Evidence of meeting #73 for Health in the 41st Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was patients.
A recording is available from Parliament.
3:30 p.m.
Conservative
The Chair Conservative Joy Smith
Good afternoon, ladies and gentlemen.
Welcome to the committee. We are so pleased to have our witnesses here today.
Dr. Lear, we are so happy to have you here. It's my understanding that you're on vacation right now. You drove an hour from your vacation spot in California to come and testify. I'm impressed and so is the committee.
3:30 p.m.
Dr. Scott Lear Professor, As an Individual
It's a pleasure for me to be here. I'm excited about the proceedings in the next couple of hours.
3:30 p.m.
Professor, As an Individual
It's a bit warmer than what you have there in Ottawa.
3:30 p.m.
Conservative
The Chair Conservative Joy Smith
Exactly.
We admire your dedication. I wanted to give you some special time because anybody who cares so much to come as a witness to our very important committee.... As you know, we're studying technological innovation and witnesses like you are very important to us. For you to be on vacation and take time away from your family to drive and get to a place where you can actually speak to us via video conference, we're very honoured to have you here, and I thank you very much for that.
We have Dr. Lear, ladies and gentlemen. You have the video conference from California in the background and what he has done to be here at committee today.
We have as an individual, Dr. David Price, chair of the department of family medicine at McMaster University. We're very pleased to have you here as well, Doctor.
We have a guest arriving, Paul Lepage, president of health and payment solutions at TELUS. He'll arrive at 4 o'clock.
We'll begin with you, Dr. Lear. You have 10 minutes.
Watch me a little because I'll gesture when you're just about a minute out. Thank you, sir.
Go ahead, Dr. Lear.
3:30 p.m.
Professor, As an Individual
Thank you again for the invitation to speak at this committee. I'm quite excited about this topic.
As we all know, the use of e-health and telehealth has been met with substantial enthusiasm as a way to bridge gaps in health care and geographical inequities of care. This has been recognized by decision-makers throughout the country. It is reflected also by the proliferation of e-health provincial offices, and many health regions also have telehealth managers, as well as the creation of Infoway.
However, despite the enthusiasm for e-health and telehealth implementation, I would say the uptake has been quite modest. This is in part due to limited evidence to inform decision and policy-makers as to what programs may be beneficial and what ones aren't. In addition, most of the initiatives to date have been directed to supporting administrative duties such as electronic health records, and the storage and forwarding of medical images, and while these things are important, there has been relatively less attention given to improving direct patient care.
In British Columbia I lead a network of health researchers and health authority decision-makers called the BCATPR, the British Columbia Alliance on Telehealth Policy and Research. Our goal is to develop and evaluate patient-focused solutions for the delivery of health care services to patients with chronic diseases.
Our initial work has been directed toward bridging this geographical gap in health services. As we know, while most of our health care resources are centred around large urban centres, chronic diseases and other conditions are ubiquitous throughout Canada. Indeed, in rural areas, we actually find the prevalence of chronic diseases is increased due to higher rates of smoking and higher rates of obesity.
Conversely, access to health care services in these areas is commonly limited to the primary care physician and the local community hospital. They have little or no access to specialty care or specialty clinics, such as diabetes teaching centres, cardiac rehabilitation programs, and others that have proven effective for the prevention and management of chronic diseases.
What we find is that the per capita hospitalization for chronic diseases in rural areas is actually quite a bit higher than in urban areas, and it may be due to this missing gap in specialty care. So basically, if care for a patient gets too complex for the family physician, their next level of attention is to refer them to the local hospital, being unable to refer them to a specialist or specialty clinic.
Now our projects to date have made use of the Internet to bridge these gaps in care, as the Internet has the advantages of using existing infrastructure such as home computers, it's widespread, and it is growing in use, and models of care can be readily scalable through the Internet.
As an example of the utility of the Internet for health care delivery, in 2006 our team conducted a survey of nearly 300 hospitalized heart patients between St. Paul’s Hospital in Vancouver and what was then called Prince George Regional Hospital in Prince George. Two-thirds of these patients had home Internet access and about 80% of those had a high-speed connection. When we asked them about home Internet use, 70% actually said they used the Internet to access health information. This was third only behind general browsing and using the Internet for e-mail. What we do know is that as we move away from urban centres, Internet access diminishes. In our rural patients, we found about 50% had home Internet access, compared to over 70% in the urban centres.
