The Nova Scotia Legislature

The House resumed on:
September 21, 2017.






Wednesday, October 27, 2010


Department of Health

Patient Access Registry

Printed and Published by Nova Scotia Hansard Reporting Services


Ms. Diana Whalen (Chairman)

Mr. Leonard Preyra (Vice-Chairman)

Mr. Clarrie MacKinnon

Ms. Becky Kent

Mr. Mat Whynott

Mr. Howard Epstein

Hon. Keith Colwell

Hon. Cecil Clarke

Mr. Chuck Porter

[Hon. Christopher d'Entremont replaced Hon. Cecil Clarke]


Department of Health

Ms. Paula English, Chief of Program Standards and Quality

Ms. Lindsay McVicar, Acting Director, Wait Time Improvement

Ms. Linda Penny, Chief Financial Officer

In Attendance:

Mrs. Darlene Henry

Legislative Committee Clerk

Ms. Evangeline Colman-Sadd

Assistant Auditor General

Mr. Gordon Hebb

Chief Legislative Counsel

[Page 1]



9:00 A.M.


Ms. Diana Whalen


Mr. Leonard Preyra

MR. LEONARD PREYRA (Chairman): Good morning, I'm going to call this meeting to order, it's 9:01 a.m. Today we're examining witnesses from the Department of Health on the Patient Access Registry. For the record, we have two members stuck on the bridge, on the other side in Dartmouth - Becky Kent, the member for Cole Harbour-Eastern Passage will be joining us today and Clarrie MacKinnon, the member for Pictou East - but they should be arriving shortly. But we don't want to delay the proceedings any longer, so we'll start with our introductions.

[The committee members and witnesses introduced themselves.]

MR. CHAIRMAN: Welcome, and we'll start with a brief presentation. I should say that I'm in the Chair this morning because the member for Halifax Clayton Park will be leading the questions for her caucus.

MS. PAULA ENGLISH: Good morning committee members. First of all, we want to thank you very much for the opportunity to share with you this morning information about an innovative wait times initiative that the Department of Health has been working on for a number of years now. We've taken a major step forward in knowing how long Nova Scotians are waiting for surgery and where they're waiting for surgery.

As part of better health for families, I'm happy to report that we have built with the districts a province-wide information system that contains a centralized list of all patients waiting for surgery in Nova Scotia, and that's the first time that we've had that information in this province.


[Page 2]

The Patient Access Registry Nova Scotia, colloquially known as PAR NS, was launched this past summer throughout the health care system in partnership with our district health authorities and the IWK, where our surgeons perform the surgeries. The Patient Access Registry system can gather and report information on how many patients are waiting for surgery, how long they have been waiting for surgery and, by next summer, will be able to report publicly on wait times for surgery using that as our source of data.

This morning I'll share with you how we got to where we are and what the future holds for patients and their surgeons, as we strive to improve wait times for Nova Scotians. We thought we'd begin by telling a story of how we've arrived at this point.

Prior to this project being initiated, surgery wait lists were managed using a variety of approaches. Most surgeons had their own personal methods for prioritizing patients. It was not uncommon for surgeons to work from their wait lists in their office drawers at each site, so there was no one list, they were scattered throughout the province. This traditional approach lacked a fundamental component. Without a centralized wait list registry, there was no way to measure how long a person had been waiting, whether they were being helped within a certain target based on their condition, or how they were being prioritized for that surgery.

In the past our wait time reporting was limited to an historical view of the wait time situation for surgeries. We knew that by working with the health districts and the surgeons to create a patient registry that we could improve the management of these wait lists, and that's the goal of this project, to help us improve the management of wait lists and thereby having better outcomes.

In order for this to happen, it was essential for us to collaborate with our providers in the health care system, starting with the surgeons themselves. Over the 18 months there were many challenges to overcome. It was a lot of people to get in a room, a lot of people to have come to an agreement and consensus on how things were going to go forward, but through strategic planning and communication we've been able to bring this province-wide network to fruition.

Gaining surgeon participation to adopt the changes in practice took time, but it was absolutely essential. I want to take this opportunity to thank the many clinicians who helped change the practice for patient prioritization and operating room booking.

To accomplish this goal we created the Nova Scotia Surgical Care Network and this is a provincial group that includes surgeon chiefs and senior clinical leaders from each health district, the IWK and people from the Department of Health. This group met monthly through the process and we relied on their expertise to identify issues that we could then work through. They also helped develop supporting policies as we went along, policies that would guide how the system would be used.

[Page 3]

We also formed surgeon working groups for each of the 12 surgical specialties to develop clinical prioritization tools and determine the minimum and maximum wait-time ranges for every surgical procedure performed in Nova Scotia.

We also created an operating room management standards group. This group was established with provincial representation to lead the standardization and implementation of an information system that would help us collect the data that we needed. All of this good work needed a reliable, dependable, operating room information system. Thousands of operating room procedure codes had to be mapped to a standardized provincial procedure list to ensure consistency across the province for accurate reporting, and collaboration and consultation were absolutely key to the success of this.

We received positive feedback from our stakeholders in health care who indicated that the project team had brought the right people together to make the decisions on the operating room standards from a provincial perspective.

We also hired individuals to look at the system on behalf of the patients who were on a wait list. There are now access managers in all districts who meet every month from across the province to discuss common challenges and standardized approaches to Patient Access Registry administration, quality assurance, reporting, communication, and the monitoring of policies and procedures. This is a new role that has been introduced into the system.

Before the Patient Access Registry was launched in each district, we needed to know if the old wait lists surgeons were working from were accurate and this had never been done before. As I said, wait lists were in desk drawers, people worked with them as best they could and our front-line partners, through this process, telephoned 14,212 patients to see if they were still waiting for surgery. That was to validate the list.

Almost half of those people were waiting for orthopaedic surgery, which wasn't a surprise to us because as we all know that orthopaedic wait times in Nova Scotia are indeed long, but it did give us valuable insight as to where they were and if they were still validly on the wait list. In fact, we found that approximately 27 per cent of the people could be removed from the wait list for many reasons. In most cases, their names were still on the list, but they had already had surgery or no longer required the procedure. In going through that process and validating the list, about 27 per cent of the people actually came off.

We needed to ensure that the data was reliable. We worked with our IT departments in all nine district health authorities to make sure that the new information processes worked for users and to ensure that the data passing into the system was accurate.

Finally, before we went live with the system, we needed major change management resources dedicated to bringing this system in. This is a change in practice, it is a different

[Page 4]

way of doing things for the providers in Nova Scotia. You can't just turn on a switch and say okay, it's different now, you have to give them support through that process. A staggered district implementation approach allowed for improvement as we went along.

Let me share some of the lessons learned from the project. This has been considered one of the most successful projects across Canada that addressed this issue. Our funders, Canada Health Infoway and Health Canada, who have a view of what's going on in the country, have told us that and they're very pleased with how it went, and our evaluation also indicated that.

We know that there are centralized registries containing surgery wait lists in place in several provinces. Saskatchewan, British Columbia, Ontario and New Brunswick already have them and we worked with our partners in these provinces, in particular New Brunswick, to learn from them before we implemented ours as well. This was completed within budget; in fact, it was within 1 per cent of budget but we didn't go over. The funding was jointly provided by Health Canada, Canada Health Infoway and the Nova Scotia Department of Health.

All of this effort was done for the patient. By having wait list access managers in the hospital, patients will have much more specific information about when they're more likely to have surgery. We know that patients waiting in the dark for a phone call for a surgery date has been a frustrating experience for people and can cause them great anxiety. People can't plan their lives wondering when the call date for surgery is going to come, so the Patient Access Registry service and the access managers, when they're up to their full capacity, will be able to give them a very pertinent source of information that will improve communications with patients.

By increasing the ability of the health care system to manage surgical resources and wait lists, we can provide better quality care. Having this reliable source of information will also allow us to report on wait times and wait lists by patient urgency category. We can see if patients are receiving their surgeries within a clinically acceptable time frame, based on the urgency for a particular procedure, so ensuring that wait times are appropriate as per the urgency of the surgery needed.

We will maintain a confidential record of when patients were entered into the system, when their surgery was booked, and if it was cancelled or delayed for any reason. If we know their surgical journey through the system, then we know where and how to improve it. We are currently in the process of validating the data with the DHAs in preparation for use in the new year.

Detailed reports will be made available to individual surgeons, including their patients' wait time information, to help them better manage their wait times. As well, the

[Page 5]

DHAs will have access to that information so that they can better manage their operating room resources.

We're targeting June 2012 to report some of this data on our wait times Web site as part of our transparent approach to wait times. For example - 2011, what did I say? I said 2012? I'm sorry, it's June 2011, I skipped a year. For example, we know the number of days a patient waits for a hip replacement at a specific district health authority, similar to the diagnostic information we are already posting on our wait time Web site.

In conclusion, I want to thank you for this opportunity to talk about this project. Our staff is now open to answering your questions on the project and how it went. Thank you.

MR. CHAIRMAN: Thank you very much, Ms. English. Before I call on the honourable member for Halifax Clayton Park, I want to say how delighted we are to have Becky Kent, the honourable member for Cole Harbour-Eastern Passage back here, safe and sound, in the relatively calm confines of the Public Accounts Committee. Welcome back, Ms. Kent.

Also, the honourable member for Pictou East has now joined us. We're happy to see you but you're here often enough that we don't miss you. Mr. MacKinnon is here.

Thank you very much. We'll call it 9:14 a.m. and I'll hand it over to Ms. Whalen.

MS. DIANA WHALEN: Thank you very much. I'd like to welcome you all here today. I know that the deputy minister said he was unavailable and it was very good that you were able to come and discuss this with us this morning by yourselves. He spends a lot of time here so I think he was happy to have a week off.

[9:15 a.m.]

I was interested in your opening statement, it certainly gave a lot of good background. I really appreciate that, Ms. English, but certainly we have some questions. One interesting thing with this topic really is that this is a system that's very new, we're just at the point of having all the DHAs adopting it. I think July was the last of the DHAs that began to put this information, I guess, on-line for internal use - and I think it's important that we recognize that, right now, the information is being used internally and is not available to the public. I think that's important for anybody who is watching and interested in wait times, to know that this is a tool right now for management, to be improving systems. I did want to sort of make that point.

Also, our committee often looks at the history of a project and that's really our focus, generally, and how well it has gone financially and how many resources have been used. When I started to read the background on this I thought there isn't a lot of history on it

[Page 6]

because we've really just brought it to the point where it's now operational. I do have some questions about where it's at and perhaps the challenges and the costs that were involved up to this point, to get us started.

You went through a few of the challenges but I wanted to know if there were any unique challenges in Nova Scotia that happened during the implementation.

MS. ENGLISH: I think that the challenges we had were commonly experienced by other provinces in that it was change of practice, so you were bringing together people who had not used a provincial registry before, folks who had been managing their own wait lists. So again, that's the big change in practice. So I don't think it was unique, I think that others had experienced it before.

