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Inside the April 2012 print edition of Canadian Healthcare Technology:


Ottawa Hospital surges ahead on wireless wave
Dale Potter, CIO of the Ottawa Hospital, tells of a recent incident in which he saw a physician using his iPad while leaning against a computer workstation. Curious about why the doctor was choosing the iPad over the wired computer, he asked, Why not just turn around and use the workstation? To his surprise, the physician told him the wireless iPad was faster.

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SNOMED is giving clinicians a common vocabulary
No, despite what it sounds like, “SNOMED CT” is not some new-fangled imaging modality designed for the snowy north. Rather, it’s software aimed at eliminating potentially dangerous misunderstandings over what medical terms actually mean to different clinicians, researchers, and even to patients.

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New website will help hospital in its role as world-leader in cancer-care
If you’ve ever ridden in, or supported a friend in the Enbridge Ride to Conquer Cancer, you’ve helped Princess Margaret Hospital become one of the world’s top five cancer research hospitals. Part of the proceeds from the Ride, which benefit the Princess Margaret Hospital Foundation, are funding the new Princess Margaret Cancer Program (PMCP) website redesign and online platform.

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Closing the med loop
Automated medication management systems, including computerized carts and bar-codes for meds, can increase patient safety, but only if the systems are in tune with the nurses who use them. We profile a successful implementation in northern Ontario.

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Smart about documents
Trillium Health Centre, in Toronto and Mississauga, has launched an electronic document management strategy that is having a dramatic impact on accessing information and reducing costs.

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No image left behind
Cleveland Clinic is making it possible for healthcare professionals to access every type of image they need, from a variety of departments across the organization. How are they doing it? We provide the details.


Highlights of HIMSS 2012
Those who pulled themselves away from the slot machines in Las Vegas were able to catch up with recent developments in electronic health records, and more. They could also attend a keynote by Twitter co-founder Biz Stone..


PLUS news stories, analysis, and features and more.

 

Ottawa Hospital surges ahead on wireless wave

By Jerry Zeidenberg

Dale Potter, CIO of the Ottawa Hospital, tells of a recent incident in which he saw a physician using his iPad while leaning against a computer workstation. Curious about why the doctor was choosing the iPad over the wired computer, he asked, Why not just turn around and use the workstation? To his surprise, the physician told him the wireless iPad was faster.

Potter has even found clinicians favouring iPads over workstations to access diagnostic images from the Picture and Archiving Communication System (PACS). Due to some networking quirks, downloading images is faster on the mobile devices.

It’s a telling commentary on the rise of wireless devices in hospitals, as increasingly, all manner of mobile devices are being used to access patient records. For its part, the Ottawa Hospital is pushing ahead with its own mobile device strategy, which has emphasized use of Apple iPads and iPhones. Under Potter’s direction, the hospital is planning to significantly increase the numbers of these devices in use this year.

Technology experts and clinicians alike have watched in awe as the Ottawa Hospital has ramped up its usage of iPads and iPhones. “They’re doing the most advanced rollout of wireless devices of any hospital, not just in Canada, but in North America,” commented Gerard Festa, director of healthcare solutions at Aruba Networks, of Sunnyvale, Calif., a multinational company that installed part of the Ottawa Hospital’s network management system.

“They’re also developing the best practices in wireless as they’re rolling it out, which is what many other hospitals are learning from,” added Festa.

Potter surprised many in the sector two years ago with the announcement that he was ordering 1,800 iPads for clinicians. At the time, the iPad was a brand new device.

The experiment has had superb results. Not only do the iPads provide fast access to information, they also allow clinicians to obtain the data they need while at the point of care. This, Potter says, has done wonders for quality of care.

“It’s allowed physicians to get back into their natural workflow, which is at the bedside,” he said. Since taking over as CIO of the hospital just a few years ago, Potter had been surprised to find physicians spending a great deal of time in meetings, pulling up reports and creating care-plans. Now, with real-time access to electronic records and results using wireless systems, physicians can obtain the information they need while tending to their patients.

Important results can be accessed at the point-of-care, and care-plans can be created or fine-tuned on the spot.

Since the original order, the Ottawa Hospital has bumped up its usage of iPads to about 3,000 units. What’s more, within the next year it’s likely to order another 1,000.

