Public Accounts Committee on June 3rd, 2010

[The Chair, Liberal, Shawn Murphy]

I'd like to call this meeting to order. Welcome, everyone.

The meeting this morning is pursuant to the Standing Orders. We're actually dealing with two reports. The first report is “Chapter 4, Electronic Health Records” of the fall 2009 report of the Auditor General of Canada, and then also “An Overview of Federal and Provincial Audit Reports” from the spring 2010 report of the Auditor General of Canada. So we're dealing with electronic health records and the implementation of electronic health records in Canada.

The committee is very pleased, of course, to have with us, from the Office of the Auditor General, Ms. Fraser, the auditor. She is accompanied this morning by assistant auditor, Neil Maxwell, and Louise Dubé, principal.

From Health Canada Infoway, we have Richard Alvarez, the president and chief executive officer. He's accompanied by the chief operating officer, Mike Sheridan.

We also have, from the Department of Health, Dr. Karen Dodds, the assistant deputy minister, strategic policy branch.

So again, welcome to each of you. I'm going to break 10 minutes early to deal with the steering committee reports and Madame Faille's motion. I'll do the steering committee first.

Having said that, we'll go right now to opening remarks. We're going to hear first from the auditor herself, Ms. Fraser.

[Sheila Fraser, Auditor General of Canada, Office of the Auditor General of Canada]

Thank you, Mr. Chair.

We thank you for this opportunity to present the results of two reports on electronic health records. As you mentioned, I'm accompanied today by Neil Maxwell, Assistant Auditor General, and Louise Dubé, principal, who are responsible for audits in the health sector.

Electronic health records, or EHRs, are intended to offer solutions to a number of persistent problems in Canada's health system, some of which may be attributed to the use of paper-based health records. It is expected that EHRs will allow health care professionals to be better able to share patient information, resulting in reduced costs and improved quality of care.

In November 2009, we reported the results of an EHR audit of Infoway and Health Canada, based on audit work completed to April 2009. As of March 31, 2009, Infoway had committed to spending or had spent $1.2 billion on this initiative. Some experts have estimated the total cost of implementing EHRs Canada-wide at over $10 billion, and Infoway concurs with this estimate.

We examined how Infoway manages the funds from the federal government to achieve its goal of making compatible electronic health records available across Canada. Overall, we found that Infoway has accomplished a lot since its inception and that it manages well the $1.2 billion in funds granted by the federal government to achieve its goal. There is good oversight of the corporation by the board of directors and Health Canada, the sponsoring department. Infoway has set the national direction for the implementation of EHRs by developing an approach as well as the key requirements and components of an EHR. It developed a blueprint or architecture for the design of the systems, and it developed strategic plans and a risk-management strategy. Infoway worked collaboratively with and obtained buy-in from its partners and stakeholders, which is critical for the success of the initiative.

We also found that Infoway approves projects, which it cost-shares with the provinces and territories, that are designed to comply with standards and that align with the blueprint. We noted that Infoway adequately monitors the implementation of projects by provinces and territories.

We reported that Infoway needs to make improvements in certain areas. Infoway's 2010 goal is for 50% of Canadians to have electronic health records available to their health care professionals. We found that Infoway needs to report more information on results, in particular, information on progress achieved towards its 2010 goal. To date, it only reports if systems are completed, not whether the systems are being used by health care professionals, or whether completed systems meet the requirements for compatibility. This information on system usage and compatibility would help Parliament and Canadians better understand progress to date.

We noted that Infoway's controls over executive pay, travel, and hospitality are basically sound, although it needed to improve its contracting policy.

Concurrent with our audit, six provincial audit offices looked at how electronic health records funded by Infoway and/or provincial governments are being implemented in their respective provinces. Each office has reported the results of its audit to its own legislature between October 2009 and April 2010. My provincial counterparts and I issued an overview of the federal and provincial reports on EHRs in April 2010.

In the six jurisdictions audited, the audits found that every audited jurisdiction had at least one core electronic health record system in place, and some provinces had almost finished implementing their EHR systems.

The six participating provincial legislative audit offices raised various concerns about EHR planning, with some noting recent progress. For example, three reported that the ministry started their EHR initiatives without having a comprehensive strategic plan. This increases the risk that the projects undertaken will not be consistent with the goals and priorities of the overall initiative and that the needs of the users will not be met.

