Nova Scotia Hospital Information System
Printed and Published by Nova Scotia Hansard Reporting Services
Ms. Maureen MacDonald (Chair)
Mr. James DeWolfe (Vice-Chairman)
Mr. Mark Parent
Mr. Gary Hines
Mr. Graham Steele
Mr. David Wilson (Sackville-Cobequid)
Mr. Keith Colwell
Mr. David Wilson (Glace Bay)
Mr. Michel Samson
Ms. Mora Stevens
Legislative Committee Clerk
Mr. Roy Salmon
Ms. Elaine Morash
Assistant Auditor General
Mr. Roger Lintaman
Department of Health
Ms. Cheryl Doiron
Mr. Dieter Pagani
Director - Information Services
Mr. Allan Horsburgh
Chief Financial Officer
HALIFAX, WEDNESDAY, NOVEMBER 9, 2005
STANDING COMMITTEE ON PUBLIC ACCOUNTS
Ms. Maureen MacDonald
MADAM CHAIR: Good morning. I want to call the committee to order. We'll start by doing introductions.
[The committee members introduced themselves.]
MADAM CHAIR: We'll start with our witness introductions.
MS. CHERYL DOIRON: I think most of the committee knows my name is Cheryl Doiron. I'm the Deputy Minister of Health. I have with me two of my staff today. On my left is Allan Horsburgh, Executive Director of Financial Services; and on my right is Dieter Pagani, Director of Information Systems, Information Management in the department.
MADAM CHAIR: I want to welcome the officials from the Department of Health. We'll start by giving you a few minutes for a brief introduction to our topic this morning on health information systems. Then we'll proceed with questions.
MS. DOIRON: Good morning all. Today I am pleased to have Department of Health staff available to discuss the June 2005 Auditor General's Report as it relates to the Nova Scotia Hospital Information System. You've already met the staff I have with me. We believe that the report gives an excellent and fair overview of the project. So I won't go into a great amount of detail on that, and I'm sure you'll have questions as we go through the session. However, it is important to note that the Auditor General expressed confidence in the approach and in the implementation of the Nova Scotia HIS project and the acceptance by users in the district.
What I would like to emphasize is that Nova Scotia, in partnership with our district health authorities, is successfully advancing health care technology. The Nova Scotia HIS project is just one example of that work. The quality of health care provided by our doctors, nurses and other providers is dependent on the quality of information they have about their patients. Health care will run more efficiently with the support of technology-based systems. They are, in Health, as they are in many other areas, an enabler, allowing people to do their jobs better.
We are moving forward on elements of a comprehensive information management and technology strategic plan that involves the implementation of the electronic health record, including primary health care information systems, picture archiving or PACS, as they call it, which relates to the sending of images throughout the province, Telehealth, single-entry access in continuing care, in which we use the interRAI suite of products. This is not an exhaustive list. I know you're aware of some other things that have progressed over the past short year or two, things such as the drug monitoring system that's now in place, other areas such as public health and systems that are more specific to program areas that we're also involved in looking at and/or implementing.
Our vision for information technology and information management is that every Nova Scotian will have a unique electronic health record of every encounter that they have within the health care system, both within the hospital and in the community, over their lifetime. This will be done in a way that protects a person's privacy and promotes patient safety. More information means more accountable decision making in health care, as well.
Moving in this direction means a financial investment for the province, and so when we talk about costs we need to consider actual system costs, hardware, software and infrastructure, that's one set of costs; the costs associated with changed management and implementation; and, finally, ongoing operational costs. I emphasize because I think, over time, there have been misunderstandings about what figures may be pertaining to, and sometimes that leads to confusion and people thinking that maybe the figures aren't correct. It depends, I think, on what you're including in those costs at the time the figure is used.
Implementing the Nova Scotia Hospital Information System has been a significant undertaking. I must acknowledge the staff of the Guysborough Antigonish Strait Health Authority, who were the pioneers in the process. They led the way, and because of that their colleagues in other districts have benefited from their experience. Today we see eight districts on the Nova Scotia Hospital Information System, a long way from last year, even when the first two districts, GASHA and Cape Breton, became fully operational with all the components of the Hospital Information System.
During the last few days, in fact, Annapolis Valley Health went live with the clinical components, completing their implementation. And just last week, Southwest Health went live with patient processing components, billing and accounting receivable and pharmacy.
Only the implementation of the clinical component, such as lab, diagnostic imaging, order entry and enterprise medical records, are outstanding in Southwest Health, and those are planned to go live in February.
In summary, the Nova Scotia Hospital Information System will be fully operational in all 34 sites by Spring 2006, with the budget of $55.7 million that was established two years ago. Nova Scotia was the first in the country to attempt a province-wide information system. This became a daunting task because with it came some challenges. I think challenges are there when you implement any information system, but when you're doing it across this many sites and it's such a complex system with so many components, you would expect some challenges. There was no example, either, of an implementation like ours that we could use as a guide and, therefore, we had to learn and adjust on an ongoing basis. There is no other province that has attempted a province-wide system.
The terms we established with staff from the district health authorities, their teams have been a tremendous benefit in the implementation, and I have to say that they should be commended for the excellent work and commitment that they made from every district in this regard. They continue to provide expertise to their districts, as well as to the province. Staff training is a huge part of the change management process, so expanding our approach to training added time and money to the project base.
At the outset, as well, developing standards in consultation with health providers was a necessary and important step, but one that, as you would expect, also added time and the cost of the resources to put those together. Understanding and responding to specific needs in each district related to infrastructures such as networking, renovations, adding additional work stations, and all these kinds of significant work, all that takes resources as well.
The team responded to all of the challenges head-on so as not to derail the work that we knew needed to be done. Consequently we are concluding this piece of the work within the time frame that was originally established. For example, we established an action team that worked closely with the nurses at St. Martha's Hospital when they encountered difficulty with the patient care system. This approach resulted in solutions for them that could be used for the roll outs that followed. When I refer to the patient care system in this case, I'm really talking about the recording of nursing notes on the patient record. The patient care system really can also refer to the entire system.
The Auditor General found that this project was well managed and that at no time did the project go over budget in any fiscal year. Now that we are nearing completion we can look back on this project and test our success.
Health care providers, patients and administrators are seeing the benefits of this system. Improved patient safety, reduced duplication of services and faster test results, which means faster diagnosis and treatment, are just a few examples. A review of the GASHA implementation found this and so did the Auditor General.
Once this project is complete in the Spring, there are a few things that still need to be addressed. First is the completion of the patient care system roll out. This requires a clear understanding of specific needs in each hospital and to this end planning is now underway to develop requirements, timelines and cost. As well is the issue of interoperability with Capital Health and the IWK.
Interoperability of the hospital system to PACS is actually now in place and we are now completing a more comprehensive interoperability plan in conjunction with Canada Health Infoway, which will contribute to the financial cost of this particular task. We have to ensure that on an ongoing basis, our investments in information management and technology are protected through proper supports and maintenance. This means the implementation of our operations support centre which provides system and network support, help desk services, maintenance and enhancements.
Taking a provincial approach to these supports is proving to be an efficient and cost-effective move. If the system were to be implemented district by district, these costs alone would likely double, and we say that having costed them out, we know that would be the case.
In closing, we know that we have done the right thing for Nova Scotians. When patients and providers encounter the system they have a high level of satisfaction. We believe that this is an exciting time for the advancement of how health care is delivered in Nova Scotia and that is why we continue to move forward.
Thank you, Madam Chair, for allowing me to take some time to address the committee and we are now happy to take your questions.
MADAM CHAIR: Thank you very much. The first 20 minutes will go to the New Democratic Party.
The honourable member for Sackville-Cobequid.
MR. DAVID WILSON (Sackville-Cobequid): Thank you for coming here today and allowing us to question you on this important technological change that we are going to see in the province when it comes to patient care. I think the underlying, most important thing is how we can improve patient care and health care delivery in the province. I have to commend, it's nice to see that Nova Scotia is leading the pack when it comes to a province-wide information system to be in place in our province.
With that, being the first definitely leaves us open to make mistakes and learning from our mistakes as the system begins to unfold and come into implementation throughout the province. So as the Public Accounts Committee, I think one of the things we do is try to hone in, especially on the costs involved, on what government spends their money on and is it the best system or is it the best way for government to spend their money, and we should question around that. So that's where I'll start today and I'll direct most of my questions to the deputy minister and if you'd like to pass it off to more appropriate staff, that's fine.
You stated that the cost estimates will be about $55.7 million. Through the Auditor General's audit they had mentioned that the actual cost, as of March, was about $47 million, so it looks like you'll be on target for that $55 million estimate of total cost. We have heard that there have been problems with the system, especially down in the Guysborough-Antigonish-Strait area, with them being the first ones to pilot the program and a need to revisit how they're going to be able to - and you made mention of the nurse's notes - enter that into the system. Has that factored into the end cost? We know there are questions around remote access and upgrade in technology. When we first initiated this, I think it was in 2001, so with technology it changes on a daily basis, especially computerized technology. Are those costs factored into that $55.7 million of the upgrades that may be needed, the additional laptops, the changes being made to address the needs for the front-line health care workers in say, the emergency rooms?
MS. DOIRON: First of all let me say that within that cost of $55.7 million, all the system components that we needed - the software and so on - were all provided in that cost, but I will go to an additional cost to explain what has happened with that.
