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Inside the April 2006 print edition of Canadian Healthcare Technology:


Feature Report: Electronic medical records


Hospitals, health regions extend use of web portals

Ontario doctors attached to York Central Hospital, in Richmond Hill, Ont., just north of Toronto, and the associated Southlake Regional Health Centre, in Newmarket, can now access their very own “Portal” and do their business as never before.

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RHIOs and interoperable systems are top issues at HIMSS 2006 in San Diego

We report on the flurry of activity surrounding Regional Health Information Organizations (RHIOs) in the United States.

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Data quality in Ontario

An information management team has analyzed the state of health data quality in Ontario and found many danger zones. It’s now helping the government implement changes that will enhance data quality and improve healthcare delivery.

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Electronic health records: Preparing for the change

Change isn’t easy. Change takes time. Change often comes with a price. Yet, things have to change. 

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Wireless long-term care

Baycrest Geriatric Health Care, in Toronto, has implemented one of the country’s largest wireless systems in a long-term care setting. The system consolidates voice and data in one network and makes communication and accessing information easier for clinicians.


Clinical decision support

With the explosion of medical knowledge in recent years, doctors are increasingly turning to a new generation of support systems to ensure they’re on track with diagnoses and treatments.


Patient-friendly MRI

St. Michael’s Hospital, in Toronto, has completely revamped its MRI department, turning a dark, basement dwelling into a bright and appealing centre that’s reassuring to anxious patients.


PLUS news stories, analysis, and features and more.

 

Hospitals, health regions extend use of web portals

By Andy Shaw

Ontario doctors attached to York Central Hospital, in Richmond Hill, Ont., just north of Toronto, and the associated Southlake Regional Health Centre, in Newmarket, can now access their very own “Portal” and do their business as never before.

Said one enthusiastic York Central physician: “The portal has streamlined my ability to see patients. I now have access to PACS, lab, historical documents, and results all in one place. The portal is efficient, timely, easily accessible and great to use. It has improved my ability to look after my patients.”

Across Canada, leading-edge hospitals are establishing web-based portals that connect systems within facilities and often link to allied hospitals or clinics. Not only do doctors, nurses and and staff within a facility gain access, but so do referring physicians, and in some cases, patients, too.

That’s the case at Sunnybrook and Women’s College Health Sciences Centre, in northern Toronto, where a pilot project is testing the use of patient access to the hospital portal.

Veronica Maidman already has this kind of access. She and her Toronto-based family doctor are both testing the hospital’s new chronic care portal. They can access Ms. Maidman’s complete medical history at Sunnybrook and Women’s – even while Maidman winters in Arizona. “It was very disconcerting that I did not have access to my health information while I traveled or went to see other physicians,” says Maidman. “Gaining access the way I can now eliminates having to ask for copies of tests and reports. I am thrilled that Sunnybrook and Women’s recognizes the need for change and is focusing on the patient’s personal needs.”

For its part, Alberta is aiming to serve the needs of caregivers province-wide when it introduces Alberta Netcare this spring.

It will vastly extend the web portal technology already used by Edmonton’s Capital Health region. A systems-checking pilot for over 300 care providers in clinics and hospitals began this spring. Full rollout should be complete this summer. That will make any Albertan’s electronic health record (EHR) available to authorized care providers throughout the province. By 2007, that ubiquitously accessible record will include diagnostic images.

“Technically, we are a little bit ahead in Alberta than other provinces,” concluded Dr. Maysan Haku-Akima, a rheumatic disease physician at the Advanced Spinal Care Centre in Calgary. “But it’s still comforting to know that you don’t have to be an IT graduate to use the program.”Although the Alberta portal is unprecedented in scale, giving physicians access to patient information via a portal is not a new idea. Portal access by patients to the same information, however, is.

One of the early providers of portal systems, and among the most successful, is McKesson. “We have over 50,000 physician log-ins monthly on our clinical portal tool in Canada, and in total about two-and-a-half million log-ins at over 400 hospitals throughout North America,” says Ron Dunn, vice president of McKesson Canada. “It’s been widely adopted partly because we used off-the-shelf industry standard technology. But also because we put a face on the portal that allows our customers to customize the look and feel of it so that it is consistent with a clinician’s workflow. The success of that open approach has spawned portals for other areas of healthcare.”

