Inside the April 2008 print
edition of Canadian Healthcare Technology:
Nova Scotia aims for
rapid deployment of provincial EHR
The decision by Nova Scotia’s health ministry to select McKesson
Canada as the exclusive viewer and health record storage provider
for its province-wide electronic health record system was years in
Dr. Day stresses
importance of healthcare IT
Dr. Brian Day, president of the Canadian Medical Association, is
well-known for urging competition to improve the performance of
Canada’s health system. Less publicized are his views on healthcare
computerization – much more is needed, he says, to boost patient
safety and quality of care.
READ THE STORY
Vancouver’s care teams
Vancouver Coastal Health’s CDM Care Connectivity Program is using
shareable, electronic health records to tie together whole teams of
care-givers, including family doctors, as they look after their
When it comes to online healthcare records for patients, the
heavyweights have entered the arena. Google is testing a system with
the Cleveland Clinic, while Microsoft is scoping out the Canadian
READ THE STORY
Kitchener’s regional cardiology database is producing a welter of
useful metrics for a wide variety of healthcare professionals – at a
speed that is surprisingly quick, in a sector that has traditionally
had trouble with timely data collection.
The United Kingdom launched one of the world’s largest
computerization projects with its healthcare IT programme. However,
the British may have bitten off more than they can chew, as the
effort is troubled on several fronts.
PLUS news stories, analysis, and features and more.
Nova Scotia aims for rapid deployment of province-wide EHR system
The decision by Nova Scotia’s health ministry to select McKesson Canada
as the exclusive viewer and health record storage provider for its
province-wide electronic health record system was years in the making.
The awarding of the $2.4-million contract traces back to a time when
Sandra Cascadden, chief information officer for the Nova Scotia
Department of Health, was CIO of the Capital Health District and was
exploring the first steps to information sharing.
“We had always wanted to share information amongst the three systems
that we have in the province,” said Cascadden. Provincial facilities use
either Meditech Magic, Meditech Client Server or a mix of McKesson,
Cerner, Agfa and GE systems in her former Capital Health District. The
smaller facilities in the province use the Meditech Client Server while
the IWK (Children’s) Health Centre relies on Meditech’s Magic system.
The new DI system, which can be shared province-wide, uses Agfa PACS
technology. Nova Scotia currently has no electronic sharing of
laboratory data, which the first phase of EHR implementation will also
Cascadden was part of a provincial “Joint Health Interoperability
Project” which four or five years ago visited a number of U.S.
facilities which had taken the McKesson Horizon Physician Portal (HPP)
and overlayed it on Meditech and McKesson systems, and successfully
pulled information out of those two systems into a common viewer.
“That product had always been in the forefront of our minds as we had
been going through the whole electronic health record initiative,” she
said. “McKesson proved that they could do it.”
That group then studied whether the McKesson HHP could meet the
province’s requirements and tested it again after Canada Health Infoway
laid out its requirements to validate the application. McKesson also had
something of an inside track with the province because it has a policy
of looking first at the products of existing vendors before seeking
solutions from outside providers.
“We already have some experience with that vendor, we already have some
expertise in our human resources and our skill sets, so why go outside
if you don’t have to?” contends Cascadden.
That argued in favor of McKesson, as did Cascadden’s preference for a
system that could, in the end, be customized by the province. And it was
found that many “off the shelf” programs can be used with the HPP
viewer. “If we ever want to do it on our own and customize it, I can go
out on the street and buy all these products and do it myself,” she
Going with McKesson was also, ultimately, a money-saving decision. The
Capital Health District already had the firm’s Horizon Care Record
system. With the largest facility in the province already on board, the
Health Department saved about $1 million in the end, estimates Ron Dunn,
vice-president of McKesson Information Solutions, McKesson Canada.
The company treated that first purchase as an initial investment on the
new viewing portal. “It ended up being a lot less expensive than if they
had come at it for the whole thing at once,” said Dunn.
The rollout of the EHR viewing and repository system will not include
any new features, at least at first, noted Dunn. “It will initially
encompass a variety of existing systems, but over time it will encompass
access to the complete records of patients in the province,” he said.
“Today, there are few, if any other provinces that can say that. Maybe
Prince Edward Island can say that. This is really going to tie all of
the in-patient and out-patient care into a single viewing capability and
it will tie diagnostics into it as well.”
For the current rollout phase which has Canada Health Infoway funding,
Nova Scotia has set a deadline of the end of 2009 to implement the
province-wide electronic health record, which includes clinicians’ main
priorities: diagnostics, lab results and DI results.
