Health Committee on Oct. 23rd, 2012

[The Chair, Conservative, Joy Smith]

I call the meeting to order.

Good morning, everyone. It's nice to see all our guests here this morning.

From the Centre for Global eHealth Innovation, we have Dr. Joseph Cafazzo. He has a PowerPoint presentation, so we're going to begin with him shortly.

From the Manitoba eHealth Program—good Manitoba, centre of Canada, let's fly the flag for Manitoba, Dr. Girard—we have Dr. Roger Girard, chief information officer.

From the Assembly of First Nations, we have Jonathan Thompson, director of the health and social secretariat. Welcome.

We have, from Health Canada, Kathy Langlois, acting assistant deputy minster for regional operations; and we have Ernie Dal Grande, national manager of the eHealth Program.

We have a dynamic group of witnesses today and we can hardly wait to hear what you have to say. Each organization will have 10 minutes.

We will begin with Dr. Cafazzo, with your PowerPoint, for ten minutes, Doctor.

[Dr. Joseph Cafazzo, Lead, Centre for Global eHealth Innovation]

Thank you very much. Thank you for the opportunity.

I'm Dr. Cafazzo from the Centre for Global eHealth Innovation at Toronto General Hospital. We have a mandate, as an academic research facility based at Toronto General, to look at the design and evaluation of future e-health innovations that will transform the health system.

[Slide Presentation]

Our mandate is to address these six chronic conditions that consume 60% of all health spending. If we consider all chronic conditions, that's as much as 80% of all health spending. The main issue we're trying to address is that we have this tendency to spend most of our health care dollars on this bottom right-hand quadrant: very intensive acute care, at a very high cost, and with a very low quality of life. The purpose of the systems and the technologies we're looking at is to facilitate the shift in the spending toward this top left-hand quadrant: the care that is closer to home, that's lower in cost, and that comes with a higher quality of life. Central to this is the mandate of the centre, which is to facilitate patient self-care, where we believe that the patient has a larger role to play if the system is designed to accommodate them.

I want to cite some examples at Toronto General Hospital. Many of you already know that patients with end-stage renal disease must have hemodialysis three times a week in a centre such as Toronto General. About 10 years ago, an experimental program was started. One of the patients who decided to opt for this program was Yvonne Maffei, 27 years old, with end-stage renal disease, and recently married. Her future was within a dialysis unit three times a week. She opted to go with this experimental program of home hemodialysis. Although it sounds crazy, the idea of putting a dialysis machine in a patient's home actually works. Because they had the dialysis machine at home, they could dialyze more frequently. Rather than get 15% renal replacement function within a hospital setting, they could get as much as 50%. The theory was that they could have better outcomes.

Yvonne Maffei was one of 20 patients enrolled in this program. They have to learn how to use the machine and self-cannulate themselves using these two big needles every single day. For Yvonne Maffei, the outcome was significant.

For end-stage renal disease patients, the idea of bringing a pregnancy to term is pretty well unheard of. She not only conceived, but she also brought a full-term baby to term nine months later, which is unprecedented for end-stage renal disease patients. She was not the first. There were many patients subsequently over the next 10 years. This was literally a baby boom amongst home hemodialysis patients, who for the first time would be able to bring pregnancies to term. These children would not have been born if it wasn't for the ability to have the system accommodate patients and allow them to create circumstances for them to care for themselves.

The outcomes over the last 10 years have shown that home hemodialysis has many improved health outcomes. You can see the long list there of improved health outcomes. The most amazing thing is that it costs about $10,000 a year less per patient, per year, to deliver in the home rather than in an institution like Toronto General, so it is a win-win all around.

I want to cite some other examples of creating systems and technologies to unlock the patient's ability to self-care. This particular group includes teenagers, and they're not necessarily known for having the skills to care for themselves. We decided to build a system around their mobile phone for them to be able to manage their blood sugars on a regular basis. With the Hospital for Sick Children we created this application called Bant. It had the ability to wirelessly communicate with their blood glucose meters and capture the blood sugar readings on a regular basis.

We also added a rewards program for these kids to be able to earn experience points. For every reading they took, they earned a times two multiplier for consecutive readings and bonus points when they took five readings in a row. They were able to redeem these points for iTunes redemption codes, which would allow them to buy music and apps. The study we did at SickKids showed that these kids tested 50% more frequently using the app than in the three months previous to using the app. It's a small step in learning how to care for themselves. Perhaps it's not as impressive as giving birth, but it's a step in the right direction for these kids.

