of Infoway in helping to fund PACS and RIS systems across Canada.

We're also working with the Canadian Association of Medical Radiation Technologists on developing physician extenders. This means training technologists to do some of the procedures that radiologists do, under the radiologist's supervision, thus freeing radiologists to do other things and to become more efficient in other areas.

We're also advocating with the Canadian Interventional Radiology Association the increased use of interventional radiology. These techniques, we believe, can move patients out of operating rooms into interventional radiology suites, where procedures can be done in less costly and invasive fashions, and free operating room time for more complicated procedures.

The fourth project is the guidelines project, and that's a project I want to spend a little time on. I'm the chair of the guidelines committee, and we believe that guidelines have the potential to make a substantial impact on diagnostic imaging wait times.

Just to give you a little background and to share a few more figures, based on a pilot project we did in New Brunswick and based on studies and the literature, we believe that at least 10% of diagnostic imaging studies performed in Canada are unnecessary. That equates, this year, to about four million examinations. That's the workload of 250 radiologists, half our shortfall. It's also the workload of about 200 average-sized hospitals. So it's a substantial number of exams, and if we could stop doing those we feel it could make a significant difference to wait lists in radiology.

So you may ask, why are all these unnecessary exams done?There are three basic reasons. One is that exams are repeated because the original study is unavailable or inaccessible, and PACS will go a long way to ameliorating this problem. There are two other reasons, though.

You have to understand that the amount of information that is being provided to physicians daily, weekly, and yearly is overwhelming, and no physician can keep up completely. So physicians often are not sure what is the most appropriate diagnostic imaging study to do. They are not always sure whether diagnostic imaging will help their patient, but they do the best they can and they order a diagnostic imaging study.

In some cases those diagnostic imaging studies are not the most appropriate studies to answer the clinical question the physician has. What happens is they then have to go on and do another study that is more appropriate.

In other situations they order studies believing that they can help them, when in fact the diagnostic imaging study will not help them in their clinical situation, or at that time.

Guidelines are designed to prevent as much as possible these inappropriate examination orders. Because of this, the CAR decided that we should develop guidelines for imaging procedures. We looked at what was available and we decided that those of the Royal College of Radiologists in England, which had developed an excellent set of evidence-based guidelines, were the most suitable for our purposes. With their permission we adopted these guidelines. We modified them slightly for the Canadian situation, and we published them in booklet form at the end of last year. The first printing has already been distributed and we're now into a second printing. I may add that they were published in both English and French.

However, we also believe that printed guidelines are not the most effective way of implementing guidelines. Busy physicians don't often have time to look things up when they're seeing patients. We believe the best way to implement guidelines and have them be effective is to provide them at the point of care.

The CAR is partnering with Medicalis, which is a Canadian medical software company based in Waterloo. They have developed an electronic diagnostic imaging order entry software called Percipio, and they have integrated the CAR guidelines into this software. When a physician orders a diagnostic imaging study, he provides clinical information. If the study does not meet with the guidelines, he immediately gets an electronic prompt suggesting to him what would be a more appropriate study or suggesting that diagnostic imaging would not help him.

We are currently about to start a demonstration project of this software at my hospital, the Children's Hospital of Winnipeg. This project has been jointly funded by Health Canada and Manitoba Health, and has the support of the Winnipeg Regional Health Authority. I may add that it also has the enthusiastic support of our pediatricians.

We're going to have an independent research team assessing the effectiveness of this software, using both quantitative and qualitative methods.

We believe it will be important to do other demonstration projects in other clinical settings, such as testing it with family practitioners in rural and remote areas and testing it in busy emergency departments, and we would very much like the support of the committee in getting funding for these demonstration projects.

In conclusion, as an association we believe that ongoing cooperation and communication between all parties--governments, physicians, and patients--is essential to initiating and sustaining change. We are committed, as a national organization of radiologists, to working cooperatively with all parties to create positive change.

Thank you for your attention.

Thank you for your interest.

[The Chair, Conservative, Rob Merrifield]

Thank you very much for your presentation, Dr. Reed.

Now we'll move to our last presenter, from Capital Health in Alberta, Dr. Richard Lewanczuk.

[Dr. Richard Lewanczuk, Regional Medical Director, Chronic Disease Management, Capital Health]

Thank you very much for this opportunity to present this morning. We had a couple of days' notice, but we'll be happy to forward some written materials to the committee.

We come from the non-procedural end of the spectrum, from the chronic disease area, and we'll highlight one of our experiences and how we're applying that in other areas in Capital Health.

