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Inside the June/July 2005 print edition of Canadian Healthcare Technology:


Feature Report: Directory of Healthcare IT suppliers


Mount Sinai to computerize outpatient clinics

Mount Sinai Hospital, in Toronto, announced that it will implement Electronic Patient Records in more than 100 ambulatory clinics, using an enterprise solution from Nightingale Informatix Inc., of Markham, Ont.

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Safer Healthcare Now! campaign launched in Canada

Last December, the U.S. Institute for Health Improvement (IHI) launched its 100,000 Lives campaign with the ambitious goal of enlisting 2,000 hospitals and reducing the number of preventable deaths by 100,000 over 18 months.

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UK’s Map of Medicine

British clinicians and researchers have developed a web-based tool called the ‘Map of Medicine’ that delivers succinct information about current best practices to doctors and nurses. It can be used at the point-of-care for quick reference.

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Wide-area PACS

Quinte Health Care, headquartered in Belleville, Ont., is investing $20 million in diagnostic imaging systems that include a regional PACs, 64-slice CT machines and both Computed Radiography and Digital Radiography.

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Supply chain process improves at L’Hôpital Sacré-Coeur de Montreal

Managing supplies is big business at L’Hôpital Sacré-Coeur de Montréal, one of six major university hospital complexes affiliated with the University of Montreal

READ THE STORY ONLINE


Virtual clinic for IBD patients

Doctors in Halifax have developed an interactive web site that allows patients with inflammatory bowel disease to contact their doctors and care-givers, educate themselves using online resources, and connect with other IBD sufferers.


Ultra-portable ultrasound

SonoSite has miniaturized its ultrasound technology to the point where a handheld unit offers similar resolution and capabilities as larger, cart-based systems, the company says. It makes diagnostic exams easier to perform.


PLUS news stories, analysis, and features and more.

 

Toronto’s Mount Sinai Hospital to computerize its out-patient clinics

By Jerry Zeidenberg

TORONTO – Mount Sinai Hospital, one of Canada’s top teaching hospitals and a leader in the use of electronic health records for in-patient care, announced that it will now begin the computerization of more than 100 out-patient clinics. The hospital’s clinics will use secure, web-based software created by Nightingale Informatix Inc., of Markham, Ont.

The Ambulatory Record Management System (ARMS) project is part of Mount Sinai’s overall strategy of creating an integrated Electronic Patient Record (EPR) across the organization. As such, it’s among the first large hospitals in Canada to computerize its out-patient clinics in a comprehensive fashion and to integrate them with its core hospital information systems.

The ARMS implementation is expected to solve a major problem. Because most hospital-based out-patient clinics are either non-computerized, or use proprietary systems that don’t mesh with the hospital’s core systems, physicians have found it difficult to track the status of patients as they move from one clinic to another, or when they shift from in-patient services to out-patient clinics for follow-up.

“It’s created an information gap at our hospital, and I’m sure, at most others,” said Dr. Lynn Nagle, senior vice president, technology and knowledge management, at Mount Sinai. “We want our clinicians to be able to see patient data end-to-end.”

Dr. Nagle explained that many of the hospital clinics work hand-in-hand – for example, the diabetes clinic interacts frequently with other clinics such as cardiology and opthalmology. Traditionally, this has meant the sharing of information has been difficult, since each of the clinics has its own system for patient records. “With ARMS, the benefit is that clinics will have a consistent approach to the management of patient records,” said Dr. Nagle. “Right now, they all have their own.”

The ARMS project will computerize the clinical and administrative operations of the out-patient clinics, which are run by approximately 500 physicians, medical residents, nurses and allied health professionals. The 100 plus clinics include ambulatory obstetrics, diabetes, family medicine, cardiology, oncology, pain management, dentistry, psychiatry and a wide variety of other specialties.

Dr. Nagle observed that the clinics themselves spurred the ARMS project, led by the diabetes group. The multi-disciplinary team in this clinic realized that a centralized electronic patient record would save them a lot of time and improve their collective access to essential clinical information.

And by striking a license agreement to include all ambulatory entities, the hospital was able to leverage the investment to the benefit of all – including a greater range of features than the clinics could have achieved by negotiating on their own.

After an official request-for-proposal and an assessment of seven practice management systems, Mount Sinai Hospital chose a solution from Nightingale Informatix.

