eHealth to use new approach with ConnectingGTA
Reports in the press provided a brief overview of the project, but largely rehashed the government organization’s past mishaps. What was overlooked is that eHealth Ontario has a new strategy for getting the system into place, and for quickly creating an interoperable system of electronic health records across the province.
“We have learned some hard lessons from our past mistakes,” said Alice Keung, senior vice president with eHealth Ontario. In an interview with Canadian Healthcare Technology, Keung and eHealth Ontario CEO Greg Reed explained how the organization is now tackling its projects.
First and foremost, Keung stressed that Connecting GTA is a user-led initiative, not one that’s being imposed from above by eHealth Ontario. She explained that the five Local Health Integration Networks stretching across the greater Toronto region are driving the project.
The five LHINs all have representatives and clinicians on a steering committee that selected the University Health Network to lead the implementation. For its part, the UHN has expertise in this area – in addition to creating interoperable electronic records for its own three hospitals, it also provides IT services to many area hospitals through its Shared Information Management Services (SIMS) organization.
“The healthcare community at large knows a lot better than we do what they need from electronic health records and networks,” said Keung. “The steering committee, which has clinicians on it, has asked the UHN to lead the implementation. We at eHealth Ontario are here to provide added-value – such as advice on network design and standards.” She said eHealth Ontario will also offer the architecture and infrastructure that it has developed over the years.
Another misperception about the ConnectingGTA project that appeared in press reports is that physicians won’t be involved. Greg Reed, the CEO of eHealth Ontario, asserted that nothing could be further from the truth.
In actual fact, physicians will have access to the system. “Primary care records really form the core of your health information,” said Reed. “Physicians are a major part of what we’re doing.”
GTA physicians – provided they have a secure internet connection – will be able to access information in the database that’s being constructed to house all of the medical records for patients in the region. Reed noted that healthcare professionals at 43 hospitals, 13 Community Care Access Centres, 30 community health centres and 175 mental health sites will also have access.
“We’re awash in electronic health records in this province,” said Reed. “The problem we’re faced with right now is that records produced by one facility can’t be read by another.” ConnectingGTA is aiming to correct the problem; in doing so, it will act as a test bed for the rest of the province.
“We’re creating three regional hubs,” he explained, with ConnectingGTA being the first. Another hub, with its own information repository, will be produced in southwest Ontario, while another is to be created for the combined northern and eastern reaches of the province.
An RFP will be released for ConnectingGTA this summer, while Reed foresees the other two projects commencing by the end of 2011. “By this time next year [June 2012], we will be building connected EHRs for 100 percent of the province.”
In order to link all clinicians with all records, a three-part methodology is being used.
First, an integration engine or middleware layer will be created to unify the various electronic records used by clinicians. A common format will be created that uses leading-edge standards and nomenclatures. This data will be housed in a central repository.
When doctors, nurses and other healthcare professionals access it, the data will be converted back and forth into usable formats – so that clinicians with a variety of systems can keep and use the computerized systems with which they are familiar.
“It’s crucial to maintain the legacy systems that are already in place,” said Reed. “Hospitals and physicians have invested millions of dollars in them, and they know how to use them.
“We’ve had lots of vendors tell us they can easily create a province-wide system of electronic health records – we just have to scrap what’s already out there and standardize on their system,” said Reed. “But it doesn’t make sense to do that.”
That’s why ConnectingGTA is using the middleware approach, something it’s calling the information highway. Asked whether such an approach would really work, Keung noted that the banking and airline industries – in which she previously worked –have had these systems up and running for years.
“Every time you use an ATM from another bank, you are exchanging data in different formats,” said Keung. “And when you fly around the world on connecting flights from different airlines, you are also exchanging information in databases.
“We haven’t invented this approach, it’s already been used for years in other industries,” she said. “We need to borrow from other industries.”
Second, the structured data will be housed in a central repository. Links will be built to all various users – from hospitals to nursing homes to mental health centres and primary care physicians – with data being uploaded and updated in real-time. The centre will be called the Clinical Document Repository.
Once the system is up and running in Toronto, it will be replicated in the southwestern Ontario and north and eastern Ontario hubs.
The tri-region approach is being used as a way to make the project more manageable. “A big bang for the whole province would be nuts,” said Keung. “It’s far better to break it down into smaller parts.”
