HANSARD

NOVA SCOTIA HOUSE OF ASSEMBLY

COMMITTEE

ON

PUBLIC ACCOUNTS

Wednesday, March 10, 2010

LEGISLATIVE CHAMBER

Electronic Health Records

Printed and Published by Nova Scotia Hansard Reporting Services

PUBLIC ACCOUNTS COMMITTEE

Ms. Diana Whalen (Chairman)

Mr. Leonard Preyra (Vice-Chairman)

Mr. Clarrie MacKinnon

Ms. Becky Kent

Mr. Mat Whynott

Ms. Lenore Zann

Hon. Keith Colwell

Hon. Cecil Clarke

Mr. Chuck Porter

[Mr. Brian Skabar replaced Mr. Clarrie MacKinnon]

[Ms. Pam Birdsall replaced Mr. Mat Whynott]

[Mr. Maurice Smith replaced Ms. Lenore Zann]

[Mr. Allan MacMaster replaced Hon. Cecil Clarke]

WITNESSES

Department of Health

Mr. Kevin McNamara, Deputy Minister

Ms. Sandra Cascadden, Chief Information Officer

Ms. Linda Penny, Chief Financial Officer

In Attendance:

Mrs. Darlene Henry

Legislative Committee Clerk

Ms. Kim Leadley

Legislative Committees Office

Mr. Alan Horgan

Deputy Auditor General

Ms. Evangeline Colman-Sadd

Assistant Auditor General

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HALIFAX, WEDNESDAY, MARCH 10, 2010

STANDING COMMITTEE ON PUBLIC ACCOUNTS

9:00 A.M.

CHAIRMAN

Ms. Diana Whalen

VICE-CHAIRMAN

Mr. Leonard Preyra

MADAM CHAIRMAN: I'd like to call the meeting of the Public Accounts Committee to order. It's just after nine o'clock and we have with us this morning witnesses from the Department of Health and they are here to discuss the electronic health records chapter of the Auditor General's Report. That would be the most recent Auditor General's Report that we just received in February.

I'd like to begin by having the members who are here today on the committee to introduce themselves.

[The committee members and witnesses introduced themselves.]

MADAM CHAIRMAN: Thank you very much. As is our custom, we'd like to begin our meeting this morning with an opening statement from our witnesses.

Just before you begin, I'd like to make note that I will be sharing the Chair today with the Vice-Chairman, Mr. Preyra, so we'll be in and out of the Chair as we go through. Thank you very much and if we could begin with your statement, Mr. McNamara.

[9:04 a.m. Mr. Leonard Preyra took the Chair.]

MR. KEVIN MCNAMARA: Thank you, Madam Chairman. I would like to thank the committee for inviting myself and my colleagues to appear with you this morning.

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I would like to begin by giving the committee members a bit of a context for our discussion today. Nova Scotia has come a long way in a short time when it comes to provincial health initiatives. The IWK and Capital Health have been investing in their own electronic health initiatives since the early 1970s and 1980s for admissions, scheduling and diagnostic imaging. However, as recently as 2002, there were no health information systems outside the Halifax-Dartmouth area.

That changed in 2001 when work began on the implementation of the Nova Scotia Hospital Information System which brought Meditech to 34 hospitals across our province. This enabled admission, discharge and transfer information, as well as laboratory, diagnostic imaging, pharmacy, patient charting, and billing and accounts receivable to be done electronically. That was the beginning of the department's e-health strategy for the provincial health care system. The goal is to implement province-wide, electronic clinical and administrative systems in order to advance the quality, safety and sustainability of health care for Nova Scotians.

Over the ensuing years we have worked closely and in co-operation with Nova Scotia's district health authorities and the IWK, our partners in the Nova Scotia health care system. This partnership has been critical to our success. Together we have made significant progress in establishing robust e-health solutions or information technology systems across the province to better support the delivery of health care to Nova Scotians.

Since 2000, Nova Scotia has invested over $100 million in the e-health system to support better patient care. We have spent $52 million implementing Meditech, which links hospitals and coordinates patient information when in and between hospitals in our province. We've invested $46.5 million in the Health Administrative Systems Project, or HASP, which will enable all of our hospitals to use the same information system for finance, materials management and human resources. We have spent $13 million on our Picture Archiving and Communications System, or PACS, which gives authorized health care providers instant access to results from X-rays, MRIs, CT scans and other diagnostic imaging. We've invested $10.5 million in Secure Health Access Records, or SHARE.

I must also stress our partnership with Canada Health Infoway, which has been critical to many of our current successes and will be an important and necessary factor in our future endeavours. Infoway's more than $55 million contribution to the e-health system in Nova Scotia has been instrumental in moving forward with PACS, SHARE, Telehealth and other projects. Our work in the area of information technology and electronic health records has led to awards, recognition and Canadian firsts.

Nova Scotia was the first province to create a provincial program to deliver laboratory and diagnostic imaging results electronically. Today we have PACS which is an entirely digital system. PACS has won national awards for service delivery to citizens and businesses, a Project Implementation Team of the Year award and an award of excellence

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for organizational transformation. Our Primary Healthcare Information Management project, known as PHIM, has also won a national award.

In November of last year, Nova Scotia introduced MedicAlert Access-En Route, the first system in Canada to enable paramedics to access the MedicAlert emergency health records of patients from ambulances while en route to hospitals.

Over the past decade we've had successes, challenges and yes, the occasional stumble. We have learned from these experiences and continue to work to ensure patient safety. We have also had some challenges with the final implementation of the HASP project. They have put us a little behind schedule in one of our district health authorities. HASP is a big, complex project and we're taking the time to make sure it's done right, but we are moving forward to complete our goal and expect to be completed by this April.

Inevitably, some people might say that $46.4 million seems like a lot of money to spend for information systems for finance, materials management and human resources. I would argue that our investment in HASP is money well spent. It's about ensuring that we properly manage the $3.4 billion invested annually in our health care system.

Most recently electronic health records was one of the focuses of the Auditor General's Report. He raised some concerns regarding the privacy and security of personal health information contained in SHARE. We agree with the Auditor General's eight recommendations and are working hard to implement suggested changes and some of them are already underway or complete.

Our department is most appreciative of the Auditor General's insights and of his office's efforts to understand our operations. The Auditor General also voiced concerns about primary care physician records, also known as electronic medical records, not being part of the SHARE system at this time. The department, like the Auditor General, recognizes the importance of electronic medical records being added to our SHARE program. As well, we recognize the necessity of continued Canada Health Infoway funding in order to achieve that goal.

Before I leave the Auditor General's Report I would note that the Auditor General made a point of saying that the SHARE project is being well planned and well managed by our department. The Auditor General also noted we are in compliance with government policy on procurement and recognize the actively considered value for money when we make purchases.

In closing, our investments in information technology and electronic health records initiatives are about patient safety and patient care. E-health requires ongoing and long-term investment as there are many more e-health systems that need to be implemented. We have made great strides since 2000, there's still more work to be done, including making

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electronic medical records accessible through SHARE and encouraging greater physician participation in electronic medical records, a provincial drug information system which would provide health care professionals with access to comprehensive patient medication profiles at the point of care.

Again, thank you for inviting us to appear before you today. We look forward to answering your questions on this issue. Thank you.

MR. CHAIRMAN: Thank you, Mr. MacNamara, for a very brief and comprehensive overview of this very important area. We're going to begin with 20 minutes of questions from the Liberal Party. The time is 9:11 a.m.

Ms. Whalen.

MS. DIANA WHALEN: Thank you, Mr. Chairman. Welcome, again, this morning. We are very appreciative to have you here and to be able to just drill down and get some more depth on what is really quite a complex area. I have to say the IT area of all of government is complex, large and very specialized and I don't think any of us here are real experts, but we want to be able to do our job which is to find out how the money is being spent, whether we're getting our value for money and just how we're going in terms of timelines.

I wanted to begin by recognizing that in the Auditor General's Report you had accepted the recommendations made and certainly just as an overview the report was fairly favourable, there were many positive things said about this particular project, the SHARE project. It's also worth noting that this was being done as a joint audit with other provinces at the same time, so we may have a chance to look a little bit in my questioning about how we shape up in comparison to other provinces in Canada.

Part of, I think, what might have been behind the audit at this point in time was the problems that had arisen in Ontario regarding electronic health records and the way that they ran into some significant problems there. I have no doubt that had something to do with us having a look at an audit across Canada at that time. Certainly, here, we didn't have that problem, it was found that our procurement was all correct and no difficulties were noted, so I think it's really important that we note that we did not have that problem.

My first question though, just going to that, was at the time that the Ontario problems were noted they certainly were very profound and there was a funding change at the time. My understanding is the federal government held off for a period of time with some of their funding. There was a figure of $500 million that was supposed to be added in the federal budget in the Spring of 2009, for patient health records. I'm wondering if you could confirm whether or not the electronic health record project was in any way on hold as a result of problems in Ontario.

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MR. MCNAMARA: There was no impact from the holding back of the $500 million on our ability to move forward. As you may be aware the recent federal budget did put the $500 million back into it, so hopefully we'll be able to access it for other projects.

MS. WHALEN: So that money is now available to us, our share of it at least will be coming to Nova Scotia and you'll be able to address other priorities within the IT area. Is that right?

MR. MCNAMARA: That is correct. We have at the present time approval from or had approval for some money toward the drug information system which was already approved. Secondly, when we make submissions now to Canada Health Infoway, that $500 million is available to us and other provinces to access.

MS. WHALEN: Can you tell me what share would be ours of the $500 million? Is there a cap on it or is it based on whether we have the best ideas and are ready to move?

MR. MCNAMARA: I'll ask Sandra to reply to that because she's our main focal person dealing with Canada Health Infoway.

MR. CHAIRMAN: Ms. Cascadden.

MS. SANDRA CASCADDEN: The way Canada Health Infoway works is they define the projects and initiatives that they are going to fund. With this new $500 million, they had previously defined categories for funding which was more funding for the electronic health record, new funding for the electronic medical record which is really a medical record inside a GP's office, is kind of the easy way to distinguish those two, and then they are potentially looking at other funding envelopes. We have to compete for that money with other jurisdictions.

What Infoway has done in the past is they have set aside certain amounts of money for each jurisdiction so it is equally spread across the country. They will continue to do that in some of the funding envelopes, but others they'll have to do on a first-come, first-served basis, which means Nova Scotia really has to be up front and able to position itself to take advantage of that money early on. We have a great opportunity to do that with our investments and our current program around the electronic medical record.