I'll refer to Lindsay, who worked very closely with the providers during this process, to see if she has anything to add to that.

MS. LINDSAY MCVICAR: Thank you, Paula. That's a great question and echoing where Paula started, this was a change management project. Now we look at the detail, we look at what we implemented and we're seeing one IT system going in for a provincial registry, we're seeing Meditech, an operating room information system being put into seven districts. This really was a people project.

We try and talk about, this is not IT, this is not IT, it's about people, it's about change. It's about what this means at the district level for the clinicians who are receiving information and using this information to better manage their wait lists, but also for the other folks in the districts who actually have to learn how to use new systems, who have to learn new booking practices. Really the biggest amount of work we had to put in here was working side by side, meeting individually with impacted stakeholders across the province in each district, to understand what the change meant.

Each district is unique because each district has slightly different practices around booking and slightly different practices for managing their operating rooms. The change is always different, depending on the user. One district went from a paper-based system to an electronic system, so in that district one of the biggest challenges was getting folks who worked in the booking office accustomed and acclimatized to using a new system. It was really taking the time over an 18-month to two-year implementation to really be diligent with our communication and stakeholder engagement.

MS. WHALEN: Very good, thank you. I wanted to ask you about the timeline. You just mentioned 18 months to two years. We understand that New Brunswick had their registry implemented in 2007. Perhaps, Ms. English, you could tell me, did both of our provinces get the funding at the same time, did we begin the project at the same time?

[Page 7]

MS. ENGLISH: No, I believe New Brunswick's funding was before ours. They had implemented the project before we did.

MR. CHAIRMAN: Ms. McVicar.

MS. MCVICAR: Thank you, that's a great question as well. New Brunswick was actually up and running for approximately a year at the time when we were starting, so now they've been up and running for between two and three years. I don't have exact information on their go-live dates.

The benefit to us was that they had not only lessons learned from an implementation perspective but they have been up and running for long enough that by the time we were implementing, we had the opportunity to see some of the positive changes that these kind of registries can bring to a province in managing wait lists. We were fortunate in being able to leverage the lessons learned there, in terms of how to communicate with stakeholders, what are some of the issues we're going to be facing and what are some of the things we can hope to see after it was implemented.

MS. WHALEN: So it definitely sounds like you conferred with them as you began the project here in Nova Scotia. I think that's important to look at our neighbours and see what they've done.

The information I have said that it was implemented in 2007 and operational in 2008. Were they able to develop it faster than we were, as far as you know? It seems like we've worked on it now for two full years.

MS. MCVICAR: Well, to my understanding, I don't have a lot of detailed information on their timelines, but what I do know is that we were able to learn what worked for them but also what didn't work. We started from their lessons learned, in terms of change management and we actually developed a more comprehensive, slightly more detailed stakeholder engagement approach and it did take a bit more time for us.

What we're seeing in Nova Scotia, one example is that we introduced new clinical prioritization tools for surgeons and we see 100 per cent compliance across the province using those. We attribute that entirely to the success of the project team working with the leadership in the districts and the great leadership provided, whereas in New Brunswick they didn't see that kind of compliance on day one. It was a little bit more of an iterative process after go-live.

MS. WHALEN: Can I just ask, when you talk about clinical prioritization tools, sometimes you might lose us so I'm just wondering, are you talking about almost the checklist chart that I think was in your PowerPoint presentation we were given?

[Page 8]

MS. MCVICAR: You're right.

MS. WHALEN: There was one there - so everybody uses the same chart in answering the questions about the severity of, I guess, the condition that the patient is in?

MS. MCVICAR: Absolutely. To be a little more specific, we developed 12 specialty-specific tools, so a cardiac surgeon would fill out a different tool than a general surgeon, but all general surgeons would fill out the same standardized tool as per the clinical severity and context and situation for each individual patient. It's submitted as a required element of the booking package.

MS. WHALEN: I wonder if I could ask Ms. English if it was the same company. I believe it was the same company that did both of our systems, New Brunswick and Nova Scotia?

MS. ENGLISH: It was. The software is the same software that was used in both provinces, yes.

MS. WHALEN: I'm not sure how we say that company name, is it Accreon? When it comes to the maintenance of the system, will they be maintaining our system?

MS. ENGLISH: The maintenance of the system, we have a maintenance contract with Accreon to continue on with that. As well, of course, the access managers and the patient access managers have a role to play in the use of it but the maintenance contract is with Accreon.

MS. WHALEN: So they would be the ones that ensure that everybody is doing what they are supposed to. Would they have a hands-on . . .

MS. ENGLISH: No, that's more the access manager's role - correct, Lindsay? - in terms of what everybody is supposed to be doing and what they're supposed to be doing, that's the access manager.

MS. WHALEN: So it's more to do with the software, the platform on which all of this is taking place technologically.

MS. ENGLISH: That's right.

MS. WHALEN: Okay. Is that the same thing that they do in New Brunswick, as far as you know?

MS. ENGLISH: I believe, yes.

[Page 9]

MS. WHALEN: Ms. McVicar.


MS. WHALEN: I guess you're working more closely with it so I thought I'd check with you there.

MS. ENGLISH: She's the technical expert here.

MS. WHALEN: I thought it was very interesting that we have such a close neighbour that has actually been doing this.

I wanted to go back to your opening statement, if I could for a second. Where you end in this it sounds like there's a lot we're not doing yet because you're using the future tense. I would like to kind of get to what it is we're not doing. We've set up the platform, we've got working groups of surgeons that have agreed to dramatically change the way they dealt with their individual patients. They used to have control of it themselves, by just keeping their own list, so there has been a cultural change there. What is it we're going to do, because on just the second last page you said, "Having this reliable source of information will . . . allow us to report on wait times . . ." - now when and how is this going to happen? How far away are we from some more accurate information and some changes?

MS. ENGLISH: There are a number of things happening right now. Number one is before we can use information at any level, to make decisions or to report publicly, we need to make sure that the information is, in fact, valid, that there's integrity to the data, that it makes sense, that people are doing the forms correctly. So we've agreed across the province that given that the last folks only came onto the system in July, that we would work through the Fall and winter on the validation of that data.

That doesn't mean that districts aren't internally using the information now to make some decisions. So we know, for example, that Capital Health, that has been on the system for some months, is taking the PAR NS information, the Patient Access Registry information, and using it to allocate operating room resources. The people who came on in July are likely not using the information in that way yet, so there isn't universal use there.

Similarly, when it comes to the province using the information, again we've said through the Fall and the winter, to make sure that the data is valid before we use it to start monitoring and making decisions and going back and questioning the districts as to how things are being done. So there are two ways: the districts themselves will be able to use the information for allocation of resources and we, at the Department of Health, will be able to monitor and will be able to say how is this going, we see some changes that we'd like to see happening and how are we going to negotiate that. That will happen. We see the . . .

[Page 10]

MS. WHALEN: Can I just ask you about how we can drill down to the benefits of this system? We're talking in a general sense that there will be benefits and more efficiencies but are we actually going to be able to have more of the operating rooms effectively used and better booked? Is that the key to this?

MS. ENGLISH: That's the key to this. There are two things that are key to this: knowing that patients are getting - to be able to look at how patients are being managed from an urgency point of view, are the patients with the most urgent needs getting their operations first? We'll have information, the districts will have information to ensure that happens.

It is the districts' responsibility to manage their operating rooms. That's within their realms so they have to do that, but now they will have the information to do that.

MS. WHALEN: Okay, so those two parts.

MS. ENGLISH: The other pieces that haven't happened yet, the access registry managers who are in the districts, some of them - again, I think the last one was hired over the summer - they are still learning to work the system, working with the information, working with teams around the information. Some of the next steps are going to be for the access managers to actually have contact with patients and to be able to liaise with patients around wait times. That part has not yet been implemented and is still getting worked through.

MS. WHALEN: I'd like to ask you about the financial costs of the whole process and the amount that was paid by the two levels of government, I guess, two different federal programs. I had printed that one page so I'm sort of looking for it. Your final figure was over $11 million, it's almost $12 million . . .

MS. ENGLISH: Yes, $11.9 million.

MS. WHALEN: In your opening statement you said you were within 1 per cent, is that the 1 per cent, $1 million on $10 million? No, that's 10 per cent.

MS. ENGLISH: The budget for the project is actually $11.9 million. What I said in the opening statement is the budget was $11.4 million and what we frankly noticed this morning was, as we were looking at the two pages, one of the pieces that wasn't included in the $11.4 million was money that was spent even prior to the project getting up and running in terms of doing the proposals, doing the work that went into gathering the information. When our finance people were going back and looking at all the money spent, that that was money pre the money coming from the federal government, so that's the difference. But it was completed within budget. Am I looking at the right . . .

[Page 11]

MS. WHALEN: In the government's press releases they had always said $11 million. I looked at a number of press releases in our package, so that's where I came up with $1 million over budget.

MR. CHAIRMAN: Ms. Penny.

MS. LINDA PENNY: The $11.4 million has been the budget of the project and as Ms. English just said, a lot work went into developing the proposals for Health Canada and Canada Health Infoway, as well as some preliminary scoping work before the project. While we included it in our total costs, those aren't specifically project costs, so that's the difference between the two numbers.

MS. WHALEN: When I look at these actual expenditures, it starts in 2007, which is fully three years ago, April 2007, but you do have Health Canada money flowing in at that point, $440,000, so it wasn't prior to your receiving any federal money. There might be project management set-up costs, but you're actually talking about hardware costs as well. I guess your pre- and post-implementation cost is the line that you're talking about, developing the proposals and getting ready to go. But it seems to have happened in that same six-month period or, I guess, one-year period to the end of March 2008. It's surprising that wasn't included in the first go-round, is what I'm proposing and also that more recent press releases, even 2009, were still referring to it as an $11 million project.

Usually government wouldn't want to underestimate a budget. If the budget is $11.5 million, you want to say it's $11.5 million because you don't want to later have it said you went over budget, so you wouldn't want to decrease that amount. I'm still a little confused why they would have been referring to it as $11 million.

[9:30 a.m.]

MS. PENNY: I guess the total breakdown of the project, in looking at the funders, we have $5.8 million from Health Canada, we've got $3.4 million from Canada Health Infoway and we've got $2.2 million from the Department of Health. The breakdown of the $2.2 million is, for the Health Canada funding, the Department of Health had to provide $1 million and the CIHI funding we had to provide 25 per cent, which was $1.2 million. So we do come up with $11.4 million, I'm just wondering if it's possibly rounding, but I would have to go back through those press releases to determine.

MS. WHALEN: In the forecasted column, the final column in that financial summary, it actually says $2.7 million from the Department of Health.

MS. PENNY: Which includes that additional $500,000 for the other work that went on.

[Page 12]

MS. WHALEN: The initial work?