Finally, a viewer will be created, allowing clinicians to access the information quickly and easily.
Reed expects ConnectingGTA to move quickly. “By March 2013 we expect 20,000 clinicians will be using it, in all types of provider settings.” It will then be rolled out to all clinicians in the 700 greater Toronto-area facilities.
He noted that various projects across the province are already at work to link electronic records among different types of providers. For example, hospitals are
pushing out electronic reports to GPs and family doctors in Thunder Bay, Barrie, Ottawa, Hamilton, London and other sites.
“We’re saying to keep doing it,” commented Reed. “Don’t slow down.” He noted that eHealth Ontario is funding many of these projects, and stressed that they’re valuable, because they’re working and they’re making clinical information more useful.
Eventually, all of these systems will talk to each other, using the three hubs that are to be created in the province. What’s more, because of the information highway and universal translators in the system, everyone will understand each other. “Everybody gets to keep their legacy systems,” said Reed. In the near future, added Reed, “What patients will see is that their providers will have more computers in front of them. And what doctors will see is more of their patients in front of them,” – in the sense that they have more information about those patients, giving them a far better picture of the problems they are dealing with.
Ontario now able to track hospital ALC and ER waits in near real-time
For the first time, Ontario will be able to understand – in near real-time – how many patients are waiting for the appropriate level of care and how long they are waiting. These patients are designated Alternate Level of Care (ALC) under a provincial definition and represent a decades-old problem that has escalated in recent years as Ontarians’ healthcare needs have increased.
This past May, Access to Care (ATC) at Cancer Care Ontario began collecting information on ALC patients from 94 acute-care and 20 post-acute care facilities – representing more than 95 percent of the province’s hospital beds.
Ontario is now a leader in this area – the first province to collect standardized, near real-time ALC data. Key to meeting the information management and information technology needs of the ALC initiative was the provincial Wait Time Information System (WTIS), which is used by participating Ontario hospitals to capture various types of clinical wait-time data in near real-time.
”This is a very exciting development with the potential to significantly improve patient care and the quality of our healthcare system,” said Lynn Guerriero, Director, Access to Care. “Patients waiting for an appropriate placement have a significant impact on overall patient flow, backing up those patients waiting in the ER to be admitted to the hospital.”
At the same time, ATC has just expanded its data collection efforts in emergency rooms across Ontario, adding five new data elements specifically related to specialist consults. ATC now collects 38 data elements related to various aspects of the patient journey. These include everything from ambulance transfer times for patients; when a patient is first seen by a physician; when a specialist consultant arrives; when a disposition decision is made; and, when the patient leaves the emergency department.
First introduced in 2009, the Emergency Room NACRS Initiative (ERNI) helps measure and report on how long patients spend in the ER.
“With our efforts over the past two years, we are already seeing dramatic improvements,” said Dr. Howard Ovens, director of the Schwartz/Reisman Emergency Centre at Mount Sinai Hospital, provincial ER clinical lead, and Toronto Central ED LHIN lead. “The addition of this specialist consult data will enable us to gain an even more thorough understanding of where some of the challenges lie and how to overcome them.”
Ontario, the first province in Canada to establish ER wait-time targets and to publicly report results, has already seen a reduction in both ER wait times and fewer patients leaving without seeing a physician. Today, roughly 90 percent of patients visiting Ontario ERs receive treatment within established targets. As a result, over the past three years the rate of patients leaving ERs without being seen by a physician has dropped from 4.6 per cent to 3.7 per cent.
Ontario is providing up to $100 million through its Pay-for-Results program as an incentive for hospitals to implement initiatives that will help reduce emergency department wait times.
As part of ERNI Expansion 2011/2012, ATC engaged with 91 Clinical Leads at hospitals across the province to assume the role of educating ER staff and championing the importance of high-quality data collection practices.
“The success of this patient-centred initiative depends heavily on effective clinical engagement and the change management processes that will ensure data is collected in a timely and accurate manner,” said Cathy Cattaruzza, senior manager, Clinical Liaison and Stakeholder Engagement, Access to Care.
“It‘s a recurring question,” said Ms. Guerriero. “How is ATC able to get already time-pressured ER clinicians and staff from hospitals across the province to record and submit – under rigorous deadlines – volumes of accurate, timely information that will meet stringent data quality standards?”