Prior to doing that I want to, however, say that with the rollout of Meditech, which is the hospital information system to which we're referring, as you probably know, Meditech is a hospital information system that was designed on an integrated basis, it's not like a best-of-breed system, the components are designed to work together. Typically, Meditech actually is in a number of hospital environments across Canada, North America and somewhat beyond. It's a system that has been well tested and it also is a system that has kept pace with developing technology and architecture, and so on, within information technology.
Implementation of this system tends to go reasonably well and in this case, in this province, it has done so for all of those components that are fundamentals such as the admission/discharge/transfer of patients, the order entry reporting system that allows ordering of lab tests, diagnostic imaging work and other things. So for the most part, the system components are implemented without undue or unexpected problems.
Where we did end up with an issue was with that patient care component, that nursing recording area. In a number of systems that we are aware of, that component of the Meditech system was not actually implemented because I think it is a bit more of a challenge. However, certainly through the nursing leadership in the province, there was advice to us to say that this is a good thing to do. I'm sure that you would - based on your background - understand the benefits of things that can be brought together in a standardized basis.
The recording of nursing notes and patients' charts has always been somewhat of a challenge because people take many different approaches to the way they do that. They may be taught some things when they are in nursing school but how that actually then gets entered into a chart can vary significantly. There are actual clinical benefits, as you probably have experienced, if you provide some kind of structure that allows some of that to be standardized. By doing that, I think, what we know will happen - and it has been tested in a couple of our districts now - is that we get more consistent charting that provides the essential elements, what the physicians, other caregivers and so on, need to know and understand from the chart. So, in fact, it raises the standard of the nursing charting which contributes better, I think, to patient information and then other decision making.
That got to be a real challenge when that particular component was introduced in the first district out in Antigonish at St. Martha's Hospital. The nurses there were finding that it took more time to actually enter that charting than the old method of simply doing it by hand.
Some of that time, I think, was because of the new approach and the time it takes to learn that and also, I think that there had been an assumption, when that particular component was envisioned and being put into place, that nurses would still do much of what they are doing now, in other words, carry paper or a notebook in their pocket, jot down notes when they're doing care in different patient rooms, at points come back to the desk and physically sit down and write things into the chart.
MR. DAVID WILSON (Sackville-Cobequid): I appreciate that and I know the deputy has been with us on several occasions and I think she is becoming quite well at answering our questions and maybe prolonging those. We do have a short period of time, I apologize for interrupting you, but I do have a few other questions.
The one question in my intro - and I guess I have to learn to maybe keep my intro down a little bit - was the end cost, the estimated end cost of this whole system. What will we see in the province?
MS. DOIRON: With the St. Martha's experience we ended up understanding that instead of going back to the desk and entering into the computer at that point, it was going to be necessary to provide the nurses with hand-held modules that they could take to the
bedside with them. That cost was not factored into the original cost of the system and that cost is a little over $2 million, I think, Dieter?
MR. DIETER PAGANI: No, $1.4 million.
MS. DOIRON: I'm sorry, $1.4 million, in order to buy all those hand-helds that will be necessary if we want to roll that through the rest of the province. That has been rolled out in Cape Breton and in the process of doing that the nurses from St. Martha's actually went and worked with the nurses in Cape Breton. It rolled out in Cape Breton on a much more efficient basis and a basis that was comfortable for the nursing staff, so they're quite happy with that module. Prior to being able to do that in other parts of the province we will have to address that $1.4 million cost and we have not yet done that.
MR. DAVID WILSON (Sackville-Cobequid): So we're looking at potentially, as a guesstimate, somewhere around $60 million or so for this total system. It is public knowledge that this program was implemented and a contract was signed in 2001, without the tender process that the government usually does. Do you feel that with the expenditure of nearly $60 million, potentially, of taxpayers' money that the government rushed the signing of that contract because they only had, I think, a matter of three and a half weeks to spend $20 million or $30 million? Do you think we rushed it, that maybe we should have had that tendering process to see what other systems may have been out there at the time?
MS. DOIRON: Basically, I think if you are starting at a point in time, you're counting a particular time frame, but there was much work done in advance of that that contributed to that tendering process. So the tendering process actually did occur and in fact the Auditor General was satisfied with the procurement approach that was taken. I'm going to ask Dieter to just give you a bit more detail about how that process actually evolved.
MADAM CHAIR: Mr. Pagani.
MR. PAGANI: I think we have to go back to at least 1997, when Cape Breton undertook to write a requirement and go to the marketplace to determine what best system would help them in implementing a hospital operational system. It didn't take too long after that when all the other regions joined in and in those days we had the regional health boards as opposed to the DHAs, so it became more of a provincial environment.
They wrote a spec and sent it out to a number of companies. Those companies responded, it was evaluated and it's very important to keep in mind that the evaluation was done by a number of people, over 100 people participated in that process: nurses, doctors, lab techs, radiology techs, and administrators. So a whole range of people went through evaluating the responses and made a selection of what they considered to be the preferred vendor, and that was Meditech.
We did a review - I joined the department in 2000 - just to make sure that nothing had changed, that the same requirements were still there and the same response would still apply and we decided, based on the study, that yes, we're still on track and we started the process. So the number of days we had to actually get things done was preceded by a fair amount of work to get us to that point.
MR. DAVID WILSON (Sackville-Cobequid): I understand that, I know this has been a long process, but the deputy minister mentioned that the Auditor General either agreed or supported the process of, I would say, non-tender, from my knowledge. At this time, I would like to ask Ms. Morash, the Assistant Auditor General, for clarification. Is that correct, was this a tendered contract to initiate the Nova Scotia Hospital Information System?
MS. ELAINE MORASH: It wasn't tendered at that time, no. It had been tendered a couple of years previous. Our issue is with respect to value for money at that point in time. So, yes, we agreed that it went through the process and was properly approved, there are alternative procurement practice approvals that are in the package that was circulated prior to the meeting, and those proved that it was in fact properly approved according to the government procurement policy. But with respect to whether value for money was achieved at that point in time, that's the issue that we can't comment on because there weren't competitive bids that were received at that point in time.
MR. DAVID WILSON (Sackville-Cobequid): Thank you for that clarification. What I'll do now, there's an area in here that really caught my attention when I went through the Auditor General's Report, and that was around the issue of training costs and that 50 per cent of the training costs will be borne by the district health authorities. Is that correct?
MS. DOIRON: That's right.
MR. DAVID WILSON (Sackville-Cobequid): That's really what I don't understand. Why were these parameters set up for training costs, when ultimately the district health authorities get their money from government, but yet we're going to ask them to take out of their operating budgets 50 per cent of the training costs?
You said in your opening statement that this is a significant procedure for us to unfold, to allow to unfold. Why was that decision made, to go to the district health authorities and make them bear 50 per cent of the cost of the system for training?
MS. DOIRON: Well, for one thing the implementation of the project was a shared experience, and so it was co-chaired by the department, a representative from the department, as well as one of the CEOs from the system. In addition to that, prior to the implementation of this system, there were some systems, certainly not complete systems, existing in some of the district health authorities and some support staff who were already in place. Basically, it was an approach, I think, that was worked out at the table with the actual steering table,
which includes the district health authorities. I'm going to ask Dieter to give you a bit more information, because he actually sat at that table.
MR. PAGANI: The way we derived, basically what you asked for, the 50/50 breakout, it was an agreement we made with the DHAs that they would provide staff for training purposes and share that cost with us. There's a big training component to it, and they were able, in most instances, to absorb that as part of their staff. So staff went through training days, and on average nurses, for example, went for two days, and they absorbed that. We did pay for the incremental costs, up to 50 per cent, for those. Now, other staff who we used from the DHAs to help us implement the system, they were 100 per cent covered.
MR. DAVID WILSON (Sackville-Cobequid): That's where I find government needs to - they're putting added pressure on our district health authorities to come within budget, and here we are, here's a system that the government has implemented - and I know the district health authorities are looking forward to implementing it, nobody disagrees that these technology changes will improve health care in our province. Let me just relay a couple of messages from what we read, or I read, in the business plans from district health authorities.
This one was from DHA 1, which is the South Shore. "Technological changes, such as the NshIS . . . will improve our ability to deliver services . . . " - nobody disagrees with that, I think everybody here would agree with that - ". . . but will also have a very real impact on our bottom lines that must be identified and supported. Once complete, implementation of the Nova Scotia Hospital Information System, for example, will have cost our District at least $250,000 in training, renovations and other one-time expenses and added nearly $400,000 in annual operating costs to our budget." That's just the one, I have several here, not all of them, because as we know not all district health authorities' business plans have been approved.
It's an identified concern from every one of them that I've looked through, that they can't implement these costs. It's going to take away from something that they're going to have to fund, or take away from funding in other areas. Do you feel that by putting this pressure on them that it's going to affect health care delivery and eventually patient care, because of this added cost to the district health authorities?
MS. DOIRON: I think it's important to differentiate between any cost sharing that was done during implementation and any kind of dollars that are required to support the system once implemented. I think what you read sort of gave an indication of both of those arenas. During the implementation, when staff were made available from the districts, that certainly could be considered part of the cost. There was also, to some extent, a backfilling of that staff, not necessarily at 100 per cent. So there were some costs that were assumed by the districts, mainly in those kinds of resources.
Where there were renovations required that were above the scope of the districts to be able to absorb, we actually did build in those costs. So once the program was started up and we had a project management office in place and could fully assess those things, then you'll see in the breakdown of the costs for the implementation of the system that there were dollars there for renovations. So we did in fact pick those things up.
