PACP Committee Meeting

     I'd like to call this meeting to order. Welcome, everyone.

    The meeting this morning is pursuant to the Standing Orders. We're actually dealing with two reports. The first report is “Chapter 4, Electronic Health Records” of the fall 2009 report of the Auditor General of Canada, and then also “An Overview of Federal and Provincial Audit Reports” from the spring 2010 report of the Auditor General of Canada. So we're dealing with electronic health records and the implementation of electronic health records in Canada.

    The committee is very pleased, of course, to have with us, from the Office of the Auditor General, Ms. Fraser, the auditor. She is accompanied this morning by assistant auditor, Neil Maxwell, and Louise Dubé, principal.

    From Health Canada Infoway, we have Richard Alvarez, the president and chief executive officer. He's accompanied by the chief operating officer, Mike Sheridan.

    We also have, from the Department of Health, Dr. Karen Dodds, the assistant deputy minister, strategic policy branch.

    So again, welcome to each of you. I'm going to break 10 minutes early to deal with the steering committee reports and Madame Faille's motion. I'll do the steering committee first.

    Having said that, we'll go right now to opening remarks. We're going to hear first from the auditor herself, Ms. Fraser.

    Thank you, Mr. Chair.

    We thank you for this opportunity to present the results of two reports on electronic health records. As you mentioned, I'm accompanied today by Neil Maxwell, Assistant Auditor General, and Louise Dubé, principal, who are responsible for audits in the health sector.

    Electronic health records, or EHRs, are intended to offer solutions to a number of persistent problems in Canada's health system, some of which may be attributed to the use of paper-based health records. It is expected that EHRs will allow health care professionals to be better able to share patient information, resulting in reduced costs and improved quality of care.

    In November 2009, we reported the results of an EHR audit of Infoway and Health Canada, based on audit work completed to April 2009. As of March 31, 2009, Infoway had committed to spending or had spent $1.2 billion on this initiative. Some experts have estimated the total cost of implementing EHRs Canada-wide at over $10 billion, and Infoway concurs with this estimate.

    We examined how Infoway manages the funds from the federal government to achieve its goal of making compatible electronic health records available across Canada. Overall, we found that Infoway has accomplished a lot since its inception and that it manages well the $1.2 billion in funds granted by the federal government to achieve its goal. There is good oversight of the corporation by the board of directors and Health Canada, the sponsoring department. Infoway has set the national direction for the implementation of EHRs by developing an approach as well as the key requirements and components of an EHR. It developed a blueprint or architecture for the design of the systems, and it developed strategic plans and a risk-management strategy. Infoway worked collaboratively with and obtained buy-in from its partners and stakeholders, which is critical for the success of the initiative.

    We also found that Infoway approves projects, which it cost-shares with the provinces and territories, that are designed to comply with standards and that align with the blueprint. We noted that Infoway adequately monitors the implementation of projects by provinces and territories.

    We reported that Infoway needs to make improvements in certain areas. Infoway's 2010 goal is for 50% of Canadians to have electronic health records available to their health care professionals. We found that Infoway needs to report more information on results, in particular, information on progress achieved towards its 2010 goal. To date, it only reports if systems are completed, not whether the systems are being used by health care professionals, or whether completed systems meet the requirements for compatibility. This information on system usage and compatibility would help Parliament and Canadians better understand progress to date.

    We noted that Infoway's controls over executive pay, travel, and hospitality are basically sound, although it needed to improve its contracting policy.

    Concurrent with our audit, six provincial audit offices looked at how electronic health records funded by Infoway and/or provincial governments are being implemented in their respective provinces. Each office has reported the results of its audit to its own legislature between October 2009 and April 2010. My provincial counterparts and I issued an overview of the federal and provincial reports on EHRs in April 2010.

    In the six jurisdictions audited, the audits found that every audited jurisdiction had at least one core electronic health record system in place, and some provinces had almost finished implementing their EHR systems.

     The six participating provincial legislative audit offices raised various concerns about EHR planning, with some noting recent progress. For example, three reported that the ministry started their EHR initiatives without having a comprehensive strategic plan. This increases the risk that the projects undertaken will not be consistent with the goals and priorities of the overall initiative and that the needs of the users will not be met.

    With regard to the implementation of EHRs, participating provincial auditors general reported that the focus for each province has been to ensure compatibility within their respective jurisdictions. It is too soon to determine whether the systems in each jurisdiction will be compatible nationally.

    Notably, my provincial counterparts found limited public reporting on progress. Provinces lack comprehensive information such as costs to date, baselines, and performance measures necessary to report progress more completely.

    Infoway, the provinces, and the territories need to work together to develop performance measures and reporting standards for each core system of the electronic health record, so that Parliament, legislatures, and Canadians can better understand progress made and benefits achieved.

    While progress has been made in developing and implementing electronic health records across Canada, continued collaboration between Infoway, the provinces and territories, and other stakeholders will be needed to address the significant challenges that lie ahead.

    These challenges include the need to increase the number of primary care doctors using computerized records systems; to upgrade completed EHR projects that do not meet all the standards for national compatibility; to address the implications of differences in provincial and territorial laws regarding the collection, use, protection, and disclosure of personal health information; to track the total costs; and to fund the completion of the initiative. A key question is whether the 2010 goal will be met by the end of this year.

    Mr. Chair, given the significance of the investments made, the potential benefits, and Canadians' interest in health care, the committee may wish to ask Infoway for an update of its action plan developed in response to our November 2009 audit. Furthermore, all of the participating auditors general have suggested that legislative committees continue in the future to provide oversight to this initiative and monitor progress toward meeting the 2010 goal.

    Mr. Chair, this concludes my opening remarks and we would be pleased to answer your committee's questions.

     Thank you, Ms. Fraser.

    We're now going to hear from Mr. Alvarez, the president and chief executive officer of Canada Health Infoway.

    Mr. Alvarez.

    Good morning, ladies and gentlemen.

    Mr. Chairman, thank you for providing us with this opportunity to speak to the committee today.

    As you stated earlier, with me is Mike Sheridan, Infoway's chief operating officer.

    Let me start by thanking the Auditor General of Canada and her audit team for what we believe to be a thorough, balanced audit report on electronic health records, which her office tabled with Parliament in November 2009 and then again in April 2010.

    As the Auditor General notes in her overview report, the provinces' approach to electronic health records is unique. Their definitions of electronic health strategies, priorities, timelines, and approaches are distinctive.

    As a strategic investor, Infoway has developed, in consultation with our jurisdictional partners, the key requirements, the core components, and a blueprint to guide—

    I'm sorry to interrupt. You may be going a little too quickly for the interpreters at the back of the room. Could you slow down about 20%? It's only nine o'clock in the morning.

    Voices: Oh, oh!

    Mr. Chairman, I was terrified you were going to cut me off after my five minutes, so if you promise not to do that, I'll slow down.

     I just have sympathy for the people back in the corner; that's all.

     Sure.

    As a strategic investor, Infoway has developed, in consultation with our jurisdictional partners, the key requirements, the core components, and a blueprint to guide the pan-Canadian developments of EHR. Infoway's strategic plan identifies those priorities, along with measurable goals and targets, and provides an agreed-upon road map for the development of the various components of the EHR that we fund.

    Madam Fraser's overview report specifically states that “at the federal level the audit reported that Infoway was exercising due regard in managing funds from the federal government to achieve its goal related to the implementation of EHRs”. As a result, today every province and territory and the populations they serve are benefiting from a share of the federal government's investments through Infoway in the new information systems that will help transform health care.

    Let me share with you just two examples. Our investments have helped to eliminate three-quarters of X-ray films and replace them with digitized images. Today some 40% of our radiologists report they are providing services to new and remote sites—that's incredibly important, given the large land mass of our country—and eliminating between 10,000 and 17,000 patient transfers per year.

    Leveraging Infoway's investments, drug information systems are now in place in British Columbia, in Alberta, in P.E.I., and in Saskatchewan. Take the system in B.C., PharmaNet, which captures every prescription dispensed in pharmacies and provides alerts to pharmacists and physicians. In 2008, more than 55 million prescriptions were processed by PharmaNet, and 2.5 million significant drug interactions were identified. When you project that across Canada, this suggests that drug information systems could significantly reduce inappropriate prescriptions and identify more than 20 million significant drug interactions every single year.

    The Auditor General made eight recommendations to Infoway in her November 2009 report to Parliament. Shortly after the report was tabled, Infoway sent its action plan to this committee as well as to the House of Commons Standing Committee on Health. Our response to the eight recommendations encompassed some 40 separate actions, which were implemented by our self-imposed deadline of March 31, 2010, the end of our fiscal year. We also reviewed this action plan with the Office of the Auditor General of Canada.

    Of the eight recommendations, five call for improving and enhancing our existing reporting, especially as we report to Canadians. In this regard, we conducted focus groups with the public across the country to ensure that our enhancements in reporting on availability, on adoption, on standards, our investment targets, and reporting variances in our business plan would be understood by those Canadians. The result of these focus group discussions helped us to improve and expand reporting on the key measures that have been integrated into our 2009-10 annual report, which will be published in a few weeks.