At around the same time, we conducted a number of interviews with decision-makers, health professionals, physicians, and patients, and all indicated that using the Internet had great potential to coordinate care and also to communicate care and health information across the key players, including the patient.
We have subsequently developed and tested what we call a virtual cardiac rehabilitation program. Cardiac rehab programs are proven effective for preventing subsequent events for patients with heart disease, but only about 15% to 25% of eligible patients actually attend these programs with the greatest barrier being transportation and geographical access. Our virtual program consists of a website that mimics the hospital-based standard cardiac rehab program and allows patients to connect with the cardiac rehab staff we have in Vancouver.
One of the innovations is that patients are given a recordable heart rate monitor that they can wear while they exercise to record their heart rate. When they get home they can upload it to the web server so that the health staff in Vancouver can actually check on their exercise heart rate and provide any feedback as needed.
After 12 weeks the patients increased their physical activity and fitness levels and reduced their cholesterol levels comparable to what we see in the standard hospital-based programs. One of the participants was quoted as saying at our interviews:
I can’t say enough about how helpful it was in changing some of my habits. The alternative would have been to go into Vancouver regularly, or to bring home a sheet of exercises and instructions...which I’ve done before and quickly given up on.
This patient lived about a two-hour drive from Vancouver.
We've since advanced to models that can be readily translated to a number of chronic diseases beyond heart disease, including diabetes, renal disease, and lung disease. In this program, patients log onto our website, which we call MyHealthConnect, and answer questions about their symptoms and how they feel. An alert may be generated if their answers indicate a worsening of symptoms.
The alert sends an e-mail to the nurse who will then phone the patient. Most commonly we find the nurses counselling a patient on supporting their self-management and behaviours. As well, the nurse, if it seemed fitting, would refer the patient to their family physician for additional medical management. Also there is the opportunity for the patient to converse with a dietician or an exercise professional.
The value of this model is that it acts as a type of early-warning system to direct patients in appropriate care and prevent downstream hospitalizations and complications. In addition, patients benefit from the nurse counselling, and as they do, the number of alerts they generate should decrease. Those patients who are stable actually don't generate alerts at all and spare the nurse's time.
This program also includes a patient action plan that is coordinated among the patient, the program nurse, and their family physician. We are currently studying this program throughout B.C. in smaller urban and rural areas, and we have right now over 70 family physicians and some of their patients participating in it.
One of the key aspects I want to stress about our work and research development regarding the downstream implementation is the inclusion of stakeholders or end-users in our design. Our team is constantly working with decision-makers, policy-makers, health care professionals, and patients to help guide our programs. For example, when designing the MyHealthConnect program, we had an advisory committee that consisted of specialist and family physicians, health care professionals, nurses, psychologists, and patients. This was extremely beneficial in ensuring that our program fit into and aligned with current primary care practices, in addition to addressing the needs of the patients.
The next step is working towards implementation. We already have one group in Whitehorse that is interested in looking at our virtual cardiac rehabilitation program in order to prevent having to send patients down to Vancouver for subsequent care or having specialists come from Vancouver to care for patients there.
Some of our future projects will look at translating these programs beyond the Internet to regular telephones and cellphones in order to increase access and use, as well as developing other solutions for patients and providers, such as an online specialist referral portal and programs to support the transition of patient care.
Just before I close, I would like to take the opportunity to suggest some recommendations as to how we might move forward in certain areas.
Number one, Infoway, which has provided extremely valuable support in electronic health records, should consider expanding its mandate to include support for models that incorporate direct patient care and also to go beyond funding health regions as innovation can come from other areas besides the health authorities.
Number two, a way should be found to promote interprovincial collaboration on telehealth strategies. We find that one of the virtues of telehealth is that it can cross jurisdictional boundaries, but sometimes these can become barriers to implementing and facilitating excellent programs.
Number three, the development and research of e-health and telehealth through the CIHR should be encouraged so that decision-makers have the evidence they need to make informed decisions for health care delivery. This can be done through the CIHR by taking a leadership role and conducting specific grant funding calls for research in technology-supported models of patient care. This may include examples of supporting patient care in the home, delivery of care at a distance, and mobile applications, as some ideas. This would also help put the data that's needed into the hands of decision-makers.
I'd like to close there. Thank you for your time and your attention.