What's important to note is now that the system is pretty well in place, the districts have become, of course, very concerned about what's going to happen on an ongoing basis to make sure that they have, both within the district and at the provincial level, the supports that are required to keep that system going and to help them to manage. We have been working through those budget numbers with the districts, and we have actually, very recently, in the budget this year, made staff available to the districts who are additional clerical-type people and so on, who are necessary for the functioning of the system.
We are just in the process now of rolling out the positions that will be necessary, additional positions in the districts, for technical support. They have worked with us on that and understand those numbers and seem to have accepted those numbers. And, thirdly, we are rolling out the operation support system that will be provincial. Those positions are about to be hired in place as well. With that all in place, I think the districts are much more comfortable that they can cope.
MR. DAVID WILSON (Sackville-Cobequid): Will the district health authorities see an increase to their budget over the next several years to help offset these costs and some of the concerns that I mentioned, like in the South Shore?
MS. DOIRON: They have seen some increase in this fiscal year, which was, probably within the last month or so, rolled out to them. They will see a further increase in this fiscal year, and they will see an increase in next year's budget as well. So the answer to that is yes.
MADAM CHAIR: Mr. David Wilson from the Liberal caucus.
MR. DAVID WILSON (Glace Bay): Good morning, Deputy Minister, and thank you for appearing this morning. It's no easy task, I guess, when you take a look at it, and you look at the scope of this project and how much is involved. I can understand, and I think everyone here can understand, this has been a huge undertaking by the Department of Health. But at the end of the day, after spending what could be close to $60 million of taxpayers' money, let me ask you this, are we left with a system that's still incomplete in your opinion?
MS. DOIRON: The Hospital Information System will not be incomplete. There are other systems that I think the health system requires that are not part of this system, such as, for example, a public health system that is currently being developed across the country and so on. The Hospital Information System would be complete. One of the elements that's required to complete it is, of course, that interoperability connect with Capital Health and the
IWK. There was consideration given, and an assessment done in concert with them, to take a look at whether, particularly with Capital Health, where they have a best-of-breed system, it made sense to try to move them over to Meditech or not.
With the assistance of some consulting help, and with the involvement of the Capital District and the department, it was determined that was probably not the best approach to take for renewal of their systems. Part of that reason was basically based on systems they have now and the cost to replace everything, but over and above that was the issue of the changed management challenge that would have been there to bring all of their clinicians, doctors and so on through the changed management process to yet another system.
So, basically, it was determined that the best way, in order for us to have systems that could talk to each other throughout the entire province was to do that through the interoperable approach with them. The IWK is on a Meditech system, it's a bit of a different variety or version than the one that has been rolled out, but they are a Meditech consumer as well.
MR. DAVID WILSON (Glace Bay): Well, respectfully, you and I have a different opinion of what incomplete means. If you're in a small province, such as Nova Scotia, in a hospital in Glace Bay, or Sydney or whatever the case may be, Yarmouth, and can't talk to the big hospital in Halifax, that leads me to come to the conclusion that you have an incomplete system. You have the province's only tertiary hospital, you have the IWK, you have doctors' offices across this province that cannot talk to each other on this $60 million system. Is that not incomplete?
MS. DOIRON: I'm sorry but, respectfully, that comment is not correct. Basically the interoperable connects will allow that kind of talking to take place, and in fact it already exists in some areas.
MR. DAVID WILSON (Glace Bay): Deputy Minister, they're not there now. They don't exist right now. After all of this money has been spent, you cannot talk to the IWK, you cannot talk to the QE II and you cannot talk to doctors' offices.
MS. DOIRON: Once the interoperable system is in place, then that will be the case. That is part of the cost that has been figured into the project. It might be helpful if I ask Mr. Pagani to give you a bit more explanation of what that's going to mean.
MR. DAVID WILSON (Glace Bay): Let me finish first. Madam Chair, if I may, let me finish first. You're talking about the interoperability of the system, that it's not done, that it's going to be done. Well, when is it going to be completed? And how much more is it going to cost?
MR. PAGANI: Thank you very much for that question. I think it's a good question. I think we've put in place a number of pieces that allow us to be interoperable. One is we had to build a complete network in the province that included the Capital District and the IWK. We accomplished that. We can now send information back and forth, and get the foundation in place for that. We do have interoperability, for example, in the diagnostic imaging area, between the systems, which means that if a request is made for a diagnostic test, that information is going to be on the PACS system, information flows from the system across and goes back. So a radiologist or a physician can take a look at those images, as well as the reports that come out of that. So we're well underway in terms of doing this.
The other component, it has been recognized across the country and I think it has been recognized everywhere else, interoperability is one of the most complex and complicated pieces of work that needs to be done in health care. This is why we're working with Canada Health Infoway, which will participate in some of the funding that we'll need to do an appropriate job on that one. Planning is underway for that as we speak. So we are on our way to doing it. We have components up and running, and we have teams in place to address requirements.
MR. DAVID WILSON (Glace Bay): Again, let me go back, Deputy Minister, to my original question and that is on the question of whether or not this system is complete. It's not complete. It's an incomplete system right now, after all this money has been spent. There are examples, for instance, this system, as I understand it, had no problem coming on stream in New Brunswick, in the United States there are places where it has no problem performing among 400 hospitals, the case may be, but yet here in Nova Scotia, for some reason, we stopped at 34 hospitals. We did not include the QE II, we did not include the IWK, and we did not include physicians' offices.
Now, I understand there are other issues regarding physicians' offices, and I think it includes patient confidentiality, but that's another story. On the incomplete part of it, if you don't have that, then tell us why the IWK and why the QE II were not included in this massive venture, this $60 million venture that you've embarked on. We understand, I don't think anybody will argue with the fact that this has to be done. They might have some problems with how much it's costing, but at the end of the day, despite the cost, why doesn't it include everyone?
MS. DOIRON: It is our opinion, in fact I think it's a fair thing to say that it's a fact, that once the interoperability mechanisms are established with the IWK and Capital Health, you will be able to send work of any type that's available on the Meditech system, it will be able to be interfaced efficiently with the systems that are IWK and Capital Health. That means that you will be able to send patient information from charts, you will be able to send test results from the lab - diagnostic imaging is there now. The technical structures, the foundation pieces to allow that to occur, are now in place.
So I think that probably within a year, approximately a year, once we have the interoperability piece in place, then you will be able to say, very comfortably, that there is a complete system. So any information that could be transferred between the 34 hospitals that are on the Meditech system will also be able to be transferred between those systems and IWK and Capital Health. From our perspective that represents a complete system. I think there were deliberate assessments and decisions made as to how to approach that, but at the end of the day the end product is a complete system.
MR. DAVID WILSON (Glace Bay): But with an additional cost, is that correct?
MS. DOIRON: The costs of interoperability were actually calculated in, so there may be some small additional costs because we're finally working out the details of what that exact cost means once you get into the detailed design of it, but all the foundational work costs were included in the project itself and that work is done. The work for the PACS system has been completed, and that's in place. I'm not saying there won't be any additional costs, but it will be marginal. Most of the cost was built into this project.
MR. DAVID WILSON (Glace Bay): Madam Chair, how much additional cost are we talking about? For instance, we've heard reference made that there were laptop computers that were required for one part of the system. Those laptop computers were not included in the original part. I'm wondering why someone didn't notice. Are there not alarm bells that sound at the Department of Health when you put in a system and someone says, well, we forgot the laptops, it's going to cost another $1.4 million to put in laptops. Isn't that concerning? Doesn't that concern you to the point that maybe we should be taking a closer look at what's actually happening with the installation of this system?
MS. DOIRON: I think that, generally speaking, when systems are introduced, even if they're being introduced into a small office or some other area, people approach that based on trying to project the most accurate cost they can. They make the assumptions about how the system will operate and what the users do with it. In consultation with the users, the district health authorities, initially, it was felt that for that particular component those nursing notes could continue to be done at the nursing desk. In fact, that system has not been used to a great extent in other jurisdictions, so I think that once we did start using it, that was one area that we didn't calculate correctly. We would like to correct it before we continue to roll it out.
But we are not going to overspend on the system. We will take that as a separate budget item and determine whether in fact that's a priority to roll forward. We would like to actualize that component, but the rest of the system works quite well without it, and didn't really throw us any of those kinds of surprises.
MR. DAVID WILSON (Glace Bay): At the end of the day, as I asked, once this project is completed in 2007, now, how much is this going to cost Nova Scotia taxpayers?
MS. DOIRON: As far as we know right now I think we're still in the area of approximately $60 million, that rounded figure that has already been put on the table. I say that because we're currently in that planning stage with Canada Infoway to design the detail around the interoperability piece. Canada Infoway will pick up a substantial portion of that cost, but there will probably be some costs that the province will have to pick up. We don't know that figure yet, because it's actually being planned as we're here. I think we could speculate that it's probably within the order of something that would be within about $2 million, but that would have to be verified through the planning.
So given the costs that have been there on the table all along, $55.7 million, and a couple of these additional pieces that we need to actually complete the whole system, we're still going to be in that approximately $60 million cost.
MR. DAVID WILSON (Glace Bay): The Canada Health Infoway initiative - I don't know if that's the proper name, but I think I'm close - the province has applied under that, for how much?
MS. DOIRON: Basically the way that works is you don't apply for a specific amount, you agree to go through phases with Canada Infoway. The first phase, as they call it, phase zero, is the planning stage. It's during that period that the actual costs are identified. Once that costing has been completed, for the components of it that Canada Infoway will cover, they are now providing funding at a 75/25 per cent split. So they'll pick up 75 per cent of the cost and we would pick up the rest.
