NOVA SCOTIA HOUSE OF ASSEMBLY
Wednesday, April 16, 2014
Department of Health and Wellness
Public Health Surveillance
Printed and Published by Nova Scotia Hansard Reporting Services
Public Accounts Committee
Mr. Allan MacMaster, Chairman
Mr. Iain Rankin, Vice-Chairman
Mr. Bill Horne
Ms. Suzanne Lohnes-Croft
Mr. Brendan Maguire
Mr. Joachim Stroink
Mr. Chuck Porter
Hon. Maureen MacDonald
Hon. David Wilson
[Mr. Iain Rankin was replaced by Mr. Terry Farrell]
Mrs. Darlene Henry
Legislative Committee Clerk
Mr. Gordon Hebb
Chief Legislative Counsel
Mr. Alan Horgan
Acting Auditor General
Ms. Evangeline Colman-Sadd
Assistant Auditor General
Department of Health and Wellness
Ms. Frances Martin, Acting Deputy Minister
Dr. Frank Atherton, Deputy Chief Medical Health Officer
Mr. Peter Crowell, Acting Director, Finance
HALIFAX, WEDNESDAY, APRIL 16, 2014
STANDING COMMITTEE ON PUBLIC ACCOUNTS
Mr. Allan MacMaster
Mr. Iain Rankin
MRS. DARLENE HENRY (Legislative Committee Clerk): In the absence of a chairman and a vice-chairman the committee today needs to elect an acting chairman from among the members present, for the purpose of this meeting today only.
The floor is now open for nominations. Mr. Porter.
MR. CHUCK PORTER: Thank you, Madam Chairman, for the time being at least. I would nominate the member for Halifax Chebucto, as he has some experience in other committees as chairman.
MRS. HENRY: Mr. David Wilson.
HON. DAVID WILSON: I’ll second that.
MRS. HENRY: So Mr. Stroink is now going to take the Chair.
MR. CHAIRMAN (Mr. Joachim Stroink): Good morning everyone, I’d like to call this meeting to order. Before we begin could you just make sure that all cellphones are turned off or are on vibrate. From there, I’d like to go with introductions starting with Mr. Maguire.
[The committee members and witnesses introduced themselves.]
MR. CHAIRMAN: Ms. Martin, I will turn it over to you to start the proceedings.
MS. FRANCES MARTIN: Thank you very much, Mr. Chairman. I have a few opening comments to help put into context the chapter of the Auditor General’s Report, so thank you very much for asking the Department of Health and Wellness to appear before the Public Accounts Committee today. It is an opportunity to really focus on some of the excellent work that is undertaken, day in and day out, with our public health group.
I’m certainly pleased to explain, specifically, the public health surveillance activities and how we are working to enhance them. Public health has made great strides through the ages. If you just simply look at where we are, in terms of vaccination, hundreds of thousands of people, at one point in our history, died of smallpox and today the disease has been eradicated through immunization. Of course not every improvement we make is that dramatic but we do continue to make important advances.
We also make significant investments in public health in Nova Scotia. The Department of Health and Wellness has a budget for public health today of $25.4 million. We have just under 70 FTE staff positions with the department this fiscal year and there are hundreds of staff who work in the district health authorities across the province. Many of those are involved in front-line delivery of services.
In addition, the district health authorities have a collective public health budget of $29.3 million. We have nine medical officers of health around the province to provide expertise and leadership.
As you know, surveillance is a critical component of our work in public health. For both the prevention of disease and the protection and promotion of good health, we need reliable information about the health of our population to do this work. Public health surveillance requires appropriate process, skilled expertise from epidemiologists, as well as information systems. Over the past couple of years we have enhanced our epidemiological capacity - we’ve gone from one provincial epidemiologist to four at the Department of Health and Wellness, and there are also four epidemiologists in the district health authorities and one at the provincial health lab.
Like other provinces and territories in Canada our surveillance systems have done a fairly good job, but there is need for improvement. These systems allow us to meet our legislative responsibilities to report on notifiable diseases, identify, manage and notify the public of outbreaks. This work could be done more efficiently and comprehensively with improved information systems. Building these information systems to better manage public health surveillance is a challenge for all provinces, but is one that we in Nova Scotia are taking very seriously.
We continue to work with our colleagues across the country and we recognize that Nova Scotia needs an electronic information system with many integrated components, including an immunization registry and other components for case managing, tackling both notifiable and non-notifiable diseases and other public health indicators. Getting these new surveillance systems in place will improve our ability to manage immunizations, address outbreaks, reduce the odds of data entry errors, and enhance the breadth of surveillance activities beyond notifiable diseases.
I’d like to give you a bit of background on the path Nova Scotia has taken to make the necessary improvements in our public health surveillance systems. In 2004 the Government of Canada, through Canada Health Infoway, provided funding to support the development of a Pan-Canadian Public Health Surveillance System. This system, which we call Panorama, the concept is one system with a large number of integrated components. Users of the system can choose which component they need and tailor them to meet their needs.
In Nova Scotia we recognize the benefits of having a national system. It is helpful to be able to share information among provinces and with our federal partners, so we did our best to participate in the effort to develop Panorama. However the initiative became too costly, the development was too slow, and we weren’t certain that at the end of the road it would meet our needs; therefore we decided to put on hold our participation in the development of Panorama in 2009. The provinces that continued working on Panorama are only now just getting some components of the system up and running.
For example, the immunization management module is implemented in three out of five participating provinces and territories, while the surveillance case management, investigation management, contact management, and outbreak management modules are still in the planning stages in other jurisdictions. There is no one province or territory that has a comprehensive system in place, so Nova Scotia hasn’t necessarily missed out on anything by pausing our participation in Panorama over the past five years. Now that Panorama has been further developed, we can look at that system and other options that have emerged for Nova Scotia to once again consider the best options to protect the public health of Nova Scotians.
We have completed our research into all other options available and, to be clear, there is no single off-the-shelf system that will perform all public health surveillance functions for us right away - we either need a set of various systems that will talk to each other or one overarching system, like Panorama was intended to be, with multiple integrated components. Any option we choose will require tailoring, and that will take time.
Through our research we have identified a short list of options that we believe could work for Nova Scotia. We are now determining the process of choosing the best one for our circumstances and getting it in place. We expect this to take several years before it is fully operational.
While we continue our work on that front, there are a number of other initiatives that will help us improve our public health surveillance, as the information system is just one component. We are close to completing a provincial health profile. This profile will report on a set of indicators that give us a clear picture of our population’s health. It will describe our population, how healthy we are, and the factors that affect our health. Indicators in the profile will include physical activity, smoking, fruit and vegetable consumption, and life expectancy. The profile will help us do a better job of planning, allocating resources, and determining what we can do to ensure that Nova Scotians are the healthiest they can be.
We have established a process for regularly reviewing and updating a list of notifiable diseases. In fact, we initiated the review process just this February. By the coming October we will have established a formalized process for seeking feedback from stakeholders on notifiable diseases and a reporting system to ensure that their needs are being met.
In addition to that, we are working on and making progress on the public health protocols. We reached a milestone in 2010 when we established our public health standards. They reflect our vision for public health, set expectations for the work in the district health authorities and the department, and support a shift in our system to place more emphasis further upstream. We are reaching other milestones this year with the implementation of the public health protocols. They describe the mandatory core work of public health, along with roles and responsibilities in order to achieve the visions set out in the standards. This work is in the area of healthy development, healthy communities, environmental health, and communicable disease prevention, management, and response. We will start rolling out these protocols very soon.
Turning to the Auditor General’s Report, it rightly noted a number of areas for improvement in public health surveillance. We agree with all of the recommendations, and I think you can see that we’ve made significant progress in carrying out these recommendations. I want to stress that the department takes the Auditor General’s recommendations very seriously.
In many instances, we’ve started work on recommendations even before the report has been released. For example, during the H1N1 outbreak, the Auditor General conducted an audit of our pandemic preparedness. So this audit was happening at the same time that we were learning through the pandemic experience, and not surprisingly, our lessons learned and the Auditor General’s recommendations mirrored each other. We completed all of those recommendations by 2013. That was within a four-year period that the Auditor General expects it should take to complete these sometimes very complex recommendations.