Chronic diseases are responsible for about 60% to 80% of our health care costs, they are responsible for about 60% of our hospitalizations, and we all know about waiting lists for hospitals. They are the most common cause of a visit to an emergency department, and we hear daily in the media about emergency department backlogs. Chronic diseases are also the most common reason for a visit to a family physician, and again, we hear daily about difficulties in access to family physicians and waits to get into see the family physician.

Chronic diseases are conditions like diabetes. One in four of us in this room will develop diabetes in our lifetime. High blood pressure is another chronic condition. If we live to 80, all of us will develop high blood pressure. Osteoporosis, the entire population by age 70 of women will have osteoporosis and so on and so forth. Chronic diseases are very common and they're a major driver in our health care system.

To put it in perspective, in our region of Capital Health in Edmonton there's about 0.2% of our population waiting for joint replacement surgery, but there's about 80% to 90% of our population who need access to chronic disease services. Internationally, within our region and within Canada, diabetes tends to be the prototype of chronic disease because it tends to be one of the major drivers behind costs for cardiac care, amputations, kidney dialysis, and a number of other high-cost areas.

In Capital Health, like many areas around the country, we had a six-month waiting list to access diabetes services, to access education, or a specialist. Some of my colleagues around the country tell me that in some parts of the country it's now a one-year wait to access diabetes services. You can imagine, if you were told today that you had diabetes and you were wondering what is diabetes, what do I have to do? Am I going to go blind from diabetes? Am I going to lose my leg? You'd have to wait one year to get the answers to those questions.

Similarly, in our region we had five centres that provided diabetes services, and all of them were at acute care hospitals. There was no coordination amongst the centres, there was no prioritization. It was on a first come, first served basis, no matter what the urgency, and despite this we were only serving, we estimate, about 6% of the population with diabetes. We knew this system really wasn't sustainable, it wasn't appropriate for the patients, and it wasn't providing good care to the public, so we had to change the system.

Beginning about three years ago we did change our diabetes system to a unified regional system using principles of chronic disease, and in doing so we were able to take that six-month waiting list and reduce it down to two weeks. We were able to catch up on about a 1,000-patient backlog from that list. We were able to triple the number of people we were seeing in our system and we were able to do it at no additional cost. It was for the same cost; we just redistributed our resources. More importantly, we also did it in a sustainable manner. In other words, we took existing resources and we just redeployed them. It wasn't pilot money, it wasn't extra money that was going to run out; it was money that was there and that would always be there. So it was a sustainable model.

How did we go about doing this? We're now applying exactly the same model to a whole host of chronic diseases in Capital Health. We did it by a principle, and I'll use an analogy. You can imagine what would happen if your 18-year-old was heading off to school in the morning and he asked you to tie his shoes for him. You'd say, that's ridiculous, my 18-year-old wanting me to tie his shoes. But that is what was happening in medical care. What we did was say, you know what, son, we're not going to tie your shoes for you any more, you're going to have to do it yourself; but we're going to teach you and help you tie your shoes.

That's what we did with our system. We changed the focus of our system from an acute care specialist based system back to the community, based on the patient, the family, the family physician, and the resources in the community. We used those resources to start providing care. That was one of the principles we shifted to.

We also took on another major principle, which was that we in the health region were responsible or had some accountability for every single person in our region who had the particular chronic disease. In this case it was diabetes. We weren't responsible only for the nice, compliant patients who showed up for their appointments and did what we told them; we were responsible for the people who didn't, couldn't, or wouldn't show up to appointments, because those are the ones who end up in trouble. Those are the ones who end up in the emergency department in kidney failure, or with major eye problems, or needing amputations. So we took on the responsibility for the entire population, and as you have heard from some of my predecessors, it's important to know who our population is, who the people are that we're treating.

The other principle we used to design our system, and it was also mentioned by Dr. Glasgow, was to go as far upstream as we could in the care continuum. In other words, we wanted to treat the disease and the risk in the community before it impacted our acute care facilities. In other words, we wanted to treat the high blood pressure before we needed to treat the coronary artery disease.

Today, each one of us in this room is going to develop 20 new plaques in our arteries. Wouldn't it be better to treat ourselves today, rather than wait until we need the coronary artery bypass or the angioplasty? That is the principle upon which we operated, trying to operate as far upstream in the continuum as possible, as you heard.

How did we do this? One of the ways has already been mentioned. We used a central point of access so all of our requests for services come in through one central point. That allows us to know where the patient population is, but more importantly, it allows us to triage the patients to appropriate levels of service.

