Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 4 - Evidence - January 29, 2014
OTTAWA, Wednesday, January 29, 2014
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:24 p.m. in order to study prescription pharmaceuticals in Canada.
Senator Kelvin Kenneth Ogilvie (Chair) in the chair.
[Translation]
The Chair: Welcome to the Standing Senate Committee on Social Affairs, Science and Technology.
[English]
My name is Kelvin Ogilvie. I am a senator from Nova Scotia and chair of the committee. I would like to have my colleagues introduce themselves.
Senator Eggleton: I am Art Eggleton, senator from Toronto and deputy chair of the committee.
Senator Seth: Asha Seth from Toronto, Ontario.
[Translation]
Senator Bellemare: I am Diane Bellemare, senator, from Montreal, Quebec.
[English]
Senator Enverga: Tobias Enverga from Ontario.
Senator Stewart Olson: Carolyn Stewart Olsen from New Brunswick.
Senator Tannas: I am Scott Tannas, from Alberta.
The Chair: I want to welcome our witnesses today and thank you so much for being here. Before I invite you to make your opening remarks, I want to say a few words. First of all, I want to welcome the committee back since the last session. I hope everybody is in fine form.
I also want to recognize that we are starting a new phase of our four-part study on prescription pharmaceuticals. The heading for our study is ``the nature of unintended consequences.'' We have what we hope is an excellent work plan for the session. I would also advise the committee that tomorrow in the chamber I will be submitting the report on our third phase, which we actually completed in late spring. However, because of the way Parliament operates, we're only able to introduce it now and so that will be introduced tomorrow in Senate.
I would like to invite from the Health Council of Canada, Dr. Ingrid Sketris, who is a councillor and no stranger to our committee, to proceed with her opening remarks.
Dr. Ingrid Sketris, Councillor, Health Council of Canada: It is a pleasure to be here today and speak to the topic of health professionals and safe prescription pharmaceutical use and to address methods of preventing the unintended consequences of pharmaceuticals.
For my presentation today I will limit my comments to a few areas of relevance to the health professional and discuss steps which can be considered to improve the safety, effectiveness and affordability of drug therapy for Canadians. These include involving health care professionals in quality initiatives, implementing models of care to facilitate the provision of integrated care and providing adequate tools and supports. Following my presentation, I would be happy to answer questions.
By way of background, I'm a licenced pharmacist in Nova Scotia, and a professor of pharmacy at Dalhousie. I'm a fellow of the Canadian Society of Hospital Pharmacists, American College of Clinical Pharmacy, and the Canadian Academy of Health Sciences. I practiced in hospital pharmacy for 20 years and now am a pharmacy teacher and researcher.
From 2000 to 2011, I held a chair in pharmaceutical policy. My research includes examining methods to improve the safe, effective and affordable use of drugs. Today I'm here both as a pharmacist and as a councillor with the Health Council of Canada. The Health Council commissioned a paper on optimal prescribing and medication use in Canada, which we provided. The report was in response to the 2004 First Ministers 10-year plan and related to the National Pharmaceuticals Strategy action item to enhance action to influence the prescribing behaviour of health care professionals so that drugs are used only when needed and the right drug is used for the right problem.
I will speak to the framework in the report and update you with newer studies and data from other Health Council reports.
There are many opportunities to improve the quality of prescribing medication use in Canada. The Health Council report provides examples of underuse, overuse, inappropriate use and misuse of prescription drugs, and variations and drug use within and across jurisdictions. It identifies barriers and facilitators and reviews approaches and evidence to improve prescribing and medication management.
Health care professionals need to be further involved in quality improvement initiatives involving prescription drugs. Federal and national organizations such as Health Canada; Canada Health Infoway; Canadian Institute for Health Information; Canadian Patient Safety Institute; Canadian Agency for Drugs, Technology in Health; Canadian Foundation for Healthcare Improvement; Canadian Institutes for Health Research; and provincial organizations and initiatives such as the Saskatchewan Health Quality Council and Drug Evaluation Alliance of Nova Scotia, play roles in measuring and improving the effectiveness and safety of prescription drugs used by patients.
However, many of the provisional initiatives are small in scale, and there are limited mechanisms to work across organizations and jurisdictions.
Other countries take a more national approach to providing prescribing advice and information. For example, the U.K. has a National Institute for Health and Care Excellence Medicines and Prescribing Centre to provide information and prescribing advice and has developed a single competency framework for prescribing for all professionals — doctors, dentists and non-medical prescribers.
The National Prescribing Service, funded since 1998 by the Australian government's Department of Health develops educational campaigns for health care professionals and consumers on quality use of medicines.
A promising Canadian development is a Canadian Primary Care Sentinel Surveillance Network, involving 476 sentinels — that is, participating primary care practitioners using electronic health records — with data for over 500,000 patients in eight provinces. It is undertaking a number of quality initiatives, including pharmaceutical use in managing chronic disease.
The health care system needs models of care that are team-based, patient-centred and integrated. In the past, much of health care was acute and episodic, but now patients receive prescription pharmaceuticals over long periods of time to prevent disease and treat multiple chronic diseases.
These prescription drugs are prescribed in emergency departments, acute care, primary care and continuing care by several prescribers. Not only are family and specialist physicians and dentists able to prescribe, but, in some provinces, nurse practitioners, midwives, optometrists, podiatrists and pharmacists can, which increases access to prescription drugs, but also complexity.
Dr. Robyn Tamblyn from McGill, who appeared as a witness earlier, published a paper called, Do too many cooks spoil the broth?, which documented that 18 to 28 per cent of potentially inappropriate drug combinations were due to concomitant prescribing by different physicians. In another publication, she and colleagues noted that patients with more than one pharmacy were more likely to have an omission in their drug list in the emergency department.
In a Nova Scotia study, led by Latter, we asked physicians, pharmacists and diabetes educators about the advice they would give to adult type 2 diabetes patients about diabetes test strips and showed variability in recommendations, so they got different advice from the different professionals. They noted this could be decreased by interdisciplinary continuing education programs.
The Department of Health and Wellness in Nova Scotia has since funded an education program: Self-Monitoring Blood Glucose: Are We Singing from the Same Song Sheet? Health care professionals need up-to-date credible information, tools and supports to make decisions about drug therapy at the time of prescribing and dispensing, in addition to having the knowledge and skills provided in their health professional training and continuing professional development.
There are over 16,000 individual drug products on the Canadian market, and new evidence is published daily. Health care professionals need electronic health records, with clinical decision support systems that allow electronic prescribing to improve quality of care, avoid preventable drug-related morbidity and provide value for money from pharmaceutical expenditures.
The Health Council's 2013 Progress Report notes that the uptake of electronic prescribing varies from 10 per cent in Newfoundland and Labrador to 58 per cent in Alberta.