McKesson’s technology is used by York Central. It’s also employed at Grand River Hospital in Kitchener, Ont. In partnership with McKesson, Grand River developed a prototype portal that’s been available to Grand River patients for nearly two years.

“The patient portal architecture is consistent with the physician portal, so it is a nice add-on that in effect just bolts on top, yet it is a separate entity,” says Dunn. “The kind of information the patient has access to are things like their care team, their schedule, and their lab results. Also the patient can access trusted databases about their disease. So they can find out about the drugs they are taking and their possible side effects. There’s also an area for writing a diary and recording how they feel. So they can sit down with their physician and use the system to review what’s happened to them since their last visit. In addition, patients can give permission for others, including concerned relatives who may be far away, to access their information, including their diary.”

That’s just the kind of functionality – and then some – that Sunnybrook and Women’s has developed on its own for Veronica Maidman’s trial run.

“To be frank, what Veronica is helping us do is develop a whole new frontier in healthcare,” says hospital CIO Sam Marafioti. “We’d been watching a trend particularly in the United States where the move is to make the electronic health record more of a tool for continuing care.

Indeed, there’s a standard that’s been developed for what’s now called the ‘continuing care record or CCR. And what that CCR does is allow all the various stakeholders involved in a patient’s care to receive and provide information for the continuity of that individual’s care. And we liked those principles, given the kind of complex, chronic, and long-term care this hospital provides.

“So we are looking at the electronic health record more broadly now. We are moving away from it being just a record of what happens to a patient while they are in the hospital. And we’re moving towards a record of what happens to patients, chronic care patients in particular, who move in and out of hospital continually.”

To that end, and with Marafioti’s guidance, Sunnybrook and Women’s began a CCR pilot project in 2005 involving the patient Maidman. Manty Leung, the hospital’s web services co-ordinator, developed the new record and its availability via a web portal. Sarina Lecce, director of eHealth Strategies & Operations, garnered clinicians from the osteoporosis program to champion the new record and is guiding the project through its next phases.

Late last year Marafioti, Leung, and Lecce handed the pilot over to the osteoporosis staff and they are now making phase II operational by seeking approvals from up to 100 patients, to put their data on the new portal CCR record.

“We will keep our hand in and continue to help develop the record, however,” added Marafioti. “And since we are using web technology, it is very easy to employ an iterative process. We don’t have to create and then re-build an entire application anymore in order to change it. We can now put the record out there and if someone suggests a change that everyone likes, Manty can do it overnight.”

Meanwhile, portal development at York Central and Southlake has taken quite a different route and moved well beyond the pilot project stage.

“We have 600 physicians affiliated with our two sites and among them there has been a 95% adoption rate of the portal,” says Diane Salois-Swallow, CIO for both hospital organizations. “From their offices, their homes, anywhere and anytime they can get on the internet, they can access not only all their patient’s results and clinical information, but they can also complete their patients charts remotely.”

That in particular, added Salois-Swallow, has proven both popular with all staff and highly productive. Turn-around-time for chart completion at the two hospitals has dropped dramatically. Other portal advantages and benefits she formally cites:

• Sets the stage for responsible transition towards a paperless EHR

• Adds to efficiency and safety of care delivery by widening the availability of results and enhancing the probabilities of informed decision making

• Meets clinician expectations for a flexible, intuitive end-user interface, single sign-on, and more reliable remote access, at reasonable cost, while preserving the investment in robust underlying HIS systems.

Informally, Salois-Swallow adds: “The key to our success so far is that we have had very strong, IT-oriented physician leaders. Dr. Jim Boyle and Dr. Karim Jessa, in particular, have been our physician advisors for the portal. They have worked with other physicians to make sure it works for all of them.”

In future, as Alberta is already doing and as Sunnybrook and Women’s has already piloted, York Central and Southlake will push portal use to the broader healthcare community.

