Health Committee on April 16th, 2013

[The Chair, Conservative, Joy Smith]

We will come to order, and I want to welcome all the committee members back. People always say “back from break”. I don't think so. We actually come back to get a rest. It's usually pretty busy during our break. I want to welcome everyone back. It's very nice to see you.

We have an outstanding panel today that's going to present to us. Pursuant to Standing Order 108(2), we are doing a study of technological innovation.

We have with us, from Health Sciences North, Branden Shepitka, emergency department health record project lead. You're from the Ramsey Lake Health Centre. Welcome. We're glad to have you here.

From the University of Ontario Institute of Technology, we have Dr. Carolyn McGregor, Canada research chair in health informatics, professor and associate dean of research, faculty of business and IT. Welcome, Dr. McGregor.

From the Huron Perth Healthcare Alliance, we have Dr. Andrew Williams, president and chief executive officer. Welcome, Dr. Williams.

From the University of Ottawa....

Pardon me?

[Andrew Williams, President and Chief Executive Officer, Huron Perth Healthcare Alliance]

I'm not a doctor, actually.

[The Chair, Conservative, Joy Smith]

Well, you look like one. They wrote this down on my crib notes. We'll inspire you. You're so well respected you are now a doctor.

We also have from the University of Ottawa, Dr. Doug Coyle, professor of epidemiology and community medicine.

Welcome to you all.

At 4:30 we're going to have a video conference with Dr. Pascal-A Vendittoli, professor of surgery.

We have a great lineup of people today. I'm going to begin with Andrew Williams, president and chief executive officer.

Welcome. Please begin.

[Andrew Williams]

Thank you very much for the opportunity to speak with you today. As you mentioned, my name is Andrew Williams, and I am the president and chief executive officer of the Huron Perth Healthcare Alliance. We call it the HPHA. We represent four hospitals located in southwestern Ontario, including the Clinton Public Hospital, St. Marys Memorial Hospital, Seaforth Community Hospital, and the Stratford General Hospital.

As an organization, we employ 1,200 staff, we grant privileges to 160 physicians, and we are fortunate to benefit from over 500 volunteers who support the services we provide. Our annual operating budget is $126 million, and we have a primary catchment population of 130,000 people who live in the two counties we provide service to.

The communities we serve are largely rural in nature. I think that's important because when we're talking technology, one of the more challenging areas to ensure appropriate access is in our rural communities across the country. Farming is the major economic driver. The population we serve is slightly older, with actually one of our census subdivisions being the oldest average age in Canada. Of course that has implications in health care delivery and the services we offer.

I personally have had the pleasure of serving our public health care system for over 25 years and have held positions in some of our largest and smallest organizations, including actually starting my career here in Ottawa. I also survey for Accreditation Canada, which takes me across the country, and when combining this with the experiences I've enjoyed throughout my career, I have developed a pretty good perspective of the challenges and opportunities we face in health care in this country.

I have come to realize that while the scope and size of organizations may vary, the basic principle is the same: namely, being able to directly provide or facilitate the provision of safe, accessible, affordable, appropriate care.

I'm keeping my opening remarks reasonably general, and I'll assume if additional details are of interest we can pursue them during the dialogue period.

When we look at technology in health care, and more specifically at the costs of technology, it is important to understand the degree to which technology now defines us. It wasn't that long ago that people were in hospital for two weeks for gall bladder surgery. Now, through keyhole surgery, they're in and out the same day. It wasn't that long ago that we were typing our health records on triplicate pieces of paper; now we're doing it through voice-activated dictation that goes right to electronic health records. It wasn't that long ago that radiologists were picking up X-ray films and hooking them into the bright screens that you used to see on TV. Now we can have radiologists read digital images from all around the world. So there's a huge change, and it's all driven by technology. When we look at the services we offer as an organization, I would say there's not a single one that is not influenced by technology in one form or another.

The challenge we face is the degree to which technology is available to us, as it varies from organization to organization, from sector to sector, and from province to province. Combined with this, we have a population that is becoming more technologically savvy, and their expectations of what the health care system can and should do for them is increasing daily.

The bottom line, though, is that we will always fall short in our ability to provide safe, high-quality, accessible, affordable care in the absence of a plan that fully maximizes appropriate technology for the people we serve.