MR. DAVID WILSON (Glace Bay): Deputy Minister, let me ask you, there were some changes, I understand, that were made to the original price tag in March 2001. They were based on a request for proposal that was provided to the department in 1999. Can you tell me about those changes, and how much money they involved?
MS. DOIRON: Madam Chair, I'm going to ask Dieter to respond to that.
MR. PAGANI: I need clarification. I don't quite understand what the question was.
MR. DAVID WILSON (Glace Bay): With the process that was undertaken by the department with respect to signing the agreement with the company, there was a request for proposal, there were some changes made to the original request, was there?
MR. PAGANI: No.
MR. DAVID WILSON (Glace Bay): There were no changes at all?
MR. PAGANI: When the first steps were taken through the RFP process that Cape Breton and the other districts used, they identified a set of in-scope items to address. And we addressed that. The scope was the same, basically.
MR. DAVID WILSON (Glace Bay): There were no changes to the price tag attached to it at all?
MR. PAGANI: Not that I know of.
MR. DAVID WILSON (Glace Bay): If, indeed, you were looking - and this is an area that I think has caused a little bit of concern about the request for proposal, you had a very short time frame there in which to sign a contract. I'd like to know what the justification was for the price tag. How did you know, in other words, that you were receiving good value for your money?
MR. PAGANI: Well, first of all we had negotiations with the company, but we also scanned the environment to understand what other people are paying for a similar environment, in terms of how much it would cost to implement the system, software-wise and hardware-wise, for a 200-bed hospital, a 300-bed hospital. We're implementing a system that's basically for 1,600 to 1,800 beds when you add up all the 34 hospitals that we included. So we had a fairly good idea, and based on the responses we got in 1997 that we were still on track, we negotiated a price with Meditech and in fact with the hardware vendor that concluded just shortly before the end of March.
MR. DAVID WILSON (Glace Bay): Madam Chair, I'm not sure how much time I have left.
MADAM CHAIR: You have until 10:04 a.m.
MR. DAVID WILSON (Glace Bay): That's great. Let me go back to what I was talking about in terms of whether or not - I think the easiest way to put it is - these computers are going to be able to talk to one another. If you look at the Auditor General's Report, it mentions, on Page 89, a reduction in scope. To be specific, it mentions that the Physician Advisory Committee cancelled the implementation of the provider order entry module, which the Auditor General pointed out is very important and includes information for doctors on patient medication documentation. The report also mentioned that the software supplier has since developed a new software program, and at this time it's considered outside of the project. Let me ask you, don't you see the provider order entry module as important, and if so then why is the new software considered to be outside of this project?
MS. DOIRON: Basically, I think at the time this was being introduced, at that point in time, the order entry reporting system was actually contained as a module for in-hospital use with the nursing staff and desk staff in particular having access to that. So the capability is there. At the time, I think the doctors were suggesting they did not see that as something they would want to be engaging in at this point in time. But that doesn't mean that we can't change that at some point when they're more comfortable to go down that road.
Given that Dieter was actually part of the actual negotiations when that occurred, maybe I'll ask him to just add a comment.
MR. PAGANI: Yes, we did include the physician order entry component. We did take a trip to see how that system would operate. The four physicians we took to take a look at it decided very quickly that's not for us, we're not ready for us and it doesn't do the job for us. So instead of wasting time and money in implementing it, we put it aside. What we did do is we did completely implement an order entry system that is used within the hospital. In fact some doctors are doing all their entry work now in that way.
Now the other part, if you take a look at the industry in terms of order entry for physicians, it is a difficult task to convince physicians to use their own order entry, to place a drug order or to place a radiology order, because they tend to think that it adds time to their workday. There is work that's going on across the country, trying to work that through, and we're working with CMA, the Canadian Medical Association, with Doctors Nova Scotia, and a number of people to address that issue.
MR. DAVID WILSON (Glace Bay): Madam Chair, so there is a part of the Nova Scotia Hospital Information System that's going to allow doctors to gather information on their patients' medication. Is that true?
MR. PAGANI: It is true, medication, as it relates to an in-hospital event.
MR. DAVID WILSON (Glace Bay): Only in-hospital. This still leaves the doctors on the outside, unless they're at the hospital. I know there has been a change in my time, that I only have another minute or so left.
MADAM CHAIR: I apologize, I made a mistake.
MR. DAVID WILSON (Glace Bay): No, no, that's okay. Madam Chair, even you can make mistakes. (Laughter) Let me go back to my original point in the minute that's left to me here. You still have a system that's incomplete. If doctors can only access medical information on their medication in the hospital, doctors' offices are here, the IWK is here, the QE II is here, and the rest of the hospitals are here. The question that I'm left with is, didn't the Department of Health, since it acts on behalf of all of the hospitals in Nova Scotia, at one point say, we are going to be left with a system that's not connecting everybody, and
that's not acceptable? It has to be done as part of the original agreement. Wouldn't you agree, Deputy Minister?
MS. DOIRON: Our objective is to have a complete system, and to continue bringing in the components that will make it complete. The system we're talking about right now is really the Hospital Information System, but we're also doing work to advance other systems that are community based. For example, we have been introducing, and we worked through physicians and others included, what would be the primary health care system that would be most effective for the province. A tremendous amount of work has been done on that, and we're in some implementation phases with that.
We have supported some of the collaborative practice groups with information systems. We are going to be making available to physicians who wish to set up in their office one of the primary health care approaches so that they would be able to get assistance through the provincial help desk, for example, as ways to support them or entice them to come forward. I'm expecting that this is a topic that is going to become of more and more interest to doctors, to be able to connect from their offices, and we're seeing some growth in that.
I think that probably we'd all recognize that as we have more and more of the younger medical graduates coming out, they tend to come into the workplace at the start of their experience looking for systems. So I think essentially it's partially a transition system that has to work its way through the medical community. We are, in fact, progressing with systems that are community based, that are going to also be able to interface with the hospital system, so progress is being made in that area.
The Nova Scotia Hospital Information System project was not started with the intention that it would actually connect every single doctor's office in the province. We are taking a variety of approaches to encourage that, so that as we continue to evolve more doctors' offices will be connected and some are already there.
MADAM CHAIR: The time has expired for the Liberal caucus.
The honourable member for Kings North.
MR. MARK PARENT: I just want to start with two quotes, one sort of in response to what my colleague from the NDP caucus raised at the start and that's by Edward Phelps, "The man who makes no mistakes does not usually make anything." And the other quote was a segue to what I want to say which was by the New Zealand physicist Ernest Rutherford, who later taught at McGill University, my alma mater, "We don't have the money, so we have to think."
I love that quote and it was raised as a segue into what I have to say because I had the privilege of being at a ministers' meeting representing Nova Scotia for e-government in Quebec City this past weekend. That was the quote that New Brunswick used to sort of introduce their system and how they got into the whole provision of service delivery and using the new information communication technology, ICT, basically using the Internet. It was interesting to see, because each province gave input of what they're doing in terms of using the new information channels, using the Internet in areas.
Specifically, the two areas that were targeted first were health care and secondly the educational system, on-line learning. We, as a province - it reaffirms what you said in your introduction, Ms. Doiron - are leaders across Canada. New Brunswick and Nova Scotia are actually leaders in using the technology and New Brunswick explained that we just don't have big provincial budgets so we have to learn how to do things more efficiently, and we have to learn how to do things less expensively. So the new technologies offer that opportunity to do an efficient and less-expensive job. There is an initial cost at first, and we all recognize that, a cost in terms of dollars, and a cost in terms of staff time and staff input.
Some of the issues that we raised there were issues that I'd like to ask you about but they probably go beyond the scope of this project, and you may feel that really you don't want to respond to them. The ministers all agreed that we can provide better government services but there are key issues that need to be discussed. One is the issue of privacy and how do we protect privacy? That's an important issue that Canadians and globally, people are struggling with. People are more and more concerned about their privacy but also concerned about efficiency; they want, when they log on, to be able to get the information and yet, that comes at a cost.
The other issue, of course, is the extent of the infrastructure. Nova Scotia is ahead of the other provinces in that 85 per cent of Nova Scotians can access high-speed Internet. Now, unfortunately, only 60 per cent are on-line right now but the infrastructure is there. We may need to do something for the other 15 per cent. Saskatchewan is overlaying a wireless system across their province in order to get their communities integrated and Alberta has just gone live with the SuperNet system, which is a wired system, but the whole issue of proper infrastructure.
The third issue is the issue of authentication. How do you know when someone logs on they are really who they say they are, which ties in with the privacy concerns.
The fourth issue, which is the issue that we've talked about here, which bedevils the other jurisdictions, is the issue of interoperability. That piece, just confirming what you said, is a very difficult piece for all provinces to get in place. Certainly it's no surprise that we're no different from other provinces in regard to trying to get that interoperability, not just
within the province and within various departments, within facets of those departments, but ultimately if we are going to provide services to our citizens who don't differentiate between different levels of government, but who just want that service between governments as well.
My first question is, could you just elaborate a little bit more about the work being done with the federal government in terms of interoperability and what support they're offering to us, and how you see the federal systems and the provincial systems working together?
MS. DOIRON: Thank you very much for that question. I think the Canadian Government recognized that if we were going to provide the best systems that we could for Canadians that we had to start looking at that kind of common infrastructure and the kind of standards for interoperability across the country in a meaningful way. In fact, I remember, it would have been back in the mid-1990s - I happened to be in New Brunswick at the time - I was on the federal First Ministers advisory committee on Canada Health Infoway. Through the discussions that took place at that table with provincial representatives, federal, private sector, whatever, those kinds of principles around the need to have that kind of common foundation piece in place for the country and have those standards clearly developed was a big issue.
