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Inside the April 2004 print edition of Canadian Healthcare Technology:

Feature Report: Electronic medical records

Web portal gives patients an active role

Grand River Hospital has launched North America’s first comprehensive patient portal – a web-based service that enables patients to access their personalized treatment plans, manage their appointments, self-monitor their side effects and symptoms and re-order prescriptions all through a secure Internet connection.


Project Gemini to launch St. Mike’s into top tier of e-care delivery

Smart system will push information to the patient bedside, and provide execs with analytical information.


The super SAN

B.C.’s Interior Health Authority, which covers approx. 20 percent of the province, has installed a Storage Area Network (SAN) solution. Storage technology at one site now replaces systems at 51 data centres across the authority.

The wonder of PACS

A new survey from the Canadian Association of Radiologists estimates that Canada’s healthcare system would save $370 million annually if healthcare providers all adopted Picture Archiving and Communication Systems.


Integrating legacy systems

It’s easy to replace old hardware systems with new equipment; it’s much harder to integrate incompatible software and electronic records into the new system. The Hamilton Health Sciences Corp. found an effective way to do it.


Decision support for patients

Bell Canada is sponsoring a patient decision-support lab at the Ottawa Hospital. Using computerized tools, including a web site that has received up to 150,000 hits a day, patients at a crossroads can make better decisions about their health.

PLUS news stories, analysis, and features and more.


Web portal gives patients an active role in care plans

By Jerry Zeidenberg

KITCHENER, ONT. – Grand River Hospital has launched North America’s first comprehensive patient portal – a web-based service that enables patients to access their personalized treatment plans, manage their appointments, self-monitor their side effects and symptoms and re-order prescriptions all through a secure Internet connection.

For several years, healthcare gurus and analysts have predicted the emergence of ‘empowered patients’ who could participate in the management of their records and treatments in this way. But it appears that Grand River Hospital is actually the first to do it.

“The portal gives patients an active role in managing their care, and makes them a part of their care team,” said Glen Kearns, vice president and CIO at the Grand River Hospital. “They’re not just having things done to them, they’re taking steps for themselves.”

Kearns explained that by more closely monitoring their symptoms, test results, medications and appointments, patients can improve the effectiveness of their therapies and cut down on re-admissions to hospital. That not only improves quality of care and patient satisfaction, but it should also result in cost reductions for the 495-bed community hospital.

In March, the hospital rolled out its Care Connections patient portal, which its I.T. team developed over a six-month period in conjunction with McKesson Information Solutions, the Atlanta-based company that supplies its hospital information system and physician portal.

The new patient portal appears to be so promising for reducing hospital costs and improving outcomes that McKesson is in the process of commercializing the solution and will be offering it to hospitals across North America. The company demonstrated Care Connections in its pavilion at the HIMSS conference and trade show, held in Orlando, Fla., in February, and attracted a large flock of visitors who were eager to have a look at the system.

Kearns explained that Grand River will use a phased-in approach for the Care Connections patient portal, starting with cancer patients, then expanding to include renal dialysis, diabetes, surgical specialties, complex continuing care and other areas.

In the initial stages, the service will offer patients the opportunity to schedule certain types of appointments, pose questions to their care-givers, and obtain detailed information about cancer care procedures, along with the reactions they can expect to cancer treatment and the myriad medications that accompany the treatment.

If they’re experiencing unusual symptoms, they’re urged to contact their care givers for feedback and assistance.

Kearns said Care Connections will be upgraded to allow patients to renew prescriptions through the hospital pharmacy, and they’ll even be able to transfer pick-up of their medications from outside pharmacies to the hospital facility.

In the next phase, the portal upgrade will also allow them to view test results from the lab and diagnostic imaging departments – enabling them to keep better tabs on their condition, and to work with caregivers on fine-tuning their medications and therapies.

The hospital expects this will result in better outcomes for patients, and fewer admissions to hospital for adverse drug events and other complications.

Kearns observed that many hospitals have patient web sites, but it’s difficult to find one that’s connected to clinical systems. “We haven’t come across anyone who has provided access to clinical information and care plans,” he commented.

Claudette DeLenardo, program director for the patient portal, stressed that patients have access to detailed treatment plans to help them with managing their conditions. For example, cancer care is broken down into care cycles, with procedures, medications, and expected side effects outlined for each week of treatment.