“Clearly, the portal can also be used by community care, nursing, and research organizations,” concluded Salois-Swallow.

Elsewhere the future promises even more portal-based linkages, says McKesson’s Ron Dunn, from the viewpoint of a company that is a leader of the healthcare portal industry.

“As we collect more and more data, and as we regionalize our healthcare environment, and as we no longer focus on just acute care but broaden out into chronic and long-term care, there’s more and more of a need to assemble that information and make it available to the patient so that it helps them through the process of their care,” said Dunn. “But as we do, we can go beyond physician and patient portals and develop others that will similarly help important segments of the healthcare community with what they have to do. For instance, we have already created a healthcare executive portal and we’re working on a healthcare staff or employee portal.”

As Dunn defines them, portals at their best, “present in a seamless format meaningful data drawn from disparate sources.”

In Alberta, the sources for the provincial portal are as disparate as Edmonton and Auckland, New Zealand. The latter is international headquarters for Orion Systems International Ltd, which Edmonton’s regional health authority, Capital Health, selected back in 2003 to provide the Orion Concerto Medical Applications Portal [in conjunction with a consortium of companies] as the platform for the region’s EHR.

The Orion-based portal, now dubbed Capital Netcare, provides authorized users access to the records of care for all the patients who flow through Capital Health’s 13 hospitals, nine mental health clinics, and 22 public health centres. And doing it so well, that the provincial health department, Alberta Health and Wellness, is migrating the browser-based record it had under development over to Orion as its new EHR underpinnings.

Strategically, the province has re-branded the EHR it has had under way since 2004 and is now using Netcare Portal 2006 as the means of spreading its Orion-enhanced EHR from border to border.

“We now have over 17,000 care providers in the province who can access records electronically. However, at last count we have about 75,000 providers in Alberta in total. So, in my mind, once we get about two-thirds of that number using the system, we will have reached a critical mass. Then the EHR becomes a standard of practice and not just a set of nice-to-have tools,” says Linda Miller, the acting assistant deputy minister for the Information Strategic Services branch at Alberta Health and Wellness.

Tools and data that registered and authorized Alberta providers – mostly physicians, nurses, and pharmacists connected with a healthcare facility or a community care centre who want to – will have at their disposal via Netcare Portal 2006 include:

• a unique pass code and a fob device for logging in

• patient list and search mechanisms in the portal that make it easy to identify and find patients

• patient demographics and event histories for each provider’s patients

• a decision-support module that offers drug-to-drug interaction alerts , a database of all available drugs and their common dosages, and links to clinical guidelines from the Alberta Medical Association.

• a prescribing application

• records of prescriptions, and drugs dispensed to patients, as well as their known allergies and intolerances

• transcribed reports including discharge summaries, text connected with diagnostic images, procedure, operating room, and consultation notes

• lab data from the regional and provincial lab systems, displaying all available results for the past two years

• diagnostic images (2007).

Most of this will not be new to Capital Health users, but what it will do for them, as it will for all Netcare portal users in the rest of the province, is to extend their reach for records beyond the borders of their own region. So that an instance of care given to a patient up in Fort McMurray will be immediately noted when the same patient comes in for further care down in Lethbridge.

“We’ve been able to do this because we have I think a more collaborative model of care in Alberta,” replies ADM Miller when asked why Alberta will achieve a provincial EHR ahead of the rest of the country. “Our clinicians, our pharmacists, our therapists have learned to co-operate largely because we regionalized them over 10 years ago. And we’re reaping the benefits of that now.”

The opportunity for the rest of the country to learn from Alberta’s advances has made Canada Health Infoway quick to finance parts of Alberta Netcare. It has helped fund development of the Netcare prescribing tool. It is also, as part of a huge $189 million Infoway investment in Alberta’s diagnostic imaging infrastructure, supporting projects that will shape how those hard-to-manipulate images are going to be added to the Alberta EHR.

Measuring the success of all this – or lack of it – Miller admits remains a challenge.