When compared with nine other countries, Australia, Germany, the Netherlands, New Zealand, United Kingdom, France, Switzerland, Norway and the United States, Canada ranks seventh, with the Netherlands at number 1 with 98 per cent electronic prescribing.
Among these same countries, Canada ranks ninth out of ten countries on the measure of being able to easily generate a list of patient medications, including those prescribed by other physicians, at 43 per cent.
All provinces are moving to drug information systems, which will allow physicians and pharmacists to be informed about medications prescribed and dispensed by others, but, for this potential to be realized, health care professionals need to understand its relevance and use it when they care for patients.
The electronic drug information management systems also need to provide evidence on the risks, benefits and uncertainty related to prescription drug use for specific indications and patient populations in formats that are useful to the health care professionals and patients and for shared decision-making between health professionals and patients.
Some Canadian electronic pharmacy and health records systems use drug information databases adapted from the United States, where the availability of the drugs, their indications, side effects, regulatory warnings and pricing may differ.
Gaikwad led a Nova Scotia study published in 2007 to determine the potential of alerts triggered by electronic medical records systems to identify serious drug interactions and avoid spurious ones in common drug interaction pairs.
What we found was that there were issues related to missing and outdated information in the databases, as well as database function discrepancies. An interesting Canadian development to generate knowledge is the Canadian Network for Observational Drug Effect Studies, CNODES, which conducts research on drug safety and effectiveness to fill some of the information gaps related to real world drug use and provides this knowledge to both national and international users.
Up-to-date, readable, relevant prescription information also needs to be provided to patients in addition to verbal counselling. In the 2010 Commonwealth Fund survey, 74 per cent of patients said that medication side effects were explained by a doctor, and 69 per cent reported that their doctor reviewed their medications prescribed at least annually.
In summary, there's a need for national coordination of approaches to improve the quality of prescribing, including the involvement of health care professions in system-wide quality-improvement initiatives. Health career professionals and patients also need to be given the tools and supports to prevent unintended consequences of prescription drug therapy.
These things are needed to achieve better health outcomes for Canadians from prescription pharmaceuticals. Thank you for the opportunity to present, and I would be happy to answer any questions.
The Chair: I will now turn to the Canadian Patient Safety Institute, and I welcome Hugh MacLeod, who is Chief Executive Officer; and Emily Musing, who is a board member.
Hugh MacLeod, Chief Executive Officer, Canadian Patient Safety Institute: Thank you, and good afternoon. My name is Hugh MacLeod. I'm the CEO of the Canadian Patient Safety Institute, but today I'm here as a patient, as a husband, as a father, as a grandfather and as a very concerned citizen.
With me today is Emily Musing, the CPSI board member and Executive Director of Pharmacy, Clinical Risk and Quality at University Health Network. We thank you for the opportunity.
As you know, a pharmaceutical prescription system encompasses four main strategies: First, research and development; second, regulatory review; third, medication manufacturing, distribution and marketing; and fourth, medication use. Each stage contains multiple critical control points by which quality, safety and efficiency can be addressed and in which breakdown occurs.
I think it further reinforces Dr. Sketris' point that a holistic approach is needed. The focus of our opening remarks is unintended consequences related to the use of prescription pharmaceuticals. Yes, we are making progress. However, in our markers at CPSI, the harm meter is still on the wrong side, and the progress is far too slow.
The bottom line is that medication reconciliation and medication management failures impact on a variety of quadrants — first and foremost, the patient, the resident, the client, and the family.
What's the impact? Loss of life, prolonged disability, temporary harm, complicated recovery time, confusion about treatment plans, loss of income, and added personal costs. What about the costs to the overall health care system in general? Prolonged recovery time increases bed utilization, which means that someone doesn't have a bed. There are increased costs and staff time due to re-work, including legal costs, increased readmissions post-discharge, and complications and confusion in crowded ER spaces. Therefore, there is reduced access and services to other folks, which means resulting wait times, whether it is in the ER or for surgery.
What about societal costs? Loss of productivity in terms of outcomes, workplace absenteeism and a growing new dilemma that is bigger than absenteeism, ``workplace presenteeism,'' the cognitively impaired, not only by the illness but also by the anxiety, stress and perhaps the drugs that they're on. Then there are the increased costs to medical plans, erosion of public confidence, and the impact on other social services, whether it be education, social services or the justice system.
I think the challenge we have in front of us was captured very well in 2001, in a sentinel document that gave rise to the 100,000 Lives Campaign in the United States and Ross Baker's work in Canada that put some quantitative figures on the level of harm.
Remember, this is 2001, and there's a really important statement here.
The science and technologies involved in health care — the knowledge, skills, care interventions, devices, drugs — have advanced more rapidly than our ability to deliver them safely, efficiently and effectively.
That was 2001. Think about the new complexity of our health care system, its pace and the wonder of wonder drugs and technology, but now individuals presenting at a much earlier age with co-conditions. No one now presents with one condition and as a result of co-conditions, multiple drug treatment plans.
If complexity was an issue in 2001, I suggest to you it is a greater issue today. We did not pay attention in 2001. We must pay attention today.
This means all of us. All of us in this room and other rooms have either legal or moral authority to promote safe medication practice; some have both. Collectively, I believe we have the power to make health care accountable to the patient, the resident and the client that we are here to serve.
Posing questions and critically examining the current state of affairs, as you are doing in these hearings, is very important and beginning to look at the holistic conditions that give rise to the problem and the challenge we have in front of us. We recognize that it will not be easy to confront some historical, systemic, behavioural barriers for change but they must be confronted. We raise a number of high-level summary things that we think have to be done.
I know this sounds very elementary but we have to get serious. We have to get serious in that we have a medication safety issue. Almost everyone being cared for in health care today is on some kind of pill. The cost of readmission is prohibitive. The error prevention strategies for high-risk medication like insulin, opioids and Warfarin et cetera are not implemented in a concurrent way across Canada. Research shows that 50 per cent of adverse events involve communications and 50 per cent of those events involve medication.
Second, medication safety is about healthy relationship patterns and interactions between people at all levels of the continuum of care. Medication safety is often about the interaction between people and technology. Patient safety outcomes are the result of the interactions between providers and the patients, clients and residents they are there to serve. Therefore, medication safety delivery is largely about the way providers interact not only with themselves, but the patients and the clients, the hand-offs from operating room to recovery room, to patient care unit and discharge.
Third, cultural and behavioural changes are required. As staffing models change — and they're always changing in the health care system — and the patient safety complexity continues to increase with aging, we need a conversation about the level of medication knowledge. We need to ensure that there is access to clinical pharmacists, not only at academic and teaching hospitals. We must do a better job of educating the consumers not only about their medication, but the risk. Caring for my belief, a personal medication list should become as routine as putting on a seat belt.
Fourth, we need to focus on the elephants in the room. We have misplaced competition and ego, both passive and aggressive, among health care providers. Often this is a lack of understanding and appreciation of each other's role in this very important continuum that we're talking about.