    We have also assessed and strengthened our management controls over contracting for goods and services to reduce the risk of contract disputes, with the introduction of additional control points, advance notice of expiry dates to contract administrators, enhanced management signature procedures and processes, as well as required workflow modifications. We have supplemented these administrative changes with an internal communications and education program for our staff.

    As recommended by the OAG, we have reviewed and modified our procurement policy with respect to contract amendments and extensions and have had the revised policy approved by our board of directors, and now it's firmly in place.

    In response to the recommendation that Infoway should better document its analysis of project deliverables to support our decision to release funds, we have revamped our project portfolio management system and have modified and updated the processes and procedures to support the release of funds for deliverables in a consistent manner. All appropriate staff have been trained on the new system requirements.

    We have also incorporated into our investment approval process for the core systems of the EHR the requirement to obtain results of conformance testing on the core EHR systems that we fund.

     We believe that we have responded to the recommendations in a timely, efficient, and effective manner and have addressed the issues of concern raised in the OAG's audit report.

     Mr. Chairman, that concludes my remarks. I'll be delighted to take questions.

    Thank you very much, Mr. Alvarez.

    We're now going to hear from Dr. Karen Dodds, assistant deputy minister, strategic policy branch of the Department of Health.

    Thank you, Mr. Chairman.

    Mr. Chair, members, I am very pleased to have the opportunity to be here with you this morning.

    I first want to thank the Auditor General and her staff for their very informative reports. Health Canada is pleased that they have undertaken the task of reviewing electronic health record initiatives. The process has provided all parties with useful feedback.

    The federal government has invested $2.1 billion in Canada Health Infoway since 2001. In this context, the audits have provided confirmation and assurance that these investments are being managed responsibly and effectively.

    Indeed, the audit of electronic health records provided an additional layer of due diligence, to support the recent release of the $500 million allocated to Infoway under Budget 2009.

    I would like to take this opportunity today to speak in more detail about Health Canada's reaction to both the fall audit report, and the spring overview report.

    As noted by Ms. Fraser, developments in the area of electronic health technologies are expected to be of great benefit to Canadians as they will enable better, safer, and faster management of patient information. Evidence of this is already being seen across the country.

    Of course, establishing electronic health technologies is a highly complex undertaking, particularly in Canada, where 14 jurisdictions are individually responsible for the delivery of health care. This makes the results of the audits encouraging, for although they identify areas for improvement, they also emphasize many achievements. With respect to the Auditor General's fall 2009 report, Health Canada was pleased to note that Ms. Fraser recognized that Infoway has accomplished much since its creation, a point that she reiterated today. In this context, Ms. Fraser also underscored that provinces and territories are individually responsible for the pace of progress in their respective jurisdictions.

    I believe this speaks to the importance of having an entity such as Infoway, which brings all parties together in a cohesive manner towards a shared goal.

    The auditor general also recommended that Health Canada fully develop and implement its framework for monitoring Infoway's compliance with the funding agreements. I am pleased to tell you that, at the time of the release of the audit report in November 2009, the department had already completed implementation of its monitoring framework. This framework has been shared with the Office of the Auditor General.

    This document is an evergreen tool that will be updated by the department on an ongoing basis to reflect the evolution of this dynamic initiative. I am pleased that the Auditor General highlighted this document, as I believe it supports Health Canada's proactive attention to accountability issues and due diligence in relation to the significant federal investments in Infoway.

    The Auditor General's electronic health records overview report, which was released this spring, provided a unique opportunity to better understand the complexity of e-health activities at both the pan-Canadian and jurisdictional levels. In this context, I was pleased to note that it further underscored the progress that is under way across Canada. For example, implementing EHRs requires the establishment of a number of key foundational components. As noted by Ms. Fraser, every jurisdiction has at least one new component in place.

    Health Canada was also pleased to note that the report highlights the important role that Infoway plays in ensuring that electronic health records are implemented across the country in a cohesive and standardized fashion. Indeed, the ultimate goal is to ensure that when Canadians move across the country, there will be portability of their health information. To this end, Infoway led the creation of a blueprint that lays out the design for a pan-Canadian EHR system. Infoway also leads the identification, development, maintenance, and application of standards, which are required to ensure that EHR systems will ultimately be able to communicate.

    The report tempers these observations of progress by underscoring the variety of challenges which face all parties as we move forward. I would like to emphasize that these challenges are well understood by governments and Infoway, and that plans and activities are already underway to address each one.

    I am also confident that the recent federal investment of an additional $500 million in Canada Health Infoway, will serve to accelerate action on many of these challenges, such as computerizing doctors' offices, insuring that systems will be compatible, and completing the establishment of electronic health records.

     In closing, I would like to reiterate Health Canada's appreciation of these informative audit reports. We look forward to continued progress in the area of e-health, and I am confident that the audit findings will help to support us in this ongoing process.

    I'll be pleased to answer any questions that committee members may have.

    Thank you very much, Dr. Dodds.

    We're now going to start the first round of seven minutes each.

    M. Dion, sept minutes, s'il vous plaît.

    Thank you, Mr. Chairman.

    Good morning, ladies and gentlemen, and welcome to our committee.

    The Auditor General's report on electronic health records is both reassuring and worrisome, I would say. It is reassuring with respect to Infoway's internal management, in fact it may be the most positive report I have read in this regard in the short time I have been on this committee.

    I did however note a point of concern regarding internal management of calls for tender: contracts were being amended on numerous occasions, costs were increasing. Infoway has recognized the problem. It has committed to suggesting the necessary changes to the board for the fourth quarter of 2009-2010.

    Was that done, Mr. Alvarez?

    Thank you, Mr. Dion.

    The short answer to that is yes, it was done. The longer answer to that is we had a board-approved policy that basically allowed us to go to market, which we did as an RFP, and basically get bids. What we didn't say in that RFP, which the Auditor General reported on, is that we could in fact have contract extensions. In the case that was quoted in the document, the scope of the project increased and it took a much longer period of time; therefore, the contract was extended, I believe, six times. We extended it without going back to market, because that was the board policy and it was okay for us to do that.

    We've now made a change to that. When we go to market in an RFP, we make it very clear and transparent that there's the possibility of being extended any number of times. That way, people realize that when they are bidding on it.

    Is Ms. Fraser satisfied with this corrective action?

    We have not seen the changes in detail, but we have seen the action plan that has been proposed, and we were satisfied with the steps Infoway intended to take.

    Thank you very much.

    I would now like to get back to the issue of concern, which is achieving results. The goal was for half of Canadians to have an electronic health record that health care professionals could consult by December 31, 2010, and 100% by 2016.

    It is now June 2010. What percentage of Canadians have an electronic health record their health care professionals can consult today? What percentage have we reached?

    Monsieur Dion, when you look at the goal, it's a two-part goal. The first part basically talks about the fact that by 2010, every single jurisdiction in the population they serve will benefit from the investment in one or more of the information systems. I can assure you, sir, that is happening in absolute spades. Whether it's diagnostic imaging or drug information systems, Canadians are in fact benefiting from the systems that have been put into place.

    The second part of that goal does speak to the fact that by 2010, 50% of Canadians will have their data available to their providers. I should preface that by saying that Infoway is solely dependent on how quickly the jurisdictions move. As you know, sir, we've had some hiccups—certainly in our larger provinces, Ontario and Quebec—which have caused some setbacks in terms of the timelines. As of today, we have about 22% in the database, but we're reasonably confident, given the undertaking by Ontario and Quebec, that we will cross that 50% threshold sometime early next year.

     So you're confident in the 2016 objective to have 100% of Canadians benefiting from it?

    Yes, we're pretty confident that by 2016 we will have that number.

    I need to understand the numbers. You say that you need $10 billion. I guess it's not $10 billion of federal money; it's $10 billion overall. But you say you're funding 75% of the project. Does that mean that between now and 2016, we need to invest $7.5 billion of federal money?

    That number really came out of a couple of studies that were undertaken—one by Booz Allen and the other by McKinsey. The number was premised on the fact that we're talking about the entire scope of the health care system—that is home care, long-term care, all the hospitals, doctors' offices, community doctors' offices, etc.

    Today our scope is rather defined. When we got started, sir, we had $500 million from the government to work with. There was no promise at that point of any additional funds. Over time, we've had additional funds. So we are really cutting our cloth, defined on priorities. If there's no more money, then we would at least have done the community positions; we would at least have done some of the hospitals, the drug information, etc. If the money flows, we start to move it out into community settings.

    But those are the numbers in terms of the 75%. Yes, we do fund 75% of eligible costs, but there is a whole host of costs the provinces have that we don't fund. So when you start to weigh what they're paying for and what we're paying for with federal dollars, it's normally about a 50-50 split.

    The Auditor General notes that there is a difference between an accessible computerized system and a system that is used. In fact, she noted that in some cases funds had been invested in systems which may never be used. You respond that it can take 24 to 36 months before an accessible system is used by professionals.