Another example is with type 2 diabetes. These patients also had the comorbidity of hypertension—a serious comorbidity. We did the same thing using a BlackBerry and a blood pressure monitor that was Bluetooth-enabled to communicate with their mobile phone. We did a randomized control trial: taking a conventional blood pressure monitor, giving it to a group, and giving another group the blood pressure monitor with the BlackBerry and the app running on it. After a one-year period we saw no change in the group that just had the conventional blood pressure monitor, but with the group that had the BlackBerry app, we saw a 20% drop in their cardiovascular mortality risk.

The other significant aspect of this study is that the physicians had really nothing to do with this outcome. No additional medications were prescribed. There were no additional visits to the family doctor. This was truly patient self-care, allowing the patients to become a lot more self-aware of their condition and more actively managing their care, whereas the patients who just had the blood pressure monitor...largely because hypertension is asymptomatic, they probably forgot to use it after a period of time.

We have been building apps for many years to deal with diabetes, working with the Heart and Stroke Foundation to do a risk assessment, and our newest application is for consumer asthma management.

One of the central key issues we are very concerned about, and one of the things we really need to deal with is patient access to their personal health information.

This is David deBronkart, who visited Toronto a few years ago from Boston with a very simple message to health providers, “Give me my damned data.”

These patients need the ability to have personal health information; they have serious comorbidities. They're managing their condition in the absence of their personal health information. It is legally their right, but there are systemic issues in the system that deny access to these patients to their health information.

Again, if we are to deal with these six chronic conditions, we need to reprioritize ourselves toward the patient in dealing with this immense burden on the health system, and there are patients out there who are more than willing and able to do this.

This is Yvonne Maffei today. Ten years later, she is still on home hemodialysis. She's still inserting those two great big needles into her arm on a regular basis. She's doing great. In fact, she now has two sons. She was not unique. Thousands of patients are doing home hemodialysis all around the world, and she is just a single example of what patients can do if the system is set up in such a way that it allows them to care for themselves.

Thank you.

[The Chair, Conservative, Joy Smith]

I'm so glad you came today. That is absolutely amazing, and I would say that giving birth is comparable to the iPhone.

Now we'll go to our second presentation, which will be given by Mr. Roger Girard from Manitoba eHealth.

[Roger Girard, Chief Information Officer, Manitoba eHealth Program]

Good morning. Thank you for the invitation to present to the committee. This is a first for me personally, and it's a privilege to be here today.

I am the chief information officer leading Manitoba eHealth, the provincial organization tasked with implementing a variety of information and communication technologies, which we call ICT, in health care. Such technologies are transforming how we work and how we live in every province and territory and in every sector, and health care is no different. I would like to take some time today to talk to you about their potential, some challenges on their implementation, and our experience in Manitoba.

Technology, like electronic records and telehealth—which is also known as telemedicine in some provinces and which is a specialized medical video conferencing service—has the potential to dramatically transform health care. We're already seeing the real impact of some of these changes. Health care is becoming increasingly advanced, with more and more research leading to new treatments, new information about old treatments, and more information to ensure treatments are used more effectively. E-health technology can support our health professionals in having the most up-to-date information as they deliver care to their patients, while improving patient flow and reducing wait times.

Health care is also becoming a challenge to sustain financially, especially with the current uncertainty in the global economy. E-health technology is playing a key role in helping provinces find efficiencies and reduce the rate at which health care spending is increasing, by better coordinating care, by reducing medical errors, and by eliminating unnecessary duplicate testing.

We all know that health care in Canada is complex. There are a variety of different organizations funding and delivering health care through different processes, standards, and policies. Implementing consistent technologies such as these in this environment is extremely challenging, as it often requires organizations to update their practices and harmonize other aspects of their operations. While this is a good thing and essential for quality, it remains that there is a natural resistance to change, and it is an important challenge to ensure that this does not cause disruption to patient care along the way. These factors mean that procuring, designing, adapting, and implementing e-health technology in a busy health care environment is expensive. It takes leadership at both the provincial and federal levels of government to ensure that e-health investments continue so that we can reach the full potential of this technology.

Here are a few words on the experience in Manitoba. Earlier this year the Manitoba government unveiled a plan to protect universal health care, called “Focused on What Matters Most”. The plan has three pillars—healthier Manitobans, better health services, and better value—to help meet the expectations of families across the province, keep up with advancements in medicine, and sustain this cherished public program in the face of global economic uncertainty. E-health technology and electronic records play a central role in the government's plan to achieve all of this.

I would like to advise you that Manitoba is a leader in e-health and in telehealth. Given our geography challenges with rural, remote, and isolated communities, this is not optional—we have to be good at it. This was not always the case. Not long ago, Manitoba was at or near the bottom of the list of Canadian jurisdictions in terms of health ICT spending. So how did we change this? The answer starts in 2006, when the Manitoba government created Manitoba eHealth and increased its commitment in funding to this important aspect of health care.

