Manitoba begins roll-out of province-wide eChart
Last December, the system went live at one medical clinic in Winnipeg, and an emergency department and a medical clinic Notre Dame de Lourdes. Since then an emergency department and two more clinics have been added in Brandon and Winnipeg – a total of six sites.
Clinicians at these locations have access to provincial databases containing laboratory data, dispensed medications from retail pharmacies and immunization information for patients across Manitoba. The plan is to have 30 sites connected to the system by July of this year; the sites will consist of primary care clinics and emergency departments.
“It’s a slow growth strategy,” commented Roger Girard, CIO at Manitoba eHealth. “We’re learning as we go, and we’re making sure that our users are comfortable with the solutions. After all, it’s a brand new business that we’re in.”
By gradually testing and expanding, Manitoba intends to avoid the problems that beset other jurisdictions which opted for big bang solutions – rolling out megasystems that either didn’t work or which neglected the views of end-users and never got the support they needed to succeed.
Britain’s ill-fated ‘Connecting for Health’ is the best-known example of the big investment strategy that failed to get off the ground. Many of Canada’s provinces have also struggled with e-health systems, announcing large projects that subsequently didn’t deliver the goods.
By contrast, Manitoba is working closely with the end-users – putting time and effort into training and change management. It is also learning from the doctors and nurses who have been using the system.
Asked if there have any surprises in the rollout, Girard answered, “We’re finding that the immunization component has been receiving much more usage than we ever expected.
“As well, the users are very interested in privacy issues,” he added. “We’re spending a lot of time sensitizing the users to their responsibilities when it comes to privacy.”
Indeed, the approach is to send teams of implementation and change management specialists into each site to get the end-users thoroughly comfortable with the new workflow and computerized systems before moving on to the next sites, said Liz Loewen, Director, Coordination of Care for Manitoba eHealth.
“We want to ensure that each site has what it needs, with good management practices when it comes to eChart,” said Loewen.
For that reason, the goal of hitting 30 sites by July is flexible. Moving on to the next location will depend on getting each set of users up and running and comfortable with their implementation. They expect to pick up the pace only when it is comfortable to do so.
Getting to this stage took little more than a year. In late 2009, Manitoba eHealth awarded a contract valued at $22.5 million to begin connecting all clinicians in the province to electronic health records, to improve and modernize the delivery of care in the province.
The first phase of the plan included connecting initial users to three major systems – lab, pharmacy and immunization records – by the end of 2010. With the go-live at six sites since December, that goal was actually reached, a pleasant surprise in the world of e-health projects.
It should be noted, however, that Manitoba benefited from years of investment in systems and repositories to house lab, pharmacy and immunization data.
The eChart Manitoba system will continue collecting results from the existing sources and in a new phase that has already begun, will begin collecting test results from private labs, as well as diagnostic imaging reports. “We’ll have DI reports in the system this year,” said Loewen.
Girard said the province has been working on a large-scale project to connect diagnostic images and reports in repositories; coincidentally, the deployment phase of this effort was also completed in December, the month that eChart Manitoba went live.
The plan is to integrate DI reports with the eChart Manitoba system so that clinicians obtain the information along with other data. If they want to view medical images, they will be able to do so through the provincial DI system, a separate solution.
To help connect the eChart system to end-users, Manitoba eHealth brought in partners IBM Canada and dbMotion, a developer of integration software with successful e-health projects around the world. Peter van der Grinten, vice president at dbMotion, said the eChart Manitoba project was done in conformance with Canada Health Infoway’s blueprint, including Infoway’s HIAL architecture. What’s more, the whole system integrates with the client identification system from Initiate Systems, to ensure the right records are accessed for the right patient.
Interestingly, the system deploys a good deal of intelligence – something called semantic interoperability. This capability solves one of the problems that plagues health networks around the world – physicians and allied health workers use many terms to describe the same thing.
The use of multiple names and numbers can confound EHRs and prevent different systems from exchanging data – thereby limiting the effectiveness of a health network.
