4th-36th Vol. 29B-Committee of Supply-Health

The Acting Chairperson (Mr. Peter Dyck): Order, please. Will the Committee of Supply please come to order. This afternoon this section of the Committee of Supply meeting in Room 255 will resume consideration of the Estimates of the Department of Health.

When the committee last sat, it had been considering item 21.1.(b) on page 71 of the Estimates book. Shall the item pass?

Mr. Dave Chomiak (Kildonan): We had left off indicating we would come back and probably do some follow-up Betaseron questions, I do not know. Is the information available?

Hon. Darren Praznik (Minister of Health): Yes, Mr. Chair, I will table this list of members of the committee. We have extra copies of the Manitoba Drug Standards and Therapeutics Committee, and all I ask is that he respect some of the privacy of the individuals for the matters outlined, and I think he acknowledged.

I also have, which is a public document effective January 1, 1997, The Manitoba Drug Benefits and Interchangeability Formulary. This is the document that I think describes the committee and the process. As I said, in working with this committee, I have come to the view that we need to be fleshing out in greater detail some of the criteria around a selection, and it would be my preference to see this developed on somewhat of a national basis.

One of the complaints we get regularly from various health groups, organizations, certainly the pharmaceutical industry, is that they very much have to go through the same process in every jurisdiction. In a country the size of Canada with only 30 million people, it does make some sense that this is an area where if we could on a interprovincial basis establish a pan-Canadian committee to make these kinds of recommendations to us as ministers of Health, along some objective criteria, it would probably go a long way to speeding up the process and streamlining it.

So that would be my long-term objective. My medium term would be to get a better set of criteria in Manitoba, more detailed criteria to assist the committee, and, thirdly, my short-term objective is to get this new red-light, green-light, yellow-light process operational.

Mr. Chair, I am just going to peruse this document on all the regions. I know last year we had a little difficulty around dates, and I want to just double-check this for the member, but he may want to respond.

Mr. Chair, this is the list of members of the regional health authorities. I believe the effective date is somewhat different for each regional health authority. I imagine it is effective as of the last time we have accessed it. I think that is the case. I provide that to the member.

Mr. Chomiak: I am going to require some time to review the information. I thank the minister for tabling it--and review some of that information. So therefore specific questions in this regard I will defer until we reach the Pharmacare portion.

I just want to return briefly, though, to the Copaxone issue to make sure I understand it correctly. The yellow-light process, what specifically does the minister mean? I, at one time deemed it conditional approval. The minister has not used that terminology, but what specifically does he mean by the yellow-light process? What does that mean?

Mr. Praznik: Mr. Chair, I do not intend it to mean that we are about to say no. It is really the intermediary change between a yes and a no. I wanted to give the committee enough latitude to be able to say in cases that were not really clear-cut that this product may be worth consideration. There are some doubt in our minds, one way or the other, and to make a recommendation not only to put it in this middle ground, this gray area, but to make a recommendation if they felt it was appropriate as to how, in fact, we should go about testing this product. So I wanted to have a fair bit of latitude. We will develop this and we will test this from experience as we move through the process. But where you only have a clear yes, a clear no, and there are, as I said, drugs that are getting into the approval, ready to say yes, but certainly do you say no, and if when you just have two clear-cut choices, there are going to be drugs that do not get moved forward because they have not quite fully made all of the go-ahead criteria yet.

So putting kind of a middle process in there that allows us to either do a limited test, a complete test, in some way, we are proving the drug with a test around it, an evaluation around it, so that ultimately when that evaluation is complete, that information will come back to the board to better help decide whether it should be a yes or a no.

I would suspect in many cases that the results will verify what many suspect, that this drug does have benefits that have not yet been fully developed or referenced in the literature, and yes, it should be included in the formulary. So, that middle ground is really the period in which you evaluate with certain criteria around the outcomes of that particular drug to see if it is delivering the medical benefits that it is supposed to. That is what I envision, and obviously we are going to have to flush this out and work it through as we move forward. Today there is no ability, or there is, I guess in the rules of the committee, but it has never been exercised to be able to that kind of organized evaluation of a product.

Mr. Chomiak: In the example of Betaseron, the government has chosen to use a pilot project, but that would be presumably only one of several courses of action available in this yellow-light scenario?

Mr. Praznik: Mr. Chair, I certainly do not want to be restrictive today of innovation. In the case of Betaseron, the claim with Betaseron is made that--what the literature suggests from my recollection of this is that it will eliminate one relapse in a three-year period. You are talking about a product that has an annual cost of about $17,000, does not--so the argument has gone--affect the long-term prognosis of MS. It prevents one relapse which could last a couple of weeks at a potential cost of $50,000. Is that a huge value?

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The committee looked at it and said the medical benefit of this product versus its cost, it is just not there. If there was a cure for MS, if it delayed the disease, the advance of the disease for a period of time, yes, it would not be a question; of course, go ahead. The patients are getting great benefit, but where that benefit is very dubious and doubtful, do we invest in providing for this medication? What we learned, both the member and I and others, as we went through this, is the claim is made, and apparently there is some growing evidence to suggest, that not only does it prevent one relapse within three years, but it may in fact decrease the severity of other relapses during that period and ultimately lead to a more improved quality of life.

So what the purpose of this evaluation will be able to do is over the next three years or so the people who will be in this particular test--I do not have all the criteria today, but I imagine it is going to be evaluating what effect this drug has had, and if we are able to determine from this and other work going on around the world that there are increasing benefits to the use of Betaseron, then of course it makes it easier for the committee with that evidence to say, yes, we will approve it, green-light it, and it becomes a regular part of our formulary, and then to obtain the drug you do not have to go through the MS Clinic specifically, but it would be a regular part of the formulary.

This committee might recommend, because of the nature of a product, that it only be used under restrictive circumstances, certain kinds of evaluations, what have you. So I want to give them the ability to have a tool to have a middle-ground process between yes and no so that they can get the evaluation to make a final decision at some point.

Mr. Chomiak: Mr. Chairperson, I will be debating this and discussing this in greater detail, the Pharmacare portion, because I think there are a number of issues arising out of here. But I would like to move on. I have one final question. Can the minister specifically verify exactly what status Copaxone is right now, because I think he mentioned it this morning, but if he could outline exactly what the status of Copaxone is right now.

Mr. Praznik: Mr. Chair, just on the last question, it was pointed out to me that one of the claims that was made by the MS community was that the use of Betaseron over a period of time will reduce other Pharmacare costs as well. So that will be another issue we will be evaluating in this particular study, which of course affects the pharmacal economic analysis.

I am going to ask Mr. Potter to update on the Copaxone issue.

Mr. Don Potter (Associate Deputy Minister, Internal Programs and Operations): Mr. Chairman, my information is that the information that was missing from the producer of Copaxone has been received and that the drug will be going to the next meeting of the Drug Standards and Therapeutic Committee for review.

Mr. Chomiak: Mr. Chairperson, just an additional question for the minister, during the Betaseron issue, we were surprised that there had not been contact between the MS Clinic and the drug therapeutic committee with respect to the utilization of Betaseron. Presumably, Copaxone is being utilized by the people through the MS Clinic in one form or another.

Has there been contact and a tie-in at that point?

Mr. Praznik: Mr. Chair, as I indicated earlier this morning to the member, as I had a chance to discuss the operation of this particular committee and their procedures, they had traditionally only dealt with a paper review of information and material. It had not been their operating policy to have representation made by individuals who had been working in the field and could directly provide scientific information, and I asked if they would consider that at their discretion as part of their process.

The first time this happened was, some of the positions at the MS Clinic were able to make a presentation to them with some of their information. Whether or not that affected their decision, I am not going to speculate on that. But if this committee feels that there is work going on and expertise that would be of benefit to them beyond which is what on the paper review--I should point out that the manufacturer of the product has the responsibility, if I remember correctly, to put the information to the committee, because it is in their interest to have the drug approved. If that committee hears of or is made aware of work that is going on with that particular product where expertise could add to their base of information in making a decision, that certainly would be encouraged by me and that is a decision that they would make based on the material that they received. So it may happen.

Mr. Chomiak: Mr. Chairperson, just a final question. Would that also include other jurisdictions outside of Manitoba?

Mr. Praznik: Yes, Mr. Chair, I have no objection to the committee. Obviously, there is a cost, an administrative cost factor involved in this, and if a manufacturer of a particular product in making their presentation felt that it would be advantageous to offer bringing a researcher in to meet with the committee, and the committee felt that would be useful to them, I certainly would not object to that happening. We are trying to have a process that provides the best information available.

Another comment I make, why I have promoted this on a national basis, as I am sure the member will appreciate, is it is just practically more effective, if we were doing this on a national basis, for those involved, with the expertise in a drug, to only have to make one presentation to a committee. In a country the size of Canada of 30 million people, it becomes very labourious to have to make presentations to potentially 12 different drug standards committees.

Mr. Chomiak: Perhaps we should move on to the Information Systems portion.

