HALIFAX, WEDNESDAY, MAY 26, 2004
STANDING COMMITTEE ON PUBLIC ACCOUNTS
8:00 A.M.
CHAIRMAN
Mr. Graham Steele
VICE-CHAIRMAN
Mr. James DeWolfe
MR. CHAIRMAN: Good morning, ladies and gentlemen. I would like to call to order this meeting of the Public Accounts Committee. The topic today is the Department of Health, focusing on the Nova Scotia Hospital Information System or NShIS. We are pleased to have with us Dr. Tom Ward, the Deputy Minister of Health. Tomorrow is Dr. Ward's very last day as Deputy Minister of Health and we are pleased that he is taking at least part of his second last day to join his favourite legislative committee. Dr. Ward, I would like to invite you now to introduce the people you have with you today.
DR. THOMAS WARD: Mr. Chairman, I have on my left Byron Rafuse who is the Chief Financial Officer for the Department of Health. On my immediate right is Ms. Mary McKeen who is the Acting CIO for the Department of Health and on my far right is Mr. Dieter Pagani who is the Director for IT Services for the department.
MR. CHAIRMAN: Thank you, Dr. Ward. I would like to now ask the members to introduce themselves, starting with the member for Halifax Needham.
[The committee members introduced themselves.]
MR. CHAIRMAN: Dr. Ward, I would now like to invite you to make an opening statement. I would ask you, as is customary, to aim for 10 to 12 minutes. Should you go 15 minutes, we will turn the floor over to the members. Dr. Ward, you have the floor.
1
DR. WARD: Mr. Chairman, thank you for the opportunity to speak with you about the development of the Hospital Information System across the province and our information management strategy, particularly as our current program relates to the implementation of a hospital information system in districts one through eight. Four and a half years ago, when I arrived in the province, I was somewhat surprised to find that the use of information technology was primarily limited to the hospitals in the Halifax area, particularly the then QE II complex and the children's hospital. In the remainder of the province, there was little in the way of information technology and managing patients.
Our health system in this province is certainly by far the largest single enterprise and the requirement in that system for modern information technology and information management is an absolute key to ensure improving accountability and outcome for patients. I think we are all aware that in the last few days a national study, which the province had been participating in on adverse events, has been released which did show that, in fact, there are a number of untoward outcomes or complications related to care, many of which could be improved or diminished by the use of appropriate information technology.
On my arrival some four and a half years ago, one of the commitments I did make, or one of my plans was certainly to try to put in place a province-wide information management system, at least at the hospital level. I would simply point out that over that time period we have made significant progress with respect to that. There certainly have been some concerns or issues raised as to whether the project was out of control in any manner and whether or not there might be some significant cost overruns. I think it is important to state upfront that we don't believe that this is the case. We think this has been a particularly well-run and well-managed initiative with proper checks and accountability mechanisms in place.
Every year the department goes, as part of its annual allocation, through Treasury and Policy Board for the funds to continue the implementation. Every year since we have started this project, we have been underbudget with respect to those funds. The initial $30 million estimate or I guess ballpark figure that was placed in the blue book in 1990, in fact was a best guesstimate. We certainly, as the system has rolled out, have come to understand that better.
With respect to costs that we have incurred over and above what we had anticipated, those have been primarily related to people. There has a been a significant investment in the health care workforce in this province to train them in the use of this particular technology. One of the things we did learn was that in many of the organizations where they had not used information technology before on a patient care mode, it was a challenge to have people move away from using traditional paper records to, in fact, being comfortable using the information technology, using a computer terminal as part of their care process. We have spent a significant amount of funding to allow those training activities to occur, particularly to backfill the staff when they were leaving the bedside for those training activities. I am sure
the members will have a number of questions over the course of the next hour and some-odd so with that, Mr. Chairman, I will turn it back to you.
MR. CHAIRMAN: Thank you very much. We will start the first round of questioning at 20 minutes each. We will start with the NDP caucus.
The honourable member for Halifax Needham.
MS. MAUREEN MACDONALD: Good morning and thank you for being here today. We had just briefly started to scratch the surface of this question some time ago in the Fall, back in October, shortly after the Auditor General had issued a report. I want to start by looking at the chronology of the development of information technology in the province. The briefing book we were given prior to today is useful in many respects but not useful in some respects and I don't fault the staff for that, there is only so much information they can put together in a binder.
The time lines that were given in our briefing notes here take us back to 1995 when there was some strategic planning done in the years of the Savage Government, I guess, to look at the need for better information technology and our briefing notes indicate that Nova Scotia was significantly behind in terms of the rest of the country. Some planning began to deal with this important issue and there were some really interesting developmental principles that were part of the strategy laid out here in our briefing notes and I just want to review them in case you don't have the benefit of having this in front of you, although I'm sure you are well familiar with them. One of the development principles was to build on strengths and investments of the current system but do not throw good money after bad. Another is that the system needs to be sustainable, affordable and can evolve over time.
Now these aren't the only development principles but I'm going to focus on these because the last time you were here, our concerns were with respect to the cost overruns and trying to establish whether or not we were getting good value for money and also to project forward to try to understand whether or not the mechanisms were in place to contain the costs that continually seem to grow.
Now Jamie Muir, when he was Minister of Health, made the announcement in April 2002 of the IT program going forward and again in his media release indicated that it would be a $30 million investment over three years. The department, at some point, revised that projection of $30 million to $41 million. As I understand, from the Auditor General's Report, we have now spent $57 million. So there is a considerable growth in the amount of money that was initially announced by the Minister of Health in 2001, then an updating by your own department, and then another updating. I want to start by asking, my understanding is that the investments, the expenditures so far have been fairly much confined to one district, and that is the Guysborough-Strait-Antigonish district. Am I correct in making the assumption
that the expenditures that have increased so substantially, in fact, are pretty well confined to one district?
MR. CHAIRMAN: Mr. Rafuse.
MR. BYRON RAFUSE: Just to provide some clarity to the $57 million, or the $55.7 million that we're now using, it's the total projected cost over the life of the project, it's not what has been spent to date. To your final question, in regard to where the money has been spent, it has been spent solely for District 7, the Guysborough area. A lot of the upfront planning work is for the entire system, and the capital component, which has already been purchased, which is approximately $21 million, $22 million of that cost, is a capital outlay for the entire system, not just for those two areas. As well, they are moving towards implementation, today, in the Cape Breton area. I'm going to hand it off to Dieter, to see if he wants to add any more to that.
MR. CHAIRMAN: Mr. Pagani.
MR. DIETER PAGANI: Actually, Cape Breton is up and running as well. So to this point in time, we have District 7 and District 8 up and running, all the components, and, in fact, District 1 is going to be up and running at the end of this month. We also had to go through a fairly comprehensive standard-setting process, which took some time to do. That is implementing the system for 34 hospitals in the province. We had to sit down and really agree on standards, what we call things, names and so on, so that was all done. We're quite a ways into it.
MS. MAUREEN MACDONALD: Nevertheless, the Strait-Antigonish-Guysborough district was the original site. I would extrapolate then that as you worked in that site, you would have encountered costs that you hadn't anticipated, and that is what led to your revising of your figures. Would that be a correct assumption?
MR. CHAIRMAN: Who would like to take that? Ms. McKeen.
MS. MARY MCKEEN: It has taken some time to come up with a detailed projection, because when the announcement was originally made the project management office was not in place, and so there hadn't been that kind of detailed consultation with the district health authorities to completely understand their technology needs and their requirements for staff training. Before the implementation in DHA 7 began, the projection of $55.7 million was in place and presented to the steering committee.
MS. MAUREEN MACDONALD: In the district where you began, what kind of problems did you encounter in implementing the new technology? Were there problems?
MR. CHAIRMAN: Mr. Pagani.
MR. PAGANI: Yes. Being the first implementation, it was quite a process, number one. One of the issues we had was resources. We basically rely on the district health authority to provide us with the staffing we need in the areas it would implemented. So we look to them for pharmacy folks, we look to them for laboratory folks, admitting folks, and so on. We ran into some availability issues, in terms of folks. Technology, our first go-round, very early on, indicated that they were a little bit further advanced than when we actually did a detailed analysis. So we learned how to do that.
[8:15 a.m.]
As a matter of fact, the overall network we had to put in place for the province needed some extra work at that time. Again, we thought we were a little bit further ahead than we actually were. So we had to do all those things. It changed management process. Keep in mind that we're changing how people do business in the hospital, how they do their job on a day-to-day basis. We spent a fair amount of extra time trying to learn how best to approach that process redesign with the folks, take a look at how they're doing things now and how they ought to be done with them, and then what kind of changes do we need to make sure it happens.
In all those things, the first time through, we really had to kind of work on that one and understand it a little bit better. I think GASHA did a tremendous job in terms of participating and moving us ahead. But those were some of the items.
MS. MAUREEN MACDONALD: Are you aware that 115 nurses in St. Martha's Hospital wrote a letter expressing their grave concern about their ability to provide adequate patient care due to the new system, and that the new hospital record system, the PCS component was cumbersome, was over-bureaucratic, was taking away time from the bedside that they had to spend inputting data, that it was creating some degree of chaos?
Mr. Chairman, I have a letter, which I will table with the clerk, that has come to my attention, that was signed, apparently, by 115 nurses, indicating their profound dissatisfaction and their fear that, in fact, this system was a squandering of public resources, and to continue on with it would be throwing good money after bad.