With regard to the implementation of EHRs, participating provincial auditors general reported that the focus for each province has been to ensure compatibility within their respective jurisdictions. It is too soon to determine whether the systems in each jurisdiction will be compatible nationally.

Notably, my provincial counterparts found limited public reporting on progress. Provinces lack comprehensive information such as costs to date, baselines, and performance measures necessary to report progress more completely.

Infoway, the provinces, and the territories need to work together to develop performance measures and reporting standards for each core system of the electronic health record, so that Parliament, legislatures, and Canadians can better understand progress made and benefits achieved.

While progress has been made in developing and implementing electronic health records across Canada, continued collaboration between Infoway, the provinces and territories, and other stakeholders will be needed to address the significant challenges that lie ahead.

These challenges include the need to increase the number of primary care doctors using computerized records systems; to upgrade completed EHR projects that do not meet all the standards for national compatibility; to address the implications of differences in provincial and territorial laws regarding the collection, use, protection, and disclosure of personal health information; to track the total costs; and to fund the completion of the initiative. A key question is whether the 2010 goal will be met by the end of this year.

Mr. Chair, given the significance of the investments made, the potential benefits, and Canadians' interest in health care, the committee may wish to ask Infoway for an update of its action plan developed in response to our November 2009 audit. Furthermore, all of the participating auditors general have suggested that legislative committees continue in the future to provide oversight to this initiative and monitor progress toward meeting the 2010 goal.

Mr. Chair, this concludes my opening remarks and we would be pleased to answer your committee's questions.

[The Chair, Liberal, Shawn Murphy]

Thank you, Ms. Fraser.

We're now going to hear from Mr. Alvarez, the president and chief executive officer of Canada Health Infoway.

Mr. Alvarez.

[Richard Alvarez, President and Chief Executive Officer, Canada Health Infoway]

Good morning, ladies and gentlemen.

Mr. Chairman, thank you for providing us with this opportunity to speak to the committee today.

As you stated earlier, with me is Mike Sheridan, Infoway's chief operating officer.

Let me start by thanking the Auditor General of Canada and her audit team for what we believe to be a thorough, balanced audit report on electronic health records, which her office tabled with Parliament in November 2009 and then again in April 2010.

As the Auditor General notes in her overview report, the provinces' approach to electronic health records is unique. Their definitions of electronic health strategies, priorities, timelines, and approaches are distinctive.

As a strategic investor, Infoway has developed, in consultation with our jurisdictional partners, the key requirements, the core components, and a blueprint to guide—

[The Chair, Liberal, Shawn Murphy]

I'm sorry to interrupt. You may be going a little too quickly for the interpreters at the back of the room. Could you slow down about 20%? It's only nine o'clock in the morning.

[Voices]

Oh, oh!

[Richard Alvarez]

Mr. Chairman, I was terrified you were going to cut me off after my five minutes, so if you promise not to do that, I'll slow down.

[The Chair, Liberal, Shawn Murphy]

I just have sympathy for the people back in the corner; that's all.

[Richard Alvarez]

Sure.

As a strategic investor, Infoway has developed, in consultation with our jurisdictional partners, the key requirements, the core components, and a blueprint to guide the pan-Canadian developments of EHR. Infoway's strategic plan identifies those priorities, along with measurable goals and targets, and provides an agreed-upon road map for the development of the various components of the EHR that we fund.

Madam Fraser's overview report specifically states that “at the federal level the audit reported that Infoway was exercising due regard in managing funds from the federal government to achieve its goal related to the implementation of EHRs”. As a result, today every province and territory and the populations they serve are benefiting from a share of the federal government's investments through Infoway in the new information systems that will help transform health care.

Let me share with you just two examples. Our investments have helped to eliminate three-quarters of X-ray films and replace them with digitized images. Today some 40% of our radiologists report they are providing services to new and remote sites—that's incredibly important, given the large land mass of our country—and eliminating between 10,000 and 17,000 patient transfers per year.