Mr. Praznik: Mr. Chair, I would like to introduce--I think Mr. Potter is going to remain, and Mr. Chris O'Neill who has been working on our information systems. These gentlemen will join us.

Mr. Chomiak: I am actually going to use this occasion to put on the record some information because it actually came out in debate yesterday. Not that I am anticipating it should change substantively the debate that will take place, but I just want to put on the record the fact that it is constantly suggested that the New Democratic Party is against technology.

I just want to point out that in the very first instance when the SmartHealth project was announced, our objection, based on information provided to us from experts in other jurisdictions, was that the SmartHealth initiative, as announced, was an extensive--and I have used the term "the Cadillac" of systems, and this has been by experts that contacted us, and that our objection always was that this project, in its breadth and in its scope and the extent and its cost, was prohibitive based on that.

There has never been a suggestion that technology and that technological advance is not necessary and important, but the objection has always been the extent and the breadth and the scope of this particular project. So I just wanted to get that on the record, not that I think it will affect debate considerably, but the fact is that it always was our position, and it remains our position.

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Mr. Praznik: Mr. Chair, an interesting comment by the member for Kildonan. I share with him, as well, the affordability of everything we do in health care. Many times the demands put upon us in the service are for the Cadillac version, and those are not always realistic, within our means or within the size of our population.

I note his point. I acknowledge it and I hope that it is also the same in other circumstances where it is appropriate. We may debate that from time to time, but it is worthy of note, and I acknowledge that.

Mr. Chomiak: I am looking at the document that originally came out during the announcement of the SmartHealth initiative, be it the press release of December 12, 1994, and the subsequent press release dated February 22, 1996, wherein under the term Estimated Five-year Cumulative Benefits there is a breakdown of both the costs and the saving initiatives that would be undertaken under SmartHealth.

Can the minister indicate whether or not all of these categories are still on as part of the SmartHealth program?

Mr. Praznik: Mr. Chairman, I am going to ask Mr. Potter to answer this as his branch is responsible for this particular area.

Mr. Potter: Mr. Chairman, looking at the document, the categories of the savings are still appropriate. The actual dollar levels are being firmed up through the SmartHealth process. So I would not want to confirm the specific number shown there at this point in time, but I believe the general intent of that document is still in place.

Mr. Chomiak: Last year at Estimates, the minister handed out a document called Project Forecast which outlined the status and the time line for the SmartHealth initiative. Do we have an update of that?

Mr. Christopher O'Neill (Health Information Network): Mr. Chairperson, we are moving along according to the time lines that were indicated last year. We are currently implemented on the expansion of the drug program network into the acute care facilities in five sites across the province. We are a few weeks behind on that time line. It was originally anticipated to be started by the end of November. Unfortunately, we did not get started until mid-December and on our initial implementation, I do not have the time line in front of me, but I believe it indicated that we would be completed by summer. It is now a couple of weeks past that, but, generally, we are on track with that one, a little bit behind.

On the diagnostic network, the time line for that is to implement initial functionality or initial applications this fall. Those will cover the reporting both of test histories and test results and also some management reporting functions such as workload measurement. That is anticipated for this fall. That project is currently in detailed design and, in fact, we have a presentation with third party vendors next week, where we are going to be releasing the communication standards and the data standards, so that third party vendors can start working towards making their physician practice management systems compatible with the network and lab information system network.

Mr. Chomiak: Mr. Chairperson, just so I understand it correctly, the category diagnostic testing I believe you referred to, and on last year's chart it was called test reporting, I assume is one and the same. That, therefore, means that test results and histories on individuals will be made available to physicians and personal care homes by this summer or this fall, because that is how I read it on the chart. Is that what you are intending?

Mr. O'Neill: That will start this fall, yes. What we are going to do is essentially a similar process to what we did with the drug program network. This fall we will be implementing in a small number of labs for the input of the results and a small number of physician clinics to give them that functionality. We will go through a period of time whereby we will test that and make sure that everything is working properly before we go into a full rollout to all of the other facilities. By the end of that total project, fully implemented, that application of test results, histories and what not will be implemented in. If the numbers do not change radically--and of course physicians come and go and what not--that application will be implemented in approximately 275 labs across the province and clinics with 1,300 physicians, plus physicians working strictly in hospitals, plus physicians working strictly in personal care homes.

Mr. Chomiak: Mr. Chairperson, so that will mean that all recent lab tests on an individual will be accessible at those sites as illustrated. As you indicated, that is the clinics, PC homes, hospitals and one other site will be accessible, and lab sites will be accessible and accessible at the terminals. Is that correct?

Mr. O'Neill: Yes, Mr. Chairperson, that is correct and not only just lab tests but also radiology tests, things like ultrasound, that sort of thing. Now when we say test results, particularly with X-ray or radiology tests, at the early stages we are not suggesting that the actual X-ray would be available on-line. It would be the radiologist's written reports regarding the X-ray. However, we have architected and designed the system so that where the need is shown for the actual X-ray to be on-line, it is designed to be able to do that. It is just at the front end, it is just the written, it is a textual result as opposed to the actual radiology.

Mr. Chomiak: Mr. Chairperson, but those test results are limited only to the sites you indicated. What about hospitals, individual physician offices, and the like?

Mr. O'Neill: Sorry. Maybe I was not clear. That is the 1,300 physicians that I was talking about, that is, in their private practices. Once we get well underway with physicians in their private practices, we will be providing the physicians who work strictly out of hospitals, physicians who work out of personal care homes. So they are included in that. And as well, by the way, physicians who work in community clinics and the community health sector, as well.

Mr. Chomiak: Mr. Chairperson, how will that work? Just in a straight simplistic role, an individual who attends at their doctor's office, and then they visit a particular clinic and have a test, and then subsequently they may go to Manitoba Clinic or some other facility and have another test, and then subsequently they are attending at a consulting physician's office at one of the institutions. Is it therefore the system will pick up each test at source and then channel it to a central repository that puts it back to the consulting physician? How does that work?

Mr. O'Neill: Mr. Chairman, what we are developing is a central database where on the labsite or the radiology site, the results of the test would be input and would be stored in a central database, and then physicians that have access to the system would access that database, so that they would all be looking at the same information.

Mr. Chomiak: Mr. Chairperson, who will input that information?

Mr. O'Neill: The information will be either manually input at the labsite by staff within the lab, or where it is deemed appropriate and where it is available, it may automatically be transferred from automated lab systems directly into the system through an interface.

Mr. Chomiak: Mr. Chairperson, the cost of the input and the cost to labour and the associated costs related to that, where will that cost be borne?

Mr. O'Neill: Mr. Chair, that is currently one of the things that we are looking at in the detailed design. We have to take into account in the detailed design that there may be some input costs and of course that has to be offset against savings. I mean, we are talking about net cost not gross cost, but I do not have any firm information at this point. That is one of the things that we are still studying.

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Mr. Chomiak: To the minister, each of the repositories and lab sites will require hardware and software in this regard. Who will be paying the bill for the supply of this material?

Mr. Praznik: Those are matters that obviously have to be worked through, but I can tell the member, and we will probably discuss this when we talk about labs, and we have spoken about that already about long-term lab plans, but that fits into this issue as well. At the end of the day obviously we want it to be done in an economical fashion, and right now we pay for, even in private labs, through our fee structure, we ultimately pay for the equipment. It is always worked into the price of the lab test. It would have to be done here, but I wanted to flag with him that there are other things which we will be discussing in the next few weeks on labs which we believe at the end of the day will probably see a reduction in our laboratory costs over all.

Mr. Chomiak: I am aware of the issue, and I am certain we will get into the specifics of it. I do want to know from the minister whether or not the costs associated with this have been figured into the breakdown of costs as included on that sheet that I distributed earlier; in other words, the $100-million to $112-million expenditure item with relation to SmartHealth.

Mr. Praznik: Mr. Chair, I am going to ask Mr. Potter to answer that. He is much more familiar with the detailed numbers here than I.

Mr. Potter: Yes, my information is that the costs of the equipment to put the infrastructure in place are part of the costs of the network that we are establishing.

Mr. Chomiak: So will that mean that the 1,300 physician offices, for example, that require terminals to be recipients and both generators, I suspect, of information, that cost will be borne within the $100-million item?

Mr. Praznik: Obviously the cost has to be borne. One of the issues that we are dealing with, with the MMA ultimately in one of the discussions we had with them, is we know that there are some costs related with physicians and how they interact the system. That is the subject, obviously, of our negotiations at larger tables, but obviously no one is expecting a free ride on anyone's back in this process. One way or another it has to be worked into the system and properly accounted for in the costs of a new information system versus how we do things currently.

Mr. Chomiak: My question was though whether the costs associated with that will be borne within the $100-million to $112-million overall expenditure for SmartHealth?

Mr. Praznik: I am advised yes to that question.

Mr. Chomiak: Moving along, the card system was scheduled last year to be operational some time this year. I wonder if we might have an update on that.

