Public Accounts Committee on June 3rd, 2010

[Richard Alvarez]

We absolutely are as a country. I've talked about the diagnostic imaging systems. In the diagnostic imaging systems we've now basically thrown away all those X-ray forms. About 70% to 80% are now digitized, which means, in fact, that those X-rays can be looked at from anywhere.

Let me give you a quick example of this. Several of our provinces now are completely digitized. We're just moving in that direction with Manitoba. Just a few weeks ago they finally got Churchill done. The day they had Churchill digitized, a child presented with injuries. Typically, they would have flown a jet out of Winnipeg to bring the child down, but they did the image and sent it down to Winnipeg Health Sciences Centre. They looked at it and said there was no need to move the child and this is what they need to do. The very next day another child presented, and this time Churchill thought they could actually work with the child up there, but they sent the image down. They looked at the image at the health Sciences Centre and said, we're sending the jet, bring the child down right away.

So there have been huge changes. We have 25% to 30% productivity gains with our radiologists. That's basically adding another 500 radiologists.

I talked about the drug information systems. Let's take Alberta. They're clearly at the leading edge. Alberta today has an electronic health record, and they have 20,000 users of that record on a daily basis. They've been able to build chronic disease management systems and registries very quickly on top of the electronic health record.

Take cancer surgery. We now have a system of cancer surgery where the clinicians are starting to record just the minimum data sets as soon as they do the surgery, as opposed to transcribing their reports. The change in that is the transcription reports used to basically take over a month to get them in hand. They can now get their reports after one hour of the surgery. They're reporting 100% of those items, and they're training our new doctors on best practice.

[The Chair, Liberal, Shawn Murphy]

Thank you very much.

Madame Beaudoin, pour cinq minutes.

[Josée Beaudin, Bloc, Saint-Lambert, QC]

Thank you very much, Mr. Chair.

Ladies and gentlemen, good morning.

Mr. Alvarez, I want to come back briefly to the problem of compatibility. In fact, I would have liked you to tell us how serious problems can get when dealing with this matter. More specifically, on page 26 of the Auditor General's report, it states that regarding interoperability between provinces that “and Canadian interoperability can be achieved”. I imagine that this is one of your priorities. You also say that “differences in standards can be mitigated”.

Is this interprovincial compatibility and this interoperability a priority?

[Richard Alvarez]

Thank you for the question, Madame.

I believe those are problems that will be overcome. I have to say that our priority is to get those standards working at local and regional and jurisdictional levels. It's really important, as the people move around from their GP to hospitals to clinics to pharmacies, that we can get that interoperability. Our priority is to make sure the vendors who sell their products across Canada implement those standards in a very consistent way and to incent them to do so.

Clearly, when we come to pan-Canadian compatibility, there will have to be translation between some of the standards. There are systems that have been there for quite a while that don't have some of the new standards, and we don't have enough money to throw those systems out and start again. But at the stage when those systems come up for a life cycle change, we will get the new standard in. Until then, we will have a translation engine that translates between the old standard and the new standard.

[Josée Beaudin, Bloc, Saint-Lambert, QC]

Thank you very much.

I would like to have some information regarding a point on page 26, in the French version of the document. There it says that you are going to do “mapping to accommodate differences in the implementation of the standards”. What do you mean by that?

[Richard Alvarez]

Basically, we publish through this collaborative mechanism—which is basically, as I said, the clinicians, the private sector, and governments—what standards need to be worked on and when they need to be worked out. It's a very expensive process to get these standards.

What are these standards? They are messaging standards, data standards, so that two heterogeneous computer systems from different vendors can talk to each other. What we try to do first is if we can borrow the standards and adopt them from international standards, we do that. If we basically can adopt them but have to Canadianize them for such things as our postal code, we'll do that. If, on the other hand, we're ahead of the curve and nobody else has the standard, as they didn't in terms of the clinical drug information systems, we basically build them from scratch. But when we build them, we build them as international standards and encourage basically as many people as we can in the rest of the world to adopt those standards as well.

[Josée Beaudin, Bloc, Saint-Lambert, QC]

Thank you very much.

This audit also took the protection of privacy into account. Could you share with us the risks that you have identified up to now?

[Richard Alvarez]

Privacy is a very big issue for us, and mercifully, as of today, we haven't had any major failures around it. There have been some incidents.

This is what Infoway does. In terms of our blueprint, our architecture, we're very clear on what the privacy and the security arrangements in that architecture should be, and we encourage the provinces to follow them. We ask right up front for a privacy assessment audit, which they have to give us for each single project before the money starts to flow. Certainly, based on Madam Fraser's recommendation on aspects of conformity, we'll be moving in that direction as well. With the new moneys, as we did with the consumer health space, we have also put in place a certification service to make sure that certification occurs for the vendor products from a privacy, security, and interoperability point of view.