To resolve this problem, dbMotion and IBM provided the semantic solution that enables eChart to recognize when different terms refer to the same diagnosis, test, medication or treatment.
While lab, pharmacy and immunization data are consolidated in a central repository, the updates are performed constantly. “It’s almost in real-time,” said van der Grinten. “With lab data, for example, the test results are uploaded within an hour after completion.
Giovanni Vatieri, national health practice leader for IBM Global Business Services, noted the system conforms to Manitoba’s requirements for security and privacy in electronic health records. It has role-based access for clinicians – with rules that allow them to see only what they need to see. eChart Manitoba also has auditing and tracking, so that probes can be conducted to see who has looked at various records.
Patients are able to block access to their records if they desire through disclosure directives, as well, although only six people had requested this as of the end of February, said Loewen.
Animation tool helps patients understand their health issues, choices
“IBERA was created to help educate patients on how the human body works, as well as major illnesses, and chronic lifestyle choices,” said Felicia Dewar, sales and marketing manager for IBERA. “It puts people in a position to better educate others and get them more involved in managing their own health.”
IBERA’s audio-visual aids show patients what happens in a person’s body when they’re sick. It’s believed that a clearer understanding of the human body will help patients make better lifestyle choices, hence fewer doctor visits and lower healthcare costs.
The name IBERA comes from Indigenous Body Education Resource Animations, though Indigenous was dropped after the company broadened its reach and scope. The original aim was to reach the indigenous peoples of Australia, to help educate them about human anatomy and illness. Since then, it became apparent that the application could assist all patients, in Australia and worldwide.
Its 70 animations cover 16 different categories, and can be adjusted to reflect whether the subject is male or female, adult, teen or a small child. IBERA is said to be a first-of-its-kind educational tool that can improve a person’s quality of life by helping them play a more active role in managing their health – simply by helping patients better understand their own bodies and illnesses.
“The animations provide clear and consistent information about changes in the body, as in the examples of smoking, fetal alcohol syndrome, and teenage pregnancy,” said Dewar. IBERA licenses were recently sold to the Aboriginal Health Centres in Bonnyville, Lac La Biche and more recently, the Kapawe’no First Nation Reserve in Grouard, some 370 km from Edmonton.
Dewar says user feedback of IBERA has been positive so far. As an example, nurses caring for diabetes patients are excited they no longer have to sketch pictures of the human body, and can even print off still photos for people to take home with them. More recently, Community Health Nurse Laura Tomkins, of the Kapawe’no First Nation, used it during a class for new and expectant mothers. “It’s very concise, to the point and easy to understand,” she said, “especially for the layperson not familiar with medical terminology.” Tomkins also says she found it simple to navigate and intends to continue using the IBERA tool.
From a participants’ perspective, Tomkins says they appreciated the graphics of the program, as well as how ‘easy listening’ it was. “They came away with a clearer understanding of what I had shown them, and even inspired a question period, which is uncommon in our pre- and post-natal classes,” said Tomkins.
Normally, educators use any number of mediums to teach their patients. They’ll draw sketches of anatomy, use reference books or even PowerPoint slides to get their points across. IBERA, however, enables a clear, consistent message for patients every time. “IBERA is very easy to learn; provides the same message to every patient and is simple to understand and share,” said Dewar.
IBERA’s many animation modules include: fetal alcohol syndrome, pregnancy, brain tumor, effects of alcohol/drugs on the brain, heart attack – muscle damage/scarring, heart with stent, bowel cancer, polyps in the large intestine, ear drum normal/infected/perforated, cirrhosis of the liver, gall stones, hepatitis C, emphysema, lung cancer, pneumonia, smoke damage, diabetes, and renal failure.
The IBERA package consists of software, security dongle and security dongle driver; full-colour manual, training DVD and fact sheets about each of the 70 animations. Once the software, security dongle and driver are installed, it’s ready for use. License fees range from $3,500 for a single license to $3,150 each for a group license (4 units), and $2,190 each for 20 or more licenses. Moreover, as an incentive, IBERA offers potential clients a free two-week trial.
