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Inside the April 1999 print edition of
Canadian Healthcare Technology:

Feature Report: Electronic commerce

Medical call-centre announced for Northern Ontario

Ontario Premier Mike Harris announces the creation of a 35-person, tele-triage centre based in North Bay, Ont. The $4.9 million program will provide advice to callers 24-hours a day, and is expected to reduce the pressure on hospital emergency departments. Also pictured are: Dr. William Orovan, president, OMA; Mayor Jack Burrows, North Bay, and Christopher Dean, president, Clinidata Corp.


MDS in Saskatchewan

Saskatchewan will become the first province in Canada to adopt a province-wide, computerized MDS 2.0 (Minimum Data Set) assessment system for long-term care. It’s rolling the system out to 168 LTC facilities across the province.


Data warehousing

At the February HIMSS show in Atlanta, Data General and Microsoft showed off a 2.5-terabyte data warehouse, filled with simulated patient information. The system was built using the SQL Server 7.0 database and NT operating system, in a bid to demonstrate that enterprise solutions can be created using off-the-shelf software.


Vascular imaging

The John P. Robarts Research Institute and the London Health Sciences Centre are launching the Centre for Vascular Imaging Research, fuelled by $16 million over five years. The new centre hopes to make breakthroughs that will save lives and healthcare dollars.

Networked docs

Markham Stouffville Hospital, outside Toronto, is running a pilot project to electronically connect family physicians to the hospital’s computerized medical records. Sixteen physicians will be able to gain quick access to their patient’s test results and other reports at the hospital.

Healthcare EDI

Electronic business is taking root in hospitals, saving some institutions hundreds of thousands of dollars. Those that haven’t yet implemented EDI are debating the use of private networks or the Internet.


PLUS news stories, analysis, and features and more.


Medical call-centre for Northern Ontario established in North Bay

By Jerry Zeidenberg

NORTH BAY, Ont. – Instead of rushing to the closest hospital or clinic when a medical problem occurs, residents across Northern Ontario will soon be able to dial into a telephone call-centre and obtain advice from a professional nurse – 24 hours a day.

In February, the government of Ontario announced that it will invest $4.9 million over 22 months to operate a telephone-triage pilot-project based in North Bay. Nurses will be trained to advise callers from across Northern Ontario about the seriousness of their medical problems and whether they need to hurry into an emergency room or clinic, wait to see their family doctor, or treat the condition themselves.

The call centre will be run by Clinidata Corp., the London, Ont.-based company that currently operates a province-wide, tele-triage facility in New Brunswick. In North Bay, the centre will be monitored by the Ontario Medical Association and the Ontario Hospital Association to ensure that high standards of service are provided.

At the official announcement, William Orovan, president of the Ontario Medical Association, noted that “telephone triage and telehealth services have been popular adjuncts to the existing healthcare system in the United States, internationally, and elsewhere in Canada. We are very happy to see this service now extended on a pilot basis to Northern Ontario.”

The 35-person call-centre is expected to improve the level of health information and care available to some 900,000 northern residents of the province. It will not only reduce the pressure on hospital emergency rooms by advising some patients that a visit is not necessary, but will also improve the level of care in other cases by urging people with severe conditions to seek immediate help.

Trained nurses, assisted by triage software, will provide service 24 hours a day, seven days a week, to callers in the 705 and 807 telephone exchanges.

The nurses will provide information to callers who believe that their symptoms (or those of a person for whom they care) warrant clinical attention, but who are unsure of what to do or where to go. The callers will be informed of their choice between a number of dispositions based on a set of medically approved triage guidelines and the nurses’ clinical experience and training. General health and drug information will also be available.

The call centre has also struck up an agreement with nearby Canadore College to train nurses in telehealth.

According to the business plan for the facility, the call centre is expected to “reduce the demand on existing healthcare resources, such as emergency departments, primary health services and walk-in clinics by providing the user with the right information, for the right care, at the right time.”

That could improve the level of service provided by emergency departments, since they won’t be slowed down by as many non-urgent cases.

