Inside the April 2010 print
edition of Canadian Healthcare Technology:
report: Electronic health records
How to prevent losing ‘mobile’ health data
When a nurse in Durham region, just east of Toronto, lost a memory
stick last fall containing 83,000 records of people who went to
local H1N1 flu clinics, all who heard about it were aghast.
Going paperless in DI
The William Osler Health System, in Brampton, Ont., has implemented
a Diagnostic Imaging portal solution that has eliminated much of the
paper formerly used in the department. The system also provides
voice-recognition dictation, greatly reducing transcription costs.
READ THE STORY
Few hospitals have tackled the complicated task of Computerized
Practitioner Order Entry systems. Toronto East General Hospital has
done it, with the goal of having all orders, including lab,
medication and DI, handled through CPOE.
READ THE STORY
New patient record system enhances cancer care
Lakeridge Health didn’t become the first healthcare organization in
Canada to implement Meditech’s oncology software system for the sake
of innovation alone. Instead, the software system is playing a key
role in helping the hospital’s R.S. McLaughlin Durham Regional
Cancer Centre meet its commitment to providing patients with the
right care at the right time and in the right location.
READ THE STORY
What’s better for a region, a group of best-of-breed applications or
a single, unified system that covers every application,
soup-to-nuts? We look at jurisdictions and organizations that are
trying to consolidate their systems.
Diagnosing eHealth Ontario
We know that eHealth Ontario and its predecessor, SSHA, didn’t
perform very well over the past seven years. We analyze what the
problems were, and offer advice for reviitalizing the patient.
PLUS news stories, analysis, and features and more.
How to prevent losing ‘mobile’ health data
By Rosie Lombardi
When a nurse in Durham region, just east of Toronto,
lost a memory stick last fall containing 83,000 records of people who
went to local H1N1 flu clinics, all who heard about it were aghast.
“It erodes public trust, and this will become a bigger issue as more
healthcare organizations move to electronic records,” says Khaled El
Emam, head of the e-Health lab at the Children’s Hospital of Eastern
Ontario Research Institute.
However, he says it’s important to keep perspective. “These incidents
are relatively rare in Canada, given the amount of health information
that’s collected,” says El Emam.
Most healthcare organizations have encryption policies in place, and
the technology is readily available. But there’s often a gap between
policy and practice.
According to the Ontario Privacy Commissioner’s (OPC) report on its
investigation, the Durham clinic had a policy in place to encrypt
laptops and memory sticks. But an unusual sequence of events led to the
loss of the USB key.
The clinic was in the middle of a migration to a new system developed by
the Niagara Health Unit last year. A virtual private network (VPN) was
meant to be used to transfer information between H1N1 immunization
clinics and the main server, but there were problems with the VPN lines.
The use of memory sticks was intended as a short-term solution to
shuttle information back and forth.
But the technical support staff member who created the process for the
new Niagara system didn’t include encryption of memory sticks, as he had
not been informed it was a requirement. When the nurse left Durham
Regional Headquarters on December 16, 2009, heading to an immunization
clinic, she believed she was transporting personal health information on
an encrypted memory stick.
SecureDoc: To prevent these incidents, staff need to be trained
about encryption requirements in addition to establishing a policy, says
El Emam. “But you need to make it easy to follow rules. People will
circumvent them if it makes it difficult to get their job done.”
There are fairly inexpensive solutions that do that. The e-Health Lab,
for example, uses SecureDoc, a product provided by Mississauga-based
encryption software provider WinMagic, says El Emam.
Many major Toronto hospitals such as Sick Kids and Mount Sinai also use
the product, says Joseph Belsanti, VP of marketing at WinMagic.
A major benefit is that the software’s workings are completely
transparent to users, so no training or extra steps are needed once the
process is set up, explains Belsanti. “Laptops and memory sticks work
exactly the same with encryption as they would without it.”
SecureDoc’s encryption is centrally managed from a server, so it can be
configured to enforce an organization’s security policies. Password
rules, port control, which devices can be connected to computers – these
can all be set up for each user. Data stored on memory sticks and other
devices will be automatically encrypted in accordance with the user’s
However, profiles can be set up to allow members of the same team or
department to easily share devices. “So if someone from Nephrology
passes on a memory stick to other staff members, they can access it as
though it were unencrypted. But if someone from Finance tries to read
it, the server won’t allow access,” says Belsanti.
If a memory stick encrypted with SecureDoc is lost, as in the Durham
incident, someone who picks it up and tries to use it will only see a
blank drive. “They won’t even see the file names on the drive,” he says.
