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Inside the June/July 2003 print edition of Canadian Healthcare Technology:


Feature Report: Directory of healthcare I.T. suppliers


Ontario hospitals enlist I.T. in battle against SARS

As doctors and nurses across Ontario rallied together to battle the Severe Acute Respiratory Syndrome (SARS) virus this spring, information technology professionals were equally prepared to lend their support.

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CHUS produces one of Canada’s first working healthcare data warehouses

The Centre hospitalier universitaire de Sherbrooke (CHUS) has a data warehouse up and running, and it’s capable of analyzing 12-year’s worth of data that’s extracted from the hospital’s electronic medical records.

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The first pan-Canadian EHR

The Department of National Defence has started work on an electronic health record system that will connect its facilities across Canada and sites abroad. The large-scale project will use Purkinje EHR software at its core.

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Teaching patient safety

Unique software under development at the University of Sherbrooke medical school, in Quebec, will allow medical students to test diagnoses, treatments and drug orders through simulations.


Large-scale EHR in U.S.

Kaiser Permanente, the largest non-profit HMO in the United States, has launched an electronic patient record system that will connect 8.4 million patients and 12,000 physicians across the U.S., making it one of the largest EHR systems in the country.

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Telestroke in Ontario

Neurologist Dr. Frank Silver is part of the NORTH Network’s new Telestroke program, which links specialists in Southern Ontario with hospitals in the North. Patients benefit through faster access to care.


PLUS news stories, analysis, and features and more.

 

Ontario hospitals enlist I.T. in battle against SARS

By Dianne Daniel

As doctors and nurses across Ontario rallied together to battle the Severe Acute Respiratory Syndrome (SARS) virus this spring, another group was equally prepared to lend its support.

Information technology professionals were also among the first to respond to the crisis.

Within days of receiving the Ontario Ministry of Health’s directives to limit and screen the people going through hospital doors, the Queen’s University Anaesthesiology Informatics Laboratory (QUAIL) team in Kingston, Ont., leveraged its experience in Web development to produce an e-SARS screening tool.

According to QUAIL medical director Dr. David Goldstein, it took 36 hours for the team to create a Web application that cut the screening process down from 10 to 15 minutes per person to a matter of seconds.

“If you have anywhere from 400 to 600 people coming in on any one shift, you can imagine the logjam,” said Dr. Goldstein, who noted that all hospitals were required to have visitors, patients and staff members fill out a questionnaire as they entered the facilities. “It was taking so long, and using so much nursing time, we said this is just not going to do.”

Another problem was identified when Dr. Goldstein randomly selected completed questionnaires and was unable to read the signatures of both the person cleared for entrance as well as the nurse responsible for the screening. “So how could I track anyone if they got sick? I couldn’t track who they were exposed to, who exposed them, nothing.”

As part of the e-SARS initiative, QUAIL researchers created bar-coded ID badges for every hospital employee – including medicine, surgery, nursing, pharmacy, x-ray, lab and students – and purchased auto-ready scanners for each entrance. They then leveraged the wireless computing infrastructure at Kingston General and Hotel Dieu hospitals to set up an automated screening process at each entrance.

Upon arriving, employees swipe their bar-coded ID badge under the scanner and the Ministry of Health questionnaire pops up on a computer screen, time stamped and dated, and with the correct name already filled in. The employee proceeds through the questions on-line, entering his/her name at the end.

Because e-SARS is a Web-based tool, the information is easily integrated between sites. This means that if an employee works between two hospitals, the previously filled-in questionnaire pops up, eliminating the need to repeat it.

“Not only did we achieve a significant reduction in delay, but we also captured digital data that can now be queried,” says Dr. Goldstein. The QUAIL team is making its tool available to other Ontario hospitals in exchange for a donation to the QUAIL research fund.

Another Ontario-based group sharing its expertise to help combat SARS is the St. Thomas-Elgin General Hospital, owner of software company Continuum solutions. The company created a mini version of its readiness for discharge assessment tool, as well as a version designed to deal specifically with SARS.

According to Larry Vanier and Sandie Jenkins, principals of Continuum solutions, the software was made available to Ontario hospitals at no charge for the duration of the SARS emergency. The goal, said Jenkins, is to help avoid premature discharge, which would ultimately contribute to spreading the virus.

