Health Committee on March 7th, 2013

[Prof. Adam Holbrook]

I have an observation, and that is when we come to setting out this economy of innovation, we forget one of the other players, which is a fairly large player in the field of health sector research: the private non-profit foundations. The interesting thing about a private non-profit foundation is that by its very nature it collects money from people who have a specific interest. For example, the Breast Cancer Foundation people are marketing that idea. The money they have comes from ordinary Canadians. They're in a position to influence what is being done in that field, because not only do they collect money for research, but of course they lever money for research as well. This past year about $800 million to $900 million was raised by health sector private non-profits. That probably was multiplied two or three times through various federal and provincial contributions.

[The Chair, Conservative, Joy Smith]

Thank you very much.

We'll now go to Mr. Kellway.

[Matthew Kellway, NDP, Beaches—East York, ON]

Thank you, Madam Chair.

And thank you to all of you for coming today and sharing your thoughts with us.

I'm well into today's meeting and I confess I'm not sure how much I've understood quite yet. One of the reasons I'm a bit uncertain is that I think you've told us something that we haven't heard before, and that is the issue about how much technology is out there and available to us that we are not taking in and adopting. Maybe it's a definition issue.

Dr. Jaffray, I think you said, “There's more technology in the world for health care than we know what to do with”. Yet what we've been hearing so far—and maybe this is the prejudice we come to this with—we had some genomics people here the other day, and one of them was talking about how only a few of the 20,000 genes are getting studied. There's this great undiscovered world out there, and we've got this science system in the universities, and I guess industry too, and everybody goes zooming in on the same ones. You seem to be suggesting today that it's not about what's undiscovered, it's about adopting stuff that's out there and that we know.

Am I right about that?

[Dr. David Jaffray]

Yes. Ten years ago the idea of putting your computer in your suitcase would have been absurd, but clearly you could put 50 iPads in your suitcase now. Technological innovation is constant. This is very important, there's science and discovery and then there's innovation in health care. We've said we should encourage people to go across there. But this is a different problem. This problem requires an understanding of the issue in health care. It requires bringing in people who understand design and understand the challenges and complexities. Companies come to us with technology and ask for help to get this into health care. They don't understand.

We also need to evaluate this. We need to turn the health care system into something that innovates and comes along. There's so much opportunity around us. We haven't figured out how to get those two markers fully integrated within heath care yet, not to mention the thousands that might come later. It's a different problem, and I don't think we've addressed it.

[Matthew Kellway, NDP, Beaches—East York, ON]

This is the second thing I'm a bit uncertain about: the sequencing of evaluation and the economy that you've been talking about. Again, we haven't looked at it this way, but if the health care system is this learning, living place, and you're investing billions upon billions, don't just think about it as giving a service, but leverage that into innovation and creation. But if the health care system is also part of your evaluation process, which I think you've been pretty clear about, how do you set up the economy in advance of the evaluation?

[Dr. David Jaffray]

It's about chicken and egg. Quite frankly, it's a lot more egg than chicken right now. A lot of technology goes in and is not evaluated, but we have a culture developing on the HTA front right now, a key development that will bridle that innovation appropriately.

[Matthew Kellway, NDP, Beaches—East York, ON]

I take it you're not necessarily supporting this model, but one example you gave of the economy is, “Can you cut our costs by 15%?” Right? How do you make that assessment to figure out whether it's going to save you 15% before it goes into the health care system?

[Dr. David Jaffray]

The model I would suggest is endorsing the hospitals to create innovation teams of some sort. They would, for example, bring forward a proposal that they would see savings, let's say, of 10%, in a certain set of procedures. They would then communicate that to an office that says, “We have this plan. If we actually achieve that, let us keep that 10% and we'll use that for further innovations within the system. If we don't achieve it, then we won't be able to keep it.”

Basically, you could propose an innovation, register it, and if you do have the savings you get to keep them in your budget and roll them forward. You would turn the hospitals into environments that would look for innovation because they would then have more resources to address the other pains that many of them are fighting.