[9:15 a.m.]

MS. WHALEN: Okay, that's very good. You mentioned that we had a project previously approved, or at least the deputy minister mentioned that. I'm wondering if you could tell me, is that one ready to be submitted? It was approved, I think, internally, if I'm not mistaken, you had it approved.

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MR. MCNAMARA: I'll respond to that. We made a submission to Canada Health Infoway. We did get approval on funding towards the drug information system and we're working our way through our existing process to see if we can get approval from a provincial basis.

MS. WHALEN: So you need approval internally, is that right?

MR. MCNAMARA: That's correct.

MS. WHALEN: Okay, so it's the internal approval. Okay, very good. That was just the little bit of housekeeping I wanted to do around the federal budget and federal monies. I'd like to return now, if I could, to the Auditor General's Report and just look at the financial side of that as well.

In the report on Page 13 it said that the cost is being shared between the province and Canada Health Infoway, which is a federal agency or body, and that the split of the money is $9.1 million and $19.2 million, so the federal government or Canada Health Infoway giving twice as much. What I'd like to know is if we could compare that to the 2009-10 budget that we have here in Nova Scotia, there's a line item called Information Technology Initiatives and it is $38.4 million, so it says in our 2009-10 budget that we've allocated $38.4 million for Information Technology Initiatives.

What I'd like to know is, is the $9.1 million for our electronic health records in that global figure of $38.4 million?

MR. MCNAMARA: Perhaps you could clarify the question for us.

MS. WHALEN: Okay, I'll just go through it again. What I'm doing is looking at the budget for SHARE, what we're talking about here, to what shows up in our estimates, in the budget we have for the province, the whole province. In the Health budget there's a line item called Information Technology Initiatives and it shows as $38.4 million. I just wanted to know, is the $9.1 million, our provincial share of the electronic health record, part of that? Then I want to find out what else is in that, so I'm looking into what is the $38.4 million.

MR. MCNAMARA: I'll ask Sandra to reply.

MR. CHAIRMAN: Ms. Cascadden.

MS. CASCADDEN: The overall number would include all of the projects that we're doing from an e-health perspective, so the number associated with SHARE is just the financial number associated with that one project.

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At any given time we could be running four, five or six projects. The larger number of the $38 million would encompass all of those initiatives, plus our operating expenses associated with once we have a system live, what it would cost to maintain that system on a go-forward basis.

MS. WHALEN: So essentially the maintenance of the systems is part of that as well. Could you, even in a broad way, tell me how much is maintenance and how much is new initiatives? Is it 60-40, 50-50?

MS. CASCADDEN: It's probably around 50-50 at this point.

MS. WHALEN: Okay, because about $29.3 million is the difference between the SHARE amount of $9.1 million, so that gives us a little idea.

Is there any particular project, and I know you've given us a chart of the different IT projects, is there any one in particular that's taking the lion's share of the new initiatives money in this year's budget?

MS. CASCADDEN: No, I don't believe that there's any taking the lion's share. The two major projects are the electronic health record as well as the HASP project and those are the two main projects. We run other smaller projects and some of those projects are actually not in the implementation stage but they could be in planning stage. When a project is in the planning stage it requires a fairly small amount of money to do planning versus implementation. So we could be planning for the drug information system, not implementing it, so planning could be a lower amount of money than, of course, the implementation of it.

MS. WHALEN: Thank you very much. I'd like to go to some questions around the timeline for the SHARE project. It was indicated in the Auditor General's Report that the SHARE project will be completed within its budget but not necessarily on time. A date of March 2010 was suggested as the time that it would be completed, at least that was what was thought initially. Could you let me know when it might be completed and where we're at in the timeline?

MS. CASCADDEN: The SHARE project, we had an original target date to complete in March. At this time we're looking to complete this phase of the SHARE project in the June time frame.

One of the things that impacted the timelines was the H1N1 because we really need to work very closely with the district health authorities and we need to have the district health authorities contribute to the overall build of the system because we need to make sure that it's going to work for them and work for the physicians providing health care.

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Of course, during the H1N1, people's time and effort was focused on that, so that put a big gap inside the project. That was really the main timeline impact on that initiative, was really the H1N1 during the Fall period because we just couldn't have - we didn't have access to folks.

MS. WHALEN: Thank you. In the same vein, I wondered if you could say at this point in time if we're able to have any patient records and I think we're looking at more like the physician records. Are they able to be shared yet on this system?

MS. CASCADDEN: In order to answer this question I just have to provide a little bit of background on that. The electronic health record is an overarching health record picking information out of multiple systems in the province. We have islands of information located in various hospital-based systems, for example, so we have three lab systems in the province, we have three admissions systems. We need to pull all of that information together so that we provide a single-patient view for clinicians, so regardless of where you have received or you've had lab tests, if a physician is sitting in Halifax they can see your lab test that you may have had in Cape Breton, in Yarmouth, in Halifax, in Dartmouth.

The overall scope of the electronic health record was determined by a number of parties. One, Canada Health Infoway, which is a fairly significant funder to the electronic health record, determined what should be in the scope of the electronic health record in the first round. In addition to Canada Health Infoway requesting certain things be in the electronic health record, we also went out and worked with our clinicians and we said, of all of the pieces of information that are available in the health system, what are the key pieces of information you'd like to see in the electronic health record in Phase I?

To say that the electronic health record will be over or finished, we're really only in Phase I of a multi-phase process of moving information into the electronic health record. So in our first phase, which we're in now, our clinicians said to us that one of the most important things to know is where the patient has been in the province - so have they been visiting Cape Breton, have they been visiting Yarmouth, have they been in the Valley? So we are pulling that information in. The other thing we're pulling in is information from the lab systems. So we actually followed the guidance of our providers about what information we put in the system.

In round two, we will start looking at the information in the electronic medical records.

MS. WHALEN: A quick question on that would be, how much more is left to be done? At the end of this phase, are we 10 per cent complete or 25 per cent complete?

MS. CASCADDEN: The way I answer that question is we will never be complete because we're going to continue to add more electronic information systems. As we move

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across the province we'll roll out EKG systems, for example, we don't have them in electronic format. Once they're in electronic format we'll move them into the electronic health record.

MS. WHALEN: There's a diagram, Ms. Cascadden, in the Auditor General's Report that shows all the circles and all the different things that have to come in. That, to me, would be the complete picture. So it has to end at some point when you've got all of those pieces linked in. I would like to suggest that there would be an end if we did all of those elements, all of those components that are shown in that diagram, would that be correct?

MS. CASCADDEN: In that diagram, yes, as it's represented by the different areas of the health system. Inside those areas we may be adding more electronic systems that we have to interface. So from a business perspective, yes.

MS. WHALEN: My time is getting a little short so I'm going to go, if I could, perhaps back to Mr. McNamara. I wanted to ask about the legislation that was brought here in the Fall of 2009. I'm just wondering if any of the delay at this point in time is related to the need for legislation or whether there are some issues that need to be clarified before you do go live with this around the legislation.

MR. MCNAMARA: No, there's no impact that I'm aware of.

MS. WHALEN: I think I'm right in saying it's really to do with privacy and security of the information in that legislation.

MR. MCNAMARA: That is correct.

MS. WHALEN: Very good - well, that's a good one. Also in the Auditor General's Report there was talk about the budget not needing to be increased but that there were changes to the project. Could you indicate whether those changes were changes in the scope in some way to stay within budget? Were they some kind of limitation to the project as you originally envisioned it, in order to stay within that budget?

MR. MCNAMARA: I'm going to ask Sandra to reply to that as well.

MS. CASCADDEN: Within the project - we actually planned the project over three years ago, so once you get into the project you realize you may need to do things that you didn't think you needed to do and not do things that you thought you needed to do. So the change in the budget can result in both of those types of activities.

There are things that we said we needed to invest in that ended up costing us more money because it took a longer time frame and was much more complex than we envisioned. For example, getting lab information in a consistent way, it turned out to be much more

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complex so we had to invest more money in that area. At the same time, we found that there were other areas that weren't as complex as we envisioned, which means we had to invest less resources, so that's the balancing that we have.

MS. WHALEN: Was there any particular element that might have been scaled back that would mean we're not getting as good a product at the end of the day?

MS. CASCADDEN: No, absolutely not. We have not compromised the scope and the deliverable of this project in any way, shape or form.

MS. WHALEN: You've used the right word - "compromise". I wondered if there was any compromise made and that's good to hear that you didn't have to. I mean I realize that sometimes it's a reality that you have to juggle those things.

There's one thing that I wanted to ask again. I have just five minutes left, so in my questioning, on Page 23 of the Report of the Auditor General there was a note about a privacy and security concern with respect to the existing SHARE system. The Auditor General said in the report - it was kind of a vague thing - that I am not able to talk about the nature of that or detail the nature of that in this report. Is that something that you could explain to us today what the concern was?

MS. CASCADDEN: What we do when we embark on any information technology project, whether it's a new project or it's revamping a project, we do something called a privacy impact analysis. In the SHARE project, when we start the project we do a privacy impact analysis on what we think we're going to be delivering because we haven't built it yet. So the privacy impact analysis deals with all of the things that we need to cover.

At the time that the Auditor General came in, that is the level of privacy impact analysis we had completed. Now that we're almost through the build, we go back and reference that privacy impact analysis. So the snapshot in time from the Auditor General was looking at something that was done almost a year ago. We're at a different stage so we've been able to mitigate any of those and address any of those issues that we thought were going to happen when we didn't have the application built yet, so we would never go live with any privacy or security or confidentiality risks associated with the initiative. They absolutely have to be resolved before we go live.

MS. WHALEN: Is there some reason why the Auditor General didn't want to detail that in the report? Is it because it's immaterial or is it because it was sensitive in some way?

MS. CASCADDEN: Most of the time it is because it's sensitive in some way. You don't want to disclose it in such a way that people would say, oh, isn't that interesting, let's go and see if we can break the system.

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MS. WHALEN: So that might have been it, I mean without asking you to detail what the weakness might have been?

MS. CASCADDEN: Yes. Usually in the information technology area when there is any sort of breach of security in particular, the industry doesn't say, oh well, our servers aren't working and all of the passwords don't work today, and broadcast that in a large way.

MS. WHALEN: All right, I see. I wonder, just in the couple of minutes I have left, if I could ask you a little bit about the recommendation that a formal IT strategic plan is needed. In the absence of that formal plan for the Department of Health, could you give me an idea - and I think this might be for Mr. McNamara - about how decisions have been made up to now about which projects to begin with, because you don't have a sort of strategic plan that lays it out?