Mr. O'Neill: We currently are beginning the process of looking at the cards in terms of what information will be stored on them and the actual design and then how it fits in both with the Health Information Network and the new technology that we are coming out with and also the existing systems for registering people and what not. At this point, we still anticipate that sometime this fall we will be ready for that, yes.

Mr. Chomiak: Are you indicating that the information is going to be encrypted on the cards?

Mr. O'Neill: That is what we are looking at, at this point in time. We have not made any decisions on that. Just to clarify, we are not looking at a smart card for the health cards. It would be like a magstripe card not a smart card.

Mr. Chomiak: I always understood the intention would be for the information to be stored in a central repository with the cards being utilized for access and information and that, from your answer, I assume is still the case.

Mr. Chairperson in the Chair

Mr. O'Neill: Yes, that is correct.

Mr. Chomiak: Moving along, the next item that was listed last year indicated the drug profile would be available at physician level, as well, this year. Is that also on target?

Mr. O'Neill: Yes, what we actually plan on doing, as I mentioned earlier, we are now in the process of implementing the drug information in the acute care sector. When we start this fall in implementing the diagnostic information in the physician's office, what we plan on doing is at the parallel time, since we are putting in technology for the diagnostic, is also making the drug information available. So they are separate projects but they are parallel processes.

Mr. Chomiak: Just returning to the cards again for a question, will each individual in Manitoba be assigned a card?

Mr. O'Neill: That is what we are currently looking at, are the pros and cons of those types of issues. I do not have a definitive answer at this point.

Mr. Chomiak: Versus a family card.

Mr. O'Neill: Yes, versus the current family card, everything being on one card. That is one of the issues that we are looking at.

Ms. Diane McGifford (Osborne): Just to flag the card, being the critic for the Status of Women and often dealing with single-parent families or families where there has been a split in the family, it might be something that you want to consider in your planning. I am envisioning somebody making off with the family cards and all kinds of possibilities, so I just wanted to flag that.

Mr. Praznik: Mr. Chair, I want to thank the member for Osborne for that comment because that is a point that must be worked into the planning. There are families that have joint custody of children, and those are the kinds of logistics that are going to have to be thought through in this process. I appreciate her flagging it with our staff.

Mr. Chomiak: The next category on last year's chart was test ordering. Can we have perhaps an explanation of that and an update?

Mr. O'Neill: What we are talking about there is that, rather than being sent to the lab, either with the patient or via fax or mail or whatever, the order would actually be entered at the physicians' offices, initially probably by staff of the physician but eventually by the physician himself.

That project is currently in the conceptual design phase, and we are still doing some work on that project, but at the moment we are currently trying to focus on the test results reporting side of it and get that underway. That is our priority at this time.

Mr. Chomiak: I assume from that response that the test ordering will not be on for this year.

Mr. O'Neill: I believe our current plans are for very late in the fiscal year, if not early next fiscal year.

Mr. Chomiak: So that I can understand it correctly, that will mean that the primary care provider, rather than enter on the paper forms that we presently utilize, will presumably enter into a computer terminal the specific tests requested. That will be the process that will be entered into, as opposed to the paper system that now exists. Is that what the intention is?

Mr. O'Neill: That is the long-term goal. Again, I think the first version of that capability that we will see will be where the physician will actually do some sort of a manual paper process and then hand it off to an administrative person within their office, but eventually what we envision is where the physician would actually have the capability right at his desk, in one form or another, of ordering tests, ordering prescriptions, also looking at histories and what not, instead of requesting them from an administrative person. That is when you really start to see the work flow and the administrative benefits, is when the information is right in the hands of the care provider.

Mr. Chomiak: For the minister, has that specific issue been discussed with the MMA?

Mr. Praznik: I know Mr. O'Neill has been involved in these issues. I am going to have him answer the current status of discussions.

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Mr. O'Neill: Yes, we have a physician and primary care provider advisory committee, which is made up of representatives of the College of Physicians and Surgeons, the Manitoba Medical Association and, as well, the College of Family Physicians and just individual physicians. And we are having those discussions with those organizations as a part of this design process.

Mr. Chomiak: So presumably they are much further ahead on this than I am, and they would be aware of the fact that this is what will be required of them in the future and that they are sort of working along those lines. Would that be a fair statement?

Mr. O'Neill: They are aware of it. I must say that we are still in design, so things are still being discussed. I also want to make the point that I do not know if it would be fair to say that it will someday absolutely be required that a physician has to use a computer. There is a broad spectrum of physicians, some of whom are very computer literate and others who are not. So I think we have to provide a broad range of capability, but our intention is to, where it is deemed appropriate and what not, to have the capability right in the hands of the physicians and alternatives where it may not be appropriate for whatever reason.

Mr. Chomiak: I would also presume for the minister that the costs associated with that will also be part of the $100-million or the $112-million overall expenditure?

Mr. O'Neill: Yes, that is correct, sir.

Mr. Chomiak: Even considering that, I would presume that that would come out of the MMA agreement to some kind of tariff and fee schedule, I would assume?

Mr. Praznik: Mr. Chair, how we provide for that is still going to be subject to negotiations and one of the issues that the MMA raised with us in dealing with their involvement in this is that we agreed that the issues that affect have a financial cost to physicians, would have to form the subject of a negotiation; obviously, it has to be worked into either fees or special payment or what have you, that we could not be offloading our system onto others. It may, in fact, be incorporated into general administrative accounting on fees, but that is something that we have to--and there are obviously offsets to that as well in savings--deal with separately once we have a better handle, as Mr. O'Neill said, on exactly what we are doing and their costs, benefits, savings, et cetera.

Mr. Chomiak: Continuing along this project forecast line, the next item is electronic prescriptions. I assume that it is similar to test ordering and would require the primary care physician, a person, the primary care person, rather than simply to fill out the paper, to input it accordingly. Is that correct or, if not, could you explain that to me?

Mr. O'Neill: Yes, again, ultimately the long-term goal is that the physician would order tests, order prescriptions, right on-line, right at his desk. Again, though, I think that the first version that you would see would be where, as currently happens, the physician does a paper process. The current system with the DPIN is that the physician does a paper process; hands it to the patient. The patient takes it to a retail pharmacy.

What we are envisioning when we have online ordering in the HIN environment would be that the physician--the first version anyway--would do a paper process; it would be keyed in by an administrative person within the physician's office and then stored on the system. Then when the person attends at a pharmacy to have it filled, they would access the system and pull it down.

Mr. Chomiak: Is there a public information campaign being planned to associate with these initiatives?

Mr. O'Neill: Yes, we have a work plan for public communications, and we do a fair amount of speaking engagements, if you will, or presentations to all sorts of various and sundry groups as a part of these roll-outs that we do. Once we get into actual applications being rolled out, we will be doing much more.

Mr. Chomiak: Mr. Chairperson, it may be appropriate for the minister or not. When you stated we, who is undertaking this communication aspect? Who in the department is undertaking that?

Mr. Praznik: Mr. Chair, this will be done jointly. I know I have had some discussions with SmartHealth. Obviously, they have a role to play. Certainly, because of being minister responsible and these issues get raised, I will want to make sure that I am in a position to be part of that as well, because we get the questions. So there will be some joint planning on ensuring that there is a good public information. I know that MLAs will want to have a material package as well when we deal with inquiries, so that is part of what will have to be developed.

Mr. Chomiak: Is Mr. O'Neill an employee of Information Systems of the provincial government?

Mr. Potter: Mr. O'Neill is a staff of the department.

Mr. Chomiak: Is he the managerial person in item 2.(c) of the Expenditure item?

Mr. Potter: Mr. O'Neill is the Manager for HIN, our Health Information Network project, and the expenses that he incurs or his office incurs are included in that line, but there are other expenditures related to departmental Information Systems as well.

Mr. Chomiak: Mr. Chairperson, so the managerial position referred to, the one position, that is Mr. O'Neill, I assume.

Mr. Potter: Mr. Chairman, I believe that particular managerial position refers to the director of our Information Services group for the Department of Health. That group is focusing on the computer, the technology resources within the department specifically, whereas Mr. O'Neill is leading up the project related to the HIN.

Mr. Chomiak: Mr. Chairperson, well, where in the Supplementary Estimates would his position be located?

Mr. Potter: I believe that position is included in the Professional/Technical category there.

Mr. Chomiak: That is where it is noted there are 48.9 FTEs, and I see there is an affirmative response.

How does Mr. O'Neill and his group relate to the SmartHealth initiative? What is the relationship between this branch and SmartHealth?

Mr. Potter: Mr. Chairman, I think the explanation should begin with indicating that SmartHealth is the contractor that is employed by the department to develop the HIN, in partnership with the department. Mr. O'Neill is the person leading the project from the department side and, in that respect, works very closely with the SmartHealth organization and staff as they proceed to do the development work.

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Mr. Chomiak: The total subappropriation in this area is roughly $7.8 million. How much to date has been expended on SmartHealth and, secondly, how much is projected to be expended by the end of this fiscal year?