The way the SARS Readiness Discharge tool works is simple. Once patient information is loaded into the Windows-based system, a screen is created for each patient that outlines 10 criteria for safe discharge put forth by the World Health Organization. For example, they have to be without a fever for 48 hours, their cough must be resolving and their chest x-ray must show improvement. Each day, a healthcare worker fills in the electronic form with updated information, marking “yes,” “no” or “not applicable” for each one. When every question is answered with a “yes” or “not applicable,” a patient can safely be discharged.

As Jenkins points out, the tool can be tailored to any discharge criteria, making it applicable to other situations as well. It can also be used to produce reports for statistical analysis. “SARS prompted us to send it out in a mini version,” she said. “Right now, we have readiness-for-discharge tools for medical/surgical patients, psychiatric patients and pediatric patients as well. We decided to focus down and give them this mini piece of it, as well.”

Continuum solutions included an HL7 ADT interface with the SARS Readiness For Discharge Assessment software. The interface tool, called Transmed, is supplied by Artificial Intelligence in Medicine, and has also been available on a cost-free basis to aid in the fight against SARS.

At the Baycrest Centre for Geriatric Care in Toronto, lending a hand was also the focus of the 20-member I.T. department, who discovered several innovative ways to help out. During the initial weeks of the virus outbreak, the centre’s 800-bed hospital facility went into protective lockdown mode, limiting access to essential personnel only.

According to Baycrest Centre director of information technology Stephen Tucker, the I.T. team was so moved by instances where family members were prevented from seeing each other, they quickly came up with ways to help. “On the way in, there was this elderly gentleman waving to his wife up on the third floor,” notes Tucker. “It was touching, an elderly gentleman waving to his little bride and he can’t be in there with her.”

The I.T. team decided to leverage its existing wireless infrastructure in order to set up two-way teleconferencing. They purchased four D-Link cameras, which were integrated into existing movable computer carts and offered family members the ability to communicate with their loved ones through scheduled meetings.

The family members could use their own home computers and schedule a meeting via a password-protected Web site, or they could use one of two hospital computers provided at two entrances. The ability to see their loved ones while talking on the phone proved so valuable, Tucker says, the centre planned to continue the service even after the emergency ended.

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CHUS produces one of Canada’s first working healthcare data warehouses

SHERBROOKE, QUE. – Many hospitals and health regions in Canada are planning to develop a data warehouse, but the Centre hospitalier universitaire de Sherbrooke (CHUS) has actually gone ahead and done it. They’ve now got a warehouse up and running, capable of analyzing 12-year’s worth of data that’s extracted from the hospital’s electronic medical records.

The system, which has been built using data warehousing software from Sand Technology of Montreal, extracts information from clinical and will soon draw on financial databases, as well.

Information is automatically converted into standardized, coded data using SNOMED, ICD-9, DRG and other systems. The data are encrypted and de-identified (no patient names are used), and researchers and other healthcare professionals can be assigned varying levels of access to the information.

“There are very few data warehouses in North America that can do this sort of thing,” commented Dr. Andrew Grant, a medical professor at the University of Sherbrooke and director of the research project.

He explained that the system enables researchers and planners to gain a better understanding of current medical practices. In this way, they hope to improve outcomes and reduce costs.

For example, the system could be used to graphically show how diagnostic tests are being requested. Dr. Grant noted that sometimes in routine tests normal values can be returned with a frequency that might suggest that some of the tests weren’t essential.

Physicians wouldn’t be asked to stop ordering tests, “but we can ask people to be more discriminating, especially in routine situations,” commented Dr. Grant, who added that the system “pinpoints possible problem areas to think about.”

The warehouse enables researchers to perform:

• Epidemiological and longitudinal studies;
• Health/risk indicator analysis;
• Outcome studies and clinical decision analysis;
• Development of models of resource management;
• Medico-economic analyses.

Sherbrooke’s new data warehouse is part of the IRIS-Q (Infostructure de recherche intégrée en santé du Québec) project. The goal of IRIS-Q is to put clinical data warehouses in place at four university hospital centres in the province of Quebec, to link them and make the data accessible via a single web portal by 2006.

The Canada Foundation for Innovation is funding IRIS-Q with $28 million. Of that, $3.2 million was awarded to the Sherbrooke portion of the project, which is known as CIRESSS (Centre informatisé de recherche évaluative en services et soins de santé.)