MR. MCNAMARA: Well, again, my tenure with the department started in July so I can't speak for the previous deputy but I can say since I've been in, what we're working on right now is looking at a couple of core - one is dealing with the physician offices and the electronic medical records. Have I the right terminology? Between the HR and the MR I have to think which is which. Secondly, one of the things we're looking at is the drug information system as something we'd like to try to move forward and advance. So those are probably our two key things from a departmental point of view that we are pushing.

[9:30 a.m.]

MS. WHALEN: Do you think there has been a danger about, as the Auditor General said, that the components may not be able to speak to each other because they're being done piecemeal or have been done piecemeal?

MR. MCNAMARA: No, I think we're trying to ensure - well, we are ensuring that they will be able to speak to each other as we work forward.

MS. WHALEN: Okay, that's good to know. Can you point out - I think it's actually a bigger question that I'm getting to on that one. I better not go there just yet.

MR. CHAIRMAN: You have one minute.

MS. WHALEN: Do I have a full minute? That's good. I've wondered about the communication between Capital Health District and the outlying districts. There have been some different systems in place there, can you briefly at least start on that subject?

MR. MCNAMARA: I'll let Sandra start.

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MS. CASCADDEN: In the province we actually have three hospital information systems. We have one at Capital Health, one at the IWK and the other system is across District Health Authorities 1 through 8. It is true that those systems do not talk to each other directly. What we're putting in place is the electronic health record which pulls the information up from each of those individual systems and allows a single view across those systems. The electronic health record is actually doing that integration without actually having to integrate disparate hospital systems, so we are going to have that single-patient view with the electronic health record.

MS. WHALEN: Thank you.

MR. CHAIRMAN: Thank you, Ms. Whalen. Your time is up. We'll move to the Progressive Conservative Party.

Mr. Porter.

[9:31 a.m. Ms. Diana Whalen resumed the Chair.]

MR. CHUCK PORTER: Good morning to you folks, good to have you here today. A very interesting topic and I'm going to bounce around a bit, I have a number of questions. I'll start with the software that we're using. PeopleSoft, I guess is the technology that we're moving forward with at this point in time, is that correct? PeopleSoft, that's not it? What is it called actually?

MS. CASCADDEN: The application we're moving forward with is the SAP application for finance, HR, materials management.

MR. PORTER: Thank you. You talked a few minutes ago about running past the March deadline and you gave a bit of an explanation for that as to H1N1. How did H1N1 affect the IT-based system that's going in? I come from a bit of a background and a former place where IT was a big thing, so I'm picturing how this project was being managed. There would be a certain person/people/department that would be managing H1N1, no question about that, very clear on that. I just don't see how that would have delayed a project because it would have been an entirely different group of people, I would have thought, managing this project.

MR. MCNAMARA: I'll start. There was the issue around H1N1 as well as the issue with negotiations with CUPE which Sandra didn't mention. When we're doing these projects we need the input from the clinical staff. IT is the implementer of the information, so it's getting all the inputs and that's where the issue lies in being able to have access to the appropriate staff. But even IT is involved during the pandemic because they have to provide support in other ways as well.

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We were trying to gather information, for example, to know what was happening across our province in each of the districts. They were trying to come up with systems that - for example, one of the things we were trying to develop is knowing what beds were available and develop a system for an ICU system so we would know which ICU beds might be available anywhere in the province if we needed them. So it incorporated all of our activities.

MR. PORTER: So it's the same people doing this, we're not outside hiring somebody to come in and manage this project totally separate from people we already have on staff, is that what you're saying, Mr. McNamara?

MR. MCNAMARA: We would have people who are working with us in the project office, but we also have inside each of the districts, who are the key partners to making this happen, the same staff that are doing everything.

MR. PORTER: Right, okay. I think that goes back to the strategic plan, perhaps, and H1N1 affected everything, that's for sure. It was an unforeseen, unfortunate thing that came along and nothing anyone could control. I know the province did their very best and managed it quite successfully, I believe, at the end of the day.

I want to go to the records. I do understand and appreciate the comments that were made a few minutes ago with regard to the phases and this is never-ending, technology just continues and it's outdated tomorrow, basically, it moves so quick. Phase I, this seems like a big event, bringing it all into fruition now and bringing it together. We're saying June, are we pretty safe on June? Do you think we're really going to be there in June? We've said March, we haven't made it, you know, H1N1. Again, part of that project plan, coming from a bit of a background where we do that, and strategic plans allow for built-in fudge factors, I guess, for lack of a better term, that says yeah, we're shooting for March but it's a pretty good likelihood it's going to be May, maybe, or June or whatever it might be. I'm kind of interested in, are we going to be on-line?

MR. MCNAMARA: I'd ask Sandra to respond.

MADAM CHAIRMAN: Ms. Cascadden.

MS. CASCADDEN: At this time, we are about 90 per cent confident that we'll make the June time frame. We have many of the components of the electronic health record live and we're actually pulling information into the system. When we go live, we actually want to have about two or three months of information in the system for the providers. We're not going to bring up a system that has absolutely no information, so we're already pulling information into the system.

[Page 14]

MR. PORTER: That kind of leads right into my next question. How much information, how far back are you going? Are you going just months or are you going from today forward, obviously you'll have to add something recent, but how far back do you plan to go?

MS. CASCADDEN: We're going back two months on most of the systems, so as soon as we have the interfaces ready, we actually start moving the information into that large repository for which people will be viewing the information.

MR. PORTER: How did you reach that two month point?

MS. CASCADDEN: We talked with our steering committee group, we've talked with clinicians and we came to the conclusion that we couldn't go back years and put years of information in the system because some of the systems didn't exist over five years ago. We also talked with clinicians and we have a sense of how far back they go in patient charts to look at the history associated with patient care. We came to the conclusion that two months and forward, so it's always a go-forward with something that was acceptable to them.

MR. PORTER: Interesting, two months. I'm just thinking like a health provider again, going back in time in history and things like that. I think of cancer patients and others who have long-term - two months may or may not be adequate, but I guess we'll learn that as we move forward and maybe add as need to certain files.

I want to talk a little bit now about some of the current system and access has been an issue. Ever since I've been on this committee, I don't know how many times we've had different departments in that have dealt with SAP regardless of where it has been. Access to files seems to continually come up in the AG's Report. I'm wondering right now how secure are patients' records by way of access and who has access? I hear stories about people having access that probably shouldn't have access.

At what level - are there levels built and I'm trying to put this question clearly so that you understand it and maybe I'll use an example, does a secretary in any given department have access to patient files? I'll just start with a secretary or administrative assistant, how much access do they have right now? If I were a worker at the hospital in Capital District Health in Hants community, you're in our district, how much access would I have to, say if I knew my brother was in the hospital yesterday and I wanted to see how old brother Tim was doing, can I type in and check him right now?

MR. MCNAMARA: I'll start and then I'll ask Sandra. I go back to my experience at South Shore Health as a CEO. One of the things we did was an audit on who accesses a record - for example, could some individual access a record? Yes they could, but we would find out and if you didn't have authorization then we would deal with that individual through the disciplinary process, whether it was a physician, whether it was a nurse, or a clerk. The

[Page 15]

system and the audit was fairly secure in being able to identify the few cases where it did occur. So can people do it? The answer is yes. Do we have a system in place to be able to check up and audit to see if someone did it? The answer is also yes and then we deal with that.

MR. PORTER: How often is the system, I guess for lack of understanding, is there something that says if I were there and I entered somebody's name, is there something to say, is there a random audit done that says, Tim Porter was audited five times yesterday and that should throw up a red flag? How do you determine - that all sounds very good, Mr. McNamara, that you do an audit if you find out, but people's rights are being violated. Potentially, there's an open access here - and this is where I'm going with it - for anybody who works in that system to access anybody they want, is that correct?

MR. MCNAMARA: No, that's not totally correct . . .

MR. PORTER: See, that's why I'm asking, I need the details.

MR. MCNAMARA: First you have to have the authority to get in. So, for example, I, as CEO, could not access a patient record anywhere in the facility. Finance people could not access a patient record, for example, anywhere in the facility. Nursing staff, physicians or other providers appropriately should be able to access it so that they can provide patient care. You can identify who accessed a certain record and by doing our QA follow-up, we would know if somebody breached the protocol and we deal with that. I'm very comfortable that the process we have within our DHAs is very strong now, I'm very comfortable with that.

MR. PORTER: Although it sounds broad because those that you listed just briefly there, physicians, whomever, can access and appropriately so, there are levels that need access. Are the levels broken out so that you could, as a physician, for example, access a certain amount of that person's record and then the next level down? Maybe you could explain just a bit of that.

MADAM CHAIRMAN: Ms. Cascadden.

MS. CASCADDEN: When we build systems we have something inside the system called role-based access. Depending on your role in a health facility and providing care it will determine what level of access you have. As a physician, you have the highest level of access to patient information and that doesn't mean you have access to all patients in the province, you have access to all the patient information who are your patients. There are some physicians, if they happen to be in an emergency department, they would have access to all of the patient information in a hospital-based information system.

[Page 16]

As you go into the other roles within the hospital facilities, if you're a dietician, you would only have access to that patient information for which you are providing care for. We do have a very strict role-based access.

Behind the scenes, we have an audit mechanism that actually shows who audited a record or who went into a record at any given time. So we would have indicators to say this record is being hit an abnormal number of times and then we would look at that and see who is accessing the record and we would find out who would have appropriate and inappropriate access and we can track and do the appropriate actions associated with that.

MR. PORTER: You mentioned briefly and I just made a note - your patients, their patients. So they don't have access to all patients within that Capital District, just as an example. Is that correct?

MS. CASCADDEN: In the different systems and their roles would dictate whether they have access to 100 per cent of a patient information in the system or not. If you were an emergency room doctor, for example, you don't know who's going to show up at the emergency room door, so you would need to have access to all of the information. But if you're a neurologist, you may not have access to all patient information in the facility because they're not your patients.

MR. PORTER: Once a patient is admitted to the hospital, does the access change? What I'm asking here, Ms. Cascadden, is, the physician who takes over on the floor will obviously have access. The nursing staff looking after the patient will obviously have access. Dieticians will likely have access. Clerks will likely have access. Does the emergency room still have access?

MS. CASCADDEN: The emergency room would have access to that patient information.

MR. PORTER: And that would stay for how long?

MS. CASCADDEN: As long as that person is in the hospital and it is an active record. It would be just exactly like a paper record in the chart room - any physician in the facilities can go in and sign out a paper record as well.