    Is there a risk that we may be investing in systems which would remain unused? She mentions the drug information system in Alberta and the registry for Quebec clients. Do you have concerns about the fact that there may have been a great deal invested into systems which, for a host of reasons, professionals are not using or will not use?

    Thank you for that insightful question. When I think about the job at hand, what information technology is going to be doing, it's really going to be transforming the health care system. It's going to be getting clinicians to work in completely different ways.

    The challenge for us here is not a technological challenge, by the way; it's a people challenge. It's a chain management challenge of getting, in many cases, these clinicians who are not salaried, who are not employees of any facilities, but entrepreneurs and small business people, to adopt these new technologies. We've known from the start that the chain management and getting used to these systems is going to be the biggest challenge.

    That is why we put in place a protection of the federal funds. We're a strategic investor, and the way we fund is once we get a signed agreement of what needs to take place, we provide 20% to get on with the job; we provide another 30% when the hardware and software are in, but we hold back 50% of the funds until we get take-up, until we get usage from the clinicians. From where I sit, we can put into place peer-to-peer groups, tools, and best practices of how clinicians should adopt this, but I can't make them adopt it. It has to be up to the territories and provinces to do that. That's why we hold back the money.

    Will this happen? There's absolutely no doubt in my mind that this will happen, that clinicians will change the way they are working. Is it slow? Yes, it is slow because there's a lot of learning to do, especially with clinicians who have been out of the system, have been out of school for the last 20 or 30 years. They are now finding new tools and how to use them. Clinicians who are in the system today will not come out and practise in Canada without these state-of-the-art systems.

    Thank you, Mr. Dion.

    Ms. Faille, you have seven minutes.

    I will continue in the same vein.

    What measures have you implemented to follow other performance indicators? Aside from indicators on buy-in among professionals, what measures have you implemented to ensure the system is compatible from one province to the next?

    Are you monitoring progress on this point?

    Actually, that's a twofold question. The first answer is that in the new reporting, we are going to be reporting not only aspects of availability, but also aspects of adoption. In the report that's coming out, I don't believe we will be reporting on use, mainly because I'm not competent in those numbers and won't publish any data until I get some confidence in the numbers that have been given to me by—

    In fact, I would like to know whether the systems that have been developed by the provinces and territories, the 14 jurisdictions, will be compatible?

    Have they used the same development standards? Who determines these standards?

    That's actually the second part of the question I was getting to. A core business of Infoway is standards development around an architecture and a blueprint. It's very simple in our world. If we're going to fund a project, you have to use the standards. If you don't use the standards, we won't fund the project. Even so, there are going to be some variances, because the business requirements change from jurisdiction to jurisdiction. That's number one.

    Number two, there are some IT legacy systems that we haven't funded and that have old standards. As these come up for redevelopment, we will ensure that the new standards are adopted. Think about your experience as a patient. You go to your GP, to your emergency room, to clinics, or to labs. Typically, we don't do that from Toronto to Whistler; we do that in the area we live in. It's important to get those data operating around the traffic patterns of the individual. When I talk about adoption, if there's not interoperability between these systems, we wouldn't pay and they wouldn't get a take-up rate. Certainly, the aim of this is that when you travel from Toronto to Whistler or wherever, you should be able to access your record in a compatible way. Over time, I believe this will happen.

    I have a question on the various contracts. Enormous amounts have been granted. Various departments are now turning to fairness monitors for the awarding of contracts and the purchase of technology.

    Do you have an individual who is designated to ensure fairness during the procurement process? Has the report been drawn up? Have opposing views been expressed regarding your extending contracts as you have done?

    I'll answer the second part of the question first. The answer is no, there have been no objections. We've never had any contract disputes.

    As to the first part of your question, no, we do not have a fairness commissioner for contracts. We do have a board. We have board procedures. If I'm out of bounds on board procedures, I have to go to the board and express that to them. We have a rigid procurement regime based on board policies, which we are bound to follow. We have a variety of audits every year, from compliance audits based on the funding agreement to financial audits that look at a variety of these things.

    That said, you have received nothing. You have not heard any opposite views, from consultants or in studies which you may have conducted internally, suggesting that you should not proceed in the way in that you did. Did Treasury Board Secretariat support your way of doing things?

    To my knowledge, we haven't received any....

    I will give you some time to check, and you can send us some information in writing if you want.

    I have definite information that when vendors don't win contracts, they're somewhat disappointed.

    This has nothing to do with suppliers. I want to know whether, internally, when you made the decision to proceed in this way for procurement, you received contrary advice. Did you seek advice to find out whether proceeding in this way held any risks?

     The answer to both of those questions is no, we didn't receive any contrary or contentious arguments. This was brought to our attention, and we have amended those procedures now to make sure, right up front, we're transparent in saying that these contracts could get renewed.

    On page 5 of the Auditor General's report, the eligibility criteria for projects are discussed, as well as the established architecture, the total funding granted for the Infoway, which is definitively determined when projects are approved. We also hear that the provinces and the territories must assume all risks of cost overruns.

    Ms. Fraser, as far as I understand, the provinces are dependent on the federal government. For some time now, the Auditor General of Quebec has been pursuing a development project that is called the Dossier de santé du Québec. Have you had an opportunity to get acquainted with the report of the Auditor General?

    Curiously enough, he is interested in the same matters as you are, at this time. He's criticizing the fact that the system is far from yielding the expected results. Have you any suggestions or expectations regarding the Infoway, so as to ensure a certain degree of leadership or so as to review, together with the provinces, the monitoring of various projects? We can see that the projects have been approved, but for some reason or other, the risks have not been correctly assessed.

    Mr. Chair, I think it is important to clarify the fact that the responsibility belongs to the provinces. The provinces submit certain projects to the Infoway, but these are not entire projects. The Infoway participates in funding certain projects, based on certain admissible costs. On the other hand, the planning, the follow-up and the rest are really the responsibility of the provinces.

    In the report that we prepared with some of our provincial colleagues, we noted in several cases that strategic planning was not done properly and that planning as a whole was defective. Telling the provinces what to do is not really the Infoway's responsibility. Of course, the Infoway can help us to establish certain strategies, such as the program's architecture. Nevertheless, the responsibility belongs to the provinces.

    I wanted to clarify the role of the provinces. Thank you.

    Mr. Christopherson has seven minutes.

    Thank you very much, Mr. Chair.

    Thank you all for your attendance today.

    I have to say, Mr. Alvarez, I agree with Mr. Dion that this is a pretty good audit, as they go. You made a big statement in your closing remarks, so I just want to put that to the test. I do think it's a pretty good audit, but you went on to say:

    Would you stand by that statement, Auditor General?

    We looked at the action plan that Infoway had prepared to address the recommendations, and we were satisfied that, if implemented, it would address our recommendations. We have not gone back to do a follow-up audit to see how it was implemented, but we were satisfied with the action plan.

    There you go. You passed the test.

    Well, the second audit will be the test.

    Voices: Oh, oh!

    You have to watch for the pauses in between. But that's okay. Around here, living for one day at a time is a win.

    I was curious that you have what you call a “gated funding model”, which means that as certain compliance standards or objectives are met, that triggers the money to be released.

    I'm taking note of what the Auditor General just said about it not being the job of Infoway to tell provinces what to do. But I'm trying to understand the difference between the provinces being allowed to do what they think is appropriate, versus your monitoring what they're doing and only funding when they hit certain trigger points. I'm curious as to how a strategic plan wouldn't be a major point that had to be reached before you would free up any money.

    Can you help me understand that a bit, please?

     Sure, and thank you for that question.

    Basically, we put in place a safeguard mechanism: if there is no take-up or the take-up from clinicians is taking a while, then we hold back that money until they meet that goal. So we have a gated funding approach.

    If provinces delay their project, it's going to cost more. But guess what? With our agreement with them, with federal funds, we limit what we're going to pay. Once we sign that deal and they want to take as long as they can, it's on their coin, not on ours.

    With all of that said, if they fail, we fail. So we go over and beyond that by trying to put to them from time to time other options and other plans. In fact, if you see the auditor's report in Quebec that came out the other day, it basically said that Infoway put plans to the government in terms of how it can move forward; the government at this stage hasn't moved on those plans. But clearly it's a failure for us to sit here with federal funds and not be able to execute on them, because those projects are taking so long. At the same time, we don't want to waste those moneys if in fact we're not getting results.

    No, I understand, but I'm sorry, I still didn't hear a clear answer to my question. And I accept it could be just me, that maybe I didn't get it.

    Again, you only give money once they've achieved certain things. I'm just curious as to how they could continue to get funding when they haven't done something like a strategic plan, which is so important and needs to be up front in the process. There are some jurisdictions that haven't.

    I'm probably not using the right terminology, but there's a checklist of things they have to do. Is a strategic plan not one of them?

    I wouldn't go as far as saying a strategic plan.... We basically fund project by project. Each of the projects is subject to a contractual arrangement, and the contractual arrangement is worked on a statement of work. A statement of work basically has the milestones and the checkpoints as to what the deliverables are supposed to be.