I include “appropriate” very intentionally as it does not make sense to have everything everywhere—something that's a bit of a challenge when planning public service delivery, as you would know. A good example of this is that we recently installed a new MRI unit—common technology and well known, I'm sure, to the people around the table. It's in a region that supports eight hospitals.The cost to us was $3.4 million, with annual operating costs of $800,000. It would not make sense to have MRIs in every hospital, although some people would advocate that they would want that because of closer-to-home care. What we need to do is look at what makes sense from an investment point of view, from a health care point of view, and from a regional perspective. Then, within that, make sure patients have equitable access based on their need. When we can't provide the service in a reasonably close geographic proximity, we need to look at technologies in different ways: for example, mobile MRIs that can travel into northern parts of the province or across the country.

I always like to use quotes when I'm talking. One from Charles Darwin sticks out: “It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change”. I think in health care, how well you adopt technology will define how well you survive.

When we look at technology in our organization, we look through a number of lenses. We look at direct patient care equipment: cardiac monitors, dialysis machines. We look at support equipment in the lab, in imaging. We look at hospital information systems, which provide the basic data for the organization to operate, in our case the MEDITECH platform.

We look at the technology that links various health care providers, both internally and externally. We also look at what systems we need to connect to our consumers, to our patients, making sure that we're taking advantage of technology. And then we need to look at the infrastructure. That's often missed, particularly in rural communities. If you don't have a good infrastructure in your community, it doesn't matter what technology you have in your health care system, it's not going to work. So we obviously have to look at a number of different variables when making investments in health care.

All of these perspectives require investments, and unfortunately organizations rarely have the capacity, in either people or money, to maximize investments in all areas. Therefore, clear and thoughtful technology plans are required, driven by safety, sustainability, innovation, and growth.

Currently hospitals in the country are graded on what's called an EMR adoption scale of zero to seven. Our current score is 3.26. This may seem low, but it's one of the highest in our region, which speaks to how advanced hospitals are—or are not—when it comes to technology. Our goal is to be the first rural group of hospitals in the country to be a seven. That will require probably a further $2 million in investment and three years of planning.

We have an annual IT budget of about $2.8 million, largely towards staffing, and it represents about 2.2% of our budget. Hospitals in our region range between 1.8% and 5% of their budget going to IT, and that's not including the technology they would buy, which I talked about earlier, the equipment for patient care. That's for the actual IT costs. There's a significant range in those. We're always looking, as you can imagine, at ways to refine and appropriately allocate costs.

The key for me, though, in this discussion is that technology is really not a cost. I view technology as an investment. Gone are the days when it would have been “nice to have”, when some organizations and communities would have it and some wouldn't. People expect it to be available, and we have an obligation to make sure it's there.

We have made a number of what I think are innovative investments, which I want to just quickly share with you. They speak to the diversity and the breadth.

First is a system called PatientKeeper. It sits on top of our hospital information system and allows physicians to access health records on mobile devices. Physicians can go anywhere in the organization. They can be anywhere in the community. With their iPads, their mobile devices, they can access information on their patients. This allows for real-time access. It allows for an improved dialogue with patients. And it certainly has streamlined our ability to provide care.

The cost for this type of system is a quarter of a million dollars. Any time you make any investment in health care technology, it's fairly significant. It gets more challenging the more rural you are, because you don't have the ability to raise the funds that larger centres do.

The second investment we've made, which I think is interesting—and in fact, we were told we're the only ones in the world doing this—is that we are engaging patients enrolled in our outpatient mental health program in their care through specific two-way video linkages.

Just this past week, in fact, the Minister of Health for the province of Ontario was in our organization allocating additional funds for this.

Each day at a defined time, health care providers connect with specific patients to discuss their care. It's basically a visit to the health care provider every day electronically. You can actually see the patient, which is important in mental health. This check-in really has improved care. This, I believe, is a sign of the future of health care, bringing care directly to patients through technology, thereby ensuring more accessible and more timely care.

The next area to highlight for you is regional programs. One of the best ways to capitalize on technology is to work in partnerships. We have a number of these in place. The one I'll highlight is a 12-hospital laboratory partnership. That's important, because it reduces the requirement of all hospitals to have all technology. It allows you to centralize some of your high-cost technology while ensuring that the high-volume low-cost tests can still be provided at local hospitals. We just facilitated a major multi-year equipment replacement program across all sites, which ensures best price, best safety standards, and best use of staff. It's a very good way of maximizing technology in a rural community.

