Horizon, Saint John hospital officials scrambled during DNA equipment fight
Documents obtained by CBC News reveal internal discussions over potential purchase of DNA sequencing machine
It was a scramble.
Last May, top officials at the Saint John Regional Hospital and the Horizon Health Network were fighting a provincial government veto of $900,000 worth of new DNA sequencing equipment.
For more than a year, they had been confident the purchase was a slam dunk: the equipment would improve patient care and it would boost the hospital's research capacity.
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But in late 2014 and early 2015, it dawned on them that the new Liberal government was applying a new two-pronged test: cost and duplication.
Horizon argued there was no cost because the equipment would be donated by the Saint John Regional Hospital Foundation, which raised the money to buy it.
But the Liberals believed the equipment would duplicate services at the Atlantic Cancer Research Institute (ACRI), located at the Dr. Georges-L.-Dumont University Hospital Centre in Moncton.
So Health Minister Victor Boudreau vetoed the purchase in March, then told Saint John officials what they had to do to change his mind.
"If we can prove that we can do this program cheaper than ACRI, [Boudreau] would consider this new information," Dr. David Marr, the medical director for Horizon's Saint John zone, emailed colleagues on May 19, 2015.
He asked Brenda Kinney, the Horizon Health Network's executive director for Saint John, to share "the business case" for the equipment to present to Premier Brian Gallant.
But Kinney came up empty.
"FYI, I don't have a detailed business case around this," she wrote in an email.
All she had was information Horizon "pulled together" for consultations by the New Brunswick Cancer Network six months earlier, she said.
Dr. John Dornan, the chief of medical staff at the Saint John Regional Hospital, told CBC News it's fair to say Horizon wasn't prepared for what the Liberals wanted.
"We based our business case on the information we had here in Saint John," he said.
Those consultations were designed to find ways for Horizon and Vitalité to co-operate. But hundred of pages of emails and attachments obtained by CBC News show the two health authorities behaved as rivals throughout the DNA sequencing fight.
The documents, released under the Right to Information Act by Horizon and the Department of Health, provide a day-by-day account of Horizon fighting to save the purchase and Vitalité seeking to make ACRI the lead DNA sequencing centre for the province.
"We need to do the math and show that we are at least competitive," said Dornan in a May 20, 2015 email to McGarry and several colleagues.
Horizon scrambled to find numbers to support the low-price argument.
Dr. Tarek Rahmeh forwarded six-month-old data, but wrote that Daryl Steeves, who had been Horizon's regional head of lab services, "does not know where these numbers came from."
Another Horizon official, Gary Foley, wrote that "staff in lab are trying to redo the calculations based upon actual implementation."
Dornan warned that data on the cost of sending tests to Moncton "may neither be accurate nor available. We mostly need to go with what we can reliably defend."
McGarry told Dornan and others he wanted everything kept quiet while Horizon tried to make its case, but the rejection became public June 4, inflaming public opinion in Saint John against the Gallant government.
December 2013: 'It certainly sounds like the same thing'
The story began in December 2013, when the Saint John Regional Hospital Foundation agreed to raise the $900,000 for the DNA equipment. Horizon had already approved it, but a few days later, CEO John McGarry had questions.
Earlier that year, McGarry was hired to run Horizon with a mandate to work with Vitalité's CEO, Rino Volpé, to increase co-operation and reduce overlap between the two health authorities.
Responding to a long email from Daryl Steeves about the sequencing plan for Saint John, McGarry said he was "about to meet" with ACRI to discuss their equipment in Moncton.
"Is this the same as what you describe?"
"It certainly sounds like the same thing from that description," Steeves answered.
McGarry asked again a month later, when ACRI's director, Dr. Rodney Ouellette, announced his institute in Moncton had bought DNA sequencing equipment with federal and provincial funding.
"Is this equipment [doing] the same work that will be done with the equipment we just had the Foundation support?" McGarry asked Steeves in the email.
"Yes it sounds like similar if not the same," Steeves replied.
February 2014: 'I can not believe this is happening'
The foundation publicly launched the fundraising drive for the Saint John equipment on Feb. 20, 2014.