“We’ve developed hyperlinks, embedded in the system, to let patients know what to do if you have, say, nausea or vomiting,” said DeLenardo. She said the treatment plans advise patients of how and when to take their drugs, what the medications are expected to do, and even how to pronounce the names of the pharmaceuticals they’re dealing with.

There’s a great deal of advice on the portal, describing what to do for each week of each cycle. “We let patients know, for example, that on day eight of their first cycle, their white blood cell counts may begin to drop and that the patient needs to monitor themselves carefully,” said DeLenardo. “The portal tells you at what point you should seek help if you are experiencing certain side effects.”

Moreover, patients can chart their own symptoms on a 1-4 scale, so they can review their status with their healthcare team. For cancer, there are approximately 30 symptoms they can monitor and discuss with their care teams.

Kearns said the system took only six months to build for a number of reasons: the project had the approval and support of the hospital’s top management, including president and CEO Dennis Egan. It also had sufficient resources, with a combination of hospital staff and experts from McKesson working to develop the service. Finally, it builds on existing systems, namely the existing hospital information system and the physician portal.

And while patients will be able to review important clinical information, such as lab results, their physicians must first approve the transfer of such results into the patient portal.

CEO Dennis Egan got the ball rolling on the project about a year-and-a-half ago, after attending seminars with a former MIT instructor who teaches executives about the productivity gains that can be made through harnessing the Internet and existing databases.

After some preliminary work, Egan persuaded his board to allocate resources to the patient portal project, citing the many benefits for the hospital: “There is major potential,” said Egan. He observed that the portal should relieve a great deal of pressure on specialists for information, test results and prescription advice and renewals from patients. It will also provide patients with a source of validated information about cancer and other conditions, eliminating a plethora of false or low-grade information they collect from countless web sources. And the self-charting feature will improve communications between patients and physicians. “Now, the patient will be able to tell us more easily what has been going on,” said Egan. “We believe we’ve really hit on something here,” he added. There’s a lot of excitement about it.”



Project Gemini designed to launch St. Mike’s into top tier of e-care delivery

By Andy Shaw

The aim was clear enough, says St. Michael’s Hospital CIO John Wegener: build an “information management house”, as he calls it, that would foster and sustain what the world will come to know as the finest academic healthcare facility in Canada.

Moreover, the underlying principle of construction was clear: a house built on a sand foundation will not stand. Reasons Wegener: such a shaky foundation could not support the overlaying weight of the heavy-duty health informatics needed to reach the upper levels of research, teaching, and patient care that St. Michael’s was aiming for. The underlying electronic foundation had to be rock solid.

“But, to be frank, it’s not a glitzy thing to go to your Board of Directors and talk about the need for things like reliable networks and data centres. Their eyes tend to glaze over,” says Wegener. “Easier to sell them on a $40 million electronic patient record system and all its wonders. But if you don’t have a sustainable infrastructure underneath it in place first, that system is not going to work for you in the long run.”

Partly because his hospital was admittedly coming from the back of the healthcare technology pack, he and others managed to convince the St. Michael’s Board to spend about $75 million on an electronic foundation that is now known as Project Gemini. And somewhat like its American space-race predecessor, Project Gemini is aimed at putting St. Michael’s clinicians and administrators into high healthcare orbit. Its goal is as simple as it is lofty: to transform clinical practice through technology.

Also like its predecessor, St. Michael’s is carrying out the five phases of Project Gemini by relying on private sector partners. Siemens Canada Ltd., IBM Canada Ltd., and Getronics Canada Inc. are all making state-of-the art contributions to the collaborative project that includes a number of first-evers.

Siemens, as the partnership’s principal software provider, announced in February that St. Michael’s would be the first Canadian site of its ground breaking Soarian workflow engine – that eventually will combine all the hospital’s diagnostic, clinical, therapeutic, and financial data into one patient-centric view available throughout the hospital.

IBM, the project’s main hardware and storage provider, is supplying the country’s first three-tier storage system to Project Gemini, that will also serve as a cost-saving prototype for other hospitals world-wide.