“We can tell you from day one how users use the portal,” says Miller. “We know how many people are signed on; how often they use it; and what kind of data they are accessing. But for judging its overall impact on healthcare, we need to do a better job of measuring. We do conduct surveys and we have anecdotal evidence, however, that it’s doing good things like reducing wait times. And we are developing a kind of benefits-realization approach that will help us decide what we add to the EHR. But, it’s like the spread of the fax machine. If you truly want to measure what kind of systemic effect an innovation is having, you have to wait until there are more than four users of it.”

So all the evidence is not in yet. But the fervent hope is in Alberta, as it is elsewhere, that web portals will soon become a grand, new entrance to better healthcare.

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RHIOs and interoperability in the air at annual HIMSS conference

By Jerry Zeidenberg

SAN DIEGO – Talk of ‘RHIOs’ dominated the annual HIMSS conference earlier this year, as close to 25,000 attendees discussed and analyzed this latest trend in U.S. healthcare I.T.

With the encouragement of federal healthcare I.T. guru Dr. David Brailer and other government leaders, medical facilities in the United States have been busily establishing Regional Health Information Organizations, or RHIOs (pronounced ‘reeos’.)

Observers estimate that several hundred RHIOs have been announced in the last two years, with more emerging each week.

In many cases, such as the San Diego RHIO announced late last year (and profiled below), healthcare providers have needed little prodding from government authorities.

Instead, the impetus has come from local doctors. They’re eager to get the benefits of faster, more accurate care that’s possible when information from labs, imaging clinics, pharmacies and other centres is instantly available through computerized networks.

The challenge, however, often lies in connecting the disparate systems that are installed in hospitals and clinics across a city, region or state. In many cases, the healthcare I.T. systems supplied by a single vendor are sometimes incompatible with one another, since they run different versions of software applications.

Various solutions are being touted, including integration engines.

Moreover, another challenge often arises – who actually runs the healthcare network and how will the stakeholders cooperate? This issue is commonly referred to as ‘governance’, and it’s often overlooked until it gums up the works of the project or halts its progress entirely.

In his keynote address at the HIMSS conference, Dr. Brailer, national coordinator for health information technology, mentioned both interoperability and governance as key issues. Indeed, he said his group will soon launch a research effort aimed at discovering ‘best practices’ in these areas among existing RHIOs so that others can learn from them.

“It’s time to support the maturation of our RHIOs and help them face their various challenges,” said Dr. Brailer. “We have to be able to support them and provide guidance for how they can be replicated across communities.”

A contract for the best practices research was expected to be announced in March, with the findings to be announced by September, the beginning of the U.S. government’s fiscal year.

Dr. Brailer said there won’t be standards imposed on RHIOs, but he believes that local networks should be able to link to a national system that’s now under development, in order to obtain additional benefits of connectivity.

While most care is provided locally, in some cases it may prove beneficial to send records beyond the RHIO – for example, to specialists in another state to examine diagnostic images or other test results.

Late last year, the Department of Health and Human Services awarded US$18.4 million for four contracts aimed at developing prototypes for a National Health Information Network (NHIN) architecture. The contracts were given to four different consortia, led by Accenture, Computer Sciences Corporation (CSC), IBM Corp., and Northrop Grumman.

In partnership with hospitals, lab, pharmacies and other healthcare facilities, the consortia are devising standards-based networks that include patient ID and information locator services; user authentication and access control; and the feasibility of large-scale deployment.

In terms of interoperability, governance and replicability, the United States might want to keep close tabs on Canada, which has been building healthcare I.T. networks for several years. Infoway has already invested $427 million in 141 projects across Canada. It has also developed standards, toolkits and governance practices.

For its part, Dr. Brailer’s group has a budget of only US$61.7 million for the current fiscal year, and is allocated US$116 million for next year. That’s intended to fuel projects and fund research in a market 10 times the size of Canada. By closely examining what’ been accomplished in Canada, in many cases, the Americans may avoid the problem of re-inventing the wheel.

An excellent example of what’s driving the rise of RHIOs can be found in San Diego itself. Announced last October and slated to start in March 2006, the San Diego Medical Information Network Exchange (SD MINE) is the brainchild of the city’s physician community, which wanted faster access to patient information that’s spread across facilities in the region.