Fabien de Lorenzi, associate director of research at CHUS, explains that while the Per-Sé electronic patient record system in use at the Centre for the past 12 years excels at meeting the day-to-day information management requirements of the hospital, it was not designed to respond to the complex queries researchers wanted to ask.

He added that, “the heavy workload on the system arising from day-to-day hospital operations meant that researchers’ complex queries have to be slotted for execution only during evenings and weekends, which meant the system was rarely used for research purposes.”

The current solution, the SAND Patient Record Analytic Server, allows researchers to ask questions of the data that were practically impossible before, and in particular allows clinical data and medical notes to be queried at the same time.

The SAND Patient Record Analytic Server gives researchers at CHUS the ability to access more than 500,000 electronic patient files and more than 3 million medical notes and reports per year. All data are held in a greatly simplified data model — reduced from 1,200 tables in the operational system to 11 re-grouped tables.

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Canada’s military starts on large-scale electronic patient record project

By Andy Shaw

If ultimate I.T. challenges are your cup of tea, here’s one to ponder:

Please provide us with an electronic health record (EHR) system that:

• maintains comprehensive health records for 50,000 to 60,000 of our people, including their drug and dental care, no matter where they move (and they move frequently);

• is available to our care-givers and patients alike, 24x7 in our one hospital and 27 out-patient clinics across the country, as well as our constantly changing missions abroad and even aboard our ships at sea;

• uses commercially available software and decision-support tools that have been proven reliable from trustworthy suppliers;

• is bilingual;

• most importantly, is so secure that not even the most skilled hackers of any potential enemy of ours can crack it;

• and finally, integrates all this into one easy-to-use, readily maintained, future proofed, and bug-free EHR that works without fail from the first day it is rolled out.

Such was the formidable nature of the criteria set forth by the Department of National Defence (DND) in a Request For Proposal (RFP) for an EHR that will underpin the healthcare of all of Canada’s fighting men and women in both the regular and reserve arms of the Canadian Forces.

Like the business of the Forces themselves, this massive undertaking is not a job for the faint of heart. Yet, nine prime bidders all responded to the RFP. In the end, the nod went in February this year to Lockheed-Martin Canada to deliver a state-of-the-art EHR, dubbed the Canadian Forces Health Information System (CFHIS).

But why Lockheed-Martin? The builder of fighter jets, smart bombs, cruise missiles, and naval frigates, among other major weapons systems? And a company with little experience in healthcare?

“That’s true about our healthcare experience per se, but obviously the DND selectors agreed with us that it was a secondary consideration. Rather, it is our strengths that are most needed by this project — specifically our general familiarity with the military and most importantly of all, our expertise at large-scale systems integration,” said Alan Steele, now Lockheed Martin Canada’s project manager for the CFHIS in Ottawa.

Steele’s qualifications include just the right amount of grey hair, he says, grown from facing the challenges of 18 years of project management for DND, including the highly successful Canadian Frigate Program that produced Canada’s widely envied fleet of modern warships.

This time, Steele will oversee a multi-year contract worth at least $56 million that calls for a test-as-you-go, phased implementation of the CFHIS. The first three phases of design, testing, and roll-out will stretch over five years.

Steele and a project team of both military and civilian personnel are co-ordinating the work of the initial five subcontractors: Dinmar Consulting, Purkinje Inc., SCC Soft Computer Consultants, Calculus Informatique, and Adstra Systems Inc.

“This is a rather unusual set-up. It’s a very, very large systems integration project for one thing,” says Richard Johnstone, senior functional analyst on the project for Dinmar. “Also what’s unusual is that this is an EHR to be used in widespread clinics and deployed abroad. The third distinguishing feature is how much energy and thoroughness is going to go into protecting privacy and security. Of course, the military has a special concern about that. It can’t ever let an enemy know the state of health of its troops.”

Johnstone was part of an earlier team that developed the multi-server, Citrix-based enterprise architecture plan for the CFHIS, an initiative that stretches back to 1998 when DND first committed funds to develop a Forces-wide EHR. This time around, he will lead the contribution of Dinmar, which brings much healthcare experience to the project. Dinmar claims it is the largest independent provider in Canada of I.T. consulting services in the healthcare sector.

Purkinje, based in Montreal, will bring the software nuts and bolts of the actual electronic health record. Its bilingual Dossier clinical notes/EHR product enables both physicians and clinical assistants to make keyboard entries into a single on-screen document. On “civvy street”, Purkinje already has a user base of 1,100 clinics.