Manitoba eHealth is the single delivery vehicle for all e-health projects within Manitoba, whether these are within regional health authorities or within Manitoba Health. Manitoba eHealth is also housed within the province's largest regional health authority, which ensures proper oversight, minimizes overhead and administrative costs, and keeps us aligned with the needs of caregivers, health professionals, and government, and it keeps us accountable.

Manitoba eHealth spearheads a number of projects in hospitals, family doctor clinics, labs, diagnostic imaging facilities, and so on. Today there are 62 active ICT projects under way. Since Manitoba eHealth was established in 2006, over $270 million has been invested in health ICT projects across our province. I'd like to share some examples of these projects and their profound impact in Manitoba.

Today all of our diagnostic imaging services in hospitals and other public facilities are fully digital, with a province-wide network that spans 58 sites. In fact, on the very day the system went live in Churchill, a fly-in northern port community on Hudson Bay, I received a phone call from an excited CEO who reported to me that an unexpectedly quick turnaround on a chest X-ray had averted the evacuation by air of a patient in the emergency room. This was only possible because of this digital diagnostic imaging network, which allowed a specialist in Winnipeg to quickly review and provide feedback to the health staff in Churchill. Before this technology had been implemented, it would have meant sending a hard copy to Winnipeg, with a minimum of a two-day turnaround.

Telehealth is also having a tremendous impact on rural health care. With 125 sites today, families in rural Manitoba can visit their local health centre and connect with specialists in larger urban centres over sophisticated networks. This saves families time and money, as they no longer have to travel to larger centres for appointments. We estimate that every year, over one million kilometres of patient travel were eliminated, saving families $2.6 million per year in their own out-of-pocket expenses. Telehealth also saves the health system money by allowing staff to avoid over another $1 million per year in travel costs.

Electronic medical records are now dramatically improving patient care. Aside from computerizing patient records, EMRs allow doctors to better monitor their patients' care and allow them to view recent prescriptions, lab results, and other information. Just a few years ago, in Manitoba, only about 15% of family doctors had an electronic medical record; today, almost 70% of all doctors have an EMR in place or on order. This is a rapid change that has the potential to deliver better coordinated patient care and to improve the quality of services that we deliver.

In our flagship hospital, St. Boniface Hospital in Winnipeg, we implemented an electronic patient record and were able to measure the avoidance of 8,600 medication errors during just their first year of operation, with a 45% reduction in reported medication incidents. But this would not be possible if we were by ourselves—the support of the federal government and Canada Health Infoway have been critical.

I cannot stress this enough: Canada Health Infoway and the financial support through the federal government have been absolutely critical to our progress. In 2006, as today, Infoway remains an important enabler for Manitoba, with $67 million of investments made or committed to our province in 24 different projects. Through Infoway, we are assured that our program is consistent with and will eventually be interoperable with those of other jurisdictions. We owe nothing less to all Canadians, and Manitoba is doing its part in this regard.

For example, several years ago, Canada Health Infoway set a bold target that 50% of the population would be served by an electronic record by 2010. Manitoba has delivered on its commitment and has met the Canada Health Infoway goal. In fact, in 2010, Manitoba went live with eChart Manitoba, which is our version of the EHR, a service that has delivered 100% of all Manitobans towards this goal. EChart is now deployed in 78 locations across all of Manitoba, and utilization of this important resource is accelerating. EChart Manitoba provides health care providers everywhere, in the city as well as in the north and in first nations communities, with a record on drugs dispensed, some lab and imaging results, and immunization records.

Infoway, and the federal government's support, have been essential to moving electronic records forward across Canada and helping us achieve the potential we know they all hold. While this work doesn't always get big headlines in the news, it is making a significant difference for patients in Manitoba and across our nation. It is making care more accessible, better coordinated, and safer, and it will continue to play a key role in transforming health care into a more sustainable system over the long term as well.

Before I conclude, I want to note that the requirements of e-health are much more than the current Infoway mandate provided by the Government of Canada. It also includes automation within hospitals, home care, community health, mental health, long-term care facilities, other diagnostic areas, and so on. We have accomplished a lot, but there is much more to do. We ask for your support to help us continue this important work and get the job done. We need the continued help and support of Canada Health Infoway and the federal government. We need your help and support.

Thank you. I am pleased to answer any of your questions.

Je suis heureux de repondre à vos questions en français.

[The Chair, Conservative, Joy Smith]

Thank you so much. That was very interesting, and we appreciate your insightful comments.

We'll now go to the Assembly of First Nations and Jonathan Thompson, please.