“For one out of every seven patients that steps into a physician’s office, there isn’t enough information available for a quick decision,” said Dr. Stephen Carson, a former Montrealer who is now the chief medical officer of the San Diego County Medical Society Foundation.

Dr. Carson and his colleagues aim to use a computerized ‘middleware’ solution to connect the county’s 35 hospitals, 7,000 doctors, 70 community clinics, 378 pharmacies, as well as community labs, radiology centres, nursing homes and other facilities that serve the 3 million residents of the San Diego area.

Not in one fell swoop, by any stretch of the imagination, but over the next few years.

Last month, as an opening salvo, the doctors were set to connect 20 hospital emergency rooms, 70 community clinics, and 200 primary care and specialist practices.

Dr. Carson and the medical society selected Sun Microsystems as the prime contractor for the solution. While numerous offerings were available, cost-control and the simplicity of dealing with just one vendor were major considerations in choosing Sun. He explained that in other U.S. projects involving multiple vendors, cost overruns have been experienced as consortium partners marked up their charges when changes to the system were made.

For its part, Sun Microsystems is now a major player in the middleware marketplace, due to its acquisition last year of SeeBeyond Technology Corp., a leader in the integration engine and EMPI marketplace, for US$383 million.

Dr. Carson believes the solution proposed by Sun will be easy to use. “All doctors will need is a high-speed connection and a web browser,” said Dr. Carson. “It works pretty much like Orbitz or Travelocity on the web. You select what you want to know, and the system goes out and gets it.”

He noted that there will be no centralized databases – instead, records or views will be pulled together from various databases on an as-needed basis. As such, no heavy investment in new storage technologies will be required.

Wayne Owens, vice president, healthcare integration platforms for Sun Microsystems, said the network is a relatively low-cost solution that will save healthcare providers and insurers a good deal of money. “The cost is less than $100,000 per hospital,” said Owens, who added that the potential savings will amount to millions of dollars through reduced paperwork for physicians and fewer diagnostic tests for patients.

Instead of ordering new tests because the information they need isn’t at hand, physicians will be able to pull up patient data – in a single-view – on the RHIO network, which uses the industry-standard HL7 protocol for transferring healthcare data.

Additional benefits are expected through faster patient care and better decision-making – with more comprehensive information at hand, such as medication histories, physicians will be able to make more accurate diagnoses and provide more effective therapies. The partners in San Diego are also devising a clinical messaging system to track hospitalized patients, a community-wide bridge to immunization and diabetes registries, and a single portal for patient education.

Interoperability is one of the biggest challenges for RHIOs. It’s also a major issue in Canada, where most provinces are currently establishing regional health information networks.

While marketing executives from various vendors tend to make ‘interoperability’ sound easy, in actual practice, hospitals and clinics have found it’s often quite difficult to get computer systems, software solutions and medical devices to mesh together.

That helps explain the rise of Integrating the Healthcare Enterprise, a joint-venture involving industrial partners and healthcare providers. Together, they’re identifying trouble-spots when it comes to connecting various systems. And they’re creating solutions called ‘profiles’.

Any vendor can incorporate the profiles into their own products. In fact, the Chicago-based IHE is strongly advising hospitals to write clauses into contracts that require vendors to conform to various IHE profiles.

For its part, the IHE emerged out of the radiology world, and has a big presence at the annual Radiological Society of North America (RSNA) conference, held in Chicago each fall. However, the organization has spread into other parts of medical I.T., including health records. It’s now got an impressive role at the HIMSS conference, where vendors crowd into the HIMSS pavilion to show how well their applications integrate with those of other suppliers.

Three weeks earlier, at a January meeting in Chicago, 59 healthcare I.T. suppliers convened for the annual IHE ‘Connectathon’. That’s where their ability to ‘seamlessly integrate’ with other systems is actually tested, and their ranks included major vendors like Kodak, GE Healthcare and Philips. According to IHE spokespersons, there was roughly a 90 percent success rate at the Connectathon. (Results are posted on the IHE web site at www.ihe.net)

The missing 10 percent perhaps illustrates why hospitals and clinics should demand real-world demonstrations of a product’s ability to connect with others before they buy it. Either that, or write into their contracts a demand for connectivity, with bottom-line financial implications.