“We’re waiting to see what Apple is coming out with,” said Potter, referring to the iPad 3, the next generation machine that’s expected to be released soon. Part of the order will be used to refresh the first generation iPads still in use at the hospital – mostly by residents and students.

The iPad 2 devices are used by physicians, pharmacists and nurse practitioners.

Potter has found that nurses seem to prefer iPhones, and as a result, he’ll be adding some 1,200 units to the wards this year – that’s in addition to the 600 to 700 that are already in use.

The hospital employs nearly 5,000 nurses, but Potter says the iPhones can be shared. “Nurses can pick them up from docking stations at the beginning of their shifts, and put them back at the end. They won’t need to take them home.”

For nursing iPhones, the plan is to make use of the hospital’s Wi-Fi network rather than using 3G cellular in the phones. That’s a cost-effective solution, as it piggybacks on the existing network rather than requiring the hospital to buy more air-time from a cellular provider.

Potter has put together a team to actively create software for iPads and iPhones, which run on Apple’s iOS operating system. About 12 to 15 staff members are working on the interface and applications, while another 12 to 15 are dedicated to integration issues with the hospital’s Oacis electronic health record system, and its other clinical and administrative systems.

The team has created many useful applications. Originally, they started with a viewer that would allow access to the hospital’s electronic health records. Since then, they’ve produced another dozen or so applications, including electronic ordering. This will enable physicians to order lab tests, and the plan is to have medication ordering by the end of the year.

For nurses, there are applications for assessing pain, the likelihood of falls, delirium, pressure ulcers and the need for restraints – all important issues.

An innovative app that was recently devised: a nurse can use a camera to photograph wounds before dressing them. That way, he or she can show the pictures to physicians, who would otherwise have to take the dressings off, view the wounds, and then leave the nursing staff to re-do the bandages.

Next in the queue are videos that can run on mobile devices, to teach patients about the procedures they’ve undergone and how to take care of themselves afterwards.

Potter said there are countless anecdotes about the clinical value that mobile devices have had at the Ottawa Hospital – including the ability to quickly explain concepts to patients using their own diagnostic images. (In one instance, a woman with an intestinal disorder was shown an ultrasound of her condition on an iPad – she responded that it was the first time she understood her own problem.)

But to attain a more systematic view of the pros and possible cons of mobile devices, Potter has asked the Ottawa Hospital Research Institute to design and conduct a study. “What we’d like to see is a study that includes both the provider and patient points of view, which could be published in a journal such as the Journal of the American Medical Association.”

What Potter already knows is that clinicians won’t give up their iPads or iPhones. “We’ve got clinicians who have forgotten their iPads at home,” he said. “They’ve turned their cars around and gone home to get them. They don’t want to work without them.”

Mobility in healthcare, in the form of wireless devices, is here to stay, he adds. “We couldn’t possibly remove it at this stage.”

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SNOMED is giving clinicians a common vocabulary

By Andy Shaw

No, despite what it sounds like, “SNOMED CT” is not some new-fangled imaging modality designed for the snowy north. Rather, it’s software aimed at eliminating potentially dangerous misunderstandings over what medical terms actually mean to different clinicians, researchers, and even to patients. What “myocardial infarction” means to one cardiologist may well mean not quite the same thing to another. Similarly, a “viral upper respiratory tract infection” will mean something quite specific to your family doctor, but you need to know whether that means the same thing to you as the “common cold”. Medical errors around the globe are made of such uncertainties.

Begun over four decades ago by a Canadian pathologist and several American colleagues who set out to standardize their own discipline’s nomenclature, SNOMED now includes terms used by every stripe of clinician and medical specialist known. Today, SNOMED CT is a massive but well-structured collection of over 300,000 mostly clinical terms. They run the gamut from terms for micro-organisms, diseases, devices, symptoms, findings, procedures, and operations, to almost everything else involved in patient care that can be expressed in words.

In simple terms, SNOMED software contains “encoding tools” that automatically ensure mutual understanding. If one attending physician, for example, uses the term “myocardial infarction” to describe what has happened to a patient, and another later writes it up as a “cardiac arrest” and maybe a third after that calls it a “heart attack”, SNOMED will see to it that their varying descriptions go into the patient record as the same thing, with the same code, so that all can understand what was truly meant by the other.