While Mount Sinai Hospital runs Cerner PowerChart software at the core of its in-patient hospital information system, the end-users at the clinics opted for the functionality and ‘look-and-feel’ of the Nightingale offering. “When you want buy-in from the clinicians, you let the clinicians make the choice,” commented Dr. Nagle.

The Nightingale system will be integrated with the Cerner systems, providing physicians across the medical centre with access to patient records, wherever the patients have presented themselves.

Samer Chebib, president and CEO of Nightingale, pointed out several advantages to the company’s software system. Chebib said the Nightingale enterprise edition has a patient repository at its core which easily handles large projects, like the one launched by Mount Sinai Hospital, with multiple disciplines and physical locations. It also offers the ability to be customized to suit both GPs and specialists.

The ASP nature of the system means that all applications are hosted remotely and are accessed using a secure internet connection.

Users don’t have to load upgrades or do their own maintenance –- it’s all done at secure servers, off-site. The upshot is that doctors can focus on providing care to their patients rather than fiddling with computer systems.

The Nightingale system also offers special features that are bound to benefit both doctors and patients. In particular, a patient-access component enables patients to see their own health records, view their lab results, fill out questionnaires, request prescription refills and schedule appointments for themselves in their care-givers’ calendars.

According to Chebib, Nightingale’s enterprise offering is priced significantly lower than other enterprise-level Electronic Health Record systems – a factor that appeals to cash-strapped healthcare providers as they seek to computerize.

On another front, Mount Sinai is in the midst of a large-scale Computerized Clinician Order Entry (CCOE) project for its in-patient populations.

Being implemented in a phased approach, by the end of the year physicians will be electronically entering all orderables, including lab, diagnostic imaging and medications. That’s expected to boost speed, accuracy and patient safety, as orders will be much clearer and re-keying will be eliminated.

What’s more, on the medication side, possible adverse-drug-events (ADEs) and other alerts have been built right into the system.

Dr. Nagle said in the future, out-patient clinics will be integrated into this part of the system. They may even be able to order medications for patients, who could then pick them up at the ground-floor hospital pharmacy.

For its part, Nightingale is building a reputation for itself as a leading-edge developer of physician practice management systems, with doctor’s offices across the country using the system.

Of note, the software has been certified by Alberta’s Physician Office Systems Program, which provides financial incentives for doctors working outside of hospitals to computerize their practices.

Earlier this year, Nightingale announced a licensing agreement with the Alberta Orthopedic Society to provide its enterprise software to all 150 orthopedic surgeons in Alberta.

Moreover, the Nightingale system has been certified by Ontario’s e-Physician program, which is now run by the Ontario Medical Association’s Ontario.MD division.

And this year, Nova Scotia chose Nightingale as the exclusive supplier for its own physician computerization program. Nightingale won in competition with several other bidders, both for its ASP (Application Service Provider) and local (server-based) solutions.

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Safer Healthcare Now! campaign launched in Canada

By Dianne Daniel

Last December, the U.S. Institute for Health Improvement (IHI) launched its 100,000 Lives campaign with the ambitious goal of enlisting 2,000 hospitals and reducing the number of preventable deaths by 100,000 over 18 months.

Groups promoting patient safety in Canada also heard the call, and in April 2005, they responded by launching a similar national effort called Safer Healthcare Now! (See the web site at: www.saferhealthcarenow.ca)

“When we learned of the 100,000 Lives campaign, we thought it would be great to have an effort that was Canadian-centric,” said Phil Hassen, chief executive officer of the Canadian Patient Safety Institute (CPSI), who is serving as chair of the Safer Healthcare Now! national steering committee. Although the group is promoting the same six interventions as the IHI, it is putting a Canadian spin on them wherever possible, he said, by using appropriate Canadian standards and reference materials.

Safer Healthcare Now! has a 14-member steering committee including Dr. Ross Baker and Dr. Peter Norton, co-authors of Patient Safety and Healthcare Error in the Canadian Healthcare Sector, as well as representatives from IHI, the Canadian Association of Paediatric Health Centres, the Canadian Institute for Health Information (CIHI), the Quality Healthcare Network and the Canadian Council on Health Services Accreditation. A portion of the campaign’s funding is provided through CPSI, which is mandated “to create a safer Canada for patients,” said Hassen.

