Health Committee on May 9th, 2022

[Tim Guest]

Yes, we have. I would say that the medical profession is further ahead on this matter than nurses are. We're advocating for a national nursing identifier, where a nurse would have an identification number that would follow them through their whole career across the country. That is not the case now. It causes much more of a challenge when you're talking about interprovincial mobility.

We saw that in the pandemic, it was a huge issue for the Canadian Armed Forces when they were trying to move some of their resources between provinces. If their resources are registered in Nova Scotia, for example, and they need them in Quebec, they ran into issues with having to have interim processes to get them registered.

There could be mechanisms that could make that interjurisdictional mobility much easier, and a unique national identifier would get us closer.

[The Chair, Liberal, Sean Casey]

Thank you, Mr. Guest and Mr. Powlowski.

Go ahead, Mr. Barrett, for five minutes.

[Michael Barrett, Conservative, Leeds—Grenville—Thousand Islands and Rideau Lakes, ON]

Thanks very much, Chair.

Thanks to all of the witnesses today. I'll take the opportunity to thank our nurses as well, on the occasion of a week of recognition for all their hard work.

I've had the opportunity to speak to some of you at previous meetings. I just wonder at what point the perfect becomes the enemy of the necessary—not even the good—just what we need to have happen so that we don't have more people running for the exits in the health care profession.

I have a couple of examples, and I've raised some of them with you before. We have virtual medicine apps, telemedicine apps, that are available where you can talk to a nurse practitioner and get a script instead of going to a doctor. We have electronic health records, so in the Canadian Forces, for example, it didn't matter which base or which physician's assistant I was talking to, because they punched in my service number and up came my record. I appreciate that, when we're talking about people's medical information, we have to be extremely careful. The highest sensitivity has to be paid to that. But do we not find ourselves where there are solutions out there that we could use, and is this a question of intergovernmental co-operation?

With that framing in mind, I would just ask, what are some things that could be done right now that would address even some of the low-hanging fruit, because I feel we have a lot of very big problems. Are there any short strokes that we can take to solve those as a country?

That question is for all of you, together.

[Dr. Brady Bouchard]

I'll take a first stab at this.

I would say certainly in the short term something that could be addressed is what we're proposing in the primary care integration fund as an incentive for provinces and practices to move to team-based care.

We know how to do team-based care. We have a model of it. As Dr. Lemire mentioned, it's been out there for quite a while now and we just need to move to those models. That would be an immediate improvement.

As for the two points you raised, certainly a single source, or integrated EMRs—I am unaware of that crossing provincial boundaries—but even within provinces that doesn't exist, at least that I am aware of, essentially anywhere in the country.

To your other point on virtual care, we'd be the first ones to say that virtual care is here to stay. It certainly enabled care early in the pandemic where we couldn't provide care safely elsewhere. That technology will be essential into the future for geographic disparities, for efficiency purposes and patients not waiting in waiting rooms. There are concerns about equity, so we don't want to replace a family physician in a rural community with just virtual care. That's not fair to them, and virtual care can't replace everything in primary care and family medicine.

The other point I would emphasize is that all family physicians, I think, want to work with virtual care, but it should be integrated into longitudinal family practice. All Canadians deserve to see a family physician and their team over time, and that could be through technological solutions or it could be in person.

[Michael Barrett, Conservative, Leeds—Grenville—Thousand Islands and Rideau Lakes, ON]

How much time do I have, Chair?

[The Chair, Liberal, Sean Casey]

You have one minute.

[Michael Barrett, Conservative, Leeds—Grenville—Thousand Islands and Rideau Lakes, ON]

Does anyone else want to contribute an answer in that one minute?

[Tim Guest]

I'd be happy to.

I would also like to add to what Dr. Bouchard talked about.

There is an ability to do more integration of the electronic health records that we have. We have spent millions and millions of dollars across the country implementing systems that were not built with standardization in mind, in that they could speak to each other. They are capable of doing it as technology evolves. We continue to add more of them and make the issue worse, where I think if there were a requirement that all new systems had to be integrated.... Alberta is an example: The entire province is moving all of its hospitals onto a single system. We're seeing similar things across the country.

I've seen examples in Ontario where an individual gets discharged from a hospital, is transferred to a hospital 15 minutes down the road and the entire chart needs to be printed off and sent in paper format with the patient, and it's then re-entered into the system in the adjacent hospital because the systems aren't integrated.

There is an ability to do that. It will be costly, and it would take some will to make it happen.

[The Chair, Liberal, Sean Casey]

Thank you, Mr. Guest and Mr. Barrett.

[Michael Barrett, Conservative, Leeds—Grenville—Thousand Islands and Rideau Lakes, ON]

Thanks for the answers.

[The Chair, Liberal, Sean Casey]

We have Ms. Sidhu, please, for five minutes.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you, Chair.

My question is for Dr. Smart. You talked about the need to improve virtual data— which is also an area of concern for well-managed health human resources—and to have a pan-Canadian health data strategy to improve the system with good data, and to inform decision-making and to measure progress. Do you have any specific recommendations about how we can improve data collection, especially to the rural communities as well?

[Dr. Katharine Smart]

To add to what we've already heard when we've been talking about data today, I think it's really important that it be standardized and that it is being used for the right reasons. What we really want to see is a data-driven, outcome-based system so that we're using the data to make sure that we're accountable for the investments we're making in health care, and that it's driving the outcomes we want to see in our system. I think if we design it from that lens, we can then use the data to be monitoring what we're doing and seeing how close we're getting to the outcomes that we want to be seeing, and also to give feedback to the providers in the system about the care they're giving to patients. There are many ways that effective use of data could improve the quality of care and accountability in the system.