MR. CHAIRMAN: Ms. Whalen, I'm wondering if you could just put that in the form of a request for clarification and then we can get an answer back.

MS. WHALEN: That is a good idea because we perhaps could go back and forth a bit with it, but if you could break it down because it's not clear in the financial information we've been given.

Let me just go on, then. We've had some discussion, I guess, I'll look for a clarification on whether or not the project was over budget more than 1 per cent - again, starting from its initial year, 2007.

I've already mentioned the $11 million, I would like to know if the ongoing costs are now 100 per cent covered by the province.


MS. WHALEN: Entirely, so we'll have no more federal help from this at all?


MS. WHALEN: I know that we're talking about wait times here and managing wait times. Earlier in 2004 - I think it was 2004 or 2005 - we had something like $5 million or $6 million provided, I think it was - perhaps even more - by the federal government for Nova Scotia to start tackling wait times. Can you, in the last few minutes left in my round, give me an idea of what we accomplished with that money?

MS. ENGLISH: I'll start and if I have to refer to Lindsay, I will. There were a number of wait time projects that we put under an acronym of WINS, Wait Time Improvement for Nova Scotians. There were three projects of which this surgical piece was one, so PAR NS was one of the projects. We had one on radio-oncology, so looking at radiotherapy for oncology patients. What's happening in that project right now is that there are new LINAC machines, linear accelerator machines, that help provide radiotherapy to patients with cancer, that's part of the project, and then the other was around looking at a diagnostic imaging pilot project with GPs around referral, if that's what you're referring to.

MS. WHALEN: I guess just for the final minute or two that I've got, I think a question for us to look at - and I appreciate the work that's going on here and that it's laying the groundwork for improvements in wait times - my concern is that even in the summer the most recent wait times report shows us dead last in terms of the wait times for orthopaedic

[Page 13]

hip and knee, very far back on cataract surgery. We don't seem to have improved and I think it's important that here at the Legislature we ask those questions. We seem to have been investing, we've got these better systems, but the improvements aren't there yet.

MS. ENGLISH: I think that what has to be recognized is that those were particular projects. The radio-oncology project is meant to improve and enhance wait times for people waiting for radiotherapy, so that was very particular to that.

As we've talked about today, this PAR NS system is just going into place, it's a brand-new system. What we've seen from New Brunswick, for example, once they really got good at using that system is they have, in fact, seen wait times improve by using that information and then, of course, the other project was different. So the projects were very targeted.

We've been working with the district health authorities, and Capital Health in particular, around their methodologies for really breaking down and looking at what are their issues around orthopaedic surgery. We're hearing from them that they're starting to see some improvement, starting to bring it down just a little bit. It is acknowledged that wait times for orthopaedic surgery is an issue and we will be continuing to work with the districts on that.

MS. WHALEN: I just have one quick question, if I could, because there's only seconds left. When you checked with all 14,000 people whose names were on the wait list and 27 per cent no longer needed surgery, did that surprise you? That surprises me, it's such a high number that you would take off the list.

MS. ENGLISH: It wasn't all that they didn't need surgery - and I'll let Ms. McVicar talk to some of that - but that was the common experience in New Brunswick and other provinces too. People go on wait lists for a variety of reasons, sometimes people work at things like weight loss and come to a place where the surgery is not needed. Some of the people had already had surgery, but yet were on somebody else's list because there was duplication. But I will refer to Ms. McVicar to see the kinds of things and why people were taken off the list.

MR. CHAIRMAN: Sorry, Ms. McVicar, Ms. Whalen's time has run out, but we've talked and we'll let you continue the answer to that question.

MS. MCVICAR: I agree, it's one of those numbers that really makes your eyes pop, but we weren't actually overly surprised because this was exactly what was seen in other jurisdictions in Canada when they undertook the same exercise. Some jurisdictions had upwards of 40 per cent reduction simply by cleaning up the queue. While that may not have a direct impact on minimizing wait times, it certainly reduces the queue, it gives you an accurate understanding of what's in there and tells the system what the system needs to know about demand.

[Page 14]

MS. WHALEN: Thank you.

MR. CHAIRMAN: We'll move to round two, Mr. Porter, for the next round of 20 minutes. It is now 9:35 a.m.

MR. CHUCK PORTER: Thank you, ladies, for being here this morning. I have a few questions. I just wanted to carry on what you started with, Ms. McVicar, the 27 per cent that you talked about. Of the 27 per cent, do we know if any of those patients are deceased, is that one of the reasons; if so, what percentage would that be?

MS. MCVICAR: We did everything we could to validate the calls we were going to make against any deceased registry we would have in the hospital. Of course, the data we have access to would be hospital data, so anyone who would have maybe passed away at home would maybe not make it into the same information systems that we would have access to at the hospital level. Making those calls, it was 1 per cent, if that. I can go check and validate that number.

MR. PORTER: The reason I'm asking, it's an interesting world we now live in and I had a lot of years in health care prior to this career and I know a little something about all of this. I read this and I talk to people every day, I take calls every day and I hear stories about wait times, I hear stories about access issues - and we're going to cover those this morning - but more importantly, people seem to be of the same frame of mind though, this wonderful technology is more of a hazard than it is a help in a lot of ways. It seems to slow things down. We spend millions of dollars, as we've just referred to, in developing what should be wonderful programs and easy access for everybody and a wait list and queues, but we don't have a program up and running yet, that's key, from what I can see, but people are still out there with their wait times.

I'm going to give you a story and I'll start it right now. I'll give you the example from a call I had last night and I asked permission from Gloria to use her name. Gloria Fogarty had an injury to her shoulder in July. She's told, okay, on December 31st you can come for an ultrasound and maybe in a year's time you'll get surgery. You can appreciate her being less than enthusiastic about all of this, given the knowledge of money being spent on these wonderful programs to help process wait times, get you through quicker and prioritize. More importantly, when I asked the question, how come so long, well, they don't do them in Windsor anymore and they don't do them in Kentville, everything has to go to Cobequid. How is that an efficiency by way of tracking anything?

We've spent a lot of time and money on this wonderful technology whereby we're supposed to be helping to speed the system but, in fact, it almost appears we're going the other way. I look forward to your comments on that.

MR. CHAIRMAN: Ms. English.

[Page 15]

MS. ENGLISH: I think that to say the technology is slowing down the system isn't doing a service to the technology. This is technology that is going to help us bring everything together in a registry so that we can actually measure things. It's new technology, we have to give it a chance. It can't fix things that are happening last week. What we really hope to do is to have this information bring us into the future.

That is not to say that there still aren't things to do within the system but we need the information to be able to help the districts move forward and make different changes. So do we have wait time issues? Absolutely, I think we all recognize that. We're building the system to be able to help people and surgeons and everybody else make decisions about that. We still have issues and they go beyond a list, they go beyond management of resources and location of resources and all those kinds of things. Putting in PAR NS is a building block to be able to make those decisions appropriately.

MR. PORTER: I appreciate that, I really do. I guess from Gloria's perspective, though, all she sees is an extended wait time and knows all this money is being spent. In your words, Ms. English, it's going to help us; the key question out there is, going to help us when? Yes, you've thrown a date at us today of 2012, corrected to 2011 . . .

MS. ENGLISH: That was my mistake.

MR. PORTER: That's a wonderful thing, as well, a year's saving right there, that's how I looked at that, that's all good. What I'm saying is that this has been going on for some time. I've been around government now and in this Legislature for four years and we're still hearing the same thing. Regardless of who is in government, it seems to be the same thing. I'm not being critical of anyone, just that technology is never-ending, it's always on the edge, you're always changing something. I don't know how many of these meetings I've sat through and talked about the SAP program. SAP isn't even - I call it a disaster because from the appearance to me and everyone else that I've talked to, that's what it is. Things aren't working, there are access issues.

I look at two things here. You have a wait time issue and you have a database access sort of system. You can type my SIN number in and you call tell anything that you want about me. Why are we getting into something so broad when everything should be in one house? I don't understand why there are so many programs, nor does anyone else. When I talk about anyone else, I'm talking about the crowd that goes to Tim Hortons in the evening and I sit and I listen to. These everyday Nova Scotians who have problems like shoulders, who have problems like the flu, who go to clinics - clinics are a great thing, don't get me wrong. I think the clinic we have in Windsor to assist the hospital is a great thing. There are a lot of things that are good in the health care system in this province and in this country, and I'm the first to say that because we have a great system. It costs us, yes, but we have a great system and nobody goes without, we should be very thankful for that.

[Page 16]

At the same time, I come back to the everyday chat at Tim Hortons and in my office from constituents whose concerns are, when am I going to get my knee fixed? When am I going to get this done? They don't want to hear, well, it's going to help us. They're not interested in, well, it's going to help us. Going to help us when, is their question to me.

I can go back and I can give them your presentation and I can say that Ms. English and Ms. McVicar passed on all this wonderful information. Again, it comes back to this whole world of technology ever-changing and it seems like we're never caught up. The question that I have with this is, what do I tell Ms. Fogarty? What would you tell her about her wait time? A year out now, and the fact that we have no service in Windsor and no service in Kentville and we're shooting everything - is this the direction that technology is now going to take us?

Are all the districts on their own separate entity, and I think you said yes, it's the responsibility of the districts to manage their lists, their queues. It's the same technology, the same across the province in all districts. I know that I've thrown a lot at you there with a couple of questions. Take the time you need to respond, please.

MR. CHAIRMAN: I think the question is, why were there so many systems and is there duplication?

MR. PORTER: I think she's got it.

MS. ENGLISH: How I interpret it is, what difference is this going to make for people and how do we communicate that these things are going to make a difference for people? I guess what I'll go back to is that the opportunities that something like the Patient Access Registry of Nova Scotia gives us is not just at the district-by-district level. We know that when people are looking at how to allocate, for example, orthopaedic OR times, they need to have a sense of what the needs are across all the services. Are they, in fact, getting the people with urgent needs in most? There will always be people who, because of the need for appropriate care, are going to need urgent care more than somebody else. I think that's a fact of life, that the best thing to do is to be able to allocate surgery time based on appropriateness and urgency.

The PAR NS system is going to be able to help us do that. I'm saying "going to be able to" because it's a new system. It has just been in since July, it has been being put in for a number of years but that's how long it takes to put it in.

Along with that there are other things happening. We have the Orthopaedic Assessment Clinic which is getting people in within just a couple of weeks, to be able to see a surgeon and a team to say okay, what's happening with you, are there things you can do while you're waiting, do you need to lose weight, what are the various things for active

[Page 17]

waiting? We're seeing a reduction in our wait one time, which is what we call the time from referral to the time they actually see a surgeon. That has been very beneficial.