“This phase is delivering on their top priorities,” said Cascadden. “The
Electronic Health Record, in my mind, will never be finished. It will be
a project in perpetuity, as we add new information services for
cardiology, or we add new information systems for the diagnostic
services, they will constantly be added in to the EHR.
As for when general practitioners, specialists and others outside the
hospitals will gain access to the system, Cascadden said it depends upon
the technologies they are working with. “The EHR will give the GPs and
specialists a view into diagnostics, but it does not perform what an EMR
would perform in their practices. It wouldn’t give them scheduling,
billing, or charting, because the EMR is a view-only at this stage.
“Any physician who has an EMR, we will give them access to the EHR as
soon as it is available. For those who do not have an EMR, we really do
have to strategically think about which one comes first, the EHR or the
Others on the phase one electronic records distribution list include
emergency departments and pharmacists and pharmacies.
The province’s CIO has a good idea about the benefits that will accrue
from implementation of the system, because of Canada Health Infoway
performance measuring and monitoring guidelines.
“We had to do that when we were building the PACS across the province,
everything from physician surveys about, ‘How much time has this saved
you?’ and ‘Are you able to do this more efficiently?’ etc.,” Cascadden
said. “We have done it before, so we know the types of things we need to
She is confident that her department will reach the end-of-2009
deadline. “We have been thinking and doing and planning this for a long
“The partners we have, McKesson, Initiate and folks at Sun, are good
strong companies and there is a lot in it for them, too, for us to make
Moreover, “Nova Scotia is a really great size to be able to do things
from a provincial perspective,” said Cascadden. “The fact is, we have
been able to achieve provincial rollouts before, as with our Agfa PACS.
We’re already in a good position in that we only have to integrate three
hospital systems, and we have no private labs.
“So we are in a much, much better situation than a lot of the other
jurisdictions to actually be able to pull this off.”
CMA president backs physician IT, sees the need for new approaches
Dr. Brian Day notes that family doctors and
specialists are essentially small business owners who face a free market
for expenses and a fixed market for earnings. No wonder they’re slow to
invest in computers.
Dr. Brian Day, an orthopedic surgeon and award winner
for his research and innovations in arthroscopic surgery, has been
called “Dr. Profit” for his outspoken advocacy of privatizing more of
the Canadian healthcare system. Agree with him or not, Dr. Day speaks of
what he knows. After BC government funding cuts had drastically reduced
his operating hours in the 1990s, Dr. Day founded the Cambie Surgery
Centre in Vancouver, a for-profit hospital which sees about 5,000
private patients a year. Day is both the Centre’s medical director and
one of its 40 shareholders. Less well known about this soft spoken,
Liverpool, England-born advocate is a career-long passion for what
computers can do for healthcare. CHT Contributing Editor, Andy Shaw,
recently visited President Day in his Vancouver consulting office.
CHT: Dr. Day, judging from what I see on your desk, and unlike
how other Canadian physicians are sometimes described, you’re clearly
not a Luddite when it comes to computers?
Day: That’s true. I started with computers back in the 1970s. It
was a Radio Shack Tandy. Then later, together with Myles Clough, who was
a resident, we wrote a paper on electronic medical records (EMRs) in
1980. I also had a summer student when we graduated to an Apple II. He
got so intrigued he went down to Bellevue (in Washington state, the
headquarters of the world’s largest software company) and has since
retired as a Microsoft millionaire. Maybe I should have gone with him.
And a few years back, I was CEO of a company that was going to develop
EMRs but that did not work out. So, I guess I have just been ahead of my
CHT: What about your peers in Canada? By comparison to countries
in Europe and elsewhere, where the uptake of computers by physicians is
90 percent or better, Canadian doctors are trailing the pack aren’t
Day: Well, we just did a national physician’s survey of the CMA,
and 26 percent of our doctors now have electronic medical records.
That’s progress, but it’s not good enough. Another survey from the OECD
(Organisation for Economic Co-operation and Development, with 30 member
countries) tells us that our spending on IT in our hospitals is only a
third of the OECD average.
So we are backward in our spending. Our governments have just not fully
recognized how important to healthcare information technology is. But I
have to add that the CMA has done so. Our subsidiary, CMA Holdings, has
a company called Practice Solutions that offers an electronic medical
record system to doctors. We’ve also been talking to major software and
communications companies about the possibilities for collaboration in
this area. So as an organization, the CMA is definitely interested in
CHT: What about from the family physicians’ point of view? What’s
the barrier in their eyes?
