STANDING COMMITTEE ON PUBLIC ACCOUNTS
Mr. William Estabrooks
I would like to welcome our witnesses this morning to the Public Accounts Committee. We look forward to your comments on this important topic. We will be engaged here - usually we say that, for our witnesses, 12 to 15 minutes would be fine as a presentation. If you need more, certainly feel comfortable about it. The most important part is the exchange between the members and the witnesses.
I would ask my colleagues to introduce themselves, beginning with the member for Halifax Fairview.
[The committee members introduced themselves.]
MR. CHAIRMAN: You, sir, could introduce yourself. I believe you are both going to speak, is that correct?
DR. THOMAS WARD: Yes.
MR. CHAIRMAN: Go ahead, please.
DR. WARD: I am Dr. Tom Ward, Deputy Minister of Health, and with me is Sarah Kramer, Chief Information Officer for the Department of Health. Thank you for this opportunity to come this morning and discuss with you the role of information technology and, I think, more importantly, the role of information management in the health care system.
Approximately two years ago, when I arrived in Nova Scotia to take over the Department of Health, one of my commitments at that point in time was to put in place an information management strategy. My previous experience in large teaching hospitals had brought to the forefront the need to understand and plan for the proper role or proper use of information within an organization. It remains a very precious resource. It is the key to quality patient care, and care that is both effective and efficient.
During the course of reorganizing the department, I made the decision to put in place a chief information officer to oversee the development of a strategy and the implementation of an information management plan for Nova Scotia as it relates to the health care system. We were fortunate in recruiting Sarah Kramer to come and join us and fulfill that role. I will turn the microphone over to Sarah so that she can provide further information.
MS. SARAH KRAMER: Thank you, Dr. Ward. I've handed out some material that I thought I could use just as an introduction both to the overall kind of plan and then specifically to a couple of key initiatives we're undertaking that you may wish to know about. The first page really talks about the overall vision, which is the end point we would like to get to, and that is the creation of a client-based or patient-based portable electronic health record which would provide information for that patient - it looks like this - and then for the population at large, to assist in the care of the patient, the care provided and the information provided to the clinicians, and also as an accountability tool for managers, administrators, funders, and government structures. Within that we would be looking at strengthening the current privacy protection that exists right now, using the electronic tools and also building on some of the principles that are being developed nationally around the protection of personal health information.
The vision talks about why we're doing this. It's important for consumers, as I said, to give them more information on their own health and how to improve that health through lifestyle choices; for health care providers in terms of giving them better information, both on the patients that they're seeing, but also access to information - the volumes of published knowledge that they have to go through in order to make those clinical decisions day-to-day, will be available electronically, and assist them in making those decisions and reduce the medical errors that occur right now; and for system managers, funders and so on to ensure the accountability and effectiveness of the system.
The ultimate result will be that the information follows the patient and not the provider. Currently you have paper charts on your health information at your doctor's office, potentially at a public health office, probably at a number of acute-care facilities, and within
those acute-care facilities a number of files that don't link to one another. The ultimate goal is to be able to have information attached to you and not to the provider, so that when you need the care and you experience a health difficulty, the care provider will be able to access that full spectrum of information and be able to make sound and effective decisions about your care.
There really are four building blocks to a health information management strategy. One - the top left corner - is really the technology, the infrastructure. I am going to talk to you a little bit about the hospital information system that we're implementing, and the two projects that are funded with some federal money: picture archiving, capture, storage, and single-entry access - I will talk you a little bit more about that in a moment - and the other corner is the protection of personal health information, and also the performance measurement and reporting. This is taking that information and using it as an accountability tool to report back to the public, report back to government, and report back to local governance structures such as DHAs and community health boards in order for them to assess how well they're doing in terms of resources applied for health care.
It's quite a complicated diagram, I'm not going to go through the detailed picture that's, I don't even know, it looks like it's complicated, because it's not an easy process to get to the point where we want to go to, but if you look at the bottom half, that's really the electronic health record. That's deriving information from the numerous service providers, building a data repository - that's one data repository that's centrally located - and ensuring that there's consent-driven access. Not everybody can get this information; only those with authority can access information about you.
Once that information is stripped of identifiers, you go above that line and the top half of the diagram talks about how we're going to transform this information into indicators of performance in the health system: how well are we doing in terms of maintaining the health of Nova Scotians, and how well are individual hospitals doing in comparing one against another in terms of performing with the resources that they have.
Why do we focus first on a hospital information system for Nova Scotians? First of all, clinical care, as I think I said before, is an information business. Nova Scotians can be singled out across the country in terms of the lack of hospital information. Every other province has, within it, hospitals that have electronic information available to clinicians. Nova Scotia, outside of the Halifax Regional Municipality area, the Capital Health District and the IWK, has very little in terms of electronic information, bits and pieces across, but nothing in a sustained integrated way.
There are serious accountability issues, as I am sure you know, from the auditor's report and from other venues, and this kind of information will support providing accountability. This kind of tool will support providing accountability information to government structures. There are utilization and efficiency concerns. Are we using the
resources that we have to the most effect? Do administrators, DHAs, CEOs and so on, know enough about what's happening within their hospitals to be able to make sure that they're doing the right thing at the right time with the right resources? They don't now and with these tools they will.
Also this hospital information system will provide that technological infrastructure on which to further build this electronic health record, and once we have this system in place, the technology will be there once we have the resources and time available to add in primary care providers, long-term-care information, the other parts of the continuum of care. So this provides that important building block.
I am sure you know that we selected MEDITECH who partnered with EMC to provide the software, and EMC, the hardware, storage hardware for the hospital information. I just want to take a minute to talk about the selection process. It started in 1997, led by the Cape Breton Regional Health Board. They brought in the other regional health boards and they went out together, they involved over 100 clinicians and administrators and spent over a year making the decision to choose MEDITECH and EMC as their preferred provider. In 1999 the government established a fund to actually implement that. The government changed. The new government also committed to implementing the hospital information system. The deputy minister came on board and brought us on board, myself and the director of IT, and gave us the orders to start negotiating and scoping out exactly how this would work with this preferred vendor.
We did take some time over the course of our negotiations and scoping to test the market informally and also the users informally to determine whether - it had been a couple of years and it was a pretty involved process - is this is something we wanted to go over again or were people comfortable that this was continued to be the way we should go? There was a comfort level. We continued the negotiations with those vendors and we signed the contract at the end of March of this calendar year.
I think the most important thing to note about that selection process was that it was so user-driven and for any of you who have been involved in even the smallest information technology implementation that's the key critical success factor for this kind of implementation. It's a significant job for all the users out there in the community. If they weren't involved in the decision making about the vendor, it just wouldn't work and we can't have that happen.
There's a slide here about the particular components that were purchased. I am not going to go over that, but you can look at that or ask me questions about it. The implementation plan is very inclusive. There's a detailed project structure in your handout, but I think the key message here is that it involves - it says 80, but when you count up all the subgroups and work teams, there are over 160 individuals from around the province, from
Dalhousie, from all the DHAs, the MSNS and so on, involved directly in the design and implementation of this system.
The timelines - we are on course. We did sign the contract at the end of the last fiscal year. We have hired Eastbridge Consulting through a competitive request for proposals process to lead the project management and we had some kickoff meetings in the summer. We're now in the process of doing the design work because we're implementing the same system across the province. We have to bring all parties into the centre to design the way it will look and work. We will start implementation in Cape Breton, the northern part of the province and then the western and southern parts of the province over the course of the next two years. That's the hospital information system.
The other big project that we're undertaking is one that was funded in part, in half, by the federal government through its CHIPP grant and that we're doing in concert with our Atlantic colleagues through a structure set up by the Atlantic Premiers called Health Infrastructure Atlantic, which was designed to really look at common opportunities to leverage cost-effective ways to set up infrastructure and information systems across all four Atlantic Provinces and also a way to leverage federal funding. The federal government looks very kindly on cross-provincial ventures in this area because that's really the challenge as we go forward - trying to create a PanCanadian electronic health record.
There were three initiatives in that project: Tele-i4, which is the PACS I will talk about in a moment and we're participating in that one; case management, which in Nova Scotia translates to single-entry access; and a common client registry, which I won't speak about directly today although I am more than happy to talk to you about it later.
The PACS project is a picture archiving capture system that's really a digitalization of images, x-rays, CAT scans, and a storage of them at the QE II. So all of the CAT scans across the province will be digitalized, put in electronic format, stored locally for a few weeks to a few months, and then archived at the QE II. That's happening across all four Atlantic Provinces so that when anyone needs to access those records, they don't have to call down to Health Records, figure out where someone had their CT scan done, try to find it, then spend three or four days getting it back to the local radiologist and having them look at it. This is an electronic version of that, so you just look in, get the person's health record number, look to see where their last CT scan was taken and take a look at it directly.
Case management, single-entry access, I believe you spoke to the people managing single-entry access roll-out in terms of the program. This funding will support the information technology behind that and provide the software and the hardware tools to allow those case managers to assess individuals and to place them appropriately.
So our next big step, really our most important thing, is to focus on the successful implementation of the hospital information system. This will be, as far as I have been able to determine, the first and only province-wide hospital information system that really forms the basis of an electronic health record. So we've got a lot of money invested in it, but we also have a lot of credibility invested in it and we have a lot of hopes invested in it in terms of our hospital community, our clinicians and our administrators. So we need to do a good job there and we're focusing on doing that.