We need policy and operational direction; it often can be fragmented and erratic at best. We need to include the patient, the family and the client voice as we move forward because they are the recipient of the care but also the recipient of the harm when that takes place.
Sixth, we need to leverage technology and transfer information to patients and allow patient input into their needs and their preferences. We need to allow access by prescriber and patient to sufficient information about the drug efficacy, its adverse effects, correct prescribing of dose and frequency en route, correct dispensing and administration, and on patient education to understand about medication and recognizing adverse events.
Finally, we need to focus on our health care workforce, the impact of absenteeism. We have more people off today in health care on sick leave, Workers' Compensation, and long-term disability than in the past. The old claims used to be musculoskeletal and soft tissue. The new claims are anxiety and stress-related. One of the largest hits on the pharmaceutical plans of health care organizations is prescriptions for health care workers to deal with anxiety and stress. I think we're talking about drugs on the other side, but we also have an issue within health care about the health of our providers and delivering that care.
In summary, we need leadership. We need leadership to understand that culture at the organizational and unit levels is key. There is a difference between a shift and a unit and it is bigger than the organization.
We need leadership to understand that entitlement, expectations and emotions sometimes trump the evidence. Where am I going here? To say it another way, silence unawareness, indifference, and complacency are the greatest enemies of patient safety improvement from my perspective.
Finally, we need leadership from government. We need leadership from boards, industry, the professions and we need leadership from the delivery system to come together to find a resolution. The neat thing about Canada is that we have an abundance of skills, talents and passion. We lack the vehicle to bring that skill together in a way where people can park their egos at the door, sign up and say, ``I want to contribute to this to ensure that we make a safe environment for the patient, the client, and the resident.''
Thank you for the invitation to present today. I look forward to the conversation.
The Chair: Thank you very much. I am going to open the floor to my colleagues.
Senator Eggleton: Let me start with Dr. Sketris. You noted at some considerable length in your presentation about the need for electronic recordkeeping and it is something that this committee has been very vocal about in past. We have had several reports where we have said, ``Look, we have to get on with doing this in a bigger way.'' It has been very slow getting to the points that would put us in the top echelon of these countries that you mention as opposed to the bottom, where we are.
What do you think we need in order to get a breakthrough here? What does the council think we can do? I know there's another agency that deals directly with electronic recordkeeping, but surely you have to be interested in doing something further about this. What do you think needs to be done?
Dr. Sketris: The approach needs to continue to be coordinated. If you look at Canada, we're developing our own drug information system in Nova Scotia, for example. Prince Edward Island and Newfoundland developed theirs. If you look at some of the other countries, that would be done at a national level. There certainly has been learning from one province to the other, but the provinces are quite small and the skill sets and complexity of both the electronic health record and the database to go with it are complex.
We either have provinces developing their own systems on the clinical decision support side, or small companies, whereas some of the other countries would have a much more national approach. For example, in the UK, the National Prescribing Centre works on the electronic clinical decision support systems to support the electronic health records across the country.
Senator Eggleton: Do you feel there need to be monetary incentives? Do they use that in other countries?
Dr. Sketris: I was in Australia on sabbatical in the 1990s when they first introduced the electronic health record to family physicians. Now it is way over 90 per cent use, but they started with a monetary incentive. When Tufts Medical Center went electronic in Boston, they backfilled with other physicians. For six months, they gave physicians so many hours a day to learn the system and backfilled somebody to take care of their patients. There are a number of ways to try and increase the uptake.
Senator Eggleton: You mentioned Australia and in your presentation you also mentioned the U.K. Now you have told us that you spent some time in Australia. Is there anything else in terms of the general subject of unintended consequences, not only the electronic records, which we can learn from the Australians rather than reinventing the wheel? If you had to choose one or two things you think are particularly solid, good practices, what would you pick out?
Dr. Sketris: I like their National Prescribing Service for a number of reasons. First, for the public education programs they do. For example, they had a program that looked at trying to decrease antimicrobial use for colds. They had a program of information for consumers, and they had little packages of Kleenex. Their message was that, when you have a cold, you may not need an antimicrobial. Sometimes rest, fluids and Kleenex are what you need. They would roll out that kind of program across the whole country. They would do it with public media. They would do it with things like our Canadian Living magazine. They would do it with health care professionals. They would launch the same campaign across the country, and they would pick a couple of subjects a year and try to make an impact.
Senator Eggleton: Thank you for that. Mr. MacLeod, you are quite definite and passionate about this, I can tell. You suggested a number of things in your presentation that you think need to be done. A lot of them are relevant to health care providers and the practitioners. We don't have direct responsibility here for those practitioners. The provinces do, but we do have, of course, a key involvement in drugs. Have you talked to the provinces about this, and what kind of reception do you get from them? Can you persuade them, at least, that, if the federal government isn't going to come to help deal with this, they might, through the council of ministers, do more coordination and sharing of best practices and moving along these lines that you suggest?
Mr. MacLeod: That is a very good question, and we do interface with every province, with the health quality councils. Our board is made up of a good representation of the country, whether at an associate deputy minister level or regional health authority level, and medication safety is one of the significant topics across the country.
So what do we have in common? Our approaches may be different, but we all understand the size of the dilemma and the challenges that are before us and we are all looking for solutions from each other.
In terms of dealing with the provider piece, it is larger than that coal-face provider. As a good friend of mine said, it takes 15 seconds to fill out a prescription. It takes 45 minutes to do an assessment.
Now, the pace sometimes and the rush raise, for me, some alarm bells. He also says to me — and he's a practitioner — ``Have we created a love affair with drugs in general, as opposed to stepping back and saying that drugs are usually coming to reduce and relieve harm or pain?'' Pain comes from a variety of things. It comes from personal injury, motor vehicle accidents, et cetera. Do we go upstream, at the same time, to understand what is causing this, and is the prescription the only remedy to deal with that pain? I don't think we're having enough conversations about that. That's not only on a policy level, but that is also at an individual level.
Senator Eggleton: I have one final question. Are you doing anything in terms of educating the practitioners, the doctors who provide all of these prescriptions and, perhaps, are not paying enough attention to the quantum and the interaction of them all?
Emily Musing, Board Member, Canadian Patient Safety Institute: I think that there is more and more information out there, coming at a faster and faster rate, to the point where, for any one physician, it is very hard to maintain expertise linked to drug use for all of their patients. At the same time, the other problem is that we live in an age where our patients have changed with regard to their interest in taking a role in decision making for their care and their idea of having access to information to make those decisions, through the Internet, through social media. Information is out there. Unfortunately, some of this information is not peer reviewed. It is not necessarily things that are appropriate for use in making that decision. So we're living in an age where there's a lot of information out there, which may not be correct information, while, at the same time, the health care professionals who need to make the decisions on care may not themselves have the time or the expertise. That's where the interaction between professions comes into play, the role of pharmacists, nurse practitioners and physicians. They are the people who really need to interact in a concerted and coordinated way so that you are making full use of the expertise around the table.