Some of the results of that particular audit were an increase in the number of epidemiologists in the department’s head office and in the district health authorities. Also, the all-hazards plan was created for the health system by the former Department of Health Promotion and Protection and the Department of Health. As the largest department in government, we naturally have the most audits and recommendations from the Auditor General. From 2005 to present, the Department of Health and Wellness has received 349 recommendations, and we have completed 75 per cent of them.
In conclusion, I give you these figures and background to emphasize our work at the Department of Health and Wellness. The health of Nova Scotians is government’s highest priority. We welcome regular audits to help us improve our work and to meet that priority that we are committed to, in terms of continuous improvement. I do thank you for the opportunity to talk about the good work that we are doing and I welcome your questions.
MR. CHAIRMAN: Thank you. I will turn it over to Mr. Porter. It is now 9:15 a.m. and we’ll stop in 20 minutes.
MR. CHUCK PORTER: Thank you, Mr. Chairman, and Ms. Martin, you are probably getting tired of this Chamber. We’ve seen you an awful lot in the last little while, especially through the estimates and that is going to continue. It’s good to have you back again this morning with your colleagues to answer a few questions on what we would all agree is an important topic.
I want to go to this whole electronic system first. I can give my social insurance number anywhere in the country, if I want to, and they can tell me all about me. They can do credit checks; they can do all kinds of things. How come it’s so complicated? There is the part I can never figure out. This seems pretty simple. We are a small province - we are 900,000 and some change in residents. It shouldn’t really be that hard. We’re not big geographically, as a rule; IT is not new. It has been around for quite a few years. I realize that leading edge changes every day or maybe I should say the bleeding edge changes every day, but leading edge technology has come along. There are writers of programs who are well known and who do wonderful work and can write just about anything you’d ever ask for.
In your opening comments there you talked a lot about how it doesn’t work well together, it’s so big and broad, things don’t work, you know, they don’t talk or you would have to write something specific to get one to talk to the other. Instead of doing that, I can’t imagine why we just wouldn’t hire a writer to go out and probably - and I don’t know because I don’t know the numbers, maybe you can speak to that as well, by way of dollars to do that and costs associated with it - I would think it would be a lot cheaper to go and write a program that would work for all as opposed to trying to mirror all these, make them all talk. I’m no IT specialist, I can tell you that right up, but I do look forward to your comments on where we are with this thing and why it is so difficult for something that at least appears on the surface to be quite simple.
MS. MARTIN: Thank you, Mr. Chairman, and thank you as well for welcoming us back to this room. I think it is important, early in this round of questioning, to recognize that sometimes the toughest decision that we can make is to make the decision that the system we are pursuing in this case is one that, at the end of the day, even though we have money invested, probably the toughest decision you can make is a determination that we could put more money into it and more effort into it, but really we are not on the right course to get the system that is necessary to give us the sort of information and the functionality we need.
You are correct that Nova Scotia is a small jurisdiction, relative to other provinces in Canada, but when it comes to public health surveillance, of course some of these diseases and other factors that we are tracking, they know no borders, and so it is really in Nova Scotia’s interest to participate with the other jurisdictions in Canada. That is what we were really dedicated to in our participation in the development of Panorama in 2009.
We do have a very high success rate and I do know that we get examination and audits from Canada Health Infoway, which is our federal funder, and of course we do get examination from internal audit and the Auditor General Reports in terms of our processes around developing some of these complex IT systems. Our success rate is very high in developing these systems, but that does mean that, in the case of Panorama, we really took a tough decision, as other jurisdictions in Canada did as well at the time, to say that we could pour more money into it, but it would not be a good public expenditure.
Dr. Frank Atherton, I think, would have some additional points in terms of the system and really what we were trying to achieve and I’m just going to ask him to elaborate.
DR. FRANK ATHERTON: It would, indeed, be wonderful if there was a system where we could just go and buy off the shelf or bring somebody in and simply build it. Part of the complexity of modern public health systems is that information comes from a wide variety of sources. If we think about just the communicable disease world, for example, you have information coming in from the laboratories, information from physicians, from public health nurses, from a range of different sources, and part of the challenge is to marry all those sources up. So we’re looking for a system that can do that.
In fact when we took the decision to suspend our involvement in the Panorama program, we did look around at what could be used as an interim solution. One solution that we did subscribe to, and that we currently use for communicable disease, is an approach called ANDS, it’s the Application for Notifiable Disease Surveillance. It kind of does what the member is suggesting, but there are limitations to what it does - so it does serve us reasonably well, but it’s not perfect.
The problems with the system we currently have are that, first of all, many of the inputs are paper based and when you have paper-based information being input into a data base, there’s always room for error, and error in duplication. So the current system we have, really which is sort of an off-the-peg version of a system which was developed and is used in other Canadian provinces, the problem with it is that it is inefficient and ineffective, and it doesn’t quite do what we need.
We do have interim solutions; we have bought into those. We are limping along with those, but what we are looking to do - in line with the Auditor General’s recommendations - is to build a more effective, more modern system.
MR. PORTER: Thank for the responses. Again, I’m not a widely technical person; I’m average probably - I can use a computer, I can build databases with access and simplicity of things, enter data. We do it in my office; it’s rather simple. I guess I get a little confused around it all because it does seem so simple and maybe it’s - you use the word “complex”, I’m sure that all of these different ideas make it that way.
Quite simply, and all you’re really doing - and I look forward to the response here because I’m going to make it very simple - very high level, people would think you’re collecting data and you’re entering it into a system and you are collating it, you are analyzing it, you are developing numbers of what exists out there, what doesn’t, what treatments have been done, all the things you would do typically once you’ve done the surveillance. Am I right there? Is it that simple?
It certainly appears that simple and if you want you can actually speak a little bit to how that is captured. I just look for some clarity. I mean if your public health nurse goes into a home and there’s an issue with some disease, if you will, whatever it might be, is it as simple as that, that person capturing that data and entering it somewhere and then we’re doing the rest with it?
MS. MARTIN: I guess what’s important to lay out is the road ahead. We are working now with our Atlantic partners, with our federal partners, and certainly focused inside the department to pull together the needs for the system. When it comes to developing an IT system, a system will do what you tell it to do. Therefore, it’s very important to do considerable planning in terms of what instructions you want to create in terms of what drives the development of that system.
We are doing that work right now. We’re doing it with a focus for what is best for Nova Scotians, and we’re also doing it with an eye to the collaboration within Atlantic Canada, our federal partners and, as well, we have studied in detail the systems in the other jurisdictions. This is where it is an advantage to be where we are, in that when the system that we ultimately have in Nova Scotia, we have the benefit of the lessons learned from elsewhere in Canada.
In terms of timelines, what becomes important for the go-forward is that we will be doing that needs analysis, we call it, throughout the next coming months. We would therefore look to have a proposal ready for the 2015-16 budget year in order to make the next important step in developing this system.
MR. PORTER: I’m going to assume “we” is the Department of Health and Wellness.
MR. MARTIN: That’s correct.
MR. PORTER: You noted in your opening statement as well under your approach, and you were talking about going forward, you talked about the Panorama, and your comment here was, “However, the initiative became too costly, the development was too slow, and we weren’t certain it would meet our needs.” How costly? What are we talking about here in numbers? I mean, what are we really looking at?
DR. ATHERTON: It’s very difficult at this stage to know, in terms of the go-forward, exactly what the costs will be. We haven’t got a tender yet, so we don’t have clear cost estimates, but if we look back to 2004, when we first launched Panorama, there were some costings done at that stage. It was in the order of $10 million to $11 million, so it was an expensive program that we were embarked on with Panorama. As the deputy minister says, in a way that’s why it was quite difficult to make a decision to halt implementation at that point, because we had gone a certain way down the road, but clearly the costs were very significant, and we wanted to be certain that we got it right. So we don’t have accurate costings for the future system. We’re currently working on those, and as the deputy minister says, we are developing a plan for the future which will include better cost estimates, but perhaps that gives a ballpark figure.
MR. PORTER: Deputy, just for clarity - you talked about the 2015-16 budget year and going there. Does that mean that you’re hoping to have a cost? I understand your point, Dr. Atherton, as well - how can you know, if you don’t know what you’re going to buy or build or develop as a system, what it would it cost? I would think that would be very difficult to determine at this point. But by that period in time is what you are referring to, having some sort of line item to put in the budget by way of making this happen. I’m just looking for a little clarity around that.