Disclosure of the lost drive and a mailing to 83,000 people would not
have been necessary, he adds.
For about $1,500, SecureDocs’ enterprise version, which comes with a
server, allows 25 users unlimited encryption for all their computers and
CryptoMill: CryptoMill, a Toronto-based encryption software
provider, uses a different approach that’s in line with Ontario privacy
commissioner Ann Cavoukian’s Privacy by Design principles, which
encompass both privacy and security in technology development without
compromising one for the other.
The company worked with the Durham clinic and the privacy commissioner
in the immediate wake of the lost memory stick to provide a fast
solution, says Nandini Jolly, co-founder and CEO of CryptoMill.
“Commissioner Cavoukian was perturbed by the incident,” said Jolly, “and
wanted the Durham folks to be properly set up with a solution in hand.”
CryptoMill’s SEAhawk product focuses on encryption for two states: data
at rest and data in motion, she explains.
For data at rest stored on computers, SEAhawk allows users to put a wall
around sensitive data by segmenting their hard drives and creating a
private encrypted disk. “When a user logs off, the private disk
disappears. A bad guy who logs on won’t even see it or know that it’s
there,” says Jolly.
Data in motion is what really worries organizations, as more and more
devices with memory capacity are proliferating. “The iPhone has immense
storage capacity – we’re seeing radiology departments use them to store
large files – and so do BlackBerries.” Attempts to move data onto a
device from a computer protected by SEAhawk are governed by the
organization’s policy and the user profile. If the user isn’t allowed to
move data, the process will be blocked entirely.
If the move is permitted, the data is automatically encrypted and
decrypted if it’s downloaded onto another permitted device. “But it
won’t decrypt if it’s moved to a non-organizational computer or device.
And it has intelligent detection for this, so the make, model and so
forth doesn’t have to be specified.” SEAhawk doesn’t physically store
the encryption and encryption keys anywhere, which adds an extra layer
of security. “That’s like storing your house key under the welcome mat –
then worrying that a thief will look under it.”
Instead, it uses three factors to authorize encryption and decryption:
the user’s organizational credentials, the laptop or device, and the
user password. “When these three line up, encryption and decryption
Since there’s no key storage or management, SEAhawk doesn’t use a
server. However, the software does come with a console. “It’s like a
server only from a connectivity perspective. It enforces the
organization’s policies by pushing them out to the actual devices and
checking user profiles.”
New radiological portal solution at Osler quickly
makes an impact
By Jerry Zeidenberg
BRAMPTON, ONT. – A new radiological portal solution at the William Osler
Health Systems – designed to improve workflow in the diagnostic imaging
department – is already paying dividends, just weeks after
The system includes voice recognition technology that converts voice
dictations into text. Radiologists can review, edit and sign-off their
reports within minutes, instead of sending off voice files to
transcriptionists and waiting until they are typed.
This functionality is becoming so popular with radiologists that just 15
days after installation at both sites, the transcription volume had been
reduced by 50 percent. Instead of sending files out for transcription,
radiologists dictate, review and sign-off reports in real time.
Because the whole process takes minutes, instead of the hours or days
required when transcriptions are involved, the portal means faster
results for the ER, in-patients and referring physicians and their
patients. Indeed, voice-recognition and self-editing can speed up
reporting turnaround time by as much as 80 percent.
Tibi Puscas, diagnostic imaging informatics manager, said he expects use
of the voice-recognition functionality to increase, since it has just
been installed and not all of the doctors have started using it. “We’ll
be able to reduce the use of transcriptionists and in-house staff to do
editing for complex reports,” he said. “That will save about $350,000 a
year in transcription agency costs.”
William Osler Health System, the largest community hospital in Ontario,
has two campuses – a site in Etobicoke and another one in Brampton that
was opened back in 2007, both on the outskirts of Toronto. A third site,
Peel Memorial, has been decommissioned, but the hospital has submitted
the business case to the Ministry of Health and Long-Term Care to
transform it in the near future into a Centre for Integrated Health and
Currently, 24 radiologists and nuclear medicine physicians are reading
exams at the two existing sites. The radiologists provide extended hours
of on-site coverage to match peak workflow in the ER and clinics.
The new portal solution, called Syngo Workflow, was acquired from
Siemens Canada. In addition to the dictation and voice recognition
capabilities, Syngo Workflow also contains many other features that are
designed to improve the way a diagnostic imaging department functions.