[Matthew Kellway, NDP, Beaches—East York, ON]

Playing that out, then, a team in the hospital, let's call them entrepreneurs or something, would say, “We can save you 15% in this department. Let us do this.”

What do they then use their savings for?

[Dr. David Jaffray]

They would use them for what the hospital already suffers from, which is underfunding on a bunch of other fronts: lack of capital support, new technologies they cannot afford, or replacing failing systems.

The budget issues in hospitals are always a problem.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Jaffray.

We'll now go to Mr. Brown.

[Patrick Brown, Conservative, Barrie, ON]

Thank you.

Thank you for your testimony today.

One question I've asked previous panels we've had on health innovation is in regard to the regulation of medical devices and products. I've heard different opinions on whether we can do a better job in Canada. We heard from one doctor who said it was incredibly difficult, and others who said it was actually quite easy in comparison to the United States.

In any of your roles, have you had any interactions or viewpoints on what we could do better, or how we're doing in terms of that federal role? A lot of health care isn't a federal role, but obviously it is for the regulation of medical devices. Medical devices can certainly be a tool for innovation.

[Dr. Pascale Lehoux]

I can answer part of your question.

I think the USFDA process is more stringent, more demanding. It's a class-based system, so depending on the level of risk associated with a technology, the requirements will be high or low. This might explain why there are different perspectives.

The FDA is more stringent, and most companies go to Europe first. The CE marking system is easier to pass through. It's a better way to get some revenue out of commercialization, and to then go to the FDA. The FDA is the big market, not Canada, so that's the way.

[Dr. David Jaffray]

If I could add to that, many of the companies we work with will submit to the FDA, and then because of the way that Health Canada requires submissions, they'll submit those later. Even if we co-create a technology with them, we're the last ones to be able to use it on humans, even though we co-created that. They go to the CE first, the FDA, and then finally to Health Canada.

It would be great if we could move this innovation evaluation curve forward by having our regulations support the adoption and keep the bar high but increase the response of regulatory submissions. Then people would bring us technologies early on and we could begin this evaluation cycle. It would make our innovators who do technology development logical partnerships because we're in this environment.

I know right now, for example, we're waiting on technology that was supposed to be back from Health Canada in 70 days. The backlog is months more than that. Our industry partners globally are saying they'd love to do something sooner but they know there are impediments.

There is room to improve.

[Patrick Brown, Conservative, Barrie, ON]

The question I have, I think would be for Jeffrey and David.

I come from the riding of Barrie. We were involved there for a while in building a regional cancer care centre. It was a huge project, over a long period of time. With Garth Matheson, who is now with Cancer Care Ontario, and was with RVH, we were looking at ways we could.... To have a regional cancer care centre meant hiring loads of people all at once. He found mobile cancer bunkers in the U.S. They hadn't been used in Canada yet. He pitched to us that we should use them in Barrie, so we used them to build the physician population, to help the regional population, and then we moved to Peterborough.

That was neat. But I know it took some time to get that approved in Canada, to get the different levels of approval that were required, both federally and provincially, to have something that hadn't already been used in Canada.

Are there opportunities we are missing? I remember thinking it was brilliant. It really made the transition to a brand new cancer care centre, which we had never had, so much more effective. Are there opportunities that we could do in the health care system in Canada that are being done elsewhere? He said those mobile bunkers have been used readily in other countries, but we just haven't used them in Canada.

[Dr. David Jaffray]

I could comment as it's a specific area of my expertise, but the issue there I think was related to people becoming comfortable with an alternative approach to using these mobile bunkers. I would have thought that it should have been relatively straightforward to get those cleared and approved through the regulatory agencies that govern the shielding-related issues. But I think it does raise another interesting element, which is the opportunity to work with our regulators to bring innovations forward. We've actually been quite successful with the Canadian Nuclear Safety Commission on bringing innovations forward. Over the past several years we've worked with them on specific technologies and they've helped us bring them forward safely.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Jaffray.

We'll now go on to Mr. Wilks.

[David Wilks, Conservative, Kootenay—Columbia, BC]

Thank you, Chair.

I understand my colleague, Dr. Carrie, has some questions he didn't get to finish, so I'm going to defer my time.