The last area to highlight is our efforts in connecting community physicians to hospital information systems. Nothing is more important to clinical decision-making than having timely, accurate information. We have structured our HIS so that it pushes out certain pieces of information to family physician offices so that they're better able to manage the care of their patients.

If l, for example, had an X-ray this afternoon at one of our hospitals, my family physician would be able to access that information in her office immediately. That, to me, is a tremendous way to improve health care.

When we talk about information in health care, we often refer to it as e-health, which is sometimes viewed as a bad word, unfortunately. In truth, though, in my view, now we're looking at a new word, which is m-health, which means mobile health. Make no mistake about it, we're at a point in time when mobile devices and information clouds are defining us, and they're defining health care.

Imagine the impact on recruitment if a graduating medical student were to come to a community, mobile device in hand, only to be told she could not use it because bandwidth would not support it. Imagine trying to recruit a nurse who has just come out of an environment in which they were surrounded by....

Do I have a few more minutes, or one minute, or...?

[The Chair, Conservative, Joy Smith]

You have about 30 seconds.

[Andrew Williams]

Okay.

The bottom line of this little piece is that the recruitment and retention of health care professionals in the absence of technology is almost impossible in today's environment. They expect the tools to be available, and if they're not, they'll seek out communities where they are.

That to me is the biggest challenge we face. It's leveraging technology in a way that maximizes health care but ensures that we can recruit health care professionals to our communities.

[The Chair, Conservative, Joy Smith]

Thank you very much, Mr. Andrews.

We'll now go to Dr. Carolyn McGregor.

[Dr. Carolyn McGregor, Canada Research Chair in Health Informatics, Professor and Associate Dean of Research, Faculty of Business and IT, University of Ontario Institute of Technology]

Bonjour. Good afternoon.

Madam Chair, members of the government, and members of the New Democratic Party and the Liberal Party, thank you for the opportunity to present to this House of Commons Standing Committee on Health my views on the costs of adopting new technologies in the health care system.

My name is Professor Carolyn McGregor, and I am the Canada Research Chair in Health Informatics at the University of Ontario Institute of Technology, at Oshawa, in Durham region.

l'd like to talk about the costs of implementing and using new technology in the health care sector, specifically as related to transforming health care through the adoption of new technology, and how doing so can impact upon the patient's journey, because this is a fundamental focus area, and about integrating that new technology with other existing technologies and analyzing the implementation and integration with analytical tools.

Patient journey modelling is using business processes to create diagrams that show the path a patient takes through the health care system: what health care workers see, what steps and procedures are performed, which technologies are used to support their care, and where the information about them is stored within the health care system. The ultimate goal is to reduce duplication, build efficiencies, streamline processes, and improve patient outcomes.

I have led collaborative research engagements between the University of Ontario Institute of Technology and two Ontario mental health providers, Ontario Shores in Whitby and Providence Care in Kingston, for this express purpose. Both were planning to move to new electronic health records.

The first engagement was with Ontario Shores. The move to the new electronic health record had the support of the senior leadership team. We worked with their health informatics department to help them determine what types of personnel should be involved in the project in addition to them. We assembled a team of health care workers from various areas of Ontario Shores and various roles, including a psychiatrist and nursing staff from several of the units.

We gathered some initial information about the patient journeys for a couple of their units and were then able to show the initial diagrams for their review. We were able to show that our diagram approach allowed them to see the patient journey more clearly than just doing a flowchart or describing what they do in words would permit. In the hour that followed, they were able to recognize that there was duplication from one role to another that could be removed to create immediate benefits for their patients.

To create the models for the whole organization would take time, so we provided them with some of our fourth-year health science students to assist with creating the models, as part of an all-year research course. This provided fantastic real-world experience for the students and gave Ontario Shores the additional resources they needed for the task. The models contained as much information as possible about the amount of time activities took, which health care workers were involved, what forms and systems, etc., and if there was a wait, they reviewed and noted how long it could be.

Through the remainder of the year and through summer internships, the students and project team worked to adjust the new models to show what life would be like with the new electronic health record. They were able to see what activities could be removed altogether, as they would be automated by the new electronic health record, such as communicating information between departments. They were also able to see what activities would require staff in various roles to work differently as they began to work with the new electronic health record.

These new and old models were put on the walls in the lunch and meeting rooms all around Ontario Shores so that all the staff, as they went about their work, could stop to look and think about how their work was going to change. This really helped the staff to see how their working environment was going to change and to see what that change would mean for their patients and the caregivers. We provided Post-it notes on which they could put comments on the old and new models, so that they could provide input as well. We followed similar steps in our partnership with Providence Care.