The PAR NS system is one piece of what has been happening. There are a number of other initiatives that are happening at district levels. The benefit of going forward, sir, is that through the Surgical Care Network, which I mentioned in the speech, that network started out as a group that was looking at PAR NS and how we make the Patient Access Registry system go forward. It is evolving into a group that is going to be looking at surgical standards across the province, looking at things like how do we use best practice, how do we move things, how do we share information about cases? We believe that as things evolve, we'll be looking at capacity in one district versus another and how patients can get the most appropriate care the fastest. We can't do any of that without accurate information.

[9:45 a.m.]

Does it help Gloria tomorrow? Probably not. I probably can't look at her and say this access system is going to help you get your surgery or get you into an ultrasound faster. But we're building a system to be able to go into the future in a more appropriate way.

MR. PORTER: Thank you for that. I think all of those things you mentioned are wonderful, they're admirable, you know, that we can share data and access that. The more you can share with one another makes us better, as individuals and doctors and cases and all of those things, but at the same time they do very little to help speed up the process. It will be interesting come June 2011 to see exactly where we are and whether or not there are any reduced times.

You mentioned a couple of other entities like oncology. We've had a recent experience there with a family member and they have been nothing but wonderful there. Again, I've dealt with patients over the years, as a medic. It has always been very good and well looked after, the people are great. It seems that you can get in there fairly quickly. It's one of those kinds of issues, diseases that need to be looked after immediately.

Would you suggest, me having said that, that there's a lesser priority for orthopaedic patients or a different kind of patient versus maybe a cancer patient?

MS. ENGLISH: I don't want to get too much into clinical pieces here but when people are looking at resources, it would be appropriate to say that we need to make sure that true urgent cases are looked after in a timely fashion. If cancer surgery doesn't happen within a timely fashion, the trajectory for that patient may not be very good. It's not great if people have to wait for hips and knees either, but it has a different consequence so that all has to be taken into consideration when they are prioritizing things.

[Page 18]

MR. PORTER: I understand that and the words "timely fashion" are very interesting that you mention those and we'll talk about that as well. I agree with what you said, cancer patients, we know the outcomes, the timely fashions that they need to be treated and that's great that we're getting them through, or at least the bulk of them, rather quickly for testing and results and potential treatments.

At the same time, here we have Ms. Fogarty. Just as an example now, she's going to be off work for a year. What does she do? You can just imagine, I think in your opening comments you mentioned the word "anxiety" - anxiety is probably putting it quite mildly, in all honesty. The stress that will now be on her for her time away from work - financial, family - I don't have to explain all this to you, you know all of these things. She would probably look at that as being somewhat significant, as well, so there are a variety of differences.

I know you can't compare apples and oranges, as much as we might like to try to do that across the board as a system and as a province. We have it broken down so bad now that we've got these districts which I'm not sure that I favour a great deal, at least the number of districts we have, because the inconsistencies among them is what has bothered me over the years that I've seen. Why do we do business different at Capital than we do in Western, for example, versus Pictou County or others?

I know for a fact that there have been inconsistencies in simple things even like procurement of equipment. I never could figure that out and I'm a bit concerned when I hear, we're going to have one system but we're going to leave it to the districts to manage it. That tells me that there are nine different management systems that are now going to manage what is supposed to be a consistent system. Am I on the right path here or am I wrong? Please clarify that for me.

MS. ENGLISH: I think what is correct is that within the districts the OR committees in the districts do allocate the resources. What this system gives us though, and gives the Department of Health in particular, is a way of monitoring that. We will have access to the information eventually, as well, where we're able to look and say, are there differences and what's happening with wait times from district to district. We will have the information and be able to question, monitor and evaluate that, as well, that's one of the benefits of this system.

The Surgical Care Network is going to be reviewing the data and will be able to look at inconsistencies and will be able to look at things and say, if we're all working from the same bases of information and yet there are differences between districts, why is that and how do we take best practice from one district and put it into another? The Surgical Care Network is meant to do that, that's one of the purposes of that and that's a very positive thing.

[Page 19]

MR. PORTER: Do you believe this system is going to tell you anything you don't already know? We already know that the bulk of the people in Nova Scotia live in the Capital District, they live here in Halifax. We know that wait times maybe are longer in Halifax or shorter in some areas. We know that patients move around from the Eastern Shore and go for surgery at Hants Community in Windsor, for a knee or some minor surgery like that, and that has gone on. Is there a real benefit? I guess that's what I want to come back to again, is stressing the benefit here and the importance of that.

It's great that we know all that, but whose decision is it going to be to manage it? You say the department - is that the minister, the deputy, the Premier, the bureaucracy? I'm interested in knowing, who's going to manage that once we know? We're going to have variables, we know that, there will be variables in different districts, that can't be helped, it's due to demographics, population and everything like that. So who's going to manage that?

MS. ENGLISH: Within the Department of Health we also have just recently undergone some reorganization to be able to look at the areas that we know need to be strengthened within the department and need to have different levels of resources. For example, within our chief information office, we're also developing a decision support system and strengthening the system that has been there, to be able to provide information to the department. Within our policy shop, we're going to have a performance and accountability system. What we've also just done, we're hiring an executive director that will be reporting to my position of health systems quality, safety and wait times.

We're setting up an infrastructure to be able to take the information that's coming from a lot of sources, not just from the Patient Access Registry, but from CIHI, from all the federal sources, take that information, work with the districts to enhance accountability and manageability. Within the DHA Act, it is the district health authority's responsibility to deliver care. It's the Department of Health's responsibility to monitor, to evaluate and to hold accountable, and we're strengthening those resources to be able to do that. There will be, as I said, within the Department of Health, a health systems quality piece and that will be managing, working with the Surgical Care Network to make sure that the changes that need to happen, happen. That's what I can tell you on that right now.

MR. PORTER: I guess it comes back to the same thing, I want to go back to the Tim Hortons crowd who talk about this system and talk about health care in general. They have no idea what you've just said. They're saying for certain that here I have a district that is managing my health care, yet I have a province that is the overseer, and I'm a taxpayer. No wonder there's such a wait time issue, a mess in the system.

Again, I'm going to come back to the simplicity of this whole thing, it's the technology. I can generate a SIN number and pump it into a system and the federal government can tell me all about me and then some, anything they want to know. Why do we have a variety of all these systems? Why wouldn't everything from my medical records

[Page 20]

to my, you name it, that's related to Revenue Canada, there's all one huge data bank there now. Why are we veering away from something that's not all in one house, for lack of a better word?

The other problem is here I have the district managing my care and I guess I understand that, sort of having worked that way, but then I have the Department of Health as an overseer, who are these people at the Department of Health? Are these folks health care professionals? I don't mean that the way it sounds, forgive my ignorance, but I'm asking because I think it's important to the people. Are these doctors and nurses who are managing and overseeing what's actually going on by way of care? I think that everyday Jane and Joe out there would like to know who the overseer is and stress the importance of that. That is a key issue for people and they sit back and say, how does - and I'm going to use your name - Ms. English know what she's talking about if she's not a health care professional and hasn't worked the system and has never been there?

This is what the people on the street tell me, so this is a great opportunity this morning to have you here and I'm glad you're here, and I would have loved to have the deputy as well. All of you, you've been around here and you're knowledgeable, so I look forward to the response to that question because the people will want to know how that's going to work.

MS. ENGLISH: I heard two questions there, one was about the systems and then the other is who are the people at the Department of Health. In terms of the systems, technology, as you have identified, is evolving, it's growing. We know that there are various systems throughout the province and throughout the country, it didn't grow up as one system, it grew up a piece at a time. That's a fact, we know that.

One of the things that a great deal of effort is being put into right now as we speak is the electronic health record. You may have seen some ads in The Globe and Mail, in different places recently, where they're doing a campaign to have all the information in one place. I'm not the technical expert on that, we can get more information on the electronic health record, but the electronic health record is being developed to take all the different pieces of information from the Meditech system, from this system, from the systems of Capital Health, from the PACS system - that's the diagnostic imaging that is all going together into a system, one electronic health record for people, to be accessible wherever they are. That is in process, sir, it takes a lot of time, it does take a lot of resources, so choices have to be made about resources and what is being put into things, that's evolving. So that's the one place for information, it is coming.

The other piece in terms of who is at the Department of Health, there are a variety of people at the Department of Health. I am a nurse by profession with a Master of Nursing, Lindsay has a technical background and things, there are many health professionals at the

[Page 21]

Department of Health who are working with this. The folks at the Department of Health are very knowledgeable and I'm very proud to work with them all.

The people at the Department of Health are a mix of professionals who are able to provide a mix of services. I guess that's what I can tell you, there are many health professionals working at the Department of Health who are knowledgeable in their background.

MR. PORTER: Thank you and we'll come back there another day.

MR. CHAIRMAN: We'll move to Ms. Kent. You've got 20 minutes, it's 9:55 a.m.

MS. BECKY KENT: Thank you very much for that lovely welcome, it certainly is nice to be back and I can't think of a better time and a few extra meetings to come to where I have the Department of Health in the room and a former paramedic in the room. I don't see anything over my head that could tend to fall down, but if it did, I know I could be cared for, so it's a good day. (Laughter) It's certainly nice to be back. I want to thank you for being here.

My colleague, a member of the committee, had referenced his own experience and one particular resident in his riding that no doubt every one of us, as MLAs, has stories like that. I can tell you for sure much of the health issues that come to us are associated to wait times and often they're just difficult stories to hear, difficult for families to manage, so that's not news. I know and I'm confident that you and your department have a sense of that.

The other thing that was suggested a few moments ago was, I got the sense, perhaps, that you're spinning your wheels, you're putting money or time into something that is not - you know, is it going to be the most effective approach? Frankly, it's your job and it's government's job to take these steps when you see the inadequacies that we are facing in our health care and our wait times that families are experiencing and people are experiencing.

To suggest that it isn't going to work or it's not the right choice, of course they can condemn that and say that's negative, but to do nothing is the opposite and that would be unacceptable as well. I'm pleased to see that you're making these strides and you're not fully there yet. I think that's an important aspect to remember. You've noted it, that we don't have all of the bugs worked out, we don't have all of the end result that we can speak to today, but you are giving us a sense.

In fairness to our colleagues who have brought this up, our accountability is to our constituents who come to our office. We look to you for ways to express and explain to them what you are doing so that at the end of the day they can go home and tell a loved one what it is our government and our Health Department are doing to help them.

[Page 22]

I, too, am still a little confused about how, at the end of the day, we can explain the positive and the impact this will have for our constituents, so I'm going to ask some more questions around that. I know you've probably covered some of it already but that's what we need to be able to do and to tell our public what it is that's going to be a positive effect at the end of the day for them.

We have a list, and I know that makes sense. Is that list complete now, do we fully have an understanding of who is on a wait list for surgery right now?

MS. ENGLISH: I'm going to hand this one over to Ms. McVicar because she has been working more intimately with it.

MR. CHAIRMAN: Ms. McVicar.