Such systematic encoding means care givers can exchange standardized and accurate patient data with consistency. In turn, that makes feasible the likes of transferrable electronic health records (EHRs), best practice decision-making tools, and shared care plans for clinical teams, among a long list of other better care possibilities.

One for instance: SNOMED CT can garner anonymous patient records from many specialities and far flung sites, then index, store, and retrieve the aggregated data. So it can be invaluable to researchers who are spotting outbreaks of malaria in the jungles way over there or to those studying the incidence of broken bones in ski country right back here.

And SNOMED CT’s reach is indeed worldwide. Its international edition is all in English, but complemented by translated versions which often contain terms unique to a linguistic region or country. In 2007 – on the heels of a 2005 world recruiting tour by two Anglo-American SNOMED boosters, one from Britain’s National Health Service and the other from the College of American Pathologists (CAP) – a new non-profit world society formed and took ownership of SNOMED from CAP. The International Health Terminology Standards Development Organization, or IHTSDO, is based in Copenhagen.

Aside from Denmark, Britain, and the USA, the IHTSDO’s nine charter members include Australia, Lithuania, the Netherlands, New Zealand, Sweden, and Canada. Its four standing committees determine the content of SNOMED CT’s ever growing vocabulary of terms; direct its research; stimulate innovation among its members; and set both technical and quality assurance standards for medical terminology usage around the globe.

These days, the multi-lingual SNOMED CT is seen by those who know it as the most comprehensive, best organized, most useful package of medical terms in the world.

So why then did the Toronto doctor who examined this reporter recently for his chronic high blood pressure – not know what the term SNOMED meant?

“Implementing SNOMED in Canada is a journey,” admits John Burns, a senior VP at Canada Health Infoway, who is responsible for deploying SNOMED CT in Canada. “In SNOMED CT, we now have the tool we need and we have gained some recognition that SNOMED is going to be the global standard, but in Canada we are still really just at the very beginning of that journey. So our number-one challenge, and therefore our number-one priority at Infoway is to make sure people first know what SNOMED CT is and then understand how to use it.”

Okay, so if SNOMED is going to be known and understood better here in the land of ice and snow, we’d all, including my blithely unaware doctor, better get a fix on what its acronym means: SNOMED stands for “systematized nomenclature of medicine”, and the CT part stands, not for computed tomography as you might suspect, but appropriately for “clinical terms”.

To make sure different terms for the same thing don’t cause confusion, in Canada at least, Infoway has hired an expert American firm, Apelon Inc.

What Apelon knows how to do better than any firm anywhere is to support the deployment of SNOMED CT with tools and associated services that make it interoperable for users. In short, so they can reliably exchange data with others, including Infoway.

“In effect, what we are doing with SNOMED for Infoway is to give it a clearer picture of what is really going on in healthcare generally in Canada,” says Jack Bowie, Apelon’s senior VP in charge of product services, from his headquarters office in Ridgefield, Connecticut. “Infoway has understood that if it is going to provide Canadian healthcare with the best possible electronic health record and other related digital services, such as best practices, evidence-based medicine – pick your favourite term – then it needs to gather information from across the country in a way that can be analyzed.”

“If you are going to do comparisons of who in healthcare is doing what and where, and do them in computer format, then you have to know that A = B, says Infoway’s VP Burns. “So what SNOMED does is that it takes the term that a physician may want to use and relates it to a number. That number in turn will trigger another term meaning the same thing but which a second physician may prefer to use. So basically, SNOMED works as a kind of thesaurus. That means that the first physician can be confident that terms he or she is presenting to the other physician will be understood.”

Needing to be understood too are the important details subtleties of the patient’s circumstances.

“When you write clinical notes, for instance, it’s not just about noting that the patient has had a heart attack,” says Burns. “You need to know also the context of that attack. You need to know the patient’s vital signs, medical history, and other details of his or her physical status. Consequently, SNOMED CT has terms for all that contextual data codified as well.”

So there’s good reason and need for SNOMED to have piled up its 300,000 terms, according to Burns: “It looks at physiology, it looks at events, it looks at drugs, it looks at diseases, it looks at body parts, and it looks at the relationships between all those things.”