Leveraging Infoway's investments, drug information systems are now in place in British Columbia, in Alberta, in P.E.I., and in Saskatchewan. Take the system in B.C., PharmaNet, which captures every prescription dispensed in pharmacies and provides alerts to pharmacists and physicians. In 2008, more than 55 million prescriptions were processed by PharmaNet, and 2.5 million significant drug interactions were identified. When you project that across Canada, this suggests that drug information systems could significantly reduce inappropriate prescriptions and identify more than 20 million significant drug interactions every single year.

The Auditor General made eight recommendations to Infoway in her November 2009 report to Parliament. Shortly after the report was tabled, Infoway sent its action plan to this committee as well as to the House of Commons Standing Committee on Health. Our response to the eight recommendations encompassed some 40 separate actions, which were implemented by our self-imposed deadline of March 31, 2010, the end of our fiscal year. We also reviewed this action plan with the Office of the Auditor General of Canada.

Of the eight recommendations, five call for improving and enhancing our existing reporting, especially as we report to Canadians. In this regard, we conducted focus groups with the public across the country to ensure that our enhancements in reporting on availability, on adoption, on standards, our investment targets, and reporting variances in our business plan would be understood by those Canadians. The result of these focus group discussions helped us to improve and expand reporting on the key measures that have been integrated into our 2009-10 annual report, which will be published in a few weeks.

We have also assessed and strengthened our management controls over contracting for goods and services to reduce the risk of contract disputes, with the introduction of additional control points, advance notice of expiry dates to contract administrators, enhanced management signature procedures and processes, as well as required workflow modifications. We have supplemented these administrative changes with an internal communications and education program for our staff.

As recommended by the OAG, we have reviewed and modified our procurement policy with respect to contract amendments and extensions and have had the revised policy approved by our board of directors, and now it's firmly in place.

In response to the recommendation that Infoway should better document its analysis of project deliverables to support our decision to release funds, we have revamped our project portfolio management system and have modified and updated the processes and procedures to support the release of funds for deliverables in a consistent manner. All appropriate staff have been trained on the new system requirements.

We have also incorporated into our investment approval process for the core systems of the EHR the requirement to obtain results of conformance testing on the core EHR systems that we fund.

We believe that we have responded to the recommendations in a timely, efficient, and effective manner and have addressed the issues of concern raised in the OAG's audit report.

Mr. Chairman, that concludes my remarks. I'll be delighted to take questions.

[The Chair, Liberal, Shawn Murphy]

Thank you very much, Mr. Alvarez.

We're now going to hear from Dr. Karen Dodds, assistant deputy minister, strategic policy branch of the Department of Health.

[Dr. Karen Dodds, Assistant Deputy Minister, Strategic Policy Branch, Department of Health]

Thank you, Mr. Chairman.

Mr. Chair, members, I am very pleased to have the opportunity to be here with you this morning.

I first want to thank the Auditor General and her staff for their very informative reports. Health Canada is pleased that they have undertaken the task of reviewing electronic health record initiatives. The process has provided all parties with useful feedback.

The federal government has invested $2.1 billion in Canada Health Infoway since 2001. In this context, the audits have provided confirmation and assurance that these investments are being managed responsibly and effectively.

Indeed, the audit of electronic health records provided an additional layer of due diligence, to support the recent release of the $500 million allocated to Infoway under Budget 2009.

I would like to take this opportunity today to speak in more detail about Health Canada's reaction to both the fall audit report, and the spring overview report.

As noted by Ms. Fraser, developments in the area of electronic health technologies are expected to be of great benefit to Canadians as they will enable better, safer, and faster management of patient information. Evidence of this is already being seen across the country.

Of course, establishing electronic health technologies is a highly complex undertaking, particularly in Canada, where 14 jurisdictions are individually responsible for the delivery of health care. This makes the results of the audits encouraging, for although they identify areas for improvement, they also emphasize many achievements. With respect to the Auditor General's fall 2009 report, Health Canada was pleased to note that Ms. Fraser recognized that Infoway has accomplished much since its creation, a point that she reiterated today. In this context, Ms. Fraser also underscored that provinces and territories are individually responsible for the pace of progress in their respective jurisdictions.

I believe this speaks to the importance of having an entity such as Infoway, which brings all parties together in a cohesive manner towards a shared goal.