Under the old system, it was presumed that everybody needed to see a specialist. We sort of denigrated the role of the family doctor and thought that they couldn't possibly look after diabetes. In fact, we know that family physicians can look after 70% to 80% of people's chronic disease, that's what they do for a living. Most of their day is spent managing chronic disease. So we shifted the focus there.

Now we've redeployed our resources so that the family physician sees the majority of the simple, straightforward cases. The specialists now see the more complicated cases, so we're better utilizing our specialist resources. The most complicated, the most sophisticated teams, now look after the most complicated patients. That's what centralized access has allowed us to do.

We've put heavy emphasis on information exchange, because again, as you have heard, not having appropriate information leads to duplication of services and a whole host of issues. Now we've put a lot of emphasis on electronic medical records so we can efficiently obtain information from family physicians, transmit it back to family physicians, allow patients access to their own records to give patients information and methods to manage their own disease.

I don't know if any of you have ever had the experience of going to an emergency department or a hospital, but if you have, probably the nurse comes and asks you questions, then a medical student comes and asks you the same questions, then the emergency doctor asks you the same questions. You think, my God, don't these people talk to each other? How come I'm asked the same questions over and over again? Having electronic records helps us to eliminate that need, because we have the information available.

We know there is in Canada a shortage of medical specialists, cardiologists, pediatricians, general internists. If I could offer you a way of doubling that number in a few months, I think we'd all be very interested. We wouldn't have to go through this whole immigration and credentialing or eight years of training business. One way in which we can do that is through the use of electronic records.

Right now, as a specialist, for example, if I see a new patient, it takes me about 45 minutes to do a consultation on a patient. But if the family physician has an electronic record and sends me electronically that patient's history, or even a printout, saying this is the medications they are on, this is the past history they have, the operations they have had, this is the family history, it eliminates the majority of my encounter. I can now do my 45-minute consultation in 15 minutes. In other words, in that 45 minutes I can see two or three times the number of patients, with no more additional specialists. That's some of the power behind electronic records and that's what we've used in our diabetes system.

We certainly support patients, so we engage our patients in managing their own diseases. We provide them with information, tools, self-empowerment tools, so that when they go to the doctor they ask why they are on this medication, or shouldn't they be on this medication, or can the doctor check their blood pressure, or their feet. In fact, we had to start giving our patients sheets of paper to give to their doctors to say the patient had been through a training program and may be a little bit more demanding than they had been, a little bit more interested in their own health.

A lot of change management, as you might imagine, is involved in changing a system like this. But we support our family physicians. We don't just dump the responsibility onto them; we provide our family physicians with the materials, education, and tools, the algorithms, the electronic methods in which to handle these patients.

As you've heard as well, we have software that embeds guidelines right at the point of care. So when a family physician calls up the patient on the electronic record, it says this is Mr. Smith or Mrs. Tremblay and they're diabetic and are overdue for their kidney test. Right at the point of care, we know what's necessary. So we use methods such as this.

We use data that we collect. We heard about the need for data, and we're thankful to Canada Infoway, for example, for supporting some of our data collection. In our region we know where the demand is coming. Every two weeks we look geographically at where the demand for diabetes services may be coming from. We may see that it might be coming in that month or in two months from the northeast part of our region, and we will actually take our health care workers and move them physically to the northeast part of the region in order to provide care. But we can only do that by having access to the data.

We've recently discovered, for example, with patients who have diabetes, that their care seems to improve for about 12 to 18 months and then it plateaus and in fact starts to deteriorate. That tells us we have to start doing something at 12 to 18 months; something different is happening. We're doing the right thing at the beginning, but we have to start doing something at 12 to 18 months. We didn't know this nationally or even internationally up until this point.

These sorts of data collection help us drive our system and provide better care to the patients and prevent them queueing up for the acute care services.

We take a very proactive stance in treating our patients as well. We contact them by telephone to see how they are doing, whether they have any problems, whether they have made behaviour changes. We will admit patients to hospital proactively if something is going wrong. For example, if a patient with heart failure is getting into trouble, rather than waiting until they're in extremis and have to show up in the emergency department, we admit them to hospital. We know what we want to do, we do what we need to do, and they're back to their primary health care provider in less than half the time they would take for a normal acute care hospitalization. We're using proactive methods like this; we're using the hospital as a tool in the whole health care system.

So these are some of the techniques we've used in our diabetes system, but we're not a one-trick pony. We've used a similar sort of system, for example, in endocrinology. That's my specialty. Endocrinology takes into account diabetes or such things as osteoporosis or thyroid disease. We've also taken the practice of having one central point of access now for endocrinology services. It's no longer the family physician phoning 11 different physicians trying to find who has the shortest waiting list—we also had six-month waiting lists.