As well, northern residents will save time, inconvenience and expense when they discover a visit to the hospital is not needed. “There’s a high cost for a person to go to an emergency department,” explained Christopher Dean, president of Clinidata. “Many calls are pediatric-related, and the parents of young children often have to leave work early, get a baby sitter and take a cab to the hospital. It can become expensive.”

He noted that a call to a tele-triage nurse could determine, in some cases, that the trip isn’t required, and that a child can be monitored at home or taken to the family doctor the next day.

For example, one hospital in New Brunswick found the number of visits to its ER was reduced significantly for conditions such as flu, viral symptoms, chronic back pain and minor abrasions once the provincial tele-triage hotline was in place. Indeed, visits by people with some of these conditions were reduced by 30 percent to 40 percent.

At the same time, however, the number of ER visits for other, more acute conditions increased. It was felt that this was due to changes in the healthcare system as a result of reform, along with demographic changes.

While asserting that studies on the New Brunswick tele-triage service have not yet been conducted with academic rigour, Dean noted that some interesting preliminary surveys have been done.

In one survey, New Brunswick used a model recommended by Dr. Bill King of the University of Alabama to study outcomes. It determined what each patient who used the provincial ‘Tele-Care’ service would have done had the telephone-triage service not been available, and compared this to the patient’s actual disposition.

Sixty-six percent of Tele-Care users indicated that they would have used ED services had Tele-Care not been available, yet only 13 percent were referred to an ED by the tele-triage nurses. Considering more than 10,000 patients call Tele-Care each month, this indicates that approximately 5,300 ED visits may have been averted each month.

The overall savings to the system are sizable, when one considers that it costs an average of $89 for an ED visit and $20 for a visit to a physician’s office.

Forty-two percent of the callers were provided with self-care advice and didn’t use any other healthcare service.

The business plan for the North Bay centre asserts that tele-triage nurses will offer up “the right resources to promote patient independence and self-confidence in their decision-making regarding their symptoms.”

In the future, home-care services could be integrated with the call centre. For example, nurses in the facility could use videoconferencing or electronic medical devices to monitor the status of patients in their homes.

This would reduce the need for nurses to make regular visits, only to find in most instances that the patients are doing fine. Instead, nurses could be sent out when the patient has a significant problem.



Saskatchewan to implement MDS province-wide for long-term care

REGINA – Saskatchewan will become the first province in Canada to adopt a province-wide, computerized MDS 2.0 (Minimum Data Set) assessment system for long-term care.

In February, the province awarded a contract to Momentum Health Information Systems of Winnipeg to deploy MDS 2.0, a clinical assessment solution based on Microsoft’s Windows/NT environment, to 168 long-term care facilities across the province.

The MDS system is said to allow district staff to identify and address the individual needs of each resident and ultimately improve the quality of service that long-term-care residents receive. MDS is rapidly gaining recognition throughout the world as the standard resident assessment tool for long term care.

For its part, Momentum Health Information Systems is a software solutions provider specializing in clinical, financial and dietary applications for the healthcare sector.

Also in February, Momentum announced that it had won the contract to supply Sysco Corp. of Houston – a US$16 billion food service marketer and distributor – with a custom dietary management solution for its long term care clients.

Sysco will market the Momentum Dietary Management System under the name Ingenium Max (Menu Automation Express), a Windows-based system that features five modules: resident care plans; menus; production; assessment; and costing.

The Momentum Dietary Management System is resident-driven. Once all resident information is entered, serving, production and ordering requirements are automatically updated. Efforts required in tracking resident information are streamlined and resources can be reallocated to provide residents with additional services.

According to Momentum, resident satisfaction is enhanced as individual meal service and production reports ensure that each resident receives exactly what he or she wants.

In Saskatchewan, MDS will be used to replace the current Level 1-4 systems. MDS is a set of questions and observations designed to gather the minimum amount of information necessary for a comprehensive resident assessment.