MR. PORTER: So X-ray techs, just as another example, would have access probably to everybody?

MS. CASCADDEN: Only as it pertains to X-rays for that patient.

MR. PORTER: How much can they see? I'm a patient in the hospital, you're the X-ray tech. I go in, I have a broken leg. I might have two or three other things going on too,

[Page 17]

right, that aren't anything to do with that, but they're in my chart, they're there, they're personal information. The X-ray tech has access to my chart now to do whatever, how much access? How far can he or she go?

MS. CASCADDEN: The X-ray tech would not have access to the information that has nothing to do with your broken leg because your chart's divided up into multiple components. You would have a mental health component, you would have other visit components and if it has nothing to do with that particular visit and that particular incident, they wouldn't have access to that information.

MR. PORTER: And there would be no way then that they could get in there? They would only have that X-ray level of access? That's in the current day, is that correct? I'm just talking current day.

MS. CASCADDEN: That's correct.

[9:45 a.m.]

MR. PORTER: Are there changes coming with the new SHARE program that's coming in through SAP? Will those tighten up? Will those remain the same? Where will that go?

MS. CASCADDEN: The SHARE initiative and the electronic health record is not being rolled out to that level inside hospital-based organizations. It's being rolled out to physicians - our primary target for the SHARE initiative. That's because it's the physicians and other care providers, and nurse practitioners would be another - it's those folks who need to see the patient care through that whole continuum.

What we're doing is, we're not rolling out SHARE to a ward clerk inside the hospital because that's not the type of information that ward clerk would need. What the ward clerk inside the hospital needs for you, as an in-patient, is what is happening to you at that time that you are receiving that care for that particular event. So we have different audiences for different things. We have a hospital-based information system which has a user community inside the hospital. The electronic health record has a user community inside the hospital as well as outside the hospital, in the fact that GPs are also interested in the electronic health record and the information it can contain.

MR. PORTER: So GPs would be able to access this information through their offices, for example, log in and pull up . . .

MS. CASCADDEN; That is correct, for their patients.

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MR. PORTER: . . . as they are doing now. I do know in some cases right now, certainly in our area, they're doing that and that's great.

MADAM CHAIRMAN: Mr. McNamara.

MR. MCNAMARA: Can I just make one quick reference. I notice that you mentioned SAP too. SAP only applies to the business side, finance, HR and materials management. There's other systems that we're dealing with for SHARE just as when you mentioned PeopleSoft before, it's an HR system that was in one of our districts.

MR. PORTER: That's why I wanted to clarify it. Thank you very much for that as well for the record, so thank you.

Just back on that, so we're implementing something here, SHARE software. How many different - I don't want to use "versions", so we're still not really all coming under one umbrella, are we? We're having a system that's going to be uploading, by the sounds of it, everything to one bigger system or central system. Is that really the gist of it?

MS. CASCADDEN: What we're doing is, we have hospital information systems out there that are designed to work in a hospital environment and a hospital environment is very isolated but care is provided across the province. So we have different programs that are provincial programs and they need to have a full patient view across the province, regardless of where that patient has received care, but the hospital information system only records for the events inside those hospitals. So you have three silos of information. The SHARE project brings those three pieces of information that may reside in three hospital information systems into a single view for the provider.

If you think of a cancer patient who may receive some level of care in Cape Breton but has to come to Halifax for care, the providers providing care in Halifax would like to see the care that has been received in Cape Breton. That is what the SHARE initiative will allow those providers to see.

MR. PORTER: So just to be clear, the SHARE initiative will be able to pull up all of what happened, as you referred to it, in an isolated area. So in Cape Breton, the example you just gave, the doctor here would be able to type in Chuck Porter, pull up everything there is to know about Chuck Porter and his health records, regardless of where they are in the hospital - is that correct, it's all loading into one system?

MS. CASCADDEN: That's correct. For the pieces that we're putting in today, which are your admission, discharge and transfer information, your lab information, your diagnostic imaging information, as well as about 35 clinical reports. So if those pieces of information are up in Cape Breton, they will be moved into the electronic health record.

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For example, if you've had an EKG up in Cape Breton and it's electronic, we're not moving that yet. So it's a very defined set of pieces of data that we're moving into the electronic health record in this first phase.

MR. PORTER: So these will all come, in time, with the phases, do you see that?

MS. CASCADDEN: Yes.

MR. PORTER: And do you see with this IT and this software - I mean it's an ever-changing system, technology is incredible where we've come. How many years are we to Phase 2. Is Phase 2 next year, later in the Fall, Spring, five years?

MS. CASCADDEN: It's a very good question. The fact that if our clinicians come to us and say, you know the next really important piece of information that we could have or should have on our patients is their EKG strips - they've had an EKG in an ambulance or they've had an EKG in Yarmouth and we need to see it in Halifax - the first thing we have to assess is, are those EKGs in an information system today? If they're not, if they're still paper-based, that means we have to implement an EKG system so that it's in electronic format to move it into the electronic health record.

That's why I say it may take longer and it's a forever kind of project because we can only implement and move information if it is in electronic format and we still have a fairly significant number of systems - hospital-based systems as well as GP-based systems - that are still paper-based. We can't move paper into an electronic system so sometimes we have to go back and say, do we have to implement that electronic system in order to collect that information in the first place.

MR. PORTER: You can't simply scan that in?

MS. CASCADDEN: Scanning is a picture. It's not discrete data and people want discrete data.

MR. PORTER: Especially an EKG. So this is a large undertaking, there's no question about that. (Interruption) One minute? Okay, I'll just go quickly.

To me, I guess what I foresee and I think that the general public perceives this, this is one project where everything comes together and everybody has access, as needed, within one system but I don't think that's quite what you've described this morning to me.

In closing, I want to ask, with all of these people who have access, and I know, Mr. McNamara, you went on about disciplinary actions of all that was needed, are these folks on a confidentiality agreement as part of - I know that I used to have to do that, you know I

[Page 20]

would sign and once I was gone and no longer employed there, that was gone, too. What's the process there?

MR. MCNAMARA: Every employee signs a confidentiality agreement, as well as it is part of the profession, as well part of confidentiality of physician or nurse or whatever. It is part of the personal practice.

MR. PORTER: So they are aware, and I know my time is up, they're aware of the repercussions then?

MR. MCNAMARA: Definitely.

MR. PORTER: Thank you.

MADAM CHAIRMAN: Thank you very much. With that we turn the floor over to the NDP caucus for 20 minutes and I wonder who is beginning with the NDP caucus? Ms. Birdsall.

MS. PAM BIRDSALL: This certainly is a multi-layered morning, we're learning so much about this whole program. Could you talk a little bit about the Auditor General's Report. It seems to me that it had a lot of good things to say about project management and risk management. Can the government learn from these findings more generally?

MR. MCNAMARA: Definitely. Every time we get a report from the Auditor General, there are lessons for us to learn. What we try to do is use that to build into our new processes as we move forward, as well as identifying the issues that may impact other projects we're working on.

I think the Auditor General's advice to us has been helpful in many aspects of doing our job. We go out and do our best with the knowledge and the speed that is available. Sometimes we don't have the time we'd like to have to reflect and plan, because of the facts of the actions that come out, particularly in the Department of Health, so with the reflections of the Auditor General, it allows us to do a much better job.

MS. BIRDSALL: Can you be more specific in what sort of things that might play into?

MR. MCNAMARA: Well, for example, if we look to the recommendations that the Auditor General has given us, even going back and making sure that our privacy fits into the programs that are going forward, to make sure that we've got value for money. It also is good for us to know that we are adhering to provincial policies or following the guidelines, particularly when we compare ourselves to other provinces that have had some issues in the

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recent past. We can hold our heads very proudly of the service that public servants in the Department of Health have done in moving these projects forward.

MS. BIRDSALL: Can I ask you to further clarify the difference between the electronic health record and the electronic medical records. I know that we've talked about it but it seems so complex, if you could just go back and sort of 101, clarify it just a little bit more.

MR. MCNAMARA: I'm going to ask Sandra to do that because I confuse them myself.

MS. CASCADDEN: We'll just start with the electronic medical record. When you think about the electronic medical record think about your GP office and what your family doctor would need in order to manage their practice. So the electronic medical record starts with you walking into the clinic, getting registered and also the whole charting that happens. So the electronic medical record is about one single person interacting with their GP. When you think of it, think of the walls of files that are in GP offices now and think electronic medical record, putting that in electronic perspective. What it does for the GPs is, it will allow them to do lab requests electronically, get an electronic lab back into their own system so that they can manage you as a patient.

The intent of the electronic health record is to pull information together about you as a patient. So the electronic medical record is more provider-centric - it's about the provider and how the provider manages the patient. The electronic health record is more about you as the patient because it's pulling information about you together and allowing the providers to see a complete view of you, wherever you've received health care in the province. In our first phase, it is really pulling the information together about you as you've touched the more formal status of the health system, which is the hospital base. So any time you've gone to a hospital, we'll be pulling that information together under the electronic health record.

Think of the electronic health record higher, at the highest level, about you as the patient and the medical record is in your physician's office. It could be in a specialist's office but it's really that physician-person relationship.

MS. BIRDSALL: Well that helps, thank you. Can you tell us how far along Nova Scotia is in implementing our service compared to other provinces? Where are they?

MS. CASCADDEN: Certainly. In the electronic medical record, we're actually doing very, very well. In comparison to other provinces, we have about 36 per cent of our GPs who are using an electronic medical record. The average in Canada is about 27 per cent so Nova Scotia is doing quite well. We're really proud of it and people do ask us, how will we become so successful in this because it is a difficult thing to do, dealing with the GPs and where they are in the province, and technology is hard to get their head around as well.

[Page 22]

On the electronic health record side of the house, we're also fairly well placed across the country in doing that. There are only a couple of provinces that may be ahead of us with their implementation of the electronic health record, one would be Alberta and the other would be B.C. So Nova Scotia is actually very well positioned to have an all-encompassing electronic health record as well, so we're very well placed.

MS. BIRDSALL: Is it because we have the right people in place to do this or the foresight and the planning? What gave us that edge?

MS. CASCADDEN: I think a couple of things. In Nova Scotia when we started thinking about implementing electronic health records and systems, we always thought about it from a provincial perspective. So when it comes to trying to implement, like pull all this information together, we only have to deal with three hospital information systems. If you go to some place like Ontario, every single hospital has their own hospital information system. So they're trying to pull together hundreds of pieces of information, all located in their own individual hospitals.