The next day, ACRI's director, Ouellette, sent an email to a large list of Horizon doctors, telling them his Moncton lab was accepting samples and to contact him "if you have any specific sequencing requirements."
That sounded more alarms about duplication.
One of the Horizon doctors Ouellette contacted, Louis Cartier in Miramichi, forwarded it to Dr. Edouard Hendriks, Horizon's vice-president of medical affairs.
"How is all this fitting with what St John [is] trying to do?" Cartier asked. "Is this complementary or duplication (two entities not talking to each other)?"
Vitalité officials raised the same issue after the foundation announcement.
"Wow, I can not believe this is happening," Stephane Legacy, a Vitalité vice-president, wrote in an email to two officials at the Department of Health.
"We have in Moncton the equipment, staff, calibration completed. And now Government or Saint John decide to duplicate very expensive equipment, staff and knowledge in Saint John. … It sure looks like duplication."
Francine Bordage, the director of hospital services and operations at the Department of Health, assured Legacy the province had "no involvement" with the foundation's fundraising decision.
There may be reason to worry.- Dr. Edouard Hendriks, Horizon's vice-president of medical affairs
But now it was on the province's radar.
"Vitalité has gone to the government," Hendriks said at a Horizon committee meeting on May 1, 2014, according to minutes.
"There may be reason to worry.
"Government will not agree to duplication," he added, "but perhaps there is a possibility to have a provincial program with both labs practising collaboration and compromise."
Over the summer, Horizon officials and doctors discussed and evaluated the cost of different molecular-testing sites, comparing an in-house Saint John service to shipping samples to a hospital in Hamilton, Ontario or the Mayo Clinic in the United States.
At least one Horizon doctor recommended collaborating with Vitalité "because New Brunswick is too small of a province to have two independent Molecular Centers here," according to minutes of an August committee meeting.
Steeves agreed to explore it, but Hendriks was reluctant because ACRI's lab in Moncton would likely charge Horizon to do its tests.
"I don't think they intend to do it for free."
And Steeves was still emphasizing speed over cost.
"It is hard to beat the turnaround time for a lab a few blocks away," he wrote.
Even so, ACRI's Ouellette was lobbying some Horizon doctors directly to send more tests his way in Moncton.
Twice in 2014, he emailed them about it. In November, he even offered to analyze samples from Horizon's Moncton Hospital for free.
December 2014: 'First and foremost we need our clinical service'
The new Liberal government asked the New Brunswick Cancer Network, the province's co-ordinating body, to organize a "clinical consultation" with the two RHAs in December 2014 to study the implications of doing testing "at one or both sites."
Daryl Steeves drafted a "key messaging" document to bolster Horizon's case, which didn't argue against the Moncton service but asserted Saint John needed it as well.
DNA sequencing needs were growing so fast, it says.
"It will be challenging for even two labs to handle this unprecedented growth."
Horizon was "open and willing to develop collaborative practices with Vitalité," it added.
Steeves sent the document around by email for feedback, but only to top medical staff in Saint John. Those at Horizon hospitals in Fredericton, Moncton, and elsewhere were not included.
Dornan says it wouldn't be right to see this as the health system still operating in silos.
"We do live in communities that are 100 kilometres apart and my role is in the Saint John area," he told CBC.
"My role is not to inform all Horizon officials and clinicians. My task is to ensure our people are in the loop, and supportive or aware of arguments we're making. It would have been inappropriate for me to pretend to advise all the physicians in Horizon."
The responses were often Saint John-focused too.
"We all know that there is a great number of clinicians that would like many more tests here in our Zone and the Region," Dr. Marek Godlewski wrote.
And when Steeves proposed acknowledging the government's concerns by making "a bold statement" about a provincial approach to genetic testing, another Saint John doctor, Anthony Reiman, told him to focus on the local hospital.
"I think for now that this might be beyond the scope," he wrote.
"First and foremost we need our clinical service and this is what we are resourced to deliver."
Horizon officials continued to weigh the cost of sending certain samples to ACRI in Moncton, concluding the per-test price of $900 there was higher than the $650 cost in Halifax, a comparison ACRI would dispute.
But co-operation between Horizon and Vitalité remained elusive.