Significantly, at William Osler Health System, the portal is eliminating
the paper that was previously used by radiologists to begin their work –
namely, the exam requisitions and technologist notes that radiologists
reviewed before starting to read patient images.
These documents were bundled together inside plastic folders and
delivered to the radiologists. Folders would sometimes be misplaced –
resulting in delays for patients awaiting their test results.
The paper driven reporting and stand-alone dictation system previously
used were based on manual processes of delivering folders by hand to the
correct location, ensuring that the right patient’s examination is
opened and that the dictations are matched to the patients properly. As
with all manual processes, some information gets lost, resulting in
delays in getting the reports out to the hospital and community
With the portal, all this has changed. Radiologists open their worklists
and the appropriate documents are available in electronic format.
Using the automatic workflow option, a patient’s requisition and tech
notes are automatically opened on screen, the appropriate images are
brought up on the workstation right next to it without any mouse click
or radiologist interaction. “It’s all RIS driven radiologist reporting,”
commented Puscas. “RIS is the master and PACS is the slave.”
Not only is the process faster, as there is no waiting for the patient
folders to arrive, it’s also more accurate, since the system has already
associated the correct patient with the right images and the correct
requisitions and tech notes. Everything is linked and launched in
“You no longer have the problem of trying to match dictations with
orders or asking radiologists to re-dictate exams that ended up
unreported because the folders were not available,” said Puscas.
The system is able to call up historical exams taken at either the
Brampton or Etobicoke site. Even though the same patient will have a
different identification number at each, the Syngo system generates a
common corporate ID for the patient using its own algorithms.
The department is a global reference site for Siemens and intends in the
future to explore the new functionality of its DI scheduling system (syngo
Workflow), PACS (syngo.plaza) and 3D post-processing (syngo.via)
The next phase of this multi-phase project is a PACS upgrade from Sienet
to syngo.plaza, which will occur over the summer. In the final phase,
Osler plans to deploy 3D advanced visualization tools, accessible at
each radiologist’s reporting workstation.
“It’s a massive undertaking to transform workflow in a department of
this size and complexity,” said Dr. Joseph Fairbrother, the corporate
chief of diagnostic imaging. “The radiologists, technologists, nurses,
our informatics team and all members of the DI department have really
done a fabulous job of adopting new and complex processes very quickly.
“Our success is due to the quality of people we have here at Osler.
These technology enablers allow us to maximize cutting-edge equipment
and services and to create a Diagnostic Imaging department. that is
comparable to the best centres anywhere in the world.”
Joe-Anne Mccue, the interim diagnostic imaging director, added that: “On
a quantitative level, throughput has become more efficient. We
constantly look at ways to carry out exams in a more cost effective
manner and we have achieved this with the implementation of our new RIS
“The bottom line is that we have increased productivity,” she said. “We
have increased the quality of service and as a result, we will have more
satisfied physicians and patients.”
The DI department regularly polls its patients and referring physicians
to gauge satisfaction levels and gather feedback, and report turnaround
time and departmental workflow is part of the mix. “Internally we’ve
already noticed quite an improvement, it’s just a matter of validating
it from our major customers, ER, in-patient wards and referring
physicians,” Puscas said.
Toronto East General is first in the city to
install CPOE and eMAR
By Karen Archer Myles
New sounds are emerging from the hallways of Toronto East General
Hospital (TEGH), as electronic medical records roll out in full force
throughout the organization. The vigorous taps of a keyboard and quick
clicks of a mouse are making a big impact on patient safety, one chart
at a time.
Two new electronic health technologies – Computerized Provider Order
Entry (CPOE) and Electronic Medication Administration Record (eMAR) –
went live in November 2009, instantly changing the work environment from
old to new and moving patient information from paper to a format that’s
84 percent electronic.
“If we look at the stethoscope and how revolutionary that was in opening
a new window into patient care in the past, then today, our stethoscope
is CPOE and eMAR,” said Dr. Pieter Jugovic, hospitalist and a physician
champion of CPOE and eMAR.
CPOE enables clinicians to enter their orders directly into the
computerized patient record instead of writing in a paper chart,
allowing immediate transmission of orders and information.
And it’s a comprehensive system. “The CPOE is for all orders,” said Pegi
Rappaport, chief information officer at TEGH. “After implementation, all
orders – labs, DI, meds, consults, dietary, etc. – are done in the
computer and paper is no longer used.”
She noted that Cerner is the vendor for the CPOE/eMAR system, and that
the project is part of a $20 million dollar investment that will see 95
percent of patient records in electronic form.