We are strengthening and refocusing the Nova Scotia Telehealth Network. Over the next year we're looking at the protection of personal health information as I described, developing a performance reporting framework, both for our own needs and also to ensure that we comply with our minister's agreement to participate in the national reporting that we have to start in September 2002, and we're continuing to work with our Atlantic Canadian colleagues in order to leverage the additional federal funds that should be starting to become available next fiscal year, I hope. As we get those structures in place, we will start to build out the rest of the health care community and get the tools in place for them in order to participate in the system, and that's it.
MR. CHAIRMAN: I appreciate you sticking to your guidelines, Ms. Kramer. Dr. Ward, do you have anything to add?
Okay, it's 8:20 a.m. and the next 20 minutes goes to the member from the Official Opposition, the MLA for Halifax Fairview.
MR. GRAHAM STEELE: Mr. Chairman, I would like to start, first of all, by saying that there are a lot of good things going on in information technology in the health care sector. I don't think anybody doubts that for a second. The province has a good envisioning document and, if we want to give credit where credit is due, that visioning started under the last government and it's working its way towards fruition. So I would like to ask you to keep that in mind - that is the context in which I am working when I move on to my other questions, which aren't quite so friendly - that the general direction and the vision is very good and nobody doubts that for a second.
My first question I guess is a rather simple one. In the government's announcement of this new hospital information system, on April 19th, it refers to $30 million over three years, and the document you gave us this morning says $20 million over three years. What's the reason for the difference?
MS. KRAMER: The $20 million is the purchase price. So that's what we paid the software vendors for the software and the hardware vendors for the storage hardware. The $10 million is for the implementation, to back fill staff for training purposes, for the project management, for bringing back fill staff. A lot of those people on those charts, those project leaders, as implementation leaders, are people from the DHAs. They're the lab techs and the
pharmaceutical leaders. They're coming in to do design work and we need to provide the DHAs the funding to back fill them.
MR. STEELE: One would think that now that this hospital information system is underway that most everybody would be jumping for joy because it's something Nova Scotia needed for a long time, but there are a lot of people who aren't jumping for joy and it's not just MEDITECH's competitors.
As I talk to people, it seems to me that the root of the dissatisfaction lies in the way this contract was awarded. Now the original request for proposals went out in December 1997 and the contract was actually awarded in April 2001. That is three and a half years, which is a long time, especially when you're dealing with computer software and hardware because things progress so quickly so that what might have been state of the art three and a half years ago is no longer state of the art today. But the dissatisfaction is, I think, deeper than that and part of it starts with the fact that the RFP was for a much more limited system, or at least that's the way I would characterize it, that the request for proposals that went out for December 1997, I will just read the first two sentences so that it will be clear what I am talking about.
This is the request for proposal and it says this: This RFP invites proposals for the supply of hardware, software, documentation, training, implementation and ongoing support for an enterprise-wide information system for operation, administration and patient care services for the Cape Breton Health Care Complex. Then it says: In addition, each of the four health care regions within the Province of Nova Scotia has expressed an interest in participating in the selection of an enterprise-wide information system.
Now, I don't have the complete RFP, but as far as I can tell that is the only place in the entire document where there's any reference to a province-wide system. The rest of the RFP that went out in December 1997 refers exclusively to an information system for the Cape Breton Health Care Complex.
Now, let me start with this general question and then we'll get into specifics. How is it that an RFP three and a half years old for the Cape Breton Health Care Complex alone has grown into a province-wide information system that includes components that aren't even mentioned in here, like a data repository? How did that happen?
MS. KRAMER: It started off as a Cape Breton-led initiative. The other four regions participated in it and I think through the process of the RFP, the additional information provided through that process and the selection criteria and so on, the stuff I have read - I wasn't here at the time - was quite clear that this was a system which would be implementing the hospital information strategy that was established in 1995 over the course of a number of years.
That started in 1997. It was over a year to actually take the selection decision because of the level of involvement from across the province. The clinicians, the administrators, the review of the RFPs, the interviews, the site visits, this is not unusual for a single hospital information system selection to take that long, let alone one for across the province. That's not unusual, to get to the point of a decision in late 1998. The negotiation and the scoping then takes considerable time. There was a change in government; there was a change in leadership within the department; there was a change in structure, and all the time the same system was being further developed and refined in terms of scoping out the needs that negotiation continued with the selected vendor.
If I could just speak to the difference between 1997 - the system in 1997 isn't going to be the same as it is in 2001; that's true. We didn't buy a 1997 system; we bought the one that was available in 2001. Part of our informal assessment of the marketplace determined that MEDITECH along with the other vendors, had moved in step in terms of where it fit on the scope of information technology providers for health care. So while the world of health information technology had changed over three years, MEDITECH'S position within that world had not changed and that was the position that was reviewed at the time of the RFP.
MR. STEELE: The dissatisfaction that one is able to hear from MEDITECH's competitors relates to just exactly the point that you made, which is that the solution MEDITECH's offering in 2001 is not what it was offering back in 1997 or 1998. Everything has evolved, right from the scope of the request for proposals to the actual technical solution that MEDITECH is offering. The nub of the problem is that these other competitors weren't given the opportunity that MEDITECH was given to let their bids grow and evolve over time so that they could jump in and bid on this as well. That's the problem that I hear.
At any rate, let me ask you this. Do you believe now, today, in November 2001, that this process was fair?
MS. KRAMER: Yes, I do. I absolutely do.
MR. STEELE: Okay. Now, if it was fair and if everybody had the right to bid on a level playing field, why was it necessary to use the province's alternative procurement practices policy?
MS. KRAMER: The original RFP was not issued by the province. The standard and specific procurement practice relates to those RFPs issued by the province. Alternate procurement practice does not mean unfair procurement practice, and I think that that really is reflected - there are appropriate reasons to go to alternate procurement. This was deemed to be one of them.
MR. STEELE: Okay. I agree with you; there are circumstances where alternative procurement is appropriate and necessary and I guess the real question is whether this is one of those circumstances. It's interesting, this is the second time in a month that this committee has heard about the alternative procurement practices policy. The last time was Knowledge House and it was used as the reason why the contract awarded to Knowledge House was never put out to tender.
Let me look at the specific report that's signed by Dr. Ward. I'll read the reason that's given for using the alternative procurement practices policy. Here it is. It says, "One source or supplier" - let me back up a little bit and describe this document that I have. This is a document headed, Alternative Procurement Practices Report. It's dated March 30, 2001. This kind of report has to be used when, for whatever reason, the normal tendering policy is not being followed and there are exceptions to that policy. It's signed by Dr. Ward and it's for $14,322,000, so this is a big contract. The reason that's given for using alternative procurement - that is, for not following the standard procurement procedure - is as follows: "One source or supplier has the technical capability, expertise, or legal right to contemplate delivering the product or service in question." It's exactly the same reason that was given for awarding the contract to Knowledge House. Do you believe that reason applies in these circumstances?
MS. KRAMER: I do because that one vendor was the one that over a year was spent by clinicians and administrators across the province, to select. So yes, I do believe that.
MR. STEELE: I understand what you're saying, but that's different from being the only supplier that has the technical capability or expertise to deliver the product that's being contracted for. I understand negotiations were long and no doubt complicated, but that doesn't mean that that company was the only one who could deliver it. Let me read you a list of competitors, when I read this list my question to you, can you say to this committee that none of these other companies have the capability of delivering this product? The list is as follows: MEDITECH - they obviously won it - HBOC, IDX, SMS, Epic, Eclipsis, Cerner, and Britech. Can you say to this committee that none of those companies has the ability to deliver this product?
MS. KRAMER: I can say to this committee that none of those companies has gone through the purview and examination that allows me to say that they'd be the only one. That's really important. One of the key criteria for success and the ability to deliver is having had the users review and improve the selection of that software. It's not just about the technology; in fact, it's very little in the end about the specific technology and software - it's about the acceptability on the part of the users.
MR. STEELE: I hear what you're saying, but that's still different from being the only company that has the technical capability or expertise, which is the reason that's cited for using the alternative procurement practices policy. At any rate, I will leave that and just say that's for other people to decide, but I think it's a legitimate question.
Did you ever personally - and I know you came on board in the year 2000 - recommend or submit a formal technical recommendation to the department in favour of MEDITECH?
MS. KRAMER: Personally recommend?
MR. STEELE: Yes.
MS. KRAMER: Absolutely.
MR. STEELE: Is that in writing somewhere, where you give your reasons as an IT professional about why MEDITECH should be selected?
MS. KRAMER: No.
MR. STEELE: Okay. Part of the vision here is of a province-wide system, and it's my understanding that the Capital District Health Authority has chosen not to use this system. Is that correct?
MS. KRAMER: They have a number of systems in place right now, so they're not part of this implementation.
MR. STEELE: I am an information technology layperson, so I wonder if you could explain to me, as simply as you can so that even I can understand it, how is it that you can have a province-wide system where what is by far the largest health authority is not participating?
MS. KRAMER: I didn't go into detail in the presentation, but the province-wide system includes the interfaces between the information systems available at the Capital District Health Authority and the IWK and the centre repository that will hold the information software and the information from the other provinces, so it will be province-wide. MEDITECH will be out in the community, the standards are being built at the interfaces between that system, and that existing at the Capital District Health Authority will be maintained.
MR. STEELE: There are some people much more knowledgeable than I am who would say that in order to integrate the Capital District Health Authority into the system with MEDITECH is probably the most expensive and least technically feasible system, that there
are in fact other vendors who offer systems that would integrate much more easily with the existing systems of the Capital District Health Authority. What would be your comment on that?
MS. KRAMER: I don't agree with that. The information we have from the professionals that we've been consulting with differs from that.