[The Chair, Conservative, Joy Smith]

Dr. Carrie.

[Colin Carrie, Conservative, Oshawa, ON]

Thank you very much, Mr. Wilks.

I want to start off by giving Dr. Hoch the opportunity to finish off where we left off last time, because I do find it amazing how we analyze and test the validity of some of these protocols. You can have an old drug, but I think sometimes a new drug doesn't have to be tested against the old drug. They're just tested against placebos. The new drugs sometimes cost 10 times the cost of the old drug. I was just wondering if you could give us some insight on your comment that we should invest in research to determine the value of these things. That's question number one.

The other question was for Dr. Jaffray. You mentioned that you did have a number of patents, commercialization, and I was wondering if you could comment on how you did it? You seem to be one of these guys who's been successful through the system. Do you have any suggestions for the federal government, perhaps recommendations on how we could cut the red tape and have more innovators such as yourself go from an idea through the commercialization, trying to get a patent and getting it out?

So those would be my two questions. I'd better shut up so you have some time to answer them.

[Dr. Jeffrey Hoch]

Thank you. I'll answer very quickly so we can hear about dealing with innovation successfully.

The short story is, the stuff you need to go through regulation is different from the stuff that people who pay care about. So if you're doing regulation, you could do placebos, you could have super-healthy young patients. When you go to the real world, it's possible doctors aren't treating people with placebos. It's possible some people who get sick aren't young and healthy. It's also possible you'd want to study people for longer than, say, six weeks. The evidence we need for the regulation part is different from the evidence we need for the payer part. If you can produce pressure to get it paid for by doing just the regulation, why would you collect the other stuff for the payers?

[Dr. David Jaffray]

I'd like to talk on that, too, madam. I'll talk about what you asked me about.

In my case, I was a physicist who worked in a hospital. Radiation delivery systems need to be managed by physicists. The technology we developed was really related to a direct observation within the clinic of a problem, and detailed insight into what was feasible. We could make this technology, but if you increase the treatment time by more than five or 10 minutes, it would not be accepted economically. It would destroy the economics of radiotherapy cancer treatment. So we had to understand that.

We had to understand what technologies were available, and we had to find an industry partner who would allow us to bring those through, all the way through, to a return to market. This is where the realization on my part came, that it's clear insight into the details of the health care system that enables technologies, which in many ways are already out there, to come together to have an impact. We patented that and it was licensed and so on and so forth. It was actually produced in the U.K., and parts of it all over the world have come together. The way the global economy works now, you work with multinationals because the time it takes them to take something to market is very short compared to a start-up. We work a lot with multinationals because you can have an impact sooner.

In terms of what the federal government can do, I think it would be outstanding if we could have some kind of responsibility communicated to the provincial health care systems that they need to innovate within their care delivery process, not just do clinical trials. Let's go back to what Jeff said, let's talk about getting data beyond six weeks. Let's turn the routine follow-up visits into a mechanism by which we collect outcomes data that is months, years. That's incredibly powerful. So turn the health care system into something that's using its internal understanding, taking the service delivery and building intellectual property. That's a huge opportunity.

That's why I was concerned about the U.S. change. It's a good thing, but in 2012 they put out a paper that said, you need to do this, you need to show us the performance and we'll pay you for it. The U.S. is investing. They're putting IT systems in, they're facilitating data collection. They're turning their health care system into something that's got an economy based on innovation. We could discuss the motivations, I agree with you, but the data collection is key. We need to do that in Canada.

[Colin Carrie, Conservative, Oshawa, ON]

Do you want to want to make a quick comment on what Dr. Hoch was saying and elaborate a bit more?

[Dr. David Jaffray]

Yes. I mentioned this at the end. Outcomes collection in health care has been largely the hobby of academic clinicians. We need to turn it into something we do as a matter of course and to supply the systems that collect that data, because we will then have one of the best systems in the world to bring technologies in, begin the health technology assessment process, and look at long-term effects. In health care you have to look for years to really see the value.

[Colin Carrie, Conservative, Oshawa, ON]

We're doing electronic health records. Is that something we could do?