MS. MARTIN: That’s correct. Again, just in the tendering process, of course, sometimes you don’t know exactly what something will cost until you’ve actually gone through the procurement process. So what we will have for 2015-16 are the needs worked out in terms of what we want the system to do, and then we will go through the regular tendering process to be able to assess what the exact costs will be.
MR. PORTER: Do you have a goal or a figure in mind there that you’re trying to stay within? That often has a great bearing on what you do develop or what you do buy. If you’re trying to stay within a figure, is there something there in mind?
MS. MARTIN: At this stage, we are really focusing on assessing the systems that are in use elsewhere in Canada. That’s a process where we will be working with our partners in the system, the many people in addition to the Department of Health and Wellness staff, working with staff in the district, and information management specialists to determine the needs for the system that will drive the design. We do not at this stage have a number in mind. That would be purely speculative.
MR. PORTER: You also state in your comments that there is no province that has a comprehensive system in place. I guess that would mean that although you might work with some other provinces, there is nothing out there right now that is satisfactory, for lack of a better word, that Nova Scotia would be interested in mirroring in any way, or part of?
MS. MARTIN: I’ll let Frank answer that detail, but it’s fair to say that, no, there is no one jurisdiction that has that comprehensive system now in place that was envisioned in 2009 when efforts were put into Panorama. Dr. Atherton can give you additional detail on that.
DR. ATHERTON: As the deputy minister says, there is no single solution which is the standard across provinces. A number of provinces have continued with implementation of Panorama and are now reaching the point where they are able to use that for some of their public health information needs, particularly around communicable disease surveillance and immunization management. There are a range of other issues within the public health world, child health information systems, vaccine management registries, which wouldn’t neatly fit within any on-the-shelf solution and so the direction that we expect to be taking in Nova Scotia is to look at all of our business needs across the whole range of public health and, yes, to say, in the communicable disease world we need to find a solution, which is consistent with what other Canadian provinces are using, but maybe for child health or for the management of vaccine supplies, we need something different.
We’ve currently, in the last year, been doing quite a significant piece of work to develop to a strategic direction for our public health information system, which is leading us to conclude that we need a suite of solutions, some of which will perhaps be similar to other provinces, to Panorama, or other models that are being used and some of which may be stand-alone within the province.
MR. PORTER: Panorama, as you’ve outlined it here, was it just too much, too complex, too big, too broad, trying to capture too much? Is that why it didn’t work or was it not focused?
DR. ATHERTON: When we suspended Panorama in 2009, the rationale was really that, first of all, it was a very complex system, but not sufficiently developed to be assured that it would be successful.
MR. PORTER: From an IT perspective, you mean?
DR. ATHERTON: From an IT perspective and in terms of meeting business needs. It was felt that it was more suited, at that time, to the needs of larger provinces and that to buy into a very complex IT system for smaller profits may not be cost effective. It was also recognized at that time that the provinces that were actually ahead of us in terms of implementation were running into some delays, so it was felt that we should bide our time, we should wait and see how Panorama played out, rather than go into it at that time.
MR. PORTER: With nothing really in place yet - you are working towards something - how are we capturing data now that we feel comfortable enough that you’re working with today? We’ve gone through some pretty significant things, as you know, in past years in this province by way of H1N1, and there will be others, there’s no question, and there have been others in the past. How can Nova Scotians feel comfortable today that we are capturing this stuff and doing what we need to do with it, by way of communicable diseases?
MS. MARTIN: To preface some of the detail that Dr. Atherton will supply, we have gone through some pretty significant flu seasons. We’ve gone through certainly the experience of H1N1, and as I indicated in my opening comments, following H1N1 there was a very exhaustive examination of what we did, based upon the resources available at that time? What could we do better? Certainly we had an Auditor General Report for which we’ve addressed all of the recommendations coming out of H1N1.
An information management system is certainly an assist. A comprehensive information management system is the goal, but we certainly have a number of measures in place to report information, and Dr. Atherton will detail that, but I do believe that Nova Scotians have every reason to be confident that between the district health authorities and the Department of Health and Wellness, as well as our federal partners, we have capably managed serious public health events and will continue to do so.
DR. ATHERTON: To continue that, I wouldn’t like this committee to labour under the misapprehension that we don’t have any system for public health surveillance. We clearly do. The issue here is that our systems are rather old; they’re not fully fit for function for the current environment we are in.
Just to continue with thinking about the communicable disease world, we do, as I mentioned earlier have a system called the Application for Notifiable Disease Surveillance, so that does capture information from clinicians, front-line GPs, nurses. When they see an infectious disease in their clinics, they are expected to notify the public health departments about that.
We do have a list of notifiable diseases and they are widely available. All physicians and nurses have access to those so they know what they should be reporting. We do have a system for the laboratory to provide this information.
MR. CHAIRMAN: Order, please. The time has come to an end for the Progressive Conservatives. Now I turn it over to Mr. David Wilson.
HON. DAVID WILSON: Thank you, Mr. Chairman, and welcome back, nice to see you here again. I know the deputy minister has been before us for a number of days in estimates and it is nice to see Dr. Atherton here with us and Mr. Crowell.
I know how important it is for public health to be tracking and understanding diseases and the work that is being done there. I understand what Dr. Atherton just finished up with, that there is a reporting system in place and Nova Scotians should feel confident that those indicators and alarm bells go off, I think, when health officials feel there is something going on in any region of the province.
I know that public health and government learned a lot over going through H1N1 and some of the flu seasons that we have had. I look forward to the continued work that public health does and responding to the recommendations through the Auditor General Reports. I know, of all the departments, Health and Wellness has been the one that has acted more efficiently than any of the other departments. I’m confident that, even with the new government, that will continue and I commend you for that.
One of the things that is also important to public health is to know the determinants of health. I look under Recommendation 4.3 in the Auditor General’s Report, and I’ll quote a bit of the response from the Department of Health and Wellness, it said: “Given Public Health’s shifting emphasis from individuals to populations, and a greater focus on addressing the determinants of health, Public Health acknowledges the need to enhance surveillance of non-notifiable disease and determinants of health.”
Would you agree that knowing the determinants of health is extremely important on moving forward and trying to address some of the health concerns in our province?
MS. MARTIN: Absolutely, and there are many players certainly in that equation. One of the areas that I am sure you are well aware of, and I really appreciate every opportunity to speak to the importance of the physical activity and healthy eating and those important aspects of lifestyle, which are what prompted us to develop the Thrive! strategy, and that is reaching out to school children all across the province, working with various publicly-funded institutions on ensuring that we keep healthy nutrition in mind.
We recognize that it is important to create the conditions where people, to the best of their ability, can make the lifestyle choices that will support their good health and we do recognize, of course, that in that regard not everyone is on an equal playing field. That is why we are quite pleased, in this fiscal year, to have $300,000 dedicated to chronic disease. When you look at the underlying contributors - not in all cases but in some instances - we know that physical activity, healthy eating, use of tobacco, consumption of alcohol and so on are all factors that kept in proper proportion can contribute to our health. So we look forward to working with our community health boards, as just one partner, we do have many partners, but that is one that we look forward to the various activities they’ll be involved in and getting Nova Scotians engaged to the extent they can through that additional contribution and funding in this coming fiscal year.
MR. DAVID WILSON: I know from my experience not only as former minister, but as a paramedic, and just educating myself on the social determinants of health that it’s not always about the exercise and the food intake that you have, there are a number of publications, studies, attitudes of the majority of those who work within public health that believe there are many causes to the health of a population. That’s extremely important to understand and move forward on, and extremely important for the government to ensure they provide programs, not only like Thrive!, but throughout all the departments to make sure they have the greatest impact to improve the health of our population.
That’s why a number of months ago I was very concerned when I read a column from the current Minister of Health and Wellness. It was February 6th in The Kings County Advertiser, and I will quote a little bit here and I will table it for the committee, but maybe after the committee because I’ll be looking at it for a few minutes.