The upshot, adds Burns, is that a broken arm or anything and everything related to a patient’s clinical diagnosis can therefore be put into a computer and SNOMED before presentation to another physician – and it will emerge in terms perfectly understood by the other physician. Also in a form that he or she can in turn pass on to other care givers via SNOMED, knowing confidently that they too will fully comprehend the original diagnosis – finding out without doubt that it was the left arm that was broken, above the elbow, regardless if even the other physician is annotating in French.

All well and good, providing those two collaborating physicians have between them some sort of communication link. Alas, the Canadian healthcare landscape is still dotted with too many information silos of doctors’ offices, clinics, hospitals, and regional repositories, all standing unconnected in not-very-splendid isolation.

Enter Apelon.

Apelon’s tools and silo-busting know-how includes the company’s own:

• Distributed Terminology Systems (DTS) vocabulary server, which distributes open-source “derivatives” of SNOMED CT so it can be tailored to the individual needs and lingo of each doctor, hospital, long-term care or other SNOMED user.

• TermWorks data mapping tools, which help organizations map their local clinical terms to the often more formal country-wide standard terms set for Canada.

As well as:

• the IHTSDO’s workbench software, which will help all Canadian users keep the Canadian SNOMED CT release in synch with the international version

• Apelon’s consultants, who will assist Infoway colleagues with the deployment of all of the above, tapping the Apelon’s vast experience of more than 20 years at doing much the same for clients with large employee or patient healthcare programs such as IBM, Intel, Philips Medical Systems, Oracle, and Kaiser Permanente.

“Last year, when we went looking for help with our SNOMED CT implementation, we did a thorough search both here in Canada and internationally,” says Infoway’s Burns, “but we found no other company that could come close to Apelon’s abilities and extensive track record.”

One of the secrets of that success, says Apelon’s Bowie, is the company’s growing embrace of open-source software: “As we concentrated more on our service offerings, we decided to take what was previously proprietary and make it open source. So now it is freely available and downloaded thousands of times by healthcare organizations around the world.”

From Infoway’s perspective, the open-source nature of what it is buying from Apelon protects its investment. Should Apelon ever disappear, Infoway and SNOMED CT’s Canadian users can carry on understanding each other, regardless.

“Open source also provides for much easier customization,” Bowie points out. “If Infoway wants to do something very specific to facilitate the uptake of the Canadian version of SNOMED CT, such as making it work in both French and English, it’s much easier. With proprietary software, it pretty much has to be a far less flexible, ‘one size fits all’ package.”

That open source-based versatility, both Bowie and Burns agree, promises the Canadian healthcare system some enormous collaborative and other benefits.

“Take referrals, for instance,” says Burns. “Say I am a physician and I want to refer something to a specialist who perhaps uses some different terminology. I can have in my computer the words I like to use presented to me on my screen. But SNOMED in behind the scenes makes what I present come up on the specialist’s screen in the phrases or wording that he or she prefers. And yet we know we are both talking about the same thing.”

Similarly, Bowie thinks the technology and Infoway/Apelon approach to deploying it makes for easier and quicker SNOMED uptake by physicians in particular: “It’s not our intent to change the way doctors document their care; nor the words they use; nor even change their record keeping and information systems at the front end, at least. What we want to achieve is pretty much all in the back-end. We want SNOMED to convert what’s put in at the front end and transform it into a standard representation and distribute that information by similarly standard HL7 version 3 messages.”

Then, as Bowie further points out, that information can be made anonymous, integrated, and culled at the regional, provincial, and national levels for a wide range of other purposes including getting a sharper real-time picture of what’s transpiring in all facets of Canadian healthcare.

“But let’s make it clear, that has not happened yet on a national level anywhere I know of. We’re still in a learning and implementation mode just about everywhere when it comes to SNOMED,” says Bowie. “But we can see what it could be like if we look at some of the bigger healthcare pools that have embraced the standardization of data for large patient populations, such as the U.S. Veterans Department and Kaiser Permanente.”

Bowie says Kaiser Permanente has been pursuing standardized data systems for over two decades to serve its patient group of now nearly 9 million health plan members. And so Kaiser can aggregate all their data to help them find out which of their doctors are best at healing patients, and which are the best practices.