Important MDS definitions include:

• RAI (Resident Assessment Instrument) – the overall process, including assessment, care planning quality indicators, program planning and RUGS classification.
• RAPS (Resident Assessment Protocols) – triggers that identify potential resident needs for staff to investigate further.
• RUGS (Resource Utilization Groupings) – Seven major groupings of residents according to their identified needs.
• QI (Quality Indicators) – indicators used to evaluate how effectively care is being provided within a special care home. They can be used to compare the quality of care.
MDS was developed by interRAI, an international consortium of 30 researchers and clinicians from 13 countries. InterRAI focuses on the development of standardized assessment tools to improve care of the elderly worldwide and conducts cross-national studies.
The consortium’s fellow in Canada is Dr. John Hirdes, of the University of Waterloo. He maintains a web site at
The benefits of MDS include:
• A standardized and automated method for information gathering and classification.
• Improved quality of information, which can be used for identifying patient needs, program development and staff education.
• Internationally established validity.
• Standardized quality indicators.

According to Saskatchewan Health, the province is currently in discussions with the provinces of Manitoba, Alberta and British Columbia to share information about MDS and its implementation.

Said Pat Inglis, director of program development with Saskatchewan Health: “The MDS/RUGS system will allow district staff to identify the individual needs of each resident and provide better care planning.”



NT and SQL Server 7.0 used to run a healthcare data warehouse

By Jerry Zeidenberg

ATLANTA – Can Microsoft’s SQL Server 7.0 database and NT operating system support giant applications, namely the computerized clinical operations of a large hospital? To show that it can be done, Microsoft Corp. and Data General Corp. have together created the TeraClin Project, a healthcare database containing 2.5 terabytes of text, diagnostic images, video and audio information.

According to a report by the Aberdeen Group, a Boston-based consulting company, many in the health sector have been waiting to see evidence that Windows 2000 (formerly NT 5.0) and SQL Server 7.0 are reliable and capable of scaling up to handle enterprise-wide workloads. Microsoft and Data General wanted to demonstrate that their software and hardware are capable of handling whatever a health system might throw at them.

“In healthcare, your data will grow over time, and your database systems can’t have a dead end,” said Michael Sutkowski, general manager of Data General’s U.S. healthcare division. “You have to show that you can scale up.” This ability will be especially important for health providers in Canada who are establishing regional repositories of patient information.

Data General and Microsoft demonstrated the TeraClin system at the Health Information Management Systems Society convention, held in Atlanta in February. It runs on two eight-processor AviiON servers with a full-fibre connection to a number of CLARiiON storage subsystems.

The database has been populated with ‘simulated’ data from a hypothetical, large-scale healthcare network. TeraClin has natural language abilities, allowing users to generate reports by asking questions in plain English.

It also makes use of Microsoft’s ActiveX components, a solution for tying together the disparate software systems that are typically used in healthcare organizations. According to the companies, by using ActiveX for Healthcare, hospitals will be able to integrate patient information, as well as data from departments such as radiology and pharmacy, regardless of the software applications being used.

“We’re showing that a commodity-priced database could meet the needs of real-world customers,” said John Carpenter, managing consultant of Microsoft’s healthcare consulting group for the East Coast.

The TeraClin Project will be housed at Data General’s headquarters in Westboro, Mass., in the Solutions Centre for Healthcare, a joint-venture laboratory launched by Data General and Microsoft. But Sutkowski pointed-out that hospitals and health regions wishing to test it could load their own data into the system and experiment with TeraClin remotely through an on-line hook-up.

The mega-database was built using Data General’s TeraClin data model and the DG PS data warehouse methodology in a speedy seven months.

A team of Data General warehouse architects and healthcare specialists, along with consultants from Microsoft, arrived at the following core business questions and requirements for TeraClin:

• What patient attributes are common across specific clinical diagnoses?
• What medications are being prescribed for specific diagnoses?
• Which patient occupations have a higher incidence of specific illnesses?
• What lab tests were performed in specific cases and what were the results?
• What is the cost/profit breakdown of the services and medication provided at each facility?