The system also provides universal access to patient information,
enabling work to be done wherever the health provider is located – from
a patient unit to the home office. Moreover, electronic access to
information means that multiple healthcare providers can view the same
chart at any given time.
“Work can now be done from wherever you are, and you’re not physically
tied to the paper,” said Carmine Stumpo, director of pharmacy and
emergency services. “That works for physicians because they can enter
the order and pharmacists can verify it from anywhere, improving
eMAR incorporates a person’s medication orders with an automatic
schedule for nurses, prompting them when to give the medications.
Previously, orders were rewritten onto a paper medication administration
record with specific times outlined.
Once the medication arrives, patients are accurately identified at the
point of care through the use of barcode technology. The patient’s
wristband is scanned, which pulls their information onto the computer
screen. This allows the nurse to check the eight Rs: right patient,
right medication, right dose, right reason, right frequency, right time,
right route and right site.
The project, which took two-and-a-half years to complete, has led to
time savings and efficiency for both patients and health providers. TEGH
was the first community hospital in Toronto go to live with CPOE and
eMAR, which also received the Diamond Award for Excellence from Showcase
Ontario in the Government Modernization category.
Most significant, however, are the benefits to patient safety. “Patient
safety was a key focus throughout the project,” said Robert Lee, manager
of clinical informatics. “The project itself was driven by provincial
statistics on adverse events, such as medication errors.”
Poor handwriting has been a notorious claim against physicians for
decades, but moving the information into an electronic format has
virtually eliminated errors related to transcription. Having physicians
type the orders in themselves ensures they’re accurate, as the system
has built-in protection that catches wrong dosages, allergies and drug
Prior to go-live, physicians would prescribe orders on paper through
memory and clinical experience. The information had to be written
clearly to ensure accuracy. Now, order sets are not only electronic;
they are integrated with additional pieces, such as clinical reference
The order sets are also standardizing the level of care by pre-selecting
the most commonly used items, supported by evidence-based medicine.
However, physicians still have the ability to add or remove items and
ultimately the tool is just that – a tool, which does not replace
“It’s like a memory cheat sheet,” said Dr. Jugovic. “When it’s a
standard treatment, things can get done faster. As well, when you see
the options there, you’re less likely to miss anything.”
Within the first week, 36,000 orders were entered into CPOE and 52,000
doses were signed off on eMAR. The immediacy of information flow has
resulted in a significant decrease in turnaround times. Prior to
go-live, it could take up to one and a half hours between writing an
order to preparing medication. Now, that information is available as
soon as it’s entered.
An unintended consequence was that orders were getting to the bedside
faster than the patient. “Post-operatively, the orders were getting to
the pharmacy and back to the unit before the patients got to their
beds,” said Stumpo. “Now it’s a matter of preparing everything, waiting
until the patients reach their destination and then sending the
Developing CPOE and eMAR took the hard work and dedication of
individuals from various disciplines –clinical, IT and administration –
to work together collaboratively. Each piece, from design and build of
the system, to device deployment, took careful planning in order to
successfully integrate together.
“It took the focus and support of the organization for this to move
ahead properly,” said Lee. “We had excellent engagement and support from
our clinicians and the senior team.”
Several new devices were introduced to support the project, including
new electronic medication carts with Bluetooth barcode scanners,
workstations on wheels, wristband printers and tablet computers.
In preparation for the go-live, every user needed extensive training.
This was one of the most challenging components of the entire project,
as it required coordinating the schedules of so many people: nurses,
pharmacists, physicians and residents.
Everyone was trained in a classroom setting and further guidance was
given to those who required it. As well, ‘super users’ (individuals most
knowledgeable about the project) were deployed in vast numbers
throughout the organization to be available for support requests and
“The feedback has been extremely positive and part of that is around the
post go-live model, which provided 24/7 on-site support to users,” said
Lee. “This was a key factor to our success. Our clinicians require
information fast, and they want to get it from the people who understand
the application and the processes best.”
The increase in technology has dramatically changed the workflow for
frontline staff as computers are now an integral part of their work day.
“With the advancement of eHealth in today’s healthcare environment,
computer literacy has become increasingly important in enabling patient-centred
quality care,” said Lee. “As a result, we have seen an increase in
adoption of technology and computer-related skills among our staff and
physicians as we continue to expand our electronic patient record.”
“People are adapting. There was a learning curve on how to integrate
this system into clinical process and work in the electronic world,”
said Jugovic. “Now it’s becoming part of the culture. It’s a tool and
those who had a bit more difficulty with it are now adapting and doing
Although the project may be rolled out, it is far from over. The
technology will require upgrades, ongoing management and maintenance, as
new orders are needed and others need updating. As well, training will
be constant as it is now a part of new-hire orientation.