The results of the two partnerships clearly outlined current processes. We identified potential areas for change, gaps in processes and policies, and a pathway to improved care. Ontario Shores is now using the new electronic health record, and Providence Care is well on the way to full adoption. Our collaboration with Providence Care was reported in the February 2012 issue of Hospital News, on page 32.

As for the students engaged in the research, some were offered positions within the organizations, some have gone on to medical school, one became a consultant in the area, and the others continued at our university, in graduate studies.

The benefit of patient journey modelling is that it goes beyond current practice. It will allow you to appropriately plan for future adoption of new technologies and processes and for how best to integrate them into the health care system.

My primary research area is the creation of clinical decision support tools or analytical tools that help clinicians in critical care settings, and in particular in neonatal intensive care. I collect physiological data from medical devices within neonatal intensive care units for every breath and every heartbeat to see whether, through this data, we can detect illnesses such as infection earlier or can improve surveillance to reduce such complications as blindness or brain damage.

This is one of the earliest research projects in health care under the area known as Big Data. This research project, known as Artemis, is in conjunction with the Hospital for Sick Children in Toronto and the IBM Canada Research and Development Centre. We have partners in the United States and in China.

This research is also one of the flagship strategic initiatives of the FedDev-funded Southern Ontario Smart Computing Innovation Platform. SOSCIP is the acronym. It is also a recognized research project of the CIHR-funded Canadian Neonatal Network. Eventually this research will lead to new decision support tools for improved patient care, but this type of transformation will require a dramatic change to clinical guidelines, and patient journey modelling will help us to address how best to implement these transformations.

The costs go beyond the technology itself. Budgets for technology adoption within health care need to include funds to support informaticians and time release for clinicians and practitioners so that accurate patient journey modelling can be developed to support the new technology adoption.

The American Medical Informatics Association, together with the American Board of Medical Specialties, has defined recommendations for a clinical informatics subspecialty within medicine. Within the recommendations for that subspecialty, they state that clinical informaticians need to use their knowledge of patient care, combined with their understanding of informatics concepts and methods, to assess information and knowledge in order to characterize, evaluate, and refine clinical processes, to help develop and refine clinical decision support systems, and to lead across all of those initiatives.

The establishment of clinical informatics as a recognized subspecialty within the medical profession in Canada will reflect positively on the maturation of technology adoption in health care. Patient journey modelling essentially addresses Health Canada' s stated initiative to implement business process changes for efficiency gains. This is an initiative I fully support, as it provides the mechanism to identify efficiencies, streamline processes, and provide better patient care at reduced cost.

We also need to plan for long-term costs associated with fully integrating new technologies with other associated technologies within the health care system. Technologies need to be able to send and receive information in direct support of the patient journey easily, efficiently, and accurately.

In the case of Ontario Shores, they require technology for the electronic health record, but also systems for pharmacy, bed allocation, finance, accounting, billing, human resources, and analytics, and these are not all usually available within the one software solution.

Finally, the true costs, benefits, and savings of each new technology adoption are best understood through the use of organization analytics with metrics from before and after the business process change. Funding must be allocated to the establishment of new or adaption of existing analytics tools to enable the recording and visualization of the metrics relating to increased efficiency, reduction in medical errors, and improved patient outcomes.

In Ontario, the balanced scorecard has been used as a standard way to report health care organization performance. This approach enables not only the reporting of financial results but also patient quality outcome metrics, together with information about the degree of organizational improvement. We need to ensure that as much as possible, the information to create these balanced scorecards or other forms of organization performance reporting is gathered automatically from the other computing systems to ensure accuracy and timeliness of information.

In closing, funding for only the technology itself—the hardware, the software, and the networking—is not enough. Policies and funding frameworks are needed that holistically support technology adoption in health care, if we are to truly capitalize on the benefits of new technologies leading to better health care for all Canadians.

As a Canada research chair, l would be pleased to continue to support this working committee to help develop these policies and funding frameworks.

Merci beaucoup. Thank you.

[The Chair, Conservative, Joy Smith]

Thank you very much, Dr. McGregor, for your presentation.

Now we'll go to Mr. Branden Shepitka.