Basically, arising out of that, I think, was the development of the Canada Health Infoway and the funding for that at a bit of arm's-length from the federal government, but nevertheless, a federal government funded project. That's the body, of course, that has been working with us and all the provinces to ensure that interoperability is going to be achieved as we continue to develop all these components of an electronic health record.
This kind of work, as you probably know from attending conferences like you have, is work that is not an overnight kind of situation. Canada Health Infoway continues to work on these elements and in the process of doing that, is basically making sure that the best of the practices, the best of the work that's being done across the world, is being incorporated into the design of how these things are designed to take place for Canada. All of the provinces have fully bought into this whole Canada Health Infoway approach.
I think that while it will still take some more time to get all of that developed to the fullest extent, and obviously this is a continually evolving and changing arena, we are feeling pretty comfortable that this kind of interoperability is something we're all trying to manage to stay with.
At the moment, I happen to be on the Canada Health Infoway board and know of that kind of work that they're doing. We also know that Canada Health Infoway was funded to a particular set of dollars and with the work that they're doing now and things that are being rolled forward, those dollars are pretty well committed. So they're going back now to the federal table to say, with the support of the provinces and certainly, the Ministers of Health
table for the country, the deputy ministers' table for the country have fully supported their ask to the federal government to make sure that we can continue to move that whole arena forward. So I would make those comments, I don't know if there's anything else?
MR. PAGANI: No.
MS. DOIRON: I think that's my answer.
MR. PARENT: We, at that conference, forwarded a draft to go to the council federation encouraging the provinces to work, and to call upon the federal government to work together, along with municipalities, too, who are key service providers - not so much in health but in other services.
One interesting aside, when we were putting together the draft, since interoperability was a key issue - we had that in the draft about working on interoperability - the representative from Alberta said, well, this is going to the Premier, shouldn't we put an easier word in? I was about to say, is that a reflection on your specific Premier, because I had no concern about our Premier understanding the concept of interoperability, but I restrained myself.
The other issue was privacy. Is that something that you'd like to have something to say on? What are we doing in terms of privacy and how do you mesh together privacy and efficiency?
MS. DOIRON: Really a very important topic, as we all know. I'm going to get Dieter to speak to this in a moment, I just want to make one statement before we do that.
We have taken this very seriously and done a tremendous amount of work to put in place what we think are the appropriate safeguards, relative to privacy, that are available to us. But I do want to point one thing out, and that is when we operated hospitals on the basis of having paper charts, we never talked as much about privacy as we are doing now. I'm telling you, I can remember situations where you'd have interns or residents doing studies, whatever, wanting to take the information maybe to a place to work, walking through the building with all kinds of paper charts, putting them down in places people might get access to them.
I recall one specific day in Saint John, when one of the residents was leaving St. Joseph's Hospital with a set of charts going to the Saint John Regional Hospital to do work, a high gust of wind up on that hill took place and the charts went flying all over and were difficult to retrieve. I'm saying that because I think while we are doing everything in our power to ensure that we're taking all of the appropriate measures for privacy, the old system had many, many issues that people didn't focus on that were problems. Now I will turn this answer over to Dieter.
The other thing, too, is the whole aspect of training. I think people have to be aware of what privacy and informatics mean, so we put on training courses for nurses, for clerks, even for doctors. Before they can access the system they are required to sign a non-disclosure agreement and they need to understand what some of the consequences are. So putting those tools in place is one thing, but the other thing, too, is how to ensure that privacy wasn't breached.
What we put in place, which is part of the system, is an auditing capability, so any time a person accesses the system, it's recorded who accessed the system, for what record, for how long, did they make any changes to it. That audit trail is available and we do audits on a random basis, we also do audits based on a patient's request. If you, for example, feel somebody is looking at your records who shouldn't, we can trace that. So those tools are all in place and like I said, it was a tremendous amount of work.
The other one, too, is that you can only access information that pertains to a job, so if you're a nurse on a particular floor, on a particular ward, that's the access you have, to the patients on your ward. If you are a technician in radiology, that's the access you have - no more, no less. So what you need to do your job in terms of the system, that's the access you have. That has been implemented and that has been working from day one. The first time we went live we had that in place.
MR. PARENT: As you mentioned, Ms. Doiron, Annapolis Valley Health is going live and I deliberately refrained from asking my wife, who is the director of the Valley Regional Hospital, because I know she told me for the next two weeks it would be a rather busy time. I'm wondering about the whole issue of staff pressure, because this is an additional sort of workload on the staff, on top of everything else they are doing. How did it go in Antigonish in terms of that? Are you monitoring that? Is there help if it's needed? Our staff in our hospitals are already working at 100 per cent.
MS. DOIRON: One of the things, I think, that occurred as we introduced the system was the pressure that we did not anticipate fully from the nursing charting component. The other aspects of the system, which is most of the system in a way, have been elements that in this province most staff have been asking for. So while it does take some time and effort
when it's being implemented, usually it doesn't take more time after the fact. Once it gets in place and people know how to use it then I think they find it to be as efficient and sometimes more efficient than what they had before.
I know that much of the work that the staff in our hospitals do can be tied to the kind of information that they can receive not just on an individual patient, but on other work they do relative to quality improvement, accountability factors and so on with patient care, or finances, or something else. Without the system in place it is very difficult for them to be able to actually pull together the information more and more of which is being asked for by a variety of bodies.
I know when I first came into this province in 2000, I was hearing that this province in some ways was further behind than others in terms of having systems out there. Once we made the move to go forward, we advanced it in a manner that, yes, is unique and further ahead than many other jurisdictions.
Really what has been happening for the most part, staff in the districts have been coming back to us where the system has been implemented, and have been extremely positive about having the system. In fact, maybe six months back, once Cape Breton was fully up and running, they actually pulled together a video that we could make available to anybody who wished to see it, but it was a whole variety of people from different positions in their organizations telling people the value of what they've seen from having implemented the system. So the only piece that we don't get that kind of response around is that nursing charting component and that's why we have kind of held back on that and said, we have to look at that separately.
MR. PARENT: One last question and I don't want to miss saying, because the really important story that should come out of today is the advances that we're making, it's a good-news story, really, today. You just ended on that and I want to reaffirm that.
One last question, refreshing software, because this is a problem with technology, I guess it's a problem with all technology but particularly with computer-based technology, it just seems like you sort of get your system in place and then you move from - I remember the DOS system - Windows 95 and 98 and everything, it keeps going up. Have we factored that into our planning?
MS. DOIRON: We have done that, Dieter can explain a bit more about that. I often go back too, I know that people say that information systems have been expensive ventures and so on, but it's not really very much different than what happened - I don't think - when people started using telephones and they kept changing. It's not much different from the fact that many of us these days are used to using a desktop of some type in our work and those kinds of systems have to keep being upgraded and the hardware has to be renewed as you go. It's the same thing for this system and certainly, part of all those upgrades is part of what is
factored into negotiations as you are going down this kind of road with the companies you're involved with. But I would ask Dieter just to be a bit more specific.
MADAM CHAIR: Mr. Pagani.
MR. PAGANI: Maintaining systems is one of the most critical pieces in the life of what's going on in informatics; it's one thing to put it in - it's like a car - you have to maintain it to make sure it keeps running. As part of the contract we have a maintenance structure in place where we pay a maintenance fee which includes all the upgrades, all the necessary changes. On average we probably do a minor maintenance piece a year, but we'll have a major upgrade next year, for example. As people use the system they gain more knowledge, they make recommendations how to change it. The background changes, like you said, you go from Windows 98 to whatever, that has an impact, but that's all part and parcel of our operational support structure that we have.
MR. PARENT: I was going to turn it over to my colleague, but it just reminded me of something else. I was talking to Carolyn Stewart once, who is in charge of some of this piece federally. The use of PDAs and I'm just wondering if in charting, the nurses' input of the data into PDAs that were wirelessly hooked up, whether that would solve the charting problem. I know they have good systems, HandyBase is one program that a lot of doctors use, where you could have a preset chart that you would just fill in and then all of that would flow through.
MS. DOIRON: Yes, that's actually what we're talking about when we said we need those devices in order to allow people to do it and feel comfortable that they can be efficient in doing it. In Cape Breton, at St. Martha's, those things were finally made available in order for them to be able to do that work. It went very smoothly in Cape Breton because they had those devices as they rolled it out. At this point in order for us to provide that to the rest of the province, we have that $1.4 million issue which we don't have in our budget at this point.
MR. PARENT: Thank you.
MADAM CHAIR: The time for the government caucus has expired. We will now go back to Mr. Wilson.
The honourable member for Sackville-Cobequid.
MR. DAVID WILSON (Sackville-Cobequid): First of all I would like to make a quick comment on acknowledging the efforts of our health care workers, especially our front-line health care workers in this province. Those are the individuals in this province who need to change the way they deliver service in health care to patients. I know, through my
experience, when changes come in it's hard to adapt and I think far too often this government doesn't take their advice or ask for their advice when they implement and make decisions when it involves health care.
I think by the knowledge of some of the complications down at St. Martha's about the nurses who were involved with that first pilot program, government needs to recognize that these are the individuals we need to go and ask how we can implement changes. I understand management levels and bureaucrats are involved in decision making but we need to ensure that we go to these front-line health care workers and find out how they do their job, for one, and if we're going to implement changes, how we can implement positive changes so it has a better outcome for the patients. With that, I do want to continue on with the privacy and protection issue with this because it is very important.