On a related front, at their HIMSS pavilion, the IHE demonstrated innovative and useful solutions, including the Cross-Enterprise Document Sharing for Imaging profile (XDSi), which creates pointers to patient images across facilities and organizations, enabling doctors to obtain all of a patient’s studies, no matter the location. For example, using XDSi, radiology, cardiology and endoscopy images, from different sites, can all be linked in a patient record. It’s a solution that was developed in Montreal, with the involvement of Canada Health Infoway, and was inaugurated a year ago. This year, it has been implemented into products by 27 different suppliers.

As well, the IHE has devised a solution called Patient Identifier Cross-referencing (PIX) for improving the performance of patient registries and Enterprise Master Patient Indexes. It, too, was being demonstrated at the IHE pavilion at HIMSS.

On the connectivity theme, various vendors at HIMSS demonstrated how they’re integrating different pieces of the hospital into the electronic patient record.

Welch Allyn (www.welchallyn.com), a well-known maker of equipment for doctors’ offices and hospitals, showed a new application called Connex that automatically charts the vital signs of patients on ‘low acuity’ hospital floors. While ICUs are already high-tech, with sophisticated monitoring equipment alerting doctors and nurses, other areas of the hospital still rely on a nurse to monitor as many as 20 patients at a time using paper charts.

Often enough, nurses are grabbing scraps of paper, scribbling readings of vital signs, and keeping the notes in their pockets. Later, they input the data into computers at a nursing station.

“We studied the workflow of nurses in low-acuity settings for three years,” said Tom McCall, vice president with Welch Allyn. “We found over 20 areas of possible error as nurses track vital signs, including misidentifying patients in their notes. There are also lots of inefficiencies and wasted time when they’re making notes and keying in the data later.” He said the new system eliminates about five hours of data transcription a day, per floor.

Using Welch Allyn devices, the solution electronically grabs the data – such as pulse, blood pressure, temperature and blood oxygen levels – and charts it on a monitor. The system has 10 different ways of displaying abnormal information, including red highlights, exclamation points and red boxes. The HL7-based solution will map to other EMRs, said McCall, such as Cerner or McKesson charting systems.

With the explosion of medical knowledge in recent years, it has been difficult for physicians and nurses to keep up with the latest diagnoses and therapies. Hence the growing importance of clinical decision support systems.

Several companies announced developments in this area:

• Epocrates Inc., provider of mobile and desktop clinical applications, launched Epocrates SxDx, a disease diagnosis and treatment reference and symptom assessment tool. The company developed the application, which provides diagnostic support to physicians, in collaboration with the Massachusetts General Hospital’s Laboratory of Computer Science.

It runs on mobile devices, including personal digital assistants, and allows healthcare professionals to enter patient symptoms and findings to generate a clinically useful diagnosis index to the Epocrates disease reference.

Additional information can be found at www.epocrates.com

• Ovid Technologies, a Wolters Kluwer company, announced the launch of ClinicalResource@Ovid, a new point-of-care tool that gives medical professionals quick access to peer-reviewed, evidence-based information. ClinicalResource@Ovid integrates key resources, including diagnosis and treatment guidelines provided by Clin-eguide; expert-authored disease monographs from the 5-Minute Consult Database; up-to-date drug and pharmaceutical information from Facts & Comparisons, including data on natural products; bibliographic data from the National Library of Medicine’s MEDLINE database; and detailed patient handouts that address over 4,000 adult, pediatric, senior, and women’s health topics. According to the company, ClinicalResource@Ovid provides Ovid current customers with one-click access to all of their subscribed Ovid book, journal, and EBMR resources. (www.wkhealth.com)

• Roiled by the SARS outbreak, and now anxious about avian flu, Canadian hospitals may be interested in TheraDoc, an expert system dealing with infectious diseases. Produced by a Salt Lake City company of the same name, TheraDoc is now installed in 43 U.S. hospitals in 22 states. They range from Johns Hopkins Hospital in Baltimore to a small, rural hospital in Arkansas. According to company president Stanley Pestotnik, sales have been doubling each year, and some Canadian hospitals have been making inquiries.