3:40 p.m.
Conservative
The Chair Conservative Joy Smith
Thank you very much, Dr. Lear. That was a very interesting presentation on cardiac care from a distance. It sounds very interesting.
I want to welcome Paul Lepage, president, health and payment solutions, from TELUS.
You have a guest with you as well, Mr. Lepage, who we don't have on the roster.
3:45 p.m.
President, Health and Payment Solutions, TELUS
I have with me Michael Guerriere, who is our chief—
3:45 p.m.
Conservative
The Chair Conservative Joy Smith
Michael Guerriere, welcome. We are so glad you could join us as well.
We've just heard from Dr. Lear and now we're going to our second witness, Dr. Price, from the department of family medicine, McMaster University.
Could you begin, Dr. Price.
3:45 p.m.
Dr. David Price Chair, Department of Family Medicine, McMaster University, As an Individual
Thank you very much for this opportunity.
As the father of three teenage girls, it's going to be an experience to have people listen politely and not interrupt for 10 minutes. I'm going to enjoy this.
My grandfather was born in Montreal and lived in a small town just outside Montreal called Chambly. One of his early chores was to harness the horses and hitch them to the wagon to take his father to the train station. He disliked horses very much so when the car came out he was one of the early adopters. Early adopters transformed the way transportation happened. We're at the same stage now in our development of electronic health records and e-technologies.
If you go to the States the CDC, the Centers for Disease Control and Prevention, this last year said that about 50% to 55% of physicians are now using electronic health records in the United States. In Canada the Canadian Medical Association estimated that somewhere around 39% of our physicians are using electronic health records.
It's clear to me that with graduating 2,000 physicians per year we've passed the tipping point. Those graduating physicians are not going to start using paper charts and move backwards. They are moving forward quickly. I think we will see a massive shift to electronic health technologies in this country over the next three to five years. That's one of the key messages here; it's happening and we're there in terms of adoption.
One of the keys is that we haven't got toward meaningful use. What I mean by meaningful use is value added. If my grandfather only used his car to take his father to the train station and back, we wouldn't really have seen any development. If we're simply using our electronic health records to replace the paper chart, we're not getting anywhere. We're maybe slightly improving our efficiency but we're really not taking full advantage. That is really where we are now, that is, to drive the meaningful use. That's what I'd like to talk about a little: what we're trying to accomplish.
McMaster University is probably well known as being one of the innovators. We developed an electronic health record called OSCAR about 12 years ago. OSCAR is now one of the leading EMRs in the country. Approximately 2,000 family physicians are using it across the country with about three million Canadian citizens being registered with OSCAR and being supported on that. However, it's an electronic health record and that doesn't meet all the needs of our Canadian public. What we really need to see is the development of tools within the electronic health record that facilitate and promote care. We've been working with our colleagues and OSCAR has been developed across the country. It's now at McGill in the department of family medicine. It's at Queen's University, McMaster, and also at UBC.
This product is now starting to mature to the point where we're starting to see more and more, I will call them apps or add-ons to this product. For example, we are seeing an increasing number of patients with chronic kidney disease in this country who require renal dialysis. Renal dialysis, hemodialysis, and peritoneal dialysis are considered an onslaught and are extremely expensive. We know we can prevent large numbers of patients from moving down the slope to needing dialysis. Part of the challenge is identifying those patients early.
One of the things we've done is we've partnered with the Kidney Foundation of Canada and the Ontario Renal Network to start to develop what we would call an app that goes on to the electronic health record and identifies those patients early. As we start to see if they have an increase in blood pressure, if they have certain ethnic backgrounds, if they're aboriginal or South Asian, or if their glomerular filtration rate or their kidney function starts to deteriorate, it sends a signal to the clinician that says this is a patient whom you might need to pay more attention to.
As a result of that, we can now start to see changes in how we manage. One of the challenges with a paper record, frankly, is if it's sitting in the back of the paper record, nobody is triggering to the clinician that you need to pay more attention to that patient and perhaps intervene early to stop the progression.
This product is being trialled. It's now ready to go. I think one of the important aspects of one of the messages I'd like to give is that this is an open-source solution. Although it's been developed on our electronic health record, it will be made and is going to be made available to any electronic health record in the country. It would be something that would be an add-on, and we give it away. It's not a matter that there's a cost for it.