Moving forward, the company hopes to make use of social media like Twitter and Facebook to help others become more informed about their own bodies and to promote a healthier lifestyle. Moreover, making IBERA available on mobile devices would benefit both doctors and patients for use at the point-of-care. “We’re currently developing IBERA for use on iPads and other mobile devices – giving people the information they need, when and where it’s needed,” said Dewar.
Researchers find that smartphone usage isn’t always so intelligent
TORONTO – At the University Health Network, consisting of three acute-care hospitals in downtown Toronto, the primary device provided to front-line clinicians for communications is a numeric pager – a 50-year-old technology.
“It gives them alerts, but they don’t know how urgent the alerts are,” commented Sherman Quan, health informatician at the UHN. “It could be about a deteriorating patient, or that a colleague’s dinner has arrived.”
Quan was a presenter at the Strategy Institute’s recent Mobile Healthcare Summit, held in Toronto. He talked about the UHN’s work to test the new generation of smartphones, to see if they are a significant improvement over traditional pagers. His conclusion? In many ways they are, but there are still certain problems with smartphones and aspects of use that need enhancing.
On the plus side, there’s a definite advantage over pagers, as there’s no need to wait by the phone for 10 minutes to receive a callback from a physician who you’ve paged. He or she can call you wherever you may be.
On the downside, Quan noted the propensity of doctors to use emails rather than making phone calls. This has been a culture shock for nurses, especially the older ones, who aren’t used to this way of communicating. They’d much rather receive a phone call and speak voice-to-voice.
Indeed, Quan said this is especially true when nurses are dealing with residents, who tend to stay a short time in the hospital and then move on. “By the time the nurses get to know them, they leave,” he said. “So the technology further reduces the person-to-person contact and makes the situation even worse.”
However, residents had the opposite reaction. “They perceived they knew the nurses better, because the nurses’ names were on the e-mail message,” said Quan. Before e-mails, busy residents often didn’t know the nurses by name!
Physicians, too, see things differently than nurses when it comes to the urgency of a situation, and tend to use technology when the nurses would prefer a phone call. Quan gave the example of family members who come to see patients, and want to talk to the attending physician or resident. The doctors often tend to be busy, so the family members wind up harassing the nurses.
When the doctor or resident does respond, it’s often by e-mail, as he or she doesn’t think the question at hand is an important one. However, the nurses tend to prefer a response by phone or a personal visit – to them, dealing with the family members is important.
Another conundrum: it’s so easy to send e-mail messages on a smartphone that doctors and nurses are receiving a flood of them. That can mean much more follow up than before, when simple phone calls were used – resulting in even more work to do.
It’s also been found that some patients are offended when they see doctors using smartphones to send and receive e-mails. They often assume the communication is of a personal nature, and that they are being ignored; they don’t realize that in this day and age, the e-mails are being sent to professional colleagues. Patients should be told that an email is being sent to a doctor or nurse to allay any misgivings or feelings of being ignored. Doctors themselves can feel snubbed when they see colleagues or students e-mailing. One situation where this occurs frequently is on rounds or at guest lectures. “When guest lecturers see audience members checking their BlackBerrys, they get offended,” said Quan. “I’ve seen it happen – and I feel guilty because I know in some instances, I created the problem.”
EHR in Atlantic Canada: Newfoundland and Nova Scotia swing ahead
“What we would like to brag about is the fact that we are just over 20 percent deployed with our pharmacy network implementation with some of the big boy pharmacies, such as Costco and Walmart already online,” says Mike Barron, chief executive officer of the Newfoundland and Labrador Centre for Health Information. “We’ve had a client registry system implemented for some time. We have our province-wide PACS system in place. We’ll soon have our pharmacy network rolled out to all 195 community pharmacies. And we are at work planning the last piece of the EHR puzzle, our lab information project. When that’s done, we’ll have essentially completed an interoperable EHR for the entire province.”
