Health Committee on Nov. 29th, 2012

[Dr. Eric Bohm]

In developing implants, we stand behind the rest of the world. We're hoping to change that at Concordia. A lot of the product development happens in the U.S. and in Europe, but I think we have a unique opportunity in Canada because we have a very close community of orthopedic surgeons who tend to work together quite well. We're developing a stronger Canadian joint registry, implant retrieval networks, RSA analysis, and so forth. So we're in a very good position to develop those implants.

[The Chair, Conservative, Joy Smith]

Thank you very much.

These questions have been very helpful. Thank you, committee.

Dr. Sellah, you're next. I understand you have a motion you're going to read.

Go ahead.

[Djaouida Sellah, NDP, Saint-Bruno—Saint-Hubert, QC]

Thank you, Madam Chair.

I would like to give notice of the following motion:

That the committee spend at least five meetings conducting a study on the social determinants of health in order to review and assess the evidence showing that social conditions play a pivotal role in health; to confirm the social or economic conditions that affect the health of Canadians and, to the extent possible, to quantify that impact; to identify the effects, including financial, of those determinants on Canada's health system; to make recommendations on how to address those determinants to improve the health of Canadians; to make Canada's health care system more sustainable and more affordable; and to report to the House of Commons.

Thank you, Madam Chair.

[The Chair, Conservative, Joy Smith]

Thank you.

I must tell you that you need 48 hours' notice. We can deal with it on December 4.

Go ahead. You still have time for questions.

[Djaouida Sellah, NDP, Saint-Bruno—Saint-Hubert, QC]

Thank you.

My question is for Dr. Fotti. I listened to your presentation very carefully. I think what you're doing is wonderful because your approach is aligned with what we're trying to get now, patient-centred care.

I would just like you to clarify something for me. Is your clinic similar to Quebec's family medicine groups, or FMGs, introduced by the province as a pilot project? If so, I'd like to know whether you receive any funding from the local government. In Quebec, for instance, we had a bad experience with Rockland MD radiology clinics. It cost us dearly, and we wouldn't want to get into a situation where we're robbing Peter to pay Paul. I also heard you say you were helping out hospital systems. I'd like you to elaborate a bit more on how you do that.

Thank you.

[Dr. Christopher Fotti]

Thank you.

My clinic model is fee-for-service. We don't get any support or funding through any public sources, with the exception, in Manitoba, of the electronic medical record program. The idea is for physician offices to convert from paper to electronic records. We do receive some funding from them to maintain and implement our electronic records, but the income for physicians and the clinic is through fee-for-service billing.

I know alternative funded models are also a very important part of this document, because there is a lot of good evidence that if the physicians are remunerated more in an alternative funding arrangement, like bloc funding or something along that line, they don't have to worry about seeing so many patients.

We're quite lucky that all of our doctors make a good living, so we don't need to see 40 or 50 patients a day. We all probably see around 20 to 30 patients a day, which over a regular work day does give enough time, for the most part, to address patient issues in a proper fashion. Obviously, the more people you see, the less that is true.

In some fee-for-service clinics, the doctors may be seeing 40 or 50 patients a day. Unless you're working until 10 o'clock at night, that means the time is short with the patients. So you definitely have to find that balance.

We don't receive any direct funding other than for the electronic records. For a hospital kind of disposition, our patients have access to us after hours. For that matter, any patient in the area has access to us after hours for our walk-in.

I do a lot of emergency room work, too. In an emergency room, if I'm not sure that the patient is going to get followed up properly or that the test they need, but not urgently, will get done or not, I tend to order it in the emergency room to be on the safe side.

When we have our own patients, I know that if you come in to see us, I can get you to see your regular doctor tomorrow morning, if needed, to follow up on things, or come back in a week and follow up on whatever treatment we started, as opposed to jumping the gun and having to do more unnecessary tests in hospital. Again, in a hospital emergency room, if the doctor is not sure you're going to get proper follow-up treatment, you tend to do more in the emergency room than you probably would otherwise.

[Djaouida Sellah, NDP, Saint-Bruno—Saint-Hubert, QC]

I gather, then, from your answer that your clinic model isn't really the same as Quebec's FMG model. As you mentioned, when you're in a packed emergency room, you can recommend that patients go to a clinic for more lab work and better follow-up. Is that right?

[Dr. Christopher Fotti]

Yes, that's correct.

[The Chair, Conservative, Joy Smith]

One more minute.

[Djaouida Sellah, NDP, Saint-Bruno—Saint-Hubert, QC]

I will use my time to ask Dr. Kerr a quick question.

You started talking about prevention for drug users. I want to give you a chance to elaborate on that.

[Dr. Thomas Kerr]

I think we have to distinguish between two types of prevention. One is primary prevention, where we try to prevent people from initiating drug use in the first place. In that regard, we're doing poorly. We invest in programs that have been shown repeatedly to be ineffective, particularly programs that try to create fear among young people by telling them that if they start using drugs they'll live a very short life. Those programs have been well evaluated and shown not to be effective.

The primary prevention programs that do work are the ones that intervene early on in children's lives, in unhealthy family environments and such.

The secondary prevention that I was referring to is more about preventing disease and death and other comorbidities among people who are already using drugs. That's where we are really doing a miserable job. The evidence is in Saskatchewan, where we have an epidemic that's out of control for which there are effective preventative measures that—

[The Chair, Conservative, Joy Smith]

I am sorry, Dr. Kerr. I have to cut you off. You're way over time, but thank you for what you have said. I know it's hard to live within the time constraints, but I try to be fair to everybody.

We'll now go to Mrs. Block and Mr. Lobb. Mrs. Block, will you start?