MR. CHAIRMAN: Dr. Ward.
DR. WARD: We're fully aware of that letter. As Mr. Pagani has pointed out, the issue of change management turned out to be a great challenge with this initial implementation. The concerns raised by the nursing staff were reviewed with members of the nursing staff, we put additional resources in to provide backfill time in order to allow the nurses to become more comfortable with the system. I think, very clearly at the end of the day, the system is up and running in that organization. The messaging we're getting back
from the staff, now that they're used to the technology, is that they believe it has enhanced their ability to provide better patient care.
MS. MAUREEN MACDONALD: That's not exactly the picture that's being painted for me by some of the people I'm talking to, or who are talking to me. There is a concern that they're unable to, in fact, get all of the information from the charts and to see exactly what is going on. They've had four, four-hour training sessions. I've been told that consultants who have come in from out-of-province, in fact, were quite surprised with how cumbersome the system is that they're being asked to negotiate, that it's a DOS-based system. Anybody who knows technology, knows that DOS is a very antiquated technology, but it's also quite a difficult system to negotiate unless you have a fair amount of computer expertise. They're also indicating that the physicians aren't charting and aren't using the system. Is this accurate, is it accurate that in fact physicians in the Province of Nova Scotia are not utilizing this system right now, but it is the nursing staff that is using the system?
MR. CHAIRMAN: Mr. Pagani.
MR. PAGANI: Just to go back, we have to take a look and see how we got to the stage in PCS first of all. Again, I have to get back to a provincial system, we had to draw up a certain set of standards. Nurses don't all document the same, they all do it differently, over the years they learned a certain way, and we had to come up with a kind of compromise in terms of how to do an assessment of a patient when a patient first comes in and so on, so it was a bit of a compromise through the standards committee. I think we learned very quickly that this would not work in the long run, that we had to actually revisit that, and we had put in place an action team that really did a good review with the nurses locally, and we clarified quite a few of the issues. As a matter of fact we put a brand new release of the system that eliminated some of those issues that were pointed out. And they were the first ones, - eliminated so in a sense, we kind of used them a little bit to learn, for them as well as us, and also the new technology we used.
The training, in terms of time is what was recommended in terms of how many hours it takes to train a nurse, and the assumption is that you would start using the system, and they did. The team we had to implement the system was all comprised of nurses, there were no IT folks at all involved in that component, so it was all nursing. We tended to go to those folks who know their business and asked them to participate with us to implement. We got caught a little bit in the standards process, trying to be everything to everybody, and since then I think we scaled it appropriately for those folks, and I think that happened after you got that letter. We got a fair amount of work done after that letter. It just so happened that we had a new release as well.
MR. CHAIRMAN: Dr. Ward would like to add something.
DR. WARD: Dieter has pointed out the most difficult part of implementing a PCIS system, and that is the development of standards to which everyone agrees to and will use. It is the standard approach to a diagnosis, the standard approach to a treatment, that does allow over time, tracking of patients to have discussions around issues of adverse outcomes
and other things. The change management piece - we'll come back to that - is in fact the requirement, a twofold piece, with the implementation of this system. We're not only asking people to change some of their definitions or how they approach pieces, but we're also asking them to use a different technology.
Rather than writing some subtle notes in the chart that may on a nursing unit mean something to that particular group of nurses, we really need to move to some sort of standard and nomenclature. What does the term "heavy cough" mean? What does the term "productive of sputum" mean? And that needs to be standardized across the system.
The second thing is moving from that, but also moving away from writing much of that information to in fact using technology for an input base. The shift, which many of us have gone through in our lifetime, of trying to move away from paper to an information technology system, whether it's a Palm Pilot, a tablet PC, or your own PC, remains a challenge. For appropriate patient care, the standardization of the terminology in approaches is absolutely a must. The issue of the physicians is an extremely difficult one. As you are aware, physicians are not employees of hospitals; they do not work for a hospital or a district health authority. They are in fact "independent contractors". Although we put in place a technology to improve patient care at the level of hospital, and attempt to work with many members of the medical staff to get them there, we do recognize that that is a major challenge.
There very clearly is a generational gap at the current time between more senior physicians and junior physicians. Senior physicians who have been in practice for 25 or 30 years doing it their way are particularly difficult to move to some sort of standardized approach or standardized naming of things. We do understand that a survey done quietly by one of our national physicians groups suggests that in spite of the belief that many physicians are computer literate and robust in their use of it, it is in fact probably less than 10 per cent across the country, and that is an absolutely staggering figure. If we are going to improve patient care, if we are going to move to standard approaches and better management of patients, the investment in the change management piece to get everybody there is an absolute must.
MS. MAUREEN MACDONALD: Thank you, I want to go back to the statement from the Minister of Health in April 2001. When he announced this, he talked about how the system has enormous benefits. It will provide patients, doctors, nurses and administrators with easier, faster and secure access to vital health information, et cetera. It strikes me as extraordinarily exceptional. If we've invested all of this money in an information system, and yet the physicians aren't participating in the process, to me that is a vital piece. I want to know how in the world can this system live up to its potential, if that critical piece is not in place? That is the first thing I would ask.
MR. CHAIRMAN: Excuse me member, your time is expired so maybe you will just have to have that question answered and hold your next question for the next round. Did you want to restate your question so it is clear?
MS. MAUREEN MACDONALD: How can the system that we've invested a lot of money in work without the physicians involvement in it, and what are we going to do about that?
MR. CHAIRMAN: Dr. Ward.
DR. WARD: I'm sure we'll get back to that particular question, but I would point out that in other systems around the world, PCIS systems, most commonly Meditech, are widely used and have proven to be of an inordinate benefit in terms of managing patients and improving care. The issue of how we encourage physicians to participate in that, particularly when they are in this independent contractor mode does create a challenge, and we will have an opportunity to speak about that later.
MR. CHAIRMAN: Thank you, we will move onto the Liberal caucus for the next 20 minutes.
The honourable member for Halifax Citadel.
MR. DANIEL GRAHAM: Thank you, Mr. Chairman, and guests for coming today. I would like to pick up on the subject that we left off on, and that is in relation to District 7, the Guysborough-Antigonish-Strait District Health Authority, and specifically what has been referenced by the member for Halifax Needham. I would like to table before the committee a letter that has the cover letter of what the member previously referenced, but it also contains with it the signatures of the nurses who were part of that group, my count puts it at 88 signatures. I've had discussions about the challenges that are being faced by nurses in Antigonish, and what I had first anticipated was frankly, Dr. Ward, and other members, the possibility for a resistance to technology changes.
We've all experienced that, I think we're all old enough to have had to make the transition from paper to computers. Maybe I'm saying too much about the age of some of the people who are in the room right now, but certainly it has been my experience, and we all appreciate the intimidation that is associated with that. But these nurses are people who, in some cases for over 30 years have had to willingly, and in fact enthusiastically, adjust to technological changes. But what I'm hearing from them is never have they seen something that is going to become such a colossal failure for the patients in Nova Scotia as this particular system.
They acknowledge the benefits that we've had in our computerized imaging system with respect to X-rays, sharing information. They recognize that it's important that we have historical data contained on computers, they appreciate that the labelling components of this new system are beneficial, but at the end of the day, it's got to work in terms of day-to-day patient care. The stuff that we, as people who will need the system someday and whose families need the system, most depend on, face-to-face time with nurses and doctors. It is those people who have been, and I appreciate what's been said about the modifications since March - this letter was written in March - but there is a small rebellion going on in the only district that we've really had any extensive history in this in, and that has only been for six months.
[8:30 p.m.]
I appreciate that we're moving on to Cape Breton and other areas, but if we are having huge cost overruns as a result of perhaps not estimating properly, but certainly, as I understand it, it relates to nurse overtime, that is the result of nurses having to work extra hours as a result of this technology, we have a problem on our hands, and at the very least, we should have a formal evaluation process before we expand this out and have it run to other parts of the province. In one of the smaller districts when one compares it particularly to the Capital District Health Authority, it is important to note that we have a multi-million dollar cost overrun, and if this is expanded out to the larger districts, then I would suggest we may have a huge problem and we only have the seed of a problem right now.
The letter that is before us essentially is asking that we go back for this period of time to the paper system, until we work out the computer system. I don't think that it reveals a resistance to computer technology. These are people who have adjusted for some period of time. What they're saying is that patient care is being compromised and, as taxpayers, they have concerns about whether or not we're moving into a system that is going to become a huge albatross and completely ineffective.
I'd ask that you respond to that generally. I'm making in part the same case that the member for Halifax Needham was making a short time ago, but I'm making it with some of the specific information and the signatures before you and I will table in a moment another letter that's written from the same group of people.
DR. WARD: Mr. Chairman, the information being brought forward by the members, we are aware of. The sense of, is it time to stop and decide whether paper is better and we should return to the Dark Ages, quite frankly, I have a difficulty with. In this province we already have a Meditech installation at the IWK hospital that has been onsite and been working for a large number of years. The staff in that organization are quite comfortable with it. We have a different hospital application called HBOC at the QE II that has been in place for a number of years and working.