“I think all of us who are in this pursuit of standardization of data want to answer the same question,” concludes Bowie. “And that is: Why can’t we get every doctor to be able to treat diabetes, say, in the same way as the best doctors do?”

Meanwhile, Burns and Infoway have not been wasting time getting the journey started. For several years now, they have been fostering projects across the country that are applying SNOMED CT in an intriguing variety of ways. Some now have SNOMED fully implemented and are building on that, others are in the process of implementation, and still others are only just doing their homework on how best to apply SNOMED.

Among them and their project leaders are:

• Brian Haynes of Health Knowledge Refinery at McMaster University in Hamilton, Ontario is using a fully implemented subset of SNOMED CT to connect authors and editors of evidence-based clinical textbooks and practice guidelines with a common understanding of the terms used.

• Marguerite Foote, the Manager for EHR Standards for Newfoundland & Labrador Centre for Health Information, is researching how SNOMED CT can help standardize imaging procedure descriptions to make them consistent for both the province-wide PACS and EHR systems.

• Michael Shreve, the director of systems and supply chain, as well as the chief privacy officer for the Canadian MedicAlert Foundation on a national level, is mapping SNOMED CT to local codes across the country so that Emergency Departments can better respond to treatment of those wearing the MedicAlert bracelet. He is using the flexibility of SNOMED to map new categories of data including allergies and implants.

• Dr. Ray Simkus, a British Columbia family doctor and primary care physician at Langley Memorial Hospital in the Fraser Health Authority, has implemented a SNOMED CT version for physicians use in their electronic medical record (EMR) systems to help them choose a diagnosis or find a procedure.

• Justin Liu, Technical Specialist at the University Health Network (UHN) in Toronto, is using SNOMED CT terms wherever possible to encode clinical encounter data that reaches the patient’s medical history, cancer treatment, ambulatory visits, medication, and discharge documents. Among the hoped-for results are fewer unnecessary visits for patients.

• Leonie Stranc, PhD, who co-ordinates information and surveillance for the provincial Manitoba Health authority, has two SNOMED CT projects under way. One is aimed at identifying vaccines entered into the Manitoba Immunization Monitoring System; the other is to use SNOMED CT to consistently identify specific organisms showing in lab reports from the Cadham Provincial Laboratory.

• Dr. Yves Lévesque, a general surgeon in Victoriaville, Quebec, also has two SNOMED CT projects underway. Nationally he is using SNOMED to standardize all the patient data stored in Medforyou’s personal health record, a bilingual PHR available to all Canadians. Dr. Lévesque is also applying SNOMED to standardize a multi-lingual vocabulary of clinical applications described in English, French, and Spanish. It will speed SNOMED’s own searching for terms in another language.

(For more on these and other SNOMED CT projects supported by Infoway, visit www.infoway-inforoute.ca/standards-collaborative/snomed-ctr/snomed-ct-in-use)

Of course, Infoway’s very selection of SNOMED CT and Apelon to help deploy it, begs the question: Were there any alternatives Infoway could have chosen? The answer is both: yes and no.

Yes, there are other methods that have been developed to standardize medical terminology. Among them, those generated by the World Health Organization and its International Classification of Diseases (ICD) initiatives. The most recent ninth and tenth revisions, known respectively as ICD-9 and ICD-10 provides for medical classification of procedures, diagnoses, diseases, their signs and symptoms, abnormal findings, and even social circumstances in which the disease occurs.

But no, ICD-9 and ICD-10 cover only diseases and have, by comparison with SNOMED CT, less than a paltry 35,000 different codes, all of which SNOMED can easily take under its huge 300,000-code wing. With typical agility, SNOMED can interoperate with and interpret any ICD code or term into whatever words you would like

And there’s one well known expert who knows his ICDs from his SNOMEDs. He’s Dr. John D. Halamka who is CIO for both the Beth Israel Deaconess Medical Center in Boston as well as for the Harvard Medical School, where he is also a full professor. And oh yes, in all the spare moments he must have, he’s an Emergency Room physician.

Recently, in his hard-to-imagine-he-has-time-for blog, Dr. Halamka has recommended that any further deployment of ICD-10 be delayed until there’s widespread adoption of SNOMED-CT-like vocabularies which most easily provide the detail coders of other classification systems need.