There’s not much doubt nor hesitation over the EHR in Nova Scotia, either, but no one is atop Citadel Hill shouting about it at the moment.
“With something like what happened in PEI and similarly earlier in Ontario and its EHR problems, you feel the hit. You do get bruised. I think what it does, though, is just make sure that we all step up our due diligence, which is not a bad thing,” says Sandra Cascadden, the province’s chief health information officer (CHIO) and who carries out Nova Scotia’s EHR mandate. “So we’re proceeding quietly, but I think we’re doing quite well with our EHR, considering. Our client registry has been installed for a while. Our HIAL or health information access layer and our EHR viewer are all operational. The one piece we are behind in is our lab information system, largely over the challenge of integrating it with the Meditech lab results systems in our hospitals.”
New Brunswick’s change of government from Liberal to Conservative last September, has slowed the pace of the province’s One Patient, One Record health portal initiative.
“It is still rolling out, however,” says Wayne Chamberlain, the vice president of marketing for the AnyWare Group whose ROAM platform supports the One Patient, One Record portal. “The province now has a new health minister and there has been a consolidation of the project management team, so they are just getting back up to speed.”
What is speeding ahead at least for the New Brunswick-based AnyWare Group is the spread of their reputation for EHR and EMR supporting patient portals to other provinces. In EHR troubled Ontario, for instance, the 10-doctor West Carleton Family Health Team has just launched an AnyWare patient portal – providing access to the EMR – to its 15,000 patients. Within two weeks of its February 1 go-live date, over 700 patients were using it to book appointments, communicate with Team caregivers, and get their test results.
Meanwhile, in PEI, the reputation of electronic health records is at very low tide. Reporting to the PEI legislature’s Public Accounts Committee, the province’s Auditor General, Colin Younker, described the province’s whole eHealth initiative, launched with fanfare in 2005, as suffering, “... five years of mismanagement, no budget controls and lack of planning created a costly project that has no discernible benefit for tax payers.”
Originally, the PEI government believed its eHealth and the EHR that went with it would cost its taxpayers nothing, thanks to $12 million worth of federal grants, but by the time the Auditor General released his scathing analysis, costs had risen to $65 million, partly because seven major pieces of software needed had not been budgeted for. One change of government, and two changes of EHR consultants since its announced beginning have helped keep project costs rising.
In a an independent analysis of PEI’s eHealth situation, Patrick Powers, PhD, a senior researcher at HIMSS Analytics who is responsible for Canada, has written in ElectronicHealthcare that there is still hope for PEI. According to Dr. Powers, the province’s renewed Health PEI Business plan lays measurable operational goals that include a comprehensive, single patient record for each of the Island’s 141,000 or so inhabitants. It will be accessible by all PEI healthcare providers and lay the groundwork for universal evidence-based care, leading Powers to conclude: “If Health PEI’s strategy can be shown to be operationally successful, then its EHR...will serve as a pan-Canadian model of how to build an entirely integrated health system.”
Maybe so, but PEI will have to sprint past Newfoundland as another pacesetter for Canada. As CEO Mike Barron unabashedly points out:
• the province was the first in Canada to fully deploy a client registry and its accompanying patient index, which are the foundations for an interoperable EHR;
• as a result, Newfoundland’s client registry is already recognized as the national registry model;
• the province was, along with Nova Scotia, the first to implement a province-wide PACS system that is now 99% digital;
• its drug information system was the first in Canada to conform to standards set in the federal EHR blueprint; and
• the Newfoundland and Labrador Centre for Health Information, because of its demonstrated expertise, has the federal Health Infoway contract to conduct benefits evaluation of all EHRs in Atlantic Canada.
CEO Barron is particularly proud of the work his Centre is doing to ensure a solid but nimble communication infrastructure for the provincial EHR.
“The real beauty of our system is that we are using the best possible communication standard available,” says Barron. “It’s known as the CeRx pan-Canadian standard, which was developed in collaboration with Infoway and we have used it to create 168 different HL7 version 3 CeRx messages for our pharmacy network. They will ensure smooth communication with our client registry. And also the messages can be shared with other jurisdictions (including every other province potentially). And those messages are not just interchanges of data. HL7v.3 is superior to HL7v.2 because it can support more clinical information.”