The particular Meditech product that we are in the process of installing across the province is installed in at least 40 major institutions across this country. Two-thirds of the hospitals in this country are on Meditech. Our neighbours in New Brunswick have all of their facilities on Meditech, and 400 of the largest health care organizations in the United States operate on Meditech. It seems to be a proven product. It seems to be working very well in all of those circumstances and in fact a somewhat older application of Meditech is working well here in the province. While I appreciate that, yes, we are quite willing to continue our discussions with the nursing staff, quite willing to take time and invest, as I've said earlier, in helping to manage the change process. But this is a proven technology.
MR. GRAHAM: The information that I have with respect to the number of nurses who have signed this petition is that it represents perhaps as much as 75 per cent of the population group of nurses who are affected by this. I would suggest that that suggests a significant problem, and I'll table before you, perhaps a letter that you're also familiar with. I see that the clerk is quite busy this morning. I'll just put to you some of the words and hopefully - you indicated that first letter that I've referenced is one that you're familiar with, but I'd like to read for you from the same group another letter written to some of the same people, but I note at the end of it that it's not specifically addressed to one of the provincial Health people, it was sent to the CEO for that district, Kevin MacDonald, and my hope is that it would have made its way to your desk, Dr. Ward.
I quote from Page 2, which I think summarizes some of the problems that these people have before they set out a six-point concern. This is in relation to ICU, one of the areas that is affected by this new computer system. It says, "In I.C.U. we are estimating that our charting is taking at least up to three times longer and imparting less information. It is incredibly laborious and time consuming, with exhaustive repetition of information. Information is spread over numerous screens so that at the end of the day, you have only a fragmented picture of the total patient's profile. This necessitates lengthy computer notes and extensive verbal reports."
Again, in my discussion with nursing staff from Antigonish, they are suggesting that in some circumstances, there is some benefit that comes from this. Over their careers, some spanning more than 30 years, they have come to embrace technological advances. What they're saying is that this particular movement is not one that is enhancing patient care, that even trying to accommodate for the fact that there's always an adjustment period that is required, they are not going to ever reach the point where patients are better served and where costs are reasonably constrained to bring the most effective use of funds to the patient.
You said that we would be moving back to the Dark Ages if we went back to paper. I can accept that, it's certainly rhetorical in some respects, but we shouldn't dismiss the possibility that a chart that actually moves with the nurses from shift to shift, and from doctor to doctor, may in some circumstances be a more effective tool to monitor things until we get a better computer system. So what I'm asking is that we not put the stop on and go back to
the Dark Ages, but at least we put a pause in place because, Dr. Ward, you would appreciate that when you put in place pilot programs like this, the most important component of the pilot is a rigorous evaluation process. So I ask, first, will you put on the pause button? Second, what rigorous evaluation process is presently underway with respect to the front-line workers who are intersecting with the patients right now in that district?
DR. WARD: I will make one general comment and I'll ask Ms. McKeen to comment on that. Your comment about the transfer of the record from nurse to nurse, doctor to doctor is that for the core of the electronic health record to allow that information to be passed from hospital to hospital, from doctor's office to outpatient clinic, we can't do that with a paper chart. That is a huge, huge problem and we both recognize it, so at some point in time, I think we do have an agreement that we will be moving to an electronic health record. That is an absolute minimum for a health care system to deal with the issues around adverse advance-appropriate management protocols and the other pieces.
With respect to a review of the activities at Antigonish at the current time . . .
MR. CHAIRMAN: Ms. McKeen.
MS. MCKEEN: Yes, we are learning as we are implementing and a very rigorous review and evaluation of the implementation in DHA 7 has been conducted and we are adjusting as we are going. Each hospital in DHA 7 has different needs, different levels of understanding of computer technologies within their institutions. Some staff are very much champions of the system, others are reluctant and resistant, so we are adjusting as we are going. There have been a number of modifications to the PC system in DHA 7 and we have learned from that experience. Mr. Pagani can add more.
MR. CHAIRMAN: Mr. Pagani.
MR. PAGANI: Thank you. Actually we did two reviews - one is just being finalized right now where we actually went right in and interviewed the nurses and there was a third party because we wanted to have an independent assessment done as opposed to one done by the teams. So that's almost complete.
But, before then, we actually assembled a task team at DHA 7 to take a look at the issues that people found as we went through the implementation process in the first few months of actually using this system to understand where the pressure points were. You're right - ICU was one they pointed out to us simply because of the activities in the ICU. It's hectic, it's busy, it's crowded, not much space and one of the things that the nurses pointed out, the devices we gave them are too bulky to move around. That was one of the reasons.
Again, we went back, we reviewed that basic standard approach in terms of screens and we did adjustments to those. I think it's a different picture now. If you go back today, I think you might get a different picture. On the training side, we did do some more training with folks - to help them better understand some of the components, but I think you'll find a better picture now.
MR. GRAHAM: In response to the going back today, I appreciate that we may have a differing view of the same situation. My most recent contact with the nursing staff was last night and the sense that was given was that the nursing staff are feeling exhausted by the fight to get some recognition that this system isn't working. To reiterate a point that I made earlier, this is not about not going forward with an information technology system. They recognize fully the benefits that come from having a computerized system where the data on a patient's history is all contained in one central place for all to access in Nova Scotia. It's just that this particular system, in their view, is not working.
I'd like to ask whether or not this most recent - I appreciate your having gotten an independent assessment that is not yet completed. I'm wondering whether or not we can receive an undertaking when that report is completed that it will be made public and available to this committee?
MR. CHAIRMAN: Dr. Ward.
DR. WARD: Yes.
MR. GRAHAM: Thank you.
MR. CHAIRMAN: The honourable member for Glace Bay.
MR. DAVID WILSON (Glace Bay): Mr. Chairman, I'd like to continue along the line of questioning that my colleague, the member for Halifax Citadel, has started. I find it somewhat disconcerting, Dr. Ward, if you're telling us this information technology system has been no problem in New Brunswick, no problem at 400 hospitals in the United States, no problem at three-quarters of the hospitals in Canada. It's been used worldwide, no problem, but all of a sudden it arrives on the doorstep of St. Martha's Regional Hospital in Antigonish and you have big problems with nurses telling us this doesn't enhance the care they're giving, it actually endangers the care that they're trying to give patients. So I'd like you to tell this committee or give us your explanation of why this problem has occurred where it has.
MR. CHAIRMAN: Mr. Pagani.
MR. PAGANI: Thank you for that question. It's a very good question indeed. I think the biggest difference we have in Nova Scotia is that we're implementing a system in 34
hospitals, eight districts versus most of the other hospitals are unique, contain components under one structure. They had to develop standards for one nursing staff versus we had to develop standards for pretty well 34 nursing staffs across the province. That added some complexity and some difficulties to the process. Then to have adoption of those standards takes time, but basically, in terms of functionality, the system does perform as it is supposed to do. I think we have to spend a bit more time as we move through with the other districts on the changed management aspect. How do we get folks to use the system? How do we use it appropriately and so on?
The nurses in Antigonish have done a tremendous job and they worked very hard with us, as a matter of fact, to get the pilot done and to get the work done and I think they'll start to get used to it much better in the future as they continue using it on a day-to-day basis.
MR. DAVID WILSON (Glace Bay): I should say I'm a little bit concerned about the impression we're leaving here, that you would have a problem just in Antigonish, that it would just be the nurses in Antigonish who would be complaining about this system. I'm really perplexed when you say that you have a system here that, to date, has cost almost $26 million more than it should have and when you look at DHA 1 through 8 it boggles my mind when I think about what happens when - I know the situation with the Capital District, that it's two different systems. At the end of the day, Dr. Ward, how much more is this going to cost taxpayers in Nova Scotia before we reach what you would consider to be the epitome of where we should be with information technology in our hospitals? How much more are Nova Scotia taxpayers going to be on the line for before we reach that stage?
MR. CHAIRMAN: Dr. Ward.
[8:45 a.m.]
DR. WARD: Mr. Chairman, two or three comments. The $30 million initial announcement basically had two components in that, a $20 million capital investment and some $10 million for implementation in the first three years of that project. We are past that. April 1, 2004 was, in fact, the end of that three-year project. There was no announcement made about ongoing operating costs of the system. Very clearly, if you bring technology into hospital, it does require some additional operating funds.
At the same point in time, we've been very clear in our presentation today that, as we've moved forward, we have met some challenges in terms of implementation and change management. In many organizations the movement of acquiring of new technology, in fact, is acquiring an upgrade of technology. The movement of a new CT scanner or a new type of IV pump, or a new cardiac monitor, were in fact new generations of old technology. In this particular case we are asking people to move to essentially a brand new technology. This is an introduction of something that has not been used in terms of the management of patients at that level. We have had challenges in the change management process. We're very clear
about that. Where we have been asked to take time, we've done that. We are using independent reviews to better understand the challenges we are seeing in terms of that.
Now, your question as to what will the final investments or ongoing operating costs of the epitome of an information system, as you describe it, I think that's difficult to estimate. I would point out to you that the future of health care is a broadly based community system integrated with much care being managed at the level of the community. Whether the technology will be applied at that level through the use of wireless technologies, hand-held devices, tablet PCs with management protocols, links back to central stations, I don't know, but if that improves care, if that improves the health of Canadians, then my expectations are that through time we will go there.
Canada Health Infoway, a federally-funded agency of which the provinces are shareholders, has $1.1 billion to invest in the development of the electronic health record across this country. The estimates, quite frankly, are that that represents probably 20 per cent of the overall investment required over time for that kind of a system, for, as you say, an appropriate information system.