The goal of Safer Healthcare Now! is to encourage hospitals to “implement changes in care that have been proven to prevent avoidable deaths.” In particular, it is focusing on the following six strategies outlined on the IHI website (www.ihi.org):

• deploy rapid response teams at the first sign of patient decline;

• deliver reliable, evidence-based care for acute myocardial infarction (to prevent deaths from heart attack);

• prevent adverse drug events by implementing medical reconciliation;

• prevent central line infections by implementing the “Central Line Bundle”;

• prevent surgical site infections by reliably delivering the correct perioperative antibiotics at the proper time;

• and, prevent ventilator-associated pneumonia by implementing the “Ventilator Bundle.”

According to Hassen, the premise is that implementing any one or all of the interventions will greatly reduce avoidable morbidity and mortality. Participating organizations – whether individual hospitals or regional health authorities – are asked to provide two measurements, the first indicating what processes they’ve actually implemented and the second providing data to show a reduction in medical error.

“This is not about trying to say who’s better than the other; it’s about really trying to say we can actually make a difference,” said Hassen.

In its first month, Safer Healthcare Now! enrolled 53 healthcare organizations and expects to have 200 or more delegates represented at its first National Learning Series session. To help co-ordinate the national campaign, three field offices have been established – referred to as the Western, Ontario and Eastern nodes – and the steering committee is hoping to add a Quebec presence as well, said Hassen.

Each node aims to enrol a minimum of 30 to 40 participants, said Cynthia Majewski, executive director of the Quality Healthcare Network and contact for the Ontario node. As of May 20, 2005, twenty-three Ontario healthcare organizations had signed up.

“When organizations join Safer Healthcare Now! they’re joining the campaign, but how they seek to learn and share is entirely up to them,” said Majewski. “In fact, what we’re working on is a menu of different educational strategies that will address clinical team needs in both rural and urban settings.”

A large part of the campaign has to do with collaboration, she adds. Emphasis has been placed on communication, so that campaign members work collectively to learn from each other while avoiding replication. For example, the campaign can serve as a mechanism for sharing expertise, like that of an ICU collaborative that has been working on three of the six IHI interventions for the past couple of years

“The reality is improvement is improvement is improvement,” she said. “People can learn from a variety of different approaches.”

While technology isn’t directly involved in all six interventions listed, campaign members believe it will be crucial to improving patient safety over time. As Hassen points out, the first step is to encourage organizations to change their processes.

For now, campaign participants will learn more about implementing the six interventions through interactive tools posted on the IHI website, informational calls and regional meetings, national web casts and workshops. In addition, Safer Healthcare Now! will be developing a publication, the first issue of which will be co-sponsored by the Ontario Hospital Association, said Hassen.

There’s no cost to sign up with Safer Healthcare Now!, but those who do are expected to be ready to make changes and report on their progress. A National Measurement working group is currently devising a measurement method, with the hope that the data collected will provide a good sense of system level improvements achieved across Canada.

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Map of Medicine provides ‘best practices’ support to clinicians via web

By Jerry Zeidenberg

With medical knowledge expanding at a dizzying rate, how is the harried physician or nurse expected to keep up with all of the changes?

Staying abreast of ‘best practices” has been a serious concern for clinicians, and also for patients, who may often wonder if their GPs are really on top of the latest medical breakthroughs – and if they as patients will receive the best care possible.

After four years of development, the National Health Service (NHS) in the United Kingdom has produced what appears to be an effective solution – one that’s also being made available to clinicians and policy makers in North America.

Called the Map of Medicine, it’s a web-based tool that presents the latest information about diseases and medical problems in an easy-to-use format. The interface is modeled on flow-charts, enabling the physician or nurse to drill-down through screens to the level of information that’s required.

“We don’t like to call it a decision support system, because it’s not replacing the GP or nurse, and the term DSS is sometimes taken the wrong way,” commented Dr. Michael Stein, medical director for the Map of Medicine, which was produced by a team of 300 clinicians with an investment of over 200,000 hours. “It’s an educational and training tool that provides the diagnostic and treatment information that clinicians need when they’re caring for patients. We like to call it a change management tool.”

In a way, it’s like having the input of a team of specialists right when you need them – with questions answered within seconds.