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New website will help hospital in its role as world-leader in cancer-care

By Dianne Craig

If you’ve ever ridden in, or supported a friend in the Enbridge Ride to Conquer Cancer, you’ve helped Princess Margaret Hospital become one of the world’s top five cancer research hospitals.

Part of the proceeds from the Ride, which benefit the Princess Margaret Hospital Foundation, are funding the new Princess Margaret Cancer Program (PMCP) website redesign and online platform. This multi-year initiative, which began in the spring of 2011, is much more than a web refresh – it is a total rethink of how content is managed and delivered to the Program’s four main groups of stakeholders: patients, families, and the public; healthcare professionals; educators; and researchers.

“We’re building all four components for this first launch,” says David Wiljer, Director, Knowledge Management and Innovation, for the University Health Network (UHN).

The Princess Margaret Cancer Program, along with the Ontario Cancer Institute, already have an international reputation as global leaders in the fight against cancer. The new online platform is a key to PMCP’s strategy to transform the delivery of cancer research, education and clinical care.

Navantis Inc., of Toronto, the largest Microsoft partner in Canada, was selected by Princess Margaret Hospital after an RFP to provide the content management system for this new online presence, using Microsoft’s SharePoint. “We looked at a whole host of document and content management systems (CMS),” says Wiljer. He cites the Navantis solution’s ability to integrate well with Princess Margaret’s clinical environment – including their external and internal clinical network, as a key factor.

Importantly for the healthcare sector, Microsoft solutions have been proven in many setting and they are also cost-effective, notes Peter Jones, Health Industry Lead for Microsoft Canada: “Microsoft health portal solutions provide a foundation for more streamlined and efficient information sharing. This helps healthcare professionals work together more effectively, respond to issues more quickly, and deliver higher quality care at a lower overall cost.”

The focus of the first phase has been building the public-facing website in Sharepoint. It will serve as the foundation for all future stages, says Eamon O’Toole, Enterprise Consultant at Navantis.

Part of that project has included incorporating large content sources like the National Cancer Institute library to serve as an online reference for cancer-related information.

Another leading-edge feature has been an online system for tracking clinical trials under way at the Princess Margaret Hospital, as well as those at the University Health Network and other centres across North America, said O’Toole, with “updates every night.” It’s a marvellous resource for researchers, physicians and patients.

One of the key priorities in the site revamp was to make it easy to use. Wiljer said, “We’ve worked hard at making it very transparent and demystifying the entire process. There’s a guide to Princess Margaret Hospital, with sections on how the referral process works, a section on planning a visit – including directions and places to stay, how to prepare for a first appointment, how to communicate with your team, how to get a hospital card, and a guide to services you might need, such as childcare and transportation to and from the hospital.

“This is a new way of engaging patients and staff in the online presence,” says Wiljer. “It’s a new way of doing business.”

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Medication management works – if human issues are accounted for

By Dianne Daniel

Call it what you will, the concept of closed loop medication administration – getting the right drug to the right patient, in the right dose using the right route, at the right time with the right documentation – has been around for 35 years or more, says Cheryl Parker, newly appointed chief nursing informatics officer at Rubbermaid Medical Solutions, based in Huntersville, N.C. What’s new is the technology piece, she says, and while there’s much promise, there are also pitfalls to avoid.

“When we were completely paper-based, we still tried to make sure we were checking at every step. But what humans aren’t good at is all of those little repetitive details – we get distracted,” says Parker, who worked as a registered nurse for 35 years, from the emergency room, intensive care unit and medical/surgery floors to telemetry, home health and long-term care environments.

“I’ve seen this incredible change from when we used to hang a clipboard at the end of the bed to the whole electronic medical record and bar-coded medication administration ... and it’s so good and it’s so bad,” says Parker.

No one disputes the value of a closed loop automated system, widely endorsed by groups like the Institute for Safe Medication Practices. But some of the pitfalls identified by Parker include the potential for line-ups at automated dispensing units, now a common replacement for pharmacy deliveries and locked medication cabinets; failure to include mobile nursing carts or carts that don’t offer a suitable work surface; and, designing systems that are too rigid and don’t allow room for documenting exceptions to the rules based on human judgment calls.

Then there’s the matter of the barcode itself. “Does bar-coded medication administration slow down the medication administration process,” asks Parker. “The answer is yes. Sorry, it does. It is slower, but it’s also infinitely safer.”