[Jonathan Thompson, Director, Health and Social Secretariat, Assembly of First Nations]

Thank you to you and to your colleagues as well, Madam Chair, for the invitation today. It's a pleasure to be here.

As all of you probably know, the Assembly of First Nations is the representative body of all first nations communities across Canada, totalling close to a million citizens over some 633 communities.

We look after many files at the AFN Health and Social Secretariat, such as public health, mental health, information management, and primary care, but one of the big ones as well, of course, is e-health. As technologies advance and as Internet access expands to our communities, telehealth and e-health are seen as indispensable tools towards developing a comprehensive, effective, and efficient health system for first nations people.

For a little context, the state of first nations health, as you are probably mostly aware anyway, certainly is lagging behind in terms of health outcomes. I was looking at the big six from Dr. Cafazzo, and I was like, “Yup, bing, bing, bing, check, check, check”.

Unfortunately, for type 2 diabetes, for instance, the rates on reserve are three to five times higher. Infant mortality is 1.5 times the national average. I can go on and on. I don't want to spend a lot of time on that. The story is well known.

Why is this the case? There are many, many reasons, but certainly one is access to care. Access to care is an issue that contributes to poor health outcomes for first nations.

In the recently released first nations regional health survey, respondents identified a number of health care barriers, which include: the inability to cover child care costs; difficulty in arranging and paying for transportation—medical transportation is another issue that is important here this morning, obviously; excessive wait times; and inadequate and culturally inappropriate care.

As well, mental health was mentioned already. That is another huge issue. Mental health and substance abuse services on reserve are often limited to paraprofessional staff with limited mental health training. The recent closure of the Aboriginal Healing Foundation and the wind-down of the Indian Residential Schools Settlement Agreement will almost be certainly felt within communities unless investments in mental health services are made.

An added complication is the fact that the first nations population is a very mobile one, both in terms of residency, moving from rural communities to Winnipeg or Saskatoon or what have you, and also in the way they are required to move between the federal and the provincial and territorial health care systems to receive care. Just to give you an idea, the RHS also looked at residency. It showed that 59.2% of first nations adults reported living outside of their communities at some point in their lives. Of those, something like 23% had moved two or more times in the last 12 months.

It's very clear that these factors present a challenge in terms of continuity of care and magnify the need for the development of electronic health records within first nations communities.

How can e-health and telemedicine help?

I don't want to present e-health and telehealth as the silver bullet; I think a number of things need to be fixed. They do, however, hold the potential for a number of different things, such as evidence-based policy development. “Give me the damn data”—I've heard that already this morning. I would echo that, for many different reasons.

They also hold the potential for increasing efficiencies by reducing transportation costs. This is another huge issue for the budgets we're trying to live with within the non-insured health benefits plan as it pertains to medical transportation. Certainly, that's another issue for my colleagues from Manitoba here, and for those first nations communities.

They also certainly could provide educational opportunities for nurses and community members; more safely manage and store health information with the community; utilize electronic health records to improve coordination of care between jurisdictions, which is a constant challenge for first nations clients; and ensure a circle of care as patients move between those jurisdictions.

As was mentioned already this morning, while the federal government, Canada Health Infoway, and the provinces and territories have made advancements in the deployment of e-health technologies and the development of electronic health records for Canadians generally, first nations e-health projects have tended to take a bit of a back seat. Investments in infrastructure, applications, and capacity development have not been made at a level that would allow for the electronic data exchange required to support health care service delivery to its fullest potential.

I know it's still a struggle across the country, and certainly what we're trying to do is keep pace. As all of you surely know, the 2004 health accord did call for the development of an electronic health record for all Canadians, and we simply want to ensure that first nations are part of that effort.

Without significant and sustainable investment within first nations communities alongside the development of technologies that align with federal and provincial-territorial systems, the wellness gap for first nations will remain.

Despite all of the challenges I've mentioned, jurisdictional, financial, and capacity challenges, e-health and telehealth projects are under way in first nations communities across the country.

The Mustimuhw cEMR, developed by the Cowichan Tribes in British Columbia, is up and running, for instance, and that has expanded to other provinces as well as other communities within B.C. I believe Saskatchewan and Manitoba are utilizing it as well.

The development of comprehensive and integrated information management and information technology services as a key feature in the exciting B.C. tripartite process is going on right now and is moving quickly toward implementation.

I would also mention that an exciting client registry project is being undertaken in Ontario by the Kenora Chiefs Advisory. The project has already joined seven first nations communities into a single database and has recently been awarded funding through the Health Services Integration Fund to accomplish numerous tasks, including developing first nations-led governance structures that support integration and address legislative and policy issues around integration.

