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Inside the March 2003 print edition of Canadian Healthcare Technology:


Feature Report: Electronic medical records


Infoway’s investments

Canada Health Infoway has started making initial investments in projects that will ultimately result in a pan-Canadian electronic health record. In the first stages, the focus is on interoperability.

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Reducing hospital stays

Software employed at a Niagara-region hospital allows managers to analyze the length of stay for stroke patients. It helped them reduce the time spent in hospital to nine days from 23 while boosting outcomes and patient satisfaction.

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Wireless tech for home care

A wireless Internet solution on handheld computers is enabling home-care nurses to check with doctors and other wound specialists about patients, right in their homes. The application is saving trips to emergency departments.

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Perioperative system provides multiple benefits

The Isaac Walton Killam (IWK) Health Centre in Halifax has found that a new perioperative system has provided multiple benefits. The system, from Datex-Ohmeda, records information before, during and after operations.

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If CPOE is proven to save time and trouble, physicians will buy into it

Although the technology has been around for a decade or more, it’s only recently that hospital clinicians are sitting up and taking notice of computerized physician order entry (CPOE).

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Aiming for PET in Montreal

Montreal Canadiens’ hockey star Saku Koivu is leading the charge to acquire a PET/CT scanner at the Montreal General Hospital. Koivu benefited from PET scans performed in Sherbrooke, Que., and now wants to bring such technology to his home town.


PLUS news stories, analysis, and features and more.

 

Infoway begins investing in development of Pan-Canadian electronic health records

By Andy Shaw

Maybe it’s just the nature of Canadian news media, but when the long-awaited report from Roy Romanow’s Commission on the Future of Health Care first burst into the news last fall, there was no mention of what the former Saskatchewan Premier thought might be contributed to our future well-being by technology. Other worthy issues abounded in those early stories in newspapers and on television. More funding needed, yes; private versus public healthcare arguments, yes; and provincial autonomy against federal will tensions, yes. But technology’s role, no.

No mention that is until the Montreal-based Canadian Health Infoway organization spotted the reference deep in the Romanow report. In its follow-up news release, Infoway, as it is now known for short, said in effect, aha, there it is on page 77: “Electronic health records are one of the keys to modernizing Canada’s health system and improving access and outcomes for Canadians.” Also cited was a reference buried even deeper on page 249 saying that Infoway, “.. should continue to take the lead on this initiative and be responsible for developing a pan-Canadian electronic health record framework.”

Hardly headline positioning. And one could have wished for more substance generally on the role of technology in healthcare from the earnest Roy and his Commissioners. But nonetheless, what they recommended was sufficient encouragement for Infoway to say in its release that it would stick to its schedule for creating: “...the foundation for interoperable EHR solutions over the next 12 to 18 months, with a goal of having the main components in place within five to seven years.”

Initially, Infoway has $500 million to spend on developing a pan-Canadian EHR, announcing just before the New Year the first of three waves of EHR investment. For starters, Infoway is putting $21 million into seven separate projects, split east and west and aimed at developing the “building blocks” of an interoperable Electronic Health Record.

“Interoperability is the cornerstone of what we are trying to do,” says Dennis Giokas, Infoway’s chief technical officer and developer of the conceptual architecture guiding Infoway’s investments.

Out west, Infoway is investing in two projects in British Columbia and Saskatchewan that are building a “provider registry”. Infoway is also backing both Capital Health of Edmonton and the Newfoundland & Labrador Centre for Health Information in their formerly separate efforts to create a workable “client registry”. On its own hook, Infoway is putting money into two other developments both geared to producing a more detailed “blueprint” of its conceptual architecture. Finally, Infoway has also backed further development of National Electronic Claims Processing Standards (NeCST) already under way as a Canadian Institute for Health Information (CIHI) initiative.

Under the provider registry banner, the BC Ministry of Health Services will work to enhance what’s been done so far by the Western Health Information Collaborative and its reusable provider registry that indexes caregivers, their roles, and their jurisdictions. In the process, the project will assess the wisdom of conversion to HL7 Version 3 as the standard for messaging between health information systems. In Saskatchewan, the Infoway money will help create a re-usable “tool kit” for provider registries that will provide registry developers with a set of best practices found in other regions. The hoped for upshot of both efforts is wide ranging – from reducing the costs of deploying provider registries, to encouraging EHR uptake, to easing maintenance, to speeding up registry software development, and to improving security and privacy.

Client registry work in St. John’s and Edmonton will focus also on building a registry that is reusable. It will provide a directory of people being served within a healthcare system. In the end, the directory should have built-in mechanisms to “uniquely identify a patient across a diverse set of point-of-care systems, within a region, a province or even nationwide.” The work involves development of an interoperable enterprise master person index (EMPI). In short, the long-term goal is to make Canadian hospitals like a chain of cheery bars: no matter where you go, they’ll know your name.