[The Chair, Liberal, Shawn Murphy]

Mr. Shipley.

[Bev Shipley, Conservative, Lambton—Kent—Middlesex, ON]

Thank you, Mr. Chair, and thank you to the witnesses.

It's a generous report. I'm not sure I agree with it; maybe I've been tainted a bit in Ontario.

Let me go to the report. I understand that a comment came out at the end of June or early July 2009. According to Health Canada Infoway, of about 322 million doctor visits that we have per year, around 94% result in hand-written paper records. When we compare Canada's position in terms of our electronic health records, we find that in the Netherlands, 98% of health records are electronic; in New Zealand, 92%; in the U.K., almost 90%; in Australia, 80%. Only the United States fares worse than Canada. I'm confused.

We have an October 2009 report from the auditor in Ontario showing that instead of being near the head of the list, Ontario is near the back of the pack when it comes to electronic health records. Where is the Department of Health, or Infoway? It seems that we hand money over. There was a billion dollars in corruption that happened in Ontario. That is partly, I'm assuming, federal dollars; maybe partly it is provincial dollars.

My point is, quite honestly, that this started in 2001; we are now in 2010. We are behind the pack in just about everything that you talk about, although I know Ms. Dodds talked about the doctors and patients receiving a benefit in comparison with some of the other countries. I think in Ontario and Canada that's what needs to be a priority. In health care, patients should be about priority, and not systems, and not computers. They need to be a part of that; the patients come first.

I understand the significance of the electronic and the digital records. We understand the need for them. But quite honestly, I believe we have not been accountable for the dollars that have gone to the system. I just don't understand why now we're developing strategic plans, in 2010. I read somewhere here that in 2006 we revised the blueprint, five years after 2001. Please encourage me. It would seem that in 2001 we had an Infoway set up by the government that threw money out without direction, and it took until about 2006 to start to get some organizational part of it in place. There is no strategic planning; there doesn't seem to be much accountability. Provinces have been all over the map in terms of continuity.

So I ask you, Mr. Alvarez, and I would ask Ms. Dodds, and I would ask Sheila Fraser, the AG, to help me understand that actually this is a continuity, that there is compatibility, because I don't see compatibility mentioned in terms of the systems that are going in. We have provinces doing different things, and there are priorities.

That is a lot of questions, but I'm going to run out of time. That's why I put them forward. Don't be discouraged; I just need to understand it, because it has not gone well, from our perspective in Ontario.

[Richard Alvarez]

Thank you.

There are a lot of questions there, and with all due respect, sir, I think there is a bit of tainting there of the province that you live in—and that I live in, as it happens.

For the record, none of that $1 billion that was spent in Ontario was federal funds that were wasted. For all the federal funds that went into Ontario we got absolute results. They have a world-class telehealth system, by the way, and we helped fund that telehealth system. A few years ago in Ontario, a senior would show up at a hospital and they would have absolutely no idea what medication that senior was on. We changed that and encouraged them to put the Ontario drug database, the ODB system, into the hospitals. As of last year, they had a million hits on that file; now they are actually looking at what individual medications they were on.

So we've had, with our federal funds, a lot of successes in Ontario. The moneys that were reported on were clearly moneys that we had no dealings with and didn't spend.

In terms of strategic plans, absolutely Infoway has from the get-go had a strategic plan in place. It manifests itself in terms of the priority areas and the programs that we would invest in. We had over 600 people involved in consensus building around the blueprint and the architecture as provinces began their work. Clearly, over time, as new technologies come along and as new learning comes along, you have to go back to revisit and refresh your plans or take them to a deeper level. That is exactly what we did six years on.

If you sat in Alberta and had an electronic health record with 20,000 users; if you sat in British Columbia and had a fully functioning pharmacy system; if you sat in Nova Scotia or Newfoundland and had all your community pharmacists on the system; or if you had an entire province digitized, I believe, sir, you would have a different opinion. A lot of progress has been achieved. I will say this: clearly, the larger the province and jurisdiction you are, the tougher the job is. It is tough for Quebec and it is tough for Ontario. Then, if you get hiccups in terms of management, hiccups in terms of governance, those plans take that much longer.

From where we sit, we can encourage them, we can incent them, but we can't do the job for them.

[Bev Shipley, Conservative, Lambton—Kent—Middlesex, ON]

Why don't you have a strategic plan as part of the funding?

[Richard Alvarez]

We absolutely do. For the programs we invest in, if they are drug information systems, lab information system, diagnostics client registries, we will have their plans; there's no question. But if I'm not investing in a home care service, or if I'm not investing in a long-term care service, then I don't have a right to ask for those plans, and they may or may not have them.

[The Chair, Liberal, Shawn Murphy]

Thank you, Mr. Shipley. We have to move on.

Mr. Christopherson, you have five minutes.

[David Christopherson, NDP, Hamilton Centre, ON]

Thank you very much, Chair.