The Map of Medicine team put a lot of thought into the appearance of the interface and the ‘ergonomic’ aspects, to ensure that clinicians would find the system easy to use. There are 208 ‘entry points’, essentially diseases and medical problems that would be encountered by GPs and nurses.

Each of these drills down to further sets of information, so that the screens are never cluttered or overwhelming. “It’s not ‘roll and scroll’,” commented Dr. Stein, alluding to traditional databases that present vast amounts of information in a single view. Instead, the Map of Medicine allows the clinician to click through flow charts – there are about 1,200 of them – to find the appropriate data.

The system is continually updated, and each page is dated to show when the information was last refreshed.

For problems and questions where there doesn’t appear to be a structured answer, clinicians can call up a query screen that taps into databases of evidence-based medicine, such as the Cochrane Collaboration or the British Journal of Medicine.

The Map of Medicine will be useful for a variety of medical practitioners, including medical students and neophyte physicians and nurses. It is also expected to be invaluable to experienced GPs encountering something unusual and who want to quickly check on the latest diagnosis or therapy.

Moreover, it will equalize regional disparities, enabling GPs in remote areas of the UK to have access to the same leading-edge knowledge as their counterparts in urban centers like London, Leeds and Liverpool. “It ensures that everyone is on the same page,” said Dr. Stein.

Dr. Stein was in Toronto in early May, attending the e-Health 2005 conference, where he conducted presentations about the Map of Medicine. He noted that the UK is now set to roll out the system to 130 local healthcare communities, offering access to every physician and nurse. There are approximately 100,000 physicians and 600,000 nurses in the United Kingdom.

A benefit of the system is that it can be customized to particular regions, so that local treatment or reporting protocols can be incorporated. “In the western world, the diagnosis of patients will be same 99 percent of the time,” commented Dr. Stein. “But treatment options will differ from region to region.”

The system can be used to generate referral letters, so that a GP can quickly produce the documentation needed for a diagnostic scan, for example. Moreover, appropriate literature can be printed out to give to patients for educational purposes.

In a second phase of the British project, the system will be integrated with electronic patient records, so that notes and referrals can be integrated into the charts of patients.

The Map of Medicine has built-in security tools, with an audit trail and permission structure. It can be set up so that clinicians have access to various types of information, depending on their needs or the policies of their healthcare organizations.

Dr. Stein noted that the Map of Medicine is being made available to healthcare organizations in Canada and the United States at relatively low cost. “It’s not about making money, it’s about getting back some of the investment that was needed to create the system,” he said. (Further information about the project can be obtained at www.mapofmedicine.com)

He added that the National Health Service is also interested in establishing collaborations with clinicians in Canada and the United States, as a way of constantly improving and updating the product.

Dr. Stein emphasized that the Map of Medicine is a support system for clinicians, and not a replacement for the skills of physicians. “It doesn’t patronize the experienced doctor,” he said. “He or she only pulls out the map when needed.”

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Quinte Health Care creates futuristic DI department – this year

By Jerry Zeidenberg

BELLEVILLE, ONT. – Quinte Health Care, a four-hospital organization located between Toronto and Kingston, is modernizing its diagnostic operations by investing $20 million in the latest medical imaging equipment over the next five years. That includes a 40-slice CT (soon to be upgraded to 64-slices), a region-wide PACS, and leading-edge computed radiography (CR) and direct radiography (DR) machines.

But it’s not high-tech for the sake of having the fanciest equipment on the block.

Instead, the investment is part of the hospital’s drive to simultaneously improve care and lower costs in a mixed urban/rural region.

QHC serves not only the adjoining cities of Belleville and Trenton, but also a huge rural region of some 700 square kilometers that’s bustling with cottages and recreational activities. In terms of volume, Quinte currently conducts 125,000 diagnostic imaging exams annually.

The major investment in DI is “also a way of ensuring that we can attract radiologists and technologists in the future,” said Rita Downhill, director of diagnostic services, emphasizing the importance of the human resources issue.

She noted that newly trained radiologists are unlikely to locate in centres without up-to-date technology –- with the 64-slice CT and the regional PACS, Quinte is putting itself ahead of most communities in Canada. It’s giving radiologists and technologists the tools that are considered necessary today to deliver top-notch DI examinations, medical interpretations and reports.