By mimicking an infectious disease expert, TheraDoc helps physicians, pharmacists and nurses with the diagnosis of infectious diseases. It also helps them make better decisions about drug therapies.

“Every doctor treats infectious diseases, but most have very little background in microbiology or antibiotic therapies,” said Pestotnik, whose company exhibited at HIMSS. “Most doctors have spent a semester on these topics in medical schools. There are very few physicians who understand them well, aside from infectious disease specialists.

“But there are not many infectious disease experts,” he added, “compared with other specialists, like cardiologists and nephrologists.”

Pestotnik said that’s why a system like TheraDoc can help most physicians – especially in this day and age, when doctors and other health professionals are expecting to see new and unusual infections.

Significantly, TheraDoc can be used in disease surveillance systems. It was used for this very purpose at the 2002 Winter Olympics in Salt Lake City, where it detected an outbreak of influenza, allowing health officials to take early action. See www.theradoc.com for additional information.

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Ontario’s info management group aims at better data and health results

By Jerry Zeidenberg

TORONTO – You can’t manage what you can’t measure. And you’re really in trouble if your measurements are inaccurate, late or non-existent. With all of these problems plaguing the collection of healthcare data in Ontario – including dead patients who were re-admitted to hospitals (at least on paper) – the province established a Health Results Team in late 2004. Its information management group, headed by University of Toronto academic Dr. Adalsteinn Brown, has taken concrete steps to help rectify the situation.

• To ensure that its proposed changes are rooted in solid research, the team has finished a massive data quality report, which will soon be available on the Ontario Ministry of Health’s web site. “It’s the largest study of its kind ever done in Canada, if not the world,” said Helen Whittome, a member of Dr. Brown’s information management group. She noted the survey had excellent cooperation from Ontario’s hospitals, with a 96 percent response rate.

• Actions have been taken to improve the quality of coding. Whittome noted that quality improvement workshops have already been held in seven regions of the province for acute and ambulatory care providers. Results have been quick to emerge – soon after the workshops were held, there were 1,400 re-submissions of data to the Canadian Institute for Health Information.

• A software ‘wizard’ for health indicator calculations, developed for hospitals by the Hospital Report Research Collaborative, is being upgraded to help hospitals produce better data. “We are in the process of augmenting this tool with data quality indicators that were used at the data quality improvement sessions so hospitals can use it to clean up their data at the source,” said Whittome.

• An online registry of ‘best practices’ for data collection and management will soon be available. “It will show what hospitals are doing in many areas, like case costing or how to complete charts in the best possible way,” commented Whittome. She said that already, some 80 to 100 examples of new processes or techniques have been collected for the registry. It’s important that word of these improvements gets around, however, so that best practices become shared practices, said Whittome.

Collecting and presenting this type of data is an important step. An additional task, asserted Jeremy Veillard, also a member of Dr. Brown’s team, “is translating data into specific outcome measures to drive performance improvement.”

Veillard previously worked at the World Health Organization, which conducted a high-profile ranking of the healthcare performance and status of 191 countries. In it, France gained the top ranking, while Canada checked in at number 30.

Veillard noted that after the study was published, many countries wanted to know how they could improve. The WHO conducted its own work to address this issue, drawing a good deal of information from the case of the Veteran’s Administration (VA) in the United States, which dramatically improved its delivery of care and patient satisfaction levels in the 1990s under the direction of Dr. Kenneth Kizer, while simultaneously reducing its costs.

Veillard observed that by focusing on 18 indicators, across the system, the VA was able to make significant improvements. These indicators included major disease states, such as diabetes and cervical cancer.

Ontario is now going through a similar process with the development of core sets of indicators and scorecards that are designed to measure performance in a number of areas.

Dr. Brown, who was recently appointed Assistant Deputy Minister for Health System Strategy for the Ministry of Health, points out that the presence of such rankings tends to spur improved performance. He explains that when the VA started to reveal outcomes, performance improved dramatically. “Within three years, the VA had implemented client health records and were generating revenue.”

