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. Its rolling the system out to 168 LTC facilities across the province.
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.
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
Markham Stouffville Hospital, outside Toronto, is running a pilot
project to electronically connect family physicians to the hospitals computerized
medical records. Sixteen physicians will be able to gain quick access to their
patients test results and other reports at the hospital.
Electronic business is taking root in hospitals, saving some
institutions hundreds of thousands of dollars. Those that havent 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 wont 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. Theres 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
He noted that a call to a tele-triage nurse could determine, in some
cases, that the trip isnt 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
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 patients 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 physicians
Forty-two percent of the callers were provided with self-care advice
and didnt 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
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
Microsofts Windows/NT environment, to 168 long-term care facilities across the
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
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
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
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
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
The consortiums fellow in Canada is Dr. John Hirdes, of the University of Waterloo.
He maintains a web site at http://interrai.providence.on.ca
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 Microsofts 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
In healthcare, your data will grow over time, and your database
systems cant have a dead end, said Michael Sutkowski, general manager of Data
Generals 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 Microsofts 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.
Were showing that a commodity-priced database could meet
the needs of real-world customers, said John Carpenter, managing consultant of
Microsofts healthcare consulting group for the East Coast.
The TeraClin Project will be housed at Data Generals 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 Generals 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
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
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
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 STIs Converge data warehousing
system with DGs AviiON family of Intel-based servers, which support UNIX and
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 STIs 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 health.net 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
Such is the lead of a breathless H&Q press release out of San
Francisco. The release promotes Fitzgibbons and Lees The health.net
industry, a report on revenue opportunities for investors and companies active in
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, wed 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
So here we will use electronic commerce to mean to any form of
electronic business done over any kind of network.
That said, theres 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 Mediconsult.com. The Unionville,
Ontario-run firm produces one of the Internets 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. Theyre 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
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
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
OConnor at York Central Hospital. OConnor, 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.
Were a just-in-time hospital, explains OConnor,
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
oclock 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
In addition to the gloves, wipes, dressings, catheters and other
paraphernalia rolling around on up to 42 carts in the wards, York Centrals 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.
Weve been able to demonstrate savings of about $250,000 a
year so far, says OConnor as he lists the benefits. With no invoices in
the mail, for example, were 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 cant
ever run out of. Finally, when I first came here, our purchasing department had seven
people. Now we have three, including me.
Of course, OConnor admits theres a substantial up-front
price to pay for any hospital wanting emulate York Central. To do what weve
done, you first of all need a materials management system in place. That will cost you at
least $250,000, so youve got to present a pretty convincing business case for it to
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 carts profile of the products it should carry. It does so for each
cart and then sends the combined order by mid-morning to the hospitals supplier,
Source Medical, via the CareNet Services Inc. network run by Shared Network Services (SNS)
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 Medicals 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 Centrals General Ledger to pay
the invoice. Payment is then made with an electronic deposit of funds into the
suppliers bank account.
If the numbers dont tally, the system signals an invoice
If there is a discrepancy we can deal with it right away,
says Denise Shoesmith, the manager for purchasing and inventory control at St.
Josephs Health Centre in Toronto, another CareNet client.
Shoesmith says such efficiencies have enabled St. Josephs to
carry on with its material management system even as staff members leave and are not
So goes state-of-the-art electronic commerce in healthcare, and all
done without the Internet.
Its 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
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
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 weve
transferred our top e-commerce people to Engineered Connections and to lead the team
weve 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. Thats
one of the reasons ProCure has been successful.
ProCures ordering method may be model for whats 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 theres no need to rebuild their proven EDI systems to accommodate
new, Internet-based clients.
Such interoperability is at the heart of the countrys most
ambitious health information networks. Manitobas 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 (Ontarios health
insurance plan) payments and funnel them back to physicians and other healthcare
providers, says Williams. Now, that truly would be e-commerce in
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 Mediconsult.com offer online medical
stores for hard-to-find equipment and even expert second opinions of a
patients medical condition for a price. In the United States, online
drugstores are springing up on the Web. Soma (www.soma.com), based in Seattle, was
launched in January. PlanetRx and Drugstore.com 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, arent getting the message.
Manitobas 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.