[Branden Shepitka, Emergency Department Health Record Project Lead, Ramsey Lake Health Centre, Emergency Department, Health Sciences North]

Thank you, Madam Chair and committee members, for the opportunity to speak before the Standing Committee on Health today. I'd like to first take a moment to introduce myself. My name is Branden Shepitka. I'm a registered nurse by training, with a clinical background in emergency and trauma care. Currently I'm the emergency department electronic health record project lead at Health Sciences North, Ramsey Lake Health Centre. In this role, I'm responsible for the development and implementation of an electronic health record within our hospital's emergency department.

I also maintain a clinical practice as a sexual assault nurse examiner with our hospital's violence intervention and prevention program, and I'm clinical faculty with the Laurentian University school of nursing. I have previous experience as a board of directors' member of the Canadian Nurses Association and have been previously the president of the Canadian Nursing Students' Association.

Health Sciences North, Horizon Santé-Nord, is a 454-bed academic health sciences centre based in Sudbury, Ontario, affiliated with the Northern Ontario School of Medicine, Laurentian University, Cambrian College, and Collège Boréal. Our emergency department is one of the busiest in the province, providing care to approximately 63,000 patients each year, and is one of only 11 hospitals in the province of Ontario designated as a lead trauma centre.

Our facility is also a founding partner of the North Eastern Ontario Network, which is a consortium of 22 hospitals within the North East Local Health Integration Network, who share an integrated patient record strategy to allow seamless delivery of health care services within northeastern Ontario.

As part of this vision, each facility has adopted the MEDITECH electronic health record system. While system-wide cost savings have been realized through our participation in the North Eastern Ontario Network, there have been a number of areas where significant cost has been incurred or will be incurred in the future related to our transition to an electronic health record.

Our current implementation is happening in two phases. Our phase one originally was supposed to go live last month. However, we've delayed until the fall. That includes nursing documentation and clerical documentation. Phase two will occur next spring, spring of 2014. That will involve physician documentation as well as computerized physician order entry.

I'd like to highlight a few areas where we have incurred additional costs that were not expected at the beginning of the project. The first of such areas is in physical infrastructure. Although our facility only opened in March 2010, it has become evident through our implementation process that the facility was not designed for electronic practice. Our emergency department lacks ethernet connections and power outlets for additional computer workstations, and we're now having these installed post-construction at significant cost over what would have been incurred if installed during initial construction. These additional costs take into consideration the need for work to occur during nighttime hours to limit interruption to department operations and stringent infection control procedures required during construction in a patient care environment.

Related to physical infrastructure is also the ability to implement clinical tools to support electronic practice. A systematic review of the literature published in 2009 in the Journal of the American Medical Informatics Association supported the use of mobile, handheld technology in facilitating rapid response, medication error prevention, and data management and accessibility. Our original implementation plan included the deployment of wireless devices for use by physicians and nursing staff for bedside documentation and patient data access. However, through an analysis of our infrastructure, we determined that our facility did not have a clinical-grade wireless system and that a multi-million dollar investment, approximately $2 million to $3 million, would be required to upgrade even just the emergency department to be able to have a wireless network and actually use handheld devices. We're now having fixed computer workstations installed throughout the department, which is a barrier to clinical adoption by both our nursing staff and our physicians.

As part of our implementation of electronic documentation, as I mentioned, we're also proceeding with a computerized provider order-entry system, where physicians and nurse practitioners enter their own orders in the computer, negating transcription and interpretation errors.

A study published in the 2006 Journal of Healthcare Information Management examined the effects of implementing computerized provider order entry and nursing documentation on emergency department nursing workflow. It found that a majority of nursing staff felt positively about the efficiency provided by electronic documentation templates, leaner processes for non-nursing interventions such as diagnostic imaging, and increased clarity of physician orders. However, nurses also commented on additional required functionality that would improve workflow. These solutions increase clinical adoption of the system but also have the potential to incur substantial capital and ongoing maintenance costs, in terms of both the software and hardware implementations and human resources.

At our facility we're currently investigating a number of solutions, including third-party clinical content to enhance documentation, interfacing systems to integrate patient vital sign information directly into the patient record without it having to be entered separately by the nurse, solutions to allow for proximity-based computer sign-on to secure patient information, order sets to improve clinical workflow, and evidence-based patient discharge instructions to improve continuity and quality of patient care.

Through implementation we've discovered that while many of these systems require a significant investment in order to implement within one department of an organization, only a small additional investment in comparison is required to expand the implementation throughout the entire facility. However, mechanisms and funding are not currently in place to support these capital purchases throughout the organization.