Mr. Potter: This explanation will get somewhat complicated in the fact that the arrangement with SmartHealth includes a deferral situation in terms of costs incurred by SmartHealth. So the costs are incurred by SmartHealth and then, under the terms of the agreement, are deferred in terms of claim to the Department of Health or to the government until a point in time is reached. I cannot remember the exact point in time right now.

Up to now there has been no cost paid to SmartHealth as a result of the work that they have done under the deferral, but the billings in total are approximately $6.7 million in terms of work performed. Those amounts will become due in the 1998-99 fiscal year, and those development costs will be borne by the Health Information Systems Management Corporation that was set up to operate the HIN.

Mr. Chomiak: Just so I understand it correctly, the $6.6 million, or roughly the figure that Mr. Potter indicated, will be applied to the $26 million, for lack of a better word, line of credit that was extended under the corporate loan for '98-99. Is that the extent of the expenditures, or have I not taken this correctly?

Mr. Potter: The $6.7 million that I referred to are costs that have been incurred by SmartHealth and billed to the province under the deferral and will become due to the province or by the government during 1998-99. The line of credit, as I understand, is an internal arrangement with SmartHealth and their corporate partner, The Royal Bank, and that is the way they finance their cost. It is not an arrangement that the province of Manitoba has in terms of this arrangement. That is an internal arrangement for the SmartHealth corporation so their costs are being paid through their internal financing arrangements which may well involve the use of that line of credit. I cannot comment on how SmartHealth does their financing, but the way the costs will be paid by the province is that these development costs will be paid through the Health Information Management Corporation.

Mr. Chomiak: The costs will be paid for by the Manitoba Health Information Corporation which is not the agency that has the line of credit arrangement with SmartHealth.

Mr. Potter: I am informed that the line of credit does equally apply to the Health Information Management Corporation.

Mr. Chomiak: So how much specifically of the $26-million line of credit has been drawn on?

Mr. Potter: I am advised, Mr. Chairman, that the line of credit could only have been drawn by the amount of the $6.7 million that has been spent today.

Mr. Chomiak: So let me understand this correctly. There is a bill that is coming due this fiscal year of $6.7 million. Presumably, the $6.7 million has been drawn from the line of credit of $26 million. At the end of this fiscal year, the $6.7 million will actually be paid out by the province to replenish the line of credit or directly to SmartHealth?

Mr. O'Neill: The $6.7 million is owed by the government of Manitoba to SmartHealth Inc., and as the invoices come due we will process payment to SmartHealth Inc. I think what we are trying to indicate here is that the government of Manitoba has not drawn on the line of credit. The way it works is, as SmartHealth invoices us, they draw on the line of credit to fund their operations and then defer our invoice. So the process is when the invoices come due, we pay the invoices and then SmartHealth replenishes, as the member said, the line of credit because it is a revolving line of credit.

Mr. Chomiak: So it is an interesting issue whether or not $6.7 million has been paid to SmartHealth. Presumably, $6.7 million has been drawn from the line of credit.

Mr. Potter: Mr. Chairman, the amount coming due by the province to SmartHealth is $6.7 million, and there is a liability of the province to SmartHealth for the $6.7 million. The way SmartHealth has financed that is by drawing on the line of credit, and we will have to pay the bill to SmartHealth.

Mr. Chomiak: So do we know how much money has been invested by our partner SmartHealth in terms of capital and in terms of costs in this area?

Mr. Potter: No, I do not know what costs that SmartHealth may or may not have incurred that are not part of their billings to us, if there are any. All I can relate to is the costs owed to them and billable to the government under the agreement with SmartHealth.

Mr. Chomiak: So the staff at SmartHealth are paid by SmartHealth. Does that money come and comprise part of the $6.7 million?

Mr. Potter: The arrangement with SmartHealth under the agreement works on the basis of approved work plans, and as a work plan is approved, included in the work plan are input costs related to salaries. These could be or would be salaries of people working in the SmartHealth corporation.

Inasmuch as these costs are accepted under a work plan, they then become liabilities of the province of Manitoba under our arrangement with SmartHealth, but there is no direct linkage in terms of SmartHealth employing someone and it automatically becoming a cost to the province of Manitoba.

Mr. Chomiak: Do we have a list of the head office staff of SmartHealth, and can that list be provided?

Mr. Potter: I do not have a list other than what is available through a telephone directory for SmartHealth.

Mr. Chomiak: This might be directed towards the minister. It is very clear that much to do with SmartHealth is contingent upon SmartHealth locating and operating a head office in the city of Winnipeg. In fact, many of the conditions of the agreement with SmartHealth are subject to a head office being operated in Winnipeg.

How can we confirm that, in fact, particularly in light of the fact that there has been a 51 percent sale of SmartHealth to EDS, how can we confirm that in fact head office operations are continuing here in order to hold them to the conditions of the contract? Because much is contingent upon that.

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Mr. O'Neill: It is my understanding that SmartHealth maintains their head office here. Since the amalgamation with EDS their staff has grown. I do not know the exact number on the date that they amalgamated, but they currently now have 80 staff here in Winnipeg. I do believe that they have opened a very small office with possibly one person in Newfoundland because apparently there is a project coming up in Newfoundland that they plan on bidding some time in the future.

I also, just via coffee shop talk, understand that they have a very small office with perhaps one person in Toronto, but their main operation, as I understand it, is here in Winnipeg.

Mr. Chomiak: I, understand as part of the EDS agreement, there was a $1-million deal to market SmartHealth. Can the minister provide us with details as to that agreement? As part of the sale to EDS, there was a $1-million provision for the marketing of SmartHealth. I wonder if we might have elaboration of those details of that?

Mr. Potter: I am not aware of the details of that. My understanding of the question is that it is an arrangement between EDS and SmartHealth, and I am not sure that it relates to the province's agreement with them, so I have no information on that.

Mr. Chomiak: So the establishments of offices in Newfoundland and Toronto and various other operations of SmartHealth are outside of the scope of our involvement with SmartHealth. Is that the minister's response?

Mr. Potter: Yes, Mr. Chairman, I believe that is the correct situation.

Mr. Chomiak: Earlier, reference was made to the cost for SmartHealth. Do we have any revised or any updated figures as to the costs?

Mr. Potter: The agreement with SmartHealth relates to an investment or an expenditure of $100 million over a number of years to produce a Health Information Network. The amount of $100 million is still the amount of the expenditure under the terms of the agreement with SmartHealth.

Mr. Chomiak: How many modules have been approved to date?

Mr. O'Neill: I am sorry, I am not sure I understand the question, Mr. Chairperson. Modules or approved work plans?

Mr. Chomiak: I am using the word "modules" because I believe that was the terminology used by the previous minister in terms of expenditures. I understand that expenditures were related to modules that are approved, and I am wondering if he might have an explanation on that?

Mr. O'Neill: In terms of modules that are approved and being worked on, again, in the diagnostic sector, work is underway in the two reporting modules and the ordering module and the linkages to research data bases modules, so there are four within the diagnostic and there is one within the pharmacy. That is the expansion of the DPIN to the acute care sector. We are doing the feasibility analysis and the consultation process on the community health at this point, and we are working on the detailed design on the actual infrastructure in the networking. I lost count as I was talking there, but that is what has been approved.

Mr. Chomiak: Mr. Chairperson, the reference to community health, and it is referenced in the project forecasts, what specifically is that reference made to?

Mr. O'Neill: Mr. Chairperson, the community health component is current in the feasibility initial-analysis stage, which means that what we have done is we have set up an advisory committee made up of representatives from that sector of the health industry and we have begun initial consultations with them. We have not completed that yet, so I do not have any specific information at this point. That process is anticipated to be completed within this fiscal year, probably by late summer, early fall, but at the end of that process we will have up to five functional modules in the community health sector.

In terms of what do we mean by the community health sector, that is one of the things that we are discussing now. As the members know, the community health sector is very, very broad. At one end such as community clinics and what not is very distinct and it is easy to define, but then you get off into the edges and it gets very vague. One of the consultations we are having is where to draw the line in terms of what is within the scope of the Health Information Network and what is not.

We know for sure at this point that the community health clinics and such distinct services as home care and what not are in. It is when you get off into things like street programs and those sorts of things that it get a little vague, and we are not sure exactly where the line is drawn.

Mr. Chomiak: Mr. Chairperson, who is making that determination?

Mr. O'Neill: We are making that determination in consultation with the community health advisory committee, again made up of representatives. We take into account their views in terms of who needs access to information and what not.

Mr. Chomiak: Mr. Chairperson, part of the program for SmartHealth is the revising and developing new clinical guidelines. What is the status of that particular item?

Mr. O'Neill: The status of that is again currently under discussion with our physician and primary care provider advisory committee as one of the things that needs to be undertaken as a part of that component. At this point, the status is that we are at a very, I guess, broader, high-level point of discussion in terms of recognizing the need for it and doing some initial analysis of what is currently available and therefore what needs to be developed.