MR. STEELE: I would like to ask you some questions about the technical merits of the system, and bear in mind that I am no expert here, but experts in the field use three words that I am going to use in a technical sense and those are: open, flexible, and scalable. I wonder if you could explain to me what the words an "open system" mean to you as an IT professional.
MS. KRAMER: Open means that it's standard-based and that you are able to link with other systems, revise as needed, adapt as required . . .
MR. STEELE: Is the MEDITECH system an open system?
MS. KRAMER: It has a lot of open parts and it is flexible.
MR. STEELE: It has a lot of open parts.
MS. KRAMER: There are some parts, like all systems, that are hard-wired, the basic standards, which we kind of want to be. We don't want it to be too open and flexible or with individual hospitals it will be revised over time. You want some standardization and some consistency. (Interruptions) You do want some standardization and some hard-wiring or the system will devolve over time and disaggregate and you won't get that standard set of information that you need to do the job.
There is flexibility in terms of building the data dictionaries, in terms of building the business processes behind it, and that's the work that's occurring between now and next year, in the design phase of the work.
MR. STEELE: Some people would say that the MEDITECH system is not an open system, that in fact there are significant, important parts of it that are proprietary, that are closed. What would you say to that?
MS. KRAMER: I would say that's not been our experience.
MR. STEELE: Okay. What does the word flexible mean to you as an IT professional?
MS. KRAMER: Open and flexible are similar. Flexible means that it can meet your needs as a client and can evolve over time.
MR. STEELE: In your opinion, is the MEDITECH system a flexible system?
MS. KRAMER: Absolutely.
MR. STEELE: If I were to say to you that some IT professionals disagree and say that it's not at all a flexible system, what would you say to that?
MS. KRAMER: I would say that has not been our experience.
MR. STEELE: What does the word scalable mean to you?
MS. KRAMER: Scalable means you can start small and move big.
MR. STEELE: And is the MEDITECH system a scalable system?
MS. KRAMER: Absolutely.
MR. STEELE: What if I said to you that some IT professionals say that it's not a scalable system?
MS. KRAMER: I would say that has not been our experience.
MR. STEELE: Okay. When you say it has not been your experience, which was your answer to each one of those things, what do you mean? What experience does Nova Scotia have with MEDITECH?
MS. KRAMER: Individuals have considerable experience across the province. MEDITECH exists in 300 hospitals across Canada. Anybody who has worked in a MEDITECH hospital has had direct experience.
MR. STEELE: When you say it's not "our experience," who is the "our" that you are referring to?
MS. KRAMER: "Our" is myself, my staff, staff in the districts, as far as I am aware. The IWK has MEDITECH, so there's experience there; we have colleagues across Atlantic Canada - all of Newfoundland and all of New Brunswick except one hospital are on MEDITECH. So we have very close colleagues who have given us some of their expertise in implementation and design.
MR. STEELE: One more quick question since I am running out of time. The Liberal Government was proposing a system costing $75 million over three years. This government is implementing a system costing $30 million over three years. What's the reason for the difference?
MS. KRAMER: We negotiated a good price on the software and hardware, and we are, over time, building in the other components of the system. This is hospital-based. We are providing some information to primary care physicians but not all of it. Over the course of time, we will be building those other components in, whereas I believe the $75 million was more inclusive in terms of the other parts of the continuum of care. We're starting here and moving out.
MR. STEELE: Mr. Chairman, I don't have time to start another line of questioning, so I think I will just pass over to the next questioner.
MR. CHAIRMAN: Mr. MacKinnon, it's 8:39 a.m. You have 20 minutes.
MR. RUSSELL MACKINNON: Mr. Chairman, I guess I would like to continue on this line of questioning with regard to value for dollar. You say that we received the best system and the professionals you have dealt with indicate that the choice you've made is the best. Am I correct?
MS. KRAMER: For Nova Scotia.
MR. MACKINNON: For Nova Scotia.
MS. KRAMER: For this project.
MR. MACKINNON: Back in the fall of 1999, there were changes to the Finance Act that essentially gave the Minister of Finance the authority to direct all differing government departments and agencies and so on and so forth, the responsibility of coming on line with one financial database system, the SAP program. Does this particular system have the capability of being integrated into that?
MS. KRAMER: Does MEDITECH have the . . .
MR. MACKINNON: Yes.
MS. KRAMER: Yes. Actually we are just scoping that out right now, the how-to on that.
MR. MACKINNON: Is there going to be an additional cost to the government, over and above what has been contracted with this $35 million, to do that or is that built in?
MS. KRAMER: To do the integration? I believe that licences have been purchased for SAP, so there might be some, but not over and above what it would have cost to have any financial system or to have purchased the MEDITECH financial system.
MR. MACKINNON: That sounds pretty easy, but can you quantify that?
MS. KRAMER: I can't right now; that's the scoping work that we're doing right now to determine what exactly it would take to implement an interface. We know it can be done. We have some of the technology specs behind us. We don't know exactly what the training costs would be, exactly how much the interfaces would cost to build and so on. That's what we're scoping out right now.
MR. MACKINNON: You indicated that the professionals' advice you received - the choice you made is based on that professional advice. Do you have any documentation to support that?
MS. KRAMER: I think we have significant documentation in terms of the original selection and the implementation and so on.
MR. MACKINNON: Would you be willing to provide that to the committee?
MS. KRAMER: Absolutely.
MR. MACKINNON: Also, with regard to the issue of value for dollar, obviously you anticipate that there will be a savings to the province. Am I correct on that?
MS. KRAMER: A savings to the province in what respect?
MR. MACKINNON: On the overall cost to health care.
MS. KRAMER: I think there will be an accountability improvement and an ability to direct resources to clinical care that's now being overspent in inappropriate use. I am not sure there will be a net savings.
MR. MACKINNON: Could you give a couple of specific examples of the inefficiency that will be dealt with?
MS. KRAMER: Well, I think right now if you talk to any clinician or administrator, they will tell you that there are lab tests that are done in duplicate, triplicate when they can't be found or when someone has moved from one place to another. There are diagnostic images that are taken again when someone is transferred from Antigonish to the QE II. Those kinds of things would be eliminated. There would be a more transparent way of looking at the way care is delivered so that you were ensuring that the right care is delivered at the right time.
Over time you would be able to eliminate some care practices that are not as effective as others and be able to streamline care from that perspective. You would also eliminate a lot of the administration and paperwork involved. Right now, for example, in Cape Breton they have a very busy lab. It's basically tally marks that they are tracking. So in terms of that kind of paperwork, the non-clinical care that doesn't add value to the patients, that's the kind of work we hope to eliminate.
MR. MACKINNON: Are you able to determine, even in general form, what type of reduction in your human resources component would be achieved because of this efficiency in process?
MS. KRAMER: We don't expect to achieve any reduction in FTEs as a result of this. We hope to alleviate some of the paperwork from the FTEs that's inappropriate and have those FTEs focus more on clinical care and provide more and better clinical care. We're not looking at reductions of FTEs now, as a result of this implementation.
MR. CHAIRMAN: Mr. MacKinnon, I believe Dr. Ward had something to add.
DR. WARD: I think the other important piece in terms of this is that it's a system that's focused on patient care and really will allow for better disease management, particularly in the area of pharmaceuticals. At the current time, estimates are that, particularly for senior citizens, depending on the jurisdiction perhaps, as many as half of the hospital admissions for seniors are due to inappropriate medication use, over-medication and other problems. Certainly, in the sense of improving patient care and improving quality, it's a very important step.
MR. MACKINNON: I would like to follow up on that particular point because, obviously, these issues were budgeted. Mr. Steele has indicated - I would say wrongfully, but that's the propensity of certain political elements when you're in this forum - that something is being done at half the cost than what was budgeted for, the $35 million as opposed to the $70 million. I believe you've correctly answered that and indicated there are other facets to the overall cost of the package. Am I correct on that?
MS. KRAMER: For the full and complete vision, there's more work to be done over the course of time.
MR. MACKINNON: That would bring it up to the $70 million.
MS. KRAMER: Or more. I don't know. We're biting off a big and chewable chunk, and we'll sort of see how the rest of it goes.
MR. MACKINNON: It would be incorrect to suggest that the package that you're securing now at $35 million - it really wasn't the $70 million package that was proposed.
MS. KRAMER: Not as far as I understood it.
MR. MACKINNON: You're comparing apples and oranges.
MS. KRAMER: I'm sorry?
MR. MACKINNON: What my colleague was doing was comparing apples and oranges.
MS. KRAMER: As far as I know. I haven't had a detailed look at the $70 million . . .
MR. MACKINNON: Now on the issue of putting more dollars into clinical health care, back in 1999 when the present administration was campaigning it said it would correct
all the problems in health care for $47 million additional. Now, obviously, we're up in the hundreds of millions of dollars beyond that. I don't want to start rehashing the obvious, but in terms of providing more health care dollars for clinical care - and I think that's really what we're all striving for, better value for our dollar - but I noticed even in the media this morning the Carefield Manor in Sydney is closing its doors because the Department of Health says no, we don't have the dollars to do that. How do you respond? If we're becoming more efficient in the high tech and the systems management process, why aren't there more dollars to deal with issues such as that at this juncture? I mean, we're two years into the process.
DR. WARD: Two years into which process?
MR. MACKINNON: Well, since the government set out this new agenda of more efficiency in delivering health care, yet we're closing down health care facilities such as the Carefield Manor; we have a doctor shortage at the Strait Regional Hospital. I can go on and on with examples, but I think you understand my concern.