MR. CHAIRMAN: That concludes the time for the Liberal caucus in this round. We'll move on to the Progressive Conservative caucus. I recognize the member for Pictou East.
MR. JAMES DEWOLFE: Thank you very much, Mr. Chairman, and good morning, ladies and gentlemen. We're certainly pleased to have you here and I, indeed, welcome you from the Liberal, NDP and Tory caucuses. Most of you are no strangers to this challenge that we put you to here every year or so, sometimes twice a year, and, Tom, it's only fitting that you finish up with one of your favourite tasks, to meet here in this Chamber.
I'm pleased that we're moving forward in our health care system. We're getting with the time, shall we say, in the electronic world and, you know, I always consider it safer. It eliminates human error and creates more privacy with the safeguards that are built in. I'm thinking back to, you may recall, a situation that Brian Mulroney found himself in when he was admitted to a hospital. Some documents were passed on and the media got hold of it, confidential medical documents, and caused some embarrassment. I would think with this type of system that that is unlikely to happen because of the safeguards that are built in and it's not impossible, but at least one would probably be able to track down who released the information if there's a log-in system and safeguards built into it which I'm sure there would be.
However, having said that, I just wanted to give you a little break and perhaps a little more entertainment and talk about the questions regarding federal funding in the health care system. It's very topical these days since we're now a couple of days into a new federal election campaign. It's going to be a topic that we're going to hear a great deal of. We've
already noticed in some of the press interviews from various provinces and communities that people do consider that pretty much a number one priority with them, is the health care, and indeed right across Canada it seems to be a problem.
We all know that health care costs are increasing. I mean, I don't think there's an individual in this province who doesn't realize that that has been happening and I just wonder how much have health care costs increased in Canada since 1993, looking back 10 years across this great nation? Maybe Byron has some idea, or Tom.
DR. WARD: The annual average incremental cost in the health care of Canada over about the last five or six years, there has been a minimum of 7 per cent per jurisdiction over a five year period.
MR. DEWOLFE: Has Nova Scotia followed the same trend essentially as other provinces across Canada? Do we follow the trend of the rest of Canada regarding health care costs growth?
DR. WARD: Yes, we're talking essentially the rest of the country. Certainly when you look at Nova Scotia, the budget for the department when I arrived in 1999, that we settled in the Fall of 1999, was $1.61 billion at that point in time. We are now here about five years later and we're looking at a budget roughly of $2.2 billion. So we've basically seen an increase of $600 million on a base of $1.61 million. So that's a fairly hefty amount of money.
MR. DEWOLFE: Looking back to 1999, I can only think, and I mentioned to my colleague here this morning - and you have been around since 1999, I recall when you first arrived here, we did a little road trip down to Pictou County, the first time I met you, doctor - how much the health care system has improved just during my time in the Legislature and it's really quite remarkable. Sometimes I wonder how we've done it with the monies that we've had to work with. It has been indeed a huge, huge challenge to this government. It seems that the gap between the federal transfers and the rising costs of health care is growing considerably and there are some suggestions that the health care spending is 50 per cent more than it was 10 years ago. Would you agree with that?
DR. WARD: It's fairly close.
MR. DEWOLFE: I've heard that mentioned. But the federal transfer payments have increased only in the last year or so to the 1993 levels. Have you any comment about that?
DR. WARD: I think it's fair to say that every government in Canada is challenged at the current time by their ability to finance the demands out of the system. I think we're all aware that there have been some changing events in the last four or five years that have brought significant pressures on to each jurisdiction. Notably, the cost of drugs, in particular, escalates at about 20 per cent per year and we have seen in the last, I guess, three or four
years, where pharmaceutical costs, at least those covered by provinces, moved into second place as a cost driver, as a percentage of the total health care system cost, passing the level of physicians. Historically, it had always been hospitals, followed by physicians, followed by the pharmaceutical piece - pharmaceutical packages now are in a robust second place with increasing demands. At the same point in time, as the care models have changed we certainly have seen a movement of care models and new delivery systems to the level of the community.
Our experience on the home care side is we've basically seen an almost 25 per cent annual growth in our home care costs over the last decade. My expectation, quite frankly, for the future, is home care in its various forms will become a significant component above any government's overall health care package. We are in a situation where, in many of our communities, there is a great percentage of unpaid caregivers, and those are primarily women who are looking after either spouses, parents or children and, as they begin to age and require care, we do not have the traditional infrastructure of many of us having children.
I have two daughters, one is living in Vancouver and one lives in London, England. I'm fairly confident that I shouldn't expect that they're going to show up on my doorstep when I require care to look after me. There will be increasing pressure on every government to come up with some substitutions or a process to do that. I think very clearly as we're going forward we're going to be seeing those changes.
The challenge for this jurisdiction and every other jurisdiction, I think, is to have a conversation with the federal government about what a reasonable health care system for Canada should look like. I think it is clear that Nova Scotia is becoming disadvantaged more every year, for a couple of reasons. Importantly, we do have the highest burden of illness in the country, much of it is related to lifestyle: we have the highest incidence of obesity, particularly in adolescents; and our smoking rates, although down, are significantly higher than in many other jurisdictions. We do recognize these are significant determinants in terms of long-term health.
The second thing is that by virtue of our decreasing population and an increasing growth in the rest of the country, our proportionate share of anything, whether it is a per capita basis or adjusted, continues to drop. We were as high as about 3.3 per cent, but in the last decade we've now slipped under 3 per cent. As Canada continues to increase its immigration - the bulk of that immigration is occurring primarily in the metropolitan Toronto area, Montreal and Vancouver - we will see a decreasing transfer, in terms of CHST, of the one-time federal government funding for the health reform fund, and all of those other activities will not be static; in fact, 3 per cent this year may become 2.9 per cent this year. So there are significant challenges.
MR. DEWOLFE: You make a point, Dr. Ward, when you talk about one-time federal funding. Although it is helpful, it is not helpful over the long term. How much federal funding for health care is comprised of one-time spending?
DR. WARD: The accord of 2000, which put some additional dollars in - in fact, those dollars lapsed as of 2003. The last accord, signed in February 2003, did provide an agreement that at the end of the five-year cycle an additional $5.5 billion would be rolled into a new type of transfer payment, presumably to be called the Canada Health Transfer. There are still some ongoing discussions about that, and that is money into the base.
There is some additional one-time money out of both of those accords. The last accord did provide us $15 million a year for three years, for capital equipment. There is some other federal funding available for activities around health, human resources and stuff, not much of which has been seen in the current time. In fact, over the next five-year time period, although there are some increments in terms of the federal contribution that will ultimately be rolled into the base, our per capita share is dropping. That is the only piece going into the base. My review and thoughts about the current proposals from the Prime Minister, in fact, although it is a significant amount of money, when I read between the lines that it's not going to the base, I read it all as one-time money. Yes, the money is appreciated. I think it would be appreciated much more if it went into the base.
[9:00 a.m.]
MR. DEWOLFE: It seems that every time Canada's provincial Health Ministers go to Ottawa with cap in hand, they go with great expectations, hoping to come back with more funding, but there's no funding, they're told, essentially, then all of a sudden, here we are, they have billions to put into the health care system. I don't know, where does this money come from, well who knows?
Ottawa cut up to $3 billion a year, for several years during the mid-1990s, out of the health care system and yet the federal government can find several billion dollars to waste on projects like the federal mismanagement of the gun registry. Of course we all know about the monies that were squandered on the human resource programs, even here in the province. Now, the sponsorship scandal. Yet, these monies just seem to float away. If only they were used for the number one priority of Canadians, I think we'd be much better off today, if that was used in the health care system. It sort of begs the question of whether the federal government is being a good steward of the public purse. I really question that and I think most Canadians, now that we're into a federal campaign, should be shaking their head and saying, you know, are they a good steward of our finances and our hard-earned taxes?
The long-term stable funding - here we are in this province, we've negotiated and supported our district health authorities, given them some hope down the road by providing multi-year funding. That would be the answer, wouldn't it? That's the ticket. That's what we
should be looking for from Ottawa, some sort of long-term funding, something that we can build our health care system on. How aggressively are we and other provinces pursuing that particular option? Why would that be important? I look at the basics thinking, well it only makes sense that we have that. Perhaps you can speak on that?
DR. WARD: I think there are two aspects to your question there, the issue about the federal government and its view on things. Those questions, I guess, should be better directed to the federal government. The concept of long-term stable funding for health care is one of the foundations, I think, to moving the system forward. There are other notable examples in the world where long-term funding programs have been in place, really to allow some planning horizon to manage change within the system. Certainly the best is probably the work that has occurred in New South Wales in Australia. They're now into their 11th year of the three-year rolling budget cycle. When you look at the movement within their system to community-based care programs, new models of care, pharmaceutical distribution and management in many areas, I think they are certainly on the leading edge. Very clearly a significant component of that is the ability for those organizations to plan on a long-term basis.
Historically operating a large health care authority or an institution on an annual basis without an understanding of what some minimum amount of money you have for the coming year has really made it difficult for organizations to manage change internally, to look at different care models. We do need to recognize that as we have the challenges of implementing change around information management systems and their application, other changes are occurring, new roles for new types of health care providers within organizations, whether that's physician assistants, paramedics, nurse practitioners in the hospital setting, other new kinds of care workers. At the level of communities, will there be new types of care workers for the future? And how do you help other professionals move to a new type of care model, a team environment, to do that?