Curiously, Dinmar will help Lockheed-Martin integrate the Purkinje record even though Dinmar itself markets the well-known OACIS health record. “It’s an acquisition Dinmar has made only fairly recently,” explains Johnstone, who further points out that Dinmar was included by Lockheed-Martin not for its products but for its general experience and expertise with healthcare I.T. systems.

“We are pleased to be working on a project of such prominence and scale,” noted Mark Groper, Dinmar’s CEO. “Our history of focusing solely on the provision of healthcare technology solutions is well-suited to the complexity of the CFHIS project.”

SCC Soft Computer Consultants will provide an ancillary suite of laboratory, radiology, and pharmacy systems, with partner Calculus Informatique of Montreal ensuring that they are all bilingual.

Adstra Systems of Toronto will contribute its dental charting and dental imaging management systems.

Lockheed-Martin will orchestrate the contributions of these players to the CFHIS, first on a rigorous, proof-of-concept test-bed located at the National Defence Medical Centre (NDMC) in Ottawa — all under the watchful eye of the “customer”, represented by Lieutenant Colonel Jim Kirkland, DND’s senior staff officer for health services informatics. He will be aided by DND’s own project manager, Bill Brittain. For those systems and contributors who pass the test, there will be yet another proving ground when the CFHIS will be placed in two pilot sites, likely at Canadian Forces clinics in Esquimalt, B.C. and Edmonton.

“We began work on this in 2002 even before we formally picked Lockheed-Martin. So now we’re six months down range and have about 30 contractors already in NDMC. We have been consulting DND healthcare providers all along to make sure we’re going to provide what they need and can use. The test-bed, all the hardware, and all the out-of-the-box applications installed. And we are configuring the security solution,” says Lt. Col. Kirkland, who is a former pharmacist turned manager with 24 years of health services work in the Canadian Forces logged so far.

“For security, we will be using PKI (public key infrastructure) to support our EHR, which I think will be a first in government. And the EHR will run over our defence wide area network, our virtual private network,” says Kirkland. “All the applications will be PKI-enabled using Entrust products, and I don’t think there is much of that going on yet anywhere else. To integrate all the applications together we are using E*Gate software. That will give us HL7 interfaces for messaging and a common look and feel to the applications.”

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Kaiser Permanente’s EPR will reach 8.4 million patients across the U.S.

By Andy Shaw

It’s big, it’s bold, and, in about three years, this electronic patient record (EPR) system promises to be bountiful. Kaiser Permanente, the USA’s largest not-for-profit health maintenance organization (HMO), is investing US$1.8 billion into an EPR program that uses software from Epic Systems Corp.

The record will service all 8.4 million of Kaiser Permanente’s members, along with its 12,000 physicians and 100,000 other caregivers in all eight of the HMO’s semi-independent regions across the United States.

When the EPR roll-out is complete in 2006, both Kaiser patients and staff will have password protected access to what promises to be the biggest patient database in the world and one that’s rich with best practices for members and caregivers alike.

Kaiser Permanente, headquartered in Oakland, Calif., announced in February that it would adopt an EPR from Epic Systems, based in Madison, Wisconsin, for all Kaiser’s 29 hospitals and 423 medical offices spread across nine states as well as the District of Columbia. It was a dramatic and somewhat surprising decision. For a decade Kaiser had been developing its own EPR with the help of IBM. But even though the work with Big Blue had produced a functional EPR, Kaiser was heading towards $1 billion in costs and at least a five-year-long rollout.

Kaiser Permanente’s new CEO decided that was going to be too expensive and too long. Soon after, Kaiser executives made a convincing business case for shelving it and writing the expense off. Then, in a competitive bid process, Kaiser turned and picked the Epic alternative.

“When George Halvorson arrived last year as the new CEO, he saw right away that the EPR was going to be our single largest capital expenditure,” explains Dr. Andrew Wiesenthal, executive director of the umbrella Permanente Federation and who is quarterbacking the Epic deployment. “So he said he wanted to make sure we were on the right path and asked us, along with a number of consultants, to re-examine what was available in the marketplace.”

Dr. Wiesenthal says that when Kaiser Permanente had first looked for an EPR in the late 1980s, there simply was none – at least not one scalable enough to handle the caseload of even one Kaiser Permanente region, never mind the whole outfit. Then in the 1990s, its Northwest region (second largest behind California) found and adopted an Epic EPR for its half-million members.