    Now, is it a strategic plan for the entire province? No, it isn't. It's a strategic plan for that set of priorities and that particular contract, and that's what we basically monitor to.

    AG, can you help me? If I'm getting the answer, I'm not understanding it.

    Well, I think the answer is no, Infoway does not require a complete strategic plan for the whole EHR project in each province before funding individual projects.

    So who would be responsible for that, ultimately? I know Health Canada now has set up monitoring, but was there not something in the planning of this that would catch this somewhere if it's not Infoway?

    I think what Infoway does is make sure the projects that are being proposed are in accordance with the blueprint, and it would be an element of that blueprint, say diagnostic systems. But to say how this is going to be implemented across a province in particular, they have not put in that requirement, though you would certainly expect each province to have that.

    That was the issue raised by my provincial colleagues. Some provinces had these strategic plans, but I think the majority of the ones we looked at actually did not. Or they had one, but it was never brought up to date or completed through. So there was a weakness at the provincial level.

    Have the provinces committed now to correct that?

    I believe that, yes, they have, and I believe they have even indicated they will do that in the response by the governments into the report.

    Mr. David Christopherson: Still good?

     One minute.

     What am I going to do with one minute? It takes me that long to clear my throat.

    Until the time runs out, Mr. Alvarez, would you speak to the doctors' office computerization? I understood what you said, that it was sort of a generational thing, ad it'll catch up eventually when the new one's ready. But that's a long term. We could go through quite a while. Is that what we're heading into, a period of hit and miss, in terms of the infrastructure within the doctors' offices?

    Sir, I don't think it's a period of hit and miss. I think it's a transformable period of basically change management. When you look at western countries across the world, Canada is somewhere dead last in terms of community physicians and automation, because there hasn't been this requirement to get them moving. That said, you've got 50% of the physicians in Alberta in the community using computers, you've got about 40% in Ontario who have moved, and in some cases the provinces have moved without any federal funds.

    What we're going to see is an acceleration over the next little while, and a vast proportion of those new moneys from the government are going to be made available to move clinicians into the community settings. So I'm very hopeful that we're going to play catch-up with the western world. We certainly plan to have about 12,000 doctors, certainly in the first movement of the $500 million, moving with computerized systems in their offices.

    Very good. Thank you.

    Thank you, Chair.

     Thank you, Mr. Christopherson.

    We'll now go to Mr. Saxton for seven minutes.

    Thank you, Mr. Chair.

    I just want to note that I think this is the first time that my colleague, Mr. Christopherson, has run out of questions before his time was up. That's a good sign, I think.

    My first question is for the Auditor General.

    The report mentions that Infoway has taken solid steps towards maximizing the use of the funds for the projects. Can you explain what some of those steps are and how they're important?

    We do actually indicate that Infoway has accomplished a lot since its inception, such as the creation of the blueprint and working together with their partners and stakeholders. I would say one of the major elements to ensuring good use of funds is the gated funding approach, which was mentioned earlier. There has to be some indication of results or take-up of these systems before all of the funds are given. We saw that there was good analysis of the projects monitoring afterwards. So we really had no recommendations actually around the funding of specific projects by Infoway.

    Thank you.

    Your report also mentions the fact that Infoway has appropriate governance mechanisms in place. Can you share with us some of the board's activities that you reviewed as well as these governance mechanisms?

    We looked at the governance. This is something we would look at in most of our audits. We found that the board was very effective, very engaged, and that the information going to the board was appropriate, that they were getting comprehensive information. They had the appropriate codes in place: the code of business conduct, conflict of interest, and independence as regards Infoway. We looked as well at the activities they were carrying out. We saw that they were, for example, reviewing approving strategic plans; monitoring Infoway's performance; that they were reviewing a succession plan for senior management, ensuring that appointments to the board were staggered, which is an issue that we've come across in other organizations; and reviewing their own performance. These are all actually indications of best practices that we would expect to see.

    Thank you very much.

    My next question is for Infoway. This is a follow-up to Mr. Christopherson's question.

    The Auditor General in her opening remarks stated:

    What actions can you take to encourage more widespread use amongst doctors?

    The actions that we are taking, again, thanks to the new money from the federal government, will be actions to accelerate the adoption of automation at community settings in primary care, so both with physicians and with nurse practitioners.

    Right now about six provinces have already moved ahead with this agenda, but the rest haven't. The provinces that have been particularly successful have set up offices between the ministry and physician associations to help doctors get computerized. We will be helping those provinces that haven't got those offices set up to do so by looking at best practices and making the best practices available. Provinces like Quebec and Newfoundland would be good examples. We will be encouraging them to sign up their doctors and nurse practitioners as soon as possible. We will be carrying half of those costs for the first two years. Again, we will be getting our funding.

    We want to make sure that these systems, as they go in, are not used as doorstoppers or desk ornaments but that they are used in a meaningful way. So we will be putting in requirements that they have, for example, alerts and reminders in their system about contraindications around medication; adverse or negative lab results; the ability to provide reminders for chronic disease patients; the ability to receive the lab tests into their systems; and then the ability to move on to things such as e-prescribing. That's all very much part and parcel of our program.

    We're also very keen about our blueprint, which Ms. Fraser mentioned several times. The blueprint is very simple. As we're building the system, we're building it around the individual, around the Canadian. We're not building it around the doctor or around the hospital. Those systems are of the past, and those have been closed systems. As patients moved around from one place to another they could never get hold of their tests, and therefore they had to repeat their medical histories. So it's very important for us now to build on all the investments we've made in the past and to make sure that these electronic medical systems in community settings are interoperable with drug databases, lab databases, and diagnostic databases so they can refresh the patient's history and get a full history of the patient.

    I have just completed a tour across the country, meeting with the provinces and the territories, and the strategies and processes are being extraordinarily well received.

     Thank you.

    It also says in the report that not all completed EHR projects have implemented the standards required for national compatibility. How does Infoway intend to ensure that these completed EHR systems are compatible across the country?

    As I said, one of our core businesses is standards development, standards implementation. If you're putting in a new system and you're getting any of our money, you have to put in the standards. It's as simple as that.

    For the standards, there are slight variations from province to province at times because of the business requirements. That said, they have to interoperate at a jurisdictional level. Those systems have to be built up, and then as we do the joins across the country, in some cases there will have to be translation engines that do those joins.

    I'll also say that we're now in an era of consumer space and consumer products and consumer health records. Earlier this week, there was a major announcement by one of our Canadian vendors allowing this to happen. There is a product that we will certify for privacy and security considerations by Infoway. Consumers will have access to those records. Those records will be portable wherever they go.

    Thank you, Mr. Saxton.

    We'll now start the second round, for five minutes each.

    Mr. Lee, five minutes.

    Thank you.

    One of the Auditor General's focuses here is to ensure that there are some kinds of benchmarking standards, measurements, to see how we're doing as we move along. This is a multi-year project; it could be multi-generational.

    I'm wondering about the business of incenting the various components of the health care sector to be involved in, to comply with, to engage in--the whole engagement on electronic health records. You've talked about incenting practitioners. Does the system incent components of the health care field, such as medical laboratories, pharmacists and pharmaceutical companies? Are they in any way incented to be partners in the engagement of local practitioners, of clinics, in this whole system?

    Thank you for your question.

    One of the major challenges of this job, by the way, is the number of stakeholders that we have to interact with, that we have to, if you like, jolly along and incent. Clearly, we're not only talking about clinicians here. We're talking about ministries, administrators in RHAs and regional health centres, clinicians, and the private sector as well, whether they be labs, whether they be—

    I know there are a lot of sectors and components.

    We have the world's only standards collaborative. When we talk about the building of standards, into that group we bring in the private sector, we bring in clinicians, nurses, pharmacists, and we bring in governments, and they basically work on what the standard should be.

    Again, with the new moneys, when I talked about interoperability, I basically want these systems to interoperate with the lab systems, with pharmacy systems, so we're going to be working with the vendors of these systems that sell to Canada to incent them to change their products. In a lot of cases, they're pretty small vendors. In a lot of cases, if they don't get this sort of incentive—and remember, a lot of this money came as part of the stimulus—

    Okay. I know how complex it is. You're saying yes, you have incentives.

    Mr. Richard Alvarez: Yes.

    Mr. Derek Lee: Has the strategic plan benchmarked engagement of the sectors? Is that part of the plan?

    Can I look at your plan, if it's there, and while I've got the microphone, can you tell me about the process of engagement of local health care components? For example, a doctor's office gets 5,000 client files. Would the doctor start on day one to begin inputting the new data on electronic health records, or would you expect a doctor or clinic to go back and convert all the existing records into electronic health care records? What have you built into your plan, your benchmarking, your measurement mechanism, in relation to that? What expectation does your plan have for those medical practitioners, whether it's a new person or a 78-year-old practitioner somewhere who's working part time?

     Your earlier question was whether I could look at the strategic plan and whether it is there. If you look at my strategies, absolutely, it is there, and those strategies were just approved last week by my board.