The auditor general also recommended that Health Canada fully develop and implement its framework for monitoring Infoway's compliance with the funding agreements. I am pleased to tell you that, at the time of the release of the audit report in November 2009, the department had already completed implementation of its monitoring framework. This framework has been shared with the Office of the Auditor General.

This document is an evergreen tool that will be updated by the department on an ongoing basis to reflect the evolution of this dynamic initiative. I am pleased that the Auditor General highlighted this document, as I believe it supports Health Canada's proactive attention to accountability issues and due diligence in relation to the significant federal investments in Infoway.

The Auditor General's electronic health records overview report, which was released this spring, provided a unique opportunity to better understand the complexity of e-health activities at both the pan-Canadian and jurisdictional levels. In this context, I was pleased to note that it further underscored the progress that is under way across Canada. For example, implementing EHRs requires the establishment of a number of key foundational components. As noted by Ms. Fraser, every jurisdiction has at least one new component in place.

Health Canada was also pleased to note that the report highlights the important role that Infoway plays in ensuring that electronic health records are implemented across the country in a cohesive and standardized fashion. Indeed, the ultimate goal is to ensure that when Canadians move across the country, there will be portability of their health information. To this end, Infoway led the creation of a blueprint that lays out the design for a pan-Canadian EHR system. Infoway also leads the identification, development, maintenance, and application of standards, which are required to ensure that EHR systems will ultimately be able to communicate.

The report tempers these observations of progress by underscoring the variety of challenges which face all parties as we move forward. I would like to emphasize that these challenges are well understood by governments and Infoway, and that plans and activities are already underway to address each one.

I am also confident that the recent federal investment of an additional $500 million in Canada Health Infoway, will serve to accelerate action on many of these challenges, such as computerizing doctors' offices, insuring that systems will be compatible, and completing the establishment of electronic health records.

In closing, I would like to reiterate Health Canada's appreciation of these informative audit reports. We look forward to continued progress in the area of e-health, and I am confident that the audit findings will help to support us in this ongoing process.

I'll be pleased to answer any questions that committee members may have.

[The Chair, Liberal, Shawn Murphy]

Thank you very much, Dr. Dodds.

We're now going to start the first round of seven minutes each.

M. Dion, sept minutes, s'il vous plaît.

[Stéphane Dion, Liberal, Saint-Laurent—Cartierville, QC]

Thank you, Mr. Chairman.

Good morning, ladies and gentlemen, and welcome to our committee.

The Auditor General's report on electronic health records is both reassuring and worrisome, I would say. It is reassuring with respect to Infoway's internal management, in fact it may be the most positive report I have read in this regard in the short time I have been on this committee.

I did however note a point of concern regarding internal management of calls for tender: contracts were being amended on numerous occasions, costs were increasing. Infoway has recognized the problem. It has committed to suggesting the necessary changes to the board for the fourth quarter of 2009-2010.

Was that done, Mr. Alvarez?

[Richard Alvarez]

Thank you, Mr. Dion.

The short answer to that is yes, it was done. The longer answer to that is we had a board-approved policy that basically allowed us to go to market, which we did as an RFP, and basically get bids. What we didn't say in that RFP, which the Auditor General reported on, is that we could in fact have contract extensions. In the case that was quoted in the document, the scope of the project increased and it took a much longer period of time; therefore, the contract was extended, I believe, six times. We extended it without going back to market, because that was the board policy and it was okay for us to do that.

We've now made a change to that. When we go to market in an RFP, we make it very clear and transparent that there's the possibility of being extended any number of times. That way, people realize that when they are bidding on it.

[Stéphane Dion, Liberal, Saint-Laurent—Cartierville, QC]

Is Ms. Fraser satisfied with this corrective action?

[Sheila Fraser]

We have not seen the changes in detail, but we have seen the action plan that has been proposed, and we were satisfied with the steps Infoway intended to take.

[Stéphane Dion, Liberal, Saint-Laurent—Cartierville, QC]

Thank you very much.

I would now like to get back to the issue of concern, which is achieving results. The goal was for half of Canadians to have an electronic health record that health care professionals could consult by December 31, 2010, and 100% by 2016.

It is now June 2010. What percentage of Canadians have an electronic health record their health care professionals can consult today? What percentage have we reached?

