Health Committee on April 16th, 2013

[The Chair, Conservative, Joy Smith]

Thank you so much.

Dr. Carrie.

[Colin Carrie, Conservative, Oshawa, ON]

Thank you very much, Madam Chair.

I want to continue with Dr. McGregor on the thought process she was just going through. First of all, it's great to have all the witnesses here, but especially somebody from Oshawa. I think all of us can tell from your accent that you're from Oshawa.

We've heard a lot about Canada Health Infoway and the government investments in research, but we've also heard a little bit about challenges with physical infrastructure. At the end of the day, it's all about the patient and the services and how we can better serve patients in Canada. I was wondering if you could provide the committee with more details about cloud technology and computing-based software, and how that would impact on the cost of innovation and improve the quality of care, things like access portability—things along those lines. Perhaps you could comment for us.

[Dr. Carolyn McGregor]

I'm going to comment as well that in a rural or remote setting you're really limited in your ability to expend money for certain care practices. That's where cloud computing platforms can really be of great benefit right across the country. What are they? It's a means of providing a service to the health care organization without their having to pay for a full holistic package, and having it supported inside the organization. Whether that be through an electronic health record or whether it be the acute care support that we're trying to provide, you have that mechanism to work with economies of scale, and you have a number of hospitals in their own isolated environments but working across and using a cloud infrastructure platform.

I can give a number of reasons that this is a benefit, and one particularly from the neonatal intensive care setting. At the moment, we can have premature babies born in the north of Canada. Unfortunately, when these babies are born they have a very low immune system and they can develop an infection in the hospital. When they're trying to support that baby, they're usually finding out about that infection when they're quite unwell. Currently they're on the telephone to a neonatologist in an open centre. It's our goal through the platform we're building that we'll be able to watch every baby, ultimately across the country, no matter where they are. We can give them the most expert care we can through computing systems wherever they're located, and we can track when they're starting to develop certain conditions and intervene straight away.

The benefits of that cloud computing infrastructure is that you can give the maximum benefit for patient care in any health care facility across the country.

Speaking also to what the government can do, I fully endorse what Mr. Williams was saying before, about that need for holistic policy infrastructure in mechanisms like Canada Health Infoway. There's a definite role for a national holistic view.

[Colin Carrie, Conservative, Oshawa, ON]

Thank you very much, Dr. McGregor.

You touched a little bit on clinical informatics. You talked a bit about efficiencies and streamlining and better care. You talked a little bit about how taking a business approach using analytical tools, technology, and score cards could help decrease errors.

What do you think the challenges are to getting the health care system to implement these types of business approaches?

[Dr. Carolyn McGregor]

I think one of the biggest challenges is that every health care role within the organization sees the service it provides as opposed to seeing the holistic overall view of the experience a patient has within a health care organization. Whether they have a chronic condition or an isolated event brings them into the environment, through their lifetime they are going to deal with a number of different people. You need to look at that holistic view across all of those different health care providers to be able to provide that integrated care.

When you look at it from a business perspective, if you can work with health care providers to allow them to change their focus—and we were able to do this very successfully with both Ontario Shores and Providence Care—that can change their perspective and how they think about the way they work.

We described narratively the same journey of a patient in two different ways. We had it as different roles: “I see these types of patients. I do this as the psychiatrist. I do this as a nurse. I do this.” We asked them to construct what the patient's journey looks like and they couldn't do it. But when we got them to step back and actually see what the experience was like for the patient, then they could do that.

One of the major things that needs to occur is that reorganization of thinking. Certainly the new CIHR initiative on patient-centred research and the SPOR initiative for patient-oriented research are starting to help people to really put the patient at the centre and first, as well as helping a lot with the economic assessment.

[Colin Carrie, Conservative, Oshawa, ON]

That leads me to my next question. We've heard a little bit about the challenge of the cost of technology and about how sometimes we aren't really going to save overall by implementing the new technology.

The way I see it, if we change the technology without actually changing the system we're utilizing, we can buy the most expensive things, but maybe we won't be implementing them and using them to do the best we can for Canadian patients.