Another area of cost that we've encountered is in software cost. In addition to our expected costs—the capital purchase of our electronic health record module and software licensing fees—we've had many unforeseen costs. These costs are for items including software upgrades to medication-dispensing machines to allow integration with an electronic medication administration system, and custom functionality requests from our health record vendor. These custom requests were extremely unexpected. Our initial thought was that when we purchased the health record module it would allow us a great deal of the functionality we required. However, as we began building and testing the system, we found a number of areas where a lack of functionality in the system posed a threat to either clinical adoption or patient safety.

Canada Health Infoway has been a key driver of Canada's transition to electronic health record systems; however, areas for growth in the world of health informatics in Canada exist. Even within individual institutions, a divide continues to exist between health informatics, clinical and information technology staff, and between the teams managing individual modules of the electronic health record. Essentially, we are still functioning in silos, although the clinical users and the IT users really do need to work together to make a system that both works on the back end for data collection, data analysis, as well as being functional for clinical end users.

Mechanisms should be advocated for that allow for collaboration and best practice sharing between individuals across organizations, and also a more integrated strategy must exist both internal to and external between organizations in their development of electronic patient records in order to ensure continuity of care both within institutions and between communities.

Additionally, funding should be targeted toward supporting capital purchases by organizations to upgrade infrastructure related to electronic practice, so that transitioning to this practice model does not lead to inefficiencies, increase in workload, and disruption of workflow for health care practitioners.

The benefits of electronic health record systems are numerous, but a large amount of funding for capital purchases and human resources are required for a proper implementation to meet clinical needs.

Thank you again for this opportunity to speak.

[The Chair, Conservative, Joy Smith]

Thank you very much for your very insightful presentation.

What we'll do is start with the Qs and As—

[A voice]

What about Mr. Coyle?

[The Chair, Conservative, Joy Smith]

Oh, I'm sorry.

Go ahead, Doctor. My apologies. You're kind of over there....

[Dr. Doug Coyle, Professor, Epidemiology and Community Medicine, University of Ottawa]

I tend to try to hide in the shadows, so it's okay.

My name is Doug Coyle. Thank you very much for giving me the opportunity to present my views today.

I am a health economist and have worked in this research area for the past 24 years. I am based at the University of Ottawa, where I teach graduate students on the methods to appraise new technologies in terms of their costs and benefits and whether or not they represent value for money.

I've conducted a number of studies assessing the cost-effectiveness of a range of technologies, including drugs, devices, vaccinations, screening programs, and exercise programs.

I'm a member of the Ontario Ministry of Health's Committee to Evaluate Drugs, where I help make recommendations on the funding of new pharmaceuticals. I was previously a member of the Canadian Expert Drug Advisory Committee, which gives similar advice at a pan-Canadian level, and also of the Ontario Health Technology Advisory Committee, which makes recommendations on the funding of new technology to hospitals.

I have in the past consulted for industry, but have no such commitments at present.

The topic today is the cost of adopting new technologies into the health care system. I'm going to take a very broad definition of what we mean by technology. I'll assume that we refer not just to devices, diagnostic tools, and information technology, but also to drugs, health care practitioners, and other health-related services, including those related to the prevention and not just the treatment of disease.

I have three points to make today. The first point I'd like to raise is that not all new technologies represent value for money. Despite the claims of manufacturers, most new technologies are unlikely to save money. The downstream costs that are averted through their adoption are not sufficient to cover the upstream costs of their purchase.

We need to assess whether prices given for new technology are justified given the benefits that are being forecasted. Thankfully there are techniques to assess the cost-effectiveness or value for money of new technologies. These techniques are mature. We can make decisions using all available evidence through synthesizing the information available. We should focus on the opportunity costs of adopting new technologies. In other words, what are the health care interventions and disease prevention interventions that we cannot adopt because of the costs of taking on these new technologies?

I'd like to give you today the example of Soliris. Soliris is a new drug for the treatment of a disease called paroxysmal nocturnal hemoglobinuria. Thankfully, we call it PNH, which makes it a little easier for us to follow.

PNH is a rare blood disorder. Soliris is effective. It reduces the incidence of thromboembolism, the major cause of mortality in this disease, and reduces the need for blood transfusions, the major management cost of the disease. However, Soliris costs $500,000 per patient per year. The funding of Soliris would cost almost $25 million per annum even if only 20% of those eligible would receive treatment. With that $25 million, we could provide many other services in terms of health care to Canadians, which would provide much greater health benefits.