Our strategy and direction has been a single system solution across the province, when we can. When we put PACS in, for example - the Picture Archiving and Communications System - we did it from a provincial perspective, so everyone has the same PACS system. When everyone has the same system, you don't have any integration challenges. That's really what has moved Nova Scotia forward in the adoption of the electronic medical record and health record.

MS. BIRDSALL: So sometimes smaller is better.

MS. CASCADDEN: Smaller is absolutely better.

MS. BIRDSALL: Thank you. The drug information system is in progress and preliminary planning is underway. Could you give further clarification about the availability of funding to move this system forward?

MR. MCNAMARA: What I can say is that we do have funding approved from Canada Health Infoway and as we're working through the provincial process to try and get the funding to complete the project. We believe that putting a drug information system in place is probably one of the more important patient safety initiatives that we can move forward so that individuals will not be compromised by getting incorrect drugs, not being able to - that there will be a system that will tell individuals if two drugs interact. As well, it would hopefully reduce the number of inappropriate prescriptions that might be filled so there would also be money saved in the long run as well.

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[10:00 a.m.]

MS. BIRDSALL: So how does that actually connect with pharmacies? How will our system interact with that?

MR. MCNAMARA: I'll ask Sandra to answer that.

MS. CASCADDEN: When we get into this project, we will actually work with all of the pharmacies in the province like Shoppers Drug Mart and Lawtons and all of the other pharmacies because we do need to interconnect. You can imagine, because of that, how complex that particular initiative is going to be. That's why it's a fairly expensive initiative, because we have to get right to the pharmacy.

Knowing that a person has had a prescription on a piece of paper is not good enough to understand what medications they are on. We need to go to the next step, understanding that they've actually had their medications filled at a pharmacy. It is at that point that we can understand things like drug interactions, because they're getting filled at that time. On this one, we're into all of the local pharmacies.

MS. BIRDSALL: And to make sure in the hospitals, too, that everything is recorded properly so every intern who is run off their feet gets it all written down in the right places. It's huge.

MS. CASCADDEN: Absolutely, we're going after the entire medication history.

MS. BIRDSALL: Amazing. Could you talk about what has been done since June to address some of the issues identified in the report and some ways, some of these things that have gone back a bit further?

MS. CASCADDEN: What we've been doing, say, for example, on the IT strategic plan, we have been working on pulling the strategic plan together and making sure that it reflects what we want to do from a health system perspective. So an IT strategic plan just for IT's sake is not what we're looking to do. We need a strategic plan where IT is the enabler for the things that we want to do in the health system.

When we have a specific focus or a priority around primary health care, one of the enablers to primary health care is the electronic medical record. That is how we're tying what we need to do, from a business perspective - if I can call health and government a business perspective - how we have to tie those two together. We're starting to do that based on the priorities that we're setting inside the Department of Health in government.

On the privacy side of the house, again recognizing the fact that privacy impact analysis was many months ago. We are and have been going through the checklist to check

[Page 24]

off all of the things that were of concern when we built the privacy impact analysis to make sure on a go-forward basis all of those things are addressed, so we're going through that normal project checklist on privacy and security as well. Those are some of the key ones that we're working on.

MS. BIRDSALL: In going through the Auditor General's Report, on Page 16 where we've got that diagram showing us how everything interrelates, it's quite complicated. Could you talk a bit about the various components and why it is important to connect those components?

MS. CASCADDEN: Our whole vision is, regardless of where you have received care, we'd like to pull the information about you, as a patient, together. So it doesn't make any difference whether you've received care either in a continuing care setting or in a hospital-based setting or GP setting, all of those bubbles represent the different business units, I'll say, inside of Health. We need to make sure that we can get all of the information about you, as a patient, into a central area so that providers who are providing you care know about your history and can provide you the best care they possibly can.

MS. BIRDSALL: Thank you. Can you tell us how the Department of Health has actually reacted to the Auditor General's Report and its recommendations?

MADAM CHAIRMAN: Mr. McNamara.

MR. MCNAMARA: Well as I mentioned earlier, the Auditor General has been very helpful to us in identifying areas where we can strengthen our programs. So for us, it is a positive report overall but it does give us some opportunities to improve.

MS. BIRDSALL: Okay, thank you. I'll share my time with Mr. Smith.

MADAM CHAIRMAN: Mr. Smith.

MR. MAURICE SMITH: Thank you, Madam Chairman. I just have some - actually some of my questions have already been answered in some of the other questions that you have given but I still have some questions around the privacy thing. I want to talk a little bit about the medical records that the GPs have in their office. Presumably if they're going under some sort of electronic recording, if that's the right expression to use, they're not just going to do the last two months of their files, I presume they're going to do all of their files. Is there any support in terms of - how are they going to fund that? I guess the next thing from that is, when would those records start to come into SHARE? For instance, I think I read somewhere in the report that only 21 per cent of GPs now are collecting electronic or doing it electronically and only 1 per cent of specialists. Do they all have to get up to the 100 per cent or close to it before that information starts to come or can it come piecemeal? Those are the kinds of things I'm concerned about.

[Page 25]

MADAM CHAIRMAN: Ms. Cascadden.

MS. CASCADDEN: With regard to the electronic medical records, when we go in and work with a GP who is completely paper based and we say, there's an electronic medical record and the GP expresses interest, what has happened in the industry is most people do a go-forward for their electronic medical records. They don't try to go back to the paper record and try to put in a lot of information from the paper record, a lot of times it's difficult to read or find or it's very complex. We leave it up to the GP about how much information they would want to put in about a specific patient.

If you were the type of patient who was just in for an annual check, you maybe had a cold or the flu, they may opt not to put any information in about you other than your normal demographics, your allergies, any key history information and then work with you on a go- forward basis to build your electronic medical record.

For those people who have a chronic disease and they really need to track something from a chronic disease perspective, those GPs may go back into the history a little bit further, capture some history and move it into their electronic records. It really depends on the GP and their preference, as well as the type of patient that you are. Like I said, if you are a chronic disease patient they may opt to put more information in than they would for a patient who is a relatively easy patient to manage, but it's completely up to the GP. When we do implementations for the electronic medical record in GP offices, we have a funding model that support them moving the electronic health record in.

MR. SMITH: Is it going to be totally voluntary on the part of these GPs to put that information in?

MS. CASCADDEN: It's totally voluntary for the GPs to first adopt an electronic medical record, so that's not mandated in any way, shape or form. It is voluntary for the GPs about how much information they wish to put in on any given patient, how far back they would want to go for a particular patient.

MR. SMITH: What if a particular patient doesn't want their information to go anywhere other than in their own GP - they've got a good relationship with their GP, they'll tell them they have AIDS, but they don't want anybody else in the world to know about that?

MS. CASCADDEN: That's called consent and you as a patient have every right to say where your information goes or does not go and with whom that information is shared. Those GPs would hold that information in a particular area - sometimes we call it a lockbox, for which is it locked down and it does not move into any other system from a sharing perspective.

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MR. SMITH: How soon might SHARE, if it's up and running in June, be able to accept electronic medical records from doctors' offices?

MS. CASCADDEN: We have to work with our physician group to understand which pieces of information that would reside in the electronic medical record in a doctor's office are the appropriate pieces of information to move into the electronic health record. One piece of information that we know that would be valuable for other providers that would probably reside in a GP system is your allergies. What we do is we'll be working with our physician population who have EMRs and say, which pieces of information in here do you think other providers would benefit from knowing? Allergies are one that we're interested in moving in.

The other one that we also believe should be moved is any immunization and vaccination shots. The detailed clinical notes about you and your visit, that's one piece of information that we're actually not looking at moving into the electronic health record at this point. We're going to deal with nice, discrete pieces of information.

MR. SMITH: I'm just told my time is getting short, but I just wanted to know, how long will these records be kept?

MS. CASCADDEN: In the electronic world they can be kept forever and what we're actually doing is, we're starting to look at just because we can keep them forever is that the right thing to do. We have laws at this point that say we have to keep records for a minimum of seven years in the paper world as well as the age of majority, plus seven years. We are looking at absolutely meeting that minimum standard.

From a research perspective or a population health perspective - not that we need to know individual people's information, so it's not identifiable information - to have historical information about the population of the province will actually help us manage what programs that we would want to put in place on a go-forward basis. So there are very interesting uses for that information from a longer-term perspective.

[10:10 a.m. Mr. Leonard Preyra took the Chair.]

MR. SMITH: If I can squeeze this question in around the privacy issue. In the Fall session, there was a privacy bill introduced with reference to medical information. Is that going to have to be reintroduced? With what's there now, will that satisfy the concerns that the Auditor General had and is there anything additional that is needed there?

MR. MCNAMARA: My understanding is that the Act will go forward. We've gone through consultation and that's where we are right now, it's in the committee stage. I don't know the full legislative process, but I know it will be brought forward for passage.

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MR. SMITH: Yes, but are you satisfied that that will meet the requirements that the Auditor General has outlined as necessary for the privacy issue?

MR. MCNAMARA: The majority of it, yes.

MR. SMITH: So by June, if SHARE is ready to go forward, that needs to be dealt with?

MR. MCNAMARA: Hopefully.

MR. SMITH: Thank you.

MR. CHAIRMAN: Thank you, Mr. Smith. You've allowed 40 seconds, that is great. I'll move to the Liberal caucus and they have 10 minutes. Ms. Whalen.

MS. WHALEN: Fourteen minutes.

MR. CHAIRMAN: Fourteen minutes, thank you.

MS. WHALEN: For our second round. We had a number of issues that I touched on the first round that I'd like to go back to and some of the information that has come up as well. I wanted to talk a little bit about the drug information system which the Auditor General says is one of the key components. Certainly, Canada Health Infoway says that is one of the key components of an effective, and I guess integrated, electronic health record which is what we're talking about today. We don't have approval at this point in time to introduce our drug information system, I gather, but you did mention it. I was pleased to hear you mention about the importance of it in terms of patient safety because we haven't talked much about the patient here, we've talked about the systems and efficiencies. Really, ultimately the entire electronic health record is about patient service and safety.

With the adverse drug reactions, we know that 70 per cent of them are preventable if the right information had been available to the prescribing physicians or people in charge. I wanted to know when it is planned to be added and what you see is the timeline? Is it your top priority, number one?

MR. MCNAMARA: It is one of our two priorities and I would say that because we're trying to deal with both the electronic medical record because that helps us move patient safety forward as well and the drug information system, so they are the two we are advocating for. Depending on the financial situation of the province and the affordability, what's available to us, is where we're going. So yes, from a departmental point of view, we are advocating.