I wanted to ask if you could expand a little bit on what you said earlier about patient journey modelling and looking at outcomes. You talked a little bit about this diagram approach. It sounds like a very patient-oriented way of looking at things as far as costs, quality control, and things like that go. I was wondering if you could relate how this could be translated into the overall health system, but also how you could utilize this type of method to see what we're going to get in terms of costs versus reward.

[Dr. Carolyn McGregor]

One of the things I found very interesting when I was listening to Mr. Shepitka's presentation was the discussion around some of the challenges. One of the things that stuck in my mind was that he said some of the health care workers have great ideas about ways they now want to change things now that they have seen what the new environment will be like. They want to change the way they will work with the electronic health system, but it's going to be at a cost.

I thought that was a really good example of something we learned through the way we were implementing. We did a lot of planning. We really spent a lot of the time beforehand visualizing and helping people to see how they were going to work. They may say to us, “If you just put a workstation out in the hallway as you're planning”—because that's what the system requires—“then I'm going to have to go in and see my client, I'm going to have to write notes, and then I'm going to have to come outside and type them in.” They could automatically see that was going to lead to medical errors.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. McGregor.

We'll now go to Dr. Fry.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Thank you very much, Madam Chair.

I want to thank everyone for their presentations, but there are some things. I agree with everyone who talked about the fact that outcomes, efficiency, quality of care, and timeliness of care are all things we should be rewarding and creating incentives for as we go about building a system based on patient-centred care. Primary and community care models will keep patients out of hospitals, and this is all good.

There are a couple of ethical things that arise out of something Dr. Coyle said. I'm not agreeing or disagreeing with him; I just want to clarify this. There have to be some commercial considerations when you're looking at research. If a drug, a device, a new treatment, or a new way of delivering care has proven to be good, one would want to commercialize it and use it.

At the same time, what are we going to do about patients who cannot be kept out of hospitals? We cannot do prevention and promotion to keep them healthy, because they have certain diseases that are rare or that may or may not be genetic. Are we helping to treat those patients if all we do is look at the cost? Are we going to be denying patients who have rare diseases and are going to be costly to the system because there are a small number of these people and it's the only way to keep them alive? Are we going to suggest that we look at ways of deciding who should get what care, that we ration care for people who do not make up a large portion of the community?

I would like to have you clarify these things. I think they're very important. I agree with all of the things you've said, but there comes this flip side to it and this ethical model that one has to consider. To whom do we say, “Sorry, baby, there are only 20 of you in the country and we can't be bothered to keep you alive”? I know you're not saying that, but I'm saying that is a slippery slope. How do we deal with not going down the slippery slope but still look at evidence?

[Dr. Doug Coyle]

It's a good question.

I didn't mention this earlier because I wasn't sure it would be coming up in the discussion today; I'm a member of the drugs for rare disease working group in Ontario. We have developed a completely new framework for making decisions about technologies for rare diseases, which is different from the framework that's made for common diseases, mainly for the reasons that you have suggested already today. Rare diseases are different for a number of reasons. They're different because we don't have as much natural history. We don't actually know what happens in these diseases. They're very heterogeneous. They're not homogenous, like some of these heart failures that have a fairly standard flow of patients. Rare diseases tend to be very, very different for individual patients.

We don't have the evidence for what's effective to the same degree. Because there are not enough patients to study, we don't know whether or not these new technologies work. As I mentioned already, these drugs and other technologies are very, very expensive: it's $500,000 per year for Soliris, which is supposed to be the most expensive drug in the world, and there are many other rare disease drugs that cost over $300,000 per year per patient.

We had a focused approach in Ontario to try to find a way to fund these drugs by giving them to those patients with rare diseases where we think they might work, and then following the patients to see whether or not they do work, and then denying care or taking therapy away when there's evidence that the drugs aren't working. There are approaches to take to do this.

However, the ethics you're looking at are very individualistic ethics. What's the right of the one patient with the rare disease? We have to take a more collective ethics approach as well. If we decide to fund a technology for which the benefits are not substantive compared with the $500,000 a year that it costs to purchase the drug, then we're denying health care to other individuals. The collective ethics say we should do what's best for society in general.