In the column the minister wrote - a number of things stood out to me and not just to me but to many groups, as I know the minister has been hearing from them over the last number of months. I’ve attended different meetings and groups have expressed concerns of the minister’s column - one of the quotes here is: “Do we need to take further drastic measures? Some have suggested looking at the banking model. . . . Imagine if healthcare worked like banks. Patients would have to prove they practice a healthy lifestyle before receiving assistance. They would have to prove that they practice the basic tenets of proper eating and exercise. Such a system would save money for those who have not abused their health and need medical care.” It goes on - and maybe I’ll get to that in a few minutes.
I know the philosophy of public health; I worked with the department for a number of years, so maybe I’ll ask Dr. Atherton if the Minister of Health and Wellness sought support in writing this column. I know as minister, when I put anything out to the public, I usually asked the experts who work in the field what they thought about what I was going to provide or put into a column, or media or talking points. Did the minister ask for any advice from public health on the column that appeared in the February 6, 2014, issue?
DR. ATHERTON: Thank you for the question and for underlining the point about the determinants of health, which are really important to us in government in terms of improving the health of the population. The member is absolutely right that it’s just not what we do in the health sector which drives population health, in fact maybe 10 per cent of the health sector activities keeps us healthy as individuals in this community. The other things which are really important are around our access to education, our access to employment, good quality employment, and our access to a healthy environment. So I’m grateful for the comment.
The minister did make some points which have resonated with people about the personal responsibility for health. I don’t think anybody would argue that individuals do have some responsibility to keep themselves as healthy as possible. As the deputy minister has mentioned, we do have a belief that we need to create the environment that supports people in making those healthy choices. The minister has been fully involved in discussions about that, he understands the concept and is deeply committed, I believe, to supporting healthy environments to make and keep people healthy.
That’s why, as I understand it, the government has renewed its commitment to the Thrive! strategy, and we are continuing our approach not just to tackling individual lifestyle issues, but also to making Nova Scotia the place where people can choose and can be healthy.
MR. DAVID WILSON: Thank you, Dr. Atherton. I know you’ve only been working with the department for a couple of years now I believe, but you didn’t answer the question. I asked, did the minister ask for assistance from public health on writing the column?
DR. ATHERTON: He certainly didn’t ask me for specific advice. My understanding is that was a personal opinion that he was writing for the journal. We subsequently had discussions with the minister, and he understands the concepts of both personal responsibility and the broad determinants of health, just as we’ve been discussing.
MR. DAVID WILSON: After the column appeared, our caucus, myself - we were very concerned with that column and what was said in it. Not for one minute did I believe that public health - yourself, or Dr. Strang, or anybody in the department - would approve of the column. So through freedom of information we did make a request in the department to try to find out if there was any support for his column, and I’ll table this after I’m finished with it. It was an email from Steve Machat, who is the manager at Prevention and Problem Gambling Services - Mental Health, Children’s Services and Addictions Branch of the Department of Health and Wellness, and it was from Mr. Machat to Dr. Strang. “Good morning…not sure if you’re receiving the same questions of bewilderment as I am around the Minister’s op-ed.” And the response from Dr. Strang was, “No questions coming my way but this does give me angst. However, I can’t and won’t try to explain the Minister’s comments. I think the only thing we can say is that the Minister writes this column on his own in his role as local MLA and it certainly does not reflect any of our thinking.”
I couldn’t agree more with those comments from Dr. Strang, and it does give me some concerns that the minister would go out on his own. He is the Minister of Health and Wellness. I understand he is the MLA for his riding, but after that column, it wasn’t just myself. I know many groups that support those low-income Nova Scotians, those Nova Scotians who find themselves in a position that I don’t think any Nova Scotian would want to be in.
It started to raise a flag and say, wait a minute here, does the minister understand the social determinants of health? Does he know that it’s not just how much exercise you get that has an impact on your health? Does he know that age, sex, and constitutional factors have a role in it? Does he know that individual lifestyle factors have a role in your health? Does he know that living and working conditions like education, work environment, unemployment, water and sanitation, health care services, housing, and agricultural and food production have a role in someone’s health, and of course the general social, economic, cultural, and environmental conditions?
These are things that Canadians have been working on for a number of years, and I’m still concerned. I know that the provincial coordinator for the Transition House Association of Nova Scotia wrote the minister, copied myself on the letter, and many other people who were concerned with those comments. I’ll just quote from this letter, and I will table all these pieces that I’ve quoted from after the committee finishes.
This is from Pamela Harrison, a letter to the minister: “To suggest that people on income assistance, or low incomes or in fact anyone who struggles with their weight and exercise regimes, do so consciously and with disregard to their own or other’s health is problematic.” She goes on to say, “At the end of your ‘if healthcare worked like banks’ comments, you said: ‘But, copying this approach would be archaic and inhumane, and it is not for me to judge those who are dependent on the system.’ Your article, in fact, did just that. You suggested that people misuse our income assistance program, are careless of their health and fitness, and are headed for disaster, and taking the rest of the province with them, because of the costs they incur.”
Ms. Harrison also goes on to say, “We respectfully suggest that an apology is owed to those on low income or income assistance who are doing their very best for themselves and their families, within the constraints of limited funds, housing, transportation, mental and physical health supports. We are available for discussion of this important issue.”
So as I said, it wasn’t just our caucus and I who took offence to the column.
MR. CHAIRMAN: Mr. Wilson, can we just focus on the topic at hand? This is a long question so if we can just get to the question, it would be greatly appreciated. It’s a long story, so if you could just get to the question.
MR. DAVID WILSON: Definitely - this is definitely in hand. As I read the recommendations from the Auditor General, in the recommendations and the comments from the Department of Health and Wellness, it states: “Given Public Health’s shifting emphasis from individuals to populations, and a greater focus on addressing the determinants of health, Public Health acknowledges the need to enhance surveillance of non-notifiable disease and determinants of health.”
As a member of the committee, we have before us the Deputy Chief Medical Officer of Health, whom I’ve worked with for a number of years; we have the Deputy Minister of Health and Wellness, whom I’ve worked with for a number of years, and I know that the column that we talked about with the minister is not reflective of the work that this department does and reflective of what public health does.
I would like to ask the deputy minister, with the comments and the concerns that have been coming into the office - I know they have - has the minister either apologized or responded to Pamela Harrison’s letter that she sent and has he met with Pamela Harrison to discuss the determinants of health?
MS. MARTIN: I’d just like to respond first by indicating that certainly since the minister has been in the department, he has expressed a tremendous amount of emphasis on the importance of THRIVE! and strategies like that. When you look at some of that correspondence you referred to, really taking it from a holistic view as opposed to certain excerpts, you’ll see that his statements are really a commitment to the extent people can - everybody has a different starting place, I think he recognizes that - that it’s important for those who can, do what they can, to ensure that they prevent the onset of chronic disease and various other things that influence people’s health.
Through activities like THRIVE!, through the commitment of the funding for the $300,000 to address chronic diseases in this year’s budget, those are at least two important areas that this minister, I know, is very committed to help those who need, in some cases, community support to be able to fully participate, whether it’s exercise or proper nutrition and so on.
What is interesting is those articles have served to create some dialogue, which I think by and large is important. During the tour, the minister had, on many occasions, taken the opportunity for the hundreds of people that we met across this province to express his interest in encouraging those to take the steps that are necessary to look after their health, and very interested and engaged in the discussion on the volunteers across the province to assist those who need some support from the community and others to take advantage of lifestyle choices if they themselves weren’t able to do that on their own.
MR. DAVID WILSON: I think every Nova Scotian should be concerned when we have people, who I believe to be experts, in public health and those who have built their careers around supporting health services, use words like bewilderment and angst. That is from our Chief Medical Health Officer. We should be concerned. I only have about eight seconds, I think.
MR. CHAIRMAN: You have a minute.
MR. DAVID WILSON: I’d like to ask the Deputy Chief Medical Health Officer, does he agree with the comments from the Chief Medical Officer, Dr. Strang, about the fact that you can’t explain - I know the deputy minister tried - you can’t explain what the minister said and it was him on an individual basis when he wrote the column.
DR. ATHERTON: Thank you and, yes, clearly the minister speaks for himself, but as I said earlier really in public health terms we are committed to developing a system which supports people to lead the healthiest lives they possibly can. That remains government policy, it remains the policy and the practice of the Department of Health and Wellness. I believe the minister is committed to that, so that’s why I’m delighted that we continue with Thrive! as a program so that we could build a healthier Nova Scotia.