    In terms of how doctors go about the conversion, I talked earlier about the fact that we almost insist that governments and physician groups and nursing groups come together and form an office that will help work with the doctors to do a few things. First, they would select and qualify the vendors who provide these products, and then they would work with them in a change management perspective of how much data they need to convert, and, no, they're not converting all of their files.

    This has been done before. It has been done very successfully in Alberta, it's been done in B.C., and it's been done in Ontario--to take from there those learnings of what they need to convert and how they need to convert it and make that available. By the way, it's not an organized process, so they don't just throw their papers away and start with the computer tomorrow. It does take a while.

    Now we go to Mr. Young for five minutes.

    I just want to congratulate you on the system and your management, which have obviously been truly first rate. I think you've underestimated the tremendous potential to improve health care for Canadians with electronic health records and underestimated savings. For example, the Canadian Pharmacists Association told the Commission on the Future of Health Care in Canada that Canadians waste $2.9 billion a year related to prescription drugs. As well, the Romanow commission reported that as much as $10 billion a year of our health care dollars is taken up with hospitalizations due to adverse drug reactions. One out of nine Canadians who enter a hospital suffer an adverse drug reaction. So if the e-health records can track adverse drug reactions and we act to address risky drugs, the reduction of human misery and the cost savings are massive.

    My first question is, how much has been saved related to remote diagnostic imaging? The report mentions up to 17,000 patient transfers a year. What financial figure would that represent, roughly? If you don't have a figure but you can guesstimate, that would be helpful.

    I'll give you the figures, but if you don't mind I'll just do a little preamble to that first.

    We are, as far as I know, the only country that systematically looked at what the benefits could be as we got into this. We talk today about the cost of $10 billion; the same studies pointed repeatedly to $6 billion to $7 billion being saved each and every year. Those savings actually come in two tranches. The major savings come through cost avoidance, through preventing adverse drug reactions and keeping people out of expensive acute care beds.

    I understand. I think you're actually a little bit low on that figure, but I do have a second question as well.

    I can give you the number. The number in the study that we did on diagnostic imaging is $1 billion annually, and we're just about to publish a number on drug information systems in the four provinces I mentioned, and that is in that region as well.

    I wanted to ask you about that as well. I wanted to ask you how much control you have over the blueprint of the records and how much the provinces have, because in just four provinces you identified 2.5 million dangerous drug reactions. They call it significant; I know it's dangerous. We know that doctors only report 1% of adverse drug reactions to Health Canada, so they're basically flying in the dark. Prescription drugs taken the right way, without error, are the fourth leading cause of death in Canada.

    I wanted to ask you about a drug that's on the market right now that increases the risk of suicide for young people by eight times over placebo, which is Paxil. One out of fifty young people who take Paxil will think about killing themselves, and some of them will carry it out. On June 7, in Toronto, there will be an inquest into the death of Sara Carlin, who did exactly that. We know that GlaxoSmithKline paid a $2.4 million fine in New York state related to the cover-up of the risk of suicide with Paxil and underwent a four-year criminal investigation in the U.K. for the same reason.

    So here's my question. Could you search the e-records and discover how many people who committed suicide in Canada were either on Paxil or withdrawing from Paxil at the time of their death?

    Certainly the jurisdictions that have the comprehensive drug information systems—that is all drugs for all people—can in fact do that.

    That is the four provinces that are doing it now.

    Yes, but there are other provinces—Ontario being one, for example, as well as British Columbia and Quebec—that have databases for the senior population because that's what the government basically funds. They can search those databases and give you that same sort of answer.

    But that's just seniors. Will they be able to do it for all the population?

    The four we talked about could, and there are about six provinces that track all drugs for all people. They could do that, but the challenge here.... The question you asked is a good one. It could be done on a retrospective basis. The kinds of systems that we have specified and got in place will have medication management at the time of prescribing and at the time of dispensing it. At this point, they mainly have the time of dispensing. They will have alert management systems, so they can look at a patient's medication history and, as the clinician prescribes another drug, they can tell at that time whether its a safe drug or not a safe drug and what the alternative should be.

     That's very helpful. Thank you.

    I mentioned earlier that the fourth leading cause of death is drugs taken as prescribed. We know that of all the prescription drugs approved by Health Canada, and the FDA in the United States, one out of five will turn out to be far riskier than ever thought. In fact, they weren't safe and effective and either have to be taken off the market or, in the U.S., be given the highest level of warning, called a “black box warning”. So you really need that retrospective look. You need to be able to look back and go back, because the contraindications are not always on the record. In fact, they build up the list of contraindications over time.

    Will you at some point be able to access, for the purposes of such research, all the provincial records to determine drug safety risks?

    The answer to your question is one that we're basically working on right now, and we're working on it together with the Canadian Institute for Health Information, which does this type of work.

    The issue for us is privacy and the security of the records. Clearly, if we have these data in these databases, it would be absolutely asinine for us not to be able to do it from a research perspective and a safety perspective. That said, one has to be very careful about Canadians' privacy.

    Can't you just search a record without the patient's name and address?

    Yes, that's exactly the kind of system that's being looked at currently. At the same time, we have also done focus groups and talked to Canadians about whether we can look at their records in an unidentified way, where the numbers are scrambled, etc. Basically, there was a high response rate to that question that was very positive.

    Thank you.

    Thank you, Chair.

    I just have an issue following up on that, and I think Mr. Young is quite right here, that the benefits here are tremendous for Canadian society. I believe Infoway, according to the audit, is doing a very good job. You are well managed and well governed, and you administer your contracts effectively and efficiently.

    But when you look at it on a Canada-wide basis, it appears that we aren't really doing that well. We're slow off the mark when you compare us internationally with other western countries, where, as you said, we are dead last. I believe some of the records indicate that 9% of clinicians are using this, according to the 2007 numbers.

    So my question is—and perhaps we'll get Dr. Dodds involved in this question—who is responsible for taking this right to the next level? Infoway is not a heavily funded organization. I think you are spending your money wisely. But we are in a country with 14 different jurisdictions, and it is complicated. It's not an easy process, and I don't think we're making the progress that other countries are making.

    We're using federal money to drive change, but when you look back at the 2004 agreement signed between the provinces and the federal government, our federal government hasn't done a good job of monitoring these agreements. While this doesn't have to do with the electronic health records, but with other issues, they basically let the provinces take the money, who stated they would not comply with the agreements or give the federal government the information and they got the money anyway.

    So I guess my question is a general one. Who is responsible for taking this to the next level, which is so important for Canadians? Is it the Department of Health or Infoway? Can you give us some direction?

    Perhaps, Dr. Dodds, we'll hear from you first.

     Thank you very much for the question.

    As both the Auditor General and Mr. Alvarez have noted earlier today, the federal government has given significant sums of money to Infoway over a period of time. I think that does show the understanding of the federal government that this does have benefits. It has been both Liberal and Conservative governments that have given funds. The benefits that can accrue to the system are apparent to different people.

    I did ask my colleagues at Infoway just the other week. Mr. Alvarez said if you look at what we call EMRs, electronic medical records—that's what the community doctor, the family doctor, has in her or his office—Canada is dead last. I asked him if you looked at the EHR, the components drug information system, diagnostic imaging lab results, where would Canada stand? And the answer was that you would turn that around and Canada would be at the top.

    Other countries have focused first on EMRs and they haven't necessarily taken a national approach. It's been a local doctor, and it's been that doctor and that doctor's patients who have had the benefit. What Canada has done, largely through Infoway's blueprint, has been to develop what I'll call the unsexy components of electronic health records.

    And I'm very pleased with the latest $500 million investment. There is a big focus on the electronic medical records, because that is when physicians and Canadians will really see the benefits of all the foundational work that Infoway has done with the partners in the provinces and jurisdictions.

    As Mr. Young said, that drug information database is not really useful until a doctor is using it when he or she is prescribing to a patient. Right now it's good at the pharmacy, but you also would like the physician to have that information when the physician is prescribing. You would also like to have the patient, himself or herself, be able to access that information.

    So as we're now really accelerating that implementation of EMRs, I think you'll see the benefits accruing and you'll see more physicians moving to EMRs.

    Have you anything to add, Mr. Alvarez?

    Mr. Chairman, I apologize if I've left this committee with any sense that we're not making progress.

    I didn't suggest that. I—

    We absolutely are as a country. I've talked about the diagnostic imaging systems. In the diagnostic imaging systems we've now basically thrown away all those X-ray forms. About 70% to 80% are now digitized, which means, in fact, that those X-rays can be looked at from anywhere.

    Let me give you a quick example of this. Several of our provinces now are completely digitized. We're just moving in that direction with Manitoba. Just a few weeks ago they finally got Churchill done. The day they had Churchill digitized, a child presented with injuries. Typically, they would have flown a jet out of Winnipeg to bring the child down, but they did the image and sent it down to Winnipeg Health Sciences Centre. They looked at it and said there was no need to move the child and this is what they need to do. The very next day another child presented, and this time Churchill thought they could actually work with the child up there, but they sent the image down. They looked at the image at the health Sciences Centre and said, we're sending the jet, bring the child down right away.