Another example is our BORN initiative, the Better Outcomes Registry and Network for perinatal and pregnant women. One of the keys here is that when you're a patient and you're receiving prenatal care from your obstetrician, your family doctor, or your midwife, that data resides on the clinician's chart. It doesn't necessarily get shared. In partnership with Ontario, as well as what was formerly called the B.C. reproductive care program—it has a new term, I'm sorry; it's in my speaking notes—the idea is to identify women and get their information onto a registry such that no matter what hospital they show up at, no matter which specialist takes care of them, their information is immediately accessible to the clinicians. That's going to lead to improved care, and less duplication of investigations.
We've also partnered with the Better Outcomes Registry to start doing prompts, again for the clinicians. When I was seeing patients this past Monday, up came a prompt that said to me the patient is 34 weeks pregnant, she has not received a certain investigation, she is already at risk because of her maternal age, because of her maternal weight, and it suggested that perhaps I should have done or should be doing a particular glucose screening. That fundamentally right there starts to change the whole dynamics of patient care because we're triggering early the information for how we're going to care for those patients.
We've also developed a program called MyDrugRef, which in a nutshell is a social networking site to try to improve how we provide care to our patients to stop the drug-to-drug interactions and to start to incorporate best practices. As a family doctor working in isolation in my office, I don't necessarily have access to a number of specialists and a number of other individuals. This is a way of having instant access to a whole variety of information. We think that's going to change how we practise over the next few years.
We've also been involved with the development of a personal health record. We've called it MyOSCAR for now, but really this is a personal health record that should be broadly available. I want to differentiate between a portal and a personal health record. A portal is a window into the physician's electronic health record. Our vision is that we develop a personal health record that you, the patient, own. It has a number of features.
Initially, we have online booking for the patient. I booked my plane ticket to come here online. Why can't I book my doctor's appointment online? Why do I have to wait? We have now instituted that and it's up and running so that patients can actually book online easily.
There's secure messaging between the clinician and the patient. My patients can send me a message over the Internet, not e-mail but secure messaging, so that I can interact with them. That could be my nurse, or one of the nurses in the unit, a dietician, a social worker, whoever is the most appropriate person.
The other thing is document transfer. When I looked online today at my patient profiles, I received the cholesterol, the laboratory results, the sugar test, etc. I acknowledged that electronically. It gets filed into my electronic medical record, but it also was sent to my patient today so that they saw it online, in their own personal health record, along with a comment from me, “Great work. Keep it up, Joe. You'd better come in and see me. We need to talk about your exercise”, or whatever it is.
It's that starting to put the care of our patients in the patient's hands, which is where it probably belongs in the first place. Through Health Canada or the Federal Economic Development Agency for Southern Ontario, we've been part of a partnership with York University and NexJ and are starting to develop a series of apps so that patients can take care of their own health themselves. It generates that sort of care for themselves.
My next point is that telemedicine—
3:55 p.m.
Conservative
The Chair Conservative Joy Smith
You're almost out of time, so please wrap it up, because we have Qs and As as well.
3:55 p.m.
Chair, Department of Family Medicine, McMaster University, As an Individual
Sure.
Telemedicine is certainly something that we need to be thinking about. As patients have more access to their personal health records, this is going to allow for communication back and forth.
That, fundamentally, is my presentation. Thank you very much.
3:55 p.m.
Conservative
The Chair Conservative Joy Smith
Thank you very much. It was very insightful and we very much appreciate what you have come to tell us today.
Now we will go to Paul Lepage, president of health and payment solutions.
Do you have a presentation?
3:55 p.m.
President, Health and Payment Solutions, TELUS
Thank you for this opportunity.
From TELUS's perspective, technology is going to be key to the transformation of health outcomes. We believe that to be successful we have to involve all of the players in the system—doctors, health practitioners, and patients.
As a company, we feel we have a corporate responsibility to step up and help health care professionals. A lot of our focus is on the tools and capabilities we can bring to market. We constantly ask ourselves whether to move the focus from illness to wellness.
From a Canadian perspective, health care is a service. It's a service-based industry and should be leveraging technology the same way as other major industries—banking, airlines, insurance—to get the benefits of IT to the patients. We focus on finding solutions that will help organize information, connecting the various health care professionals, moving information securely, and making information more meaningful.