ATC’s deployment model provides hospitals with “a straight-forward and intuitive framework for project delivery,” said Steve Carroll, ATC’s senior manager, service delivery and management. “We are committed to a ‘no surprises’ approach to project management and believe transparency is a critical factor in achieving successful outcomes.”
“Our delivery model begins with open and regular communication to ensure stakeholders understand what we are going to deliver, when we will deliver it, and how progress will be measured. This creates a level of transparency and engagement from the outset. Our philosophy, together with our deployment model and supporting toolkit, has proven effective in delivering provincial deployment initiatives,” said Carroll.
CHAMP project will reduce IT costs through joint use of Meditech
The partnership was created by the Queensway-Carleton Hospital and Bruyère Continuing Care, both of which are in Ottawa and had planned to upgrade to the Meditech 6.0 electronic patient record platform. An independent study showed that if they shared a Meditech system running on a single data centre, they would save on the cost of the hardware, along with software, training and ongoing support costs.
Queensway-Carleton already has two other hospitals piggy-backing on its own Meditech 5.5 system – the Carleton Place and Arnprior hospitals. These two organizations have agreed to go ahead with the upgrade and will contribute their share of the costs.
So far, that’s four hospitals who are involved in the joint system. The partners plan to bring additional organizations into the consortium, known as the Champlain Association of Meditech Partners, or CHAMP, further reducing costs over the long term. Up to now, the partnership has worked in harmony, and is striving to maintain the philosophy of ‘a partnership of equals’.
The Royal Ottawa and Montfort hospitals are currently participating in standards groups with the CHAMP hospitals, and have signaled that they will join CHAMP in the near future.
Already, with the current partners on board, the savings amount to some $2 million in hardware and software, commented Michael Cohen, vice president, Clinical Support, Information Management and chief privacy officer at Queensway-Carleton Hospital. “It will save our hospitals millions more in consulting and labour costs,” he added. “Those funds will be deployed in patient care.”
There are many savings to be made by joining forces, said Dr. Frank Knoefel, vice president, Medical Affairs and Health Informatics at Bruyère Continuing Care, which provides hospital and continuing care services at four Ottawa sites. “It means that we don’t have to support two large data centres.”
“Having two sets of servers in two buildings, plus backup, is significantly more expensive than having one set.” Queensway-Carleton is currently optimizing its own data centre for the Meditech 6.0 upgrade; partners will pay a portion of the costs.
What’s more, for each and every clinical application, the partner hospitals will only need one team to develop a solution – rather than one at each hospital. Dr. Knoefel explained that in the case of the new regional pharmacy system, staff from various hospitals will be needed to create the tables and dictionaries to be used by the partnership.
“We were budgeting for five people to build our pharmacy module, and Queensway-Carleton was budgeting for seven. Together, we won’t need twelve people – we will probably do it with nine.”
Indeed, over the long term, “the bigger cost savings are in reducing the total number of people and hours spent on the project – also causing fewer disruptions to the bedside,” said Dr. Knoefel.
Creating joint systems of this kind, he added, will make things easier for physicians and nurses, too. “They often move from one hospital to another,” said Dr. Knoefel. “As they do this, they won’t need to keep learning new electronic health records and systems.”
That’s a big assist for smoother workflow and also means there will be less need for training.
Going forward, Bruyère is taking a modular approach to Meditech 6.0, while Queensway-Carleton has chosen a ‘big-bang’ implementation, with a full suite of clinical applications set to go live in October 2012. That will include some 16 different clinical modules.
For its part, the Bruyère hospital will actually go live before Queensway-Carleton does – it will power up with Phase One of its implementation in February 2012.
For data communications, the hospitals will use the eHealth Ontario network, a high-speed system that has been under-used to date. There will also be a back-up network, in case the primary network goes down for one reason or another.
Both Michael Cohen and Dr. Knoefel expect that additional hospitals will sign on with CHAMP, given the savings that can be produced. They’re modeling CHAMP, in part, on the NEON network in northern Ontario, which has achieved savings for members through a joint IT systems strategy.
Cohen pointed out that each hospital will still need an IT staff, to some extent. “There will always be some applications that will be local in nature,” he said. “These may include bed flow, patient tracking, and many others.” Member hospitals will still have their own networks, with staff for on-the-spot support.