    So there have been huge changes. We have 25% to 30% productivity gains with our radiologists. That's basically adding another 500 radiologists.

    I talked about the drug information systems. Let's take Alberta. They're clearly at the leading edge. Alberta today has an electronic health record, and they have 20,000 users of that record on a daily basis. They've been able to build chronic disease management systems and registries very quickly on top of the electronic health record.

    Take cancer surgery. We now have a system of cancer surgery where the clinicians are starting to record just the minimum data sets as soon as they do the surgery, as opposed to transcribing their reports. The change in that is the transcription reports used to basically take over a month to get them in hand. They can now get their reports after one hour of the surgery. They're reporting 100% of those items, and they're training our new doctors on best practice.

    Thank you very much.

    Madame Beaudoin, pour cinq minutes.

    Thank you very much, Mr. Chair.

    Ladies and gentlemen, good morning.

    Mr. Alvarez, I want to come back briefly to the problem of compatibility. In fact, I would have liked you to tell us how serious problems can get when dealing with this matter. More specifically, on page 26 of the Auditor General's report, it states that regarding interoperability between provinces that “and Canadian interoperability can be achieved”. I imagine that this is one of your priorities. You also say that “differences in standards can be mitigated”.

    Is this interprovincial compatibility and this interoperability a priority?

     Thank you for the question, Madame.

    I believe those are problems that will be overcome. I have to say that our priority is to get those standards working at local and regional and jurisdictional levels. It's really important, as the people move around from their GP to hospitals to clinics to pharmacies, that we can get that interoperability. Our priority is to make sure the vendors who sell their products across Canada implement those standards in a very consistent way and to incent them to do so.

    Clearly, when we come to pan-Canadian compatibility, there will have to be translation between some of the standards. There are systems that have been there for quite a while that don't have some of the new standards, and we don't have enough money to throw those systems out and start again. But at the stage when those systems come up for a life cycle change, we will get the new standard in. Until then, we will have a translation engine that translates between the old standard and the new standard.

    Thank you very much.

    I would like to have some information regarding a point on page 26, in the French version of the document. There it says that you are going to do “mapping to accommodate differences in the implementation of the standards”. What do you mean by that?

    Basically, we publish through this collaborative mechanism—which is basically, as I said, the clinicians, the private sector, and governments—what standards need to be worked on and when they need to be worked out. It's a very expensive process to get these standards.

    What are these standards? They are messaging standards, data standards, so that two heterogeneous computer systems from different vendors can talk to each other. What we try to do first is if we can borrow the standards and adopt them from international standards, we do that. If we basically can adopt them but have to Canadianize them for such things as our postal code, we'll do that. If, on the other hand, we're ahead of the curve and nobody else has the standard, as they didn't in terms of the clinical drug information systems, we basically build them from scratch. But when we build them, we build them as international standards and encourage basically as many people as we can in the rest of the world to adopt those standards as well.

    Thank you very much.

    This audit also took the protection of privacy into account. Could you share with us the risks that you have identified up to now?

    Privacy is a very big issue for us, and mercifully, as of today, we haven't had any major failures around it. There have been some incidents.

    This is what Infoway does. In terms of our blueprint, our architecture, we're very clear on what the privacy and the security arrangements in that architecture should be, and we encourage the provinces to follow them. We ask right up front for a privacy assessment audit, which they have to give us for each single project before the money starts to flow. Certainly, based on Madam Fraser's recommendation on aspects of conformity, we'll be moving in that direction as well. With the new moneys, as we did with the consumer health space, we have also put in place a certification service to make sure that certification occurs for the vendor products from a privacy, security, and interoperability point of view.

    Mr. Shipley.

     Thank you, Mr. Chair, and thank you to the witnesses.

    It's a generous report. I'm not sure I agree with it; maybe I've been tainted a bit in Ontario.

    Let me go to the report. I understand that a comment came out at the end of June or early July 2009. According to Health Canada Infoway, of about 322 million doctor visits that we have per year, around 94% result in hand-written paper records. When we compare Canada's position in terms of our electronic health records, we find that in the Netherlands, 98% of health records are electronic; in New Zealand, 92%; in the U.K., almost 90%; in Australia, 80%. Only the United States fares worse than Canada. I'm confused.

     We have an October 2009 report from the auditor in Ontario showing that instead of being near the head of the list, Ontario is near the back of the pack when it comes to electronic health records. Where is the Department of Health, or Infoway? It seems that we hand money over. There was a billion dollars in corruption that happened in Ontario. That is partly, I'm assuming, federal dollars; maybe partly it is provincial dollars.

    My point is, quite honestly, that this started in 2001; we are now in 2010. We are behind the pack in just about everything that you talk about, although I know Ms. Dodds talked about the doctors and patients receiving a benefit in comparison with some of the other countries. I think in Ontario and Canada that's what needs to be a priority. In health care, patients should be about priority, and not systems, and not computers. They need to be a part of that; the patients come first.

    I understand the significance of the electronic and the digital records. We understand the need for them. But quite honestly, I believe we have not been accountable for the dollars that have gone to the system. I just don't understand why now we're developing strategic plans, in 2010. I read somewhere here that in 2006 we revised the blueprint, five years after 2001. Please encourage me. It would seem that in 2001 we had an Infoway set up by the government that threw money out without direction, and it took until about 2006 to start to get some organizational part of it in place. There is no strategic planning; there doesn't seem to be much accountability. Provinces have been all over the map in terms of continuity.

    So I ask you, Mr. Alvarez, and I would ask Ms. Dodds, and I would ask Sheila Fraser, the AG, to help me understand that actually this is a continuity, that there is compatibility, because I don't see compatibility mentioned in terms of the systems that are going in. We have provinces doing different things, and there are priorities.

    That is a lot of questions, but I'm going to run out of time. That's why I put them forward. Don't be discouraged; I just need to understand it, because it has not gone well, from our perspective in Ontario.

     Thank you.

    There are a lot of questions there, and with all due respect, sir, I think there is a bit of tainting there of the province that you live in—and that I live in, as it happens.

    For the record, none of that $1 billion that was spent in Ontario was federal funds that were wasted. For all the federal funds that went into Ontario we got absolute results. They have a world-class telehealth system, by the way, and we helped fund that telehealth system. A few years ago in Ontario, a senior would show up at a hospital and they would have absolutely no idea what medication that senior was on. We changed that and encouraged them to put the Ontario drug database, the ODB system, into the hospitals. As of last year, they had a million hits on that file; now they are actually looking at what individual medications they were on.

    So we've had, with our federal funds, a lot of successes in Ontario. The moneys that were reported on were clearly moneys that we had no dealings with and didn't spend.

    In terms of strategic plans, absolutely Infoway has from the get-go had a strategic plan in place. It manifests itself in terms of the priority areas and the programs that we would invest in. We had over 600 people involved in consensus building around the blueprint and the architecture as provinces began their work. Clearly, over time, as new technologies come along and as new learning comes along, you have to go back to revisit and refresh your plans or take them to a deeper level. That is exactly what we did six years on.

    If you sat in Alberta and had an electronic health record with 20,000 users; if you sat in British Columbia and had a fully functioning pharmacy system; if you sat in Nova Scotia or Newfoundland and had all your community pharmacists on the system; or if you had an entire province digitized, I believe, sir, you would have a different opinion. A lot of progress has been achieved. I will say this: clearly, the larger the province and jurisdiction you are, the tougher the job is. It is tough for Quebec and it is tough for Ontario. Then, if you get hiccups in terms of management, hiccups in terms of governance, those plans take that much longer.

    From where we sit, we can encourage them, we can incent them, but we can't do the job for them.

    Why don't you have a strategic plan as part of the funding?

    We absolutely do. For the programs we invest in, if they are drug information systems, lab information system, diagnostics client registries, we will have their plans; there's no question. But if I'm not investing in a home care service, or if I'm not investing in a long-term care service, then I don't have a right to ask for those plans, and they may or may not have them.

    Thank you, Mr. Shipley. We have to move on.

    Mr. Christopherson, you have five minutes.

    Thank you very much, Chair.

    The proof is going to be in the pudding, as the Auditor General has said, concerning the follow-up, as to whether everything that makes for a fairly good picture today holds.

    I have to tell you, Mr. Alvarez, you certainly give the impression of being someone who is very forthright and who knows his file. Notwithstanding that this isn't perfect, you seem to have a good handle on your organization. I have been impressed. The challenges here are serious.

    I'm going to give Bev a quick heads-up.

    Bev, if you want to do a follow-up question, I'm prepared to give you a minute or two of my time. You seem to have some good questions, and I will offer that time to you, as I'm just wrapping up here.

    Again, I would just wish you the best, and we'll see when we do the follow-up how things are. But if it's anything like the impression you've given today, I'm feeling more confident than I might have before this meeting was held. Thank you for that.

    I offer to my colleague, Mr. Shipley, the balance of my time, if he would like it.

    Thank you, Mr. Christopherson.

    I have just one question.