DR. WARD: I do appreciate your concern. I think as you sit back and look at the health system in this province and across Canada, very clearly it's under significant pressure in every jurisdiction for a number of reasons. The choice to move forward and implement an information management system that will improve patient care, allow for more cost-effective care and help us begin to understand both the current challenges in the system, and the trends, and plan for the future is absolutely important. At the current time, we basically have, outside of Halifax and for many aspects of the system, a paper system. We're getting information one year behind and trying to plan for one year ahead. It is most difficult.
The cost pressures in the country are inordinate. Pharmaceuticals, which are an increasing component of every government's budget, are increasing annually by about 20 per cent - just fixed cost, no new drugs, just the cost of pharmaceuticals alone - which basically is putting on everybody a fixed cost drive of anywhere from 2 per cent to 3 per cent on a department's global budget. We recognize and understand those things and we're trying to balance off the provision of better care within the dollars we have. The decisions in terms of prioritizing - is it more important to invest in opportunities for better management for this system, better management for the future, versus dealing with the short term issue today? Those are challenging ones and those are certainly the issues that I think you need to be discussing with your colleagues on this side of the House.
MR. MACKINNON: One short snapper before I turn it over to my colleague. Those points that you've raised are quite significant. Obviously they are increasing costs that, for the most part, we don't have control of because we have we have an aging population, increased health care needs and so on. That information would generally have been known - I mean if you look at the demographics and the whole health care profile. These are issues that are essentially identifiable over a period of time, am I not correct? In other words, you would know, say, in 1990 what your expected health care costs would be because your population has aged or has an increase of demand for long-term care, that sort of thing. You would generally have some idea of that, would you not?
DR. WARD: We have some, but at the current time it's, at the very best, a guesstimate. Certainly we have an understanding of the aging population, but we have other issues. As an example, in Nova Scotia, the rate of obesity has doubled in the last decade. It's tripled in adolescents. Obesity is the single leading cause for type 2 or adult onset diabetes. We're now seeing 10 year old kids with type 2 diabetes. In this province, of our current population of known diabetics, which is about 5 per cent to 6 per cent of the population - that represents about 40 per cent of our cardiac surgery.
MR. MACKINNON: Why aren't we embarking on this Participaction-type program like what was done back when Trudeau was in . . .
DR. WARD: Those will be programs that you'll find the department rolling out in the next year. Again, as you're looking to the future, your comment is very clear. The opportunities to get out and deal with the determinants of health and prevent that burden of illness are very important. In order to be able to do that, we need to have the information. To learn today from a report that's two years old, to start to plan, is nonsense. We need better information. That's the purpose behind moving forward with a province-wide information management strategy.
MR. CHAIRMAN: Mr. Downe, you have seven and one-half minutes.
MR. DONALD DOWNE: Dr. Ward, you're absolutely right. We had the same problems looking at the Department of Health for a long time and realizing the information flow they were getting was so outdated. By the time we tried to fix that problem, we had another problem. Thus that's why the so-called vision of moving into more technology - and I do compliment my colleague for some of his comments being very non-partisan and being very factual. I remember the debate very well. We needed to do something a long time ago. I remember one of the debates was on the issue of just putting MSI on a computer system instead of manually doing the work and the millions of dollars that saved for the Province of Nova Scotia, ultimately at the end of the day cutting the health care costs, although we never saw the true effect of that.
Back to some of the questions on the dollars that are being spent. I know when the original proposal was brought forward, and these are ballpark, general frameworks of costs so we could have some budgetary item for which both current and Opposition Parties have voted against this proposal, but nevertheless, there was a proposal to bring in the information management strategy for information technology implementations within the Department of Health, and I understood the numbers were closer to, the one-time project cost for health information system was estimated in the fall of 1999 somewhere in the vicinity of $35 million. I believe the AG report back in 2000 - around that - said if that is implemented right away it would save approximately $2.5 million. Is that accurate, Dr. Ward? You would have been dealing with the AG's department.
DR. WARD: It doesn't ring a bell.
MR. DOWNE: You don't remember that? When we talk about the $35 million or $30 million program that we have before us, there are a number of systems. Just trying to drill in a little deeper than what my colleague was talking about, the data warehouse that would be required for that, have you any idea what the cost will be for that component?
MS. KRAMER: The data repository - where the data sits - is part of this implementation.
MR. DOWNE: That's part of the $35 million?
MS. KRAMER: Yes.
MR. DOWNE: And the cost to run it?
MS. KRAMER: I have that - I think it's going to be a little under a couple of million a year to run it. Over time? You mean the ongoing operating costs?
MR. DOWNE: It's $2.5 million a year?
MS. KRAMER: That we have there? I have it here - hold on a moment - $2.4 million.
MR. DOWNE: Yes, $2.4 million. In 1999 the basic cost was $35 million for the base program and I understood the, what I call it warehouse, was $11.4 million. Now we're talking about doing the same thing for $30 million over a three year period. This has all been based on the fact that technology has gotten cheaper over the time from 1999, when you were talking about the program, until today.
MS. KRAMER: I am just trying to clarify which numbers are which. It depends on what you're including in each of those sets of numbers, so . . .
MR. DOWNE: The base program, what we understood was a base program, was around $35 million.
MS. KRAMER: Right.
MR. DOWNE: And then there was the data repository - you're saying that is part of the $35 million. We understood that was a separate line item for $11.4 million.
MS. KRAMER: No, it's part of the $35 million in terms of the implementation costs of it, how you get it set up, the design, the purchase of the hardware, all of that and that's part of that $35 million. The ongoing costs after we implement, after year three, are $2.5 million.
MR. DOWNE: We have different numbers involved . . .
MS. KRAMER: Maybe I could just clarify because it could just be a different spreadsheet.
MR. DOWNE: The CHIPP program, which is a federally-funded program offering 50 cent dollars, was there anything used in the Y2K transfer to be able to springboard or leverage to use for those CHIPP program dollars?
MS. KRAMER: I'm afraid I don't know.
MR. DOWNE: There were some technologies brought in for Y2K.
MS. KRAMER: Right.
MR. DOWNE: Any of the expenditures in Y2K that would trigger some of the CHIPP dollars?
MS. KRAMER: I don't believe so. These are new projects.
MR. DOWNE: How does this 50 cent dollar work in developing strategic alliances within Atlantic Canada or within the Maritime Region or within province-to-province? Can you give us an idea of what you are working on now? Maybe this would be more appropriate for the Deputy, Dr. Ward. Can you name one or two projects that you're currently looking at that would actually be able to lever some of the 50 cent dollars from Ottawa?
DR. WARD: Do you mean in terms of the current CHIPP projects?
MR. DOWNE: Yes.
DR. WARD: As Sarah had spoken about earlier, we are basically involved in two major pieces out of the three components. One of them is the PACS.
MR. DOWNE: The what?
DR. WARD: PACS. Picture archiving system.
MR. DOWNE: Acronyms are great if you know them all, but when you don't know them . . .
DR. WARD: It is basically a system where a digitized image is made. A CAT scan or an x-ray is digitally put together, packaged up, and can be sent from Antigonish to the QE II, or from the QE II to Antigonish, so you don't have to worry about sending the old-style films. In fact there are quite significant savings in doing that.
The second piece we are involved in is case management. That is really a process of identifying and following individuals at the community level. We are doing that in partnership with P.E.I. and Newfoundland and Labrador under the CHIPP piece.
The third component, and we are not part of that, is a thing called common client registry and P.E.I. is taking the lead on that. This consortium, Health Information Atlantic, was put together through an initiative of the Deputy Ministers of Health early in the spring of 2000 and it really was an opportunity for us to begin to work together.
The response to our applications - there was $80 million in the CHIPP fund. We ended up, as a consortium, getting $12.5 million of that, or about 16 per cent of the money, which for 8 per cent of the population is a pretty fair rate of return, given our previous history. We were very pleased with that.
The second piece that I think has been quite good, from our viewpoint, is that in this process we have been able to negotiate with the federal government our 50 cents, on occasion, as being in kind, using current resources, so that in fact we have not had to come up with additional money in many circumstances. I think the second important piece in all of
this is that when you begin to think of a health care system, particularly for the higher-end tertiary-quaternary cardiac transplant programs and other things, we really are, in Atlantic Canada, a health region. Very clearly, for that population of patients, at some point in time, we need to be thinking about a common electronic record for those clients from Bathurst who have been here for a cardiac transplant.
MR. DOWNE: What are the . . .
MR. CHAIRMAN: Excuse me, Mr. Downe, I'm sorry you are going to have to save that for the second round, if you wouldn't mind. It is 9:00 a.m. I would like to turn the next 20 minutes over to the members of the government caucus.
The honourable member for Sackville-Beaver Bank.
MR. BARRY BARNET: Mr. Chairman, before I begin asking questions I just want to make a brief comment. I find it interesting that here, this week, government is being criticized by the NDP member for taking too long to enter into an agreement with an IT firm, when two weeks ago we were being criticized for rushing into these things. I wonder if there is a magic number the NDP might have for days that you have to evaluate these things before you determine whether or not it is the right approach to go with one carrier or another carrier in terms of IT, but I find it somewhat hypocritical that we can't win on this one. We either take too long or we don't consider things long enough. That is just an opening comment.
My opening question will be to Dr. Ward. Over the past number of years, we have talked about evidence-based health care, to the point where it is becoming somewhat of a catchphrase now in the Province of Nova Scotia. My question will be, how do you see the MEDITECH system assisting with evidence-based health care and what benefit will the individual Nova Scotia patient see as a result of us implementing the system?