The role that CPSI takes is to ensure that there is that connectivity, that the patient is involved in that discussion and that the tools are out there. You spoke earlier with regard to technology and bringing that forward. I think one of the issues with using technology as the way to solve issues is that technology is very expensive, and, without a national coordinated effort as to how we bring forward technology, the people who will be able to afford the technology — large acute care hospitals from which I myself come — will say, ``We have the money. We're going to bring this technology in.'' We need a coordinated, national effort to ensure that that technology is useful across the continuum of care between different health care professions for the good of the patient.
Senator Eggleton: Coordinated, national effort.
Mr. MacLeod: I think your question and the response from Emily ties back nicely to that 2001 warning about the speed of technology and the access to information. The pace is beginning to outstrip our human capacity to actually deliver safely and effectively.
Senator Stewart Olsen: Thank you for being here. I have a few questions. You may have touched on them, but, for clarification, is there a concentrated effort for an online, central database of the current medications? Right now, I'm speaking of practitioners. I'm really not speaking of the public, but it could be. Suppose you are a nurse practitioner. You have done your exam, and you're thinking of prescribing something. Is there some way you can tap that in, get on the web and get the information you are going to need right there, clearly and concisely — what it does, adverse reactions, contraindications? Does someone monitor that and keep that available? I recognize I'm not asking for a national anything. That's something very difficult, but, in this case, I think it would behoove pharmaceutical companies to put some money into this kind of database. Anyway, I'm just asking: Does that exist?
I know that, years ago, there used to be the blue books, but that can't keep up with today. So I'm just wondering what there is today. Is there something centralized that people can access?
The Chair: While you're thinking, we dealt with this one fairly extensively in our last study, and there are linkages through Health Canada's website to those issues. I'm just giving you time if there's something else you want to add.
Senator Stewart Olsen: Yes, I have read that, and I'm just wondering.
The Chair: The international ones you mentioned, Australia and other places that have this. I'm just filling the void here in case they have something new to add to the documentation we got in the last study.
Now, you have had a chance to think. Have you got an answer for the senator beyond what I've just summarized?
Dr. Sketris: I think the E-CPS — the blue book — is now online. So that's useful, and medical practitioners can access it. There also is the Cochrane Library, which some provinces, New Brunswick and Nova Scotia, for example, subscribe to, so that's another evidence-based source.
Senator Stewart Olsen: But there is no one central up-to-date thing that would be rolling up-to-date?
Ms. Musing: There are different products out there but no one database.
Senator Stewart Olsen: I know, but I think a concentrated effort on something like that might be good. The other thing — and I think Senator Eggleton touched on this — is the education provided to health care practitioners. How does that happen? Who puts that together? Would each institution put together what they actually teach their practitioners, or is there some way of centralizing that kind of attack on this?
Dr. Sketris: Australia has a national prescribing curriculum that can be accessed by any medical school in Australia.
Senator Stewart Olsen: That's good, but what do we have?
Dr. Sketris: Each school does their own curriculum. They have standards to meet but they do their own curriculum, so they don't share it quite that way, as other countries do.
Mr. MacLeod: There are a number of initiatives taking place across the country. I believe in your package we provided a backgrounder on Safer Healthcare Now!, which is a national program with CPSI but is really led by hundreds of people across the country. It's a starter kit, a GSK, if you will, for that front line on medication safety.
We're also now working with a variety of universities, both at the nursing-school level and the physician and pharmacy level, to embed into the curriculum design — these are our future leaders — the importance of medication safety, and really being quite deliberate there. We are getting good traction, not fast enough or deep enough, but we are getting people to pay attention to the need for our future health care providers to pay attention to medication safety.
I would say that there are multiple collaboratives taking place across the country where folks are trying to reach out at multiple levels — the care provider level, middle management level, CEO and board level — about elevating the conversation on medication safety and safety writ large. Ten years ago the primary conversation taking place at boards was fiscal. The conversations taking place now are on quality and patient safety. Is it deep enough and far enough? No. But at least the shift has begun to take place, where wicked questions are being asked by the board — as they should be — to their CEO about what kind of improvements we're making. I am also aware there is good work at the college level.
Ms. Musing: Certainly I know that the College of Physicians and Surgeons worked with CPSI to develop an actual patient safety competency listing that now various faculties, whether it's physicians, pharmacists or nurses, have taken to heart, to look at that as the gold standard of how to build curriculum and ensure this happens.
The other thing that is happening across Canada is this whole concept of inter-professional education. Part and parcel of that is not only bringing people together to talk about a disease state and how to treat that with medications, but how to get the different professionals to work together and understand each other's roles. So, in essence, they are able to do much better in caring for that patient, identifying what their medication needs are and prescribing the correct medications and following up on that.
Senator Stewart Olsen: Who maintains a list — and I know this was covered before — of the adverse drug reactions? Really we are kind of hiving down in this study on that. I was a bit shocked in the report that I read that there wasn't a really good reporting mechanism. I was shocked by that because I thought there was. I thought there was and that it was compiled and kept in this central area so people could review and understand steps that needed to be taken.
Mr. MacLeod: I will take it at a high level first.
You're quite correct: there's not enough of that sharing. Almost every province has some form of an incident- reporting system. That information, though, is contained within the province and most of it is not shared across. Manitoba is the outlier in that: they actually share their incident reports.
The reason we know that is because at CPSI, 18 months ago, we went out to 23 world leaders and asked them. This would be NHS, the ministry in France, Belgium, Hong Kong, Australia, Harvard, a variety of folks, to say, ``You're issuing, on an ongoing basis, incident reports that deal with not only medication but safety issues writ large. Will you give us your sentinel document?'' We then summarized that document, using the WHO classification system, and we created a portal called Global Patient Safety Alerts. Today we have over 1,500 alerts on that portal with 5,200 recommendations to prevent it from happening.
ISMP Canada, which actually tracks some of this, is one of the inputs from Canada, and the other one is Manitoba. We're now trying to work with Alberta, Saskatchewan and Ontario. Give us your alerts to put on this portal to share with folks so they can be armed with trends that are beginning to develop, et cetera.
My simple analogy is that if a Boeing 737 were to land in Vancouver and a mechanic found an orange wire dangling from the left motor, within a nanosecond an alert would go out to the system. Where is our alert system for the health care? We should have that same discipline, to go back to your point. This is not to accuse folks, but to forewarn them. More importantly, what have you done with that alert to ensure we don't have a reoccurrence of that issue again? That's what we're attempting to do through the global patient alert system.
I think the other organization you can speak to, ISMP Canada, is also doing some tracking on adverse events.
Ms. Musing: Originally, the collection of adverse medication events was dealt with in a voluntary way, but certainly it's — depending on the province — moving toward mandatory reporting, which I think is a good thing. First we need to collect the data and then, as Hugh says, we need to make that data accessible, not only to the province collecting it but to everyone.