MR. CHAIRMAN: Thank you, Dr. Atherton. Now I’ll turn it over to the Liberals, starting over at the other end with Mr. Maguire.
MR. BRENDAN MAGUIRE: First of all, I just wanted to say to the member opposite, I respect his experience and his opinion, but this government encourages free thinking and proper constituency representation.
Ms. Martin, my question to you is, so the implementation of Panorama started in 2004 and was paused in 2009; for me and the people of Nova Scotia, and the people in my riding, I’d like to know, how much money in resources were spent over this time frame?
MS. MARTIN: Thank you for the question. The estimate at the time was approximately $11 million for the development of the system. I am very pleased, though, to tell you that some of that money went for the purchase of certain computer equipment - for example, servers that would have been necessary to have supported a system like Panorama, and recognized at the time when we paused we were able to reap the full advantage of that investment of public dollars into the equipment and were able to direct the use of that equipment for other priorities that were taking place at the time.
For some of the other funding that would have been expended during that 2005 to 2009 period, there was work completed in terms of some of that analysis that is necessary to do the system design. So as we turn our focus back to, and intensify our efforts on the design work we are fully utilizing the analysis that was created in that 2005 to 2009 period.
In summary, I’d say that we were doing our very best to reap the benefit of the investment made, even though we did have to make a very difficult decision, like other jurisdictions in Canada did at the time, to pause our efforts.
MR. MAGUIRE: Just a quick follow-up and then I’ll pass it on. My background is IT, so education-wise I’m a programmer by trade. I’ve implemented many servers and networks so I have a bit of an understanding on what goes into setting up the IT systems in large corporations and organizations. For me this comes down to services provided, but it also comes down to dollars and cents. The people in Nova Scotia always are concerned about where the money is being spent and if it’s being spent wisely, so the follow-up question for me, for the people of Nova Scotia and for the people of my riding, was this money well spent?
MS. MARTIN: I would say that any time you put a system on pause there’s a certain amount of loss of efficiency in terms of the dollars invested, but we did our best given the difficult decision we had to make to repurpose those dollars, which I did reference in my last answer.
I think what’s important in the here and now is to focus on what we are doing today in terms of redoubling our efforts and working with our federal partners, working with our Atlantic Canadian partners and across Canada, to get serious attention placed back on the development of this important system. We are looking toward working hard to be ready for the 2014-15 fiscal year.
MR. CHAIRMAN: Ms. Lohnes-Croft.
MS. SUZANNE LOHNES-CROFT: What improvements have been made in the past few years in public health surveillance, for example the H1N1, what did you learn and implement following that experience?
MS. MARTIN: That is an important area of Dr. Atherton’s work so I will ask him to address that question.
DR. ATHERTON: In 2009 H1N1 was indeed a challenge in Nova Scotia and elsewhere and we did learn a huge amount from that and have improved our system since then in a number of ways. First of all, I think I mentioned earlier, we did develop an interim solution, a notifiable disease surveillance system, the ANDS system, so that we are better able to track diseases, to know when outbreaks are occurring and to understand the burden of notifiable and communicable disease in the province.
We also did build our epidemiology capacity. I think the deputy minister mentioned in her opening comments, we have expanded our capacity in Department of Health and Wellness and in the district health authorities so we now have nine epidemiologists across the province altogether.
We also renewed our efforts to make sure that our notifiable disease list was up to date and we’ve created a group which allows us to do that. We’ve also worked very closely with colleagues in other provinces and other jurisdictions to improve the way that we share information across boundaries because diseases don’t know jurisdictional boundaries and we do need to know what is happening elsewhere in other parts of Canada and indeed across the world. We do have a stronger system now for complying with our requirements under international health regulations.
Back in 2009 we had very little information about what was coming out of other parts of the world, specifically coming out of China and Mexico, and we now have far better information. We have a system of IHR point people - I am one such in Nova Scotia - and so we get much better information. For example, we now have a lot more understanding of what is happening in China at the moment around H7N9 and in Saudi Arabia around coronavirus, these viruses which could cause us problems, so our ability to look outwards is much stronger.
We’ve also strengthened our processes for some of the nuts and bolts interventions that we need to control diseases. We do a lot of education with physicians. We make sure that they understand those viral diseases. We communicate regularly with them through Doctors Nova Scotia and directly, and we’ve also brought new health workers into the system, so for example, in just the last flu season, we brought pharmacists on board so that they can support immunization with flu vaccines. There’s a whole range of things where I would say things are better than back in 2009, that’s not to say that there isn’t still work to be done, that we couldn’t make further improvements and that’s really what we’re trying to do with the public health information system as we go forward.
MR. CHAIRMAN: Mr. Horne.
MR. BILL HORNE: Thank you for being here before us today, I think it’s a good thing that you’re here to give us some support on where we’re going with communicable diseases. The Panorama program obviously wasn’t working very well to your satisfaction, and I note the Auditor General talks about identifying information system that you would like to use, obviously you are gathering information from other systems and putting it together. Can you just comment and take us through some of the more important parts of putting a system together that you’d be satisfied would meet national and international criteria.
MS. MARTIN: Sure, and perhaps it’s important to note that Panorama is the system for a particular company and so as we go forward and do that design work and determine what sort of system we need, what sort of information it has to yield for our public health officials so that we can ensure that we have good information to manage any public health outbreak, or even better, understand - and that’s one of the important areas - the immunization rates among Nova Scotians.
As we go forward and do some of that detailed work, which Dr. Atherton can supply some additional detail on, what we would be doing is going forward with a procurement and going out to the marketplace to determine what companies may have solutions to address our needs. Recognizing in this field some of the improvements that Dr. Atherton was referring to is that when it comes to supporting individual Nova Scotians in this last Fall’s flu season, for the first time we were able to have pharmacists in drug stores that are in communities throughout Nova Scotia provide immunization very conveniently, in addition to doctors’ offices and clinics that might be arranged by the district health authority.
I just raise that as one area that - this is a system that has to collect a broad array of information from general practitioners, from pharmacists, and from health providers all across the province and be able to very quickly provide us with information to make decisions - whether it’s managing an outbreak, or it could range to determining that we need to redouble our efforts in educating the public on the importance of coming forward for general immunizations or the annual flu shot. As an overview, perhaps I could ask Dr. Atherton to detail.
DR. ATHERTON: Well, maybe a specific example might help. We talked about the lack of a vaccine registry as being a significant gap in our systems here. Immunization is a complex subject, and what happens with vaccination is children get vaccinated either through their general practitioners or through public health nurses. A paper record gets generated, that then gets compiled. Now, that’s fine - it’s well and good - but what it doesn’t tell us is the level of population coverage for immunized children, so when we have a threat as, for example, we have now - we have measles around in other parts of Canada, fortunately not in Nova Scotia - it’s very difficult for us to look at our records and to say, well, which children do we need to target for immunization with measles vaccine? Where do we have gaps in our coverage rates? Where should we put our best efforts if we’re going to contain any possible outbreak or head off an outbreak that might be coming our way?
That’s the kind of example where a proper integrated system, a proper vaccine registry, would give us information which we don’t currently have, and which we really need if we’re going to manage population risk effectively.
MR. CHAIRMAN: Mr. Farrell.
MR. TERRY FARRELL: I thank our guests for their comments. I have to say, every time I read a section of the Auditor General’s Report, I always get a sense of despair. It’s good to hear that there are many good things happening in the department, and much progress is going on in all these areas.
Could you bring us up to date on what some of the other similar-sized jurisdictions in Canada are doing with respect to moving towards a surveillance solution - whether it’s similar to Panorama or whether it’s entirely different? Are we coordinating our efforts with what’s happening in the other jurisdictions in Canada that haven’t opted into Panorama?
DR. ATHERTON: It’s part of our strategic intent that we’ve just spent the last year looking in detail at what our public health information system needs. We did a complete jurisdictional scan to see what other provinces were doing. There is no single solution which all provinces are buying into. A number, three or four, are pursuing Panorama for some elements of their public health system.