Day: It’s partly an economic one. Physicians in Canada, for the
most part, are small businesses that are placed in a very awkward
position. On the one side, as small businesses they are exposed to a
free market when it comes to their expenses – but they face a relatively
fixed market for their earnings. Now, for them to upgrade their offices
to an EMR requires both a capital expense and additional ongoing
operating costs. The major benefits of that expense will go to the
government and to patient care rather than to physicians. So there is no
financial incentive for them. Governments here and there have come up
with some financing to encourage doctors to invest in IT, but they need
to step solidly forward and offer consistently available financing.
CHT: Does it work that way elsewhere?
Day: Yes. In Britain, for instance, family physicians are not
paid on a fee-for-service basis. They don’t operate a private office as
doctors do here. The facility in which they practice is owned by the
health authority. So when they get new information technology it is
funded for them. And that springs from an understanding on the part of
government there that it is cheaper to invest in information technology
than not to invest in it.
CHT: Why is IT such a good investment?
Day: For one thing, we have 24,000 avoidable deaths a year in our
hospitals, many of which might be the result of lack of information,
lack of data, and mistakes made in transferring information. All that
leaves caregivers without the knowledge they need to give proper care.
For example, a big story in the Vancouver papers here recently told how
the paper record of positive test results in a mammogram had gone
missing for two years. That’s an information transfer issue and we’re
performing very badly on that particular score at the moment without IT.
CHT: The universal EHR supposedly will fix problems like that.
What’s your view of the pan-Canadian EHR?
Day: There are three components to any health record: one is the
hospital or institutional record; then there is the doctor’s office
record; and also there is what Microsoft and others are pushing – the
patient-based record. So the main challenge in Canada is to somehow get
those three talking together and brought in line with each other. The
CMA wants to get involved and help make that happen. One part of that
challenge that we can help with is that there is a lot of distrust
amongst physicians right now over the confidentiality issue. They are
concerned that patient information, particularly any stored on line by
an application service provider, can be hacked into.
CHT: As a physician yourself how do you feel about that?
Day: If I have a history of heart disease and I happen to be on
vacation in Paris, France, it would be good, if I have a sudden chest
pain, that the cardiologist over there can look at my ECGs and other
records. So we’re wondering if there is a role for the Canadian Medical
Association here – because of the distrust I mentioned. What people are
worried about most is who stores the information. It may be that a body
like the CMA could be involved as the “storage vault” or a central
storage agency. I think doctors and patients may not trust government,
and they may not trust a private technology company to store their
information, but I think they are likely to trust the CMA.
CHT: Claude Castonguay’s report has just come out in Quebec. Its
recommendations suggesting greater privatization of the healthcare
system have hit the headlines across the country. But less noticed was
its calling for more IT in healthcare. What do you make of that part of
the report? Did it say anything new?
Day: Well Andy, Castonguay’s report was supposed to be
de-politicized through having each provincial political party involved
equally in preparing the report. Unfortunately, after its release, it
has become politicized. The report rejects the status quo. Some of the
media ignored significant and important proposals. Filling the “IT gap”
was one of those, but other recommendations, such as patient-focused
funding, dealing with the reality of unsustainable cost increases, and
calls for increased accountability and responsibility were significant
and constructive recommendations.
Vancouver project allows access to electronic care plans and records
By Michelle Perrault
VANCOUVER – A new initiative, launched in January by
Vancouver Coastal Health, uses innovative technologies and processes to
provide whole teams of caregivers with access to the electronic records
and care plans of their patients.
The CDM Care Connectivity Program is a two-year pilot project aimed at
increasing system capacity and reducing demands on acute care services
as a progressive step towards Primary Health Care system redesign.
The project makes use of a comprehensive, team-based approach, with
primary care physicians as key players. It also encourages a more
At the core of this effort is the ability to share information across
the care continuum, giving physicians quick access to data and enabling
patients to obtain the appropriate services and support, when and where
“Incomplete patient information is a significant challenge facing family
physicians when caring for highly acute patients with multiple chronic
conditions,” explains Dr. Garey Mazowita, head of the department of
family practice at Providence Healthcare and medical director for the
CDM Care Connectivity Pilot.
“This project addresses the gap by providing family physicians in their
offices with electronic access to patient care plans, health records and
other information to support care planning and decision making,” said
Dr. Mazowita. “It can be as simple as being alerted when a patient has
been admitted to hospital or finding out what medications they were
prescribed upon discharge.
