Inside the April 2004 print edition of Canadian
Feature Report: Electronic medical records
Web portal gives
patients an active role
Grand River Hospital has launched North Americas
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
Project Gemini to launch St. Mikes into top tier of
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 Canadas healthcare system
would save $370 million annually if healthcare providers all
adopted Picture Archiving and Communication Systems.
Integrating legacy systems
Its easy to replace old hardware systems
with new equipment; its 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.
READ THE STORY
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 Americas 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. Theyre
not just having things done to them, theyre taking steps
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
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
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
If theyre experiencing unusual symptoms, theyre 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 theyll
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
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
its difficult to find one thats connected to clinical
systems. We havent 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.
Weve 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
theyre dealing with.
Theres 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 hospitals
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. Theres a lot of excitement about it.
Project Gemini designed to launch St. Mikes into top
tier of e-care delivery
By Andy Shaw
The aim was clear enough, says St. Michaels
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. Michaels
was aiming for. The underlying electronic foundation had to be
But, to be frank, its 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 dont 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. Michaels 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. Michaels 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. Michaels 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 partnerships principal software provider,
announced in February that St. Michaels would be the first
Canadian site of its ground breaking Soarian workflow engine
that eventually will combine all the hospitals diagnostic,
clinical, therapeutic, and financial data into one patient-centric
view available throughout the hospital.
IBM, the projects main hardware and storage provider, is
supplying the countrys 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. Michaels information networks, in a precedent-setting
Together, Wegener says, St. Michaels and its three partners
are now rounding the far turn of implementing Project
Geminis 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 hospitals 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 departments
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
Phase 2 clinical documentation, cardiology, and
Phase 3 medication administration and patient scheduling;
Phase 4 physician order entry;
Phase 5 intensive care unit and operating room
But what that doesnt 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.Michaels hospital
bed delivering the advice of the Soarian software to caregivers
at a 40 megabit per second transfer rate.
Its an active rather than a passive system,
says Andrew Hind, the Siemens Canada vice president who heads
up the companys 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
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.
Whats 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
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
physicians first priority.
Meanwhile, the nurses 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. Michaels was similarly smart about how it formed its
relationship with its network builder, Getronics especially
given the hospitals impecunious history.
In simple terms, St. Michaels 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, Getronics 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 IBMs 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 Infoways PACS
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. Thats 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
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. Theres quicker reporting of
results, the specialist and GP can review together, there are
no lost films, and theres 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 cant be done, or cant 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 & Womens
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 wont 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, its 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
thats 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. Josephs 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 Columbias Fraser Health Region.
In Ontarios 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. Josephs 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
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 wasnt 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
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 wasnt 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 wasnt
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
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
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
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.