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MS. WHALEN: You mentioned that you already have made an application to Canada Health Infoway for the drug information system and that has been accepted from that federal body, but you're working your way through the provincial. Does that mean you need to get financial approval?

MR. MCNAMARA: That's correct.

MS. WHALEN: Has it gotten sort of tacit approval in terms of yes, this is an important project?

MR. MCNAMARA: I think it's understood by government that it is an important project, but again, the province has to look at its own financial situation and they will advise us through the budget process what we can get this year, and what we don't get this year we'll go back for next year.

MS. WHALEN: Do you have a cost associated with the drug information system? I don't think it's on the chart that you gave us today. So what would it cost in order to add that to the existing work that you're doing?

MR. MCNAMARA: About $27 million in total on the capital side, of which Canada Health Infoway is about $9 million toward it.

[10:15 a.m.]

MS. WHALEN: It's interesting, you said $27 million, so one-third of that would come from the federal funding.

MR. MCNAMARA: That's correct.

MS. WHALEN: On this current project with the electronic health record, they're paying twice as much, so it's a reversal - they're doing two-thirds, we're doing one-third. So is there a normal sort of funding formula? That seems really strange to me, that it's completely reversed.

MR. MCNAMARA: Every formula appears to be different. Sandra could maybe answer better, but there are different percentages for different projects. For example, when we were doing our HASP, it is 100 per cent provincial, there's no Canada Health Infoway funding, so it goes from zero to the higher percentages. We haven't found one that they paid 100 per cent yet, have they? No.

MS. WHALEN: So there's no hope to get more than $9 million towards that project?

MR. MCNAMARA: I would doubt it.

[Page 29]

MS. WHALEN: Even though they have $500 million more put in this budget?

MR. MCNAMARA: It is based on how they would also treat other provinces as well, so they use a formula across the country, so it depends on - some projects are unique, as Sandra mentioned, on a first-come, first-service. Drug information is one that they see as for every province, so there is a different formula that they would have used.

MS. WHALEN: Okay, well that's disappointing, really, particularly in these hard times. This project is one that could really prevent a lot of other illness. I know that as deputy minister, you would be looking at the global cost. There's a cost-benefit here and we would have tremendous benefits if we could prevent hospitalizations and adverse drug reactions that could lead to people staying in hospital longer. There are immense benefits to catching that and I think there's quite a high incidence of incorrect drugs being administered or prescribed. Perhaps you have an idea how big that is.

I'd like to know if you've done a cost-benefit analysis on the drug information system.

MR. MCNAMARA: Sandra is nodding "yes" so I'm going to let her speak to it.

MS. CASCADDEN: Thank you. We do a very rigorous process as part of our planning process and we go through two planning stages before we even get to an implementation stage. During those planning stages we actually have to deliver a business case to Canada Health Infoway in order to get any funding from them whatsoever, so we have a very strong business case that actually shows where the payback is on implementing a system like this.

MS. WHALEN: So it definitely shows that benefit. Is there a dollar figure you can put to that today to tell us?

MS. CASCADDEN: I can't put it today but I can certainly get it for you. It is part of our detailed business case.

MS. WHALEN: If you would provide that to us that would be great because I think we would all like to see that and I think it helps for supporting projects like this. What I really saw was that although you've made a good start on the electronic health record, there are so many big pieces that are left to come in to make it really, I guess, from a patient's perspective, to see that it's nearly complete. That was one of the ones that concerns me the most, definitely.

When you get this drug information system up and running, as you envision it, will community pharmacists have access to that record?

[Page 30]

MS. CASCADDEN: Yes, they will.

MS. WHALEN: So that would be across the board? Would there be an option for them to have it or not, or are we going to make sure they have it? I think they want it.

MS. CASCADDEN: They absolutely do want it. Some jurisdictions have had to put legislation in to mandate the use of the drug information system in the province, to ensure that everyone is inputting the information from a patient medication perspective. Others haven't gone quite as far as putting legislation in because most people recognize the criticality of having a system like this and want to participate in the first place, so they don't need to be mandated to do it.

MS. WHALEN: Okay, well, that's very good. I'm glad to see that they definitely are part of the process because for most people, their community pharmacist is a very important person in their medical care. I think in the future we see them playing an even greater role, so I want to make sure we've got them clearly in our sights.

I want to go back to a couple of financial questions, if I could. That has to do with the chart that you provided for us today which outlined the various technology projects that are underway at the Department of Health. We're talking about significant dollars when we look at the full thing, $108 million was the total of all the projects with various funding, not all provincial but almost $67 million provincial money in that chart.

My question really goes to the SHARE project. The figures that we had are different from what show on that chart. I would have thought that your chart would be the most up to date. In my first round of questioning I referenced $19.2 million coming from Canada Health Infoway for SHARE but your chart shows almost $1.5 million less and it shows the provincial contribution is more. So had that changed over time? I use $19.2 million and $9.1 million.

MS. CASCADDEN: To my knowledge, the contribution from Canada Health Infoway has not changed, which means the contribution from Nova Scotia hasn't changed either. I'd have to go back and cross-reference the two documents from a financial perspective.

MS. WHALEN: Even the total that I have was $29.3 million and it is $1 million difference.

MS. CASCADDEN: Right.

MS. WHALEN: I wonder if Ms. Penny might know that.

[Page 31]

MS. LINDA PENNY: The numbers that I have are what are on the chart there, so I wasn't sure where the $19 million was coming from.

MS. WHALEN: All right, I wondered that. Perhaps that is something we can clarify later. It seemed to me there might have been a change.

Again, because it's a short round, I have to hurry to my next question and that is around the physicians coming on-line with the electronic medical records. There was funding made available in the master agreement in 2008, that is the agreement that was negotiated for physicians' salaries and funding arrangements. It said there would be $7.5 million set aside over five years, to encourage doctors to introduce electronic medical records in their offices and begin to be part of the system.

What I see here is that they would have received $5,300 for each doctor who introduced the system. That was for start-up and then ongoing training of $2,000 a year if they had a system in place. So could you indicate the uptake? I think I heard you say 36 per cent, but could you indicate the total uptake and how many have established them in 2009?

MS. CASCADDEN: I know where we are today, from a number perspective. We have 298 physicians on the system, which actually equates to over 1,000 users because, of course, we have to put their administrative staff on and anyone who works within their practice, who could be dietitians or other folks like that.

I would have to go back and find out what the uptake is for this fiscal year, specifically what was the difference between this fiscal year and the last fiscal year.

MS. WHALEN: Could you do that for me?

MS. CASCADDEN: Yes.

MS. WHALEN: That would be great and again, for the whole committee, because we'll all receive that information.

I wanted to check with you, you mentioned 36 per cent, but I think in the Auditor General's Report it referenced 29 per cent or 28 per cent or something like that, for the uptake in terms of our doctors. Has there been that much of a change since June?

MS. CASCADDEN: When we look at percentages, sometimes the percentages are quoted based on how many physicians are on the PHIM program, which is the Nightingale system, versus how many physicians have an electronic medical record. So before we came in fully supporting electronic medical records, there had been a number of earlier doctors of electronic medical records in the province. Those folks we actually count in the 36 per cent

[Page 32]

but we don't count them in the 27 per cent, which have adopted the EMR in the Nightingale system, which is the one that we're funding and moving forward with.

MS. WHALEN: So the one we're funding is the Nightingale system? That's the first time we've heard the name of that one. So 27 per cent is still accurate, it hasn't jumped dramatically. I was hoping maybe we were seeing a huge uptake but anyway, that explains that.

Are there any EMRs that exist in physicians' offices that don't link to SHARE? You're talking about the 36 per cent, would those ones in that category who were early adopters, are they able to communicate within your SHARE system?

MS. CASCADDEN: With the early adopters, well, right now none of the EMRs communicate with the SHARE because we just haven't built that into the plan. So when we are moving forward, we have to tie the EMR strategy to the EHR strategy so that will be our first thing. So are we going to put all of the EMRs in the SHARE or not and what does that mean from a financial perspective, having to integrate those different systems or would it be easier to move people to a similar platform, for many, many reasons?

MS. WHALEN: Have you studied that impact yet so see which is the best way to go?

MS. CASCADDEN: We have studied the impact of having multiple electronic medical records in the province versus having one medical record and certainly from a fiscal perspective, it's much more beneficial for the province to have a single electronic medical record, as well as from a program delivery and a patient care, as well as from kind of working with the physicians in delivering care. It is also easier if we have one electronic medical record because then we can say across the province, we'd like to have an initiative that all of the physicians are engaged in around diabetes care for patients and then we can track it within one system. If we have multiple systems, then we have to retrofit every one of those systems.

MS. WHALEN: Can I just ask you, would you see the funding that was made available in that agreement with physicians, would it be there to help them change to a new system, if they were given $5,300 for introduction of this system?

MS. CASCADDEN: That's one of the things that is under consideration at this time.

MS. WHALEN: Because that would probably answer your question - if they're already technologically savvy, they'd be willing to switch. Anyway, I'll leave it at that.

I just wanted to go quickly back to the June 2005 report that was done on the Nova Scotia Hospital information system. That was an Auditor General's report then, there was

[Page 33]

only one recommendation and it said, "We recommend the disaster recovery plans and procedures be formalized and tested."

At that time, it was noted there was no formalized plan for recovery of information in the event of a disaster and the systems are down. Could you tell me what the status is of those recovery procedures now?

MS. CASCADDEN: Certainly, in 2005 at the time of that Auditor General's Report, we didn't have a single entity that was responsible for that system, we were still in the implementation of the system. Since that time, we've put together an organization called Health Information Technology Services-Nova Scotia or HITS-Nova Scotia. They are responsible for the disaster recovery plan, the data backup plan, working with the district health authorities that they have downtime procedures, so if the system is not available, how do they still deliver patient care during those times. So with the advent of HITS-Nova Scotia, we have been able to deal with the disaster recovery recommendations of 2005.

MS. WHALEN: So you're saying that HITS has now got a plan in place?

MS. CASCADDEN: That is correct.

MS. WHALEN: And that we don't need to worry about that anymore? That's very good because one of our jobs here at the Public Accounts Committee is to follow up on those earlier recommendations of the auditors, so we're glad to see that is done. I believe my time has elapsed. Thank you very much, I appreciate your answers today.

MR. CHAIRMAN: I'll call on Mr. MacMaster. The time is 10:26 and you have 14 minutes.