I know the deputy minister stated in our current system it hasn't been in the forefront but with that, and the analogy used about leaving patients' charts open for people to see, here we are talking about maybe 100 people who may walk by that chart and look into it but with the technology we are venturing on, this leaves it open to thousands, if not millions, of those who use these technologies and enter into unauthorized areas. That's, I think, one of the reasons why it is such a big issue.
The former privacy commissioner from British Columbia was in the province and was actually interviewed last week. One of his comments was around the concerns he had that Nova Scotia doesn't have a privacy commissioner here in the province. I know that's not your job to ensure that government has one but I also know that with doctor care co-operatives now handling some of the patient billing and electronic medical records in the province, and I know that they are looking at expanding those services in the province, which may open up the door for other companies to come in, especially American companies, to do the same job as this, so it may eventually spread throughout the province.
The concern we have, especially around health care records that these companies are going to have access to, especially American companies, is with the U.S. Patriot Act. With this Act it may open up the door for the U.S. Government to be able to look at any of these records. What discussions have been made to ensure that patient records in Nova Scotia, in Canada are going to be left to the privacy of our province and that things like the Patriot Act will not affect the privacy of Nova Scotians in their health care records?
MS. DOIRON: That's a very interesting question. I certainly appreciate the comments that you've made about the potential exposure if, in fact, the system is not protected efficiently and effectively. Indeed, to your last issue, there have been discussions about the Act that you refer to, both at the deputy table and in the Department of Health as well, as it applies to the Hospital Information System, or actually any of the information systems that we are working with in Health. I know we have also given some specific consideration to that and I'm going to ask Dieter to give a response.
MR. PAGANI: Yes, we actually did a fair amount of work looking at that concept of the Patriot Act and initially we were concerned about it. Number one, all of our data is kept in the province, that's the most critical piece, so none of our data is outside the province, it is here. Secondly, we have safeguards. Number one, how you access the system, you can only get access externally. For example, we do have access to our vendor to maintain the system, you have to have that. If you have a problem you need the specialists that they have to go in and do the fixes, but they can only get in on our approval. We have a mechanism in place that will say, if you want to come in, I will let you come in. So we did everything we could do from a Patriot Act point of view that protects our data so it can't be accessed by anybody externally. We are applying standard methods that are used in industry. So that is the biggest safeguard, our data is in the province, it is not outside the province.
MR. DAVID WILSON (Sackville-Cobequid): Do we need legislation to be brought forward to ensure that this is going to happen? I know Meditech, I believe, is the name of the company and it is actually an American company. I know that you're saying they need to ask our permission but do we need to be looking at legislation in this province to ensure this? Is that something that has come up that we may need to look at?
MS. DOIRON: I think that the Act you're referring to has more application than simply Health, as we know. At this point in time, departments that I'm aware of and certainly our own, have not identified areas that we are suggesting legislation around, but I also think that we have to understand and have some experience with that Patriot Act before we can determine fully whether in fact legislation mechanisms would be helpful. So at this point in time, to my knowledge, there isn't an intention to go forward and do that, but there is a real heightened state of awareness around watching the implications.
MR. DAVID WILSON (Sackville-Cobequid): That's good to know and definitely, we'll keep an eye on the proceedings and what will happen in the next months and years.
As I mentioned, the former privacy commissioner from British Columbia was interviewed, I believe it was on CBC Radio last week. In his interview, he cited the Health Information System in Nova Scotia would be a key reason why Nova Scotia should have a privacy commissioner of its own. I hope that the Premier and government have recognized that and maybe potentially down the road look at implementing and having a commissioner of our own. With the absence of a commissioner here in the province, can you tell me who is ultimately responsible for maintaining the privacy with this new information system when it comes on-line? Is there one person we can turn to and say, this is the person responsible? Is it the Minister of Health who will be ultimately responsible for this?
MS. DOIRON: I'm not sure if it is appropriate for me to answer that in a sense. I will say that we see it in the department as the responsibility of the department, meaning, I suppose, that would flow up to the minister. But I also see it as a responsibility of management in the department and, more specifically, the management within information
systems to ensure that we have those appropriate systems. I think we are happy to see external reviewers come in and test us on that and that would be something that we invite - we were delighted, for example, to have the Auditor General take a look at that and comment to us.
I believe also that the whole arena of privacy with information technology will continue evolving. We have to stay up to date with that, so I think we're compelled to take that on as a responsibility like we always have done in terms of protecting whatever we need to do relative to policy to protect patient information, period. So protecting patient information, as it relates to technology systems, I think is part of that, but not the only piece of it.
I think it is a departmental requirement. I also however think it is important to recognize that on an increasing basis, we are co-operating across departments in this government to look at the issues related to information systems and technology, and that through Economic Development and sort of a lead role that they're playing in the coordination of some of those issues in the province, that we're a player in that as well. For example, I sit at that BTAC committee table, so we have various approaches right now that are promoting that. I think we have to stay current and vigilant with it.
MADAM CHAIR: Mr. Wilson, you have three more minutes.
MR. DAVID WILSON (Sackville-Cobequid): I think you have left it wide open to include yourself in having some responsibility with this. I hope that down the road we will never have to question, we told you so, when it relates to this important issue.
Mr. Pagani mentioned - and we did receive the information that you sent prior to the meeting, which we appreciated - about the privacy committee that you had. It lists the stakeholders who are represented there and it goes through many of them. One of the departments I don't see on this is the Freedom of Information Office, or the officer, Mr. Darce Fardy. Was this department or Mr. Fardy ever considered to be an important person to have maybe on this committee, where he does deal with what you could call privacy issues about information being released, especially when it's dealing with government? Was his name or that department ever looked at to maybe be on this privacy committee?
MR. PAGANI: In the department we have a FOIPOP section that works with the privacy components, we have a manager, and those folks are involved in that process. At the appropriate time they would have consulted with those folks.
MR. DAVID WILSON (Sackville-Cobequid): I know I have probably a minute or so left. The only other burning question that I think I've had through this whole process, and I know the member for Glace Bay had mentioned it, about having a system for the hospitals throughout our province, it's not the same system as the QE II or the IWK. Why did we not
go with the system that they use? Here we have the tertiary care hospital for our province, those most serious patients that we see in Yarmouth, in Sydney, in Antigonish, will end up in the Capital District Health Authority. Why did we not go with the system they had in place? Would it not be cost-effective to do that and have the same system that the QE II has, where they do take in those most serious patients not only in the province, but in Atlantic Canada? Could you comment on that?
MS. DOIRON: Given that one of the requirements that we had in the design phase of this or the initial phases was that at the end of the day we had to have a system that was interoperable across the entire province. Given that that is the reality, then I think the consideration that was taking place initially that involved all of the districts, including Capital Health, tried to make the best judgments they could in how we could progress through the province in the most cost-efficient way, in a manner that would allow the best integrated system to result, so consideration was given to that.
I believe that some of the systems that they have at Capital Health have been put in place because they have a different level, to some extent, of complexity, they also have different factors to consider relative to a lot of the teaching responsibilities that occur and some of the impacts there around work that they've been doing and research and so on. Having already gone down that road for best of breed and having been as advanced as they were within it, that was the difficult call to make, do you change all that?
The systems that they had, probably at the end of the day, were not the systems that maybe needed to be in all of the smaller districts. Maybe that's a bit of an intro but Dieter was at the table for that kind of discussion so I will defer again to Dieter.
MR. PAGANI: I think it is a very complex issue in terms of that selection process and how you look at that. One of the key items is a best-of-breed environment. Basically a lab component would be put in place to best fit the lab requirement. The approach we took is we wanted to have an integrated system where data can be exchanged easily between the components in a hospital. How does a lab test get ordered? How does it flow to the lab? How are the results coming back? The more integrated that process is the easier it is for those folks who have to use the system. We moved forward on that basis.
I think the deputy was right in saying that we address hospitals from small to fairly large size, Cape Breton being the largest in the system we have, but we also have smaller hospitals. Some of those other systems would be plain overkill, it's as simple as that. But nevertheless, I think, we looked at it and the cost we figured to bring it all in line would have been prohibitive. The main reason Capital District is where they're at is they have been at it for a lot longer than we have. The regions have not had the opportunity to move forward
in terms of informatics like the Capital District did, so we're just catching up to them, basically.
MADAM CHAIR: The time has expired for the NDP caucus.
The honourable member for Preston.
MR. KEITH COLWELL: We have been talking a lot about details on how this system is going to work and I can tell you, I'm not in a position to question how it's going to work and I don't want to get into that. I don't think any of us here are capable of doing that and probably even yourselves, you have to leave it to the people who do that work, to resolve the little problems that always come up with a new system that is in place.
I have some serious problems with this. This was a non-tendered, go-ahead-forever project, literally go ahead forever where the company has dictated to the government they must buy this kind of computer, you must do this, you must do that. You've estimated a $60 million budget but yet you say there are going to be implementation costs, there are going to be ongoing maintenance costs and all the other things that go with us.
My guesstimate is - and I've worked a lot in computer integration systems and I've been one of the people in the province who pushed and pushed for computerization both in business and in government, and I'm fully in favour of it, don't get me wrong. I think it's a wonderful thing if it's done right, it's done on time and with people who can make it happen. Sometimes you buy programs and the people you have on-site just aren't capable of resolving the little glitches that you've been talking about. Then you have the issue of data point entry, that is continually a problem, no matter what you do, where you work, what the project is, with data entry.