There is also one that I think my colleague here is involved in with the trilateral working relationship in Manitoba with the Manitoba first nations.

Where do we go from here? As a national-level advocacy organization, the AFN has neither the resources nor the mandate to engage in e-health projects on the ground. However, we continue to engage in projects that support first nations e-health activities. For example, the Assembly of First Nations has taken early steps to engage first nations and federal-provincial-territorial partners in discussions to accelerate the journey toward e-health alignment, convergence, and clinical data integration.

On June 20, 2012, the AFN teamed up with COACH, which is Canada's Health Informatics Association, with the support of my colleagues from FNIHB and Canada Health Infoway, to co-host the First Nations eHealth Convergence Forum. Attendees included chief information officers and information management e-health staff from the provinces, territories, the federal government, and first nations e-health leaders. We're working to ensure that the watershed discussions at this event are not lost, and certainly we're working toward moving that forward.

Other projects currently under way include the development of an e-health strategic framework to assist first nations in developing and implementing fully aligned e-health projects based on first nations principles and priorities. As well, one of the other issues that we need to deal with, of course, is data sharing, so we're working on a data-sharing agreement guide that will provide first nations communities with many of the tools required to develop their own data-sharing agreements as they venture into this field and look to align themselves with federal and provincial systems.

It is worth noting that the e-health infrastructure program at FNIHB is up for renewal in 2013, and support from this committee here today would be greatly appreciated, so that FNIHB and first nations can continue to bring the transformative potential of e-health technologies to the communities that need it most.

In closing, I would like to take this opportunity to encourage committee members and this government to engage with first nations, provinces, and territories in coming to the table to recommit partners to achieving priorities of national importance, including the development of health technologies, to all Canadians, including first nations. I would also say that the renewal of the 2014 health accord could provide that opportunity.

With that, thank you very much, Madam Chair. I would be happy to take any questions.

[The Chair, Conservative, Joy Smith]

Thank you very much for your very helpful information today.

We'll now go to Kathy Langlois, acting assistant deputy minister. You may begin your presentation.

[Kathy Langlois, Acting Assistant Deputy Minster, Regional Operations, First Nations and Inuit Health Branch, Health Canada]

Good morning.

On behalf of Health Canada, I would like to thank you for inviting me to speak today on the issue of emerging technologies within the context of first nations and Inuit health.

I am joined by my colleague Ernie Dal Grande, who is the national manager of e-health programs at the First Nations Inuit Health Branch at Health Canada. He will be happy to answer any detailed questions you may have.

First Nations and Inuit Health Branch investments in emerging technologies are targeted at improving the effectiveness and efficiency of health services delivery in first nations and Inuit communities. We promote the development and uptake of emerging technologies such as e-health systems, tools, and practices that encourage innovative health care delivery practices.

Today I will discuss our work in e-health and investments we are making in emerging technologies for nurses and community-based workers.

The e-health infostructure program supports the development and adoption of modern systems of information and communications technologies for the purpose of defining, collecting, communicating, managing, disseminating, and using data to enable better access, quality, and productivity in the health and health care of first nations.

This program evolved out of the increased need for Health Canada to align with provincial governments towards the increased use of information and communication technologies to support health service delivery and public health surveillance. It works in close partnership with other federal departments, such as Aboriginal Affairs and Northern Development Canada, Canada Health Infoway, provincial governments, regional health authorities, the private sector, and first nations leadership and communities, including the Assembly of First Nations.

Three major activities for the e-health infostructure program are telehealth, connectivity, and Panorama.

Telehealth technologies assist in extending basic and specialist health services and health promotion and disease prevention education to underserviced areas, particularly in remote and rural areas where many first nations communities are found. Telehealth also provides professional support and continuing education opportunities, which helps in recruitment and retention of health professionals.

There are currently over 300 telehealth or video-conferencing sites in first nations communities, offering a wide range of services such as tele-visitation for family members, tele-education for workers, tele-diabetes, and tele-mental health, with future plans to introduce more clinical services in communities. For example, as of March 2012, there were 26 first nations communities with telehealth services in Manitoba, with almost half of the total events identified as clinical in nature.

Telehealth in Ontario is supported primarily through Keewaytinook Okimakanak Telemedicine, or KO Telemedicine, which provides access to health providers and services in 27 first nations communities. In addition to telemedicine, 71 first nations communities have access to video-conferencing equipment for administrative and educational uses and can access Ontario Telehealth Network and Keewaytinook Okimakanak Telemedicine educational sessions.

As to connectivity, sustainable broadband connectivity is the key basic element for modernizing community-level service delivery, especially telehealth in first nations communities. The better the connectivity, the better the quality and range of telehealth clinical services available to communities.