The second point I want to raise is how best to provide support for innovative products. When I present my research, such as the Soliris study, a question I often get from the audience is, “When will Canada start paying for innovation?” The implication of this question is that by restricting or denying funds to new technologies, we are ignoring innovative products. However, we have to define what we mean by innovation. Innovation must include considerations of effectiveness and cost-effectiveness.

In Canada we do reward innovation. We provide patent protection to new products and we give tax credits for research and development. Funding technologies that do not represent value for money simply leads to our inability to fund other technologies that provide greater benefits to the population as a whole.

Much of the focus on innovative products and their lack of funding, and the focus on new technologies rather than existing technologies, emanates from industry, those who support industry, and those who industry supports. We need to take a more considered approach to funding decisions relating to all technologies, not just those that are commercially sponsored.

We should ensure that funding is given to those technologies that represent value for money, including those that are not commercially sponsored. We need to encourage risk-taking in our manufacturing industry related to health care technologies. By guaranteeing funding to new technologies, we are not helping industries. Industries that become too reliant on government subsidies and preferred supplier arrangements stagnate and decline.

We need a much more transparent process in making decisions as well as transparency in agreements between manufacturers and health care payers. Such agreements at the provincial and federal level are typically confidential. Openness encourages innovation and assures fairness.

The third point I'd like to raise is the one I really want you to take home—the need for a more comprehensive approach to technology funding. The focus currently is very much on the funding of new technologies that have a commercial interest. This leads to funding decisions that do not recognize the current funding situation, such as the fact that we have limited resources available for health care, nor does it consider all the alternative technologies available for health care.

In economics we call this isolation bias: the focus on the decision of funding one technology while ignoring all the alternatives available. It causes bias because individuals have the idea that we can fund everything if we only consider one technology at a time, as opposed to taking an approach that considers all available technologies.

We need to consider all the technologies that are out there. Many of these existing technologies are under-funded, yet have the evidence to support their effectiveness and cost effectiveness. Many of these do not have commercial sponsors.

I'm going to give you a list of some of the technologies that have been shown to be both effective and cost effective:

-physiotherapy appointments to assist recovery from and the prevention of surgery can actually save us money;

-chiropractic care for lower back pain;

-exercise programs for patients with chronic illness, which have been shown to be more effective and less costly than drug therapy;

-elimination of co-payments for necessary heath care such as transportation by ambulance;

-improved housing conditions to reduce health care expenditures in the long term;

-providing well newborn visits by public health nurses;

-providing hospice respite care, so those who look after their loved ones can have some breaks and carry on providing unpaid services, which saves our health care system a very large amount of money;

-providing services to support the mentally ill living in the community, which is one of the few technologies we have shown that actually saves us money in the long term;

-providing harm reduction services such as needle exchange programs and safe injection sites.

These technologies suffer from a lack of commercial interest in promoting them. No one is conducting research to highlight their benefits, and there is no limited lobbying, because of the lack of a commercial sponsor.

To summarize, I'd like to reiterate three points. First, not all new technologies represent value for money. Second, innovation must mean representing value for money and is rewarded through patent protection. Third, decisions relating to health care funding of technologies cannot be taken in isolation and require consideration of all potential technologies, not just those for which there are commercial interests promoting them.

I thank you all for your time.

[The Chair, Conservative, Joy Smith]

Thank you, Doctor.

We're expecting another doctor to come on, but we're experiencing a few technology problems. So we're going to go into Qs and As. If you'll bear with me, as soon as the doctor comes on, we'll interrupt the question period to hear his presentation.

We will begin with Ms. Davies.

[Libby Davies, NDP, Vancouver East, BC]

Thank you very much, Chairperson.

And thank you to the witnesses coming today.

I think as we get into this study more we're beginning to realize how complex the issue is that we're taking on in looking at technological innovation. The questions that keep coming up for me...there are two questions, really, one of which is, what is the federal role? Health care is delivered provincially, but there is a federal role in terms of oversight under the Canada Health Act and in terms of research. The other question that keeps coming up for me, which you've all tackled, but particularly Dr. Coyle, is really the value for money. I think we realized at some point in our study that we actually needed to speak to people who are researching the economic issues in health.

Most of the discussion today is focused on acute care facilities, and I find that very interesting. I'd like to begin with you, Dr. Coyle, because I see that you're also involved in community medicine.