No jurisdiction is using one solution to cover everything, to cover all their public health needs. One jurisdiction, Alberta, for communicable disease work has opted for a different provider, a system called Atlas. That’s kind of where it is at the moment. Many of the other provinces are really broadly where we are, so we’re not so dissimilar from the majority of provinces - no province has a fully-integrated system for public health surveillance as we speak.
What has happened in the intervening years between 2009 and now, of course, is that Panorama as one option that we might need to reconsider, has developed and some jurisdictions are now starting to bring modules of Panorama on-line so they are in a better position than we are to have vaccine registry and proper information to manage communicable disease outbreaks. We’re kind of in the middle of the pack, I would say, in terms of where we’re up to currently.
MR. FARRELL: Are we going to end up with some kind of national patchwork where there is no ability to have a national dialogue between all these different systems, or I guess a network to allow us to share this information across the country?
DR. ATHERTON: That would be a risk that I think is recognized across Canada. In an ideal world obviously everybody would use one system which can connect up and provide information at a national level as to what is happening in every province.
In the absence of that and given that some jurisdictions will be moving down the route of providing different vendors, the art will be for the IT specialists to develop ways in which the information can be pooled and centrally coordinated.
MR. FARRELL: I guess Microsoft and Apple finally did it, so hopefully they’ll get it together as well, I’m sure.
MR. CHAIRMAN: Mr. Maguire.
MR. MAGUIRE: Just to have it on the record, I want to apologize to all of you on behalf of this committee. The purpose of this meeting is to fact find and to get an update, it’s not to misquote columns for political use, so I want to apologize from this side for that. I just wanted to assure you that your time is not being wasted.
The reporting indicates that all data held by the department should be available to the population health assessment and surveillance team - is this taking place?
MS. MARTIN: Yes, that absolutely is taking place. That is one of the recommendations in the Auditor General’s Report. Just so you know, inside the department we have staff in the Public Health Unit. They have a certain capability in terms of data and information management. They are expert in public health and related data and information management. Then we also have a central group, so we do link with them. That is one of the important steps we have taken and do appreciate the recommendation from the Auditor General’s Report to make that correction.
MR. CHAIRMAN: Ms. Lohnes-Croft.
MS. LOHNES-CROFT: Are there any tools and programs and strategies that other provinces are using in regard to surveillance that you should consider doing in the future, or you are thinking of doing?
MS. MARTIN: Thank you very much. I guess just to put that into context before Dr. Atherton provides you with the detail, we did indicate here earlier, just so we’re clear, that the estimate for the development of the Panorama system was $10 million and that was an estimate. Just to be clear, the actual amount spent was $1.3 million, of which the province spent $400,000. I just wanted to clarify that detail.
The remainder of funding was provided by the federal government. So, yes, I had mentioned earlier that one of the things we are doing is reviewing the information that was compiled between 2005 and 2009. We also have taken a number of other steps to ensure that in addition to developing the system we are improving our efforts to protect Nova Scotians, and that does include addressing all of the recommendations from the Auditor General’s Report. In addition to that though, Frank can provide some elaboration.
DR. ATHERTON: The question was what can we learn from other jurisdictions and other places? We have been looking at this very carefully as part of our strategic intent work over the last year to really clearly define what that information system needs. We indeed did look at every province in depth and beyond that we looked at international best practice as well and so we looked at systems that were being developed and being used in the U.S. and in some European places.
MR. CHAIRMAN: Order. Thank you very much. I’ll turn it back to the Progressive Conservatives.
MR. ALLAN MACMASTER: My first question is can you give us an example of a disease that has spread because of limitations of the current public health surveillance system?
DR. ATHERTON: I think you asked is there a disease which has spread because we don’t have a system, is that your question?
MR. MACMASTER: I was asking if you could give an example of a disease which has spread because of the nature of our current surveillance system.
DR. ATHERTON: I can’t give you a specific disease which has caused us problems. What I can do is to outline where management of disease is, management of outbreaks as perhaps being more difficult than it would otherwise have been. The example I gave earlier was around measles. If we did have a measles outbreak here in Nova Scotia, it would be extremely difficult for us to know which kids were unvaccinated. In theory we would have to go back to a paper-based system and trawl through those and that would take months. By the time that happened the outbreak would be over and gone. With an integrated system we should be able to know exactly where we have pockets of unvaccinated children, get public health nurses to go out and mount clinics and deliver an effective response.
It’s a theoretical example rather than a real one. One more real example is recently, just around Christmas time, we did have an incident in our vaccination program - you may well have heard about it - where a physician provided immunizations inappropriately to some children. We had to undertake quite a significant remediation around that and that involved us really understanding what children had been vaccinated with what vaccine, what location, on what date and in what physical location on their body. That information just wasn’t available so in the absence of that we had to look to a number of information sources. We had to trawl through billing data, the physician’s records, and try and compile a picture whereas if we’d had a vaccine registry we would have been in a much better position to know exactly who had required additional supports.
There are a couple of examples which might help you to understand.
MR. MACMASTER: Is it becoming more of a problem, again, that people aren’t vaccinated against things like measles and other diseases that we used to see more often at the turn of the century? I’ve been reading a book lately and it’s taking place around the time of WWI and it’s amazing how many diseases the soldiers were encountering and the suffering they were going through because I think things have changed a lot from then until now. There are vaccinations for a lot of things. Are we starting to see this as becoming a problem again because many people haven’t been getting vaccinated in recent times? Is that potentially a greater risk now than it might have been 10 or 20 years ago given the fact that our surveillance system isn’t what it could be right now?
DR. ATHERTON: I think we are in a very fortunate position in Nova Scotia. Most parents get their kids vaccinated. We haven’t seen the decline in vaccination uptake which some other jurisdictions have seen. You will be well aware that there was a particular concern in some other places, particularly in the U.K., around the MMR vaccine where parents were misled by false reports of side effects. We haven’t seen that in Nova Scotia, most parents get their kids vaccinated, and our vaccination rates are pretty good. The problem we have is we don’t know exactly what they are because we don’t have a vaccine registry, so we do need to build that. But we know they’re pretty good, because we don’t see regular outbreaks of these communicable diseases.
I’m old enough to remember working as a family physician and seeing measles during the winter months on a daily basis and seeing the misery and the complications that brought. We don’t see that these days. We don’t see that even in parts of Canada where we are seeing small outbreaks. We are hopeful that we won’t have an outbreak of measles in Nova Scotia, but that depends on parents taking those wise choices and having their kids vaccinated.
I’m optimistic about vaccination rates. I think we’re in a pretty good position, but we need to have a better understanding of exactly where any gaps in vaccination coverage might be.
MR. MACMASTER: You mentioned the example earlier of not knowing who was vaccinated and who was not vaccinated. What would you do right now if there was an issue? Would you just approach the public and say: making a public appeal here, anybody who has not been vaccinated, please contact your local physician, your family doctor or go to your local hospital to get vaccinated? If there was an outbreak, is that what would happen now?
DR. ATHERTON: That’s pretty much what we do at the moment. Last year, we had a small number of cases in the province of pertussis, and we did use that as an opportunity to remind all parents that pertussis vaccine is available, safe and effective. We did see people coming in for vaccination and some catch-up there. That’s exactly what we need to do.
In an ideal world, we would be able to do that, but also be able to have a more targeted approach, focusing on those children who we would know to be under-vaccinated. But you are absolutely right.
MR. MACMASTER: I know the department has looked at other systems; I know you’ve been talking about them earlier today. What would the system look like? How would it help? Would it give you - it’s going to be taking in information, presumably from various health professionals across the province - what does the output look like? Does it show - can you do statistics on what’s happening, to be able to prioritize where the health system should focus its energy given a particular outbreak or an instance of a certain degree of illness? Can you give us some examples of what a system would look like?
DR. ATHERTON: The sort of information that I need as a public health physician managing an incidence or an outbreak and that we would expect a proper vaccine register to give us would be not just the population coverage. I need to know whether in Nova Scotia, 85 per cent of our kids are vaccinated against measles or 95 per cent. I need to know that.