Getronics has designed, implemented, and will manage and monitor all St. Michael’s information networks, in a precedent-setting outsourcing relationship.

Together, Wegener says, St. Michael’s and its three partners are now “rounding the far turn” of implementing Project Gemini’s Phase 1. It adds the first three basic building blocks to support what will eventually be an end-to-end electronic medical record system.

• Clinical access – replaces the hospital’s clinical database and allows clinicians to view lab and radiology results as well as dictated transcription reports.

• PACS – creates and archives digital diagnostic images to replace X-ray films.

• RIS – replaces the Medical Imaging department’s current radiological information system. It includes templates that streamline the entry of data such as patient demographics, scheduling, billing, and mammography reports.

Future phases will add more building blocks to the infrastructure as follows:

• Phase 2 – clinical documentation, cardiology, and pharmacy systems;

• Phase 3 – medication administration and patient scheduling;

• Phase 4 – physician order entry;

• Phase 5 – intensive care unit and operating room systems.

But what that doesn’t tell you is that the whole infrastructure will also be smart – all the way through to the bedside. Two network ports will flank every St.Michael’s hospital bed delivering the advice of the Soarian software to caregivers at a 40 megabit per second transfer rate.

“It’s an active rather than a passive system,” says Andrew Hind, the Siemens Canada vice president who heads up the company’s Medical Solutions Division. “It will push information at the caregiver through what we call its Smart GUI interface. So for the physician, for example, it will provide not only the latest clinical guidelines, it will also flag any order-entry the physician might make that deviates from normal hospital practices with a query like: Are you sure you want to do that?”

Hind says that while Soarian comes with an extensive library of best practices, it is built on industry standard software and can be readily modified by a hospital to suit its idiosyncrasies and changing practices.

What’s also smart about Soarian is that, on start-up by users, its interface automatically appears in different configurations to suit their particular roles, even though all interfaces spring from the same SQL, Windows 2000 database and server. It automatically anticipates what their likely individual needs are – with the net result that patient care and use of resources are better timed.

“Both a physician and a nurse, for example, will see Windows-like user interfaces that are similar,” explains Virginia ‘Ginny’ Hamilton, Siemens’ director of health services. “But the screens will have different priorities at the top. The physician, to cite a basic example of what the system does, might see five patients that need discharge orders written that day, as the physician’s first priority.”

Meanwhile, the nurse’s view has quite different look and feel. Her priorities, laid out by Soarian, might be to document what the doctor has prescribed for the exiting patient, as well as notifying Dietary and Housekeeping that the patient is going. And from there, to adjust her staffing plans for the ward.”

Soarian is also tracking all this and laying the groundwork for others to make similarly smart and timely decisions. Its “group analytics” feature provides hospital administrators with a steady stream of outcomes, cycle times, and other performance measures taken over periods of time.

St. Michael’s was similarly smart about how it formed its relationship with its network builder, Getronics – especially given the hospital’s impecunious history.

“In simple terms, St. Michael’s realized their core competency was patient care, not wires and walls, switches and components – and that they therefore needed a partner like us,” says Bruce Yott, Getronic’s director of marketing. “So we developed what we called a ‘utility model’ for them that required no cash up front. We own and operate the network in return for a monthly fee. And that includes providing instant fixes for anything that might go wrong 24 by 7.”

As far as Yott knows, that outsourcing relationship is unique but could serve as a model for the rest of the healthcare world.

“One thing it can do for a hospital is take away the fear of technology that some have and that prevents them from putting it to use,” concludes Yott.

One other fear hospital administrators naturally have is the normally high cost and vulnerability of electronic storage. But IBM has laid those concerns to rest for Project Gemini with primary storage and back-up systems that are in part virtual.

“It was an unusual implementation,” says Mercer, who is IBM’s healthcare storage rep responsible for Toronto hospitals among others. “Usually, back-up sites mirror the original site identically. But that requires an enterprise-to-enterprise storage system that, because of its high-grade components you need in both, is the most expensive arrangement. So instead we were able to put the back-up site on less expensive mid-range storage, yet we were able to maintain all the convenience associated with an enterprise-to-enterprise set-up.”

The secret of how to do that is no longer any secret, explains Mercer: “What we did was to layer over the primary and secondary storage systems with another layer of software. And what that does is make it appear to the user as if all those separate storage pools are just one pool.”