MR. ALLAN MACMASTER: Where are these electronic records accessible? I get the sense that they can be accessed by a number of health professionals. Could you give some background on exactly who would have access, from ambulances, outpatients, family physician offices, specialists, et cetera?

[10:27 a.m. Ms. Diana Whalen resumed the Chair.]

MS. CASCADDEN: Different electronic health records can be accessed by different people. One example would be, we actually have an electronic medical record that is built for the ambulances. That record is only accessible by the paramedics providing care to the patient at the time that they're in the ambulance, so it's only accessible to those folks for that particular episode. What they can do is transfer key pieces of information to the emergency department so that it's there for the people who are providing care. Their system itself is not accessible by the emergency department, it's only pieces of information that flow into that system.

[Page 34]

The same with the electronic medical record, it's accessible only by those who have user names and passwords to their system. If you're a GP, you only have access to your patients for which you're providing care and that information doesn't go anywhere else. What we do is feed information into that system, so we feed lab results in - as a GP, if you've ordered lab results, we can get the lab results out of a hospital system and move it into your system. That information doesn't go anywhere else and no one else has access to it, except for those people who have the appropriate user accounts based on their roles and responsibilities inside your organization.

It gets a little more complex when you talk about the electronic health record for which multiple pieces of information are flowing into it. Again, access is based on roles, responsibilities.

MR. MACMASTER: Have you considered or was it considered at one point in time of having one record that, depending on your role, you could access that one record, but in your password you access the record but there may be various tabs. If you were an X-ray technician, a lot of the information might be blanked out, but you could click on the tab which would have the information you would need. Maybe that's the way it looks?

MS. CASCADDEN: That's exactly what the vision is. You go to one place to get access to the appropriate information based on what your role is in the health system and where that patient is and what type of care you need to provide to that patient at that time. So that is exactly what the vision is for the electronic health record.

[10:30 a.m.]

MR. MACMASTER: What do the records look like? Do they have records of people's allergies, their medications, their past medical history, obviously?

MS. CASCADDEN: In a GP office, that electronic medical record would have everything from your scheduled appointments, past and into the future, and then it has a record of your interaction with your GP. It would have your medications, it would have your past history, it would have your allergies, immunization, lab results, whatever that GP needs in order to provide care to you. In the electronic health record, because the health system is so large and information is everywhere, that's when we've parsed out, what are the key pieces of information we have to put in this phase of the electronic health record.

What we have in the electronic health record is every visit that you have had to one of the hospitals in the province. We have all the lab results that you have had if you've gone to a lab associated with a hospital, they are being pulled into the electronic health record. All your diagnostic images are being pulled into the electronic health record as well as over 35 different reports that are in a hospital, a discharge summary, so when you leave the hospital your discharge summary is in the electronic health record. That's the full scope of what's in

[Page 35]

the electronic health record at this time. Again, as we evolve, we'll be adding more pieces of information to create that single view of you as a patient to provide care.

MR. MACMASTER: Are pharmacists able to have access? The reason I ask this question is because I see the importance of a pharmacist maybe looking and filling out medications and they have the expertise to notice perhaps when a patient is on two conflicting medications that may have gotten missed by the physician; our physicians are very busy. Is there an element there where a pharmacist could look at the medication component?

MS. CASCADDEN: Yes there is when we have the drug information system because that's exactly the role that the drug information system will provide. The other thing that we've done is we know that the pharmacists are very important to the whole of patient care, so they've actually been sitting at the table with us during the development of the electronic health record. So we've had pharmacists also at the table at that time knowing that the drug information will flow into the electronic health record as well, so we've had them there. The drug information system is the system that they will tend to work in on a day-to-day basis, they may not have to go to the electronic health record, because their information really is contained within the drug information.

So different groups will work in different systems depending on what type of care they're delivering at a certain time. Not everyone will go to the electronic health system, they may keep working in their own individual systems because that's all they need to know about the patient.

MR. MACMASTER: Is there an element that tracks the cost of various health services that are provided in the software?

MS. CASCADDEN: The drug information system actually can track costs in an indirect way in that we can see what the prescribing pattern is across the province, what types of drugs are being used by different clinicians, what different types are being prescribed to different patients, so there's an element in there.

What we've done with the HASP or the SAP system, that's really where we'll be tracking the costs associated with the health system, is really through our finance, our HR and material management systems and not the patient care system, but through that SAP system because it's now across the province as a single system. We now have for the first time a full financial view of the health system from a finance and HR materials management perspective and that's how we're going to be able to track costs more efficiently and effectively.

MR. MACMASTER: I think that's great because as you know our health budget is growing at a rate of 7 per cent a year and from my background in finance, I know if you can

[Page 36]

invest your money at 7 per cent a year you'll double it in ten years. In this case with the cost of health, it's something that's so important and if it grows unsustainable, I just make the comment that I'm glad to see that you're starting to have the tools to measure these costs so that we can keep health care sustainable for Nova Scotians.

I can appreciate this is early on, but has there been any evidence that these records are helping physicians and pharmacists provide better prescriptions? I raise this because I remember reading years ago that one of the main costs or inefficiencies was medications that were either improperly taken or not taken and as you know, a lot of money goes to support drug companies for the medications they provide. Do you have any comments on that?

MS. CASCADDEN: There are a number of research initiatives and surveys that have been done all across the U.S. and Canada that show the investment in information technology does pay for itself, both from a financial perspective as well as better patient care which ultimately is really why we want to do this, especially the drug information side of the house.

I was recently at a conference with Dr. Blumenthal, who is the head of the U.S. initiative to do exactly the same thing. He is a physician and he said when he first used the drug information system in the hospital he was prescribing drugs to patients and he saw the first what is called a contraindication. He said, I saw my career flash before my eyes because of what that could have done to the patient if that information system wasn't there to tell me that at that particular time.

MR. MACMASTER: How are these records going to benefit Nova Scotians who interact with the health system? Could you give some hypothetical examples of somebody who comes in? One of the things I think about is, I've been to Outpatients with family members before and you come to the desk and immediately they're asking for information and in some cases, the person coming to the desk is really in no shape or mood to be giving the information because they might be in pain or they might be very sick. Can you give some hypothetical examples of how these records might help people right in the front lines for people who are coming in for the services?

MR. MCNAMARA: I'll start with a response and I'll first use an easy one, using the PACS system. Let's say, for example, you're an individual who has a certain fracture or something that requires a specialist. So you could have a GP, who is looking at the X-ray in his office through the computer, you can have the radiologist looking at it in his office within the hospital, you have a specialist in Halifax look at that same X-ray. All three of them at the same time could discuss that patient to come up with a treatment, that's one.

In terms of the longer care, you were talking about it being able to deal with patients. To me the electronic medical records is a way that we can deal with individuals, as you said, that might come in and, for example, might be unconscious. The information, if you know the patient's identity, you could check the information without having to ask them. The other

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thing is at a time of any medical emergency it is great stress on the individuals and they forget information. Electronic medical records means that information is going to be available very quickly to the caregiver to make the right decisions or even if you talk in the simple case of talking to say Dr. David Gass who talks about primary health care, who will say, for example, having electronic record means that you can see if somebody had their inoculations, when they had their last flu shot and you can make decisions. If you think of the paper record, they're searching through the paper, they may have lost it, they can't make out their writing or somebody else's writing, so it changes the whole way that we look at health care.

I think if we can think of any way we can improve health care, this is probably one of the most effective ways. It will do better than giving someone a prescription, quite honestly.

MR. MACMASTER: I've got two minutes left. I have two quick questions and one of them, I think, is my most important one of the day. Will these records help physicians as being kind of a checklist for their patients?

MR. MCNAMARA: That is already the case to some degree. For example, even from the information we supply there are some comments from some of the physicians of how immediate they can get the right information and it would help them in being able to look at contraindications or other things that are going on, also to know what has happened elsewhere. We can stop repeating some of the tests if you already know somebody has had it.

MR. MACMASTER: Now here's my most important question of the day. Is there a component that physicians can use for proactive health care? In other words, is there a way that they can kind of track any kind of recommendations they might make to patients to improve physical activity or healthy eating? The reason I raise this is because I think it's an area where the culture and the mindset has to change. We have to get Nova Scotians, give them encouragement to live healthier lives because at the end of the day they're going to be happier for it, too.

MR. MCNAMARA: The record would have the information. What we're trying to do is help people self-manage their own care, which is really what you are saying. By having an accurate record, an individual would know what, for example, advice was even given to the patient last time to follow up with them.

We know, for example, if you just deal with smoking, the most effective way to stop smoking is for a physician to look the patient in the eye and say you have to quit smoking. So he can double-check it the next time he comes back, did you follow my advice, as an example.

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MR. MACMASTER: Thank you very much.

MADAM CHAIRMAN: Thank you, and with that we'll turn to the final round of questioning from the NDP, which is a 14 minute session. Mr. Preyra.

MR. LEONARD PREYRA: Thank you, Madam Chairman and thank you, Mr. McNamara, and your team here. I just say the last time we had you here we were in the middle of a pandemic and everyone was worried about the various waves of the virus and we seem to have survived that very well. I know you are telling us today that there was a little bit of a delay in the implementation of this program and if that's the only casualty of that, we're doing very well. Thank you very much on behalf of all of us for your handling of the pandemic at the time and I'm glad we all came out of it well.

On the SHARE program, I must say this is very exciting that we have this program that is going to provide real time information, accurate information, it is going to reduce duplication and it is, as Mr. MacMaster says, it has the promise of providing whole patient care as well down the road. So although we've talked about information technology what we're really talking about is the quality of information that we can get out of the system itself.

I want to ask you a question about access to information because it has come up now several times. What I hear Ms. Cascadden saying is that on one hand we want to make this information accessible as quickly, as reliably and to as many people who need it but, on the other hand, we also want to protect the privacy of that information and protect the privacy of the patients. So the system that you have developed here or are developing here tries to strike a fair balance between those twin goals.

The people who will get access to information are those who need to know that information at that time, in that place and role-based access is really saying that there will be a limited number of people who will be allowed access to that information and the system will know when people are accessing the system, whether they need to know it or not and there will be a way of following back.

To your understanding, is that in accordance with the best standards of the industry and are you comfortable that this protects the privacy of patients and also gives us the access that we need to make good decisions?

MR. MCNAMARA: I'll speak first and then Sandra may wish to add to it. I am very comfortable that our system has the appropriate checks and balances in place. For example, we deal with individual patients who can make their own decision on how far they want their information to do. Secondly is it is much safer, even though it might go to a broader span of people who can access the information, we can do the audit. If you think of the old paper trail, we didn't always know who went into a chart room and looked in somebody's record.