The logical and physical data warehouse design utilizes a “star schema” architecture with supporting data marts, and was created to answer the above questions and many more.

Core business measures, known as ‘facts’, reside in very large tables at the centre of the data model. Attributes defining available segregation of data, known as ‘dimensions’, surround the fact table much like spokes in a wheel or the points of a star – hence the name star schema.

The enterprise data model to support the TeraClin project included six fact tables for business measures (encounters, prescriptions, billing, lab results, encounter audio/visual, and lab audio/visual), and nine shared dimension tables (patient, facility, physician, diagnosis, procedure/services, lab tests, time, medication and insurance.)

Image and audio data are stored in Microsoft SQL Server 7.0 in BLOB (Binary large objects) format. Using BLOB data types, TeraClin can electronically archive images (in formats including BMP, JPG, GIF), faxes, MS Word documents, audio files (in WAV and MID), streaming video in AVI and a variety of other data formats.

Also on the data warehousing front, Data General announced an alliance with Systems Techniques Inc. of Atlanta to market STI’s Converge data warehousing system with DG’s AviiON family of Intel-based servers, which support UNIX and Microsoft NT.

According to Sutkowski, Data General and STI will provide a series of enterprise data models aimed at various healthcare practices, such as outcomes and utilization. He said that Converge and STI’s implementation methodology reduces development time, resolves meta data and integration issues, supports data management, and reduces the manpower needed to maintain a warehouse.



Electronic commerce gathers steam, provides hospitals with major cost savings

By Andy Shaw

“The Internet will dramatically change healthcare by enhancing communications, streamlining processes, and creating new business opportunities, says a new research report from Hambrecht & Quist. ‘The ‘’ companies that stand at the confluence of healthcare and the Internet will reap the rewards of progress,’ according to H&Q analysts Stephen M. Fitzgibbons and Richard Lee.”

Such is the lead of a breathless H&Q press release out of San Francisco. The release promotes Fitzgibbons’ and Lee’s “The industry”, a report on revenue opportunities for investors and companies active in online healthcare.

Hambrecht & Quist is a leading technology investment banking firm in the United States. So it knows where to make a buck or two in high tech stocks. And Fitzgibbons and Lee say companies that will make the most bucks quickest are providers of electronic commerce to the healthcare industry.

So maybe before you call your broker or dial up your online stock trader, we’d better decide just exactly what we mean, class, by the term electronic commerce. Literally, it refers to any business transacted using only electronic forms and records. However, electronic commerce has taken on a more restricted sense. For many, electronic commerce means business done only on the Internet, not over other networks. Others see it as Internet trading done only between business and consumer, not business-to-business. The one aspect that tends to get ignored in these semantic shenanigans, is the oldest form of electronic commerce – electronic data interchange or EDI.

So here we will use electronic commerce to mean to any form of electronic business done over any kind of network.

That said, there’s still no doubt that the Internet is where electronic commerce in healthcare is hottest right now. The Hambrecht & Quist report details revenue opportunities for healthcare suppliers that are doing business online for a profit. One such company “standing at the confluence of healthcare and the Internet” and profiled in the H & Q report is The Unionville, Ontario-run firm produces one of the Internet’s most visited and successful medical Web sites. Fitzgibbons and Lee also look at other firms that provide the hardware and software to wire suppliers and providers together. They’re all going to make money, say the boys, but: “Of these, e-commerce, estimated to be in the hundreds of billions of dollars, represents the largest and most immediate opportunity,” concludes the report.

How come?

E-commerce, say Fitzgibbons and Lee, will do more than anything else to eliminate the colossal $250 billion the world wastes annually on unnecessary or avoidable care, redundant tests, and excessive administrative costs. Strangely enough, it can sometimes cost $20 to $60 just to push one paper purchase order around to its supplier and back.

If Fitzgibbons and Lee want to have a first-hand look at the rosy future they are predicting for e-commerce, they should come north and pay a visit to Paul O’Connor at York Central Hospital. O’Connor, in all modesty, says the Toronto area hospital for which he is the Director of Materials and chief purchasing agent, is first to enjoy the benefits and savings of the only “fully automated and unattended electronic commerce process” in North American healthcare.