We have to weigh it all up. It's a very difficult to weigh up the demands of individual ethics versus collective ethics. Those are decisions that, I have to say, politicians have to make. They have to make those decisions, because they represent the society in general. We have to realize it is not simple. If we decide to fund these technologies, we are necessarily denying care to other patients with more common diseases.

[Hedy Fry, Liberal, Vancouver Centre, BC]

I agree with you that it's not simple. I'm asking you whether politicians are the ones who should be making those kinds of decisions. As a physician, I can tell you that when my patient comes to me with a rare disease, my first duty is to my patient, and I have to do everything I can. There's going to be a huge push-back on this. Politicians won't want to make these decisions, because there would be a backlash from the people who suffer from these diseases. They will say, “Are you telling me that I'm not worthwhile, that I have no value in your society?”

It is a difficult thing for politicians to do, as it is a difficult thing for physicians to do. The big question is, who's going to bell that cat and make the decision on what those guidelines are going to be? Have those guidelines been made? What are they?

[Dr. Doug Coyle]

In Ontario, there is a Citizens' Council. The Citizens' Council has explored the issue of rare diseases and has made recommendations on how we should make funding decisions concerning treatments for rare diseases. I suggest you look at that approach that is taken there. They have recommended an approach that is very similar to the approach that has been adopted in Ontario by the drugs for rare diseases working group. It's recognizing the special case of rare disease, but it's not as straightforward.

[The Chair, Conservative, Joy Smith]

I want to give some time to Mr. Williams as well. He wanted to answer that.

Can you go ahead, Mr. Williams? We have one minute.

[Andrew Williams]

Obviously, treating people with rare diseases is hugely important, and I think the system has other areas that need to be focused on to find efficiencies.

In Ontario, there's a major initiative currently looking at the high users in the system, not those who have true needs but those who just use the system a lot. The numbers are staggering. Upwards of 80% of our resources are consumed by 5% of the population. So it's not looking at the people who need it; it's looking at those who are using the system and don't need it.

Part of the challenge for us is that because we don't have technology and information systems that connect primary care with hospitals and with community, these people are falling through the cracks.

If we can focus on that population, we can free up a lot of money to ensure that the people who truly need it have it on a go forward basis. That requires political fortitude, because you're telling people that they've used the system, but they have used it inappropriately.

[The Chair, Conservative, Joy Smith]

Thank you, Mr. Williams.

We're going to suspend for one minute to allow Dr. Vendittoli to join us.

We'll resume now and go right into your presentation, Dr. Vendittoli. You have 10 minutes and you may begin now.

[Dr. Pascal-A Vendittoli, Professor of Surgery, Funded Clinical Researcher, As an Individual]

Good afternoon.

Allow me to introduce myself. My name is Pascal-André Vendittoli. I am an orthopedic surgeon and professor at the University of Montreal. I receive funding from the Fonds de la recherche en santé du Québec. My research program involves the clinical assessment of new arthroplasty technologies for the lower limb. The inclusion of new technologies in clinical practice is a key aspect of my research program.

I will attempt to explain how we assess new technologies and their benefits in an orthopedic context. As you will see, what I will explain can apply to all areas of health care. We will mainly be discussing the use of new implant technologies. When it comes to implants, we are not talking about medication, but technological tools and devices which are implanted in certain patients, which engender a major proportion of health costs.

This is not unique to Canada. Across the whole world, the use of implants and their introduction into clinical practice are different from what is done for medication. Indeed, the various design and marketing stages medications must go through do not apply here. Some very innovative people in the field working in Sweden, including Henrik Malchau, have developed a strategy to introduce new technologies which they've called “Stepwise Introduction of Innovation into Orthopedic Surgery.”

This technological development includes four main stages: preclinical assessment of the implants, clinical assessment with specific methods to permit the assessment of these implants in the short term, the use of randomized controlled trials using patients, and finally, the marketing stage, during which the effect of these implants will be observed in patients, through registries, in populations such as Canada's.