But I need more granular information when I’m managing outbreaks. I need to know geographically where there are problems, where there are communities that have relative under-vaccinations so I can target resources, if needed. I need to know which groups - do we have lower uptake rates in our First Nations communities? I need to know those kinds of things. I need to know whether some of those socio-economic conditions which we talked about earlier, whether they are affected. So are people from a lower socio-economic group particularly seeing under-immunized? Because then I can target messages, both for catch-up, for campaigns to tackle outbreaks, but also on a routine basis to strengthen the base of children who are vaccinated, to know where we should put the effort, where do public health need nurses to make their efforts to contact parents and to educate parents.
MR. MACMASTER: Are there massive amounts of money that could be saved with an electronic system, or is it more about better health outcomes that may have marginal savings for government?
DR. ATHERTON: I think it’s both. It’s better outcomes, and the sort of outcomes I just talked about are really, really important. But it’s also about ironing out inefficiency in the current system of nurses and doctors filling in paper-based forms, which then go off to somebody else to input into a database, and for somebody else then to do the data checking. There’s so much inefficiency in that, there will be savings on that.
MR. MACMASTER: How important is speed in the response to an outbreak?
DR. ATHERTON: It’s vitally important. I mean the quicker an outbreak is identified and a response is put in place the more likely it is that an effective response will be put in place. It’s an important principle of outbreak management that you act promptly and in a timely way.
MS. MARTIN: I just want to provide further context on some of the questions that we’ve been asked. We fairly regularly, for a variety of different reasons, have to mobilize pretty quickly and get information out to the public. So while I know we’ve talked a lot this morning about the information management system, which Dr. Atherton has rightfully outlined the importance of why we need to have a system in place but when we need to get information out to the public, for example, if we anticipate a heavy flu season and depending upon the intensity of that, we engage 811, which is a number that many Nova Scotians are familiar with - a registered nurse online who is able to provide information to the public. We provide information out to the district health authorities and sometimes, depending upon if it’s a flu outbreak, they can mobilize quite quickly to develop clinics and get information out to their residents, and then not to mention our good partners like Doctors Nova Scotia and sending information directly out to physicians’ offices.
Those are all mechanisms that we would continue to use even if we did have a system in place, because it’s important to get information out to both the care providers and the public, who are relying upon them for services. That would be a pretty standard way to ensure that we mobilize quickly when we need to.
MR. MACMASTER: Appreciating that - I mean there’s obviously a system in place now that has benefit. Can you give us maybe some indication, on a scale of one to 10, where you would rate the current system versus more of an IT-based system in the future?
MS. MARTIN: I think that it would be pretty difficult for us right now to put a number on. We have gone through some instances in the past - flu seasons, H1N1, and so on - and we know that the health system can mobilize quickly with its federal partners and district partners and care providers. Certainly it would be assisted with an information management system but it would be difficult to answer your question.
MR. MACMASTER: Would the current system maybe be a six and an IT-based system an eight out of 10?
MS. MARTIN: Again, it would be very hard to put a fine point on that.
MR. MACMASTER: Okay, I can appreciate the response and I guess the reason why I was asking the question was just to get a better idea of making the investment in a new system, how much better it is going to make things. That’s what I was getting at there.
Another question - Mr. Chairman, how much time do I have left?
MR. CHAIRMAN: One minute.
MR. MACMASTER: Just one minute. One last question, are there any downfalls to moving to more of an electronic-based system over a paper-based system? I think of cases where we might have some kind of a disaster where the power is out, I know that there are steps that are taken to protect against that, but is there any downside towards moving towards an IT-based system with respect to that?
MS. MARTIN: For any system that’s developed, especially important health information systems, we would have contingency plans in place to ensure that we have a fail-safe in place. I recognize that systems are subject to outages from time to time but we also have a lot of experience because we do manage a number of systems for the province and we would certainly have contingencies in place.
MR. MACMASTER: Thank you, Mr. Chairman, I’ll conclude with that question.
MR. CHAIRMAN: Perfect, thank you. I’ll turn it over to Mr. Wilson.
MR. DAVID WILSON: I found it quite interesting to hear the member for Halifax Atlantic apologize for political use of this committee. I don’t know if he was talking about the fact that each Party in this committee brings four potential witnesses, and the fact that the Liberal members on this committee voted down every single one on the Opposition witness list, and we’re going to go forward with just the Liberal witnesses as we go forward. I don’t know if that’s what he was apologizing for, but I know that it’s extremely important for government, for MLAs when they make comments, when they provide Nova Scotians with information on the direction government’s going to go, it’s important for them to defend that.
I’m glad the member for Halifax Atlantic believes he’s in a Party that allows for free thinking, and that’s the concern I have. We’ve seen the comments from the Minister of Health and Wellness around the column, and I think either the minister doesn’t understand the social determinants of health, or he doesn’t support them. I do feel bad that the witnesses are here today having to defend those comments. I know the chief medical officer stated in the email that I provided to the committee that he can’t and won’t try to explain the minister’s comments.
With that, I’m wondering, Dr. Atherton, if the minister has requested for public health any additional information on the social determinants of health, or has he requested any of the number of studies, reports, and papers that talked about social determinants of health?
DR. ATHERTON: In terms of the minister having arrived in the Department of Health and Wellness and getting fully up-to-date with his brief, there is a whole system of briefings in place. As part of that, we are talking to him about a number of issues from a public health perspective, including the development of public health renewal, the development of our standards and our protocols. As the member knows, underpinning all of that is a strong desire and belief in the need to address the social determinants of health. So in terms of briefings being given and received, absolutely, that’s in place.
MR. DAVID WILSON: I’m so glad to hear that, and I hope that Dr. Strang, yourself and all your staff continue to make sure the minister understands those determinants. With that, I will come off that topic and go into another area that is important.
I know after the Auditor General’s Report, I initially stated that I know the Department of Health and Wellness responds quickly and efficiently with the recommendations. The first one, Recommendation 4.1, has asked that the Department of Health and Wellness expedite the approval process and move forward with the public health protocols in a timely manner. I know you discussed that a little bit in some of the questions.
In the government response, the Department of Health and Wellness agrees with the recommendation, and the internal Department of Health and Wellness process for approval of the protocols is currently underway. We know that direction for approval of the protocols will be sought from the new government. I’m wondering, have you been given the direction from the new government on moving on this recommendation?
MS. MARTIN: Yes, as you know, the development of the protocols is an extremely important piece of work with the department. It’s led by our public health group. At the root of it is really re-examining how they can ensure that their efforts benefit more and more Nova Scotians. They will do that by engaging with partners in the district health authority, with various organizations that work to improve the health of Nova Scotians, and certainly community health boards and so on.
To answer your question quite directly, it is now a policy in the Department of Health and Wellness that the minister has endorsed the public health protocols. They are officially a part of the department’s policy, which means they do guide us in the delivery of public health services. With any new policy, there are certain things that fall into place immediately and there’s work that takes place over time. This is a policy that falls into that category as well, in terms of it will take us some time to fully engage our partners and ensure that we are improving our service to Nova Scotians.
MR. DAVID WILSON: Under Recommendation 4.2, I know in the response from the department, it said that you will be including timelines with that. If the protocols are approved, I know you need to do the engagement, but what is the timeline? There must be - okay, let’s say - six months? A year? What is that timeline that you anticipate?
DR. ATHERTON: One of the recommendations was around whether we need an implementation plan. The protocols are not saying that, which we believe actually needs a plan. What we need is that the protocols are approved, they are now official policy. It is a matter of working with partners over time to build those into our system so that our public health system works in a different way. As part of that, for example, we had plans in February to meet with - to get a number of people from primary care and public health together to look at roles and responsibilities and how they might shift over time. That meeting was cancelled because of the weather and has been rescheduled and will be held very shortly.
We are now in implementation. The district health authorities are currently - public health staff and others are looking at the implications for the work, refocusing, moving work upstream, working out those relationship issues between public health and primary care. So it’s already ongoing, and as Deputy Minister Martin says, that’s something that will happen over the next two or three years really.
MR. DAVID WILSON: In the response from the Recommendation 4.2, the department did say that it will continue to work with district health authorities and community partners to provide guidance and support for the system-wide implementation of the protocols and that’s extremely important.