Through having a central point of access, every day the endocrinologist goes through the requests for services and picks out the urgent cases. Most patients are seen sometimes the same day, sometimes the next day, but within a day or two. The only limiting factor is the patient's availability. Patients who are less urgent we will see in a few days. Patients who are routine can wait a month.

One of the things we learned from our diabetes system is that you can actually have too short a waiting list. We found that when we shortened our waiting list to two weeks, patients didn't have time to arrange time off work or to arrange child care. We found that the optimal waiting list for routine types of care was about three to four weeks. We use this sort of technique in endocrinology. By doing it, we've taken our six-month waiting list and.... In fact, waiting list really doesn't mean much to us anymore, because we see the urgent patients when they need to be seen, the semi-urgent ones when they need to be seen, and the routine ones on a routine basis. We're also able to handle about 25% of our cases over the phone, so we don't necessarily even need to see patients.

So there are a number of innovations we're able to apply in this whole area.

In conclusion, then, there are a number of recommendations we would suggest. Some of them are that rather than focusing strictly on things such as wait lists, we focus on the whole access to appropriate care at the appropriate time—as we say, the right provider, the right place, and the right time—things such as centralized registries in order to know who our denominator is and who the patients are, investing in electronic health records, system redesign to support primary care providers and the patients, taking into account the community providers as well, and continuous monitoring.

We thank you for this opportunity. We're optimistic that we will be able to change our system. It is starting to happen. It does seem to be starting to work, and we really need your help to drive this system.

Thank you very much.

[The Chair, Conservative, Rob Merrifield]

Thank you to all of the witnesses and the presenters. You're all very passionate about some of the success stories you have to share, and we want to thank you for coming.

I now will open it up to the questioning part of the meeting. We'll start with Mrs. Brown, please.

[Bonnie Brown, Liberal, Oakville, ON]

Their presentations were so helpful and so clear I don't really have a question, other than some things I'd like to ask the endocrinologist. I'm going to pass to Mr. Steckle, who has questions.

[Paul Steckle, Liberal, Huron—Bruce, ON]

Thank you.

[The Chair, Conservative, Rob Merrifield]

Absolutely. Mr. Steckle.

That seldom happens, by the way. I've never heard of that happening before.

[Paul Steckle, Liberal, Huron—Bruce, ON]

I have many questions and many comments, but having just come from the agricultural committee you would wonder.... I'm subbing this morning. But I do thank you for coming. I feel privileged to be able to be at the table and listen to your presentation. It was very interesting.

You people are making a lot of progress. In the past we've always believed money was the answer to our problems: if we had more money, we could resolve our problems.

Do you believe the money that was committed to the 10-year accord is adequate? I'll put the question to Dr. Frank. I want to get into some of the things you have done; I know you haven't done it by yourself. I want to know this. Do you feel the 10-year commitment that was made to money by the provinces a year or so ago is adequate, going forward?

[Dr. Cyril Frank]

I don't know yet. I would like to have better information before giving you a solid answer.

It's a lot more predictable than we think, because we know the population demographics better than ever before. If we knew the costs of care and of the infrastructure required--that would be acute care and human resources--we could answer that more clearly.

But I would like to have that discussion with real information, through central data registries and real population demographics and real cost information, to be able to give you a solid answer. I think we're heading in that direction, and I've heard the same thing from everyone here.

[Paul Steckle, Liberal, Huron—Bruce, ON]

Information sharing with the institute and the work you're doing there, the early prognosis, and the early results you seem to be indicating, what interest and what sharing of that information is there among other provinces, among other hospitals?

[Dr. Cyril Frank]

We've been giving our information to similar groups in other provinces from the time of our announcement to the present day. We believe it should be shared and best practices should be emulated, and knowledge transmission is one of our key themes.

[Paul Steckle, Liberal, Huron—Bruce, ON]

Dr. Lewanczuk, you mentioned that if you could, with a flick of the finger, if you could move quickly, we would have more doctors. Is the system able to sustain more doctors?

We have doctors who were trained in other countries who are driving taxis today and who would like to get back into the practice of medicine. We're a little slow on the draw to get these people back in again. We're graduating young doctors who are, in many cases, immigrating to the United States.

Do we, as government, have some obligation to put measures in place to keep those doctors here at least for five years? Would that be a positive, from your standpoint, to have these young doctors spend five years here, or perhaps three years in northern Canada or in some remote place, so they don't simply run off from grad school into the medical system in the United States, or elsewhere for that matter?