The architectural blueprint Infoway is developing itself is dubbed its “IT Migration Plan” and is meant to help the country’s regional health authorities migrate their individual EHR set-ups to an interoperable system.

“There are three deliverables for the Plan,” says CTO Giokas. “The first is to understand and describe what interoperability solutions are already implemented in various jurisdictions. You might call that the ‘as is’ state. Then, based on that understanding, we will drill down into our original conceptual architecture and come up with a much more detailed ‘to be’ state. So at that point, we’ll be able to help jurisdictions see the gap between where they are and where we would like them to be.”

The objective of the NeCST undertaking is to develop a ‘to be’ state for readily exchanging health claims information between providers and payers. It will pave the way for future Infoway investment in drug information exchange systems.

All of this, including two more waves of investment will have swept over the country before summer if Infoway sticks to its schedule.

“It’s an aggressive timetable,” said Linda Lizotte-Macpherson, Infoway’s president and CEO. “But it’s one that was set out in our business plan and endorsed by all the federal, provincial, and territorial health authorities in 2002.”

In late 2002 unfortunately, Lizotte-Macpherson herself was temporarily felled by a back operation. However, Infoway’s vice president of portfolio management and general manager of Infoway’s Toronto office, Sue Hyatt, took over as interim CEO until Lizotte-Macpherson’s expected return this month. Hyatt’s chief task was to oversee and complete the due diligence of deciding on who gets how much of Infoway’s next two funding waves.

“We’ve been talking to physicians, nurses and other members of the provider community across the country quite a bit about what they would like to see developed next for the EHR,” says Hyatt, “and they were very clear with us. We were told categorically, especially by physicians, that getting lab results was key.”

As a result, Hyatt says Infoway’s second round of spending will put an emphasis on developing compatible lab results systems. Another priority identified by Infoway’s cross-country homework will be developing common techniques for ensuring privacy and confidentiality in the EHR.

“There are privacy projects going on in various parts of the country but there’s been no mechanism, no tool kits, in place for sharing that experience,” says Hyatt.
The third and final wave of Infoway spending expected to be announced in April will put its money on what Infoway sees as the next two most needed components of the EHR, diagnostic imaging and drug information.

Infoway is going confidently ahead with its investment despite skepticism elsewhere about the feasibility of ever developing an EHR that a whole country can share. As Dr. Gordon Atherley pointed out in this publication last month, efforts to establish a pan-Britain EHR are in serious disarray.

Yet Hyatt remains confident about Canada’s direction. “We scan what’s going on internationally, certainly. But we find it very encouraging that both the Romanow and Kirby (Canadian Senate) reports have endorsed having an interoperable EHR. They both recognized that Canada can be a world leader in this field.”

Hyatt does admit that to assume such leadership will require Canadian caregivers to become more enthusiastic adopters of technology. “We’ve got to play catch-up on that score,” says Hyatt. “Our caregivers do lag behind some other countries in the uptake of technology”

They’re not technology laggards, however, at the Toronto-based electronic Child Health Network (eCHN). That’s where the only operational EHR in Canada that is fully integrated and shared beyond hospital walls runs today. The eCHN collects data from a wide variety of patient records, imaging, and laboratory sources and integrates them into a single view that can be called up by doctors, nurses, and other care-givers in eight different institutions.

“It’s not yet a complete record. We’re still working on that and adding new elements regularly. But so far as I know it is the most advanced of its kind anywhere,” says Andrew Szende, CEO of eCHN.

Szende says he’s hopeful that Infoway will invest in further development of what has already been built by eCHN.

“They’ve said they are going to build on existing infrastructure and projects that have already shown success,” says Szende. If they do what they say they are going to do, then I applaud them. It would make no sense at all to try and invent the wheel again and start experimenting with people who are promoting vapourware.”

“If they really want to see some results quickly, they should be looking at eCHN as a living lab,” says Szende. “We’re open to them enhancing what we do and letting people learn from our experience, as well as making our network even bigger and helping other people build their networks.”

Szende says once a network like eCHN is established, it is readily scalable. “We could be serving 80 institutions, ten times what we do now. All it needs is some investment.”

In Infoway’s investment announcement, the key word to note is “interoperable”. Interoperability is the Everest of what Infoway must conquer. The enormity of making health record systems interoperable was made clear last November in Düsseldorf, Germany. There an august panel of Canadian and German medical information technology experts at the Medica 2002 trade fair and conference laid out all they thought must be done before the daunting peaks of interoperability are scaled.

“With the kind of networks we have in place around the world now, making healthcare systems able to talk to each other will be highly complex and expensive.” said Eugene Ingras, chief technology consultant to the Alberta Research Council. “Because what we have in place now is analogous to needing a separate telephone to call each country.”