MS. MCVICAR: Thank you. We have the Patient Access Registry implemented as of July. As Ms. English was saying earlier, we are in a process now of having the districts validate the information that they've put into the system because flipping a switch on a system, there's a lot of work that goes up into it. The bulk of the work, for clinicians and folks on the ground, was taking their wait lists that existed on paper and pumping them into a new electronic system.

You need to go through, work out the bugs, work out data accuracy: was the data entry done appropriately, are there errors? Then there's a second level of vetting that needs to happen at the district level and that's really where the clinicians get a look at their wait lists for the first time and they do some integrity work on it - does this look like my service? What's going on here? Is this accurate? - and then vetting the information throughout the organization at the district level.

[10:00 a.m.]

While yes, we have some preliminary information, the caveat is that there's still some validation happening at the district level and we won't consider it complete until January 1st, the date we have agreed to with the district health authorities for having the information.

MS. KENT: Okay, that was my next question, is there a timeline within which they have to respond? Are they responding well to this process and the development of this, the district health authorities? Are you getting any push-back, is that going well?

MS. MCVICAR: Yes, adoption has been going well all along. I attribute that to two years of engagement leading up to it and explaining what this means: explaining what the transition is; explaining, as we are doing today, to the folks who work in the district health authorities, what are the benefits, how is this going to work for me, how is this going to change my job? I'm used to going to this piece of paper, I don't want to go to your system.

[Page 23]

It's working through that kind of process: here are the benefits, here's what it offers you, the user.

MS. KENT: But they have been fully engaged in that so - I mean they're on the ground, they're there in front of those patients and those families every day.


MS. KENT: That's good to hear. So let's look a little further out, let's look to 2011. We have this list compiled, we have this report that you're working back and forth with our district health authorities, and all of a sudden you recognize that something is out of line, something is unacceptable. What kinds of - and perhaps that's not fully fleshed out yet, so I'm not going to necessarily hold you to it 100 per cent. In your mind's eye, what do you envision the Department of Health could do or direct a health authority to do to correct that if, in fact - because the end result is if we come across wait times that are unacceptable, after we've got everything up and running, what kinds of steps will we do to fix that and pull it back to right?

MS. MCVICAR: That's a great question and I just want to pay attention to how you've described this. We're talking about a list and, as Ms. English said earlier, a huge benefit, actually taking the lists that existed here, there and everywhere into a centralized location for the districts and the Department of Health to access and be able to review is very positive.

There's more than a list in the system. It is a robust reporting tool for folks at either the operational level or the provincial level and that's really important to know. I can give you an idea of some of the benefits we could expect to see, absolutely, particularly based on the experience that we've seen in New Brunswick. One example of this is that there's a report in the system that will show who is waiting but it breaks it out by different urgency levels. So patients who really should have their surgery done in a week will have their wait times, here's the 50th percentile, here's when most are getting in, all the way out to the folks who are the more elective patients.

What we can begin to see when we look at this information and what we've seen in New Brunswick and have had huge success in that province is being able to see, okay, are the folks who should be getting in within two weeks getting in within two weeks? Are the folks who should be getting in within 12 months getting in within 12 months? What they were able to do in New Brunswick is look at this information and say whoa, our least urgent patients are actually getting in before our most urgent patients. By taking this information and being educated and more familiar with how wait times are allocated and how our time is being allocated based on patient urgency, they were able to bring their wait times under two years, then under 18 months for the whole province. Now they're aiming for under 15 months.

[Page 24]

Those are exactly the kinds of benefits we are expecting and hoping to see in Nova Scotia because it is not about removing wait times altogether - there will never be a zero wait - it is about getting patients in within a clinically appropriate period of time.

Back to the piece around the question the gentleman asked earlier about what is new, you're not seeing anything we don't know. Well do you know what? Seeing the data presented in this way is actually a fabulous step forward, in terms of - there's one thing about knowing things anecdotally and our clinicians are extremely knowledgeable about their own wait lists and what is going on in the district. But to be able to pull it together from a provincial perspective and see the information broken out by surgeon or by procedure - we can slice and dice this data in numerous ways but being able to see the clinically appropriate wait time period that patients are getting in within is a huge help.

I don't want to take up too much time but we actually saw an interesting effect early on in one district that went live, where it showed oh my goodness, your least urgent patients are getting in well before your most urgent patients, what is going on here? The thing is that before the system was in place, you wouldn't have this information, you wouldn't be able to ask those kinds of questions. So the question was asked, well what is this effect, what are we seeing? It turned out that once the access manager was able to dig down a little bit deeper into the situation, that there was a new surgeon in this district and that surgeon had received patients from a number of surgeons. The surgeon happened to have received a bunch of elective, non-urgent patients. He was using his OR time and it just so happened that for that reason, elective patients were getting in very quickly, because it was a new surgeon. That effect would eventually go away in that district, as that surgeon's patient list changed.

The ability to ask that kind of question, to have the information at that level and to drill down into that individual patient if we want to, who is this outlier, who is this person waiting 900 days, for example - it is a great step forward.

MS. KENT: Thank you. Again I'm trying - my question will be around trying to understand a little further out, the ripple effect of scheduling changes and how that is communicated to our patients. We hear some stories where someone gets in because of the urgency of it and another person might have a five month out date. Then we hear of someone who gets a call and says that's changed. Inevitably sometimes those things change.

As this system becomes effective, which I have every reason to believe it will, what is the communication process for our patients? Do you have input into that? Ultimately this is the department's overseeing umbrella mechanism at the district health authorities. What can you do to help with that, to see that this system becomes well-communicated to the patient who, at the end of the day, is most directly affected?

MS. MCVICAR: As Ms. English was saying earlier, a lot of that function in terms of communication with patients will be through the access managers because they are put in

[Page 25]

place in each district to have that patient level information, to be able to drill down and see an individual patient's journey. The system tracks every point the patient has on their way to surgery, whether it is cancellations, the reason why they were cancelled, the fact that a patient may be in Florida six months of the year, all of that information, to be able to have a more detailed conversation about the patient, look at the wait list they are currently on, look at the length of the wait list and help communicate with them on the particulars of their wait.

From a different perspective, another policy we're recommending provincially is really based around the success we had validating the wait list initially before turning the system on. We're advocating and recommending that access managers stay in touch with their long waiters. This has worked very well in other jurisdictions in Canada, again, particularly New Brunswick, where after a year or after 18 months or whatever time period we agree is appropriate, that long waiters will be contacted - how are you doing, are you still waiting - to ensure that the wait list is validated but as well to let patients know that there is going to be a communication channel there, there is a role in the district that is a liaison between the clinical and administrative worlds, that they can communicate with about their issues and about their waits.

MS. KENT: Good, thank you very much. I want to switch now to the surgeons. What role did they play in helping develop where you are today? How is the feedback with that, as far as their embracing of it? How does this benefit - I mean they are one of the biggest common denominators that will most affect this wait time. How does this affect them in how they do their job? I guess before that, what role did they play in getting to here?

MS. ENGLISH: Yes, they were instrumental in that. As we talked about, the Surgical Care Network was set up at the beginning of this project that had all the surgical chiefs and their anesthetists there as well, as well as there were surgical working groups that worked on the prioritization tools. So it wasn't that we handed them a tool and said here it is, boys - they were part of developing those tools as well. We had something to work with but they had to make sure that they were part of that, so they were instrumental in the introduction of the whole thing.

They had to be working with changes, they had lots of questions, they had changes of practice they had to work through. I would say that to some extent they are still working through them, in some of the districts that is still happening but there is very good compliance to this. They were part of it, they came together, they had consensus and they went for it. So absolutely, the surgeons were part of it.

The biggest change to their practice, I believe, is two-fold. One is that they now have to do a prioritization check list before a patient is put on a wait list. They would have had their own method of prioritizing and now there is a standardized way of doing that. It doesn't mean they can't have clinical judgment but there is a standardized way of entering people into the wait list, so they have to do that for every patient.

[Page 26]

The other piece is going to be as the information is used around the management of OR times, so they'll be involved in that. Surgeons are represented on OR committees and there may be changes in OR times to individual surgeons but that is going to be based on prioritization and information, and as we all talked about, getting the most urgent patients in the queue at the right time. Lindsay, is there anything you'd like to add to that?

MS. MCVICAR: I agree with everything you've stated. Another change for surgeons throughout this project and these new processes is that wait lists now exist in a central registry. That's a culture change and a game-changer for the entire health care system. For some clinicians, that is something to get used to. It's a new concept in terms of who is able to look at wait lists and have accurate data and timely real time data on the wait lists.

For some surgeons who were using local systems or had their own local really good processes in their own offices, it's not to come in and say oh, the way you were doing things was bad; it's about coming in and saying, here's the provincial benefit to it. That was working with those clinicians who had to maybe change their processes that they valued a lot, to bring them up to speed with the province or, in some cases, have the whole province catch up to them.

MS. KENT: When you referenced standardized - we're talking about a patient in Shelburne, a patient in Musquodoboit, a patient in Cape Breton and a patient here in HRM. Can you just give me a little sense of what will change in what they're receiving now, to when this is in full benefit, what that standardized process will do for them and why is that different now?

MS. MCVICAR: The standardization has to do with it being a common tool being used by all surgeons within a specialty, the same questions being asked of every patient and that information all flowing together to calculate a score and a target surgery date for each patient, based on how the questions are answered for these tools. So a patient in Yarmouth is going to be prioritized with the same tools as a patient in Cape Breton, asked the same questions and the score being generated in the exact same way.

What this gives us is again, a wait list that actually divides patients out by their urgency category and which may not be an obvious nature to a patient. For the people who are responsible for scheduling and for the people who are involved in monitoring the health care system, it is of utmost importance because in the past we were able to provide wait time information as a province but when you can't break it out by your urgency categories, it really becomes less meaningful and less valuable across the board, in terms of making those improvements that we need to for patients.

MS. KENT: We've called this a list or is it a report? The information that you have, you've gathered and you're going to have in the department - what things are in that report? What information is there and will it be published and who would get to see that and how

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often will that happen? How often will you update this information? Is this an ongoing thing or is it just every so many months, years?

MS. MCVICAR: A good question. There's really a two-fold answer here. The first is that there are a number of reports that go into the system. First and foremost, surgeons are going to receive their wait list, as you've been describing, that will show all of their patients, based on their urgency category - are you past your target date, are you nearing your target date or are you still within more than a month away from your target date?

There are a host of other reports that show more aggregate level information, to show how are we doing as a service or how am I doing, in general, across all my patients, in terms of my wait times for getting patients done, who are my outliers. When it comes to generating reports, surgeons and administrators at the district level or at the DOH can receive reports any time they want from the system. One of the biggest benefits of putting the Patient Access Registry in place is the accessibility of the information. This could be a big issue with information systems being able to generate reports and have them readily available in a timely fashion for those who need it when they need it and this system is in place and able to provide that.

In terms of public reporting, we will be using the Patient Access Registry as our source for surgical wait time, reporting to the public in the Spring. We're thinking in the June time frame. We will probably start with quarterly wait time reporting and refresh the data every quarter.