“All our regions had recognized the need for patient-record automation. Some were heading down the path of internal development working with IBM, as we were at the time in Colorado, while others went looking outside,” says Dr. Wiesenthal. “But by the late 1990s, Kaiser Permanente recognized that it should make a unified effort. Of course, we were all aware of what was happening in the Northwest, but we made the decision to go with an internal IBM solution largely because we thought it would be more scalable.”

However, when directed by their new boss to look again, Wiesenthal says they found the marketplace had changed. “It was very clear that the market had matured and that Epic had evolved its EPR’s functions, technical capabilities, and robustness substantially. It was also developing faster than our EPR and we saw it would pass ours by. It’s what happens when a company directs all their energies into their product. We were happy with what we had done (with IBM). There was nothing broken about it. It was working but it was clear that we would be left with something that wasn’t the best.”

What’s more, the Epic record was proven. So it needed no long-running trials or pilots – only careful adaptation to the legacy systems and idiosyncrasies of the seven other Kaiser Permanente regions.

The Epic system includes a full medical record, physician order entry, clinical decision support, scheduling, and billing modules. Through a Web portal, the client-server based system will be open to patients to create and update their own personal health pages, request appointments, ask for prescription refills, and otherwise communicate with their care providers.

All this will function in an encrypted environment and provide secure access around the clock. Patients and caregivers gain access according to strict rules set for their roles. They can delve into medical histories, test results, diagnostic imaging, prescription information, and up-to-date medical sciences information to the extent authorized. Caregivers will be able to practice evidence-based medicine drawing on the aggregate data of the central EPR repository and benefit from built-in checks against medical errors.

Challenges of rolling all this out, says Dr. Wiesenthal, include getting the data definitions right in the final configuration. So, while there will be no pilot projects per se, there will be some unit testing of these definitions. That’s all to be done by September, when delivery to each of the regions is scheduled to begin. During the transition to the common record, each region will keep its legacy systems up and running, and will independently deploy differing parts of the Epic system as suits their situation.

“One of the great advantages of the Epic system, is that it is highly configurable and adaptable to the local circumstances,” says Dr. Wiesenthal.

Nonetheless, when asked how do you manage such a huge and variable deployment, Dr. Wiesenthal replied: “Really carefully.”

With a implementation project team that will rise at Kaiser Permanente headquarters to as many as 200 people and involve as many as 1,500 when counting those in the field, Dr. Wiesenthal says the hardest part for them all will be training and support. “We face a lot of resource allocation issues in terms of getting people in the right places at the right time. We have to put a lot of time, energy, and effort into appropriately training people and supporting them as they implement this software. Otherwise, you run the risk of failure, and we don’t intend to do that.”

That job will be made somewhat easier by the nature of the network Epic will function on, and Epic’s track record in the Northwest and in Georgia, where some of the Epic modules have also been in use.

“We have a private network running on T1 lines already in place. So we don’t have to build a new one, and we don’t have any telecom issues to deal with in the roll-out as a result,” says Dr. Wiesenthal.

Perhaps more importantly, ever since the Northwest region began piloting the EPR system in Oregon back in 1994, Kaiser Permanente has actively encouraged and sought detailed feedback from physicians and other caregivers. It has made a study of gaining user “buy-in” and made many modifications following caregiver input.

Judith Faulkner, CEO and founder of Epic Systems Corp., likes the emphasis Kaiser Permanente has give to such collaboration.

“Kaiser Permanente’s vision offers significant advantages for providers and patients alike, especially in sharing information across locations and over time,” says Faulkner. She goes on to point out that users can gain secure and instant access to EPR information at every point-of-care which, in turn, encourages providers and patients to collaborate more and thus streamline the care process.

Those benefits and others have not gone unnoticed internationally, says Dr. Wiesenthal. “We’ve had several hundred visitors here from Britain, for example, after an article appeared in a medical journal over there. It concluded that a patient being looked after by Kaiser Permanente would be a lot better off than one being looked after by their National Health Service.”

So far, no Canadian visitors in any numbers have shown up. But maybe they should. Dr. Wiesenthal says that despite the fundamental differences between the privately driven U.S. healthcare and taxpayer-driven Canadian model, there’s no reason why the Epic system, given its proven flexibility, couldn’t be adapted to a public healthcare system.

“I think they could learn something from what we are doing,” concludes Dr. Wiesenthal.

 

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