When faced with a clinical problem for which a new technology is available, as clinicians, we must ask ourselves the two following questions. What results are we obtaining from the treatments we are currently using? What costs and risks are associated with the new treatment being offered? As you can imagine, if in most cases we have a very effective treatment for the condition, the new implant will have to be highly effective and outperform the treatment that is currently being used.

In most cases, when it comes to orthopedic surgery, we have very effective treatments. Take for example a total hip replacement. As you no doubt are aware, that treatment has the same cost-effectiveness as coronary bypass surgery. In all the countries of the world, it is used as an indicator to measure the effectiveness of a health care system.

Here are two examples of implants that have been on the market for over 25 years: a Corail femoral stem and a CLS stem. We have results from patients who received the implant 15 and 20 years ago with a success rate of approximately 98%, which means a failure rate of only 2%. These implants, for example, are quite inexpensive. In fact, the price is around $1,200; the price varies according to the annual rate of inflation.

However, manufacturers are currently developing new implants of all shapes and forms. For example, several of these implants are approved by Health Canada each year then marketed. As you can imagine, these implants are far more expensive than conventional implants and are put onto the market without any assessment of their clinical value.

Let us look at a very simple example. The Accolade implant was marketed by the Stryker company about seven years ago. After only five years, its failure rate was 5%. That femoral stem had been approved by Health Canada although its initial cost was two to three times that of conventional implants. If you consider that its failure rate is about four to five times higher than that of an implant being used for the last 15 to 20 years, you can see monster costs for the health care system.

The company recalled this implant in 2013 and replaced it by the Accolade II stem, which was just approved by Health Canada once again. You must understand that manufacturers are putting implants on the market here in Canada and elsewhere in the world in order to maximize their own profits even if their implants have not demonstrated that they are more beneficial than other established products.

Here are some other examples. Some implants look alike and the photographs seem identical. With respect to hip resurfacing, a Smith & Nephew implant demonstrated excellent results. After 10 years of follow-up, the failure rate was only between 2% and 5%. Since then, the company has marketed a similar product whose failure rate is 20% after five years. For the health care, that means many revisions, with all the associated costs, for an implant that was not sufficiently tested in a clinical setting before being marketed here.

There are many other examples. I could spend a whole hour showing them to you. There are cone-shaped modular stems that will fracture, and implants that cost the health care system a great deal, without presenting any proven clinical advantage. They were approved by Health Canada because they resembled older implants which had worked quite well.

We find ourselves in a situation of chaotic innovation in the world of implants. If you look at the graph and compare it to the first one I showed you, you will see that we have very few preclinical tests. These implants are being put on the market rapidly in order to meet manufacturers' needs and maximize their profits. Then, clinically speaking, we attempt to assess their performance retroactively. This has major repercussions on the Canadian health care system, on patients and their health.

Formerly, the patient enjoyed major benefits and faced minor risks, whereas today's patients receiving implants based on new technology are receiving few benefits and being exposed to much higher risks. You cannot see my slide on the screen, but I will continue to try to show it to you. My PowerPoint document does not seem to be going forward.

Please look at the bottom line with the short columns. For example, the number of hip implants inserted in Canada has slightly increased, whereas the costs have increased far more rapidly over the last 10 years, without any noticeable improvement of the care patients received or the quality of the surgeries.

So who is benefiting from this change, if not the manufacturers and those who sell the implants to the Canadian government and the provinces? At this time, the choice of implants is left up to surgeons and hospitals. It's much more about what is fashionable than scientific knowledge. Therapeutic choices made by Canadian doctors, when using implants, have no basis in science and should be monitored by organizations.

We should turn the clock back and develop a government plan to move from the chaotic introduction of implants and new technologies towards phased innovation, meaning premarket trials that include preclinical tests, high precision metrics using small groups of patients, and technological methods which I will explain to you, as well as clinical studies. Once the implant is approved for use, national registries would obviously be most useful.