[Kelly Block, Conservative, Saskatoon—Rosetown—Biggar, SK]

Thank you very much, Madam Chair, and I'd like to thank all of our witnesses for being here today.

I want to focus my questions to you, Dr. Fotti, just in terms of the...I guess it's a medical clinic you created. I want to establish what the difference is between your clinic.... Your website states you're trying to offer excellent care “in a spa-like but technologically advanced setting”. Can you just describe that a little bit more for me?

[Dr. Christopher Fotti]

Yes. When we designed our clinic we wanted it to be a nice place to work. In some of the other clinics I worked at in the past, you went into work and you got depressed a little bit because of the paint scheme and all that kind of thing. When we did our clinic, we put a little bit of extra design into it. We get a lot of comments, including a recent comment I had from one of my patients who's dying of cancer. He was coming in to get some more pain medicine. He doesn't have a heck of a lot more time—a few more months. He's in with his wife and his son, and he said, “You know what? When I come here everybody seems happy. It looks nice.” He said, “I don't feel like I'm going to see my doctor to get pain medicine for the cancer that's going to take my life.” He said he feels like he's just coming to talk to a friend.

So we get a lot of comments from our patients that the setting, the visuality of the clinic, makes them feel at ease, and sometime it makes the office experience, where you have to give bad news and all that kind of thing, a little bit easier. Plus it's just nice to work in a nice place.

[Kelly Block, Conservative, Saskatoon—Rosetown—Biggar, SK]

I have just one other quick question and then I'll turn it over to my colleague. You may have mentioned this in your opening remarks, but I just want to go back and find out. What kinds of technologies does your office have that perhaps other family physicians' offices may not have?

[Dr. Christopher Fotti]

I think a lot of family physicians' offices probably have somewhat similar technologies, but we're all fully electronic. All our records are fully electronic. All the interface is electronic. Our interface with our pharmacy is all electronic. We have portable ultrasounds and Dopplers. We do some more specialized tests in the clinic, such as ankle brachial indexes for perfusion to the feet. Then we partnered with some other businesses to get the X-ray clinic, which is technically next door to our clinic, and not only just to have it but so that it links to us electronically instantly, so that we can instantly review test results and things like that.

A lot of clinics may have X-rays and other kinds of things there, but that sort of instant electronic communication may not be there, and that's very key. If I see you as a walk-in and I think you need an X-ray to help me make a diagnosis—maybe I think you have a fractured hip or something like that—you can get your X-ray. If I'm not sure, I can talk to the radiologist right then and there. If your hip's fractured, then you're not really for the walk-in, but we'll get you off to the hospital with all that information already done.

[Kelly Block, Conservative, Saskatoon—Rosetown—Biggar, SK]

Thank you.

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

My question is for Dr. Bohm.

When I first started my working career, I worked in the auto industry. Obviously, Lean initiatives and Six Sigma are ingrained in the corporate identity. From the shop floor worker who starts day one, it's safety, and then it's pretty well on to Six Sigma and Lean and finding initiatives to improve efficiency.

Can you give us a better idea of how ingrained this is coast to coast in the medical profession, the health care industry? What is it going to take to help continue to develop these opportunities for improvement?

[Dr. Eric Bohm]

It's a good question. Thank you.

From my perception, what I see is pockets of this sort of philosophy developing across Canada. There are small pilot projects. I think you've heard about that already today. Hospital organizations are embracing this. I think we're seeing pockets of that across Canada. There is some progress towards tying these people together into larger groups to share their experiences and their challenges, and to help promote that uptake across.

I do think it's a challenge. Michel and I were talking about this last night in the taxi, actually. It's almost a cultural shift. You're embracing a new way of delivering care, of tracking outcomes, of reporting on outcomes, and changing the care you deliver and acting on the data. We were talking about how you start that culture change. I think that's the most important thing and the biggest challenge. I think we'll get there with these groups of people working together.

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

I was glad to see that you put the book Theory of Constraints up there. That's pretty well every manufacturer's bible, I think, in the industry, so I was glad to see that you put that in there.

[Dr. Eric Bohm]

And it's so simple.

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

Yes.

I have just one quick question for Dr. Fotti. I know my time's running short.

One of the concerns I have with Infoway and the digital initiative we have coast to coast here is just what you touched on: the integration of all the different systems. We've heard different witnesses give conflicting testimony. But I also heard from the software industry, and I know that this is a big issue. You've already felt it in your own practice. What can we do to get ahead of this pending problem?

[Dr. Christopher Fotti]

That's a good question, and I don't think there's a very simple answer.

The best way would be for everyone, as a whole, to negotiate for either one system or systems that can fully communicate properly with each other. Right now we're just so fragmented. Our system can actually communicate with their system, so we could actually transfer your records from my records to the other vendor with no problem. The records would go in and populate appropriate spaces and all that, but they don't have the technology to do it the other way around. So whether you're using one vendor or you're using multiple vendors, the vendors' mandate, when you're getting them to quote for your areas and regions, has to communicate with all of these different types of things, and list out eChart and X-rays and whatever it is you think is important for your area. It has to communicate.

[The Chair, Conservative, Joy Smith]

Thank you very much, Dr. Fotti.

Now we'll go to Dr. Morin, please.

[Dany Morin, NDP, Chicoutimi—Le Fjord, QC]

Thank you very much, Madam Chair.

My first question is for Dr. Tétreault.

Thank you kindly for your presentation. I found it fascinating. I also want to commend you for the great work you're doing in your hospital.

In your presentation, you offered a number of solutions and initiatives that I think fall more within the province's domain. I would like to hear what the Government of Canada can do, within its jurisdiction, to support your mission and your initiatives, while respecting provincial authority, of course.