In connecting professionals, one of the challenges we have in health care is that it's a very siloed industry. We need to connect all of the various providers along the continuum of care. As to moving information securely, this is where a large carrier has a role to play, because we move lots of information today over our broadband infrastructures and our wireless networks. Organizing information is also key. Applications have to be set up in such a way that health care providers can easily use the information provided to them. Finally, making information more meaningful has to do with taking the information we have and presenting it back to health care providers or patients so they can take action on it.
We have solutions that address the continuum of care, that go across that continuum. TELUS is active in most of these areas, whether it's providing electronic health records, clinical information systems in hospitals, or electronic medical records. For example, we have about 34,000 clinicians involved in our solutions. In our first line of care, we have about 3,500 physicians using our EMRs.
Then we move towards the other end of the gamut, which is home care and self-care. At the end of the presentation I want to show you a video where you'll see live Canadians actually using some of our solutions. One of the areas of focus is remote patient monitoring. It sits between the first line of care and self-care—
4 p.m.
Conservative
The Chair Conservative Joy Smith
Excuse me, Mr. Lepage. I just have to interrupt you for a moment. My apologies, but my understanding is the video cannot be shown because you only have it in English. You don't have it in French.
How does the committee feel about that? With your permission, can we show the English one? The French one is not available. I just found that out. What's your feeling? Is that okay?
4 p.m.
NDP
4 p.m.
Conservative
The Chair Conservative Joy Smith
We have to have consensus of the committee to allow it to happen and we have one member who says this is not generally what we do. So I'm sorry, Mr. Lepage. Continue on.
4 p.m.
President, Health and Payment Solutions, TELUS
One of the areas that we have focused a lot on is remote patient monitoring. In the information that we supplied to you is a study that was done by HEC, École des Hautes Études Commerciales, on the benefits of remote patient monitoring and the implementation of e-solutions.
What you would have seen in the video is a patient using a terminal at home. This patient is discharged from the hospital, is assigned a care plan, and is asked to follow this care plan. In this case, we did a study on patients who were suffering from chronic obstructive pulmonary disease. The study from the HEC shows that by providing the terminals and the care plans, we've actually decreased the number of admissions to emergency by 34% and the total cost of hospitalizations by 66%. The study is there. I think the study is available in both official languages. It's a good example of how you can get the patient more involved in his treatment and drive lower costs in the system.
In the video we also have two different patients using a personal health record.
In one case, we are doing a project with the Lawson Health Research Institute relating to mental health. We started with 200 patients who are suffering from a form of mental illness, schizophrenia in most cases, and we supplied them with a personal health record. That personal health record is configured in such a way that the provider as well as the patient, obviously, have access to the record. The patient enters his symptoms during the day and exchanges information with a physician. The outcome has been one where in many cases the testimonies from the doctors have been around the fact that they've moved treatment forward. In some cases, having a patient on the system, after two or three weeks, they've gathered more information on that patient's mood and issues than they have had in six months of treatment. That's another example of how the personal health record comes into play.
The other example that we have on the video is where we've partnered with University Health Network to build an application called “bant”. We've enabled a personal record which sits behind bant. In this case the trial was with young adolescents with type I diabetes. What we've seen is that by supplying them with a personal health record, we've increased the amount of readings these adolescents are taking on a daily basis, how many times they're checking the blood glucose levels, by about 100% and their A1C levels have been reduced over time. That study is also available.
One area that we're extremely focused on going forward is the notion of collaboration. When we look at the health care ecosystem, one of the key elements is how you connect the various players in this health ecosystem so that we're sharing information along the health ecosystem, and how we put in place increased collaboration among the various players along the health ecosystem.
We introduced either personal health records, and in many cases, patient portal solutions, where the patient can go in, for example with various pharmacy chains, and sign up on a portal and get electronic refills of their prescriptions, monitor their medications, and set reminders for taking their medications. These solutions started out with two small regional pharmacy chains in Quebec and we're up to hundreds of thousands of people who have signed up for it. We've performed over 1.3 million electronic refills over those solutions, with only two pharmacy chains.
I guess one of the key messages to the committee is that not only do we have to connect the various players and providers in the health ecosystem, but we also have to enable the patient to play a more active role. Whenever we've provided solutions whereby the patient can play a more active role, patients are willing to embark on doing this because they're doing this in other walks of life.
4:05 p.m.
Conservative