The Picture Archiving and Communication System (PACS), along with the CT and radiography machines, are all being supplied by Philips Canada. Philips won the contract in competition with several other vendors after Quinte had completed a DI needs assessment, strategic plan, RFP and vendor selection.

Among other factors, Downhill said the organization’s radiologists were won over by the consistent ‘look-and-feel’ of the tools and interfaces in all of the new Philips modalities, and by the open architecture of the system.

Quinte Health Care also put a premium on the vendor’s adherence to Integrating the Healthcare Enterprise (IHE), the standards and connectivity group that’s gaining ground around the world.

Not only is connectivity a burning issue within the four-site hospital, where various types of hardware and software systems must be linked inside and outside the radiology department. Downhill and her colleagues are thinking ahead, and they’re considering links to Kingston General Hospital, the area’s major referral centre.

What’s more, with the provincial regionalization strategy spurring the rise of Local Health Information Networks (LHINs), there are likely to be connections built to PACS at medical centres throughout the South Eastern Ontario region as a whole.

For her part, Downhill recently assisted Chatham-Kent Health Alliance select and implement a PACS while serving as diagnostic services director for that organization; earlier, she helped Headwaters Health Care Centre, in Orangeville, Ont., get a PACS up and running. She has acquired a great deal of expertise in this area, and when she came on board at Quinte in 2004, she guided the development of strategic planning in the DI department.

Downhill said the PACS is expected to provide a gamut of well-documented cost savings -– by computerizing all images, film and chemical costs will be eliminated, storage space will be freed up, and the time and expense of filing will be reduced.

What’s more, the PACS is expected to improve workflow and the quality of care across the region. In particular, it will ensure fast readings of exams in Bancroft, where there is no radiologist on-site, and Picton or Trenton, when the radiologist is off-duty. Technologists at these locations will be able to transmit the images they’ve taken to Belleville, where radiologists can interpret the exams and quickly provide results to physicians at the remote sites.

QHC will also be implementing a Voice Recognition transcription/dictation system as a component of the Philips purchase. It is the expectation this total integration of HIS/RIS/PACS/VR will dramatically improve the turnaround times of the radiology reports to physician offices.

Improved workflow is a major aim for Downhill and her colleagues. They’re working with Philips to reduce the steps previously required by radiologists and technologists – steps that have sometimes resulted in administrative delays. For example, when technologists conduct exams, the PACS will automatically send data into the hospital’s financial and statistical systems – previously, this was a separate procedure for technologists, one that was sometimes neglected in the din and fray of the hectic work day.

Bruce Pye, director of information technology for Quinte, said the PACS is being run through the Smart Systems for Health Agency network. The SSHA network connects all four Quinte sites and currently offers 5 megabit/sec bandwidth. In the future, Pye would like to see a 100 to 300 meg network used, so that offsite storage for disaster recovery becomes feasible. “You need that kind of bandwidth to do off-site backups of all your information each day,” he said.

For the time being, the main Belleville site is making do with twin EMC systems, a main storage system and one for redundancy. In addition, there is an archiving system for historical data – older information that’s not frequently accessed.

Patient throughput is expected to be accelerated by the new, multi-slice CT, DR and CR equipment. And by using the advanced radiography equipment, the organization will be able to consolidate X-ray and fluoroscopy services in fewer rooms.

By 2010, the plan is to use DR technology for all X-ray exams.

With PACS, the 64-slice CT scanner will revolutionize diagnostic and clinical services at Quinte Health Care.

According to Dr. Matt Downey, medical director of radiology, the use of X-ray for medical diagnosis is significantly shifting from conventional two-dimensional projection image acquisition to three-dimensional computed tomographic image acquisition.

Using multislice CT, routine examinations such as in orthopedic imaging, spinal and maxillofacial trauma, and assessment of the surgical abdomen are performed in a fraction of the time, with vastly greater accuracy than conventional radiographs. Moreover, new applications such as cardiac CT, CT angiography, and CT perfusion are presenting unprecedented opportunities to diagnose patients non-invasively in their own community hospital.

The improved speed of image acquisition is expected to reduce waiting lists and provide more timely diagnosis while containing operational costs. Indeed, Dr. Downey predicts that, “Any acute care hospital with emergency, surgical and medical inpatient units will require on-site CT scanning to achieve equivalent standards of patient care to their peer hospitals. CT is now available at a range of acceptable capital investment.” This is the rationale for Quinte Health Care’s decision to install a second CT scanner at its Trenton site.