Certainly, as I said before, the work that has been done in New South Wales has been absolutely remarkable, as is much of the stuff in New Zealand. At the current time, for us, the closest jurisdiction in which we're seeing some absolutely remarkable changes has been the NHS, the National Health Service, in Great Britain, in which they have really put forward a massive change process for that system, in which they're really moving a quantum in the course of a short time period. They have a national patient safety agency, a new modernization directorate which is responsible for bringing the latest and best technology into organizations, investment in new types of patient care teams and a new approach to managing that. It's a staggering investment in the development of electronic health records, we're talking hundreds of millions of pounds to put in an electronic health record across Great Britain, recognizing that that is really at the core of managing the system for the future. Just an absolutely remarkable change process.
MR. DEWOLFE: That's very interesting. The federal government used to contribute 50 per cent - we always hear this 50/50 cost share. It's now down to 16 per cent; yes, the federal government is estimated to be contributing as low as 16 per cent of the total cost of health care funding. Now, the Romanow report, as we all know, suggested that we should bring it up to 25 per cent. I know Dr. Hamm had gone to Ottawa, requesting $90 million, which would bring this province up to close to that figure. I know I'm on my last seconds here, but do you think that the 25 per cent Romanow suggestion would resolve a lot of the woes in the health care system, or do you think we can do with less or do we need more? I know there's no end to what we could spend if we had it, but to get us on track, to put some fairness back into this.
DR. WARD: I think, very clearly there is a requirement for some further investment in terms of the health care system. The issue about the 50/50 represents a big challenge for every jurisdiction. The Canada Health Act and the Established Programs Financing Act, the EPF Act, which was put in in 1977 and then rolled over into the CHST piece, in the midst of all of that, there was very clearly a 50/50 cost-sharing for acute care hospitals and physicians. Every other program is a cost borne by the province. Out-of-hospital pharmaceuticals, long-term care costs, home care, public health, community mental health, any of these other activities that are not under the guise of being acute care or physicians, in fact, are costs borne by hospitals.
The issue, as provinces are moving to a new community-based model, where we recognize chronic disease management programs, health maintenance and investments in communities to keep people healthy and to help them manage their disease better so they don't go back into hospitals are 100 per cent borne by the provinces.
MR. DEWOLFE: Thank you very much, Dr. Ward.
MR. CHAIRMAN: We have time for a 15-minute round. So for the next 15 minutes, I will turn it over to the member for Halifax Needham.
MS. MAUREEN MACDONALD: Mr. Chairman, I'm very aware of how quickly 15 minutes can go, so I'm going to ask you to get your pencils out because I have four questions. I'm going to put them as a group, and then you can answer them as a group. The first question, back to my last point, when I last had a chance to speak, how are we going to get physicians to participate in this, what will it cost, and has that cost been factored into the initial cost summary for the project or will this be an additional cost? I presume you're in discussions with the Medical Society around that.
My second question is about the Capital District, the fact that the QE II and I believe the IWK are using different systems. How close are we to making those systems able to transfer information, the interface stuff, and is that within the budget projections? If not, are there overruns, what will it cost, where are we at there?
The third question I have - these next two questions are tied together. The Auditor General in his report says, "The July report to the project steering committee indicated the implementation date for the first DHA had been extended due to concerns surrounding sufficiency of testing days, large number of staff to be trained and change management activities at the site. The remaining DHAs are to be implemented concurrently in order to achieve the original completion date. These concerns have also led to an increase in the project manager's forecast project costs to $57 million. The steering committee has directed the project manager to reconsider the forecast project costs."
I want to come to this question now of whether or not we still are using this same set of numbers. Today the deputy minister has said that initially the belief was $30 million - $20 million for the one-time fixed capital costs, $10 million for the ongoing operational costs. We know that was adjusted upward to $41 million for the initial one-time costs and $32 million for the ongoing operational costs over a seven-year life cycle. My information is those latest figures were the figures that were being used in March 2001 so my question is, do those figures from March 2001 remain the figures that we're working with now or have they been adjusted in any way upward or not? Those are essentially four questions I'd like to have your response to.
MR. CHAIRMAN: It's an interesting strategy to ask so many questions all at the same time. We'll see how it goes, but let's start with Dr. Ward.
DR. WARD: Thank you. Let me begin by making a couple of opening comments. Earlier one of the questions had been about potential costs for the system for the future. I did indicate that of all the businesses or activities in the world, health care is, bar none, the single most information-intense activity that we know of. It is the most complex, it is the most difficult.
If you turn and look at the banking and financial world, their annual expenditures for information management of just our bank accounts normally runs in the range of 12 to 15 per cent. If we applied those numbers to the health care system in this province and to the department's annual budget, we would be looking at an investment or a cost for IT of somewhere between $275 million and $325 million per annum. At the current time we spend about 10 per cent of that or less.
We do have a significant technology issue here about managing this vital resource of patient information. Thinking about Mr. Wilson's question about how much is it going to cost, I think it is fair to suggest it's going to cost more.
[9:15 a.m.]
One of the challenges for every health care system as we're moving to better managing the information, dealing with adverse outcomes, constancy of information and
management protocols for patients, it does require ongoing investment, and IT is expensive. We have no hesitation about spending $5 million to buy an MRI and $2 million a year to operate it for 1,000 patient exams, but we have a great reluctance it seems to spend any money managing the information of every citizen as it relates to their health in this province. So I do think it's fair to suggest that that will be forthcoming.
Now, the second, in terms of the series of questions about sort of shuffle the deck and pass some of the things around, the issue of physician participation in the system will remain a challenge and, in fact, our sense as we're moving forward as our biggest opportunity to involve physicians in this process is to recognize and understand how they practice. They do not practice solely in hospitals, they practice in their office and part of, I think, our long-range view of this is very clearly, as we get the systems up and going, we would like the opportunity to directly link physicians' offices into the hospital system for the purpose of allowing what's called order entry and results reporting.
A physician who orders a test on a patient, those tests are done in hospitals. As outpatients, the blood is collected, and it's done in those organizations. That's where our lab and X-ray facilities reside for the most part, and so for the order entry results reporting, the opportunity for a physician in their office to book a patient for a lab test, or a CT scan, give that information to the patient, the quid pro quo from the system part of it is that those results will be returned electronically to that physician. He doesn't have to wait for that piece of paper to go from the lab, via a courier, or mail, from the QE II out to Noel Shore or wherever he happens to have his practice.
The second piece that we think is vitally important in this is that we will put in place at the same point in time a pharmacy package, the opportunity to help manage the medications issue. Very clearly, I think the opportunity for physicians to access that for their own patients, to ensure continuity of care in terms of medications in hospitals, the continuity of that record in their office is a huge plus. We are in discussions on an ongoing basis with the Medical Society. There are several champions within the Medical Society who are very clear that the computer-based record or electronic health record is vital in terms of moving the system forward, so we will continue with that.
It still will remain a challenge for us at the level of hospitals to have physicians who are normally used to telling somebody do this, this and this - you know, I need a CBC and I need an SMA 12, and, get a few of these other things and do your analysis - as they walk off the unit. We're asking them not to do that; we're asking them to change and, in fact, to participate a bit more in the care process. It will require some work, but I do believe when I see other systems - and having practised myself and used the systems, it took a bit of time to get there, but when you get comfortable with it, it's fine. We will continue to move that forward.
Now, the second question you asked was where does the Capital Health District fit in all of this. I think very clearly the rollout of the information system, we've stated up front all the time that it's for Districts 1 to 8. We were very clear at that point in time that the Capital Health District, in fact, did have some technology. The IWK is on Meditech. Our hope is that we will simply upgrade the operating system to the latest version of Meditech. The Capital Health District really runs on what's called HBOC. It's a combined system with a core and it's what people describe as a plug-and-play, so they may have a different lab module versus a different whatever else module.
We are in the process of having an assessment done with a view that there are three options. One of them is that you maintain HBOC and build interfaces; a second option is that you gradually move some components of HBOC to a Meditech system, or the third option is you make the decision at some point in time to move entirely to a Meditech system. Expectations are that the change process there will be as challenging as it is anywhere else, but that is certainly our current sense of where we think that we will be going. Your last two questions, issues around sort of the comments for the Guysborough-Antigonish-Strait Health Authority, I will ask Dieter to begin with that and Byron Rafuse can talk a bit more about the AG's part of it.
MR. PAGANI: First of all, on the first question with respect to physicians, we have a physician advisory group that assists us in taking a look at the issues related to physicians. In fact, in St. Martha's Regional Hospital and in GASHA, physicians participated in checking out and piloting access to results. So as soon as the lab result is done, it's available to them. That has been quite successful, but the next step in terms of order entry and so on, I think, requires more work and more work with physicians to get to that point and not too many jurisdictions have made that transition very successfully. So we have to be very careful how we approach that. With respect to capital, is that what you meant, the second question? (Interruption)
Yes, and you're talking about the auditor's statement in your third question. The auditor's statement I think indicated that we would have a $57 million budget and send us back to take another look at it. We basically got that to $55.7 million. So we did reduce that budget and we'll continue monitoring that budget to make sure that we are staying on. We have very good controls in place. As a matter of fact, we have a financial working group that really checks up on us on a regular basis. I think we recognized very early that this is a significant project, a lot of people involved, a lot of districts involved, and we want to make sure the flow was correct. The number in place in 2001 - right now our budget is at $55.7 million, that's what our estimates are and I think we're going to stick to that budget.