In addition to taking stock, looking to the future can also provide the kind of information that is needed to guide the development of policy and healthcare decisions that will stand the test of time.

“Where will we be a generation from now?” asked team member Matt Norton, noting that our position 20 years from now will determine our needs for human resources, education, training and equipment. But Norton said the picture can be continually refined through the use of innovative methodologies such as long-range scenario planning. This methodology has been increasingly recognized over the last decade as a useful tool for guiding decisions with long-range implications in highly complex sectors like healthcare. “We are currently testing this methodology in the field, in collaboration with the Specialized Paediatric Coordinating Council. The objective is to develop a series of long-range planning models to help predict the future need for specialized paediatric services in Ontario.”

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Electronic health records: Preparing for the change

By Jerry M. Garcia

Change isn’t easy. Change takes time. Change often comes with a price. Yet, things have to change.

Unlike the private sector, like a large bank, the healthcare system has more emotion at stake when it comes to technological changes such as electronic healthcare records (eHR). And as electronic healthcare records mandates enter into Canada’s healthcare system, change management will play a huge role in its successful design, delivery and deployment.

In the end, the success of eHR is built by and with people and not just with technology. Most clinicians will not simply adopt technology because it has been dropped on their desks. If you can confidently prove that this technology will help provide better patient care, then clinicians will embrace it.

Involve them early, involve them often: The one thing for certain in the change to eHR will be the long-term journey. To ensure this journey is successful, one of the most important steps is ensuring that your organization and the proposed technology change are aligned.

Don’t just seek out only the champions, but also the detractors to change. Also, you will need to seek out the influencers and opinion leaders in the organization. A high level of collaboration with all those invested in eHR is important to ensure no future animosities to the technology. Clinicians tend to be more forgiving of the system’s imperfections, and the bit of extra time it may take to use, if they were involved in its design and implementation from the beginning.

Prove the value: Always keep in mind that the motivators for caregivers are the desire to give quality care to patients. In implementing eHR and its processes and technology, there is no stronger motivator for physician support than a clear demonstration that this will help them take better care of their patients.

Acknowledge the barriers: Realistically, despite the claims of vendors, eHR takes more time than handling pieces of paper, although it reduces the clerical functions of other clinical staff. Physicians have three kinds of interaction with clinical information system:

• Access to results

• Electronic documentation

• Order entry

For instance, experience has shown that the real challenge in gaining physician acceptance of a clinical information system is in reducing the perceived time to conduct a transaction.

Find your pathways: Showing respect for active resisters to eHR is an effective strategy, even though there are costs involved in providing a parallel pathway. The parallel pathway should not be so attractive as to cause defections from the groups adopting the new tools, but hospitals that fail to provide a workaround for resisting change often learn that clinicians have built them themselves. Sometimes it may involve simply finding champions who will work with technophobic clinicians to print out lab tests and patient records.

Continuously show improvement: Electronic healthcare records are a never ending process. Continuous improvement of the system is required to retain clinicians previously recruited. Expectations evolve and change over time. In one example, a client with a clinical information system in place for seven years initially had 60 to 70 percent of its physicians agreeing that the system brought value to them personally. Hospitals with eHR implementations that have been most successful at not just recruiting, but retaining, clinical users have built disciplined and formal communications models around the experience of using the tools. eHR deployment – everything from application design to placement of workstations – must be constantly re-evaluated for new expectations, innovation and evolving needs.

Physicians will adopt change in clinical processes and technology if they believe it will help them provide better care for their patients. Ensuring that clinicians’ interests and concerns are adequately addressed will go a long way in ensuring the eHR’s successful journey.

Jerry M. Garcia is managing partner, Health and Life Sciences, Accenture, in Toronto. Additional content for this article was provided by Healthcare Technology, Volume 3: Steps Toward Developing an Electronic Health Record, article entitled; “Securing Physician Adaptation and Adoption of eHR”, by Manuel Lowenhaupt, M.D., Lawrence M. Hanrahan, M.D., M.B.A., and Scott J. Cullen, M.D., Accenture.

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