DR. WARD: The concept of evidence-based health care is really a phenomenon that has gained international acceptance, and it is primarily as people have begun to understand the complexity of health care, the amount of information around each patient, it has become very clear that you need a system which will support the gathering of information and packaging it up so that in fact good decisions can be made. I think, as Sarah had talked about earlier, at the current time, we have a lot of difficulties in the system in the sense of delaying in terms of lab tests, lost tests, inappropriate information, inappropriate use of medications. It is really through the use of a system such as MEDITECH and the gathering of information with respect to the entire population that we can in fact make those decisions about moving the system forward.
For the individual patient, the opportunity to have a seamless, electronic health record which any health care professional can access and make better decisions about their care - the immediate improvement in quality will be quite remarkable. As an example, an individual who was in a car accident somewhere else in the province, when taken to an emergency department, hopefully in three or four years, the emergency room staff should be able to access that individual's previous history, even if they are unconscious. They should have access to histories of medications, previous tests, underlying conditions, and be able to treat those patients appropriately.
Specialists who are following patients should be able, in conjunction with family doctors, to follow trends in terms of lab tests and the activities around patients and make better decisions. For the province and for the broader citizenry - I talked about this issue earlier, the sort of epidemic of obesity we are seeing and this sort of tidal wave of type 2 diabetes coming at us. If we had better, almost real-time information, it would allow us to become much more aggressive in terms of planning and dealing with the determinants of health. Very clearly, we need to be at the level of the pre-school in terms of identifying and following those populations and planning for the future.
MS. KRAMER: I think, from a clinical perspective, just also to give you a bit of an example, there is a lot of information coming out right now, both in Canada and the United States, about the incidence of adverse drug effects, drugs being prescribed that have adverse effects on patients. Normally Dr. Ward waves this book, but I will wave it. This is the Institute of Medicine from the United States, which talks about the quality chasm and the issues around quality in health care and notes specifically the issues of adverse medical events and drug events and, specifically, how information systems can help.
So in this case, if a doctor is prescribing a drug within a hospital, he or she will prescribe it and if there is a counter-indication - if a patient is already on a drug that will have a negative effect on him if the second drug is prescribed - that alert will be provided to the physician right away. If it is a child and the dose is inappropriate, that automatically will be an alert. Physicians have a lot of information to keep in store, general and specific information about the patient, and it is not reasonable to expect someone to have that breadth and specificity of information at the same time. These tools will help them do that in a way that will prevent some serious harm that is sometimes caused inadvertently.
MR. CHAIRMAN: If I may, Mr. Barnet. Could you just clarify, for my interest alone, the book that you're referring to, I never caught the title, and maybe Hansard might appreciate, Dr. Ward, your reading that into the record. Could you read that into the record?
DR. WARD: The book is entitled Crossing the Quality Chasm, and it was published by the Institute of Medicine. It really is the discussion of a new health care system for the 21st Century, and it focuses primarily on the need to monitor and track all activities related to patients and all indicators of patient health. Included in this is a recommendation - this is an
American publication for the federal government - to invest significant dollars in terms of building a national system for the United States to track those. I would say that in Canada, as a result of the First Ministers agreements last spring, there is a national agreement for us to move forward and develop 14 national comparative indicators for the performance of the health care system, very much in keeping with these. The other thing of interest is that there was a recent OECD meeting in Ottawa, which is really talking about system performance indicators on an international basis.
MR. CHAIRMAN: Thank you for that clarification. Sorry, Mr. Barnet, I'm cutting into your time.
MR. BARNET: I'm not sure how my question turned into a book review. (Laughter)
MR. CHAIRMAN: I will ask for the report next Thursday.
MR. BARNET: I guess my next question is, how will this system trickle down to the GP, the family doctors, or will this system move right down to the family doctors? If, for example, I go to visit my family doctor, will he be connected to this, will he have a terminal in his office where he will be required to input specific health records through this system?
MS. KRAMER: Eventually, as part of the vision, that's absolutely a key component of the vision. In terms of the implementation that we talked about today, it's focusing on hospital information because that's where the volume of critical events occur and it's where the infrastructure exists to actually manage those technologies right now. However, we are, within this implementation, providing for access to physicians in their offices via the Web, a secure access via the Web, to get information about lab results for any tests that patients have in-hospital, any diagnostic imaging, some of the discharge information. They are able to get that information very quickly, not waiting for the fax when the lab tech has enough time to take the result and fax it to the family physician.
They are also able to - and this is another example of administrative efficiencies - book appointments for patients from their offices, so they don't have their secretaries calling every lab in the near vicinity and having to call back the patient and figure out when they're available. They are able to do it live on a computer terminal while the patient is there and have it be that much more convenient and that much less onerous from an administrative perspective.
MR. BARNET: That will be good. It will be good to see that the health care industry will finally catch up to the rest of the world. My practical experience in business was in real estate, and frankly the real estate agents have been interconnected by a multiple listings system and sharing information for years and years and years. It's somewhat surprising that there isn't some integrated system for health care.
I want to go down a road that Mr. Downe had talked about, and that was the comparison of the $75 million versus the now $30 million cost. I have a specific question with respect to that, do you know whether or not the $75 million that was originally estimated for the cost of this program included within the capital expenditure of that $75 million, operating expenses or operating initiatives that would normally be considered operating? And you spoke earlier about the warehousing of the information, I'm not sure what the term was that you used for that warehouse system. It had a $2.5 million operating component. Was the operating component of that included in that $75 million? Could it be considered that a portion of that $75 million would have actually been operating expense and not actual capital?
MS. KRAMER: I'm afraid I don't know the answer to that question. That's something I can look into.
MR. BARNET: That would certainly help us understand whether or not, in fact, the $75 million included within its budget an amount of money that you would normally use for operating and it might have helped in terms of balancing an immediate budget but it would have capitalized what most people consider operating and simply would have been borrowing the money over a longer period of time to cover some operating expenses. We all know what has happened with provinces and the federal government with respect to that type of accounting: it's either good for the current taxpayers or good for the future ones.
My next question is with respect to staff acceptance of this. I have had some personal experience in municipal government with staff acceptance of financial IT packages, and some resistance from the staff level to do the routine and the process of inputting the information, and there has been some criticism, why are we asking for all this information if we never, ever use it. What is the department doing to ensure that staff have a complete buy-in to this, and that the information that's being gathered and collected is information that is necessary and will be used at some point in time?
MS. KRAMER: I think you partially answered it yourself. Something that I feel very strongly about is that if the information that's collected is not important and usable by the person who is collecting it, it either won't be collected or it won't be valid, it won't be correct. That's number one, to ensure the users are involved in the design of the system, which they are, over 160-plus back at home in terms of training and so on. And that they're involved in the design of the reportings of the system. You put the information in, part of it is a communication and changed management and training effort to allow people to understand that this is instead of paperwork in many cases.
Sometimes people think about the extra work involved in computer systems and they don't think about the work that, hopefully, will be taken away in terms of the paperwork and the administrative work that they did instead. That's part of the message we would like to impart. Then the reports, what do they need from that data set - from the ward clerk, to the
family physician, eventually to the CEO of a DHA, to Dr. Ward - what do you actually need out of that system to help you make your clinical, administrative and management decisions?
MR. BARNET: My final question before I pass it on to one of my colleagues - probably, in some people's minds, the most important question I will ask - is the question with respect to safety and security of the system. There has been a great deal of media attention to those smarter people who are able to somehow work their way into systems. These systems are developed by smart people but breached by even smarter people. We hear in the media that often the smarter person is a 15 year old or a 16 year old computer genius who is able to remove information that some people might consider very private and very sensitive.
What has the department done to ensure there is due diligence in terms of developing a firewall between those people who want to enter that system, who are not part of the health care system and are simply looking for information that they have no right to get? How can we assure Nova Scotians that their private records will remain private?
MS. KRAMER: I think we're working very closely with the vendor and the designers and technology experts from across the country to ensure that the level of technical security is there to ensure that level of privacy of personal health information. The other thing to note is that the software vendor and hardware vendor that we're working with, as well as many others, have long histories of being able to maintain that security. They are under considerable stress to do that, both here and in the United States. We haven't had any breaches in Canada. That's something we hope to continue, going forward.
Lastly, it's important to note - it's something we're trying to kind of communicate over the course of the implementation - is that electronic systems can be more secure in some ways. You can actually track who has access to your information and bar people from accessing your information. That's very difficult to do in paper records. It is much easier to maintain a consent track, who can and who can't, than it is in the paperwork, or where there is, perhaps, a student manning a health record office that may or may not know which physician, or clinician, or neighbour could come in and get information. So part of it is we're doing everything we can to ensure that the records are secure and accessed only appropriately and the second is, it's actually more secure than some of the paper management systems we have in place right now. So it will be improved in many ways.
MR. BARNET: I said that was going to be my last question, but one more thing and I don't want to sound like a shell-shocked politician after what some would describe as a not so pleasant experience with an IT firm, but for my own information and for the information of Nova Scotians, how long has MEDITECH been in business developing software?
MS. KRAMER: I think it is over 20 years and they are a completely debt-free company. They own all their own property. They have no mortgages, no debt, nothing, and they have been in business in Canada for years. They're in over 300 hospitals. They are very sound financially.
MS. BARNET: I will pass the rest of my questions on to Mr. DeWolfe.
MR. CHAIRMAN: Mr. DeWolfe, you have under four minutes.