In an effort to better leverage regional, provincial, and private sector connectivity infrastructure investments and to maximize first nations access to broadband services, First Nations and Inuit Health Branch and Aboriginal Affairs and Northern Development Canada are working together to better invest in and support first nations community connectivity.

For example, it was announced in July that Health Canada, in partnership with SaskTel and the Federation of Saskatchewan Indian Nations, will invest $5.8 million over five years to supply 83 first nations communities with better Internet access, allowing Saskatchewan first nations to gradually add more community-level e-health services to their health care system.

In addition, the northwestern Ontario broadband expansion initiative, which my colleague spoke about, worth $81 million, will bring a state-of-the-art fibre optics network to 26 Nishnawbe Aski Nation, NAN, communities in Ontario's far north. This includes a federal investment of over $23 million, a provincial investment of $32 million, and private sector investment of $26 million. Our branch's direct investment is $2.7 million. So you can see the power that we have in leveraging other resources.

Panorama is a bilingual, electronic management and surveillance tool for front-line health care workers dealing with communicable disease. The integration of first nations and Inuit clients within provincial efforts to implement Panorama, including shared services, standards, and training, will lead to more effective public health service delivery.

This tool will support the identification, management, and control of infectious disease cases and outbreaks that pose a threat to the public's health. It will enable Canadian health care professionals to collect, share, and analyze a wide range of health information critical to the management of communicable disease and immunization issues at the regional and FPT levels. This system has been developed, and certain provincial implementations will proceed in 2012-13—I should say they are proceeding in 2012-13.

Another key initiative related to emerging technologies is to provide increased access to nurses who work in remote and isolated first nations communities.

Some examples include that several nursing stations in Alberta have piloted the use of remote pharmacy services to support client education, information, and monitoring of medication. They also introduced new software to effectively manage prescription labelling and the maintenance of medication inventories.

In Alberta a centralized nurse practitioner on-call service has been established to provide consultation and treatment to support the primary care nurse on duty in remote and isolated communities, effectively supporting 24/7 delivery of primary care.

Robotic telemedicine functionality was successfully tested in a remote Inuit health clinic in the Atlantic region, involving the efficacy of digital X-ray via robotic technology.

The patient data assistant—hand-held technology—is enabling nurses in Saskatchewan to access clinical information to support patient care and education.

Several e-learning programs and tools have been very successful in demonstrating effective and efficient access to education, professional development, and training for nurses and other health care providers practising in remote and isolated regions.

In addition to nurses, you will know that communities employ a range of workers, which include maternal child health workers, mental health workers, community-based representatives, and home care workers, just to name a few.

Another way that we support the uptake of emerging technology is in training for these community-based workers. Through distance education they are provided with more opportunities to have the skills and certification comparable to workers in the provincial-territorial health care system, including training of first nations health managers to run effective health systems.

Training programs that use innovative distance education models are strongly encouraged, as they allow communities, where access to educational opportunities can present certain challenges, to access those services, and it helps reduce the overall cost associated with training.

Our longer-term vision in Health Canada is that first nations and Inuit will have access to the same quality and availability of e-health services as the rest of the Canadian population. Our branch, the provinces, and first nations communities all face the common challenge of sustaining the quality, safety, accessibility, and productivity of first nations health services, while exercising greater accountability in a tighter fiscal environment.

As I've discussed today, we are working with other jurisdictions on innovations to modernize and transform the way health services are delivered in order to contain costs, but also to better manage health information so that we can practise greater accountability and evidence-based decision-making.

FNIHB's investments in emerging technologies support the development and diffusion of health technology to improve people's health through innovative e-health partnerships, technologies, tools, and services.

Health Canada is committed to achieving a fully integrated, sustainable health service for first nations and Inuit communities that gradually adds more community-level e-health services and that enables front-line health care providers to use these technologies to improve health delivery and outcomes.

I'd like to thank you for the opportunity to be here today to speak with you about these issues. My colleague and I will be happy to answer your questions.

[The Chair, Conservative, Joy Smith]

Thank you very much.

This has been an extremely interesting panel this morning.

We're going to begin with our Qs and As for seven minutes, beginning with Ms. Davies.

[Libby Davies, NDP, Vancouver East, BC]

Thank you very much, Madam Chairperson.

Thank you to the witnesses for coming today. I feel like you've provided us with so much information, it's hard to know where to begin to follow up.

My colleagues will actually address some of the questions as they relate to first nations, so I won't deal with that; you'll hear that later.