Mr. Chomiak: Mr. Chairperson, is it still the intention to integrate population-wise statistical information on illness and treatments, the pre-existing base together with this new base. Is that still the intention?

Mr. O'Neill: At the present time, yes, and again, that is still under discussion with the physician community.

Mr. Chomiak: Is it still the intention to maintain individual health records at the central database on individuals?

Mr. O'Neill: Sorry, I want to be very careful in my answer here, because what we are not looking at with the Health Information Network is a centralized, all-encompassing patient medical record. What we are looking at with the Health Information Network is a series of profiles, of pieces of an all-encompassing medical record, those pieces being what is important to be shared amongst providers over time.

So, what will be on the Health Information Network will be a subset, if you will, of what might be in a medical record in, say, for instance, an acute care facility or a physician's office and only that information which is useful to others outside of that environment.

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Mr. Praznik: One point, just on Mr. O'Neill's comment, when I was dealing with the physicians in the MMA, a point that they made to us and to me, and I share it with members of the committee, is just, for example, when you see a physician and you are diagnosed with a particular illness, the diagnosis might be very important to other care providers. The personal notes or information that may surround it, how you got the illness, that may be very sensitive to an individual on the practices in their life, sexual practices, what have you, that may form part of the record. That is not the information that is part of this, and I know that is a point, I think, that is very important to make so that the confidentiality of that kind of note material is not part of the network of the system but the kind of information that is essential to other health care providers, the results of a diagnostic test, a diagnosis, a treatment pattern.

Just for example, Mr. O'Neill may want to elaborate, but I think the member raises a very important point, and I think it is important to have that on the record.

Mr. Chomiak: That is a central point, and I would like some elaboration on what the intentions are in this regard.

Mr. O'Neill: Well, again, that is a good point that the minister made. That is what I was trying to indicate when I said that it is a subset. We do not want all of the information on the network, because some information, first of all, is sensitive to the individual. Second of all, it really has no value over a period of time or to another provider.

For instance, just to use another example, people in hospital, quite often, the volume of liquids that are taken in by them in a day and expelled by them in a day are kept on a record, but that type of information has no value after that person is discharged from the hospital. So what we are doing is, we are consulting with the providers themselves to try and determine what specific information has value to the providers, and that is what we will put on the network.

Then, of course, we have to balance that off with things like the privacy legislation, privacy confidentiality and what not, and time relevance.

Mr. Praznik: Just on the issue of time relevance, for example, when we did the roll-out on the Pharmacare side of this, and I know the member was at the announcement at Seven Oaks Hospital, and I attended the one at Beausejour Hospital. It is important to note, I think, the information falls off the network, in essence, after the end of the sixth month. So it is in essence, the longest any of your prescription history could be on would be a day short of seven months, I gather.

It was felt with the care providers that after that length of time your prescription history is really not relevant to care providers. So, again, these are the types of issues that are being worked on and developed as we move forward to ensure that it is information that has a use that is respectful of privacy legislation, individual's privacy. It has a use to other providers and it is structured in a manner that it is time dated. So when the relevance of that information is no longer there, it should not be available on the system.

Mr. Chomiak: So, if one would assume that on the record would be a diagnosis of tuberculosis, relevant lab tests, various X-rays, prescription drug pattern, presumably that would be the kind of information that would be on the central record. Would that be correct?

Mr. O'Neill: Yes, I think that is a fairly accurate description of what might be there.

Mr. Chomiak: But then within the context of that, presumably at some point that information would be available at the institution, but it would be a portion of it, for example. The pharmacists, for example, would not have access to the lab tests or the X-rays, et cetera, but only have access to the prescription profile, et cetera. Is that the intention?

Mr. O'Neill: Yes. The security model that we are looking at--and I confess this is an extremely complex area that even I am learning a lot in lately--is whereby providers would only be given information based on their need to know. So depending on what their role is, what their profession is, also where they are located--physicians have a different role in their private practice than they do in an acute care setting or a personal care home, and of course physicians work in all those environments--so the security model and access model that we are working on implementing would be based on who the individual is, what their specific role is and where they are actually located, and then, as well, the confidentiality wishes of the individual whose information they are looking at.

Mr. Chomiak: The proactive clinical guidelines in enabling preventative care programs, what is the status of those?

Mr. O'Neill: That is a part of the consultations that we are having at a high level in terms of feasibility in our consultations with the physicians and primary care providers.

Mr. Chomiak: The previous minister three years ago told me that this would entail something like individuals, for example, who might have a genetic predisposition to a particular illness, say, colon cancer, being regularly informed that they need a particular kind of examination. Is that still the intention?

Mr. O'Neill: That is one of the things again that is being looked at as a part of this feasibility study in consultation with the physicians and primary care providers.

Mr. Chomiak: Is it also intended to maintain a database that would enable studies and analyses to be made on an anonymous basis?

Mr. O'Neill: I am sorry. I did not hear the latter part of the question.

Mr. Chomiak: Would it also allow the maintaining of a database that would allow for research studies and other studies on an anonymous basis?

Mr. O'Neill: Yes, that is correct. The Health Information Network project consists of two databases, the first one being the one we have been focusing up to now of the patient-identified information used for providing care to individuals. That database will then provide aggregated data to a data warehouse which could be used for research purposes or policy planning purposes or health administration purposes at the facility level. But the information within the data warehouse would be aggregated anonymized information.

Mr. Chomiak: Much has been made about the availability of data. Can the minister confirm that the data that will be warehoused will not be used for profit by SmartHealth or any of its subsidiaries?

Mr. Praznik: I am going to have Mr. Potter or Mr. O'Neill answer this because I believe it is dealt with specifically in the agreements, if I am not mistaken, as well as the legislation which Mr. O'Neill was part of drafting and one of my key people in putting it together.

Mr. O'Neill: I do not have the act in front of me, but I believe that is specifically prohibited in The Personal Health Information Act.

Mr. Chomiak: Perhaps we should take a break at this point for a few minutes.

The committee recessed at 3:48 p.m.

The committee resumed at 4:01 p.m.

Mr. Chairperson: Order, please. The Committee of Supply please come to order. We were into the Estimates of Health.

Mr. Chomiak: What is the status of the remote lab testing portion of the SmartHealth initiative?

Mr. O'Neill: I am not terribly sure. I know for the test results reporting, as I say, we are in detailed design on that. Specific to the remote lab testing, I am not sure. I would have to check that out and get back to the member if I could.

Mr. Chomiak: You are familiar with what I am referring to, or is it--because under the tactical initiatives put together by SmartHealth there was a category called remote lab testing. Tests can be taken locally in remote areas, interpreted or analyzed through technology such as remote imaging or accessed to diagnostic specialists and major medical centres. This would reduce the need for people to leave their home communities to obtain medical tests.

Mr. O'Neill: I am familiar with that. That also ties into the whole area of telehealth and what not. As I say, I understood the question. I am just--off the top of my head, I am not sure exactly where that is at.

Mr. Chomiak: Can you elaborate on what is telehealth?

Mr. O'Neill: There are a number of areas in telehealth. The one that people tend to hear most about, of course, is on-line live video diagnosis or consultation, but, as well, telehealth involves such things as remote transmission of test data to be reviewed later, all of those sorts of areas.

The general approach that we take with the Health Information Network is start off with things that are needed but that are relatively, in the overall scheme of things, simple to do and then build on from there. So in terms of telehealth, it is one of the consultations that we are having that is a part of the community health component, but the applications that we are looking at at the front end for first versions would be the lower end, the more simpler, less technological telehealth applications.

Mr. Chomiak: When you refer to telehealth, are you referring to a sort of generic description, or is that sort of the terminology being utilized within SmartHealth and environs for some particular projects?

Mr. O'Neill: No, I use it in the generic sense--all of those technologies or all of those services that are provided remotely, from the very simple to the extremely complex.

Mr. Chomiak: But are we looking at those particular projects to be on-line and operating within the five-year period; well, I guess now within the remaining three-year period?

Mr. O'Neill: Again, we have designed an architect at the network to be capable of providing on-line, real-time diagnostic capability. In the short term, for the first five years, we will probably, my guess at this point, not be doing the on-line, real-time diagnosis but other telehealth applications. For instance, we are looking at providing functionality to northern nursing stations as a part of the project within the five years. Specifically what would be provided, though, I cannot really say at this point because we are still in the feasibility discussion stage.

Mr. Chomiak: This might be to the minister or the associate deputy minister. Is there any kind of a schematic or any kind of a forecast that updates the sort of overall status of those initiatives in an overall sense? There must be some kind of departmental outline of that.

Mr. Potter: There is nothing available at this point, but we can put something together and provide it.

Mr. Chomiak: I thank you for that. I may return back to this, but on some more general oriented questions; there has been much talk for many years about the information system requirements for the Home Care program.

What is the status of that? Where is it found, and is it any relation to the SmartHealth initiative?