MR. CHAIRMAN: Mr. Rafuse.
MR. BYRON RAFUSE: I just want to add to what Mr. Pagani was saying. The estimated cost at $55.7 million, that is the cost for the complete rollout which will take us
out to 2005-06 and that's the last data for the last district. Just to be clear on that, it's not the cost to date, it is our anticipated costs based on our current implementation strategy. As well, it is not the costs associated with operating the system. That is a cost associated with implementing the system. The cost of operating the system is currently being evaluated. There is one major component that is up and running now and that is the central data centre and that has been operational, or needed to be operational since the first district went live, but there are additional operating costs that are currently being evaluated as well as the efficiencies that will be gained at the district level that will offset some of the operational costs associated with that and I will throw out one. If you go from a completely manual lab system to a computer-based lab system, one would believe that there would be efficiencies gained to that process.
I just want to go back as well to the, I think you talked about the original costs and some costings that were in the AG report. The original $30 million estimate, the Government of Nova Scotia does not have what I would call a project cost system, we are not, say here's $30 million and go out and buy the system. It is an annual process, both from the capital and operating perspective, and on an annual perspective we have deliberations with Treasury Board as to what our needs are in regards to operating and capital for the implementation of the system based on that current implementation strategy and that strategy was revised at one point as the project office was up and running and we had a better indication about what those costs for implementations would be, but on an annual basis for each of the years since the system has begun, this project has never gone over the annual allotment, both from a capital or an operating perspective.
The total of the project has grown and we've discussed that, but it has never gone over budget. From an allocation perspective as to what the Estimates of the House that are approved on an annual basis, it has never gone over that. So I just want to make that clear to you. The second point is the costs that we talked about for physicians, or the interoperability part for Capital Health, are outside the scope of the implementations project. So any costs associated with that would be outside the $55.7 million. That's not included in that.
MR. CHAIRMAN: Thank you. That went exactly two seconds over the allotted time. So thank you to our guests today for their brevity in answering those many and difficult questions. I would like to move on now to the Liberal caucus. I recognize the member for Halifax Clayton Park.
MS. DIANA WHALEN: Mr. Chairman, I'd like to continue with the answer that you were in the midst of there, Mr. Rafuse, if we could. You were just finishing up saying the cost of operations or implementation was never included in the original estimate. Could you just clarify that?
MR. RAFUSE: The cost of ongoing operations is not included in the $55.7 million. That is separate. What was originally included in that is the implementation costs.
MS. WHALEN: Okay, and that would seem reasonable that you would have to have implementation costs. I wanted to look a little bit at the time line, because I think we just need to clarify and be sharp in our understanding of where it was originally intended to be by this point, and where we are. My understanding is that it was initially announced as a $30 million, three-year project and that we would be fully implemented by the end of the third year, and that has just passed in the last month, right? So we're just past the three-year point and we have not gotten to the point which was in the original announcement that the hospitals would be linked and we'd be at a point where we would now be at ongoing costs. So we're still in the rollout stage and really quite early in that stage since we've only piloted in one district.
I wonder if you could talk to me a bit and clarify this time line and how that's changed and when that was decided, that we'd now be looking at, the estimates I have here is it might be the end of 2005 for most DHAs, and 2006 before all DHAs will be linked to one system. First of all, are my figures right in terms of the time expectation?
MR. RAFUSE: I'm going to hand that question over to Mr. Pagani or Ms. McKeen, they have a better understanding of the rollout.
MR. CHAIRMAN: Mr. Pagani.
MR. PAGANI: Thank you. I think a couple of interesting things happened in the beginning of the project. Number one is the standard-setting process I mentioned before. It turned out a little bit more complex than we thought. Again, back to 34 hospitals, 34 different organizations, 34 different ways, that kind of set us back a little bit.
MS. WHALEN: How does that affect your time target?
MR. PAGANI: It took more effort, it took more people, and then we ran into trying to find people to participate in that, but that added on to time, a significant amount of time. The other one was when we had an original date of November 1st, for GASHA, for example. GASHA was November 1, 2002, because of the process change management, the actual team asked us that we move that out to February. Actually, they asked us to move it out further but we said, no, we can only go until February. It's been an accumulation of little pieces here and there, but overall basically we reassessed the requirements. We reassessed the dates on an actual basis as we went along, and reflecting the reality of where we were at the time.
DR. WARD: Mr. Chairman, as Mr. Rafuse pointed out, on an annual basis we negotiate with the Treasury and Policy Board for our funding for this and every other project. Certainly, our requests were not met on a couple of occasions by Treasury and Policy Board and we in fact made the decision by virtue of not having what we thought was the appropriate funding to push things forward, to actually delay some of the implementation pieces.
There will always be ongoing operating costs for the project, and in that sense we do need to maintain the project office. Even though we are not as active as we would like to be. At the current time we are, hopefully on target.
MS. WHALEN: If I could, Dr. Ward, the thing is that the public or the members of the Legislature would have had an expectation that three years was the duration and if the estimate was reasonable in the beginning - maybe you could comment on whether the $30 million was well founded in the first place - that was our expectation, so although you've been doing adjustments and modifications, I don't think that the Legislature has been aware of the time line and those changes, and we've still, up until very recently, referred to this as a $30 million project. The comparison and the cost overrun is always used with that $30 million as the base amount, the expected amount. Could you comment on whether or not the $30 million was ever a reasonable estimate?
DR. WARD: I think when I look back on through the Summer of 1999, there were two numbers floated out, one of them was by the Liberal Party, which suggested that $75 million was an appropriate number for the project.
MS. WHALEN: Sounds more realistic.
DR. WARD: The now governing Party in their blue book suggested $30 million.
[9:30 a.m.]
MS. WHALEN: That sounds like an underestimate. Those are two very different figures, with a wide variation. I'm just asking whether $30 million was right to tell the public, to tell the Legislature, that we can roll out what you've said to us today is a complex and large integrated system for $30 million.
DR. WARD: I think when you go back and look at the estimate of $30 million, it was approximately $20 million for capital . . .
MS. WHALEN: . . . and $10 million for implementation . . .
DR. WARD: We have been fairly close on the capital side.
MS. WHALEN: What was the final comment, please?
DR. WARD: I said we've been fairly close on the capital side.
MS. WHALEN: Well, that's good, and that's a firmer figure to tie down as well. Would you say, just answer, please, the 2001 figure - not 1999 - when the project was
announced officially by the former Minister of Health it was said to be a $30 million project, was that a reasonable estimate of cost?
DR. WARD: If we had the opportunity for a three-year implementation, I would suspect we could have been pretty close.
MS. WHALEN: So really what you're saying is part of it was that the resources weren't available to allow you to really aggressively or systematically roll this out as you would have liked.
DR. WARD: I think that's a fair comment. The opportunity, if all things had been perfect, if things had gone tickety-boo, if we wouldn't have had some change management issues, if we wouldn't have had some delays in doing the standards - for us, at the end of the day, the value of a province-wide system based around electronic health records is an absolute must. Is it going to be expensive? Yes, it's technology, it costs money to operate. Is it important? I think it's absolutely the most important thing we can do for the system.
MS. WHALEN: I can see that. And you see that there will be savings down the road if we get this in place. I do see that. Could I ask you now to give us a firm figure on what you would now estimate the total rollout cost will be? I'm hearing the $57 million, I'm also seeing that this is going into 2006, and we've spent - I'm not sure how much to date - $50 million maybe?
DR. WARD: As Mr. Rafuse pointed out earlier, our projected costs for rollout through the eight districts is $55.7 million.
MS. WHALEN: Could you tell me how much has been spent to date right now?
DR. WARD: The exact number, as of this moment, we're not sure, but it's approximately $40 million, and we would be happy to provide you with an update.
MS. WHALEN: So that's the closest. What I would like to ask is that you provide the committee with a timeline that shows where you hit different changes in your estimates and the timeline that would be required to roll this out. I don't think we've seen it laid out for us, just the bullet points of the milestones, and the places where you changed gears and extended the length of the project and the cost of the project, not today, but I would like you to provide it if you could, if some member of the staff could generate that, because I think it would help us to have a better understanding and perhaps better certainty that this is going to go forward as expected with a $55 million estimate.
Could you indicate to me, please, how many consultants have had to come in, outside of your own core staff, to help implement, up to this point?
DR. WARD: In our process, we recognize that the information technology in itself and the rollout is fairly complex, and we have been quite comfortable in acquiring skill sets from outside. One of the things we have done to help our own comfort level is that for each phase we have actually gone out and asked an external firm or experts to review our costing, to review our plans - people with experience - to ensure that, in fact, we're doing reasonably well in terms of that. As Byron has pointed out, to date, in our annual allotment process from Treasury and Policy Board, we have been very comfortable, we have managed within the budget allocated to us.
MS. WHALEN: Do you have a total figure for the amount we've spent on consultants, external consultants?
DR. WARD: We can get that for you.
MS. WHALEN: No ballpark figure available?
MR. PAGANI: I would hesitate to guess that.
MS. WHALEN: Okay, I understand that, that's fine.