I think what's going to be critical and why we feel this needs to be a pan-Canadian approach is to allow for that standardization across the country and to make sure that we're creating those basic standards across the country so that we're all moving in the same direction. I think that's true from the patient data side.

From the human health resource planning side, I think the data is going to be needed so that we can actually know what we're trying to do. I think from what you've heard today, some of why it's hard to answer some of the very specific questions about things like how many nurses and doctors...and where exactly they are, is that we don't know.

The other problem is that sometimes we're not counting the right things. We could probably tell you how many people are licensed as a family doctor in Canada, but how many of those physicians are actually providing primary care in a rostered or longitudinal manner may be more difficult to do. That's why things like saying we need x more people is challenging, because if you add a thousand family doctors to a province but none of them actually takes on a patient panel, it's not solving the problem of access to primary care.

I think we need to be really clear about what we're trying to collect with the data. We need to make sure that it's linked to the outcomes that we're wanting in our system, and that the whole point of it is accountability, because we know that investments in the Canadian health care system are a very significant use of our tax dollars.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you, Dr. Smart.

My next question is for all of the witnesses. We heard about the need for more administrative staff to remove health care professionals from the paperwork process. What improvement can be made to this process, and how impactful can these improvements be? What should we do so that health care professionals don't need to do the paperwork when the doctors need to know what has to be placed in there? What is the process we need to result in a tangible outcome/income?

[Tim Guest]

I can take a stab at this. I think what we have suggested is an option for the federal government to provide resources to the provinces and territories to be able to add additional capacity into the system so that they have individuals who can do some of those tasks to free up physicians and nurses to do the tasks that only they can do. That's some of what we have suggested. It's a matter of needing additional resources to put those workers in place.

[Dr. Francine Lemire]

The challenge is that we have different systems that are not talking to each other as we speak right now. The solutions, I think, will need to be adapted to regions and locales to be effective. I don't think there's a one-size-fits-all solution here. I'm trying to think here of my own practice, when I had one, and using my EMRs. I actually had a clerk do the ordering of some of the things that I was doing, and the way the system was working, I think it might be quite difficult. There really is a need to have conversations at the regional level to see what could be farmed out to individuals to provide that clerical help, as Mr. Guest has mentioned. It's difficult to have one solution, unless Dr. Smart or Dr. Bouchard are aware of any one solution to help with this.

[Dr. Katharine Smart]

No, I would agree. I don't think there's a single solution, but I think some of the things we have heard....

The other thing we have seen to be effective in some settings is having access to a scribe, someone who's working with you, documenting for you, filling out the forms as you go and supporting that work. That can be a way to really bring down that administrative burden as well.

I think there are lots of different strategies. I think it would probably be a matter of picking two or three, trying them to see how they work and then looking at what could be scaled into different environments.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Smart.

Mr. Garon, you have the floor for two and half minutes.

[Jean-Denis Garon, Bloc, Mirabel, QC]

Thank you very much, Mr. Chair.

I have a question for Dr. Lemire.

First of all, hello, Dr. Lemire. I have not had the opportunity to ask you any questions yet.

You talked earlier about a targeted federal fund, which the provinces could access to work on the most effective and promising models developed by the provinces. You referred to family medicine groups in Quebec. I like them very much, I am a patient of one of those groups. Please tell me if I have understood your idea correctly.

Let us assume that the federal government establishes a fund, subject to certain conditions. Quebec develops a model like that, which ultimately proves successful, despite all the financial constraints in Quebec's health care system. Quebec could then request access to a federal fund, subject to certain conditions, to finance its own model, the one it has developed.

Is that correct?

[Dr. Francine Lemire]

That is one way the fund could be used.

In Quebec, I believe about 70% of family doctors can belong to a family medicine group. You might know the figures better than I do. From what I have heard, it is a promising model, but there is still room for improvement. The fund would make it possible to look at what you are doing now and try to improve the system you have, and allow more family doctors to work as part of a team under this model which, we hope, could be further improved.

[Jean-Denis Garon, Bloc, Mirabel, QC]

Dr. Lemire, I just have a few seconds left.

In a well-funded system in which the federal government increased funding to the provinces and Quebec under the Canada health transfer, the provinces and Quebec would have the means to develop better models. And provinces that are well-funded could of course draw on the models developed by other provinces to make reforms.

What do you think of this approach of providing more funding to the provinces to enable them to develop new models and feed off each other?

[Dr. Francine Lemire]

That is actually what we are trying to promote. Perhaps you are thinking of a different model. I do not understand your question.

[Jean-Denis Garon, Bloc, Mirabel, QC]

A substantial increase in unconditional health transfers would enable the provinces to develop such models and to feed off each other. The lack of innovation could be partially explained by the provinces' limited funding and the fact that the proportion of health system costs covered by these health transfers has dropped over time from 35% in the past to 21% today.

[The Chair, Liberal, Sean Casey]

Please be brief, Dr. Lemire, if you will, because the member's speaking time is up.

[Dr. Francine Lemire]

We think it is important to have funds earmarked for the type of reforms and improvements that are needed. That does not preclude allocating funds more broadly, but at this time we think it is important to allocate funding for the type of improvements we are suggesting.