[10:15 a.m.]

In terms of best practices, it is really a toss-up between refreshing your information monthly to the public or refreshing it quarterly. It is really trying to achieve that balance between timeliness of reporting versus making sure the data is as quality and as accurate as possible.

MS. KENT: You mentioned about performance policies and accountability policies. That's an important part of it, audits of the system that we have and so that makes sense. I'm pleased to hear that there will be a rollout to that, so the public understands at the end of the day the evaluation of, is this working. That's an important part, of course, this committee, but the public should have access as not everyone tunes in to this lovely event at the time we have these meetings.

On an ongoing basis, though, you have real time information that's coming back and forth from the district health authorities, even though a report is not being generated. To be very clear, it doesn't mean that information is not constantly being communicated back and forth through the department through this process, is that correct? Yes, okay.

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Audit, is that something that's forthcoming? How often? Do we have that established?

MR. CHAIRMAN: Ms. McVicar, I was going to say that Ms. Kent's time has run out and maybe we can come back to that in the next round. We'll move to Ms. Whalen.

MS. WHALEN: Thank you very much. I would appreciate it just if your answers could be a bit short because our time is always limited here at Public Accounts Committee.

I did want to ask you just once about the timeline of the introduction of this entire new system. Clearly it seems to be a good idea, it has worked well in the four or five provinces that you've alluded to in your report.

When I asked you about the earlier wait times money that was made available from Health Canada and that we were to address our wait times, that was practically when I was a new member and I've been a member seven years - I think it was 2004, it's been years ago. When I asked you that question, you said that they had actually at that time looked at a number of different things that you needed to do and one of them was this Patient Access Registry, it was recognized as a need. Can you tell me how long we've sort of been looking at it and why it wasn't done sooner; really that is what I want to know. So how long have we been considering it and what took so long?

MS. ENGLISH: I just want to make sure I'm answering your question accurately. I want to make sure that the money that I referred to around the projects is the same money that you're referring to that came in 2004, because this money did not come in 2004. I'm wondering if we're talking about the same thing.

MS. WHALEN: In reducing wait times, you've made the case and the minister has in her press releases and so on that this Patient Access Registry is going to lead to better and more prompt service.


MS. WHALEN: So we know the bottom line is we're paying almost $12 million and have paid that out, a lot of it leveraged from the federal government, thank goodness, so it's not all Nova Scotia, but still, every dollar we bring in to the province we want to see that it has a benefit to patients. The bottom line is better service to patients and less wait times. Again, why wasn't this done sooner? It seems to be that we needed that in order to shave down the wait times on all of the surgeries.

MS. ENGLISH: I guess the answer that I can best give to that - and I'll ask my colleagues if they have a different answer than that - is that the money that was available for the information system part of things through Canada Health Infoway and Health Canada

[Page 29]

came to us at this time, in 2007, I believe, is when it all started. So that's when targeted money for those kinds of things came out, Ms. Whalen.

The money that you're referring to in 2004, and frankly that predates me being with the department so I'm not 100 per cent sure what that piece is, when money came that was available for targeted initiatives around patient registries, that's when we went forward and made sure that happened.

MS. WHALEN: Again, we talked about this being a two-year project, but New Brunswick got theirs begun in 2007 and up and running in 2008. Can you give us some indication why we were slow?

MS. ENGLISH: I guess Ms. McVicar alluded to that earlier. New Brunswick started out, they did their piece of work and we learned from New Brunswick that there were some things we needed to do in terms of an incremental approach to things, of not putting everything in at the same time, of making sure that the change management was done appropriately and so we took longer because it was indicated to take longer was better.

MS. MCVICAR: I'd just like to add to what Paula was saying, to point out that in Nova Scotia we also implemented operating room information systems as part of this initiative. In New Brunswick they either stayed with the same information systems that were on the ground already or devised a more manual approach with the Patient Access Registry. There was a lot of interface building between the systems that are currently used in Nova Scotia, in the operating rooms, as well as the implementation of new ones in seven districts. That, in and of itself, was a huge effort and a huge component of this.

We recognized that operating room information systems were something the districts had wanted for years, so then they had seen the great value. We wanted to take the opportunity with this federal funding to put something in place that would be of great value to them operationally, as well as from an access recording piece, but also for the maintenance and use of their OR time every day.

MS. WHALEN: I do understand what you're saying, if you added an extra system, but I have two questions that would follow up with that. One is, we often hear this at the Legislature - when we're here at Public Accounts particularly - is that we have too many different systems out there and they don't talk to each other. We've seen it in the diagnostics trying to be digital with X-rays and sending files back and forth, we've got all kinds of different systems, which is a tremendous inefficiency. Was that one of the impediments that you faced?

MS. MCVICAR: In this project, it was not. It was very clear that the Meditech system was the one that would go into the districts that required a system. From an access registry perspective, this system - and I don't want to get into the IT stuff - the OR information

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systems sit at the district level and they feed up to a registry that sits over all of them, so the interfaces were vertical not horizontal.

MS. WHALEN: And every DHA is using the same one? Meditech system is being used everywhere?

MS. MCVICAR: In seven of the 10 districts in Nova Scotia.

MS. WHALEN: Is Capital Health one that doesn't?

MS. MCVICAR: Capital Health and the Valley share a system and the IWK uses a different version of the Meditech system.

MS. WHALEN: Capital Health being our biggest one. Was it no trouble that they were using a different system?

MS. MCVICAR: It was no different than the Meditech system in terms of creating an interface for information to flow to a registry.

MS. WHALEN: As I say, I'm not a technical IT person either, so I don't want to go into it further than that, as long as you tell me it didn't cause any trouble. I just wanted to ask a further question on the timing and the rollout. If we knew that New Brunswick and Nova Scotia got the money at essentially the same time, was it a deliberate decision internally to wait and watch New Brunswick and see what they did and whether we learned from any of their mistakes?

MS. MCVICAR: I believe New Brunswick was already implemented and rolled out by the time we got around to planning.

MS. WHALEN: The information I have is 2007, they were implementing in 2008, they began in earnest, it went live, I guess. So it would seem that it overlapped. Have you been in the position for three years?

MS. MCVICAR: In this particular position? I have been involved in wait time reporting for over three years, yes. They were nearing the end of their implementation when we were getting started in planning, I shouldn't say they were entirely up and running and live, but we were able to leverage the lessons learned during that period of time.

MS. WHALEN: I do go back, again, to the timing because they seemed to have been able to do it in a year or within a year at least on paper, it appears to have happened. We seem to have taken three, if you look at the financial rollout of this from the early proposals to now. We're not yet ready to make it live for the public or have reporting available because it's going to take time; I understood about validation. We're not really there yet until 2011,

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which is even longer, so I'm just wondering how we can reconcile that it took us that much longer?

MS. MCVICAR: I can't speak in any kind of knowledge or detail to exactly what the project planning around the New Brunswick project was really about. What I can say is that it was an immense achievement in Nova Scotia to implement the number of activities, information systems, policies, process changes, get the buy-in and the support from the stakeholders that we need to along the way. What we ended up with is a system that is being used, compliance is 100 per cent with using these new tools and we're very fortunate to be in the position we are now.

MS. WHALEN: When it does go live, I just wanted to go to the kind of reporting that New Brunswick does. One of the criticisms we've heard in Nova Scotia and frankly a question I had when we looked at this system when it does go live, is we do have the other Web sites, My Surgery, which people can look at and the wait times information that is kept on the Department of Health Web site. So now we're going to have a third one which will be this one. No? How are you going to integrate those two then? It seems like we may have a proliferation of them.

MS. ENGLISH: We're not going to have a third Web site for wait times. This information from PAR NS - the Patient Access Registry - is going to be the source of truth, if you will, for the wait times Web site. So the level of detail of the reports that you see, those are not going to be reported publicly. Those have patient names, those are for internal use and for management. This is the information that will populate our wait times Web site.

MS. WHALEN: I'd like to ask about how that format on that wait times Web site will look? When you look at the New Brunswick one, they show you a tremendous level of detail. They show it by facility, so I'm just looking at the first page of it that we had printed, but it will show every one of the facilities that does surgery and it shows it by type of surgery - there's a whole list of different surgical procedures and how long people are waiting. The other important thing is they show it by percentage and by the actual number of people. We've been criticizing government over the years that all we see are the percentages and that is quite misleading, is it 10 people and you're talking about 10 per cent or is it 1,000 people at 10 per cent? It makes a huge difference. Can we look forward to seeing a level of detail that's much greater than we have currently?

MS. ENGLISH: I'm going to put that to Lindsay.

MR. CHAIRMAN: Ms. McVicar.

MS. MCVICAR: We couldn't agree more with your observations. We recently redesigned and relaunched the Nova Scotia Web site in preparation for the IT system that is

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coming in place for surgery and to bring the Nova Scotia provincial wait time reporting Web site up to standard in terms of national standards and best practices for reporting wait times.

We know exactly what our colleagues are reporting in the other provinces and we admire the work that is done in other provinces, and strive to get there ourselves. What you need, of course, is a source of information that's robust and provide the accurate and timely information we need to provide that additional . . .

MS. WHALEN: So you will give us the actual number of patients? Obviously, we protect privacy, we don't need to know names, but by facility, actual numbers and by procedure. Can we look for that level of detail?

MS. MCVICAR: Yes, so surgical volumes is something, along with other things like trending . . .

MS. WHALEN: Because it hasn't been very robust at all, it wasn't very helpful. If you were a person - as we talked about - an individual who has an injury and you wanted to know where you stood, you'd have no idea how long it was going to be. I think that's the key thing here, that one of the things the minister has said is that you're supposed to be able to find out where you are in the queue and how long it's going to take. That is important for people to know so that they can plan and understand how much time they're going to have off work and so on.

I think there's very little time left. I wanted to ask you about the capability of this system, I'll just be brief. Basically, will it have the capability of letting surgeons assign a surgery to another district where there's a surgeon available? Will they be able to be involved directly so that they could say to their patients, there's more room in another district, you can go over there?

MS. MCVICAR: To identify capacity in neighbouring districts to potentially . . .

MS. WHALEN: If they know the waits aren't as long.

MS. MCVICAR: That is something that this kind of system would absolutely be the kind of information source that could inform those kind of decisions. I don't want to play down the complexity of patients travelling for surgery because it is significant for certain specialties but yes, this is the kind of information source for that to inform that kind of decision.

MS. WHALEN: So the surgeons themselves could look at that information and say, I'm booked up for three months but my colleague in Windsor can take you next week.

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MS. MCVICAR: To be specific, the surgeon in one district could not go and look at the data from another district but there's nothing stopping surgeons from having dialogue with each other within a specialty, now that they have this information. Again, I want to point out, Ms. English said earlier about the Surgical Care Network - this is exactly the kind of issue that having a provincial body that consists of chiefs of surgery and other clinical leaders and administrative leaders, together with the Department of Health, looking at the data to answer those kinds of questions.