We know that the current government is undertaking a huge transformation with district health authorities. I’m not here to debate if it’s a good change or not. I’ll save that for the floor of the Legislature. We are going through a major transformation of district health authorities, and from my understanding from the government, they’re looking at everything under the districts on how they can implement the superboard and amalgamation of that. When you do that, people are taken off projects and are taken away from important work - and I’ve said this before - like the protocols that you’ve just approved. Do you anticipate that, potentially, there could be a delay in that because there is this massive amount of work that needs to be done between now and less than 12 months from now? Will it push off that two- to three-year because people are going to have to spend some time on the amalgamation of district health authorities?
MS. MARTIN: There are certainly employees in the Department of Health and Wellness that will be involved in and dedicated to the work on the restructuring, but the reality is that many of the staff in the department come in every day and focus on their particular subject matter. In this case, it would be the public health staff. Certainly, they will be consulted and engaged in some of the work related to the transition, but their primary duties won’t be impacted.
I believe there is a tremendous opportunity, and I do have this conversation with the lead of public health on a fairly regular basis. We really have to look to the opportunity of having a consolidated district health authority at a time when we’re coming out with this relatively new protocol. It really will create a platform where we have a greater opportunity to have consistency in terms of how we roll out this policy or protocol across the province.
MR. DAVID WILSON: What I take from that comment is that it would be more beneficial, I think, to potentially hold off on some of the work within the districts, because we really don’t know at this time what the structure will be for a number of - it could be primary care, public health, continuing care, all through the districts. That has been the concern that I’ve tried to raise over the last little while, around when you take resources away from what they normally do in the districts and in your department and my concern is - I know that you’ve answered a few questions, I think it was last week, in Public Accounts Committee around - soon we’ll hear what staff in the Department of Health and Wellness will be working on, on the restructuring, but we know that there are staff within the district health authorities that are going to need to work on that also.
That’s the concern I have, it’s that projects like this will be delayed and pushed back. I’m not saying they’re not going to be done, but they will be delayed and affected by it. That’s the concern I heard from Ministers of Health across the country, for example. When jurisdictions undertook a similar exercise, it takes away the resources of people who are working on important projects. I know they’re not just going to forget about them, but I mean people only have so much time in the day. That’s the challenge we have, and that’s what I see in front of us over the next year. It’s a delay in important work like this.
Maybe one last question - I know I only have a minute or so - am I hearing you right that, yes, there may be a bit of a delay because, really, the structure that will have to implement the protocols that the government approved, we really don’t know exactly who in - well, in the one district and the IWK - who will really actually oversee them. Will there be a delay? A simple question I think.
MS. MARTIN: A simple question; a simple answer for that question is I’m very confident that we will move our key priorities. Certainly, the Department of Health and Wellness is a very busy department. We always have a number of large-scale priorities that we move. The work that public health has been undertaking for the past several years is work that will continue. It was in the initial briefings with the minister. The policy has been endorsed by the department. I don’t see the restructuring delaying our efforts to ensure that we’re continuing to improve our services to Nova Scotians related to public health.
MR. CHAIRMAN: Mr. Horne.
MR. HORNE: A follow-up to a previous question. In developing your surveillance program, do you feel you have the appropriate full-time staff or adequate staff to look after this and bring it to fruition? And how long will that take you? I think you might be saying 2015.
MS. MARTIN: Just to clarify, is this a question about the information management systems specifically?
MR. HORNE: Not necessarily, but just that you have a complement of experts that can put this program together.
MS. MARTIN: Yes, we do in the Department of Health and Wellness have a number of information management systems underway at any one given time. I believe that last week, I talked about our drug information system as one that we were working on the development and the rollout. There are a number of other systems. When it comes to the development of the public health system, and we were just in exchange of questions and answers related to priorities, that the development of that system is a priority. I’m very confident as the acting deputy for that department, that we have the expertise within the department. We also participate in national networks where we are able to benefit from the other jurisdictions that have these systems in place, and we also have tremendous expertise within the department.
With any new project or effort, there are times when we go to the marketplace to secure experts from the private sector or the academic community, what have you, whatever sort of expertise we need. That is some of what we would do, in terms of this undertaking.
MR. CHAIRMAN: Thank you. Mr. Farrell.
MR. TERRY FARRELL: I want to ask briefly about Recommendation 4.8 in the Auditor General’s Report. It talks about Public Health Canada’s appointment of a field surveillance officer. I realize that’s technically outside the jurisdiction of the Department of Health and Wellness, but could you update us on what’s going on with respect to the appointment of a Public Health Canada field surveillance officer, and what the involvement of the Department of Health and Wellness is in facilitating that getting done, or encouraging it being done?
DR. ATHERTON: I’m pleased to tell you that that is moving on very well. Public Health staff have been continuing the dialogue with Public Health Agency of Canada; that has gone very well. That post is currently in the recruitment pipeline, so we are optimistic that that will be in place very soon.
MR. FARRELL: Is there a time target or a time frame set out?
DR. ATHERTON: It’s really tied into recruitment processes and they sometimes take longer than we expect, so I can’t give an exact date.
MR. CHAIRMAN: Thank you. Mr. Maguire.
MR. BRENDAN MAGUIRE: My question is around the field surveillance officer position. We all know this is an important position. What has the province done to encourage the Public Health Agency of Canada to fill this position? (Interruption) Oh, and there goes my mind. Who stole my question? (Laughter) I’m good.
MR. CHAIRMAN: Okay, Ms. Lohnes-Croft.
MS. LOHNES-CROFT: I had started a question before, and I was cut off because of time. I was speaking on what we’re learning from other jurisdictions on what tools we could be adapting for Nova Scotia. Could you continue on that line?
DR. ATHERTON: Yes, I think where we got to was that we did report that as part of our strategic intent work that we’ve been doing over the last few months, we did consult with - we did look at all other jurisdictions to see what information systems they were using, what they were planning to use, where they were up to with particular vendors. We also did look outside that, beyond the bounds of Canada. We looked at U.S. systems and some systems in Europe as well, so we have a pretty good idea of what is working where.
I think the comment made earlier about there’s no single place that we can point to and say there is success, still holds true. There are pockets of good practice elsewhere, in different places. For example, we know that a couple of jurisdictions - Ontario and Quebec - have used the Panorama program to develop effective case management. That’s already implemented, and they are learning from that and that’s in place.
We know that some of the jurisdictions - Ontario, for example - have also used Panorama for a need to develop its immunization registry. We know that Alberta has some experience with a different vendor, a different system in those two areas. So we do continue to look at those other jurisdictions.
We have a public health network and a public health information steering committee as part of that public health network, which helps us to bring that kind of information on a regular basis back into Nova Scotia. So yes, we do look at successes and failures elsewhere.
MR. CHAIRMAN: Thank you.
MR. FARRELL: We don’t have any further questions from here, Mr. Chairman. Thank you.
MR. CHAIRMAN: Excellent, thank you. Ms. Martin, did you want to have some closing remarks?
MS. MARTIN: Thank you very much for all of the questions today. It has been a privilege to appear here today to further elaborate on the good work that our public health group is undertaking. It’s an opportunity to explain that, like any other area, there are challenges with updating our public health system, but what is important is the progress that we have made and do plan to make in the coming year.
As I said earlier, the Auditor General made note of numerous improvements that were needed in our surveillance work. We have agreed with all of the recommendations of the Auditor General, and we have taken action on all of them as well. While it will take some time to finish our work to secure the best option for an immunization registry and the other components of an integrated electronic public health surveillance system, we are moving in the right direction. Thank you.
MR. CHAIRMAN: I think we’re finished with you guys here, and I guess we’re on to other committee business. Is there any other committee business?
MS. LOHNES-CROFT: Our colleagues in the Progressive Conservative caucus have proposed that next week the Department of Labour and Advanced Education speak at the committee on workplace safety. They have proposed three topics, and I would like to introduce a motion to merge these three topics into one, similar to what we’ve done on our pension topics.
MR. CHAIRMAN: Are there any comments on this? Mr. MacMaster?
MR. MACMASTER: I certainly would have no problem with that.
MR. CHAIRMAN: Okay, great. Thank you.
MR. FARRELL: I would call for the question on the motion.
MR. CHAIRMAN: Would all those in favour of the motion please say Aye. Contrary minded, Nay.
This motion is carried.
[The committee adjourned at 10:53 a.m.]