MR. JAMES DEWOLFE: Thank you, Mr. Chairman, and welcome, Dr. Ward and Ms. Kramer. We've talked about all the nuts and bolts of this system and, it's rather a lot to absorb in a short time. So let's talk about a real life situation. I go to my local family practitioner with some chest pains and he, in turn, sends me over to the Aberdeen Hospital to have some tests done and refers me to a cardiologist. So where do we go from there now? Can you explain how this system is going to work for me, what it's going to do for me, and what am I going to notice as a patient when I go in there? Am I going to notice anything different under this new system?
MS. KRAMER: You should notice, first of all, that when you go to your doctor and you have chest pains, he's going to be able to book you in, I mean just from a convenience perspective, very quickly and get that test done at the hospital immediately and on-line. You will head over there. If you've had any other tests or any other indications, results from diagnostic images done in the past, whoever is seeing you at the hospital will be able to call that up and be able to better assess what's going on with you right now. I don't know if you would notice that, but certainly you would notice that in terms of the quality of care that you've gotten.
If you needed any kind of scan or a diagnostic test done and there wasn't a specialist there to see it, if it's a CAT scan, for example, it would be easily shipped down to a specialist in Halifax potentially. They would be able to view it and you could use the Nova Scotia Telehealth Network, for example, to have a live consult between that specialist in Halifax and whoever is caring for you in the Aberdeen Hospital and be able to deal with it right then and there, hopefully, given that there were no further complications. Then, if everything turned out all right, you would go home. Your home physician then, the next time you go and visit him, would be able to access the results, be better able to counsel you on the next steps, and be able to manage your care over time in a better informed way.
MR. DEWOLFE: Does that CAT scan go through an electronic media, like that just goes zap, right up there so, hopefully, it would be . . .
MS. KRAMER: Yes, live, almost live.
MR. DEWOLFE: Yes. So, hopefully, it would be read and studied immediately. So let's take it a step further then. The front-line health care workers, the doctors and the nurses, the backbone of our health care system, how does this improve their ability to provide quality patient care? What's that going to do for them as physicians, nurses, and specialists?
MS. KRAMER: In the case that you just described, for example, whoever sees you at the Aberdeen Hospital would have a much better sense of what's going on with you. They wouldn't need to go over all of your history, all of the drugs that you might be taking, which might have a cause or have a negative reaction to whatever treatment they want to prescribe. Health care provision really is an information business. They need to know what your problem is, they need to know what the best application of their clinical care is, and with information systems they're better able to do that.
MR. DEWOLFE: Thank you, Ms. Kramer, maybe we can come back to this, as I am getting the old cut-off message there.
MS. KRAMER: Yes, I saw that.
MR. CHAIRMAN: I've got to change my hand messages.
MR. DEWOLFE: I am starting to catch on to the chairman's new signals.
MR. CHAIRMAN: It's 9:20 a.m. and we're into the second round. I will give each caucus seven minutes to allow for a wrap-up from our witnesses. Could you begin, Mr. Steele.
MR. STEELE: My colleague, the member for Cape Breton West, raised the issue of SAP and I would like to go back one step before where he started. I wonder if you could explain to the committee what SAP is, please.
MS. KRAMER: I am not as familiar with SAP, but it is a financial and human resource information system that was purchased by the government with enough licences for the entire MASH sector, which includes hospitals which will implement a standard way of providing human resource and financial information across that spectrum of services.
MR. STEELE: Are you aware of how much money was spent to buy those licences?
MS. KRAMER: I am sorry, I am not.
MR. STEELE: Would we be talking millions, tens of millions, what order of magnitude are we talking about?
MS. KRAMER: I honestly don't know, I would be happy to get that information from my colleagues at the Department of Finance.
MR. STEELE: Is it not the case that the Capital District Health Authority, in fact, has refused to use the SAP?
MS. KRAMER: Not as far as I understand.
MR. STEELE: Are you aware that they've chosen a different financial product, namely PeopleSoft?
MS. KRAMER: They had that system in place and we allowed them to expand it currently because right now we have a patchwork of financial systems across the province in hospital systems. We agreed that we need to focus on the patient and administration systems, so we put kind of band-aids in place to manage over time until we get the capacity to implement SAP. So they didn't select it as a new system, as it became the Capital District Health they wanted to have a standard system across, including Dartmouth and the Nova Scotia Hospital, and that's what they were allowed to do.
MR. STEELE: Yes, but let me put this to you as directly as I can, and you can tell me if I am right or if I am wrong, or if you just don't know. It is my understanding that the province has bought enough SAP licences, as you say, for the entire MASH sector which includes hospitals, it is also my understanding that the Capital District Health Authority has refused to use those licences because they have chosen a different financial product for their purposes, and that therefore the province has bought literally thousands of SAP licences that will never be used. Now, is any part of that correct or incorrect?
MS. KRAMER: I guess I wouldn't cast it as they have refused to purchase SAP. This is the information that I have. They needed something immediately, and the SAP implementation will take time. They have an interim approach which allows them to expand their current software, so they didn't make a new selection, they didn't go to the market, they didn't refuse SAP per se. They expanded their current system, but they are part of the Council of CEOs before whom I have brought the proposal to have SAP implemented, not this year, but over time and I have not heard a refusal from them on that front.
MR. STEELE: To your knowledge, is SAP widely used in the health care sector across Canada?
MS. KRAMER: It's not widely used in health care across Canada and that's part of what we're exploring to determine what would need to be done. It has been implemented in B.C. in one region, in Ontario in one set of hospitals - actually in two sets of hospitals - so that's part of, I think when I answered an earlier question, there is some examination being undertaken right now to sort out how we would actually do this in Nova Scotia.
MR. STEELE: I think Dr. Ward had something he wanted to add as well.
DR. WARD: Yes. I think the other important piece, my understanding is that the provincial SAP licence covers the province, but it's set up so that as users are brought on it's incremental. It's not as if 1,000 licences were bought; it's a licence which is expandable depending on the number of users.
The second important piece in all of this, I think, is that we very clearly have to differentiate between a patient care system, a system that is focused on the patients, the information around the patients, to provide for better patient care outcomes, better management, against financials. Finances, the tracking of the dollars and trying to link that back to patient care, they're two entirely separate systems at the current time. Now it's only at some point in time that you're going to be able, as we roll MEDITECH out, to link some of that back to the financials and come up with the cost per patient or cost per cases. The province-wide move to use SAP for financials and human resources is currently, in my understanding, in use in Cape Breton, HRM and many of the other municipalities for the financial pieces. The human resources piece will be rolled out at some point in time across the province.
Very clearly, those programs will be applied to the health care sector at some point in time. There is no doubt about that. The issue that Sarah has talked about, the scoping out of how that is going to be rolled out to the districts, how it is going to relate to patient care activities, how we are going to be able to track dollars and match them to patients and outcomes, that is the challenge.
MR. CHAIRMAN: Under a minute, Mr. Steele.
MR. STEELE: Okay. Dr. Ward, I wonder if you could provide to the committee documents that you have relating to the SAP licences because I think, obviously, it is an important difference whether licences have been bought but will never be used or whether there will actually be no money spent unless they are in fact used. Because the information I had was that the licences had been bought and paid for and the Capital District Health Authority has simply said, we are not interested. So it is an important difference in opinion and if you have documentation on that, I would certainly be interested in having it.
I guess I will just wrap up, Mr. Chairman, with a comment and that is that at the core of my concern here is that the Capital District Health Authority I am told, is not using the provincial financial system, that the Capital District Health Authority, Nova Scotia's largest health authority, is not going to use this hospital information system. That has led people much more knowledgeable than I am in the field to raise some concerns.
MR. CHAIRMAN: Your time has elapsed. Would you like to comment on that, Ms. Kramer or Dr. Ward?
MS. KRAMER: I guess just to say that they are not going to use the MEDITECH software, but they are part of the hospital information system because we consider the hospital information system to be the MEDITECH software, the data centre and the interfaces from the current systems in the Capital District Health Authority. We consider all of that part of the hospital information system.
MR. DOWNE: I remember when we first went into Telehealth and then we went into information technology in health delivery - and it is going to be a vital part of the success, or hopefully success, of delivering a health care system that is affordable and also predictable. That is, I guess, the issue. The deputy minister mentioned that under CHIPP although we are 8 per cent of the population within the region, we have received 16 per cent of the dollars. But I would say that possibly when you take a look at the QE II, we represent all of Atlantic Canada health delivery, to some degree. When it comes to cardiovascular surgery, there is not an awful lot done in Charlottetown, P.E.I., so we do it here. There is not a lot of cardiovascular surgery in Newfoundland. We do it here. There are other specialties that as a province we do for the region. My question is, will this technology, the information that we are trying to get from this process, be able to show us whether or not the other provinces are paying their fair share toward the utilization of the health care system in the Province of Nova Scotia as we know it today?
MS. KRAMER: Absolutely. This will certainly help us in getting at the residents' location and the cost of care.
MR. DOWNE: And whether or not those inter-chargeable costs between provinces will then be able to be quantified so that we know we are getting our share financially from the other provinces for the cost of administering health delivery for their patients in our jurisdiction?
DR. WARD: Yes, that remains a challenge for us at the current time, but as we roll this system out, we will have a better understanding of the cost. As you are aware, we have a reciprocal billing arrangement, inter-provincial, with three levels of funding in which the top level very clearly does not cover the cost for a day in the intensive care unit at the QE II and certainly does not cover many aspects of our high-end programs. We do bill back, at the current time, some of the hardware costs - pacemakers, those kinds of things. Our billings to New Brunswick last year were about $1.25 million. So we do that.