MS. WHALEN: Okay. On another point, in one of the minister's press releases from September 2009, she indicated it would help make decisions where we can put health care dollars or health care resources to better use. I'm wondering if there's any move afoot to have incentive pay around performance?

The reason I ask that, too, is there's a reference in your PowerPoint that talks about surgeons' remuneration in semi-annual payments, starting October 10, 2010. It is not said why it is on Page 5 of the presentation. Could you relate to that? Will there be some sort of incentive pay?

MR. CHAIRMAN: Ms. English, I'm afraid that Ms. Whalen's time has run out. Maybe the Progressive Conservative caucus can follow up on that but in the second round it's a little harder to allow for extra time.

We'll start with Mr. Porter for the Progressive Conservative caucus and then we'll move to Mr. d'Entremont, I believe. You have 13 minutes.

MR. PORTER: Thank you, Mr. Chairman. Yes, I'll take a few minutes and then I'll hand it over to Mr. d'Entremont. I want to just talk a bit where we left off, it was around resources. There's a resource issue today, there will be a resource issue tomorrow and in June 2011, there will still be a resource issue. What you have described to me as we'll then be able to take all this wonderful data and help resolve some of the resource issues. Did I hear that correctly? I just want clarity on that.

[10:30 a.m. Ms. Diana Whalen took the Chair.]

MS. ENGLISH: What you heard me say is that this data will help us and help the districts allocate the resources they have more appropriately.

MR. PORTER: Okay, thank you for that clarity, that's sort of along the same lines. So having said all that, that's great to say. How and where are the people coming from to offset the resource issue? It's good that you can look at the data and know that we have an issue. I think we know where our issues are today, we've got hospitals closing, recommended to be closed, people are upset.

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I'm not clear and I'm not saying I don't believe you because that's not it. I know technology, I know the value of having such data, I think it's good. I don't want to take away from that, I think that this was put in place and it was a good thing to go in place; it's always this time issue. What people want to know for their $11 million, if that's the price tag on it - how are we going to fix the problem? It's great to know the data, what are you going to do with it?

MS. ENGLISH: The way I answered your question first was that to help the resources that we have to be allocated appropriately. As you . . .

MR. PORTER: Not to interrupt then, just quickly on that, does that mean you are going to send Doctor A from Halifax to Glace Bay to do surgery?

MS. ENGLISH: I think it's premature to say that. I think what it does is, it gives the information so that the Surgical Care Network, for example, can have that kind of dialogue to see what's appropriate. It opens up the opportunity. In terms of resources and where are the people going to come from, we're always going to have parameters on what our resources are.

MR. PORTER: And this comes around again to what I was saying about districts all doing their own thing, not a consistent application; procurement was just one example. It is the whole thing. We are one province, we are less than one million people, how hard can that be? It is incredible to know how hard that can be but one of the problems, I understand - what is it, 425,000 or something now live in the HRM, almost half, and more than that again travel in here every day. I understand all those demographic issues.

The people are looking for an answer to how good the system will be. I think the system is going to provide something valuable, it is what we do with it, with the valuable tool and information gained from that that will be the real benefit, I think that's fair to say.

MS. ENGLISH: I think that is fair to say. You can have a bunch of information, but if you don't do anything with that information its value is lessened.

MR. PORTER: So I guess on behalf of my constituents and everyone in Nova Scotia, my message today is caring that there is the piece that is really key when you are out talking to the folks at Tim Hortons or on the street or in your office. This is what they care about, they don't understand way up here, nor most of the time am I getting, they don't care about way up here, they want to know when it affects them, why this is. This is when we are getting our calls and our questions - why is this so hard? - because they don't understand all of this above.

I appreciate your answers on management earlier, you spoke about clarity of who you all are, by way of profession. I think that's important because I'm going to take the Hansard

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of this back and I'm going to show it to the people who are asking, that they actually do have people who are qualified to be in those seats making those decisions, helping with the overall system management and surely to God those decisions will be made based on experience and the right values.

I want to move quickly to something you said here in your opening comments, Page 15. This is a great concern for me as well and I'll give you an example of why - we will maintain a confidential record. Are you telling me now that you're not maintaining a confidential record? Could I clarify that, who has access to patient information?

MS. ENGLISH: I guess what I would say to you, and again I'll ask Ms. McVicar to correct me if I'm wrong, is that because there hasn't been a provincial registry before, the province has had nothing to do with the wait lists that were sitting in, for example, physicians' offices. So that was to the physician and to the district to keep those records confidential. We are now going to have access to information and it will be held confidentially.

MR. PORTER: Okay, maybe on the technical side of it then I'll go to Ms. McVicar for a question and again around this. It seems to me at this point in time - and correct me if I'm wrong, please - at this point in time there are issues with the security of the system, who can access it and who cannot and get information about patient records, whether they are surgical or otherwise.

MS. MCVICAR: Are we speaking in terms of the health care system in general or Patient Access Registry?

MR. PORTER: We are, indeed, yes, Patient Access Registry.

MS. MCVICAR: Well, first of all, speaking broadly, every time we do any kind of an IT project you start with a privacy impact assessment. That is standard practice for the government. We did that for this project and we're actually in the process now of augmenting it because there's a difference between implementing a system and having it being operational. Now that we have a better understanding of how it's being used, we're augmenting the impact assessment to reflect the users.

What we're doing for the Patient Access Registry is having a very strict access to it, in terms of who can access it. Right now it's really just the access managers and the registry manager and I believe one scheduling clerk and an IT person in the district. All of those individuals have signed confidentiality clauses as part of their profession and professional activities in the district level and at the Department of Health.

MR. PORTER: What would happen if those were broken? I'll give you this example and you can give your thoughts on it. I don't want to take a lot of time but I am aware a

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family member has a son who is involved in an accident, goes to the hospital. Lo and behold, another family member works in the hospital as a ward clerk. Before the doctor even gives an assessment to the mother and the father of the condition of the son, the ward clerk is in the hallway spilling it all because she has access to the records.

You can see my concern with regard to confidentiality and records. One, it is okay to say that we're going to sign a confidentiality - I think that's pertinent, that's standard practice. More importantly, why or how could this person have access to the system at certain levels? Again, technology is a wonderful thing and it's nice to be on the leading edge not the bleeding edge, where are we? Are we in a place where we can't control our technology?

MS. MCVICAR; We absolutely are able to track. There's a software, there's auditing capability in the system that tracks every person who has looked in there and what they have looked at.

MR. PORTER: How often is that monitored? Monthly? Weekly? Yearly?

MS. MCVICAR: That is the responsibility of the district privacy officers.

MR. PORTER: Here we are again, back to the district. Okay, so everything keeps coming back to a district. Again, I don't mean to harp on this, guys, and I don't want you to take it in a personal way, it's not meant that way, it's just a systematic thing that does not work. There's too many inconsistencies when you break things down to district and you pass the responsibility on to someone else. Again, it comes back to the overseer and that's why I asked the question about monitoring. You are the more technically capable person here, from what I understand, who has been part of this implementation, so my question is who is going to monitor?

There's a belief, at least in my opinion, that ward clerks probably shouldn't have any access to a chart, unless it's maybe page one of five. You know there's got to be these levels. How defined are we?

MS. MCVICAR; Well we define access to any system based on the person's role in the health care system. In the case of a system like the Patient Access Registry, an operating or information system where all the data comes from in the first place, it would be on what your role is. As I understand, ward clerks are responsible for entering, for example, post-operative information into a system, so they would therefore need to have access to the system for the duration of the time that they enter that information and for the scope of the information that they enter for that particular patient. Can they go search the system for every single report that's in there? No.

MR. PORTER: But they can see and have access to every little thing that is in that chart over the course of my lifetime, if it's all in there? If there was something personal there,

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if I had something happen to me years ago that I wouldn't even want my wife to know, just as an example, yet this came out through this system, we know right now in the secure system, by way of the old paper chart, that's not possible because numbers of levels of people cannot pull that up. Only they can pull up the current chart, I'm in the hospital, I'm being charted, whatever. I have family members who are expressing this as a great concern and they're worried about it because we have a confidentiality law in this province and that's being broken every time this door is opened, so to speak. Ms. English, did you want to . . .

MS. ENGLISH: I think it has to be recognized that there are members of a health care team and that members of that health care team don't only include the providers, the nurses, the doctors, but they also include people like ward clerks and booking clerks. They have a job to do and you wouldn't want the doctors or the nurses to have to spend their time doing the clerical pieces of work that others are better trained to do and that the nurses and doctors are doing theirs. I think we have to acknowledge that they are members of the team.

As Lindsay indicated, there are parameters around what the booking clerk can get into and what reports she can do, she only has a piece of it, for example. So we have to acknowledge that others are part of the team and need to be part of the team for efficiency.

The district health authorities who are responsible for the delivery of care by the Act, they also have HR policies and confidentiality policies. I've spent over 30 years in the health care system and I know and have been aware of people who have been terminated because of breach of confidentiality, because somebody picked up a phone and said, I understand a baby is born, when they wouldn't have known that if they hadn't worked in the hospital. People lose their jobs when they have a breach of confidentiality.

MR. PORTER: Just for clarity, Ms. English, the proper channel that's here is to follow through with that HR director, et cetera, whatever and force that to the limit without any issues, that is what you would recommend as per normal and any other kind of employment where such laws would be . . .

MS. ENGLISH: Absolutely. There are policies there to be put in place, if people are aware of breach of confidentiality, the people in the districts need to be made aware of that so that the appropriate action can be taken.

MR. PORTER: Is there any consideration being given in the system - and I'm talking about family here - about family not having access? Let's say Susie is the ward clerk and her sister Joan is the patient. Should Susie have access to the patient records?

MS. MCVICAR: Absolutely not, unless the patient gave explicit consent for her or him to get that information.

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MR. PORTER: Is that something, Ms. McVicar, that we would be looking at by way of policy to go in place if it doesn't already exist? This is the example that I'm using, this is real, so then put yourself in this lady's position, this family, the position that they're in, just having everything spilled. Who is the ward clerk to tell me about my son's issues that are severe from a motor vehicle accident and I haven't even seen the specialist or the doctor yet? Why does this happen, how can this happen? So you can see where I'm coming from with this and it's all a patient record thing regardless of it's in the ER, surgery wait time, what you're doing, you know what I mean. This is all very relevant in my opinion.

MS. MCVICAR: That's a very serious situation and I can say those policies already exist. To me, it sounds like a breach of . . .

MR. PORTER: In your opinion, these are all in place now?

MS. MCVICAR: At the district level, and you would follow up with that individual district privacy officer to discuss it.

MR. PORTER: With regard to family versus family they would be there?

MS. MCVICAR: Absolutely.