I'll go back to the slides that were put up for the Centre for Global eHealth Innovation. This may be obvious to you, Dr. Cafazzo, but I'm not sure it's obvious to all of us. In your slides—I don't know whether we can get them back up there—on page 3 of your handout, it talks about the improved health outcomes for home dialysis, and you list, as you said, these awesome outcomes.

I actually don't understand why. What is it that caused the improvement? Was it just being better off at home? It's not clear.

I have one other question.You listed another one about blood pressure with a Blackberry, and you said there was a 20% drop in risk of heart attack or stroke—that's on page 6. Again, I'm just not quite clear on what's happening that causes it to happen. I do have one other question, so maybe I could put them both out there.

Maybe all of you could address the second question. I think what you're telling us is incredible. The concern I have is about accessibility. How do we make sure that these issues are addressed across the board? To hear what Manitoba is doing is really exciting. I'd like to know what you think Infoway should be doing more of to make sure that you're completing your project in Manitoba or elsewhere, and how do we ensure that there is equity across the country?

We had one witness at the health committee last year who said that Canada was a country of pilot projects, and everybody laughed. In actual fact, it's really true, so we have all of these amazing projects going on, but how do we ensure that there is some sense of sustainability and continuity, and a sense of equity across the country? To me, this is going to be a question that comes up again and again in this study we're doing.

I'd like you to address that, but could I briefly get the first question answered first? I didn't quite understand it.

[Dr. Joseph Cafazzo]

The mechanisms in terms of how home hemodialysis improves these health outcomes are that...normally when a patient with end-stage renal disease uses conventional hemodialysis three times a week in a hospital setting, the renal replacement therapy they get brings back about 15% of their renal functions. With home hemodialysis, they can dialyze more frequently. They dialyze nocturnally, which brings up their renal replacement to about 50% to 60%. That means there are fewer toxins in the blood, and hence they can conceive, they can bring a pregnancy to term,and all of these other health outcomes improve. Our kidneys work 100% of the time. When someone has end-stage renal disease, they may have no residual kidney function, and again, conventional therapy only gives them about 15% of that function back.

It's simply the fact that they can do dialysis more frequently in the home.

[Libby Davies, NDP, Vancouver East, BC]

What about blood pressure monitoring?

[Dr. Joseph Cafazzo]

The behavioural mechanism around that is—what we believe happened—because this application prompted them to take their blood pressure measurements on a more regular basis, these patients became more aware of their blood pressure. They took their medications more frequently, and the follow-up was closer.

For those patients, again, hypertension was asymptomatic. With the patients who had none of that engagement with a conventional blood pressure monitor, they often forgot. We suspected that the group hadn't used the blood pressure device very frequently, and obviously hadn't taken their medications on a more regular basis. It is a behavioural intervention in the end.

[Libby Davies, NDP, Vancouver East, BC]

Okay.

Could I get some response to the second question about the accessibility equity issue and how we address it? If I could sharpen that up a bit, what does the federal government need to do to ensure that it happens across the country?

[Roger Girard]

Let me start.

I've been in the health care infomatics industry for a very long time. Ten or twelve years ago it would have been impossible to come to a table like this from different provinces and be speaking the same language on this topic.

One of the major improvements that Canada Health Infoway has introduced over time, and it has been a long battle these last 10 or 12 years, is in making sure that we are aligned. My presentation made mention of the fact that we are more aligned across the country on the topic of information and in the use of information than we've ever been. This doesn't mean that we're where we need to be. The provinces are at different stages just by virtue of the way the health care system works.

To give you an idea of access, increasingly it doesn't matter where you are. I think a lot of the examples Dr. Cafazzo used are of the leading-edge innovations that are happening. But increasingly, even for the simple things—I mentioned diagnostic imaging—if all of the radiologists are in the south and none of them are in the north...now it's possible to get the same radiology service in the north, if you're a resident of the north. You don't have to travel to the south to get these services. That's huge, for a person who chooses to live in the north or in a rural isolated community. That's one example.

The telehealth examples are very mature. We've been doing telehealth in this country in virtually every jurisdiction now for 12 years. We do a lot of it, because we have to. That's where our people are.

I think information is becoming democratized, if you will. It's not only the people in the south who have access to information; it's the folks everywhere across the province. That's what we're doing increasingly.

Your question about equity and pilots is an interesting one. I've heard that quotation as well. If you actually travel the country and see what's going on in the field of e-health in every province, and Manitoba is certainly no exception, there are a lot of really good projects under way.

[The Chair, Conservative, Joy Smith]

Thank you very much, Doctor.

[Roger Girard]

Thank you, Madam Chair.

[The Chair, Conservative, Joy Smith]

We'll now go to Dr. Carrie.