Dr. Sketris: The information is available to the health care professional, but do they have to go into the portal? Ideally it would be on a computerized physician-decision support system when it's relevant so, as soon as they're prescribing, a real-time alert will come up and they'll know it's a valid alert.
[Translation]
Senator Bellemare: I have not been sitting on this committee for a very long time. I did not participate in the examination of research in this area. I am a little naive. I listened to you and the problem to be solved really seems enormous to me. The holistic approach does really seem like the way to go.
The issue of leadership is a big one in Canada, in particular in light of the fact that you have the provinces and the federal government and agencies that do not communicate. As an economist who has thought a little about the new technologies — perhaps that is what your ``Global Alert System'' is — I think that the Web 2 can indeed allow us to share a lot of information; there could be wikis for the prescriptions, and people could then have access to that. However, all of that does obviously have to be monitored so that the information is always validated, but everyone could contribute.
Wikis are the future. I do not understand why they are not used more in the medical field. Clearly, good will is required. I would like to know what you think of that and about their use in this complex context. You referred to that and my colleagues also put some questions to you. The complexity of it all requires that the information be coordinated through some mechanism, but the individual also has to take responsibility, because the person involved can prevent mistakes. If we could find a way to have people turn up at the drugstore with their card and be the ones with the information on all of their medications, that would be good. Wherever the person went, he could present his medication record. Has this type of approach been looked at?
[English]
Dr. Sketris: During our Health Council of Canada National Symposium on Quality Improvement, we had a patient present, and he always carried around his neck a USB stick with all of his information. He was an IT professional and he said it took him about six months to put together the information so it would be ready for him and he could always present it.
I think the other thing you brought up about Web 2.0, a number of people are exploring Twitter, Facebook and all those things for both patient engagement and engagement between patients and health professionals.
Mr. MacLeod: I will go to your second question first and then come back to the first one.
On the whole topic of complexity, I don't think we understand complexity. I think we move too quickly for a quick fix without really understanding the root of the problem. It is scary and big but if you unpack it properly and layer it back, it usually has the components. You need prevention, education and you need to look at the prescription and treatment. You need to look at monitoring, surveillance, enforcement and the proper levers for both legislation and regulation. You need research to validate and you need evaluation. But there is another piece you need on complexity to understand our system. I spoke earlier about the changes in demographics, in cultural aspects which get to health literacy.
Recently, I was both fortunate and unfortunate; I was with a family member for 14 hours in an ER. I got to play amateur anthropologist and watch everything that was happening around me. I was astounded how confusing it was for the majority of the people in the ER, particularly for the elderly and those new to Canada trying to understand our language and jargon in our signage.
We have to understand complexity first before we move forward. If we were to unpack it properly, there is an abundance of skill in this country. Start assigning people and get them, in a collaborative way, to take the elements and park the turf and ego. We are not 200 million as a population. You would think if any country can do it, it should be Canada. On the first piece, we do not understand complexity and often rush too quickly on one narrow band and get surprised by the law of unintended consequences.
On the other piece, I agree with you. We are in a new era of technology. Let's use that as a drive forward but ensure that it has proper backing with good evidence. As was said earlier, unfortunately the consumer has a wide audience and new library, and often it is not anchored in good evidence. We have to use the speed of technology but with a discipline you've probably never seen before in the rigour to ensure it stands up to the evidence base. We have technology that we need to exploit in a positive way.
[Translation]
Senator Bellemare: Who could take the lead in this matter?
[English]
Mr. MacLeod: The first answer is that leadership is in every room I go into to. I see too much nodding that this is what we should do. By the time they get to their cars they think about their own region or territory and forget what they had nodded to do. There are people nodding now and saying it's time for action. I would hope that part of your deliberations will begin to lay out a potential framework, a blueprint for people to say, ``You are not pushing it down to me, but I can begin to hang my work on this framework and get other people to hang on it'' and see a collective push as opposed to an individual one.
Senator Seth: Thank you for such an interesting topic. I have a little change of topic here. One of the most unintended consequences of prescription drugs is addiction and abuse. In your opinion how can it be changed, adopted or prevented and reduced? Can you elaborate?
Dr. Sketris: That is a very complex issue that has many aspects. I will talk about one.
Nova Scotia has a prescription monitoring program as some other provinces do. Before physicians prescribe, they can look at every other prescription prescribed by anyone else in the province to try and determine the past history and have a sense as to whether or not the prescription they're writing is appropriate as one step in the process.
Senator Seth: Would you like to answer?
Mr. MacLeod: Sure. I'm going to start my answer by putting a framework first. You are quite correct. We have an addictions problem. In some cases we call it a ``prescription problem'' but in many areas it has become an addiction problem. If that is true, we also have to say there is accountability for the manufacturer because they are the ones marketing. There is accountability for the provider, patients, family and government.
As I said in my opening remarks, in a crazy way we also have gotten into a love affair with drugs. My children and grandchildren live in California and watching the television there is obscene. Every second ad is for some kind of drug. Now there is a cure for everything and, if not, there is a drug invented to find the illness to care for.
Everybody has accountability and responsibility for this. We have always glamorized it. I recently went to see the movie The Wolf of Wall Street. What is the opening scene? The way to stay on top of the market trading is to take cocaine so you're up. We have glamorized addictions. I know we can't resolve that overnight but we need an honest conversation about the state of where we are at.
The issue is beyond prescription in many of these areas. The recent stats in Ontario in terms of deaths last year connected to opioid use are haunting at 500 people. To me, that is a serious addiction problem. We need to be big enough to have that conversation, take it square on and find out how to resolve it.
Senator Seth: Often I notice the professional or the providers of the prescription when the patient goes to ER for an accident. The first thing I see is that a narcotic is prescribed. And it is a long prescription for a month. They come back to the general practitioner's office and often need a repeat by the time they get addicted. This is another common thing and I have no solution on how to avoid this.
Mr. MacLeod: That's why I said it takes 15 seconds to fill out a prescription and 45 minutes to do a full assessment.
I will simply leave that on the table.
Senator Chaput: My question has been partly answered but I still want to push a bit further. You talked about a blueprint. In the presentation you heard about the national perspective and the coordination of whatever needs to be done to ensure we get that blueprint. As you said, sir, people agree and nod but then who takes the lead. I would like your thoughts on the leadership or the role of the federal government in this initiative. Push your thoughts a bit further. How do you see the leadership of the federal government?
Mr. MacLeod: There is a lot of work to be done, but I'm encouraged. Maybe I am an optimist by nature, but I had the pleasure on Friday to attend a symposium hosted by the minister on this very topic. The minister was there for the full day and participated in the round table conversations.
She had the right people at the table: justice, the police, the provider community, the colleges and researchers. It is evident from the conversation that took place that this is an important agenda item for the ministry and the minister. I began to see significant leadership on this file on that day. They are looking at what would be a holistic approach to dealing with the issue and everything from prevention to research and treatment, et cetera.