[Richard Alvarez]

Monsieur Dion, when you look at the goal, it's a two-part goal. The first part basically talks about the fact that by 2010, every single jurisdiction in the population they serve will benefit from the investment in one or more of the information systems. I can assure you, sir, that is happening in absolute spades. Whether it's diagnostic imaging or drug information systems, Canadians are in fact benefiting from the systems that have been put into place.

The second part of that goal does speak to the fact that by 2010, 50% of Canadians will have their data available to their providers. I should preface that by saying that Infoway is solely dependent on how quickly the jurisdictions move. As you know, sir, we've had some hiccups—certainly in our larger provinces, Ontario and Quebec—which have caused some setbacks in terms of the timelines. As of today, we have about 22% in the database, but we're reasonably confident, given the undertaking by Ontario and Quebec, that we will cross that 50% threshold sometime early next year.

[Stéphane Dion, Liberal, Saint-Laurent—Cartierville, QC]

So you're confident in the 2016 objective to have 100% of Canadians benefiting from it?

[Richard Alvarez]

Yes, we're pretty confident that by 2016 we will have that number.

[Stéphane Dion, Liberal, Saint-Laurent—Cartierville, QC]

I need to understand the numbers. You say that you need $10 billion. I guess it's not $10 billion of federal money; it's $10 billion overall. But you say you're funding 75% of the project. Does that mean that between now and 2016, we need to invest $7.5 billion of federal money?

[Richard Alvarez]

That number really came out of a couple of studies that were undertaken—one by Booz Allen and the other by McKinsey. The number was premised on the fact that we're talking about the entire scope of the health care system—that is home care, long-term care, all the hospitals, doctors' offices, community doctors' offices, etc.

Today our scope is rather defined. When we got started, sir, we had $500 million from the government to work with. There was no promise at that point of any additional funds. Over time, we've had additional funds. So we are really cutting our cloth, defined on priorities. If there's no more money, then we would at least have done the community positions; we would at least have done some of the hospitals, the drug information, etc. If the money flows, we start to move it out into community settings.

But those are the numbers in terms of the 75%. Yes, we do fund 75% of eligible costs, but there is a whole host of costs the provinces have that we don't fund. So when you start to weigh what they're paying for and what we're paying for with federal dollars, it's normally about a 50-50 split.

[Stéphane Dion, Liberal, Saint-Laurent—Cartierville, QC]

The Auditor General notes that there is a difference between an accessible computerized system and a system that is used. In fact, she noted that in some cases funds had been invested in systems which may never be used. You respond that it can take 24 to 36 months before an accessible system is used by professionals.

Is there a risk that we may be investing in systems which would remain unused? She mentions the drug information system in Alberta and the registry for Quebec clients. Do you have concerns about the fact that there may have been a great deal invested into systems which, for a host of reasons, professionals are not using or will not use?

[Richard Alvarez]

Thank you for that insightful question. When I think about the job at hand, what information technology is going to be doing, it's really going to be transforming the health care system. It's going to be getting clinicians to work in completely different ways.

The challenge for us here is not a technological challenge, by the way; it's a people challenge. It's a chain management challenge of getting, in many cases, these clinicians who are not salaried, who are not employees of any facilities, but entrepreneurs and small business people, to adopt these new technologies. We've known from the start that the chain management and getting used to these systems is going to be the biggest challenge.

That is why we put in place a protection of the federal funds. We're a strategic investor, and the way we fund is once we get a signed agreement of what needs to take place, we provide 20% to get on with the job; we provide another 30% when the hardware and software are in, but we hold back 50% of the funds until we get take-up, until we get usage from the clinicians. From where I sit, we can put into place peer-to-peer groups, tools, and best practices of how clinicians should adopt this, but I can't make them adopt it. It has to be up to the territories and provinces to do that. That's why we hold back the money.

Will this happen? There's absolutely no doubt in my mind that this will happen, that clinicians will change the way they are working. Is it slow? Yes, it is slow because there's a lot of learning to do, especially with clinicians who have been out of the system, have been out of school for the last 20 or 30 years. They are now finding new tools and how to use them. Clinicians who are in the system today will not come out and practise in Canada without these state-of-the-art systems.

[The Chair, Liberal, Shawn Murphy]

Thank you, Mr. Dion.

Ms. Faille, you have seven minutes.