Rubbermaid is aware of only three hospitals in Canada that have either obtained or are close to obtaining closed loop medication administration, one of which is North York General in Toronto, a Rubbermaid customer. Another is St. Michael’s Hospital in Toronto, which is using technology provided by Healthmark Services of Montreal.

Meanwhile, many Canadian hospitals are still working towards achieving “barcode-ready” status, notes Healthmark Director of Pharmacy Services Barbara Steddy. “We know that healthcare is gearing to bedside medication verification, for patient medication safety, so everything we sell is configurable for bedside medication verification,” says Steddy.

One hospital joining the ranks of barcode-ready facilities is the brand new Meno Ya Win Health Centre in Sioux Lookout, Ontario, a fully accredited hospital with 41 acute care beds, five chronic care beds and a 20-bed extended care facility. One of the first steps was to introduce unit dose packaging for oral and liquid medications, a move that the physical layout of the old hospital building simply wouldn’t allow.

After issuing a request for proposal and going through a vendor selection process, Meno Ya Win chose Healthmark because it was able to supply all three pieces required to lay the groundwork for closed loop medication management: on-site unit dose packaging, automated dispensing units (ADUs) and mobile nursing carts. The company also supplied consulting services to help establish an interface between the Med Dispense automating dispensing unit and Meno Ya Win’s existing electronic medical record, supplied by MediTech and provided through Thunder Bay Regional Health Sciences Centre

Now, instead of packaging medications based on a one-week supply per patient, the hospital’s four pharmaceutical distribution specialists prepare unit doses for nearly all oral and liquid medications, and maintain consistent inventory levels in four Med Dispense units strategically located throughout the hospital. When a nurse needs to administer a medication, he or she logs onto the Med Dispense touchscreen computer, calls up the patient record and reviews the list of pharmacy orders entered. Once they select a specific medication, an automated drawer pops open with the required dose inside.

From there, nurses transfer the medications to a mobile cart that also contains medication drawers, one per patient up to a maximum of six. In the near future, once barcode technology is introduced, the bedside administration process will go something like this: scan the patient barcode, scan the label on the drawer, respond to any alerts, administer the medication, automatically update the electronic medication administration record or e-MAR. For now, nurses rely on a paper MAR and a visual check to ensure the proper drug is being administered.

“We did fairly extensive in-servicing of nursing staff before we started with the automated dispensing units,” says Albert Wiebe, pharmacy manager. “A comment we often hear now is that nurses like the new system because medications are available to them at any time.”

Meno Ya Win isn’t able to provide numbers yet, but since going live with Med Dispense, unit doses and mobile carts in June, 2011, the medication review committee is reporting a decrease in the number of incidents. One plus is that daily reports are automatically generated so that pharmacy always has a record of what medications were pulled from Med Dispense and by whom.

Another benefit is that the automated dispensing unit is able to manage expiry dates as well as inventory levels.

“It just makes things so much simpler, safer and easier in the long run,” notes Steddy, referring to the use of automated dispensing units together with unit doses and mobile nursing carts.

The automated medication system “is definitely the safest way to provide medications to our patients,” commented Sue Mittleholt, pharmaceutical distribution specialist with the hospital who was instrumental in the success of the project.

With the right amount of planning – and flexibility – both Healthmark’s Steddy and Rubbermaid’s Parker point out that the potential pitfalls can be avoided. For example, Healthmark recommends a minimum of one ADU per nursing unit of 20 beds or less so that line-ups are less of an issue. Both companies suggest incorporating override capabilities so that nurses can always access replacement medications if necessary, providing a reason as to why. And both vendors aim to make their mobile medication solutions as configurable as possible, right down to the number of trays, drawers, IV poles or cup holders.

“Technology is a wonderful thing, but it’s a tool, and that’s all it is,” says Parker, noting that vendors need to shift their focus from the tool to the problems it is intended to solve. “My brother is a carpenter, but he doesn’t focus on his hammer. What he’s focused on is whatever he’s building. I’m a nurse. I should be focused on my patient and the technology should support my practice, improve my patient care ... and we’re getting there.”