For radiologists, Dr. Downey said, “Perhaps the most exciting aspect of state of the art CT is the ability to finally take full advantage of new digital technologies in the way we view images. Under the supervision of radiologists, CT technologists will acquire and process isotropic CT data for interpretation, just as technologists currently do in ultrasound. You can take 3D and multi-planar images with equal resolution in any axis. You can artificially straighten non-linear structures, flatten curved planes, curve flat planes, color code data, cut away or render transparent overlapping structures. All of these tools advance the perception, diagnostic confidence and understanding of disease processes to the benefit of our patients.”

Dr. Downey cautions that, “While patient benefit justifies the expected increased use of ionizing radiation for medical diagnosis, the responsible use of CT becomes all the more imperative.” In this regard, radiologists through the Canadian Association of Radiologists are developing guidelines to assist their clinical colleagues in the best and most appropriate use of the various diagnostic imaging modalities available to them.

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Supply chain process improves at L’Hôpital Sacré-Coeur de Montreal

By Dianne Daniel

Managing supplies is big business at L’Hôpital Sacré-Coeur de Montréal, one of six major university hospital complexes affiliated with the University of Montreal. From a double bin replenishment system and “warehouse keepers,” to standardized software and electronic commerce, the hospital has successfully reengineered its supply chain – resulting in significant savings of both time and money, says director of materials management Clement Roy.

“Three years ago nurses were doing replenishment,” says Roy. “Now we’re able to take the nurses’ time and direct it towards the patient.”

According to Roy’s estimates, L’Hôpital Sacré-Coeur will save $1.8 million in nursing hours over five years as well as $1.2 million in costs following a recent overhaul of its supply chain processes. The first of several steps, he says, was the implementation of a new procedure for replenishment that relies on enterprise resource planning software from SAP Canada, of Toronto.

Whereas nurses used to be responsible for ordering supplies on a departmental basis, now it is the job of 20 full-time warehouse keepers. Each nursing unit is equipped with two identical supply bins; when the first is emptied, the bar-coded product list of its contents is placed on the wall. A warehouse keeper (on rounds) then swipes the barcodes, and all of the information is automatically transferred into SAP for processing.

“We are able to handle eight orders for eight different units simultaneously,” notes Roy. “The warehouse keeper fills the orders and brings the supplies back to the unit.”

Most medical supplies are stored on-site in the hospital’s warehouse. When certain minimum inventory thresholds are met, additional supplies are ordered based on pre-existing contracts and negotiations established with suppliers.

Roughly 80 percent of L’Hôpital Sacré-Coeur’s purchasing volume is fulfilled through 35 suppliers, half of which are represented on the Global Healthcare Exchange – a healthcare trading exchange founded in March 2000. Recognizing the benefit of communicating directly with its suppliers electronically, the hospital signed up for a $500 yearly membership fee and is currently live and trading with three of its major suppliers, including original founding member Baxter Corp. A year ago, placing orders with Baxter was done by fax and it would take one to two days to complete an order. Since signing on with GHX in January, says Roy, orders are now completed on-line in it what amounts to about 10 minutes.

“By automating our ordering process, we’ve saved one full-time person,” points out Roy. “And it’s always perfect. Every order passing through our GHX connection is exactly what I’m receiving,” he adds, noting that the hospital has freed up the time of one warehouse keeper by replacing routine inventory inspections with spot checks.

This spring, the hospital intends to begin processing electronic invoices for payment as well. A key advantage to moving invoices on-line is timing. “If I receive an invoice by mail, we lose approximately three days,” explains Roy. “If I receive it electronically we can pay it immediately … and I can take additional discounts for rapid turnaround.”

Moving to an electronic supply chain or e-supply chain “requires fewer people, less labour time” and results in “less problems,” he adds. In fact, operations are so smooth, the hospital is entertaining the notion of moving to Radio Frequency Identification (RFID) tags in the future.

Right now, the intent is to use a wireless infrastructure developed by Hewlett-Packard Co. By placing an RF antenna near the shipping and receiving area, palettes of products equipped with RFID tags can be automatically scanned and the information imported into SAP as they are received, replacing a manual process that currently involves keying items in one at a time.

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