Still, large cost reductions can be achieved through joint efforts on the major clinical applications – namely, when several hospitals tap into the same Meditech 6.0 system. Said Cohen: “The savings are significant.”
Long-term cost-reductions will require upfront investments
It is also my opinion that HIM/IT (Health Information Management/Information Technology) is an enabler – well, today I believe it is more like a super-enabler. More and more people are turning to us to enable better healthcare for our citizens and to do it in such a way that there are cost savings for the health system.
I know that those of us in healthcare who have traditionally twitched when healthcare and money are mentioned in the same sentence – well, we are all going to have to get over it!
In Nova Scotia, the Department of Health and Wellness priorities are aligned with three government priorities:
• Making healthcare better for individuals and families
• Creating good jobs and to grow the economy
• Getting back to balance and ensuring the government lives within its means.
The priorities of Better Care and Back to Balance certainly pertain to health. When healthcare comprises 43-46 percent of the provincial government budget, there is a significant focus on our contribution to the back to balance priority.
At first, when looking at this through a healthcare lens, Better Care and a Back to Balance strategy may seem like polar opposites. However, today we need to manage priorities that may appear, on the surface, to be opposites.
There is actually something called Polarity Management – it is where there are interdependent pairs of different or opposite goals, values or points of views.
It is not about “either/or”, it is about “both/and” problem solving. And it really does start to engage more transformative processes. So for us, better care and back to balance priorities are polarity management at its finest!
We have a number of initiatives under way that are wonderful illustrations of how we have been able to move forward when we problem solved with the “both/and” point-of-view.
I would like to pause and make sure everyone is clear about to whom I am referring when I say “we”. Because it is important to understand that it is not just government, nor the Department of Health, nor our District Health Authorities, and so on – it is all of us working together in a collaborative and cooperative environment that is making this happen. It takes all of us to do this.
So it started with government offering to invest in innovative projects that support the Back to Balance priority. We’re targeting projects that required a one-time investment and would generate ongoing cost savings within 2-3 years.
Projects for which the various departments could put forward a request for funding and that clearly demonstrated long-term savings.
The Department of Health worked with the District Health Authorities (DHAs) to strategize about the types of potential projects that fit the Innovation Fund criteria.
The DHAs chose the projects and built the business cases and put forth their proposals to the Department. In turn, the Department supported the proposals and secured the funding from the Innovation Fund on behalf of the DHAs. The Department provides oversight and the DHAs are responsible for delivering the projects within an agreed upon time line and budget.
We have been able to move three projects forward that have been stalled in a queue waiting for funding since 2008 – a couple of them I would hazard to guess have been in the queue since 2006.
We are now about to move forward with Bed Utilization and Management, which was first discussed in 2008 – a project that will help the DHAs/IWK deal more effectively with the daily issues associated with bed planning and management. These issues include extended waits for beds, delays in treatments, and even surgical cancelations.
This project required a $2.4 million investment and produces an ROI in under 3 years and ongoing savings, not to mention the obvious impact on better patient care. Scope of the installation is province wide.
The second project involves scanning paper into the Meditech Enterprise Medical Record (EMR) for both Meditech Magic and Meditech Client/Server. This was another initiative that has been discussed for a number of years.
It required an investment of $1.3 million and has an ROI of 3.8 years. It will enable the transformation from paper-form centric processes into efficient, paperless or paper-light workflows. Scanning is considered Phase One in a three step plan to implement an electronic health record.
The third project is Staff Scheduling, which involves the creation of a centralized staffing service that uses an electronic workforce management tool. It will support the standardized processes for all staff scheduling, facilitate strategic scheduling, optimize front-line staff to best meet patient needs across the system and will reduce overtime and agency costs.
The implementation is at Capital District Health Authority, IWK and Cumberland Health Authority. The investment required is $2.4 million and the ROI is under 3 years with on-going cost savings.
So why were we able to move these projects forward? It is because we embraced the polarity we all face within healthcare – how do we deliver the best possible care within the fiscal realities we are all facing? Polarity of priorities or objectives does make us think differently – and that is a good thing!
Sandra Cascadden, P.Eng,CPHIMS, PMP, is Chief Information Officer, Department of Health & Wellness, Province of Nova Scotia.
HOME - CURRENT ISSUE - ABOUT US - SUBSCRIBE - ADVERTISE - ARCHIVES - CONTACT US - EVENTS - LINKS