MR. PORTER: That's good to know, I appreciate that very much. Thank you for being here and answering my questions. I'm going to hand this over to Mr. d'Entremont, who is anxiously waiting to ask a few questions.

MADAM CHAIRMAN: Mr. d'Entremont, you have a minute and a half. (Laughter)

HON. CHRISTOPHER D'ENTREMONT: It seems to me this happened last time I came to Public Accounts and I let him have my 10 minutes. All I can say is I'm very glad to see you here today. This is a wonderful project, I think it has taken a little longer than I would have anticipated when we first got the dollars available for it. I think I will save my comments on whether it's a good system or bad system, when it does get implemented in 2011, and we start to see some of these pieces of information on wait times. Again, it's good to see you here and we'll be watching it closely.

MADAM CHAIRMAN: With that, we'll turn it over to the NDP, just a little bit ahead of schedule. Mr. Preyra, you have the floor for 13 minutes.

MR. LEONARD PREYRA: I do appreciate you being here and it sounds like a great project in the works, we're looking at it somewhere in the middle from the sounds of it.

I want to follow up on a question that Mr. Porter was asking about, confidentiality. I heard you say that access to information will be restricted to the access manager, to the

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registry manager and - on a need to know basis - to the people who are actually serving the patient. Is that fairly standard practice? I know you said a number of provinces were implementing it. Does that conform with best practices as far as you know, in terms of access to information?

MS. MCVICAR: Absolutely and our priority is adhering to privacy policy and being consistent in Nova Scotia with what our privacy policies are and with other systems that are on the ground.

MR. PREYRA: The relationship with the doctor and patient and the access to documents relating to patients, those conventions have been developed over a couple of hundred years. Are those practices still being followed in terms of who gets access to a patient's record? Does the registry change anything in that regard?

MS. MCVICAR: No, doctors are accessing all the information they would have ever had access to in a paper form in their own office, just via reports that are provided to them by the access manager.

MR. PREYRA: So essentially what we're looking at then is a larger system that's being created that would allow health care centres and health care providers to share some information to reduce wait times, is that . . .


MR. PREYRA: So let me just ask in general, a question was asked earlier about what we're not doing. My question is, where do you see the system going down the road? What are we trying to accomplish? What are we trying to build here? Ms. English?

MS. ENGLISH: This system has begun and we called it Patient Access Registry for Nova Scotia for a reason. Right now it's being used for surgical wait times and that has been the experience in New Brunswick and that was our need. There is potential for this registry system to be used in other areas as well beyond surgery. We want to make sure that we have the surgery bit down pat before we move into anything else and assess it and evaluate it, but there is potential to use a system that goes beyond surgery.

[10:45 a.m.]

So that's potential, we have to evaluate to see if that's where we're going to go. Again, it's the use of a single source of truth to be able to make decisions upon, talking about the evolution of the Surgical Care Network and how the Surgical Care Network will use this information to have discussions and make decisions on how surgery evolves in Nova Scotia, how best practices can be used and those are some of the pieces. So it's the potential to go beyond surgery and it's making sure - to have a surgical network address some of the issues

[Page 40]

that the honourable member here talked about in terms of district by district, it gives that potential to look at things provincially and how things are looking and not just within the single scope of a district health authority.

MR. PREYRA: Very soon, I understand, from earlier hearings we had that this will be married into the larger electronic health record system as well and there are a number of units entering the system and they are being merged and reconciled as we speak?

MS. ENGLISH: Yes, that's right. It's compatible with exactly where it stands in the queue to go in as part of the EHR, I'm not 100 per cent certain, but when that time comes, the compatibility is there for it to be compatible with the electronic health record.

MR. PREYRA: At the moment, there are these various systems that we're trying to bring together so there would be some consistency and some coherence, so these various units would talk to each other?

MS. ENGLISH: That's right and don't forget, with the Patient Access Registry system, it is not a patient-specific system, it's a database whereas a lot of the electronic health record is going to be specific to a patient, so it's a little bit different in terms of its purpose. It's a database, when we talk about the electronic health record it's going to talk about people's visits to emergency and their diagnostic imaging and it's very much more patient-centric. This is a database that covers a lot of things, but it is compatible with the electronic health record.

MR. PREYRA: As I understand it, the main priority is to establish a real-time triage system where you're tracking the system, you see where the gaps are, where the services are available, who has been waiting and what section. At this stage it's more of a monitoring, trying to get a better sense of how things are working right across the system?

MS. ENGLISH: That is correct.

MR. PREYRA: The system as it stands, the Patient Access Registry system is live for people who are, in fact, working within the system and that there's a validation of data, but there's a lot of data being used at the moment in establishing those priorities.

MS. ENGLISH: It is live, yes.

MR. PREYRA: And that system, along with the electronic health record system, is being sequenced in as they get validated, as the data reaches the threshold that you're setting for standards for use of that data, that those systems will come in as they are validated.

MS. ENGLISH: Yes. I don't want to get too confused between the electronic health record and the Patient Access Registry system. They are two different things but as the

[Page 41]

information is being validated through the Patient Access Registry system, it is being used in some districts now and it will continue to be used and by January it is the source of truth.

MR. PREYRA: So this is part of what you would consider ordinary due diligence, to validate the data, to monitor it, to make sure it is accurate because people's lives are at stake?

MS. ENGLISH: Absolutely. If we want to have certainty of the data that we're using for decisions, everybody involved needs to make sure that it is good data, that it is clean data, that it is complete data. Only then will people have confidence to be able to use it for decision-making.

MR. PREYRA: Now I know that some of this - well, I had a note but I lost it here - a number of provinces are using a similar system. What kind of information sharing is going on? Are you comparing it with other provinces and what kind of learning is going on there?

MS. ENGLISH: At this point I'll start the question and then Ms. McVicar can carry on. There are a number of sources of information that we get information from across the country, so CIHI - which is the Canadian Institute for Health Information - is one of the areas that gathers up information from across the provinces and does reports. There are a number of sharing mechanisms from across the province and then how we use that information.

I think our relationship with New Brunswick has been the most intimate on this one because of the use of the system. I think that the opportunity within Atlantic Canada to be sharing information more fully and working together on a lot of things, be it networks or whatever, is there. Again, it is with that information that is going to give us the bridge to be able to do more work. Anything else you would add to that, Lindsay?


MR. PREYRA: Thank you very much. I recall from earlier discussions that we've had about electronic health records, and I think it was Ontario that had terrific problems in their implementation. Did you look at the experience in Ontario and the problems they had in setting up this system?

MS. ENGLISH: I guess what you're referring to is the eHealth issues in Ontario. We have not experienced the same kind of issues that they have in Ontario, from a governance point of view, from an accountability point of view. I know the AG and Internal Audit has been involved with some of the work that we've been doing and Nova Scotia has done this work very well.

In terms of the province that we liaised most closely with, PAR NS in particular, it has been New Brunswick but I think it's true that as we look at the electronic health record,

[Page 42]

Sandra Cascadden, who is our chief information officer, has a wide network of colleagues and is very involved in the pan-Canadian kind of work that is going on this area. So we're learning from all the provinces in the bigger scope of things, all the time. There's a lot of communication at that level and thankfully we are not in the same position as Ontario in the governance of their system.

MR. PREYRA: I suppose because we've learned from that experience, we're considered one of the most successful projects in implementation. I know when we compared our Auditor General's Report on the electronic health records to the Ontario reports and some of the other provinces, we actually came out looking pretty good.

MS. ENGLISH: This is done very well in Nova Scotia.

MR. PREYRA: I know Ms. McVicar alluded to this earlier in talking about New Brunswick, that one of the benefits of that process was that we were able to build on that experience. I'm looking at things she said about the operating room inflow system which was integrated into this system, the type of stakeholder engagement that went into the development of the process itself. So in a way Nova Scotia has learned a lot from that experience and I assume that now people are learning from Nova Scotia. Ms. McVicar?

MS. MCVICAR: Absolutely, yes, you are absolutely right. We were able to take some materials, tools, practices, lessons learned, best practices from New Brunswick and we do interact on a regular basis with all the provinces at a CIHI working group around wait time issues, to ensure that while we're looking for standardization and consistency in Nova Scotia, we're also looking outside of Nova Scotia for best practices and standardization between the provinces as well.

MR. PREYRA: I think I'm done with my questions, Madam Chairman. I started early and I'll end early.

MADAM CHAIRMAN: That's good. No other questions from the NDP caucus, thank you very much, it's still a good time for us to wrap up. I wonder if you'd like to have any final closing statement at all, Ms. English, I'll turn it over to you.

MS. ENGLISH: I think that it's fair to say that we're very excited about the opportunity - excited might be a strong word - we're enthusiastic about the opportunities that this information system that we have not had before, the districts have not had before, gives them a chance to plan and allocate resources appropriate and gives us the opportunity as a province to be able to monitor, evaluate and hold accountable, which is our role within the District Health Authorities Act.

This is a new opportunity and I think that for the record I would like to compliment all the stakeholders and all the people within the health care system that we had working on

[Page 43]

this very complicated project and the work that they did in the changing of their practice to be able to come to where we are today. They've done a wonderful job and the Surgical Care Network on a go-forward basis, again, is such a place for potential to be able to look at how we do things across the province in a less fragmented way.

This is a building block system. It's like when we get into a car and we turn on a car and say, thank goodness it turned on today and we're not thinking too much about all the work that went into the engine. Well, this is the part of the engine that we're building to be able to make decisions on and it's a very important part of our information infrastructure. Thank you very much for all of your questions today, they were helpful to us in our go forward as well.

MADAM CHAIRMAN: Thank you very much, Ms. English. We'll also be watching and hopefully have you back as it unfolds further. As I said in the beginning, we tend to look after the fact to see how things are being maintained and the budgets are being spent, so we'll hopefully have you back again in a year or two to see how things are going. Thank you.

There was one request for information on the budget that was following up on one of my questions, whether or not the budget was overspent or just where we were at and if you could at the same time provide information on the budget for this year on the maintenance and operating of the system. We didn't get into this year's budget, so if you could provide that for all members of the committee, that would be something that I'm requesting as well.

I think there were a couple of things that, Ms. English, you said that you would provide. One had to do with the percentage that were not on the list now, the 27 per cent that no longer needed surgeries. I think you said that you would give a breakdown on what the reasons were for those people coming off the list. I'm not sure that Mr. Porter asked for that, but it came out of the discussion. That would be great and, again, we appreciate you being here.

On committee business you will notice there was correspondence from the Department of Finance; it was answering some questions we had a few weeks ago on the October 13th meeting. We have received notice from the Auditor General, so you can schedule in for November 17th, an in camera meeting on their Fall report and again, on the 24th, we'll have a public meeting also related to the Auditor General's Report.

Next week we have the Gaming Corporation coming, which we're pleased to see with the Support4Sport being the program that we are going to principally look at. With that, I would ask for a motion to adjourn. Thank you.

We are adjourned.

[The committee adjourned at 10:56 a.m.]