    Auditor General, in paragraph 12 of your speaking notes you say “it is too soon to determine whether the systems in each jurisdiction will be compatible nationally”. I would have thought that at the start of this thing in 2001 there would have been some sort of plan that would say that systems had to be compatible. Here we are now, in 2010, and we're asking the question.

    Is it not something that should have been there? It was just a sort of guiding comment, I guess, but it goes back to my concern about the lack of direction, the lack of accountability to move ahead. Nine years later, now, we're sitting at 50% of where we should be.

     I think on the question of compatibility, the committee has to realize that many of these systems had begun or were in place in certain jurisdictions even before Infoway came into being. I think the province of P.E.I. has one that's fairly complete, so those systems would have been introduced before the blueprint was established. So there are questions around how they will take existing systems and modify them or make a link or do this translation that Mr. Alvarez has talked about to ensure compatibility with the rest of the country.

    So those are some of the challenges. I think the newer systems that have come in and the projects that have been introduced or have been co-financed by Infoway clearly meet the standards that have been established. But there could have been systems previous to that. As well, I guess this is one of the joys of living in Canada, but provinces do what provinces want to do, and the federal government is not going to dictate to them what to do. There has to be respect for their jurisdictions, but I think this is an issue that as auditors general we would certainly encourage the committee to continue to follow up on, to see how these challenges are being met and if the provinces are responding. This could be a discussion perhaps for a meeting of CPAC or something, where you have all the public accounts committees present. What are the other provincial public accounts committees doing as well on this issue?

    If there is any extra time, my colleague may have some extra questions.

    I'm going to go to Mr. Kramp now anyway.

    Thank you, Chair.

    Similar to Mr. Shipley's comments, my concern is, where did we start with this? If we started back in 2001, did we say we had a goal, so let's work toward it, or did we have a signed agreement with a strategic plan that said, let's do this: your obligations are this, my obligations are that.

    In other words, did we have a formal agreement between the feds and the provinces before we commenced this project?

    Infoway was set up by the first ministers as a national organization to work with the federal government and to work with the provinces and territories to move this agenda along. The basic mandate was to accelerate the adoption of these systems. One of the first things Infoway did was to sit down with the provinces and territories to understand and define what the priorities should be. From there, we have six core programs and 12 programs in total, and then we worked with the provinces. Once they decided on priorities, we then asked them to give us their three-year plans of how these priorities were going to be rolled out, which they did.

    Based on those three-year plans, I went back to the board and said the goal should be that by 2010 we should hit 50% of availability. As I've said before, as these systems roll out they will, by 2010, start to impact and provide benefits to every citizen in the provinces and territories. The first part of that goal has happened. The second part is slower in coming. At the end of the day, as Madam Fraser said, we are very much dependent upon the pace of the provinces, but they've agreed to what the priorities are. In those priority areas, we certainly have strategic plans, and we have their plans, which we build on.

    The fact that we obviously have different levels of success in the provinces concerns me. Is it because we're not all singing from the same song sheet, or are we just ineffective? As an example, we all heard the horror story in Ontario about the millions of dollars, with consultants who hired consultants to hire consultants.

    Did Infoway funding go to any portion of that?

    No. I've answered that question before. Infoway's funding absolutely did not go to any funding of that. We didn't even have a contract with e-health or with the Smart Systems for Health Agency.

    I just wanted that crystal clear.

    Do you want in on that issue, Dr. Dodds?

     Yes, thank you.

    Your question came back as a basis to where did we start. I want to come back to one of the points that my colleagues made. Within Canada we started across the country in very different positions. Even within provinces, you start from different positions, with some hospitals having their own well-developed systems, maybe two decades old, and some provinces having none. When Infoway began, there was a vision and there was a goal. One of Canada's opportunities is that from the beginning the goal was national—to have information that moved nationally, which was identified with the patient and not with just the hospital or the physician. I think it is a significant goal, but it takes time to achieve.

    Look at Denmark and New Zealand—they are examples of the time required in small countries. New Zealand has only two million people, and think of the geography. With a very federal system, it took them 17 years. It took Denmark 16 years. It took Veterans Affairs in the United States 16 years. So good progress is being made. There are areas of difficulty, but there are significant benefits. The audits have been extremely helpful in pointing out where things need to be strengthened; they have called attention to this issue.

    Granted, there have been a number of successes. We're pleased. With health care demands rising dramatically, e-health is critical and crucial. We understand that reality. Still, there appears to be a situation. Does our confederation serve us to the best of its ability? Well, we have what we have, so it's a bit of a problem. In a perfect world, a benevolent dictator would give you the perfect solution, but we're not there. We have other people now in other sectors, private sectors, coming up with solutions, embracing technology in a different way.

    There is the Telus proposal. I wonder, Mr. Alvarez, if you could discuss briefly the potential implementation or collaboration. Is there a conflicting proposal? Where do you see this working within health care assessment?

    There's a whole host of safeguards and principles that we've operated on from the get-go. One of them was that information systems of this nature should be coming out of the private sector. We are not funding governments to build huge bureaucracies to develop these systems.

    The other issue is, we wanted to make sure of two things. We wanted to make sure we had a strong and vibrant software industry in Canada that could sell globally, given that some of the issues would be clearly on the leading edge. We also wanted to make sure that we could replicate these systems across the country, and that's exactly what we're doing. You can't take government systems and try to replicate them. Who maintains the system at the end? So the private sector has a role to play.

    One of the differences that differentiated us from the efforts in England and other places was that we worked closely with the private sector, telling them where the puck was going to be: what the requirements are, what the standards are, what the availabilities are, when the provinces are going to be ready to start to tender out, to start to get their RFPs. This way they can bring their resources and their intellects to bear.

    There's a major report by an international group, which reports on IT systems, that gives us high praise for the blueprint and how it's been orchestrated. The vendors have been working with that blueprint as they develop the system.

    Thank you, Mr. Kramp.

    Mr. Dion.

    Thank you very much, Mr. Chair.

    I would like to revisit the three main points that have been raised here, especially by Madame Beaudin and Mr. Shipley. The first one is the target. The second one is pan-Canadian interoperability. The third is confidentiality.

    Let's look at the target. You said, Mr. Alvarez, that we are now at 22%, and that you are confident that next year at this time we will be at 50%. First question: is it a robust 22%? Are we able to say that a fifth of Canadians, when they go to see their doctor, will be able to use an electronic file on their health?

     Sir, this is the way the target is measured. We have six core systems: drugs, diagnostic imaging, lab results, a provider registry, a client registry, and some clinical reports. As we look at a province, if they have 100% of their database completed in five areas but zero in one area, we count them as a zero. So we set a very high standard. They could be getting tremendous benefits out of the drugs, out of the diagnostic imaging, but maybe they haven't as yet got their clinical reports available. Where we're at today is looking to Ontario, in terms of the provider registry, to bring that on board, and we're looking at Quebec in terms of the drug information system they need to get on board before we can get to that 50% of data.

    Now, I will caution and be quite clear on this. We're talking about the availability of these systems; we are not talking—and Madam Fraser pointed it out very astutely—about the use of these systems. The only analogy I can give is a situation where you have all these paper files. If you look at a building, you have to make the building available first before you can move the tenants in. You have to have the utilities in that building, etc. The statistic we're quoting here is basically having that building available. If you don't have the stuff in electronic form, you can't have use of it. So we have to move with availability, and from there we will see use.

    I'll just add that in Alberta they have availability and they have 20,000 users using the file. So that will come over time.

    But you don't know if it's actually used.

    No. We're absolutely going to be reporting on absolute usage of those available files.

    What percentage is actually used today?

    I couldn't tell you those numbers. Those are the numbers we're still gathering in terms of the provinces. They measure in a different way, but we certainly will have those numbers to report on.

    This committee will be very pleased to see them.

    I'll be delighted to share it with you, sir.

    How come we will catch up so spectacularly in a year, from 22% to 50%? Between 2001 and 2010, we went up only to 22%.

    Sir, the two that I'm hoping will play catch-up are our two largest provinces. As part of that methodology and equation, we look at the population distribution. When you look at the population distribution, if I can get Ontario with the provider registry, say, and Quebec with the drug registry, that's a huge population base we're covering, which will get those numbers up.

    How come we are lagging behind other countries, then?

    Again, I want to be clear. We're lagging in the electronic medical space, which is in clinicians' offices. Those numbers are at about 37% today. But we're not lagging in some of the drug information systems, the diagnostic information systems, the lab information systems that we have. It is in clinicians' offices, and we'll be using the new moneys from the federal government to basically accelerate that agenda.

    How would you assess the risk that at the end of the day we will have a patchwork of systems, instead of a system that Canadians may use from coast to coast to coast?

    If we have a patchwork of systems, then we've failed in our job. Our job is basically to make sure we have a coherent, interoperable basic system, and I can assure you, sir, that we're working at that very, very diligently.

    Thank you.

    Thank you, Mr. Dion.

    Mr. Dreeshen, five minutes.

    Thank you very much, Mr. Chair. Thank you, everyone, for being here today.