I worked with some very large companies that are completely computer integrated, absolutely, totally computer integrated that actually when you do these things properly it means you reduce the administration costs, you reduce staff in administration, if it's done properly; if it's not done properly it doesn't, it increases costs. It sounds like it's going to increase costs, so there seems to be some little problem here with what's going on, an open-end book and the whole thing. Without a tender I can't imagine why you would award it, and I'm not saying the company it was awarded to isn't probably the best in the field, I have no expertise in that field so I don't want to insinuate that or say that, but without a tender to compare it with. The IWK and Capital Health's system that has already been mentioned here by more than one member, one of our members indicated that they're not going to use this system, they're going to integrate with it.
I can tell you that I have seen integration with different systems and they don't always work great, there are little tiny glitches. When you're dealing with someone's life, with a doctor who has to make a decision based on the information he has and hopefully, it's the
best possible information he can get, if one of those little glitches gets in there, someone could lose their life, someone could have some serious problems that could lead to lawsuits, there could be all kinds of problems that would go from this.
So I'm very disappointed with the way this was tendered. I realize you got a lump of money at the last minute and had to move forward, and you had to spend the money in that year. I think that was poor planning on the part of government, period, nothing to do with the Department of Health but you should have been aware a lot earlier than that that this possibility could come, and get prepared for it. I know you have done a lot of work and a lot of research.
I'm really nervous about the whole thing. I'm fully in favour of computerization, it does save costs, it makes information handling very easy and very accurate. I know my own family doctor has a system that goes on-line immediately and orders prescriptions and everything else, but he's not tied into this system, which hopefully someday he will be which will make that a lot easier too.
Confidentiality. There was a statement made here that there are protocols put in place where you have to get authorization from the Department of Health for even the designer of the system to go in and change the system. That's a good thing but the reality is, anyone who designs a system can get in anytime they want, any way they want, or else they're not very good at what they're doing, quite honestly. We should be aware of that.
I know a lot of the firewalls don't work effectively. There are people out there who have the ability to crack into these systems very easily and there are actually people employed by the federal government to do exactly that, for security reasons. They wouldn't be interested in patient information, that's for sure.
I don't know how you explain it because I don't think you'll ever give an explanation satisfactory to me, maybe even to the people of Nova Scotia, and I'm not sure the Auditor General is totally happy with the way that this purchasing was done. This is a multi-year contract worth millions of dollars, you're tied into a hardware supplier that your software supplier says you have to use - and in today's technology, that doesn't really seem to be necessary anymore, so they have one or two operating systems, that's it, so that gets very expensive to the point that I'd like to be the computer company supplying these computers, if I was in business, and I'm not, but that would be quite a lucrative business for me I would think.
How do you justify all of this? I'm guesstimating, based on the experience I've had dealing with computerization, not at this level that you're dealing with, but at levels quite similar to it in other large companies that I've worked with. How can you justify going out and buying, on a public purse, a project that you have already admitted is going to be $60 million with extra costs on top of that already that you're aware of? I can guarantee with the
implementation and the integration between the IWK, the central health system and Meditech, there are probably going to be some problems that arise that are going to be quite difficult to handle, and you've already indicated some with the teaching and the other things with research they have to do, and that's all justified.
Why wasn't more time put into this? You can justify it by saying, we only had the $30 million come up all of a sudden, bang, we had to do it. How can you really justify this? Did you really, really have a firm number? I would suggest that the answer is probably no, for the next 10 years, what this thing is going cost, on what this is going to be. I'd like to get a short answer, not a real long one.
MS. DOIRON: Okay, the short answer to a long speech. I think the tender process or the review of that has to include all the work that was done when the districts were out there as regions, because the work was all done during that and the whole province was involved in that work. When we brought them to the table to say, we actually are now going to do something, with many of the same people at the table to say, you have been through this process and we now need to kind of design, what is the next step that we can take to get this moved on, there was a review of that material. In consultation with the districts and the department, some decisions were made about what were those next steps that we needed to ensure we could move forward on the good review work that had occurred, but also take a look at the best pricing at the time that we could get.
While there may be some questions about maybe having gone back out to tender, I think with the anxiety and eagerness that we had to provide some of these support systems to the organizations, repeating it within that go-forward time frame did not seem to be at anybody's mind, an issue. In fact, it did comply with the procurement processes of the province because we ensured that actually had taken place.
So while I guess we can have different opinions on that, we feel that with the accumulation of the work that was done over a period of a couple of years, that effectively that review was probably done as well as it could have been and it actually then cut back on the amount of time that it would take to start moving things forward. That's one of the issues you raised.
Second issue, in terms of the cost savings that you hope for from these kinds of systems, in certain areas when you implement systems there are definitely cost savings, but generally that is not in a health care kind of an environment. There may be pieces of the health care environment that are usually more of the support type services where you can accomplish that.
I know in my own history where we have introduced certain kinds of clerical systems, where at times we have introduced maybe food service systems or other things that are supportive to support services, that we have been able to gain some efficiencies. Even where
we, in the past, have introduced a public health system, because public health must record, by hand, all the kinds of things that take place around immunization and all those work things that they do, usually that's done by the nurses. If, in fact, they had a system that could do that, it frees up a lot of that nursing time, so I've seen that occur.
For the most part, the kind of work that is done in the health care system is the care-giving work. So what the system does is not replace that, what the system does is enable the people who are actually out there doing that bedside work, it enables them to do their work more efficiently, better and safer.
I know the third point you referred to is to look at the error part of this and the potential danger that there is. Certainly, there's a whole body of research at this point in time that has followed that very topic in health care. In fact, when you put in systems, while you can always have a system glitch, and nobody is denying that those things can occur, but the danger in terms of safety is much, much less in the computerized environment than it has been in the environment where everything was done manually or by hand.
The human error side of that, the changes in the transcribing of information by hand on medication dosages or other factors such as that can lead to errors in the health care system that, in fact, are not completely but almost completely eliminated with computerization. So those would be my answers to the topics you bring.
MADAM CHAIR: One more minute for the Liberal caucus.
MR. COLWELL: My colleague.
MADAM CHAIR: The honourable member for Glace Bay.
MR. DAVID WILSON (Glace Bay): In the very brief time that we have I just wanted to raise this issue. On May 26, 2004, this committee had an appearance by Dr. Tom Ward, the former Deputy Minister of Health. At that time one of the things a member of our caucus asked for was - Dr. Ward mentioned there were external firms or experts brought in to do a review of costing and to review plans that were done with regard to the Nova Scotia Hospital Information System - a total figure of the amount that was spent on external consultants and that sort of thing. As of yet we have never received that information, so I'm requesting again of you, Deputy Minister, to provide us please with that information as soon as possible.
MS. DOIRON: I'm going to turn to Allan to see if he might be able to give you some of that information at this point, but we'll make sure that we do also take it back to review it to ensure we've been as comprehensive as we can be.
MADAM CHAIR: Mr. Horsburgh.
MR. ALLAN HORSBURGH: I have a document I can table here which shows the consultants engaged over a four-year period and the cost per year. I will take that back and have Dieter take a look to make sure it's accurate, as he has the content knowledge, but we can table that over the four years.
MADAM CHAIR: Thank you. You can provide that to the clerk.
MR. DAVID WILSON (Glace Bay): That will be tabled here today?
MADAM CHAIR: Yes, that's right. Yes, please proceed.
MR. HORSBURGH: Roughly there were over a dozen firms engaged. In 2001, roughly $632,000; in 2002-03, $1.8 million; 2003-04, $1.2 million; and in 2004-05, almost $1.3 million. I'll table this sheet here today.
MADAM CHAIR: Thank you. The time for the Liberal caucus has expired. We will now go to the government caucus.
The honourable member for Waverley-Fall River-Beaver Bank.
MR. GARY HINES: Last week this committee was afforded the privilege of having a wonderful presentation again by Ms. Morash, it's always very comprehensive, thought-provoking and informative. In that conversation and all through that conversation the Auditor General's department showered praise on the Government of Nova Scotia and your department in particular for having the foresight to proceed with this project.
That being said, there are some who seem to believe or seem to live in a vacuum when it comes to understanding that implementation of a program can have increased costs. I personally believe, and I think the people of Nova Scotia believe, that the front-line health care workers who are the recipients of new programs are the best people available to add content to the discussion on what might be needed to enhance the programs.
I heard my colleagues opposite shower praise on the front-line health care workers and the work they have done regarding this, but they're living in a vacuum if they think that the suggestion they make in coming forward can be recognized and adhered to in terms of providing new equipment or the new direction you need to take for the implementation of a perfect program.
That being said, I guess my question to you, realizing that most of the conversation to date has focused on cost, but there has been no opportunity to recognize the achievements of the project to date. Now I understand the vast majority of the project members are front-line health care workers. They are investing a lot of energy and expertise into making this as successful as possible, there have been growing pains. Who has been involved and what approach has been taken to involve those who will be using the system in the decision-making process?
MS. DOIRON: I'll again make a brief statement and ask Dieter to go into more detail because in every section of where there has been implementation of a component of the system, there has been front-line user committee involvement. Maybe Dieter could expand on that a bit.
MADAM CHAIR: Mr. Pagani.
MR. PAGANI: Yes, I think right from the outset we recognized very early on that what we were doing was implementing a system that has to be used by people out in the field on the front lines. I think in another part of the package we gave you is a chart that shows the organizational structure we put in place to help us implement the system. You will see there that we have committees that are made up primarily of front-line folks. So the nursing committee, for example, the physician committee that we have, the working groups and so on, but that isn't where we stopped.