Ms. Sue Hicks (Associate Deputy Minister, External Programs and Operations): Mr. Chairperson, the Home Care has looked, is looking at a number of information areas. I am not sure which one you are referring to. We do have a plan for an assessment information system that is being planned, and has been planned specifically for home care uses, but the intent is to link it into the information system, eventually with the department. That is the SACPAT program that has been discussed.

Mr. Chomiak: Could you perhaps give me a little broader description of the SACPAT program?

Ms. Hicks: Mr. Chairperson, the SACPAT program is an automated program that does the assessment of clients, and so it would then have the ability to standardize the assessment for home care clients, and can basically be the entrance point, we hope, for assessment for home care categorizing and also for personal care homes, and for essentially determining the level of care and the needs of people entering into that component of the system.

Mr. Chomiak: Correct me if I am wrong, but at present there is a fairly extensive written document that is used as the basis for assessment program that is utilized in the home care system. Is that correct?

Ms. Hicks: Yes, that is correct. It is done manually at the moment.

Mr. Chomiak: The plans are to take that manual program and convert it into an electronic or an autronic program. Is that correct?

Ms. Hicks: The plan is not to take the exact program. It is similar information with some improvements, we hope, but basically to achieve the same purpose, only much more standardized and much more efficient.

Mr. Chomiak: This is what is referred to as SACPAT, which is an acronym for?

Mr. Praznik: Mr. Chair, I think that, when we get into areas of regional health authorities, later on, obviously there is an interest in this area. We may want to, along with Marion Suski, also make sure John Borody, who is dealing with home care in the Winnipeg region, be available as well, who will probably have more information. So we will note it, and we will make sure that we get you someone who is more involved in the details of it.

Mr. Chomiak: What is the relationship and the integration between that proposed program and the SmartHealth program?

Mr. O'Neill: The discussions that we are currently having is that, once that program is developed and available, making it available online, so that--and again this is still in a preliminary discussion phase--whereby people who have to require input information into that program can do it electronically via the Health Information Network. Or people who are wanting, for placement purposes, to see who is on that system, and what their needs are, would be able to access it remotely.

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Mr. Chomiak: In September 1995, the minister indicated that the home care computer project was part of the ISM project. Can I have some elaboration on that?

Mr. Praznik: Mr. Chair, my staff are not quite sure of the member's question. Perhaps he would like to elaborate a little bit more.

Mr. Chomiak: When querying the minister in September '95, I asked about the computer program with respect to providing for better data information as it relates to home care. The minister at that time indicated in a response to me that the home care computerization program was part of the ISM network program. Now, that may or may not be correct, but that was the information that was conveyed to me by the then minister.

Mr. Praznik: Mr. Chair, it goes back some time, obviously before I was Minister of Health. I am going to ask the member for his indulgence. We are going to check back on that record and check back as to the context. Perhaps we will be able to provide him with an answer.

Mr. Chomiak: One of the issues that has been constantly flagged with respect to home care--and this may be better elaborated later on, but I will pose it anyway--is the whole question of information system management as it relates to home care. Aside from the SACPAT program that is being developed, what are the other areas that require work?

Ms. Hicks: Mr. Chairperson, the areas that we have been focusing on in home care have been in the assessment through the SACPAT tool, which is a tool that has screening and care planning and those kinds of things that will essentially provide a more efficient care plan and standardized assessment tool. The other area that we are focusing in on has been the financial, to get the units of service and the costs of the units of service to the point where we can access it readily as opposed to doing it manually.

Mr. Chomiak: I am sorry. I do not quite understand that last answer. Can you perhaps elaborate on what you are proposing to do?

Ms. Hicks: Mr. Chairperson, I cannot elaborate in total detail at this point because we are working on it, but essentially what we want to do is streamline the financing, so that we can more accurately determine the costs of the service, what the service is providing for us and where it is going, and then link the service back to the assessment, so that there is confidence that the assessment is streamlined and that the costs and the appropriate service are going to the client.

Mr. Chomiak: Is it the vision that the individuals who will take part in each of the assessments with respect to home care will be provided with laptop computers or some other form of technology of that nature?

Ms. Hicks: Mr. Chairperson, I am not positive whether or not everyone will be equipped with a laptop, but there will be definitely electronic entering of the information. There are certain people in the home care program that do the assessments. Not all home care workers obviously do the assessments, so the case co-ordinators would be entering it through computers, and presumably in some instances laptops, and then that would go into the system.

Mr. Chomiak: From my understanding, the costs associated with that would be appropriated from where in the Health budgets?

Ms. Hicks: Mr. Chairperson, for SACPAT?

Mr. Chomiak: Yes, for SACPAT, as a start.

Ms. Hicks: Mr. Chairperson, where it will be located in the budget at this point, it has not been funded yet. Just one correction to that. We have been piloting the SACPAT program, and we have provided the funding for those pilots.

Mr. Chomiak: Most--not most but a good portion of the expenditures in the book make reference to a new rate structure for computer--well, that was two questions actually. I will come back. There is a new computer desktop initiative undertaken by the government, and some of the appropriations in the budget deal with that on an individual basis. Do we have a figure of the overall cost of that particular initiative?

Mr. Potter: I believe we have a number for the department and it is going to take us a few minutes just to find it.

Mr. Chomiak: In the interim, I note on the expenditure item under total Other Expenditures there is a reference to a new rate structure regarding computer processing that sees an increase of about $600,000. I wonder if I might have elaboration as to what that refers to.

Mr. Potter: Mr. Chairman, that relates to a cost increase to the Department of Health as a result of a restructuring of the rate charges that are coming from the ISM Corporation. The Department of Health continues to have computer systems which are operating out of ISM and we are charged a portion of those costs based on our agreement, contractual arrangements that exist between the province and the ISM Corporation.

For '98-99, the contractual terms have resulted in the costs for the Department of Health going up for the use of the ISM cost.

Mr. Chomiak: Do we have an overall figure for the cost of the rates charged, or not the rates charged but the overall cost to the Department of Health for the utilization of the ISM system?

Mr. Potter: Again, that information can be provided.

Mr. Chomiak: We have canvassed somewhat the DPIN and the HIN initiative under Information Systems. There are 92 staff years at Information Systems. Can I get a rough breakdown as to the activities of that particular branch? In other words, to make it simpler, I know that, for example, Mr. O'Neill and some group of individuals are charged with HIN. What are, in rough terms, the other 92 individuals' activities they are engaged in?

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Mr. Potter: I can provide again at a later date a more specific breakdown, but there are several components within this group. One area that needs to be noted is that, again, based on the Legacy Systems that the Department of Health has in place, we have a large number of data entry positions within this group, and their function is just that. It is data entry of information that comes in from physicians' offices and other health facilities for our computer system. On top of that, we have staff who are working on maintaining or operating the in-house computer facilities that we do operate, for example, in support of the DPIN system.

We have a small group of staff who are what we call a decision support group, and their function is to assist the department in the evaluation and the utilization of data that comes in through our health system, and we have a number of systems analysts, of course, who support the business function, but we can provide a detailed breakdown by grouping.

Mr. Chomiak: Is it a separate data system and information system which was formerly the MHSC component of information?

Mr. Potter: The MHSC computer system is integrated now within the Department of Health, and it is part of this unit.

Mr. Chomiak: Does the unit also maintain the warehoused information as it relates to our health data that is utilized by the Centre for Health Policy and Evaluation? Is that a separate system, or is there another system in addition to that?

Mr. Potter: I am advised that the data that the centre utilizes is part of our data which is serviced by ISM Corporation, so it is the data that is utilized or captured through that process, and it is provided to the centre under an operating agreement within a lot of restrictions as to the nature of the data, et cetera.

Mr. Chomiak: In five years of doing this, I have never totally understood the ISM arrangements and agreements. Is there any way I can get a brief description and breakdown of the systems, a breakdown of that information?

Mr. Potter: Yes, we can certainly do that. Basically, ISM is a service provider. When you require data-processing capacity, you really have two options. You have an option to build it in-house, and you have an option to outsource it by acquiring it from a service provider. For the Department of Health we have utilized both options to provide our information technology needs.

ISM operates what are termed legacy systems, and these are systems generally which are somewhat old and are operated under various old platforms. We also have a number of operating systems which are in-house systems, and DPIN is an example of one that was established more recently, and it operates on equipment which is owned and operated within the department itself.

We can get you a better description of the services that ISM provides to the department, but it really is just that; it is a data-servicing provider.

Mr. Chomiak: I appreciate that response. It is actually quite helpful.

There has been much talk over the years of a Central Bed Registry, for example, and there has been, I assume, work done on a Central Bed Registry. Has it been done out of this area of Health?

Mr. Potter: I am advised that, no, the issue of a Central Bed Registry is not falling within the information technology group.

Mr. Chomiak: Then can you give an elaboration as to where it would fall?

Mr. Praznik: Yes, Mr. Chair, I am just going to have Ms. Hicks answer that particular question because a Central Bed Registry is really a function of the new Winnipeg Hospital Authority, and how it fits into their planning and effort, I know we have been doing some of it based under the Misericordia over the winter, but really, with the WHA in place, they now have the ability to do it.