There are other aspects of the system that are a problem for us. The Canadian Blood Services, as an example, billing is based on province of utilization. We run all the high-end programs and we end up paying significantly higher costs. Through this system, we will be able to identify costs and track them by patient and then have some, I would presume, animated discussion with our Maritime or Atlantic colleagues as to the funding of the system.
MR. CHAIRMAN: Mr. MacKinnon, you have just under five minutes.
MR. MACKINNON: I want to be clear on this SAP program. Has the Minister of Finance given any written directive to the Department of Health in terms of its systems management, in essence, given direction to the Department of Health to put all its systems under the SAP program?
MS. KRAMER: I think in terms of there's a regulation or a policy that all systems need to be approved by the Department of Finance . . .
MR. MACKINNON: Will you provide that documentation to the committee?
MS. KRAMER: Yes. I can't remember what form it's in, but there is one and we need to seek the Minister of Finance's approval if we're going to use something other than SAP, for example. So, he provided us approval to purchase MEDITECH. I'll get that to you.
MR. MACKINNON: Thank you. Does that directive equally apply to the QE II, to the Capital District Health Authority?
MS. KRAMER: I believe so.
MR. MACKINNON: So it does. So even if they have a different system, there is some directive from the government that they have to come on-line or somehow be integrated, is that correct?
MS. KRAMER: Yes.
MR. MACKINNON: Whether they want to or not?
MS. KRAMER: One presumes.
MR. MACKINNON: I want some clarification because my colleague from the NDP caucus was leaving the impression that we're going to be operating in a vacuum here versus the rest of the province. I think, in fairness to the people of Nova Scotia, we have to give them a comfort level that we're not going haphazard on the management systems.
Last week before our committee, we had various members of the Department of Health and one lady, Joanne Bree, she was manager of the financial eligibility for individuals going into nursing homes and so on. She indicated that they do not keep a record of the applications for those waiting to get into nursing homes. Is that the norm? We're talking of systems management here and yet we have no system in place to be able to identify what the
needs are for seniors vis-a-vis nursing homes in the province. Is that a problem in the Department of Health?
DR. WARD: It's a problem in the system. One of the challenges, very clearly, is with a number of private operators. The single-entry access piece has really been the opportunity to begin to define the population of patients who require admission, either into long-term care facilities or require some home care. The cleaning up or purging of wait lists of various institutions within a district can produce some amazing results. As an example, when we began to pilot the single-entry piece in Cape Breton - we had it early on - I think it was last fall, October - something like 300 individuals on the wait list, but as we managed to sort out things we would find people on the wait list for four or five institutions. Within three months, that list was under 100 people. So very clearly the roll- out of our single-entry access piece is the beginning of an opportunity to define this.
MR. MACKINNON: Perhaps then, Mr. Deputy Minister (Interruption) How much time?
MR. CHAIRMAN: Thirty seconds.
MR. MACKINNON: Would you be able to give us - in written format - some indication as to what policy you contemplate in the near future on that? Also, Ms. Bree gave an undertaking to the committee that she would provide a copy of the entrance requirements for nursing homes. She advised that it was put in in 1988, but she has not to date been able to produce that document. The only document that was available is the one from March, 2001. She gave an undertaking to the committee she would provide that and we've tried your department several times and have not been able to secure that document. Would you please give an undertaking to the committee to provide it?
DR. WARD: Absolutely. One of the problems of not having an information system in the department, there is no document tracking and many other things.
MR. MACKINNON: Or good human resources that will respond as they say they will.
MR. CHAIRMAN: Thank you Mr. MacKinnon. Are you okay with that, Dr. Ward?
DR. WARD: Yes.
MR. CHAIRMAN: It's 9:35 a.m. and I turn the floor over to the member for Kings West.
MR. JON CAREY: Mr. Chairman, just a couple of short questions. As a rural member, will this system have any beneficial influence on attracting and/or keeping doctors in rural areas, in your opinion?
MS. KRAMER: Well, it certainly provides them the tools that they would expect in a modern community, a modern hospital. Right now one of the issues, nationally anyway, in terms of recruiting is that if you don't have - people coming out of schools - basic information systems like you would in any other business and like you would in medical school, it's very difficult to attract people. In terms of attraction and retention, it's helpful. It's also helpful because it provides a link back to the specialists on whom they rely for that additional support for clinical decision making.
It's an electronic link in terms of the lab results and consults; it's an audiovisual link in terms of the Nova Scotia Telehealth Network; and it's clinical expertise in terms of accessing information, the latest bookshelf information, about what is the correct and most recent protocol for treatment of a certain disease. It helps people out in the field who are a little more isolated do their jobs better and be more connected back into the centre.
MR. CHAIRMAN: Dr. Ward wants to add something to that.
DR. WARD: I think the other important piece in this is very clearly that this concept of the electronic record is very supportive to the health care team of the future. It's very clearly my sense in many communities we will be looking at a new type of health care team which will involve physicians, nurse practitioners, nurses, dieticians and others. The opportunity to have a single record to support their activities, to make it readily accessible if an individual from your community travels to the regional hospital to get a lab test done, those results will be back and available for the team by the time you get back to the community. I think, as Sarah said, it's very supportive.
The other two really important pieces are the clinical expertise, the opportunity, if somebody is concerned about a medication, to be on-line to ask or to delve more in terms of drug reactions, to identify cross-reactions; very important. I think the third piece is the ability over time through Telehealth to conference, to have the peer support, the direct support of your peers in terms of managing patients. Our view is that it will be a very positive event.
MR. CAREY: Canada-wide, I believe we were told that we're late getting into this game with this system. After it's implemented, where will we be positioned?
MS. KRAMER: Actually the benefit of starting out behind is that we can leapfrog ahead. Part of the negative consequences of not having invested over time in these information systems turn into positives when we are able to have a greenfield to implement a single system across the province. Other provinces that have invested in legacy systems are dealing with the more expensive and cumbersome issue of connecting old systems across a
bunch of hospitals. We don't have that problem because we don't have those old systems, generally speaking. As I say, as far as I can ascertain from my colleagues across the country, we will be the first ones to have a centrally-accessible and housed hospital information system which links to all of the hospitals and all of the acute care institutions within a province. We will be ahead, and we are being looked at at the national level as leaders in this. That's why I sort of said in my next steps, we really have to focus on doing a very good job here.
DR. WARD: As a follow-up to Sarah's comments, I think the excitement nationally is the fact that our strategy is really to put in place an information management system with a population of approximately 1 million people. Certainly, if you begin to look at the potential to attract research and research dollars around population health, long-term follow-up programs and the development of systems in this particular area, we believe that there is a very significant opportunity for us to continue to find additional resources from outside the province to finance these activities.
CHIPP was a good step for us, but as Sarah noted in her opening remarks, there are some additional programs up and coming, including the new Canada Health Info 4 Inc. and other opportunities. We believe that we are very well-positioned to take advantage of these opportunities and, basically, get some additional funds into the system.
MR. CHAIRMAN: You have one minute remaining, Mr. Carey.
MR. CAREY: Quickly then, Ms. Kramer, does any high-level health committee or person work with you as this process goes forward so that there's a correlation between the two?
MS. KRAMER: In terms of the implementation, you have a chart in your handout. We have two executive sponsors, myself and John Malcom, who is the CEO of the Cape Breton District Health Authority, and he and I are co-leading the implementation of this project. On the steering committee, which is kind of overseeing the high-level perspective of the project, there is representation from all of the DHAs, including the Capital District Health Authority and the IWK, as well as experts from the physician community, the nursing community, and the academic. We have Dal as well.
I know your hand signals now, too.
MR. CHAIRMAN: You know my hand signals by now. We certainly have a few moments for a wrap-up from either of you or both of you, and I invite you at this time to take the opportunity.
DR. WARD: Mr. Chairman, the move forward in this province with our information management plan and strategy, I think, is a very important and exciting event in terms of the provision of health care to Nova Scotians and improving the overall system. Health care is quite remarkable in that it is an absolutely information-intense enterprise at the best of times, and yet we spend less than 2 per cent of our operating dollars for the support of information systems or information management. Compare that to the banking industry, which is another information-intense business, where most corporations are spending someplace between 10 per cent to 12 per cent of their operating dollars in the support of their information management.
The challenge will always be for us, as we move forward, to separate out, sort out and prioritize the activities in terms of supporting the system, trying to improve care, and providing for better management while at the same time trying to deal with the clinical pressures that Mr. MacKinnon had pointed out earlier. The people in the field in this province, the people I talk to, are absolutely thrilled with the opportunity before them as we're rolling the MEDITECH piece out. Certainly we are the envy of many other jurisdictions and we do believe that at the end of the day this is going to improve the quality of service to Nova Scotians.
MR. CHAIRMAN: Ms. Kramer, anything to add?
MS. KRAMER: No.
MR. CHAIRMAN: On behalf of the committee, I would like to thank you for appearing this morning. We're going to take a quick recess and then we will reconvene for an item of business.
[9:43 a.m. The committee recessed.]
[9:45 a.m. The committee reconvened.]
MR. CHAIRMAN: I received a piece of correspondence dated November 13, 2001 from the member for Halifax Fairview. Mora made copies available to the caucus and I feel obliged to put it on as some business at the end of the meeting. Mr. Steele, it's your correspondence. Can you give us some direction here?
MR. STEELE: Perhaps the best way to proceed is if I actually read the motion I intend to make and then speak to it briefly, and perhaps it would be best if we dealt with the two motions separately. Deal with one, have a discussion and a vote and then deal with the second, if that's all right with you?
MR. CHAIRMAN: Proceed.