“This information enables us to follow-up more effectively and prevent
the patient from ending up back in the emergency department, which is
all too often the case.”
The CDM Care Connectivity pilot brings together family physicians,
specialists, chronic disease nurses and other providers in a
collaborative approach that is focused on developing and implementing:
• Shared Care Model – a team of clinicians working from and contributing
to a single electronic care plan for each patient.
• CareConnect, VCH’s Electronic Health Record – enabling authorized
family physicians access to CareConnect remotely, linking them directly
to a shared care plan, patient-centric data and clinical information
such as lab results, transcribed reports and health system encounters.
• Electronic Medical Record – used by the chronic disease nurse to
collect medical histories, care plans, health targets and other
patient-specific information. This information is used to create a
Shared Care Plan for the patient and incorporates access to
• Chronic Disease Nursing Role – nurses working with family physicians
to proactively manage and support complex patients, using the Electronic
Medical Record system as a key tool for collecting and sharing
information with other health providers through the Shared Care Plan.
• 24/7 Telecare Service – provided by HealthLine Services of BC,
patients have one number to call for round-the-clock assistance. The
service links them to healthcare professionals who are trained to
support patients with multiple chronic diseases and are available to
provide advice when needed. They can proactively provide medication
reminders, patient education, and counseling.
• Privacy/Access Standards – addressing the policies and processes
protecting patient confidentiality and ensuring clinicians have
appropriate access to information when and where required to support
“We know that patients with more than one chronic illness need more time
and attention from their family doctors and require hospitalization more
often than other patient groups,” said Dr. Heather Manson, Vancouver
Coastal Health vice president and project sponsor for the CDM Care
“Our expectation is that by proactively managing these patients with a
shared care model that emphasizes patient self-management and health
promotion, we will reduce demands on the acute care system and improve
the quality of life for these patients,” said Dr. Manson.
A cornerstone of the CDM Care Connectivity Pilot is the ability for
clinicians to get access to the information they need. For example, when
patients call the telehealth number, they are connected to nurses who
can access their electronic care plans and provide advice and support.
If a patient arrives in the emergency department, the attending
physician can access this information via CareConnect.
“Timely access to information supports better decision making, which
drives utilization of healthcare services,” explained Greg Feltmate, VCH
chief information officer. “Without this information, most health
professionals are limited in what they can do outside of the hospital
setting. The CDM Care Connectivity Pilot is an opportunity to
demonstrate the clinical value of technology at it relates specifically
to patient care and to the health system overall.”
Online patient records arouse interest at
the 2008 HIMSS conference
ORLANDO, FLA. – It was
Google’s first appearance at the annual HIMSS conference in February,
and the company was showing off the ‘beta’ version of its new product –
As if exhibiting were a last-minute idea, the company had a modest booth
that was nearly lost in a sea of giant corporate pavilions. That didn’t
stop the attendees – maybe they located it through some kind of online
In the end, there was a crowd spilling over at the Google booth each
day, eager to get a peek at the mock-up of its new online system
The masses were also found at Microsoft and Revolution Health, both of
which have thrown their hats into the Personal Health Record (PHR)
That’s one way of judging what the hot topics and trends are at a trade
show – just follow the crowds. And attendees at the Healthcare
Information Management and Systems Society conference were excited about
There have been many who’ve pooh-poohed the idea of online, personal
health records – essentially web-accessed, electronic health records
that are controlled by patients. But PHRs are sparking a great deal of
discussion, and companies, hospitals and patients are quickly moving
into this new field.
Representatives from Canada Health Infoway were close observers of the
PHR phenom at HIMSS, checking out the systems and talking with Google
and Microsoft executives, among others.
The general consensus is that services like Google Health and Microsoft
HealthVault still have a long way to go – especially when it comes to
setting up shop in Canada and understanding the nuances of provincial
privacy laws and EHR practices. But at the same time, the folks at
Infoway realize that once internet titans like Google and Microsoft are
involved, many others will follow and public awareness about online
records is bound to be raised.