So Mr. Potter is going to answer another question, provide some information you requested earlier, while Ms. Hicks prepares to answer that question for you.

Mr. Chairperson: So who is going to be first?

Mr. Praznik: Mr. Potter.

Mr. Potter: The question was asked previously of the cost to the Department of Health for the implementation of desktop management. The information is that the net increased cost to the Department of Health on an annual basis is $800,000 for '98-99.

Mr. Chomiak: Yes, perhaps while Mr. Potter is still here, I will just go back to another question while he is still at the microphone. Just to go quickly back to SmartHealth. The $6.7-million expenditure, is that what is intended to be expended or billed or invoiced, whatever term we use, for '98-99 total, or is that to date?

Mr. Potter: The $6.7 million relates to costs incurred and billed to date under the deferred plan and will be paid by the government in '98-99. There will be costs incurred during '98-99 which will be billed and paid at a subsequent time.

Mr. Chomiak: So it is safe and correct to state that in '98-99 no other costs other than $6.7 million will be paid by Department of Health with respect to SmartHealth, and I assume that is because those were costs that were borne in last fiscal year; is that a correct assumption?

Mr. Potter: Yes, that is a correct assumption.

Mr. Chomiak: And then costs that are entailed in this budgetary year, that is, '98-99, will presumably be paid in '99-2000.

Mr. Potter: Within the terms of the deferral, yes. It is not necessarily a year-by-year deferral, but essentially that is correct. Costs that are incurred by SmartHealth this year will become due and payable by the government in the succeeding year.

Mr. Chomiak: I appreciate the response. I do not quite understand it. I mean, in my reading of the agreement, I do not quite see how that is, but I accept that that is the factual way that it is proceeding.

Mr. Chairperson: Ms. Hicks. Go ahead, please, Ms. Hicks.

Mr. Chomiak: Yes, are you aware of the question that I had posed?

Ms. Hicks: The bed registry is a tool that we do plan to have introduced, and it will be an operating tool of the Winnipeg Hospital Authority. At this time it is not linked into the information system that is being developed but, with the information systems that the Winnipeg Hospital Authority is looking at, I understand that eventually there will be a melding of the bed registry into that. And I am not talking in technology terms here, but it is not a priority of their information system, it is a priority from their operating perspective. They will have it operating, and then it will eventually fold into the automated system or into the information system.

Mr. Chomiak: I appreciate the fact that it has now come under the auspices of the Winnipeg Regional Health Authority. Is that a correct assumption?

Ms. Hicks: Yes, the intent is that it will be a tool for the hospital authority. It is an operating tool, so the hospital authority and, obviously, Manitoba Health will use it, but it is being dealt with through the Winnipeg Hospital Authority.

Mr. Chomiak: Has there been work to date done on the Central Bed Registry?

Ms. Hicks: Yes, there has. We have a manual bed registry process right now, semi-manual actually, where at certain periods of the day reports of the beds are sent to a central location, and everyone is informed of the status of the beds daily.

Mr. Chomiak: How long has that been operating?

Ms. Hicks: We have had versions of that operating for years. We formalized it a little more during the flood, I believe, of last year and are continuing with that process until we have got a more sophisticated process developed with the hospital authority.

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Mr. Chomiak: Would it be possible to see what a daily report of this kind resembles?

Ms. Hicks: Yes.

Mr. Chomiak: So I take it that will be tabled for my review?

Mr. Praznik: Yes, Mr. Chair, it will be.

Mr. Chomiak: There has been much discussion recently about the Cervical Screening Program. I wonder if we might have some elaboration as to what the problems were in that regard and what the status is of that particular program.

Mr. Praznik: Yes, I am going to ask Ms. Hicks to give us an update on that particular area.

Ms. Hicks: The Cervical Screening Program is one that has been in effect for a number of years. We have been working with it, but, just to clarify, we have and always have had a screening program in Manitoba. Women can have pap smears from their family physician at the required time, and, in fact, many women do.

So what is in place is the screening program. What we are still working on is the information system, which is the registry for the screening program and the follow-up capability of the program so that women who have not been availing of a regular pap smear can be notified.

Mr. Chomiak: How is it envisioned that program will work, firstly? Secondly, will that then be an initiative through SmartHealth?

Ms. Hicks: Right at the moment we keep track of all pap smears that are currently done in the province. It is envisioned that this information system that will be developed will, in fact, keep track of the individuals who receive a pap smear and the regularity that they receive it. Individuals then who are delinquent would get notification. It would also provide an opportunity for us to send personalized-- very similar to the Breast Screening Program--send women notice that their test is due and also to apprise them of how regularly it should be done. It is anticipated that it will be part of a health information network. We would most likely establish the registry at the Cancer Foundation, and it would then link into our system.

Mr. Chomiak: So your reference to the Health Information Network indicates that in fact the system, as well as the Breast Screening Program, would be plugged in with the HIN system, I presume, as part of the preventative care program or some other form?

Mr. O'Neill: Mr. Chairperson, that particular program, like a number of programs, is not within the specific scope of the Health Information Network project like DSIN and some of these others are that we are working on. However, we have said with the Health Information Network that once we establish the general communications technology infrastructure, it could be used for all sorts of things that are currently not within our scope.

Once you have the infrastructure there, you can use it for that, so that particular registry is one that we are aware of and that we have had some discussion with the professional community, the physician community and community health and all of those communities in terms of perhaps if there is a need from another system to send a notification to a physician or another care provider, the Health Information Network could be used as the highway or the pipe to send that notification.

Mr. Chomiak: Mr. Chairperson, as I understand it, presently there is a breast screening program and a notification. There are plans to put in place a cervical central registry with notification program. Ultimately, it is designed to function with the HIN network but, at present, effectively, it is outside of the scope of the actual HIN program. Is that a correct summation?

Mr. O'Neill: Yes, that is correct, Mr. Chairperson.

Mr. Chomiak: Are there any other preventative and screening related programs that are anticipated to be introduced in this regard?

Ms. Hicks: Mr. Chairperson, at this point in time, no.

Mr. Chomiak: Mr. Chairperson, so there are no plans, for example, for a prostate screening program and registry to be introduced?

Ms. Hicks: Mr. Chairperson, at this point in time, no, there is not.

Mr. Praznik: Mr. Chair, as issues develop and health needs are recognized, they are all a possibility as a matter of policy. Once the technology is set up, obviously if the capacity is there, they become much easier to do, so certainly at some point in time we may be looking at those.

Mr. Chomiak: Mr. Chairperson, would perhaps the minister agree that it might be useful to actually pursue the introduction of a prostate screening related program?

Mr. Praznik: Mr. Chair, once we have the capability, and I gather as networks get set up, it would be much easier to do absolutely. I see that if we look ahead to medical issues that are coming forward, that certainly is going to be. We have breast screening now, we want to get cervical screening underway, and certainly prostate would be one. We have immunization as well. That is another area. So yes. The beauty of getting a system in place that can provide us that information is, it becomes easier, I gather, for us to do this on a more regular basis where medical need dictates.

Mr. Chomiak: Mr. Chairperson, underneath the HIN steering committee and the various committees that are attached to HIN, is there a body or a group that are reviewing these particular issues?

Mr. O'Neill: Mr. Chairperson, the answer is yes. The physician and primary care providers committee is discussing some of these things like immunizations and the cervical cancer registry. As well, although we are still at a very preliminary stage, these are some of the topics that are also being discussed by the community health advisory committee and then, of course, as we move forward on these, they are also discussed by our privacy and confidentiality committee to ensure that privacy and confidentiality issues are taken into full consideration.

Mr. Chomiak: But, effectively, at present, the cervical and the breast screening will remain outside of the HIN program, is that correct ?

Mr. Praznik: I look to Mr. O'Neill to correct me if I am wrong here, but the Health Information Network is developing the infrastructure in essence, the roadways. What we put on the roadways becomes a policy matter for the Ministry of Health. The network is being developed. Obviously we have two of those programs who want to get into that network, but once the roadway is built, our ability to put more on it is certainly there, and that becomes a policy decision within the Ministry of Health.

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Mr. Chomiak: Recently the chairman of the Winnipeg Regional Health Authority was quoted as indicating that infrastructure technology requirements for the system could be as high as $60 million. How does that and how does the need for technology within that sector relate to SmartHealth and relate to the overall initiative of the information systems of the department?

Mr. Potter: The initiative that the member is referring to is an initiative which is currently being developed or underway within the Winnipeg Hospital Authority. As part of its mandate to regionalize the health care system within Winnipeg, they are looking at all the information systems that are resident in the existing facilities. They have a project underway to identify a way of integrating all of those systems into one system for the Winnipeg health system.

The estimate of $60 million, as I understand it, is just that. It is a number that was sort of taken out of the air as a potential cost. We are not aware at this point what the ultimate cost of implementing such a system could be or will be. There is a review underway that is looking at that issue. We are, however, within the Department of Health, participating in that review and Mr. O'Neill, as a matter of fact, is a part of the committee and to ensure that as they proceed looking at this issue within the Winnipeg Hospital Authority that the linkages will be there with the Health Information Network.