Radiologists call on provinces to match Infoway’s PACS investments

By Jerry Zeidenberg

The technology known as PACS – short for Picture Archiving and Communication Systems – would save the Canadian healthcare system $370 million annually if implemented across the country. That’s one of the findings of a recent report by the Canadian Association of Radiologists, a Montreal-based association that is urging greater investment in computerized medical imaging systems to improve the quality of healthcare and to lower its costs.

Much of the quantifiable savings would come from the elimination of film and chemistry, the recovery of real estate currently used for storing film bags, and the manpower needed to process, file and search for hard-copy studies.

In addition, dramatic improvements in efficiency are in the offing through the use of digital imaging and networks as opposed to films. “PACS lead to a 15 to 25 percent increase in the efficiency of radiologists, and a 10 to 15 percent increase for technologists and administrative staff,” said Dr. Richard Rankin, chief of radiology at the London Health Sciences Centre, in London, Ont. “Those kinds of gains are nothing to be sneezed at.”

Dr. Rankin was also chairman of the steering committee for the study, titled “PACS for Canadians,” available from the Canadian Association of Radiologists.

Efficiencies for radiologists are usually expressed as an ability to see more patients and interpret the results of diagnostic tests more quickly – a process referred to by some observers as “throughput”. Not only does this save more patients from waiting for tests and results, but it also means they can start treatments sooner. And that leads to more effective healthcare, along with more satisfied consumers.

In his own London region, Dr. Rankin said PACS would lead to reduced spending of $5 million over five year in his own London region – and that, he added, was a conservative forecast.

He also pointed to the anticipated efficiency gains from digital imaging and networks. “There’s quicker reporting of results, the specialist and GP can review together, there are no lost films, and there’s fewer re-takes,” said Dr. Rankin, who summarized the report at a recent CAR conference and offered insights of his own.

He mentioned that PACS systems include viewing stations that provide powerful interpretive tools for radiologists – such as the ability to magnify specific areas of an image, change the lighting and contrast, and automatically calibrate lesions. All of this simply can’t be done, or can’t be done as easily, using film and the traditional light box.

What’s more, PACS networks can automatically retrieve previous patient exams, enabling the radiologist to make comparisons much faster than when using films.

Dr. Harry Shulman, chief radiologist at Sunnybrook & Women’s Health Sciences Centre, in Toronto, was even more sanguine about the benefits of PACS. His organization was one of the first in the country to install such a system. According to Dr. Shulman, who also spoke at the CAR conference in Toronto, “Using the PACS, our operational costs amount tore half those of running a film-based environment.”

However, to reach the annual savings of $370 million touted by the CAR, the association stresses that digital imaging systems must be implemented throughout the hospital sector, with connections to referring physicians. At the present time, the radiology association reckons that only 20 percent of the hospitals in Canada have a picture archiving system.

To boost usage levels to 90 percent or more, the CAR is calling on provincial governments to match on a 50/50 basis the investments in PACS that are planned by the Canada Health Infoway over the next four years.

The federally funded Infoway, which has been seeded with $1.1 billion to spur the rise of electronic patient records throughout Canada, intends to invest between $220 million and $280 million toward diagnostic imaging initiatives over the next four years. The organization views digital images and computerized radiology reports as crucial building blocks for the pan-Canadian EHR.

According to the CAR, however, this investment won’t be nearly enough – it estimates that closer to $1 billion must be invested in PACS and digital imaging equipment alone to obtain the vaunted benefits.

To get closer to this goal, it’s urging provincial governments to step into the funding fray, as well.

A model for this kind of federal-provincial PACS funding partnership emerged in February, when the government of Ontario announced it would contribute an additional $20 million to the $15 million that’s being invested by Infoway in a region-wide, shared PACS in southwestern Ontario.

Eight hospitals are participating in the pilot, which has now attracted $35 million in government funding. They include the London Health Sciences Centre and St. Joseph’s Health Care London. Both government partners are making one-time investments in the project; the hospital partners will be responsible for on-going costs such as upgrades. The other six hospitals are:

• Alexandra Hospital, Ingersoll;

• Four Counties health Services, Newbury;

• St. Thomas-Elgin General Hospital;

• Strathroy-Middlesex General Hospital;

• Tillsonburg District Memorial Hospital;

• Woodstock General Hospital.