"The hope is that eventually there will be a meeting between the two RHAs, but Dr. Hendriks has not heard anything as of yet," according to minutes from a Horizon committee meeting in January 2015.
March 2015: 'You should expect fallout'
Then in March, McGarry heard rumours that the purchase would be vetoed.
He emailed Tom Maston, the province's deputy minister of health, that after five months of delay, "positions in SJ are hardening very quickly. …You should expect fallout. The word is that the answer is `no' and I certainly disagree with it and must say so."
Boudreau's veto was made official in a March 31, 2015 letter to David Ferguson, the chair of Horizon's board.
Given ACRI could already do DNA testing in Moncton, Boudreau wrote, "I cannot support the purchase of any additional DNA sequencing equipment when we currently have excess capacity within the province."
McGarry forwarded the letter to top Horizon officials.
"Cannot believe this decision and the lack of appreciation for what the decision will cause to occur," he wrote.
One Horizon doctor, David Marr, asked about Boudreau's mention of ACRI: was this "the cancer guy from Moncton" who "had personal interest in his program at Dumont?"
That's a reference to Ouellette, and a mistaken one: ACRI is not part of Vitalité, but is a private, non-profit operation housed at the Dumont hospital.
Ouellette's only salary comes from his Vitalité lab job.
"Tell me this is an April fools joke," Dornan wrote to McGarry the next day. Kinney emailed: "This is going to cause so much upset, really unfortunate!"
Dornan emailed his fellow doctors to "determine next steps" on trying to change Boudreau's mind.
It was during that scramble that Kinney acknowledged she didn't have "a detailed business case" for the sequencer and could only provide information "pulled together" for the Cancer Network meeting six months earlier.
June 2015: 'We need to be very clear on this matter'
Even in early June, when the Liberal rejection became public and Premier Brian Gallant's office was asking for an "updated briefing note" on the issue, Horizon officials still didn't have the figures they needed at their fingertips.
When the health department asked for the number and cost of all tests sent out of the province the previous year, Horizon needed time to compile it from various facilities.
"Most of my data is focussed around what Saint John refers out," wrote Heather Kyle, an administrator for Horizon's lab service.
"To get this for all [Horizon] labs will take a few days."
But Dornan says after officially not being prepared, Horizon was increasingly aware of Vitalité's plans and was able to hone its own arguments.
"We each became aware of our business cases and we were able to help each other improve our business cases."
Vitalité was keeping up its own pressure. An assistant deputy minister at the Department of Health wrote that Vitalité was willing to be "the provincial lab" for all testing, but would come to the province for the money to pay for Horizon's tests.
McGarry, meanwhile, was asking his executives to clarify what Vitalité would charge Horizon. If Horizon got any numbers wrong, he wrote, "our claim that we can pay our current providers less than ACRI will be shot!"
Twice in June, Dornan took the unusual step of emailing Boudreau directly, acknowledging Horizon needed "to work more closely and collaboratively" with Vitalité.
He proposed a deal to have Saint John doctors steer samples from outside Saint John to ACRI.
"All parties agree this is a growing need," he wrote.
"We should help ACRI get to their minimum 1,300 specimens per year."
Two days after Dornan's second email to Boudreau, Gallant went to the Saint John Regional Hospital to announce he was reversing the veto.
"We're very excited about what this will be able to do for the region and for health care in general in the province," Gallant said of the DNA sequencing equipment.
"We do have fiscal challenges as a province and I do appreciate their commitment to make sure that they keep expenses down and make sure that while we deliver strong health care we also look at the bottom line."
Since Gallant's announcement, little has changed.
ACRI continues to do some testing for Horizon hospitals in Moncton and Fredericton, and the foundation still hasn't bought the equipment for Saint John that triggered the crisis, though it says it will happen "imminently."
And there's still no agreement for how Horizon and ACRI might work together to create a single two-site testing system that avoids duplication.
"A provincial committee has been established," a spokesperson for the Department of Health said in a statement, "and Vitalité and Horizon are identifying the next steps."
Dornan says, though, that while there isn't "an exact map" for cooperation, Vitalité sends tests to Saint John and Horizon sends tests to Moncton.
Once the equipment is in place in Saint John, he says, the two systems should work well together.
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