I'm encouraged by that. The proper framework for regulatory and legislative change will probably come out of the deliberations, but that alone won't do it because you can't prescribe behaviours and people will do workarounds. The federal government has a role to play and they're demonstrating it. The provider and professional communities also have a role, the royal colleges, CNAs, societies of pharmacists and the regional health authorities. If there is one thing in common across the country, it is medication safety writ large. What's not in common is the approach. What's not in common is the transparency of the sharing of information, as we talked about earlier. And what's not in common yet is everybody marshaling together to work in a collaborative fashion as opposed to one province saying, ``This is the B.C. way versus the Ontario way.'' What about using your way to create a Canadian way and a pathway going forward?
Are there hurdles? Yes, some of this is historical and behavioral, but I do think progress is being made because people are beginning to understand the importance of this file.
Senator Chaput: What would be the next step that you would like the federal government to take? You mentioned this meeting with the minister. What's the next step?
Mr. MacLeod: I would like to see some action coming out of that day, and I think that day was a call to action.
But I think the work you are doing and that you are reporting in terms of this blueprint can be a nice complementary piece saying we've gone through a series of critical examinations by bringing people to this table, and that could be a reinforcement of the importance not only of the topic but of action to move it forward.
Senator Seidman: Thank you for being here. I'd like to ask you about a particular study that you did, the Canadian Patient Safety Institute, the one called Safety at Home: A Pan-Canadian Home Care Study. I'd like to ask you about that particularly because home care, care in the community, is becoming a larger and larger issue. It will, of course, become an even larger issue as we all continue to age.
I'd like to ask you specifically about medication management. One item that you put forward and I think is particularly revealing, if I might bring it up, you say on page 16 of your report that Table 4 presents the types of adverse events that were identified through chart review. It shows that the most frequent adverse event was an injurious fall but that medication was a contributing factor in almost 25 per cent of these cases, including falls.
That is one example, but I would like to discuss this particular study and what you think we can do to deal with this important problem.
Mr. MacLeod: Thank you for that. It was with multiple partners we did that study. It's actually the first study of its kind in the world on home care, and I will use a non-clinical description of what it said to me when I read the report. What it said to me — I started in health care in 1980 — we have acute care services now being delivered in a home care environment 24/7, often by family members, unregulated and regulated staff. So we have toxic cancer drugs, IV pumps, machines doing work that 10 years ago was done in a hospital. Therefore, the potential for harm is huge. Often we talk about an indicator called falls, but one of the contributors to the falls could be medication.
The report, where you put a spotlight on us, indicates the level of harm that is currently taking place in home care, the level of harm that could continue to take place in home care, and if we don't really begin to address it, we will have very busy ERs, which again goes back to the impact of not paying attention to the fullness of a system because then we get overcrowding in ERs.
Do you want to speak to some of the medication issues in home care, Ms. Musing?
Ms. Musing: The other issue that people don't often think about is not only does medication play a role in actually causing the fall, in turn putting a person at higher risk for the fall, but it places a person at a higher risk when they do have a fall.
We have a lot of patients in acute care or in their own homes who are on anti-coagulants, for good reason. However, when they have a fall, they are at much higher risk for having hematomas or some form of hemorrhage, which may or may not be recognized initially. Especially when they are not in an acute care setting, fast action is not taken to do some sort of a CT scan to see whether there is something that needs to be corrected or dealt with or whether the person needs surgery as an afterthought.
There are a lot of links among safe medication use, appropriate medication use and understanding how that has an impact on something like falls and the implications of having a fall.
Mr. MacLeod: If I could add to this, going back to your question about action and the important role that you are playing, creating the right narrative for your report, from my perspective, is crucial, which is telling the story differently.
For example, I've sat down with ministers and talked about readmission post-discharge, and depending on the province, it is suggested that 20 to 23 per cent of readmission is directly related to medication safety mishaps post- discharge. The trouble is we haven't built the story line, so I tell the minister what happens wherein when that person comes back in, they will be in a bed longer, and now you have taken a bed out of service. You have probably knocked someone off the OR slate, so now you've got an increased wait time. Because of that bed now being reoccupied, you have probably created some ER internal medicine congestion. Oh, by the way, your costs have just gone up.
So we're not painting a strong enough picture with the totality of the impact. We tend to treat patient safety as something separate. It's not; patient safety is cost, it impacts wait times and it impacts quality.
I would hope when you put the narrative together, people see the connectivity of all the pieces because if not then people will gravitate again to a silo approach in trying to deal with the issue. I think by your questions you understand this is a holistic piece that must be layered.
Senator Seidman: If I might, then, you've raised a critical point when you say it's about the narrative and how it's presented. How, then, would you suggest the narrative is presented in order to ring the right bells?
Mr. MacLeod: Well, if you start a narrative to determine who we are doing this for, whether it's for the patient, the resident and the client, that can help begin to shape the narrative because then everything goes around about their patient experience, which could include the preventive side, the treatment side, the follow-up side, et cetera.
So I am always encouraged when I see the focal point is why are we doing this? We are doing this for the patient experience, and then you wrap everything else around that.
Senator Cordy: Your presentations have been excellent and practical, so thank you very much.
I know that you have both spoken about medication management, and Dr. Sketris, you spoke about the Health Council report about underuse, overuse, inappropriate use and misuse. I think we talk a lot about overuse and misuse but not necessarily a lot about inappropriate use or underuse, which can be just as bad for the patient as the other two.
In your report you spoke about the barriers, the facilitators and the reviews. What do you do with the information at the Health Council? I know you put it in a report and it goes out, but who do you give the information to when you gather it? It's very relevant and important.
Dr. Sketris: For this report we had a symposium where we invited people from the health professions and others to discuss it. I think various people have done various things around addressing the issue of medication management.
One thing that has happened across Canada is that pharmacists are starting to have an increased scope of practice. Pharmacists are now starting to prescribe — Nova Scotia is one of the provinces — for a specific number of indications. Also in Nova Scotia, if a patient is on a certain number of medications or if they have particular chronic diseases, then the pharmacist can sit down with that patient and review all of their medications. There are a number of things going on related to making sure that all of the medications are reviewed on a regular basis.
Senator Cordy: That is extremely important. It is interesting that this committee, when Senator Kirby was the chair, actually did a health care study, and we talked about the importance of pharmacists being part of the health care team. I'm from Nova Scotia, and they also give flu shots. So I think really good things are happening in terms of including pharmacists as part of health care teams. I know somebody who took a prescription to a pharmacist in Nova Scotia. The pharmacist said, ``No, this will conflict with something else you're taking'' and actually phoned the doctor and said, ``I will not fill this prescription,'' which was really good of the pharmacist. So it is great to see those things happening.