[Dr. Richard Lewanczuk]

To address the first part of the question, there are other techniques we can use to extend our physician abilities, and using other health care professionals will certainly extend the capabilities of the existing physicians that we have. As you can probably tell, I could go on for hours and hours in this area.

Across the country, there are various forms of primary care reform that are now introducing nurse practitioners, nurses, pharmacists, and mental health navigators into the health care system. That certainly extends the capabilities of our existing physicians. Having nurse practitioners work with specialists extends what they're able to do. So by using other health care professionals and other techniques--for example, the electronic medical records--we can expand our capacity. Certainly we can still use more physicians, and as you point out, particularly in rural and remote areas.

I guess many medical organizations wrestle with this question. It's always difficult to compel someone. But I think the way we're heading in Canada is that we can develop systems where we become so attractive that people really don't want to move. I know some of my colleagues have moved to the United States. They find that they're only allowed to keep the person in hospital for three days. It doesn't matter that the person is 90 years old and has every complication, the administrator says, “No, the book says three days. Why are you keeping them in longer?”

All of the difficulties and challenges in other countries actually make our system look appealing. I think that having these other professionals, the electronic records, and a really well-integrated system actually attracts, or at least keeps, people. I think it's always difficult to compel people.

Personally, I would hope that people realize it's we the taxpayers who fund a lot of the education for these people and that there would be some obligation.

[Paul Steckle, Liberal, Huron—Bruce, ON]

I know sometimes we get down on ourselves. We think our system has many shortcomings, and it does, but when we compare what is happening in the U.S.--the costs, the amount of people they're seeing, and the results--we have a fairly favourable response in this country.

But I want to point out something that I think is very important. I think if you're going to be honest with us this morning, you're probably going to have to agree that this is happening. Do we not have too much infection in our hospitals today?

I say that with a great deal of authority. I come from the London region. I have a family member who is still on antibiotics one year after surgery. I can point to three or four places where we can eliminate it. I'm not a doctor, and I don't want to take your position, but I think in terms of infection that occurs with the migration of people into areas they shouldn't be, is it not time that we start looking at that as a high cost to the system?

I'd like a comment, quickly, on that.

[Dr. Cyril Frank]

Sure. I'd like to comment on that.

I agree that safety and prevention is a key strategy with infection, because we know a large number of them would be preventable. Again, I believe that with the right information, a lot more of that is predictable, to risk manage patients more appropriately, to make sure their diabetes is controlled, that they're taking the correct medication and they've done whatever can be done to try to prevent that. There are other measures that could be used to probably decrease infection rates within the acute care settings.

There's obviously a lot of work going on in that area, but I agree that it needs to be a focus, because it is driving an enormous use of resources.

[Paul Steckle, Liberal, Huron—Bruce, ON]

Who should drive that? I don't want to take away from your time, but who should drive that? Should the public be driving that? When nurses ask us to do something about this, there's a serious problem.

[Dr. Cyril Frank]

I think it requires a team effort to solve it. It's the teams that need to solve it, including administrators, with people watching from the public.

[Dr. Richard Lewanczuk]

May I respond as well, Mr. Chairman?

I agree with you. There's a whole host of things we can do. I'll give you one example of a patient across town in our region who had this methicillin-resistant staphylococcus, one of the most problematic causes of infection. It showed up at my hospital, the university hospital, because we couldn't exchange information and we had no idea that this person had this infection. So what happens is that the infection spreads. That's a matter of information exchange.

We know that one of the difficulties is the over-prescription of very powerful and potent antibiotics. But as we also heard, if we can embed some of these guidelines right at the point of care for the family doctors, saying that when a patient comes in with a cold you shouldn't be prescribing this antibiotic, that will also help us.

There's a whole multi-faceted approach that we could take.

[The Chair, Conservative, Rob Merrifield]

Madame Gagnon.

[Christiane Gagnon, Bloc, Québec, QC]

Good morning and thank you.

Your solutions are mainly patient-centred, and you have had quite a bit of success with this. I would like to put some questions to Dr. Cyril Frank.

Following the plan that you have implemented, you found some ways to solve urgent problems. Among other things, you said that you identify urgent cases sooner, and that in order to help patients after surgery, you have changed some practices and offer certain kinds of support. Besides, when the need arises, you often rely on other health care networks, for instance physiotherapists in order to strengthen the muscles before an operation. You also offer support to some patients who need help after surgery. Basically, you have taken measures to help patients recover more quickly.

You said that the costs had been cut by 10%. There are many phases of health care that come before and after surgery. With regard to home care, did you have to transfer funds to certain sectors or did you keep more or less the same budget for the hospitalization procedure?