Together, they form the Thames Valley Hospital Planning partnership. Infoway originally chose the grouping as a pilot investment for “shared services” in computerized digital imaging because the hospitals had a history of cooperation, and the region boasts a large geographic area and a substantial patient population of 1.5 million – large enough on both counts to provide a cost-effective laboratory for developing a shared service model that could be duplicated in other parts of the country.

Infoway is also investing funds in a region-wide PACS project in British Columbia’s Fraser Health Region.

In Ontario’s Thames Valley, the plan is to begin with PACS in one of the major hospitals, and roll it out to the others over the next two years. The central archive and application data centre are to become operational by June 30, 2004, with the first hospital having achieved filmless adoption by September 30, 2004. In addition to the cost savings, the partners expect that faster handling of patient exams and more powerful digital tools will result in better patient care.

“Patient care will be greatly enhanced through electronic access to digital images,” said Diane Beattie, chief information officer and integrated vice president of St. Joseph’s Health Care London and London health Sciences Centre. “Diagnostic imaging systems are an essential cornerstone in developing electronic health record solutions.”



Hamilton Health Sciences finds effective way to consolidate legacy data

By Issie Rabinovitch, PhD

Hamilton Health Sciences Corp. was formed in 1996 when four hospitals in the Hamilton area merged, creating one of the largest teaching and research hospitals in Ontario. It has about 1,160 beds, 8,000 employees, and 1,000 physicians. It also had over 250 legacy systems.

Each of the four hospitals entered the merger with its own technologies and ways of doing things. With so many unconnected islands of hardware, software and data, it wasn’t possible to get a global view of a patient. Furthermore, the cost of supporting so many different platforms was extremely high. Legacy software often runs on legacy hardware. Moving data off such a platform has many benefits, not the least of which is the savings in monthly maintenance costs.

The goal, from the outset, was to be able to do online searches across all data and all patients without difficulty. It was clear that this wasn’t an easily reached goal and would need to be approached in stages.

I spoke with Winston Sullivan, Manager, Information and Communication Technologies, Hamilton Health Sciences about the challenges he faced and how he arrived at some of the decisions that were made.

In talking to other hospitals, Sullivan found that no one kept all data on disk. Hospitals have traditionally kept patient data on microfiche or even paper. In his research, he wasn’t able to find a single institution that was able to archive its data online, let alone make it searchable. There is a considerable difference between making data viewable online and making every data element searchable.

The first step in setting up a standard system that worked across the four sites was to replace the various business systems with one system – PeopleSoft. That was accomplished in the year 2000.

The next step was to replace the 250 applications in the clinical system, which were supplied by a variety of vendors and ran on a varied collection of hardware and operating systems, with a common Meditech solution. That occurred in 2002.

The final piece of the puzzle was to find some efficient means of moving data off the legacy systems into this standardized framework and enabling all of the searching and reporting capabilities required by the users.

Sullivan wanted a solution that was easy to use, OS-independent and had the option of a Web-interface. A Web-interface was considered to be important since the cost of installing and supporting software on thousands of computer systems is considerable. Since each of these systems already had a Web browser and users understood navigation methods in a browser, training costs would also be minimized.

After an extensive search, only two possibilities emerged. A solution provided by a vendor in the U.S. met most of the criteria but it lacked a Web-interface. A less expensive and more powerful solution, with a Web-interface, was found in Canada. FileNexus, an application and data repository with seemingly magical powers developed and marketed by Loris, a Toronto-based company with customers around the world, was identified as the product of choice.

I spoke with Sal Bevan, President and CEO of Loris. My first reaction to his description of FileNexus was that he was surely exaggerating its capabilities. It turned out that I was wrong.

FileNexus is able to take data from any source, regardless of the application, operating system, or hardware it is on, and make each field discretely searchable. All that is required is that the application can generate a print stream, the data that is created when a report is printed.

As Bevan explained, Loris differs from most of its competitors by proving their approach works before a contract is signed. A pilot project can be done in days. There is no large up-front payment, and the licensing is on a monthly basis. Customers can quit at any time.