Speaking of including pharmacists, I actually was listening to CBC this morning, and they were talking about seniors and home care and the community, as a whole, being mindful of the possible deterioration of a client coming to the bank or to wherever it might be. We have done a good job, I think, in Canada, for airport security, of saying that, if you see an empty suitcase, let somebody know.
Should we be doing the same kind of thing with the general public if they see a senior? Schools will often look after children and report things that may not be as good as they should be, or they should be reporting that. Should we be getting communities to look into this?
This morning's guest who was being interviewed was actually at work for the bank and said that you see the seniors coming in and occasionally you'll notice their cleanliness or that they're wearing the same clothes all the time or that they're just not looking well. So that can be reported to a health care worker. Should we be doing those things?
Ms. Musing: Some of that is being done currently, and that is one of the reasons why it is wonderful that there is this increased scope of practice for pharmacists because the pharmacist is one health care professional who is easily accessible to patients and actually sees those patients in their home environment because they're in the community. Often, that individual may not be coming in for a prescription. They may be coming in to buy something else within that pharmacy, but it is an opportunity for that pharmacist to have that relationship. They're often the people who notice that something is slightly off with Ms. Smith; she's not acting in the same way. Their thoughts will immediately go to, ``Is it something to do with their medications?'' But that pharmacist then also has the ability to connect that patient back to their family health team or their family practice physician to actually do that assessment or to send that person to the emergency department. So that is happening.
Senator Cordy: I see the report in your presentation, Dr. Sketris, about the Commonwealth Fund International Health Policy Survey, and 74 per cent of patients noted that side effects were explained by a doctor or a staff person, 69 per cent that their doctor reviewed the medications every 12 months. Were these stats for the Commonwealth, or were they specifically for Canada?
Dr. Sketris: Specifically for Canada.
Senator Cordy: And 74 per cent doesn't sound that bad in one way, but then there's 26 per cent who are not receiving any discussion whatsoever about the medication that they're taking. How do we deal with that?
Dr. Sketris: I think part of it is the question. If they're practicing, for example, in Ontario or Alberta, they have family health teams. It could be that the physician didn't explain the medication side effects, but either the pharmacist did or they also met with the nurse practitioner. Maybe, with the way the question is worded, it could be under- reporting as well.
Senator Cordy: Yes.
Dr. Sketris: Still, ideally, it should be 100 per cent. Once you get a medication, you need to know both about its benefits and risks in order to take it appropriately.
Senator Cordy: What we have heard happens is that, if it's not working properly, a patient will put it in a drawer and get something else. Anyway, thank you very much.
The Chair: I want to go over some of these things again. You have all covered a number of things that we have been dealing with throughout these studies and, indeed, some of that goes back to our review of the Canada Health Accord, where they first arose in terms of us identifying them as significant issues. Very clearly, one common action category that flows through everything is communication.
Communication has many dimensions to it in terms of actually making it happen, and it is also dependent upon the right things being communicated to the right people at the right time with regard to the right issue. In the complexity of the health care system, that's not an easy thing.
Let me just go over a few things, and then I will get you to respond in some way.
We heard you mention some of the alerts that are going out in the provinces. We have heard that before, but the real issue is, in the case of pharmaceuticals and also, of course, medical devices, that, unless the actual experience of a patient is reported in some way, it can't form any aid in advising future patients.
Clinical trials are done for both prescription pharmaceuticals and medical devices, but they're clinical trials on a very defined population.
The real clinical trial of either of these occurs once it is approved and gets in the general population. We have argued, as vigorously as we're capable of in polite language, in our previous reports, that we must do a far better job of collecting the reactions of individual patients. The evidence shows, depending on which document you read, a figure of somewhere between 1 per cent, as an optimistic term, and 3 per cent. Occasionally, you see that 10 per cent of adverse reactions are reported. Frankly, we think it is in the 3 per cent or less category.
So we have proposed a number of ways that this could be improved in terms of collecting this information. They're all based on an electronic system. It is not easy for a patient to even know that they have the right to submit an observation on why they stopped taking their medication — because they felt really miserable in the middle of the night or whatever else it was. It is not easy for them to know what to do because they're not provided with any of that information. We have argued that they should be provided with clear electronic access to Health Canada to make this report.
Second, we have identified, throughout all of these reports, the report on health care and our first three studies in this area, the role that pharmacists are playing and the role they could play. We believe that they are a key, if not critical, link in this whole issue. We have recommended the issues with regard to electronic collecting of the information and disseminating it through the pharmacists and giving the doctors much more information on the actual status of the drug as opposed to what they pick up from pharmaceutical representatives, all the way through to the pharmacist being involved in this kind of situation.
We have talked further today about information and the delivery in the provincial system, but, on a national basis, we have the Canada Health Infoway system that is supposed to have been developing these health records, essentially the passport with regard to the health issue. We have heard all kinds of reasons why that can't advance or haven't advanced fast enough to be incorporated. Many of those are due to the silos in the medical system and the reaction of the individual practitioners with regard to cooperating.
The biggest single barrier appears to be the obsession with privacy. Now, all Canadians report, on their income tax, all their personal information. We know it's not a perfect system, but surely to goodness the health records system can be made as private as that is. There is no reason why it has not advanced further. Until we get there, we won't be able to achieve many of the things that you have identified here today. Many of us — I have done it myself — I have my data on a little data pin. But that's because I'm prepared to do that. We have to go further in this particular area.
You mentioned the issue of things being out there on Twitter. Senators mentioned Wikipedia and so on. We know that those systems are risky for the reasons you have indicated. Wikipedia is not a managed editorial system. Individuals can edit the information on Wikipedia, but it is still a source that most people go to first for information.
We have driven the population, because they're way ahead of the delivery system in terms of gaining information. It's not the individual's fault that they're going out there in chat groups and these areas. They know the information must be available. They want to get it, and they're even forming groups.
We heard in our last study about colitis groups that are getting together over the Internet, forming chat groups and sharing information and so on. Yet there isn't a mechanism for that to be delivered to Health Canada and disseminated back to the practitioners that's working. We have argued for that. Based on your testimony, we're going to be arguing more strongly. We're escalating our recommendations in this area as we go forward.
Now we come to the home-care issue. Here's another two-sided issue. Medical evidence shows that people who are able to recover at home recover faster and better than they do in an institution. In fact, being in an institution isn't free of complications. Indeed, evidence shows that if you are in a ward of four people and there are already three patients there when you arrive, within 24 hours you have the flora and fauna of the other three people in the room.
You've identified problems with home-care issues. Again, to a fair degree, it's communication and the responsibility when patients are returned home with regard to the medications they are being treating with. I'm going to finish this up and come to you.
I want to make sure that I don't forget to say this: After you leave here, when you think about the things that I'm going through, summarizing what my colleagues and you have dealt with today, if you think of mechanisms — you have said someone has to take charge, you can't nod your head and go out in the parking lot and forget everything. There have to be recommendations of good ideas to go forward that organizations and leaders can pick up.