TEGH plans to continue to move ahead with electronic health, rolling out
more patient information electronically in the future.
“It’s surprising how quickly it has become a part of the way we
operate,” said Stumpo. “It’s already critical to how we function.”
Meditech’s oncology information system enhances
care at Lakeridge
By Linda White
Lakeridge Health didn’t become the first healthcare
organization in Canada to implement Meditech’s oncology software system
for the sake of innovation alone. Instead, the software system is
playing a key role in helping the hospital’s R.S. McLaughlin Durham
Regional Cancer Centre meet its commitment to providing patients with
the right care at the right time and in the right location.
“We’re always searching for opportunities to improve
care,” said Kathy Fraser, information technology manager for McLaughlin
Durham centre. “The software application – which we have dubbed the
Meditech Oncology Regional Record (MORR) – lets us improve quality,
patient safety and streamline documentation.”
The McLaughlin Durham centre provides care for 400
outpatients a day and more than 4,200 patients a year, providing 27,500
radiation treatments and 21,000 chemotherapy treatments annually.
For its part, Meditech has been a leading software
vendor in the healthcare informatics industry for 40 years.
The MORR application addresses the unique needs of
oncology care, which often requires the treatment of patients over long
periods of time. The system provides interactive, role-based displays of
oncology-centric clinical data.
Using the new system, the oncology team has access to
the most up-to-date patient information, including lab values, clinical
documentation, allergies and medication history. Fast access to accurate
information is needed to determine the appropriate treatment plans and
to optimize care for cancer patients.
Additional features include TNM [primary tumor (T),
regional nodes (N), and metastasis (M)] disease staging forms, patient
scheduling, chemotherapy-specific computerized physician order
management, medication reconciliation, prescription management and
“Our commitment to patient safety was a driving force
in adopting this new application,” said
medical oncologist Dr. Leta Forbes, lead for systemic therapy at the
McLaughlin Durham Regional Cancer Centre and Central East LHIN. “We
welcomed the opportunity to streamline chart and ordering processes.
“All the information you need to make a decision
about a patient’s chemotherapy dose is at your fingertips,” said Dr.
Forbes. “Electronic orders are being used by a lot of cancer centres,
but are still being transcribed into a separate pharmacy computer system
to dispense the chemotherapy, which can lead to errors. This application
will automatically flow the physician order into the pharmacy computer
system, eliminating the transcription step altogether. This will
absolutely mean better care for our patients.”
Once the electronic order is reviewed and
electronically verified by the pharmacist, it is released to the
electronic medication administration record, where the oncology nurse is
able to review the order and document the delivery of the chemotherapy
medications at the patient’s chairside.
Lakeridge Health is just one of seven healthcare
organizations in the world and the first in Canada going live with the
application. It’s implementing the system at the McLaughlin Durham
centre, located in Oshawa, and its affiliate clinics in two phases. The
first phase was implemented in late 2009 at both MDRCC and the
Peterborough Regional Health Centre, where some patients in the regional
cancer care program undergo chemotherapy treatment and receive
consultation and follow-up services with both medical and radiation
The second phase, to be launched in spring 2010, will
usher in computerized physician order entry (CPOE), widely considered
the “Holy Grail” of electronic health records. “Physicians at our cancer
centre have been trailblazers – generating a patient-specific preprinted
chemotherapy regimen through the hospital’s e-chart,” says Fraser.
“However, that method still involves a piece of paper and the order must
be re-entered by a pharmacist into the pharmacy module.”
The whole process will go electronic with the
implementation of CPOE this spring.
The oncology management program is also integrated
with the Meditech Health Care Information System – in use throughout
Lakeridge Health and many other hospitals in the Central East LHIN – and
automatically shares available clinical history. Lakeridge Health is a
leader in making creative use of that system to successfully serve the
cancer centre’s information management needs.
“Meditech welcomed the clinic staff’s feedback and
enthusiasm for adding additional functionality,” said Greg Hoeft,
director of sales for Meditech Canada. “LH is a shining example for
others who wish to improve oncology care processes.”
To ensure the implementation went smoothly, Lakeridge
Health’s IT staff and a Meditech applications specialist wore blue
tee-shirts with the words: LIVE MORR 2009 in the days following
implementation. “Anyone experiencing a problem could easily find help,”
said Fraser. “That was a key success factor in the training of 120
nurses, physicians and clinicians.”