    I spent a number of years as a hospital board chairman in Alberta. We worked closely with our surrounding hospitals and tried to make sure.... Even though we were one organization, there were a number around us. This is the type of thing we've been doing for perhaps 15 or 20 years, so I'm certainly well aware of the challenges there are in the delivery of the health care system.

    Again, I'm very pleased to hear some of the things that everyone now is hearing about the Alberta system, and some of the things that out of necessity we were forced to do. Yet, when we look at the type of training that doctors have, I'm just hoping.... I guess my first question is to ask if you're aware of any types of courses that are being given in universities where doctors are being trained about the business aspect of it, and also this type of clinical training. Perhaps you could start with that.

     I can perhaps start.

    Health Canada actually funded faculties of medicine to do a review of the educational requirements to receive an MD degree. It was the first such review in quite some time.

    One of the things we've been doing, which I think my colleagues at Infoway and other places are doing too, is to encourage the use of electronic technology for information in the curriculum. It's not part of the training now. They may use the specialty aspects of it. A radiologist is used to special equipment, but in terms of the recording of clinical notes, etc., it is not an aspect they currently receive. It is different from many other professions, where you can't imagine graduating from university and not having that background.

    Thank you.

    I must admit that we're talking about younger doctors, but my doctor has been out of university as long as I have, and he was one of the first ones to be able to use this. There are people who recognize the significance of it. I'm glad it was brought up.

    We talked about the cost of the system, but we then recognized the $6 billion of annual savings that was spoken of. There were some discussions you had earlier on the great amount of savings there are.

    Mr. Alvarez, are there any other key components of savings that you might want to put on the record for us to consider?

    As I said, we've done a couple of studies.

    On one of the things we did, again, as far as I know—and I've now been in this job for the last six years and I have a pretty good handle on it internationally—we're one of the only countries that has had a benefit measurement framework.

    Not only have we taken these reports and said it's $6 billion and $7 billion—and we've heard it could be higher—but we wanted to put in place a benefit mechanism that asks whether we are getting those benefits.

    We brought in some of the brightest minds from the research community, some of the international guys, and a lot of our guys in Canada. They designed a framework for us that has a variety of indicators. As we fund projects and these projects come on line, we then go back and systematically measure whether those benefits have been achieved.

    I've talked about diagnostic imaging. We're about to publish one on drugs. For even the few provinces that we have, we're looking at benefits in the region of about $450 million a year. When you extrapolate that, it's well over $1 billion a year for Canadians. There are big benefits.

    Again, as some of the other systems come on board, we'll be doing the same type of measurement work.

    Madam Fraser, in future audits, would you look into that type of breakdown of the benefits as well?

    Chair, we would look to see what the organizations have done in terms of evaluating the benefits. We would not do an evaluation ourselves, but we would certainly look to see what type of information is being collected.

    As you're pointing out and as members are pointing out, I think it is very important that the legislatures and Canadians understand the benefits that come from these systems.

    Thank you.

    Thank you very much, Mr. Dreeshen.

    That concludes the second round.

    You have a very brief question, Mr. Young.

    I want to move on, because there's another meeting.

    I understand. Thank you.

    I want to ask Madam Dodds this. You know there's a rich potential in this information with regard to prescription drug safety. Do you have any process or do you have any plans to access that information to improve prescription drug safety and act on it?

    Yes, as Mr. Alvarez said, Infoway, Health Canada, and a number of the provinces are working very closely with the Canadian Institute for Health Information on the very responsible ways of using the information to benefit the health system writ large, instead of the individual doctor and the individual patient.

    You haven't started yet.

    Yes.

    You have started.

    Yes, we've started investigating the ways that we can do it. Privacy is one of the key issues.

    That ends the questions, colleagues.

    I have a couple of minor items of business I want to attend to.

    But before we leave, on behalf of all members of the committee, I want to thank the witnesses here today.

    Mrs. Fraser, do you have any closing comments?

    Thank you, Chair.

    I'd like to thank the committee for their interest in these audit reports.

    As we've mentioned, my provincial colleagues and I certainly think this is a major initiative across the country that obviously involves significant sums of money, but there are great potential benefits. We would certainly encourage this committee and perhaps your provincial counterparts as well to continue to follow this.

    We've encouraged Infoway to give more comprehensive information. I would suspect, at some point in the future, we will be going back to see what has been accomplished on this.

     Thank you, Ms. Fraser.

    Give me 10 seconds. You can rule me out if you want.

    Ten seconds you will have, Mr. Christopherson.

    Thank you.

    I just wondered, is there any way we can influence the public accounts national conference that's coming up so that they put this on their agenda? It's a great opportunity for us to do the follow-up that's been suggested.

    I'll just leave it with you, Chair.

    We can bring that up, Mr. Christopherson. I believe the agenda is set, but I certainly think it's a good idea. We will bring that up.

    Mr. Alvarez, do you have any closing comments?

    First, thank you for this opportunity. If I said it would be a real joy to come back, I may have been overstating the case—

    Some hon. members: Oh, oh!

    Mr. Richard Alvarez: —but I will obviously be delighted to come back.

    I will leave you with this. I often get asked the question, because of its great importance to the transformation of records: why is it taking so long? My response is, why is it taking so long compared to what?

    When you think about our banking systems today, it took 10 years, from when the first bank got its general ledger in, to get the rest of its branches online. It took an additional 10 years, meaning 20 years in total, for the first Interac transaction; and it took an additional 10 years before you or I could access our own bank account at home. When you think that it took 30 years, or 20 years at minimum, for the banks to do that and you think about their credits and debits, and you also think about the number and complexity of transactions in health care, it's going to take a long while. I believe that in the next 10 or so years, this country will make tremendous progress.

    Thank you very much, Mr. Alvarez.

    Dr. Dodds, do you have any closing comments? Okay.

    Again, on behalf of all members of the committee, I want to thank you very much. The witnesses are excused.

    Before I adjourn, there are two items I want to deal with. The first item, colleagues, is the approval of the minutes of the steering committee. They've been circulated.

    I just want to highlight three things. One, of course, is that we are scheduling a hearing for the peer review in September. Because it will be done via teleconference with the principals who are in Australia, it will be done outside normal hours, probably in the evening—but you will be given sufficient notice.

    The second item is that we are going to have hearings in the fall on the Auditor General's special report on the Canada Post Corporation and the Canada Science and Technology Museum Corporation.

    Thirdly, the committee has authorized our budget to be presented to the Liaison Committee for our attendance at the annual meeting of the Canadian Council of Public Accounts Committees, which is being held in Quebec City in August of this year.

    So people have read those minutes. The chair would entertain a motion.

    I so move.

    (Motion agreed to)

    The second item is Madame Faille's motion. I'll let her speak to it briefly, but I understand she is going to amend the last paragraph, where it says “estimates of government spending on information technology” and insert the words “of the following agencies”. There will be 15 agencies and departments mentioned. Those have been circulated. In my view, it's not a substantive amendment. It actually restricts the motion. I will allow the amendment.

    Did I capture your amendment correctly, Madame Faille?

    In fact, I want to say that this was a joint effort. It was done after my meeting yesterday with Mr. Kramp and the discussions we had with Mr. Lee. We emphasized the fact that the Parliamentary Budget Officer could do it within the existing resources. I amended the motion so that there would be no further requests for supplementary budgets, etc. I brought this amendment to satisfy my colleagues around the table.

    Mr. Kramp also mentioned restricting the study to targeted departments. In an arbitrary way, I kept the departments that my colleagues and myself had reviewed during the session. Fifteen departments appeared before the committee. The Auditor General had identified within these departments some problems relative to information technology.

    In this respect, I limited my work to these departments, simply so that everyone could have a point of reference, so that the department could be viewed in its entirety. This is why the motion was amended. This was, in fact, discussed previously.

     Thank you very much, Madame Faille.

    Madame Faille has moved her motion with the amendments included, so it does not require a vote on the amendments.

    Mr. Kramp.

    Mr. Chair, I'd just like to speak for a moment. I agree, after having a conversation with Madame Faille, and I certainly respect her diligence. She's thorough. I have no difficulty with that. Moving forward with the principle of what she's asking, I certainly don't have any difficulty with that.

    My first concern was, where do we go from here? It's huge. There are 112 different departments and agencies. To suggest that we need to access thousands and thousands and thousands...the budget officer is going to be there for years. So let's define this.

    I don't really know where Madame Faille is going with this. If we had a sense of direction, I would have no difficulty, but I just don't want to be going like a scattergun and asking the budget officer to deal with a grand, grand problem, particularly in light of two or three observations I might make.

    I'm sorry, but I'm going to have to interrupt you.

    I do want to end the meeting before 11. Unless other people want to speak on this, I'm going to have to table this discussion until our next meeting.

    There are two people on the list. I don't—

    Okay, but it's worthy of discussion.

    Yes.

    So this issue will be tabled and will be the first item brought forward at the next meeting. It is one minute to 11, so I do feel I have to adjourn.

    The meeting is adjourned.