The momentum is certainly there. One of the educational sessions at
HIMSS noted the existence of at least 120 online PHR services. Former
America On-line (AOL) co-founder Steve Case is operating one of the
biggies – it’s called Revolution Health, and Case gave one of the
keynotes at the conference. For its part, Revolution Health already
claims to have become the top healthcare site in the U.S. According to
Case, “Revolution Health Network is now the largest health property on
the Internet. Less than one year after launching, the Revolution Health
Network generated 256 million page views in January, enabling it to pass
The site is at
The idea of PHRs, despite the obstacles they face, is not so
far-fetched. Sunnybrook Health Sciences Centre, in Toronto, has already
launched something along these lines, called MyChart. It allows a
patient to access his or her health records – drawn from the hospital’s
own EHR – over the Internet. As a result, the patient has access to the
information 24/7, wherever he or she might be.
Other Canadian hospitals have launched portals that also offer access to
patient records, but most are incipient efforts that offer a slice of
the hospital’s data.
For its part, Google is talking about building upon these models and
allowing patients to aggregate their data from a wider variety of
sources – with records from one or more hospitals that may house the
patient’s data, along with information from labs, pharmacies and
clinics. That way, patients could have a complete and up-to-date chart,
all in one place.
Google plans to do it in a ‘virtual’ manner – data would stay put
wherever it is physically housed, in hospitals, labs or clinics. But it
would be pulled together by an integration engine, as needed. This is
the Travelocity model – the travel booking service that calls up the
latest rates and locations for hotels, plane fares and vacations from
various databases, according to the needs of the user.
The snag? Healthcare data is notoriously complex, and tying databases
together in this fashion may be the easy part. What’s difficult is
getting the data to work together in common formats.
(For a deeper discussion of this problem, see our report in this issue
on Kitchener-Waterloo’s regional cardiac database. Linking 10 different
databases in real-time was easy, compared with collating the data types
in a meaningful way.)
That’s assuming, of course, that electronic databases are available. In
both Canada and the United States, many providers have yet to
computerize their patient records. Most hospitals may be doing it, but
how many doctor’s offices have shareable electronic data? In this
country, possibly 20 percent, according to recent studies.
And just look at how long it has taken the Ontario Lab Information
System to link laboratory results – after years of tinkering, it’s still
in pilot mode.
Still, the clever young minds at Google are forging ahead. And in the
long run, they just might accomplish what they’ve set out to do.
Already, they’ve struck up their own pilot project with the Cleveland
Clinic to test Google Health. Like Sunnybrook, the Cleveland Clinic also
uses MyChart. And as part of the project with Google, up to 10,000
patients will gain a Google Health account, which will be populated with
MyChart data and information from the patients’ other caregivers.
Microsoft, on the other hand, is taking a somewhat different approach
with its HealthVault product. Intead of creating a virtual record, the
Bellevue, Wash.-based software giant is offering the means to store all
of a patient’s health information in centralized repositories, or
What’s more, it sees the HealthVault as a platform that can be used by
various partners – such as medical device manufacturers, as well as
hospitals, associations and other organizations. So far, more than 40
partners have signed on or expressed solid interest.
And in a fascinating move for a company that has jealously guarded its
technology in the past, Microsoft is now opening up much of the
HealthVault system to partners, to make it easier to devise linkages and
new solutions. (During the HIMSS conference, news came out that
Microsoft was being slapped with a $1.3 billion fine for defying a
previous European Union order to open up its technology to developers.
Microsoft executives at HIMSS asserted that they’ve mended their ways.)
The advantage of working closely with medical device manufacturers, and
others, is soon apparent. Once you’ve got medical device developers on
board, you can collect data such as vital signs in real-time, and house
if for up-to-date analysis and reference.
Chronic care patients could wear monitors that automatically upload data
to a HealthVault. Patients, their families, and their professional
caregivers could regularly check the results over time – and armed with
alerts or trendline data, take a more proactive approach to the
patient’s data than ever before.
Theoretically, this could translate into marvellous medical outcomes.
One recent British study, for example, showed that when diabetic
patients managed just a 1 percent drop in their glycemic HA1C hemoglobin
level through consistent self care, diabetes-related deaths declined by
21 percent; strokes dropped 12 percent; and peripheral vascular disease
that can lead to leg amputation sunk by a whopping 43 percent.
Of course, the Microsoft methodology has its problems, too. For example,
where are the data ‘vaults’ to be located? Who is to be liable for the
data in case of a breach or unauthorized use?
Microsoft executives say they’re interested in expanding the system to
Canada, and currently, they’re conducting a careful study of the privacy
laws in each province. “We don’t want to launch in just one province,”
says Grad Conn, senior director of product marketing, Microsoft Health
Solutions Group. “When we’re ready to go, we’d like to do a national