The proof is going to be in the pudding, as the Auditor General has said, concerning the follow-up, as to whether everything that makes for a fairly good picture today holds.

I have to tell you, Mr. Alvarez, you certainly give the impression of being someone who is very forthright and who knows his file. Notwithstanding that this isn't perfect, you seem to have a good handle on your organization. I have been impressed. The challenges here are serious.

I'm going to give Bev a quick heads-up.

Bev, if you want to do a follow-up question, I'm prepared to give you a minute or two of my time. You seem to have some good questions, and I will offer that time to you, as I'm just wrapping up here.

Again, I would just wish you the best, and we'll see when we do the follow-up how things are. But if it's anything like the impression you've given today, I'm feeling more confident than I might have before this meeting was held. Thank you for that.

I offer to my colleague, Mr. Shipley, the balance of my time, if he would like it.

[Bev Shipley, Conservative, Lambton—Kent—Middlesex, ON]

Thank you, Mr. Christopherson.

I have just one question.

Auditor General, in paragraph 12 of your speaking notes you say “it is too soon to determine whether the systems in each jurisdiction will be compatible nationally”. I would have thought that at the start of this thing in 2001 there would have been some sort of plan that would say that systems had to be compatible. Here we are now, in 2010, and we're asking the question.

Is it not something that should have been there? It was just a sort of guiding comment, I guess, but it goes back to my concern about the lack of direction, the lack of accountability to move ahead. Nine years later, now, we're sitting at 50% of where we should be.

[Sheila Fraser]

I think on the question of compatibility, the committee has to realize that many of these systems had begun or were in place in certain jurisdictions even before Infoway came into being. I think the province of P.E.I. has one that's fairly complete, so those systems would have been introduced before the blueprint was established. So there are questions around how they will take existing systems and modify them or make a link or do this translation that Mr. Alvarez has talked about to ensure compatibility with the rest of the country.

So those are some of the challenges. I think the newer systems that have come in and the projects that have been introduced or have been co-financed by Infoway clearly meet the standards that have been established. But there could have been systems previous to that. As well, I guess this is one of the joys of living in Canada, but provinces do what provinces want to do, and the federal government is not going to dictate to them what to do. There has to be respect for their jurisdictions, but I think this is an issue that as auditors general we would certainly encourage the committee to continue to follow up on, to see how these challenges are being met and if the provinces are responding. This could be a discussion perhaps for a meeting of CPAC or something, where you have all the public accounts committees present. What are the other provincial public accounts committees doing as well on this issue?

[Bev Shipley, Conservative, Lambton—Kent—Middlesex, ON]

If there is any extra time, my colleague may have some extra questions.

[The Chair, Liberal, Shawn Murphy]

I'm going to go to Mr. Kramp now anyway.

[Daryl Kramp, Conservative, Prince Edward—Hastings, ON]

Thank you, Chair.

Similar to Mr. Shipley's comments, my concern is, where did we start with this? If we started back in 2001, did we say we had a goal, so let's work toward it, or did we have a signed agreement with a strategic plan that said, let's do this: your obligations are this, my obligations are that.

In other words, did we have a formal agreement between the feds and the provinces before we commenced this project?

[Richard Alvarez]

Infoway was set up by the first ministers as a national organization to work with the federal government and to work with the provinces and territories to move this agenda along. The basic mandate was to accelerate the adoption of these systems. One of the first things Infoway did was to sit down with the provinces and territories to understand and define what the priorities should be. From there, we have six core programs and 12 programs in total, and then we worked with the provinces. Once they decided on priorities, we then asked them to give us their three-year plans of how these priorities were going to be rolled out, which they did.

Based on those three-year plans, I went back to the board and said the goal should be that by 2010 we should hit 50% of availability. As I've said before, as these systems roll out they will, by 2010, start to impact and provide benefits to every citizen in the provinces and territories. The first part of that goal has happened. The second part is slower in coming. At the end of the day, as Madam Fraser said, we are very much dependent upon the pace of the provinces, but they've agreed to what the priorities are. In those priority areas, we certainly have strategic plans, and we have their plans, which we build on.

[Daryl Kramp, Conservative, Prince Edward—Hastings, ON]

The fact that we obviously have different levels of success in the provinces concerns me. Is it because we're not all singing from the same song sheet, or are we just ineffective? As an example, we all heard the horror story in Ontario about the millions of dollars, with consultants who hired consultants to hire consultants.

Did Infoway funding go to any portion of that?

[Richard Alvarez]

No. I've answered that question before. Infoway's funding absolutely did not go to any funding of that. We didn't even have a contract with e-health or with the Smart Systems for Health Agency.

[Daryl Kramp, Conservative, Prince Edward—Hastings, ON]

I just wanted that crystal clear.

[The Chair, Liberal, Shawn Murphy]

Do you want in on that issue, Dr. Dodds?