What I really wonder is who's doing the research, or is there research being done, more at a primary level of care? If we shifted to that and we focused more on keeping people out of the emergency rooms, keeping people out of acute care, and having much better primary care, which was multidisciplinary, where there was an array of services, community-based, with community involvement so that we could address some of the social conditions that you have raised here today, to me that makes sense. It seems intuitive that this is the right way, but of course one always has to look for the evidence.

I wonder if you can address that and tell us, first of all, if you have knowledge in an expert way about that evidence of value for money, if we have that kind of shift. Secondly, if that is the case, what should the federal role be, then, in really advocating for that and trying to make that shift in this very complex system we have?

[Dr. Doug Coyle]

Thank you.

I will try to answer the first question. I'm not sure I can provide much input for the second.

There is research that's been done on trying to reorganize primary care to try to make it more efficient, and doing some of the services you've mentioned, which is the delay of acute emergency care, which occurs because of lack of primary or community medicine initiatives. There's a fair amount of research being done, but the research funding for that pot is pretty limited. It's research that would have to compete with what's called the Canadian Institutes of Health Research for funding, and it's up against people who want to do research on new drugs, new technologies, etc.

Part of the problem, as I said before, is the issue that there's not much of a commercial interest in terms of trying to improve primary care and trying to make it more efficient. Therefore, that's not a very, shall I say, sexy topic for people to do research, and therefore there isn't much money available. Much of the work that gets done, in terms of presenting the value of money of new technologies, is industry-sponsored. When I sit on committees such as the Committee to Evaluate Drugs, in Ontario, the only research we see is industry-funded research because the Ministry of Health doesn't have the resources available to look at the cost-effectiveness or value for money for technologies that aren't being pushed by industry.

Either we have a mind change in terms of the fact that we need to provide a pot of money to evaluate existing technologies that have no commercial sponsor or we're going to still be stuck with the situation that the type of research that's being done, in terms of primary care, is fairly limited in comparison to other technologies.

[Libby Davies, NDP, Vancouver East, BC]

And the federal role? You've identified one already, which is that we need to have more research done.

[Dr. Doug Coyle]

I think the idea that CIHR should focus on the evaluation of the organization of health care, not just the evaluation of the value of new technologies, would be a good step forward.

[The Chair, Conservative, Joy Smith]

You have a few more minutes.

[Libby Davies, NDP, Vancouver East, BC]

Okay.

I'd ask the other witnesses if they'd like to weigh in on this. You're more in the acute care field, but do you agree that if we had a shift where we were focused more on primary care and innovations in that area we would actually be helping the job you have to do? I know you presented us with some very specific issues that you're facing, but is that kind of shift something you advocate for in your expertise?

[The Chair, Conservative, Joy Smith]

Ms. Davies, Mr. Williams would like to make a comment.

[Andrew Williams]

Even though I work in the health care sector, I will say to anybody who listens that the most important part of our health care system is our primary care, the health promotion, disease prevention components. I think if you look at some of the initiatives we're doing, one is aimed specifically at keeping people out of hospital by providing care at home. The other is ensuring that the primary care providers have information on their patients in real time. I think that's probably the biggest barrier to research in primary care. It's the lack of electronic health records to be able to pull information in an easy way.

We've seen in the last five years, with the introduction of family health teams in the province of Ontario, a much more robust ability to generate data. I think there are really great opportunities now if we can approach the physician groups that are now in place across the province with specific questions that will allow research. I think it's really important.

The sustainability of the acute care system depends on how strong the primary care system is, quite frankly, and how healthy the population is. Isn't that right?

On the role of the federal government, personally, I feel there's a very important role around ensuring standards, ensuring that the five principles of the Canada Health Act are adhered to provincially, and ensuring that infrastructure is available in a consistent way across the country. Canada Health Infoway is a good example of that, where we can access pipelines for data flow, which is hugely important to our ability to provide care.

[The Chair, Conservative, Joy Smith]

Thank you very much.

We'll just have a quick comment, Dr. McGregor.

[Dr. Carolyn McGregor]

I just wanted to comment that while my research around Artemis was really focused on what we're doing in neonatal intensive care, we see benefits when you step down a baby and graduate them and take them...[Technical difficulty—Editor]...monitoring, and when you're trying to monitor a patient in a home, if they're older, before they go into intensive care. The technologies we're building have direct applicability in the primary care setting because we're able to create this complex observation, and then we can watch patients in their home if they're developing infection or other things. So there are relevant benefits in this.