[Colin Carrie, Conservative, Oshawa, ON]

I want to thank the witnesses for an excellent presentation so far today. It's hard to know where to start, but I want to talk with Dr. Girard.

In your presentation you mention that “in 2010, Manitoba went live with eChart Manitoba, which is our EHR, a service that has delivered 100% of all Manitobans towards this goal”. I'm from Oshawa, Ontario, and I've been following Infoway. I realize that from a federal standpoint we've put aside $2 billion, I think it is, and we'll pay up to 75% as reimbursements to provincial and territorial governments that are implementing these things.

I'm extremely impressed with what you've achieved over the last few years. Could you elaborate a little concerning the funding you received from Infoway to implement these goals for electronic health records in your province? Also, could you help us out, those of us who live in other provinces, concerning some of the challenges you've encountered and how you overcame them?

[Roger Girard]

First of all, I appreciation the promotion. It's “Mister” Girard, but I'll take “Doctor”.

The way you go about implementing an electronic health record in a small province—it's a large province geographically, but a relatively small province by comparison with Ontario or Quebec or some of the other larger jurisdictions—is a bit simpler, but it has the same moving parts, so it's very complex.

We have a project on which we spent roughly $40 million implementing this over the space of four or five years. It was co-funded with Infoway, roughly 50-50. I'm not going to suggest to you for a second that it was easy, because it wasn't. It's the standardization of data and making sure that the information you're getting, which has been collected historically using different data standards, and the whole aspect of change management.... How do you introduce these systems so that a physician can use or access the information without any extra steps? They don't have time to hunt around looking for information.

There are many changes like that. It becomes easy, once you put them into practice, because it's infectious. Even physicians have approached me, physicians who have said that this isn't really going to make a big change in their practice. In actual fact, they've noticed that they've learned something and that it is making a difference.

Change is a lot easier to introduce when there's value associated with it, and our program, which we branded eChart Manitoba, is beginning to deliver it. It's hard to keep the genie in the bottle, if we even wanted to; it is really everyone who wants a piece of it. Our resources now are being stretched to the limit just keeping up.

That includes first nations, by the way. We went live on our first nations site about a month ago. We were very proud of that, because it shows the partnership that we're now having across the country, which wasn't there before.

I forget whether you had a second question, but hopefully that answers this question.

[Colin Carrie, Conservative, Oshawa, ON]

That's great.

I do have some more questions. I look at northern Ontario and at Manitoba, and we're neighbours and share geography. One of the programs you put in is the telehealth “Reclaiming Hope” program, whereby you're working with remote communities. I've read that it involves televisions, cameras—the whole bit—whereby you link psychiatrists from Winnipeg with first nations youth, who can sit in a private room in nursing stations. One of the things we've heard is the problem of sometimes getting the right professionals to these remote areas.

Could you comment on how effective that program is? And do you have any numbers on how much it's saving in medical transportation expenses and things like that?

[Roger Girard]

Yes. It's in my report. We did a study with Canada Health Infoway, just for the Manitoba portion of our clientele. We estimate $2.6 million of patient savings. It's family savings, in most cases, because the burden of transportation for Manitobans—in first nations situations, it's a different formula—was $2.6 million worth of savings and about a million kilometres of travel that was avoided.

If you're meeting with a specialist at a distance, this is like having the person in the same room. We have dozens of testimonials from patients all over Manitoba who have done this.

I'll point out also that the telehealth program in Manitoba supports northern Ontario. We interconnect with KO Telemedicine, the network that my colleagues spoke to. We support Nunavut in the north. We're good partners, because they are our clientele also. We do work wherever our customers are, and our customers are in the far north and to the east and west of us.

It's very exciting, and the value.... We have stories—there were some stories given, and I could give you more—that touch the heart. When you connect families at great distances, it's pretty heartwarming.

[Colin Carrie, Conservative, Oshawa, ON]

I am concerned. I'm a chiropractor, and the therapy that chiropractors give is hands-on. I can see telehealth and telemedicine really helping for certain things.

When technology is overused, or when people are not getting the care they want face to face with health care practitioners, what do you suggest could be done to address this challenge?

[Roger Girard]

Well, not all health practices need a doctor hands-on, certainly not a specialist. This does not replace the health care practitioners—the nurses, the nurse practitioners, and so on who are in these communities. The whole area of self-care is a different topic; Dr. Cafazzo spoke a bit to that.

I think the point is that if you make a difference with 20% or 30% of the clientele, you have a substantial impact upon services to a remote community—let alone the reduction of transportation and so on. This doesn't have to address 100% of the population, just a subset of the population.

[The Chair, Conservative, Joy Smith]

Thank you so much, Mr. Girard.

We'll now go to Dr. Fry.