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Paper document scanning system has produced benefits for Trillium

TORONTO – Trillium Health Centre, with sites in West Toronto and Mississauga, has been moving full steam ahead with a program of scanning paper documents and making them available electronically. It’s all part of a ‘go electronic’ strategy that will result in a single, electronic source of patient information.

During the initial stages of the project, paper records were still being maintained in parallel with the development of an electronic patient record and were stored off-site at a facility that was rapidly running out of space. Lease costs were high, as were courier costs to retrieve and shuttle charts between the storage facility and Trillium’s two sites.

In a typical day, between 700 and 1,000 charts were pulled for multiple clinics; some of those charts were needed in several places at the same time. There was no concurrent access, and tracking the charts was becoming increasingly complex.

Operating the storage and retrieval service seven days a week required 12 full-time staff members to manage the process. In addition, the logistics associated with managing paper records were becoming increasingly difficult.

For example, there were a large number of incomplete charts, and physicians could not always complete their charting because files were unavailable or didn’t arrive when expected. A 2007 accreditation survey documented more than 9,000 incomplete charts.

“It was at this point that we began looking at alternatives,” remembers Valerie Alston, director of health information management and privacy officer for Trillium. “We also wanted to know how we could reduce costs and actually get rid of the paper. That’s when we seriously started to look at scanning.”

After an extensive, competitive procurement process, Trillium selected a document management and imaging software solution called ChartMaxx, from MedPlus, the healthcare IT subsidiary of Quest Diagnostics, located in Mason, Ohio. In conjunction, Trillium began outsourcing paper chart scanning to document conversion and scanning provider Salumatics Inc. of Mississauga, Ont. “The ChartMaxx-Salumatics partnership really worked for us,” says Alston.

To facilitate the change management process and overcome some initial skepticism, Alston’s Health Information Management (HIM) team conducted extensive consultation and training with stakeholders, including physicians, nurses, clinical managers and unit clerks. According to Alston, having the clinical managers on board was the key to helping move the process forward. “We needed their help to get this working. They needed to see this as their project as much as our project. That was a critical success factor for us.”

Trillium selected its surgical clinic as the first scanning ‘customer’ due to the enthusiasm of the nurse manager. Salumatics picked up boxes of paper charts daily, and transported them in unmarked trucks to a secure production facility. Charts were prepared for high-speed scanning, then scanned, indexed and uploaded into ChartMaxx.

Once the charts were uploaded into ChartMaxx, users with secure access were able to concurrently view and work with charts 24 hours a day, seven days a week. Clinicians could use ChartMaxx on the web for remote access, and the HIM department could easily monitor deficiency compliance, access records for analysis and disclosure, and completely eliminate off-site storage space and labour-intensive chart retrieval.

Emergency department clinicians especially appreciated the quick and easy access to patient records from prior visits.

Initially, Alston’s team reassured clinical staff that they would run a parallel system, meaning charts scanned daily for the next day’s clinic patients would still have a paper record pulled and available. This parallel system was used for four months, as acceptance of the software and scanning process increased.

Scanned charts were configured in ChartMaxx to use the same color-coded format as the paper chart, so the electronic chart looked familiar to users. This similarity between the paper and electronic charts contributed to easier adoption of the new technology.

Before the project started, the emergency department usually held onto patient charts for seven days for clinical needs. By the time Health Information Management received charts a week later, some were incomplete or missing altogether. In order to reduce chart time in the Emergency Department and still offer secure access, Trillium approached Salumatics to develop a customized service.

Salumatics developed a plan to have an employee work on-site at Trillium to scan charts, ensuring that patient charts would not leave the building. “Salumatics bent over backwards to make the project work in the ED,” says Alston.

Now, because staff are so familiar with ChartMaxx, other departments have expressed an interest in the system as well, including human resources, finance, research and legal. The extended functionality of ChartMaxx includes a correspondence module for release of information, cold feed of transcribed reports, chart completion notifications to physicians, and statistical analysis. In its evolution as an HIM tool, ChartMaxx serves as a critical component of Trillium’s hybrid legal health record for the patient.

Using scanning services and document management software has transformed workflow processes in HIM. Previously, the records process involved manual assembly, filing, retrieval and checking, work that was done by 12 people. Now that records are scanned, and retrieval is electronic, Trillium has reduced clerical headcount by the equivalent of 10 full-time staff.

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