This admirable robustness, however, does make version 3 of HL7 a challenge to implement, at least at the outset, as Nova Scotia is finding out: “We are working with HL7 version 3, too, but because its new there is not a lot of expertise we can call on yet to help us handle it,” says CHIO Cascadden.
Nonetheless, Cascadden’s implementation team now has used version 3 to enable 35 different clinical reports to flow into the provincial EHR system, including all the digital diagnostic imaging reports flowing out of Nova Scotia’s fully connected PACS system.
“We launched our EHR viewer in September last year as part of what we called our Discovery Wave,” explains Cascadden. “That initial Discovery Wave deployment of the EHR went to over 100 of our care providers because we wanted to better understand the impact of introducing the EHR on their workflow and how much they valued that impact.”
The providers included in the Discovery Wave were a variety of physician, nurse, and other provider types, including rural GPs, who together were a cross-section of Nova Scotia’s healthcare workers.
“I highly recommend to anyone implementing an EHR to do a Discovery Wave deployment first, because we learned a lot of things from it,” says Cascadden. “One encouraging thing we learned right away was that the overall reaction to how the EHR would affect their workflow was very positive. Especially when it came to how the provincial EHR might be integrated with the doctor’s own office EMR, for instance.”
Cascadden adds that the Nova Scotia EHR has a short learning curve: “It took people in the Discovery Wave about 15 minutes on average to learn how to navigate the EHR themselves and then they quickly began figuring out how to work it into their daily routine.”
One piece of Discovery Wave feedback from one rural GP, according to Cascadden, went along the lines of: “Like a lot of other rural GPs I work a lot in the emergency department of the local hospital, so if a patient presents to me there whom I don’t know, then I will probably go to the EHR to look up all of their previous history first.”
Music to the ears, of course, to all those who see the EHR as the first instrument of evidence-based care – the first piece of evidence being: what’s happened to this patient before.
“But we also heard loud and clear from our people that lab results were very much needed as a fundamental part of the EHR, so that is our next EHR milestone in Nova Scotia: to have the two of three lab information systems used here that are Meditech’s fully integrated,” says Cascadden. “And then once we have done that we’ll begin co-ordinating with our district health authorities with what the full rollout will look like: who is going to go first, who is going to go second, and third, and so on. And how we are going to support them as they do.”
But that support will be tempered by a certain discipline, warns Cascadden gently: “We are getting much more hard-nosed about everyone going out and buying whatever they want to – because we will never be able to support an interoperable EHR environment that includes the complexity of someone saying, ‘I need this information from your system, so you have to connect it to mine.’ We have made some single system decisions for the province and at least that way we have a fighting chance of being able to move and share information.”
The next such interoperability milestone for Newfoundland in Mike Barron’s telling will be passed soon, when all 150 pharmacies in the province are linked to the EHR. Afterward will come completion of what’s termed the iEHR/Labs Project, which will bring in personal test results to every Newfoundlander’s electronic records. Beyond that EHR-completing accomplishment, Barron and his Centre know no boundaries.
“Like a lot of provinces and territories, we have to provide healthcare delivery to a large geography that includes some very remote areas,” says Barron. “So last year we conducted over 8,500 telehealth appointments over the same network we use for diagnostic imaging and PACS. With that experience behind us, we are in the planning stages of a multi-jurisdictional telepathology project with Manitoba and the UHN (the three Toronto-hospital University Health Network) in Ontario.
One side effect of that joint venture, one hopes, is some passing on of Atlantic provinces’ know-how to the tail-end Charlie of EHR progress in Canada. But it will no doubt be done realistically given its huge population.
Says Nova Scotia’s Cascadden sympathetically: “The complexity Ontario has to deal with when it comes to its provincial EHR is of a magnitude that just can’t even be imagined by us small fry.”
Some small fry, though.
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