The whole implementation team that we built and put in place consists of staff from the DHAs. So when we implemented the lab system, we used lab technologists from the DHAs, folks who have to work with the system once it's implemented. The collaboration and co-operation we had amongst the different folks has been just great, they picked up on that and they worked together very hard.
Very few actual IT folks were involved in the project to be honest. Most of it was done by folks who have to use the system. We took the recommendations seriously, we applied changes as they requested and the training programs, for example, we developed were also developed by them. So we took it right to the front line and said, you tell us how we're going to do this and you work with us and that has worked.
MADAM CHAIR: Ms. Doiron.
MS. DOIRON: I would just add to that that Meditech also has a Meditech user advisory group and they meet on a regular basis. On an annual basis they have an international experience where they bring people together to look at the improvements that can be made generally to the Meditech system, but they also do user conferences and they have, I think, four or five of those across North America; they have them in the United States and they have them in Canada. Eastern Canada, which was from Ontario to the East Coast,
that conference, MUSE - Medicare Users Software Exchange - they were here in Halifax having their conference within the last two weeks.
I had the opportunity to go and address that group and based on that, I also know that many of the front-end users get to that conference, it's not all the technological people, it's also the people using the system because they have so much to offer to say how Meditech can actually improve the overall system. So through the work we're doing and the work they're doing, there's a fair bit of input from the front-line users.
MR. HINES: What are you hearing from the district health authorities, the people managing the health care system at the community level? What are they saying to you? Are they eager to see the system up and running and are they eager to see their thoughts and suggestions that will improve the system implemented, knowing that there are increased costs?
MS. DOIRON: Certainly at the district level for the system that, of course, is going to be available in the hospital there is a tremendous response from the districts of great satisfaction and basically they're very happy with the systems that are now in place. The last two organizations that are coming up to speed, Southwest Nova being the last, I was talking with them within the last week, and they are very delighted that they now have much of the system in place and will be completed soon. We haven't had any negative response, it has all been positive.
What we are hearing in terms of push is about other systems. For example, we're looking as well at the systems that are out in the community. We have, for example, introduced the interRAI tool which is the assessment tool for people going into home care or long-term care. That is done with the care coordinators doing those assessments, carrying their laptops, taking them and doing the assessments, we're building a whole body of information that has been very helpful in terms of planning for long-term care, for example, and home care.
What we don't have is, there is one set of those tools that can be used in nursing homes themselves. We tested it for nursing homes and they were very happy with it. We were able to sustain it in those homes following the pilot but we haven't yet had the dollars or been able to make it a priority to roll that out through all of the nursing homes, and they're just itching to get that.
We also know that on an increasing basis, the doctors are coming up to the plate and wanting to have information systems in their offices. We're making good progress with that through the primary health care approach, but there is more work and obviously there will be some more costs there depending on who assumes the cost.
So we have a whole other suite of systems that we're working to move forward as well, so that we can have the totally integrated system across both the hospital and community.
MR. HINES: Do you believe it's a fair statement to say that the proponents or providers of this system have been handed, forever and a day, a project that they can contribute to reap benefits from? My suggestion would be that apart from the decision making to award the contract to a specific proponent, regardless of who the proponent was, would that not be an ongoing opportunity for them to sell their product and so on? It's a bit of a moot point to suggest that if there's a problem with the way the process is done that it's a continuing problem, because would not whoever got the project be the one providing the service and implementation of new products?
MS. DOIRON: I guess that would be a fair statement. Although, having said that, of course, we know that this particular company that provides this particular product is not a fly-by-night, we know that it has been out there for a number of years, we know that there has been a great deal of satisfaction with their integrated system in many environments. So there is reasonable expectation to think they will be able to continue that. The experience that people have had with them in many other jurisdictions would support the fact that they tend to come to the table and provide the supports and enhancements that are required.
MR. HINES: Thank you.
MADAM CHAIR: Mr. DeWolfe.
MR. JAMES DEWOLFE: Welcome back. Deputy, I have listened to all of the comments here today and it seems that, in my mind, this is a very good-news story; it's good news for those served by our health care system. I assume that the system will save lives and it will help with patient diagnosis. For example, it will prevent drug prescription conflicts and hopefully reactions and it will also make it, I would think, easier for patients to move through the system.
I guess the bottom line is, my colleague to my left was concerned with how we justify this, and I think these questions will answer that. Will the system make the health care system better, I guess, is the first question? I assume it will. But will the system save lives? In my mind, that is the bottom line.
MS. DOIRON: Yes, we believe that - and I think there's good evidence to support - putting in systems of this type actually does enhance the safety for individuals. Putting in systems of this type actually does decrease the amount of duplication in terms of testing and so on that is done in the system. Systems of this type increase the potential for access, not only to the primary area where the person makes their first contact with the system, but it facilitates the access and flow of information in and out of areas where there are
consultations taking place within the same locale, or anywhere in this province. Basically, a system like this leads to a bit of a transformation in terms of how people work.
The system also provides the basis to support the kind of work that must take place in the health care environment in order to step up to the plate and analyze data, information and to be accountable for what's happening both in clinical and financial areas. Without the systems that's very difficult to do.
MR. DEWOLFE: We're getting a full-fledged IT system at a fair and reasonable price and it's going to save lives, that is the bottom line. You can't put a price on a human life. Has the government gotten a good deal?
MS. DOIRON: I believe that we have achieved an effective implementation which is almost complete in a very effective way. I think that it is the right deal for this province. We are really quite happy with the way it has gone.
Much of the consulting fees that you heard about were purposely built in there because we made sure as we went down this road that while we had the supplier, and that was fine, we also contracted project management to make sure that those two pieces were independent. We had people on a project management basis who were very up to date with this kind of work, who were able to kind of be our overseers working with us, who were answerable to our steering committee. Where you see cases where the supplier of the equipment software and so on is also the project implementer, there are more often problems with the way things get implemented, but in our case this was done and I think it proved to be quite effective.
MADAM CHAIR: The time for questions has expired. I would like to ask one short snapper though.
When I was first elected there was a unit inside the Department of Health with two or three staff members whose job it was to write programs, design programs and they worked in the hospitals. I'm wondering if this unit still exists and have they been involved in the program?
MS. DOIRON: I'm going to defer this to Dieter.
MR. PAGANI: Yes, actually, they are still involved in the program. Their main responsibility was to maintain a system called the PASS system, that was the tool that some of the hospitals used out in the field to register patients. One of the most critical pieces that we had to do was to bring the data over from the previous system to the new system. We engaged those folks to actually work with us to make that happen and that has become a very smooth process, it goes quickly, and that makes sure that we have the right patients on file
for all of those. They are still with us, and these positions will depend on the rest of the project and where we go from here.
MADAM CHAIR: Thank you. At this time we will give the deputy a minute to wrap up.
MS. DOIRON: Actually, I don't have a lot to say. I appreciate the fact that you've invited us to clarify some things in this particular initiative because I think for a period of time there was a lot of confusion about what the actual costs were. We, I think, were under, at least, some umbrella of concern as to whether this had been done effectively. I think that with the diligence that we have put into this and reviewing our own approach to it, we're comfortable that we have done what we think is the right and best thing to do for the province in this regard.
I certainly want to compliment all of the districts, the CEOs and their staff, because it is very atypical to be able to get that level of provincial co-operation, we've actually had that co-operation. Even smaller provinces than ours, while they might be doing good things, do not have that level of provincial co-operation which leads us to very natural outcomes such as provincial technical support, provincial help desk and things of that nature, which actually are extremely cost efficient, and allow us to build that body of knowledgeable people at a provincial level, where if we dispersed it at a district level would not really bring together that synergy that those folks working together can get.
I think that while we don't want to pat ourselves on the back too much, I think this particular system development and implementation has gone quite well, given what people tried to accomplish. I'm sure there will be issues as we continue and I'm sure as we continue down the road with other systems we're going to have challenges. What I want to suggest, I guess, to this committee and to the public is that we will attempt to do every part of due diligence that we can to ensure that the way we work these kinds of information systems and technology is done in the best, most efficient, safe and effective way for service to the public. Thank you.
MADAM CHAIR: Thank you very much and thank you for being here today. (Interruption) Mr. Colwell.
MR. COLWELL: I'd just like to put a motion on the floor that the Department of Health supply us with all costs associated with this project, including: consulting and implementation costs; ongoing yearly costs, including internal staff; ongoing system costs from program; original contract costs; hardware costs; and all integrated costs associated with the program, both soft and hard, now and into the future. I so move.
MR. DEWOLFE: Madam Chair, on a point of order. We don't need a motion for that, we can just request that as the Public Accounts Committee. I don't think it needs to go through a formal motion process.
MADAM CHAIR: Actually, I was going to ask the deputy if that information could be provided to the committee.
MS. DOIRON: We would be quite happy to provide the information broken out the way it has been requested. The only caveat I would add to that is that while we can project some future costs at this point, if there's a record kept of this statement that it's all costs now and into the future, forever, I think that's a very difficult request to make of anybody. So we will do the projection of what we know is going to happen to put this into operations and sustained operational dollars that we are going to be putting into the system to ensure that that can move into the future. So with the best projections we can give we'll do future costs, but we will definitely provide all of the other break outs as we have developed.
MADAM CHAIR: Thank you. We'll look forward to getting that information.
Is there a motion to adjourn?
MR. DEWOLFE: I so move, Madam Chair.
MADAM CHAIR: The meeting is adjourned.
[The committee adjourned at 11:03 a.m.]