MR. STEELE: The first motion that I would like to make is as in the notice that I gave to the other committee members. It reads as follows:
I move: That the Public Accounts Committee directs the Chair to write to Jack Sullivan, John Cameron and Marie Campbell to invite them to appear at the earliest opportunity before the Public Accounts Committee to speak to the manner in which public money was spent at the Strait Regional School Board during their employment or term of office; and that the committee directs the Chair to advise Mr. Sullivan, Mr. Cameron and Ms. Campbell that the Public Accounts Committee will consider issuing a subpoena if they do not attend voluntarily.
That's the motion, Mr. Chairman. I wonder if I might speak to it briefly?
MR. CHAIRMAN: Yes. As long as it's a reasonable time.
MR. STEELE: I will be very brief. Mr. Chairman, as we're all aware, the matters going on at the Strait Regional School Board are a matter of great public interest and comment. We're also aware that there are other processes going on. The reason I am bringing this motion forward is that I believe that the Public Accounts Committee has a unique role to play that is not capable of being played by the other processes. There is currently, we are told, a criminal investigation underway. The purpose of a criminal investigation is to determine if a crime has been committed. We have no idea how long the investigation will take or whether there will be charges and if so, who will be charged. Of course, as everyone knows, in the criminal process there is absolutely no guarantee that the principals involved will actually speak publicly about their roles.
There's also a forensic audit going on, but it too is a process with a different purpose. It's to determine where the money went and what processes were in place that allowed these various things to happen. Only the Public Accounts Committee has the power to ask these people to come and attend and to pose questions to them in an environment where they are free from liability. I would suggest that the reason for these historic rights of the committee is precisely so that we can inquire into the public accounts without worrying ourselves overly with the impact on parallel processes. So, with that background, that is the reason why I am bringing this motion forward for the consideration of the committee.
MR. CHAIRMAN: Thank you. I have a couple of speakers who also want to speak on this motion. Mr. Langille.
MR. LANGILLE: This was dealt with in an in camera session about this motion and about bringing the Strait Regional School Board into Public Accounts Committee. At that time, Mr. Steele was advised of our thoughts on that and I will reiterate what I said in the in camera meeting. There is a forensic audit going on and there is also an RCMP investigation going on into the Strait Regional School Board. The investigation might last a month, it might
last longer, we don't know. But in that time, looking at the investigation that's going on, it would not be in our interest - I believe - to bring them into Public Accounts Committee while there is an investigation going on. I don't understand why the NDP is pushing this until after the investigation is completed, after the Department of Education is advised. Thank you.
MR. CHAIRMAN: Thank you, Bill. Mr. MacKinnon?
MR. MACKINNON: I will make my comments very brief. I am in full support of accountability. I think anyone who knows me on this committee knows that irrespective of what one's political stripes are, I do demand full accountability. However, as the committee had agreed in general principle, we would allow the Minister of Education sufficient time to conclude the proper investigations and deliberations that were required, there is a forensic audit, a possible police investigation - or there is a police investigation - I think it's prudent to wait for the information to come in. I have confidence, based on the comments that were given by the Minister of Education in the House, that we will get to the bottom of it in a rather timely fashion. It appears they are moving as best they can, given the circumstances.
I know Mr. Steele is even going to great theatrics to start - contrary to the rules and the traditions of the House - printing up House of Assembly letterhead with his picture on it. I don't know if there's a competition going on between him and Mr. Deveaux for the leadership coming up in a few months' time or if he's craving attention or what . . .
MR. STEELE: If I may, Russell . . .
MR. MACKINNON: . . . but the fact of the matter is, Mr. Chairman, I think we should respect due process and allow the Department of Education to provide us, and we certainly are within our rights if, in a reasonable period of time, we feel that things aren't being done to our satisfaction, to support Mr. Steele's motion, but at this juncture I think it would be highly, highly inappropriate until we have sufficient information coming forth, particularly since some of these individuals are the ones who quite apparently could be under the scope from a forensic audit and a police investigation.
MR. CHAIRMAN: Thank you for those brief comments. Do I have other speakers on this motion?
MR. STEELE: Mr. Chairman, I would just like the opportunity to respond briefly to some of the comments that were made.
MR. CHAIRMAN: I would like to clarify a point, the question about your picture on the letterhead, I am going to clarify with the Speaker . . .
AN HON. MEMBER: How do you know that's really him?
MR. CHAIRMAN: There's a lot less hair. However, Mr. Steele, I know you want to speak to the point, please. I will recognize you now.
MR. STEELE: Mr. Chairman, with due respect to the member for Colchester North this motion was not dealt with in the in camera session, it deals with a different set of people; the second motion does deal with that earlier issue. I can't say strongly enough this is the Public Accounts Committee. It is the only forum that has the right to request that public officials appear, and the power to compel them to appear. There is no other forum in which that can happen. A forensic audit does not involve public questioning of public officials. The police investigation is a separate process.
As for Mr. MacKinnon's comment that this is theatrics, Mr. Chairman, I care very much about the role of this committee and the accounting of public money. This isn't theatrics, this is my job, and I am not going to apologize for it to him or anyone else.
MR. CHAIRMAN: Would all those in favour of Mr. Steele's motion please say Aye. Contrary minded, Nay.
The motion is defeated.
Mr. Steele, you have a second motion?
MR. STEELE: I do, Mr. Chairman. Just for the record I would note that all of the other members of the committee voted Nay on that motion. My second motion is as follows . . .
MR. CHAIRMAN: Excuse me, Mr. Steele, I don't think that comment was necessary.
MR. STEELE: In that case, Mr. Chairman, I would like to ask for a standing vote.
MR. CHAIRMAN: And I don't think that is necessary at this time. I would like to move on to the second motion, please.
MR. STEELE: Mr. Chairman, my second motion (Interruptions)
MR. CHAIRMAN: Excuse me. Could I have order, please.
MR. STEELE: We'll see who goes outside and actually stands up and says . . .
MR. CHAIRMAN: Order, order. Mr. Steele, I have given you the floor to make a second motion and I would like you to proceed with that now, please.
MR. STEELE: Mr. Chairman, my second motion is as follows: I move that the Public Accounts Committee rescind its earlier decision to defer calling Jane Purves, Wayne Gaudet, and Robbie Harrison to appear before the Public Accounts Committee, and direct the Chair to write to Miss Purves, Mr. Gaudet, and Mr. Harrison inviting them to appear at the earliest opportunity before the Public Accounts Committee to speak to the manner in which public money was spent at the Strait Regional School Board during their respective terms of office as Minister of Education.
Mr. Chairman, if I may speak to that very briefly.
MR. CHAIRMAN: Yes.
MR. STEELE: I would reiterate the same reasons I gave in support of the first motion and say that this is really the only forum in which questions of accountability of the Ministers of Education can be properly examined. It is very much apparent that the other processes currently going on cannot do that, and that's the reason why I am putting this motion forward for the committee's consideration.
MR. CHAIRMAN: Mr. Barnet.
MR. BARNET: Mr. Chairman, two things. One is that, essentially, what Mr. Steele is asking us to do is to reconsider a motion that was defeated at the last meeting. My experience is that most rules of order prevent the reconsideration of a motion unless there is notice given at that time. I'm not sure whether or not our rules prevent that, but I would say that's the normal process.
The second thing is that Mr. Steele has provided absolutely no new information for us to reconsider this. The same members are here now who were here then, and essentially what he's doing is asking us to reconsider a decision that we've already made based on the same information that he provided last time. So I would suggest, Mr. Chairman, to members that we provide the same answer back, and I certainly will not be supporting it.
I would like a ruling on whether or not our rules of order allow for a motion like this, that is exactly the same, to be reconsidered without notice at the previous meeting.
MR. CHAIRMAN: If I could, before I recognize the next speaker, it was a deferral motion, it wasn't defeated, and the other request came from another member. So I recognized another member of the NDP caucus. So I ruled that this motion could be brought forward at the time. I could be proved incorrect on that, Mr. Barnet, but the motion has been put and I am going to let it stand for this meeting. If it is redundant, I will have to come back to you with an apology for the fact that I have erred. I don't mean to cut you off, but I would like to recognize Mr. MacKinnon.
MR. MACKINNON: Two points, Mr. Chairman. Again what we see is a member of the NDP caucus trying to circumvent the rules of the House of Assembly. Once we have an in camera session, he will use just about any tactic possible to make an in camera session public. Second of all, I have full confidence, not only in the process as has been outlined by the Minister of Education, our RCMP, the independent auditors, PricewaterhouseCoopers, but also the Auditor General's Office, and I have full confidence that at some point in time full accountability - and not the distant future, but the very near future - these points will be addressed. I think it is highly inappropriate. We've made a policy decision on this, and to allow a member of the NDP caucus to continue with this type of theatrics is just a reinvention of a previous member of that caucus who sat on this committee.
MR. CHAIRMAN: Has the question been called for? (Interruption) Then I am going to put the question. Would all those in favour of the motion please say Aye. Contrary minded, Nay.
The motion is defeated.
Just one moment, please.
MR. STEELE: Mr. Chairman, I request a standing vote.
MR. CHAIRMAN: I will recognize that at this time. Those in favour of the motion, the Chair recognizes the member for Halifax Fairview. Those opposed, could you stand and I would recognize each of you - Mr. Downe, Mr. MacKinnon, Mr. DeWolfe, Mr. Langille, Mr. Barnet, Mr. Morash and Mr. Carey - as opposed. Is there other business? Seeing none, could I have a motion for adjournment.
MR. MACKINNON: I so move.
MR. CHAIRMAN: The motion is carried.
[The committee adjourned at 10:00 a.m.]