The Health Information Network, as has been described to me before, is a network of roads that takes you to the door and then you need systems within the facility or within the door that will hook up to the Health Information Network. The intent, of course, is to ensure that all of these systems work well together and integrate well together.

What Mr. O'Neill and the SmartHealth partnership are working on is that network to the door, and what the Winnipeg Hospital Authority is looking at is the systems behind the door in the Winnipeg hospitals that would then interconnect with the Health Information Network.

Mr. Chomiak: I appreciate that response. I first posed this question about three or four years ago with respect to the linkages and at that time was assured that there was an input from the Department of Health and SmartHealth that sort of monitored. Because there obviously is a problem if systems are not compatible or if major expenditures are undertaken with respect to systems that ultimately are rendered, although things are rendered useless in six months in the technological system now, almost, obsolete. Can I get an outline of who is on this committee and what their terms of reference are?

Mr. Potter: We can bring that information for the member. I do not have it with me at this time. It is a fairly significant listing of people participating in the steering committee. Representation from each of the facilities within Winnipeg, as well as the Department of Health, and with also, I believe, some of the community facilities. But we can bring that information.

Mr. Chomiak: Just so that I understand the system and the network, along the lines that were described by Mr. Potter, presumably the costs are borne by SmartHealth et al right up until the door of the hospital or the institution, including the computer. After that, it is the responsibility of the local institution to plug in. Is that correct?

Mr. Potter: As always, things are a little bit more complicated. For example, with the rollout of the DPIN system into the hospital emergency wards, the cost of providing the hardware within the hospitals is part of the SmartHealth network. It is correct, however, that the internal systems of a hospital, such as its administration and finance system or its admission and discharge system, would not be covered in any way through the operations of SmartHealth. But if those systems are going to be replaced with a new system, we would expect and insist that those systems be consistent and be able to be integrated into the Health Information Network so that the data from one facility could be very quickly integrated with the data from another facility from like systems.

Mr. Chomiak: When can we anticipate all Winnipeg hospitals, and then when can we anticipate most rural hospital centres, are plugged into the DPIN program?

Mr. O'Neill: Our intention is to begin the process from moving beyond the initial five test sites, starting approximately late May, early June and to be in all 81 facilities across the province by early fall, early winter.

Mr. Chomiak: When recently visiting at Concordia Hospital, a project undertaken in their pharmaceutical department was brought to my attention that provided drug information, a computerized system that was not only providing drug information to care providers but to individuals, et cetera, a made-in-Manitoba-developed system. Has the Department of Health or SmartHealth looked at that system, and do we have any ideas whether or not it can be integrated or expanded?

Mr. Potter: I am aware of the system that is being referred to. In fact, I had the opportunity to see it myself, and I have to agree that it is a very impressive system. What I can tell the member is that as part of the review that is being undertaken by the WHA, pharmacy systems are one of the categories of systems that are being reviewed, and as part of that review they will be looking at the system that is in Concordia, as well as the systems that are in the other facilities.

Mr. Chomiak: Technically, can that system be integrated within the SmartHealth network, or does it sort of fall outside of the mandate?

Mr. O'Neill: It is my understanding that that is one of the things that the WHA is reviewing when they go and they review all of the pharmacy systems. I am not aware at this point where that system is or is not because it is still under review.

Mr. Chomiak: Mr. Chairperson, would it be possible to get a list of what the overall review plans are for the WHA with respect to systems? Would that be possible?

Mr. Potter: Mr. Chairman, that would be possible. We will bring that information.

Mr. Chomiak: Mr. Chairperson, I appreciate the information that has been provided. I am basically going to be winding up here. There are more questions I would like to ask, but there are time constraints so probably this will be the balance of my questions in this area. I appreciate the information and the fact that people have taken me through it so that I could understand it. I anticipate that we can move on as scheduled on Tuesday in the USSC.

My final basic question in this area is: can the minister perhaps update me as to, because they vary, the present relationship between the MMA and doctors and the government with respect to the SmartHealth initiative, what the general issues are and whether it is a functional relationship at this point? That might not be the best choice of words, but that is sort of a general.

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Mr. Praznik: Mr. Chair, my understanding is that the Manitoba Medical Association is involved in our steering committees, and I am going to get Mr. O'Neill to give the members of the committee the detail of that.

As contracts end, one is into disputes over fees and issues and processes, and I am sure we will have a chance to discuss that on the appropriate line when the member wishes to do so, but to date, none of the contract-negotiation issues have in fact affected our discussions as far as I am concerned.

One of the things that Dr. Ian White and I agreed that was fundamental to that relationship was to ensure that we separated the financial-cost-issues physicians from developing the system and dealt with those as part of our bargaining or on whatever arrangement. The fear of physicians having to have additional costs on our system was one that I think kept them away. There are other issues and things involved, but it was of concern to them, and we have acknowledged and separated that.

Dr. White and I both, I think, recognize that there are costs and there are savings and that has to be part of that separate negotiation, but on the technical development of the system, my understanding is the MMA and physicians through the College of Physicians and Surgeons, as well, are involved in this process.

I am going to ask Mr. O'Neill just to give an overview of the committee structure and the MMA presence in those committees as well as the college.

Mr. O'Neill: Mr. Chairperson, yes, the Manitoba Medical Association does now have a seat on all of our steering committees. We have a multistakeholder steering committee that looks at the project on a global basis from a strategic point of view. We have a physician and primary care provider committee that looks at that particular sector, a privacy and confidentiality committee, which, of course, is focusing on the privacy and confidentiality issues. They also sit on the diagnostics advisory committee looking at DSIN, the DPIN committee, I believe the community health committee, and along with the College of Physicians and Surgeons and the College of Family Physicians and other physician representatives are being very, very helpful to us.

One of the specific things that they are assisting us with on the DSIN project is they will be assisting us in the near future in terms of a survey of physicians in terms of what technology is out there as we complete the detailed design of the DSIN project, and the MMA has been very helpful to us in designing that survey.

Mr. Praznik: Mr. Chair, if I may add as well, one other issue that we discussed in terms of information technology, it is not quite in the same line as health information systems, but I flag it for the member now is obviously the ministry now is gaining the capability to go to computerized billing. That does present some problems for some physicians who are not used to that system or offices or may not be geared to that system.

In the discussions I had with Dr. White and Dr. Ritchie and others at our principals table, it became clear that for everybody involved in the system, there were tremendous advantages to going to a computerized billing system. For Manitoba Health it would be a much faster, less complicated system and a much more cost-effective system than our current paper billing system. For physicians, it would allow for much speedier payment, which has a value to them within the system, but we recognize that should not happen overnight and that it would have to be developed in a manner that we moved forward in some reasonable basis.

Some of the powers we need to deal with that, particularly with respect to the cost, et cetera, we will discuss when we get into some of the legislative amendments. One of the housekeeping amendments is involved in this area. I just wanted to flag it with the member, but again, the process that we want to deal with on billing is one that allows enough time for a reasonable transition so that those physicians who are more uncomfortable with moving to this particular system have plenty of opportunity to gain some experience with it before we would eliminate the old paper billing methods.

Mr. Chomiak: I do have a written document requesting documentation. I am going to be also asking if I could have a list of the individuals who are on these various advisory committees under HIN.

Mr. Praznik: Does the member want to table that with us today?

Mr. Chomiak: I have not proofread it, so if one could accept it for just--

Mr. Praznik: What I will do is I will accept a draft copy of this, noting that it is draft, and I will provide it to my staff for response for Tuesday or for next week. Perhaps then the member might indicate whether--it might be a few days before we can give a response. If there are any issues that we have difficulty with we will flag with the member, or any questions we have. If the member wants to formalize that as an official copy or provide us with one, we can do that on Tuesday.

Mr. Chomiak: The only caveat is I dictated it while watching Geraldo Rivera last night. If there is any reference to Monica Lewinsky, it is simply because I was tired and dictating.

I just have a final question, and that is: have there been any savings to date with respect to the SmartHealth initiatives that can be identified?

Mr. Potter: There are no tangible savings related to the extension of the DPIN system at this point.

Mr. Praznik: I think it is important to point out that we are just starting that process, so savings that would come will come at a later date. Mr. Potter may want to elaborate.

Mr. Potter: I just want to add that the savings will largely accrue once the diagnostic components of the system are up and running and that the pharmacy system which is already in place largely throughout the pharmacies in the province does not carry a lot of additional savings extending it to the hospital.

Mr. Praznik: Just one last matter. The SACPAT stands for Screening Assessment Care Plan Automated Tool. So the member does not have to write that down, I will just hand him my note.

Mr. Chairperson: Order, please. I think I saw some sun out there just a while ago. I hope that means we have a nice weekend coming up, and I wish to extend a happy Easter to all of you.

The time being five o'clock, committee rise.