Just a couple of questions. One of the things you mentioned was that most systems - you were praising the system, this Meditech system, and saying how well it works in all these other hospitals - you said that most elsewhere have essentially stand-alone systems that use one set of standards and they're different from hospital to hospital. Would that be the case? I guess what I'm saying is that it seems to me that little Nova Scotia, being a small province, it would be unusual that we would be the only one that was trying to integrate hospitals. How is it that we're different and that this has become more complex here in a small province like Nova Scotia?
DR. WARD: I'll jump in to start with and then my colleague, Ms. McKeen, will continue on.
MS. WHALEN: I want you to be brief, if you could.
DR. WARD: Oh, we've got lots of time.
MS. WHALEN: I'm watching the clock.
DR. WARD: Very clearly, the issue of standard approaches to the care and management of patients is absolutely vital. Now the adverse events study that came out highlighted the fact there are many different systems and there is no comparability. The single biggest thing that got me excited about information systems in this province was the fact that it was an opportunity to move to a single system, not 34 separate systems that
couldn't talk to each other. I could just picture us being here in the Public Accounts Committee being asked how come this hospital is different than that hospital, when in fact we're going down the pathway of at least providing some sense of uniformity.
MS. WHALEN: Are you saying that in other places each hospital moved independently and therefore they had to sort of piecemeal together, patch together a system?
DR. WARD: No . . .
MS. WHALEN: In other places.
DR. WARD: Oh, yes.
MS. WHALEN: And we had a blank slate essentially; you could start here. Okay, thank you very much.
DR. WARD: Well, call it a green field, not a blank slate.
MS. WHALEN: I'll turn it over, please, to the member for Glace Bay.
MR. CHAIRMAN: The honourable member for Glace Bay, with about four minutes left.
MR. DAVID WILSON (Glace Bay): Dr. Ward, just continuing along that line of questioning. I'm sitting here listening, and I think everyday Nova Scotians would listen to what has been said here today and they would say cut it, dice it, chop it, make julienne fries out of it if you want, but you have a program here that is millions of dollars overbudget. You have a program here that, as yet, is not up and running in three out of eight districts. You have a project here that is not going to be implemented in the largest district, in the largest hospitals in this province. So how can you possibly say that at the end of your tenure, the end of your four-and-a-half-year term, as the longest-serving Deputy Health Minister in this province, how can you possibly say that that is an example of what should be done?
MR. CHAIRMAN: Dr. Ward.
DR. WARD: Mr. Chairman, the $30 million announcement was not a $30 million budget announcement, it was a $30 million project announcement over three years. The three years have passed. It was not ongoing in the sense of operating, it did not discuss the issue of the Capital District or any other place. We've been very clear in our discussions that the interoperability of the system over time was the end point. Very clearly, when we moved forward in this project, we did announce that the two organizations which had PCIS, patient care information systems, in place would be left to operate on those systems, and we would
bring the rest of the system up to a reasonable benchmark and then we would deal with those. We are moving down that pathway. Has the implementation been delayed? Yes.
MR. DAVID WILSON (Glace Bay): Let me put it this way, Dr. Ward, you're quoted in the papers today - and, by the way, I wish you well in your new job. I know that health care is not the easiest job in which to be employed in the world, good luck to you - yesterday, as you stated on your way out the door: "Politics sometimes got in the way of health-care delivery." I would suggest to you that this is an instance where politics got in the way, that that $30 million figure should never have been announced by the Tory Government, because it was not a true figure, and it has proven, today, that it is not a true figure. You're looking at anywhere from $75 million to $100 million before this project is even anywhere near completed. I will allow you to comment on my comments.
DR. WARD: Thank you for the opportunity, Mr. Wilson. I would choose not to comment on your comments.
MR. DAVID WILSON (Glace Bay): Dr. Ward, I should say that - I only have a minute left - I'm not, I don't want to cast aspersions upon anyone in the Department of Health or upon yourself or, again, your tenure here over the past four and a half years. When I read the paper, the article is in the paper today, there are still long waiting lists in this province, there are still overcrowded emergency departments, there are still rising drug costs in this province, and the overall level of health care in this province is not what it should be, and I take exception to anyone who had been in your position, moving on and saying that things are improving to the point where people should - and I also take exception, sometimes I found the blame tends to be cast on Nova Scotians, whether it be for our lifestyle or whether it be that we can't handle information technologies, whatever the case may be. There is more to it than that, sir, and I know you understand that, that health care is a complicated issue, it always has been and it always will be but, again, in this province, my opinion - and again, you can comment if you wish - things have not improved to the point where we have access to a level of care that we should as Nova Scotians.
MR. CHAIRMAN: Dr. Ward, would you like to comment?
DR. WARD: No.
MR. CHAIRMAN: Thank you. We will move on to the Progressive Conservative caucus.
The honourable member for Chester-St. Margaret's.
MR. JOHN CHATAWAY: Certainly, our panel today is very informative as they always have been. I said right off, we were very pleased, Dr. Ward, in your last few days on the job that you've come to speak to us here. I wish you the best of luck for the future, I
understand you are going to Toronto. Basically, you came to Nova Scotia from B.C., now you're going to Ontario, so nationwide, people certainly respect your great expertise and your dedication. Just before the meeting, I heard you on CBC discussing and letting many Nova Scotians share in some of the challenges.
The Department of Health in any province, or pretty well anywhere in the western world, is a number one concern. Certainly, everybody does respect your dedication and of course, some people say well, he's been the deputy minister of four and a half years, the government before us stayed in power for six years and they had eight deputy ministers in those six years. So your dedication is far more than just the stamina you take to the job. I know that time is running short, so the very best of luck.
I think we are, in fact, getting a full-fledged IT system for our health care system and many of the comments are attributed to that concept, but at a very fair and reasonable price. New technology does not come cheaply but the government certainly has gotten a good deal so far, just the facts and figures we have heard, and you and your people should keep up the good work. Certainly a new IT system will help find inefficiencies in the system and that will obviously save us money but to improve the quality of care for patients, an absolute must and will prevent anyone from falling through the cracks. Every so often we hear in this House of this person falling or that person through the cracks . Fewer people will fall through the cracks by ensuring patient information travels with them throughout the entire health system.
Just one thing, with much of the media attention focusing on the costs, this hasn't been much of an opportunity to recognize the achievements that the costs have made to date. If you really think about it, especially the people in the system themselves, the doctors, nurses, and technicians, they have said my, we have a good system and it certainly has improved. I understand that the vast majority of project team members are frontline health care workers investing a lot of energy and expertise into making this as successful as possible. Everybody has challenges but everyone also has a basic idea that yes, we're getting ahead.
Who has been involved - maybe you could just clarify - and what approach has been taken to involve those who will be using the system in the decision-making process?
MR. CHAIRMAN: Mr. Pagani.
MR. PAGANI: I think it goes right back to when the decision was made to select a system, a very large team consisting mostly of clinical folks: nurses, doctors, lab technicians, radiologists, admitting clerks and so on to decide what system to use. A fairly large team went out, took a look at the system and made that decision. As we moved along into implementation I think we had maybe one or two IT folks on the team, but it was mostly run by folks who would use the system at the end, the nurses, the lab folks and so on. Those folks
were involved right from the start, right from the standard setting part, so throughout we educated, we trained, and we made sure at the end of the day we have a legacy in terms of folks that know what they are doing. That is something that we had to do, and we are doing it on an ongoing basis. At one time we had up to 200 people working on this project to get work done. It is an extensive project. They were involved from day one. IT folks did not do the work.
[9:45 a.m.]
MR. CHATAWAY: Well, certainly I think many people compliment you for that attitude. The people who are using the system are giving you information on how the system should work, et cetera, because they will be using it. I think it has given the impression that we are certainly getting ahead. Another issue, surrounding patient privacy is sometimes discussed when we talk about electronic records. Health care professionals conduct themselves ethically and responsibly in terms of patient privacy. All patient information, whether it is held electronically or in paper format should be secure, I think everybody agrees with that. Patients need to feel confident that their personal health information will be maintained in a private, confidential and secure manner. Can you describe the steps that have been taken to protect the data within the system? How does patient confidentiality in the new system compare to that of the old paper-based system?
MR. CHAIRMAN: Ms. McKeen.
MS. MCKEEN: Thank you for the question. Of course personal health information is extremely sensitive. As Mr. Pagani was talking about, of the number of users and teams involved in the design and implementation of the hospital information system, one of the most critical teams has been the privacy policy team. That team is made up, it's interdisciplinary, there are representatives on that committee who are physicians, nursing staff, health records management staff, district health authority administrative staff and from the Department of Health's perspective, our privacy policy staff as well.
The process is to consult with this group and develop recommendations about who should have access to a person's health information. Those who are accessing that information should be on a need-to-know basis. Only those who need a piece of information in order to provide patient care should have access to that very personal information. Recommendations through this team are developed and then go to the steering committee and then to the department to become formal policies about who should be given access to personal health information. We are considered to be very advanced in the country.
Dr. Ward and Mr. Pagani at various points have referenced Canada Health Infoway, which is a federally funded organization. Very early on they approached Nova Scotia, before my time and asked us to work with them to map out best practices because of the work we were doing in the hospital information system.
