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Inside the April 2010 print edition of Canadian Healthcare Technology:

Feature 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.


Leading-edge CPOE
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.


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.


EHR strategies
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 profile.

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 devices.

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 happen automatically.”

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 implementation.

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 Wellness.

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 physicians.

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 context.

“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) solutions.

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 portal.

“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 efficiency”

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 interactions.

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 material.

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 clinical judgement.

“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 medication up.”

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 troubleshooting.

“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 well.”

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 point-of-care documentation.

“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 oncologists.

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.”