So, after you leave here, if you think, based on your experience of specific things — and don't necessarily go to the 30,000 feet and everything included, even if we can get single examples that can become best practices they can act as catalysts for the future.
Finally, you included the Osler quote in your document. What is really fascinating about that is that that was in 1904. What it really means is individual patient and patient-oriented health care. Here we are moving into the era where individual patient health care can be applied. But it comes back to one of the things I said at the outset that if there are hundreds of thousands of prescriptions for serious pharmaceuticals, and we are getting 1 per cent or less than 3 per cent of adverse reactions to them reported, the adverse reactions are almost certainly coming out of the subsets of the population, that is individual category people that weren't included in the first area. That means we need to collect that data critically so that the advice can go to the practicing physician, to the pharmacists and others that are dealing directly with those prescriptions to give the advice based on the individual character of the patient. The Osler statement was from 1904.
That's an overall summary of much of what we've covered here today, and that is in your documents and you have elaborated on it. I'm going to turn it back to you and tell you that we don't want to pass the buck in this committee when we write this report. This is our summary report of four documents. What we want from you, and all the other witnesses who come before us, even pieces of steps, little steps or bigger shoes, whatever it turns out to be, we want those things that help us make recommendations that can actually lead to change.
Mr. MacLeod: Wow. Can I start? That was a great summary. And it also magnifies the challenge, but with that challenge is the opportunity. I think you're also seized with a great opportunity here.
While you were talking I was thinking about my travel here. I had to fly here. I won't say the airline, but if the airline had a big banner to say, ``Oh, by the way, today we're 95 per cent safe,'' I don't think I would have gotten on the plane.
I get really concerned with even a 2 per cent error. We should strive for 100 per cent error-free, knowing full well we may not get there. That builds complacency, where people say, ``I'm at 85 per cent of hand hygiene compliance.'' That's not good enough. It should be 100 per cent. That's my first advice.
The Chair: The worst is that the percentage goes down the higher up you go.
Mr. MacLeod: Exactly. The second piece is you led with communications. I'm a junky for leadership studies, I teach in many schools. A friend of mine, Ron Short, had a wonderful line in a book called Learning in Relationship, because that's what I think we're talking about here. You learn in a relationship.
He said that what goes on between people defines what an organization is. I think what goes on between people defines what a health care system is. If the relationship patterns are healthy, if the hand-offs, the communications, are healthy, magic happens. I think sometimes we don't understand that, with all of our drive to technology and devices, we're a touch business. Always have been, always will be. We deliver services through people.
If we truly understand the people side of our business, the cultural side of our business, really impact it and promote it and not have tolerance when it goes off keel, I think that's crucial.
You talked about leadership. If you identify whatever your themes are, because I'm sure coming out of this you will have a series of themes, everything from prevention on the front end to research, et cetera. You know the organizations in Canada. Boldness would be to say that we think the following organizations should take the lead. And, oh, by the way, maybe they should talk to the following organization to staff that lead to begin action, and I think you name them. I think we know who they are. Canada Health Infoway has a role, CIHI has a role, Accreditation Canada with Standards and ROP has a role, the colleges have a role, CPSI has a role. After you've identified your themes, say who should be in that lead pack to drive this agenda. Almost embarrass them into it by identifying that they have the capacity to do this.
The other piece is going back to home care. Again, do you understand the connectivity of all these pieces? Home care is the future. It's not about the sickness model. We have to move beyond the sickness model, and I think it's important for you, in your deliberations, to actually say that, because everybody is talking about it, and be deliberate. It is no longer a sickness model. It's a different model. But that means really paying attention to what is taking place within that home-care environment and having an honest conversation with the consumer about risk.
My example is would I rather have my loved one in a long-term care facility where the rest of their lives it's a quality of life which means they get up and walk about, but with that there's the potential of a fall? Or do I want the other path, to heavily sedate them, strap them in the bed so there is no quality of life? By not having that up-front conversation, unfortunately what happens when the fall happens, that facility is drilled in the media and so what's their reaction? ``Well, let's drug them up and let's keep them in a bed.'' To me, that's not quality of life. The problem is we haven't had the front-end conversation.
I would hope the report begins to pave a way for an honest conversation with the consumer and the public about risk, but risk on the balance of quality of life. I don't think we have had an adult-enough conversation on that yet.
Those are just my first thoughts.
Dr. Sketris: One of the things I think we need is a better understanding of, across the whole country, how much inappropriate drug prescribing and how much misuse there is, and so on.
What the European Union has done for seniors is to develop STOPP criteria, drugs that should be stopped in seniors; and START criteria, drugs that should be started in seniors. They've developed the criteria so that they can be rolled out across all 27 EU countries. They've put quite a bit of money into that so that people can look across countries and benchmark themselves against others.
If you develop prescribing indicators at, say, the provincial level, sometimes they can also be used at the hospital level or the physician could look at how they're prescribing compared to other physicians and so on. That system is less well developed in Canada than other places.
I think the other thing that you talked about is collecting adverse drug reaction reports. There are many ways that can be done. One of the models I like is in the Netherlands. We said that they're number one in terms of electronic health records. But what they also do, for example, with an older drug like acetaminophen, we pretty well know what its safety profile is, but we have new drugs coming out every year. What they do then is have a plan where the pharmacists and the physicians with the electronic health records track the patients taking new drugs particularly closely in a very systematic way rather than with the ad hoc reporting method, so they get a good idea of exactly what percentage of patients are likely to get an adverse reaction and what their characteristics are so they can try to prevent it. Those are a couple of thoughts.
Mr. MacLeod: What Ingrid triggered for me — and I think there's good evidence and we can share with you where to find that evidence — is that it would be kind of interesting in your report if you proclaim these are the ``never events,'' events that should never happen on one side and here are the ``always events'' that should happen. That might begin to crystallize a collective thought across the country because one would have to think a ``never event'' and an ``always event'' should cross political and provincial boundaries.
The Chair: We recommended in our last report, based on the issues you're talking about, identifying the serious issues, the triangle, black box, and so on, issues of labelling. We're hopeful that Bill C-17 will show signs of significant change with regard to requiring label changes on pharmaceuticals in Canada. I think we have the opportunity to start moving forward and I thank you.
The final thing I will leave you with is that we identified one of the major reasons for the issues in the health care system are the silos, and you mentioned silos throughout. It has been suggested that won't change until there's something major to drive change and innovation within the health care delivery system.
I will leave you with a thought that competition has been identified in many areas as the thing that drives people forward in innovation and to suddenly start communicating within their own bailiwick if their efficiency is so low compared to what is alternately available. I don't want comments on that. I simply leave that thought with you because we're not going down that road today.
With that, I thank you very much for your contributions. I thank my colleagues for their questions that have led to this discussion. If you think of anything after departing here that is a concrete step, let us know. With that, I declare the meeting adjourned.
(The committee adjourned.)