MR. CHATAWAY: Certainly you people deserve a compliment. The rest of Canadians in other parts of Canada have said you guys down there in Nova Scotia are doing a good job. Just maybe a comment. When you talk to other provinces and jurisdictions, and we certainly appreciate what you said about New South Wales and England. But when you talk to other provinces, what are their impressions of what is taking place in Nova Scotia?
MS. MCKEEN: Nova Scotia is the envy of other jurisdictions. As was mentioned earlier, they have inherited legacy systems. They have hospitals which have "best of breed" solutions, but are not interoperable. Outside the walls of that hospital, they cannot send messages to the clinic which is a block away, or another hospital which is two blocks away. So they are working to build interfaces so that they can communicate, whether it be labs or X-rays.
Because of the unique position that we were in, which was actually fortunate for us that there had not been significant investments outside of the Capital District, we had the luxury of building and implementing a very fine system throughout the province which will allow us to be interoperable in 34 hospitals. As others have already addressed, we have a review process that will provide us with good information that will then help us to make decisions how to make that system interoperable with capital.
MR. CHATAWAY: I'm sure we all have challenges, I'm sure you have many challenges, but you're certainly winning the game, that's for sure. You're just as good as Calgary - they only won one game so far. I'd just like to let my colleague have the remainder of my time.
MR. CHAIRMAN: The honourable member for Waverley-Fall River-Beaver Bank.
MR. GARY HINES: I guess what I would like to do this morning is take you to Fall River. I'm very fortunate as the representative for that community to have a medical office in Fall River that probably has been upfront and foremost in development of their IT system. In fact, to the point that when I was still in HRM Council, the federal minister then, Anne McLellan, came to make an $11 million announcement at that facility for the simple reason they had advanced beyond a point in their IT development.
I guess what I want to know about is integration from system to system - are these systems such as the one that was developed in Fall River and was spoken so highly of by Minister McLellan - in fact, she spoke highly of the Nova Scotia system to the point that I happened to be sitting that day beside Minister Geoff Regan and she was so complimentary to then Minister Jamie Muir and to the Nova Scotia system that he looked at me and he said, what Party is she with today? That was two years ago and that says something for the advancement, but I want to know, the small systems that would be developed, like the Fall River office and so on, are they going to integrate well with the new system?
MR. CHAIRMAN: Mr. Pagani.
MR. PAGANI: Actually, we've done a fair amount of work with the folks in that clinic and the chief there is participating on the physicians' advisory committee so we're quite in the loop as to what's going on. One of the key items and one of the key end points
is to be able to interface with those systems, absolutely, so that if a test result is ready, out of the lab in a hospital, it gets transmitted or made available to that system there.
The primary health care reform part has an IT component that talks about how we do that, how we rolled it all together to make sure it's a cohesive, integrated interoperable system.
MR. HINES: That same integration will apply to the new Cobequid medical service centre as it is developed?
MR. PAGANI: Cobequid is a part of the Capital District, so they are already hooked into the district in terms of their capabilities so they can access the Capital District's lab system and radiology system and admitting system and so on. They'll also have the PACS component in terms of the ability to exchange images back and forth for diagnostics, for X-ray and so on.
MR. HINES: My IT skills are not that strong, but I've had to develop them to the point that I certainly can empathize with practitioners who are adapting to IT systems and the problems that they're running into. In fact, I still go home at night and turn my pants upside down to get out all the notes of paper and so on that I've made, despite the fact that I carry a recording device. So I understand that and I hope that they stick with it and that you give them the resources and the education that they need to make this a very vital part of the system. But I do understand their frustration in making that conversion.
What are you hearing from the district health authorities, the people managing the health care system at the community level? What are they saying about this system as it gets up and running?
MR. PAGANI: It's interesting, yesterday we did a bit of a review in Antigonish as a matter of fact. The bottom line is that the system we put in place works. It does the job. On a daily basis now it's part of their routine. The lab operation, the process, how samples flow through, how results are done - all that works right now. They're quite content with what they have, they're happy with what they have.
We had remarks from folks in Cape Breton, the second largest facility in the province, they're live now and they're quite pleased. Their lab is running very smoothly and that's after a very short period of time. I think that speaks to the excellence of the teams we have on this project and their dedication, what those folks have put into place to make sure this thing happens. I can only say it's the best team that I've ever worked with, and they contributed, and they're quite happy in Cape Breton. So the job was done.
MR. HINES: Now, the other health care workers, the behind the scenes people such as the radiologist and lab technician, et cetera. How were they affected by the system?
MR. PAGANI: Well, they all have their little pieces of the pie. The radiologist, for example, through the PACS system, which is not part of the NShIS, of getting new tools and having new tools that they find tremendously effective, they use it on a daily basis. The lab people, it's in their daily operation, they use it as a tool every day.
MR. HINES: Thank you. Mr. Chairman, those are all my questions.
MR. CHAIRMAN: Thank you very much and thank you to our guests. Dr. Ward, it's probably appropriate that on this, your second-last day on the job, that you should have the last word. You may have up to five minutes to make a closing statement, if you wish.
DR. WARD: Thank you, Mr. Chairman. It has been an interesting four and a half years. I entered into this job from the field. I had previously been a CEO of a large teaching hospital on the West Coast, and I'm returning to that role and taking over The Scarborough Hospital which is two large community hospitals, with a number of satellites, serving 1.2 million people. It's a very diverse community growing at 10 per cent a year, so it will be a bit of a challenge for me.
I came into this job new to the bureaucracy and I think I've always felt that one of the fortunate things was, by not having been a bureaucrat and not understanding the political process all that well, I sort of ignored much of it and went on and did what I thought was appropriate.
I have served four and a half years; a colleague of mine, Glenda Yeates, in Saskatchewan, has also resigned as of a couple of weeks ago and she's moving on. She preceded me into the job by three weeks. There are 14 deputies across Canada. Behind us we have seen 37 changes. I, in my four and a half years have served three ministers. That does not say much for continuity or stability in the system when we allow a system to move forward in which we see that type of change. It is difficult to think that anything will change when there is not that stability. Yet, in our hearts, we all recognize the system must change if it is to be sustainable. It must move out to the level of the community. We must develop our communities. We must engage our citizens as full partners in the management process and the caring process, to give them the abilities to look after themselves and manage their diseases better, to put that technology in their hands.
I would say that the last four and half years have not been without their challenges. There are many things I would have liked to have accomplished, but I do recognize that there are financial limitations. As many of the members have commented over the course of the discussions today, there will always be the opportunity to spend more money. I think the challenge will be to spend it so that it is effective.
The move for the future as we move to the community will be a demand for value for money. To prove that we do need another hospital bed, that it will improve care, and that we don't need another home care worker. That is part of the movement forward on the information system.
On a personal note, I have enjoyed much of this. There are some things I have not enjoyed at all. I have often been accused of taking some of this personally. I do. I've been in this business for 30-odd years, I look after people, and I care about people, and I do take things personally. That's okay by the way. I'd be scared silly if somebody didn't care. Thank you, again, for the opportunity.
MR. CHAIRMAN: Thank you very much, Dr. Ward. Ladies and gentlemen on the committee, some scheduling difficulties arose with respect to our next item, dealing with InNOVAcorp, which we're still trying to iron out. As we sit here today there are no further meetings scheduled; however, the clerk of committee will be in touch with the respective caucuses once those scheduling difficulties have been ironed out. I'd also like to remind members that we have all agreed to meet to receive the Auditor General's Report, which will be delivered on or around June 11th. Again, the caucuses will be notified in due course.
Yes, Mr. DeWolfe.
[10:00 a.m.]
MR. DEWOLFE: Mr. Chairman, with regard to the scheduling difficulties, it was initially agreed that we would finish up with the Public Accounts Committee at the closing of the House and we did agree to two more sessions, as in weeks, and it's not the sessions that are a big concern to me, it's the scheduling of our time. Here we are, getting back to our constituencies, trying to get caught up on work, and, as you know, there are other challenges facing every Party right now in this province. I would totally not be in favour and would be against scheduling another meeting.
We agreed to the next two weeks, and agreed to somewhere around June 16th for the Auditor General. Now, were we going to have a briefing with the Auditor General? Or do we handle it all in one session? Were we going to have a briefing, was that the plan prior to that, or just one meeting with the Auditor General?
MR. CHAIRMAN: My recollection was that last week we didn't make a decision on that, but the normal course would be that we would receive the report with an in camera briefing, followed by a public session, probably the following week. But that's all part of what has to be ironed out, in consultation with the respective caucuses. I'm well aware of the scheduling difficulties that all members have, and that is, indeed, exactly what needs to be ironed out, about whether we can have the session with InNOVAcorp at all, and, if so, when. It's not going to work out on the date that we had scheduled it for.
MR. DEWOLFE: At any rate, I just want to go on record to state that I would be against scheduling another meeting on top of the aggressive schedule that we've had over the course of the Winter and what we have before us right now. Please keep that in mind. We have other commitments that we've already planned on. I know most of my side of the committee has other commitments, including myself.
MR. CHAIRMAN: We'll certainly take that into account and, believe me, you'll be included in the consultations as we decide where and when to go from here. Are there any other items requiring the attention of the full committee before we adjourn? If not, a motion to adjourn.
Would all those in favour of the motion please say Aye. Contrary minded, Nay.
The motion is carried.
This meeting of the Public Accounts Committee is adjourned.
[The committee adjourned at 10:02 a.m.]