[Page 39]

I would never be able to know that so-and-so accessed. With today's electronic system, because of how you have to sign onto it, we know who accessed the system.

Also, there's a time-out in the system as well so it doesn't stay open for somebody else and you, as an individual who accesses, are responsible to make sure you close it down after you use it. If somebody else unintentionally goes in and looks at it, then you are going to be held accountable for that as well. So I'm very comfortable with the system we have, it is as good as we can have under any circumstances.

MS. CASCADDEN: And I'm equally as comfortable as the deputy has mentioned. Certainly we are using best practices that are available today, we're using technology that is available today. As the technology is enhanced, we will add those components as well. Just think about your credit card now has a chip on it; a couple of years ago it didn't. So as the technology enhances, we'll actually build in enhancements to this as well but today, I'm very comfortable with what we're doing.

[10:45 a.m.]

MR. PREYRA: Thank you. I also have a question about the distinction between SHARE and the health record universe in general. I heard you saying earlier it will never be completed with this project, in large part because the parts of the system will grow, our knowledge will grow, the technology will grow - what we would like to get out of the system will grow. So what you're talking about is not just inter-operability of the system. What you are talking about is this whole general universe and how we fit the parts together.

Are you comfortable with the plan you have in place for the road ahead? You sound like you've developed a system of consultation, for example, with the clinicians and probably Doctors Nova Scotia and all that, in terms of what Phase 2 would look like. Are you comfortable with that part of the planning process?

MS. CASCADDEN: We're certainly very comfortable that we have adopted the technology which we can grow with and will allow us to have the inter-operability. We have together the teams and the people we need to talk with, based on our plan today. We still need to formulate our plan for out-years, as we understand what the priorities are that we're going to have within the Department of Health and within the government. So what areas are we going to focus on, because then we need to focus our direction there as well.

The whole system - what we're doing is we are actually transforming the health system from a paper-based system to an electronic system and it is huge. So we need to follow the direction and the priorities of government and the Department of Health and take those pieces of the health system and move those ones forward.

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MR. PREYRA: Thank you. We had a brief round with the Auditor General and Ms. Colman-Sadd earlier and they were filled with high praise for the way in which this project has unfolded. I think in closing, they said they are very comfortable and confident that the next phases and the other things that remain to be done will be done well, not just here but also relative to the other provinces. So it is pretty high praise.

Are there areas that you would like to go into next, I mean in terms of the Auditor General's Report, that you would like to build on and go forward on?

MS. CASCADDEN: Certainly we're looking at the Auditor General's Report and keeping an eye to the things like the IT strategy and really we have an informal process around that now to really formalize that process. I think that will help all understand what the vision and the direction is for electronic health in the health system on a go-forward basis. That is one of the areas that we're concentrating on.

Some of the other areas are specifically focused to the SHARE initiative and those will unfold as we go into the next phases of SHARE, so we're looking at that as well.

MR. PREYRA: As I understand it, a lot of these directions will depend on the extent to which the federal government would commit to particular types of information sharing or information gathering. They are one of the primary funders, either directly or through transfer payments. Also what the users of the system identify, it is possible that the pharmacists will come back and say people are - I don't know if double-dipping is the word, but you know they are using drugs twice or they are pharmacy shopping or doctor shopping and we want to flag that and we need to find a way of doing that. So presumably those kinds of issues will arise and you might want to coordinate with new partners and other partners to exercise some oversight on that.

MS. CASCADDEN: Absolutely. As we roll these things out, we talk with many partners to understand what their goals and objectives are and how we can enable them because we're really enablers. So we don't say oh, we've got a really great idea, we actually work with our partners to find out where their issues and concerns are and try to build them into a plan where technology and information systems can actually help them.

So you have to be very cautious about whether you're leading or you're following in support of, right, because it's not about the technology. It's about how we can use the technology to provide, first, better patient care, safer patient care, quality care and access to services. So those are the things that we need to follow and track and say, we might have a solution for you, based on what the different groups are saying about what their challenges are within the existing system.

MR. PREYRA: Thank you, Ms. Cascadden, a very exciting area. Madam Chairman, I'm going to pass my time over to Ms. Kent, the remaining time that we have.

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MADAM CHAIRMAN: Very good. Ms. Kent.

MS. BECKY KENT: Thank you, Madam Chairman, and thank you, Mr. Preyra. Thank you very much for this information, it's really helpful, first of all, but I want to go directly to a very specific type of issue that has been brought to my attention, certainly through constituency struggles and frustrations with medical care. No doubt, perhaps, I believe, in the past, colleagues of mine have brought this to the department a number of years ago and it's around closure of doctors' practices and around the medical records that then are - and you mentioned earlier - locked in, locked down. For me that kind of fit what's being described to me by people who are frustrated with the situation. They get a letter saying their records are now in some kind of vault or locked away somewhere and understandably there is a way to access them, but there is a cost associated to it and a frustration and a trauma attached to it.

Before I sort of go on to my views on the matter and get to further questions, can you clarify to me if that is, in fact, what is happening here in Nova Scotia?

MR. MCNAMARA: I can respond to that. What happens when a physician closes his or her office is that physician, under the College of Physicians and Surgeons, is responsible to find someone else to look after their records for them because in a sense, many physicians are businesses and they have both their business and their patient records. It is their obligation, as part of being a physician, to find someone to be the protector of those records. There are some situations where an individual may leave the province or go to another country and yes, records might be put into a warehouse or something, but they still have to provide some access to it and it is very difficult sometimes for some patients to access that information.

If we look at where we can go in the electronic medical world in the future, there will be better opportunities to be able to make sure that information is shared with another provider, so this will give us a much better access than the old paper way.

MS. KENT: I'm glad to hear that and that would have been my lead into the presentation that we have today. There's no question, when you have care in Nova Scotia, yes, it has its challenges and yes, we've faced issues that we clearly want to improve upon and correct. Nonetheless, we do still have a good quality of care here in Nova Scotia, but when you're in the middle of care, whether it's for you personally or someone who is near and dear to you, a family member or a child, whatever, and then to suddenly have that disappear, and to an individual that's what it feels like. Then, to be presented with an option of you can get your records but you have to pay for them, I struggle with that and I know that many Nova Scotians do.

So I understand when you say a physician is responsible to find some other way, am I right in understanding that in the way I just described it was an option for that physician or

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that they just get an entity, and without knowing a specific entity, that those records are there - they're here in Nova Scotia, they're available, but an option is they can choose one that then someone might have to pay to get the records, because not everyone can do that.

MR. MCNAMARA: To back up a little bit, the obligation of being part of the College of Physicians and Surgeons and having a licence, that's where the obligation comes in, it's different than a provincial regulation. Secondly, does the record have to stay in Nova Scotia? Not in all cases. I know of some cases where, for example, a physician returned to Montreal and took the records with them, but individuals from here could still get access the same as you could anywhere.

The difficulty becomes at times if, for example, a physician passes away suddenly and the records are there and then the estate has to make sure that those types of securities are put in place, it isn't an easy situation. But we believe that as we move forward and more of these become electronic, then our ability to work with patients or other providers, and the college, to address this issue, it would be much easier.

MS. KENT: Yes, certainly as I was hearing you unroll the information to us that this would capture that and I think that's a really positive aspect that can really resolve a lot of trauma in Nova Scotia citizens' lives.

I don't think I have very much more time other than perhaps could you comment briefly on the Auditor General's Report suggestions around the procurement process and if there's any attention that you're giving to that.

MR. MCNAMARA: We believe we've followed the procurement process as outlined by the Province of Nova Scotia and have been very diligent for all our projects in doing that.

MS. KENT: Thank you. I believe, Madam Chairman, we're just about out of time.

MADAM CHAIRMAN: We're just about done, that's right. Thank you very much and I appreciate that. I appreciate the answers and the fulsomeness of the discussion today.

As is our practice, you have a few moments if you'd like to take a couple of minutes to close and have any comments.

MR. MCNAMARA: There are a couple of points I'd like to say. I'd first like to thank the committee for allowing us the opportunity to talk with you and talk about our situation. I think that when we look at the whole IT issue, one of the key things in looking at patient records, we can say they're secure, that they're safe and that they're protected for patients. We can also look at IT as a way to be better able to utilize spaces in our facilities. If we can think of the diagnostic imaging, as we go to PACS, not having to store bulky X-rays will give us

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space to be able to do other things. Building space in hospitals is one of the most expensive things we do with little return, sometimes, for what we're spending our dollars on.

In terms of patient care, I think it would be one of our best ways of providing safe and secure patient care. It's not just in the access to information, but it's ensuring that you can read what you write. There's a joke about doctors' writing, but it's not always a joke, so this is one way that we can ensure the information is accurate that somebody else looks at.

Somebody mentioned discharge summaries and one of the complaints from physicians was if a patient came to Halifax to one of the specialties and they used to get it at South Shore, the patient would show up at South Shore to be seen for follow-up and the discharge summary didn't arrive because it's paper. With this electronic system, eventually the record will be there before the patient and it will make it, again, much easier for the patient.

I also want to acknowledge the strides we have made and the co-operation of the DHAs and their staff, as well as Doctors Nova Scotia and physicians, EHS and other agencies to move this forward. We wouldn't have achieved what we have without their support and their work. I also want to acknowledge the leadership of Sandra Cascadden and her team in moving us forward. I think she and her team have done a tremendous job in keeping us in the forefront. Thank you very much.

MADAM CHAIRMAN: Thank you very much. I think it was clear to us today just how complex and broad this undertaking is and again that there are real benefits that we will see once it's all in place. With that there were two items that we did ask that you would follow up on, one being the analysis on the dollar figure, if you could sort of break down the dollar figure, where it comes from, that cost benefit analysis for the drug information system and the number of physicians that are now tying into the electronic medical records. Those were the two things asked for follow-up and I thank you very much, again, for coming and explaining it more to us today.

For the committee we have no committee business today, but we are following this meeting with a meeting of the Subcommittee on Agenda and Procedures, so just three of us will stay back to help set the agenda for future meetings.

With that our next meeting is set for March 24^th. Next week is March break, so the week after, March 24^th we'll be listening and hearing from the Department of Education about P3 schools. So if I could have a motion to adjourn, we will adjourn the meeting.

HON. KEITH COLWELL: I so move.

MADAM CHAIRMAN: Thank you very much. We are adjourned.

[The committee adjourned at 10:58 a.m.]