“We’re a just-in-time hospital,” explains O’Connor, “ and that means we do five-day-a-week replenishment and keep absolutely minimum stock on hand. Once the supplies on the carts on the floors have been checked by six o’clock in the morning, the ordering, purchasing, receiving, and replenishment of those supplies and the payment to our suppliers can all be done same day without paper.”

In addition to the gloves, wipes, dressings, catheters and other paraphernalia rolling around on up to 42 carts in the wards, York Central’s various departments also do their ordering of non-stock items electronically. Operational for the past two years, the system has already afforded York Central huge savings of money, time, effort, space, and people.

“We’ve been able to demonstrate savings of about $250,000 a year so far,” says O’Connor as he lists the benefits. “With no invoices in the mail, for example, we’re saving more than $40,000 a year on postage. When we were handling ordering and stock manually, we would handle an item on average nine times. Now it is handled twice before it is used on a patient. We used to have a warehouse full of $275,000 worth of stock but now our stock is down to $40,000 worth of items we can’t ever run out of. Finally, when I first came here, our purchasing department had seven people. Now we have three, including me.”

Of course, O’Connor admits there’s a substantial up-front price to pay for any hospital wanting emulate York Central. “To do what we’ve done, you first of all need a materials management system in place. That will cost you at least $250,000, so you’ve got to present a pretty convincing business case for it to hospital management.”

The HBOC materials management system at York Central kicks in once attendants report the number of items remaining on their carts from the day before. It automatically issues a purchase order for replacements needed after the system has checked that particular cart’s profile of the products it should carry. It does so for each cart and then sends the combined order by mid-morning to the hospital’s supplier, Source Medical, via the CareNet Services Inc. network run by Shared Network Services (SNS) Inc.

Source Medical, also on CareNet, checks its client mailbox at SNS and sends out the requested items. Usually, York Central has the item in hand by 3 pm the same day. Meanwhile, Source Medical has sent also via CareNet an electronic packing slip for the order and an invoice. The HBOC system then mirrors the packing slip to the purchase order and checks them against the invoice with Source Medical’s electronic pricing and sales catalogue. It is available online through CareNet and kept accurate up to the minute. If all figures match, the system cues York Central’s General Ledger to pay the invoice. Payment is then made with an electronic deposit of funds into the supplier’s bank account.

If the numbers don’t tally, the system signals an invoice rejection.

“If there is a discrepancy we can deal with it right away,” says Denise Shoesmith, the manager for purchasing and inventory control at St. Joseph’s Health Centre in Toronto, another CareNet client.

Shoesmith says such efficiencies have enabled St. Joseph’s to carry on with its material management system even as staff members leave and are not replaced.

So goes state-of-the-art electronic commerce in healthcare, and all done without the Internet.
“It’s EDI done over a private network,” says Herb Martin, the director EDI services at SNS. “We are working on Internet solutions for the future, but I think electronic business in healthcare will remain largely EDI based for some time to come.” The reason Martin adds, is that a lot of healthcare providers and suppliers have invested heavily in their EDI infrastructures and are keen to keep them operating and profitable.

CareNet, a consortium of both providers and suppliers, recently signed up its 200th Canadian hospital, the Ajax and Pickering Hospital in the Rouge Valley Health Region of southern Ontario.

“If those hospitals were to switch to an Internet solution they would have to replicate all that they can do now with EDI,” observes Martin.

Given the state of healthcare financing, few could afford such a dramatic change. Besides, SNS has been running the technical end of CareNet and proving its reliability since 1991. And CareNet does it over networks that, unlike the Internet, raise no serious doubts about their confidentiality.

“We use DataPac, the Bell/Stentor offering,” explains Martin. “With our redundant Tandem computers and servers we can take in, translate and send out just about any communications protocol that exists, including asynchronous, X-25, X-400, and even fax.”