One example of high precision metrics available in orthopedics is testing through radiophotometry or stereophotometry. During the surgery, tiny tantalum beads are inserted in the bone, which allows the measurement of the implants' performance in the very short term. A two-year follow-up—

[The Chair, Conservative, Joy Smith]

Dr. Vendittoli, excuse me. I have to say you have a rather long presentation—it's a very interesting presentation, but we've gone quite a bit over time. We have your presentation right in front of us now, and I think there are committee members who would like to ask some questions before too long.

Our bells are going to be ringing at 5:15 today, and we have to go to votes at that time. We have only a short time.

Can you wrap up within the next 30 seconds so that we can get those questions in, please, Doctor?

[Dr. Pascal-A Vendittoli]

Sure. I will do it in two slides.

In this first slide, if you compare the revision rate or the re-operation of patients in the U.S.A. versus Sweden, you can see that the Swedish action taken on the introduction of new technology was very effective, and I would say in Europe there is a broad change to move forward with the evolution of new technology, including precision technology.

I conclude by saying that the introduction of new devices is driven by the industry and its financial benefit. New device introduction in the Canadian health care system should follow a similar path as drug introduction, and clear rules should be determined to protect patient health and reduce costs.

Thank you.

[The Chair, Conservative, Joy Smith]

Thank you very much, Doctor.

There are seven minutes for Mr. Lobb, please.

[Ben Lobb, Conservative, Huron—Bruce, ON]

Thanks to all the guests for appearing here today.

Mr. Williams, you talked briefly about a rating system that your Huron Perth Healthcare Alliance has. Could you tell us more about that and where you stand in the province? Is that the Canadian standard or is it provincial only?

[Andrew Williams]

It's a Canadian grading standard to identify how far along you are in adopting electronic health records. They look at how many areas of the organization are electronic. They look at the level of complexity of the systems, how integrated those are, and they score you.

The major areas that affect the scoring most are when you get into things like physician order entry, where physicians can order medications directly on the computer system, which improves safety significantly. They require you to have a number of systems in place to score at the highest level.

As an organization, we're a little higher than most in our region, but we're probably where most are. A significant investment is required to get to the top of the scale and you need to have a very clear plan to get there. We have that, but right now we're probably two-thirds of the way through.

[Ben Lobb, Conservative, Huron—Bruce, ON]

You mentioned in your presentation that you've been doing this for 25 years. Obviously, technology has changed a lot, in the last couple of years especially. Given that you have four hospitals under your administration, what challenges have you seen with having four hospitals to try to implement, versus, say, one?

[Andrew Williams]

The biggest challenge stems from not having consistent standards at all the sites. That's something we have tried to do, and I'm sure that NORTH Network is the same with its MEDITECH platform. When we introduce an IT system, you have to say to organizations that everyone is going to have the same standards, which can be a challenge sometimes when you have unique practice patterns.

We have it in over five hospitals, in fact. We have our four, and we have a fifth hospital that purchases services from the IT program. The key is making sure that the procedures and processes are the same, making sure you standardize. Going back to something the government can do, more mandating of standards would help with uptake of information technology and would allow us to move along the scale faster.

[Ben Lobb, Conservative, Huron—Bruce, ON]

Maybe just to help us, or walk me through it anyway—when you're implementing something like the PatientKeeper you were talking about, is that something you would go through the province and Canada Health Infoway federally to implement, or does that come out of your operating budget?

[Andrew Williams]

That would come out of our operating budget. It would be an identified need the organization has, and then we would go through a competitive process to identify a vendor. One of the challenges we face with information technology adoption is the funding. It typically has not been something that has formed part of the budgets, and I think that's something that needs to change. There needs to be an expectation that organizations commit a certain percentage of their budget to information adoption so that we can get to the same playing field.

There was a comment made earlier about research. You have some organizations that do an awful lot of research and are able to introduce the latest practices and technology, and you have some that can't do any of it. I think we need to get everybody at least to a basic level of information adoption. Part of that requires a shift in the funding philosophy we have. That's going to require us to shift funds from other aspects of the organization to information technology.

In the case of PatientKeeper, we knew it would improve outcomes because physicians would be more engaged electronically and would have faster access to information. It costs $250,000 to implement, but then you see savings down the road with respect to length of stay, ordering practices, and things like that.