Such adaptability has meant any hospital in the country with as little as a standard PC and a modem or a fax can effect electronic transactions regardless of what systems their suppliers use – if they do it through the clearing house of CareNet. The result is that CareNet handles the e-commerce for 1200 Canadian healthcare providers and their suppliers. This accounts for about 98 percent of all the healthcare EDI in the country. Not surprisingly, CareNet has just renewed its contract with SNS for another four years.

Another well-established, e-commerce player has also just renewed itself, but this one already plays seriously and securely on the Internet. In February, Livingston Healthcare Services Inc. spun off a new e-commerce focused company, Engineered Connections Inc. Livingston develops and sells supply-chain software and is best known in healthcare for its ProCure system. With ProCure, hospitals can order even controlled substances and narcotics over the Internet using software that the RCMP has pronounced secure.

To head up Engineered Connections, Livingston airlifted home Neil Barran, a Canadian with extensive supply chain and Internet experience in Britain.

“We realized as a company that we had a very good knowledge of supply chains, EDI and the Internet,” says Livingston Group Inc. president Jean-René Halde. “So we wanted to set up a team that was free to develop customized Internet supply chain solutions using all three areas of expertise. As a result we’ve transferred our top e-commerce people to Engineered Connections and to lead the team we’ve picked the best person we could find,” adds Halde.

Clearly Halde and Livingston see a different future for e-commerce in healthcare than does EDI-favouring Martin and CareNet. Halde thinks Internet transactions will come to healthcare sooner rather than later, especially in Ontario, the johnny-come-lately province in health informatics.

“There are a lot of hospitals in Ontario who are not EDI capable. So they find Internet based solutions very appealing,” says Halde. “That’s one of the reasons ProCure has been successful.”

ProCure’s ordering method may be model for what’s to come. In effect, it is a hybrid. It enables users to generate a purchase order using Internet technology and then converts it to a standard EDI transmission sent directly to the manufacturer. So there’s no need to rebuild their proven EDI systems to accommodate new, Internet-based clients.

Such interoperability is at the heart of the country’s most ambitious health information networks. Manitoba’s province-wide SmartHealth is now in its third year of a $100 million five-year development. A brainchild of the Royal Bank and the visionary Dr. John Evans, SmartHealth has become its own corporation. It is now jointly owned by the Bank (49 percent) and EDS Canada (51 percent). As a company, SmartHealth is turning its Manitoba experience into profitable ventures elsewhere, including a significant e-commerce initiative in Ontario.

“We developed SmartHealth terminals that run point-of-sale software and can read magnetic-striped cards,” says John Williams, the Toronto-based President of SmartHealth. “And right now, with the blessing of the Ontario government and both the Ontario medical and chiropractic associations, the Royal Bank is rolling them out to about 1800 private doctors, chiropractors, and hospitals.”

The SmartHealth terminals can read debit and credit cards as well as validate Ontario health cards. But they could do much more. “Technically there is no reason why the SmartHealth terminals could not handle all the OHIP (Ontario’s health insurance plan) payments and funnel them back to physicians and other healthcare providers,” says Williams. “Now, that truly would be e-commerce in healthcare.”

True e-commerce healthcare is also burgeoning among consumers who are using their home computers and credit card numbers to purchase medical products and services online. Medical web sites such as offer online “medical stores” for hard-to-find equipment and even expert second opinions of a patient’s medical condition – for a price. In the United States, online drugstores are springing up on the Web. Soma (, based in Seattle, was launched in January. PlanetRx and were scheduled to start up in March. Both companies will offer 30,000 drugstore items for electronic sale.

Such public response suggests people are ready for e-commerce in healthcare on a personal level. But provincial governments, even the most progressive ones in information technology-based healthcare, aren’t getting the message. Manitoba’s government has been taking a slow, cautious approach. Earlier this year, Newfoundland put its SmartHealth initiative on hold with an election call (albeit allowing Williams and company time to heed the call to Australia for some SmartHealth consulting work). The Ontario Cabinet is yet to formally approve any funds for building its much-planned health information network.