Or a separate phone to call each province, or each region, or each hospital, or each department, or each doctor’s office you may want to share information with.

On the other hand, Dr. Sami Aita, the evangelical founder, chairman, and CEO of Toronto-based MedcomSoft argues persuasively there’s a cost-saving, simple short-cut to interoperability currently being ignored in Canada by government-backed EHR initiatives. But it has already been adopted by the no-nonsense U.S. Department of Defense (DOD).

“After considering the alternatives available, DOD selected the Medcin medical vocabulary from Medicomp as the basis for its EHR,” explains Dr. Aita,” principally because Medcin has been built up over 25 years and now provides over 70 million links between medical terms and diagnoses, which can then be reduced to numeric codes. So the acquisition, interpretation, and distribution of healthcare information is enormously simplified. You’re not trying to deal with huge, unwieldy tracts of text, you don’t need great repositories and powerful servers, and complex communication standards to handle and move records around, because all you need to package up are numbers, pure data. And it’s data that can be called up and turned back into text or links to other sources of patient information in a simple spreadsheet format.”

Aita says MedcomSoft’s Medcin-based spreadsheet software is already winning plaudits from over 120 installations the company has in North American physicians’ offices. MedcomSoft claims to have the first medical record that numerically codifies the entire patient encounter. Users create the record through intelligent checklists and other spreadsheet forms. It therefore eliminates the need for lengthy text descriptions or transcription of dictated notes. “Also, by using a secure Web portal,” adds Aita, “the record is scalable up to provincial, national, and even international interoperability today.”

If that’s true, and given the enormous investments of public funds already being slated for EHR development of a different sort, maybe somebody should at least alert the news department.

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Shortening hospital stays of stroke patients and delivering better care

By Patty Welychka, R.N., and Craig Muir, M.D.

Niagara Health System, which serves a population of 400,000 in Ontario’s Niagara region, admits nearly 700 patients a year who have suffered from strokes. With a large baby-boom population now approaching the prime years for stroke risk, we expect this number to climb, making this condition a significant health and resource issue for our health system.

We knew that our stroke patients, on average, tended to stay in acute care beds for a long time. We began to examine these stays in the winter of 2001-2002 to determine whether the amount of time was appropriate given their care needs.

If the hospital stays appeared longer than designated by benchmarks, we needed to investigate the reasons for overstays and create solutions for optimizing the care plans for these patients. Our goal was simple: to improve the quality of care we provide to our stroke patients.

Learning from the Past: When we launched our three-month pilot program for stroke at Welland Hospital, a facility with 169 acute care beds, stroke patients were staying an average of 23 days. We were fairly certain it was too long, but we weren’t sure of the reasons behind the long stays.

To conduct an objective analysis, we needed:

• A standard for how long each patient should stay in the acute care setting before being relocated to a less medically intensive milieu

• The ability to pinpoint and track the specific reasons for any delays in our processes of care

• The ability to determine the most appropriate next level of care based on appropriate criteria

We turned to McKesson’s InterQual Criteria, an evidence-based clinical decision support tool that we have used since 1997 for a variety of quality and utilization initiatives throughout the health system. We applied it to an earlier project at the Greater Niagara General Hospital in Niagara Falls, where the government had mandated the elimination of 45 beds over a one-year period.

To intelligently reduce our number of beds, we applied InterQual Criteria for Acute Care and were able discern at what point our patients should have been transitioned from acute care to another care level or been discharged. We discovered that two-thirds of the overstays occurred because we had no appropriate alternative setting for the patients once they were stable enough to leave acute care.

Over the past few years, information like this has helped us gain a system-wide understanding of our bed needs across all levels of care.

Further, using the software form of InterQual Criteria to perform reviews enabled us to delineate the reasons for delays related to internal workflow. With very precise data in hand, we could make the changes necessary to eliminate those delays. Ultimately, we were successful in meeting the Ontario government’s directive, recognizing savings of $8 million to $9 million a year.

Launching the Stroke Program: At Welland Hospital, we first conducted an InterQual review of 176 patient days over a one-month period, determining that patients had spent 74 of those days in acute care beds unnecessarily. Then we began probing into the reasons, also using the criteria.

We discovered that many of our patients were medically stable and ready to move to a less intense level of care somewhere between day six and day ten. But because we weren’t flagging these patients for transfer, they lingered in the acute setting for up to two additional weeks.

Once we began applying InterQual Criteria, we began to see common scenarios. For example: it’s day eight of a patient’s stay in acute care, and he has been recovering quite well. Alerted to this fact by his nurses, the case manager appears on the floor, accompanied by her laptop loaded with the criteria.

She reviews the patient’s case and validates that he meets the criteria for transfer to a rehab setting. When the patient’s physician makes her rounds, the case manager asks her for an order to move the patient to rehab. It’s granted, and the patient moves the following day to begin the next recovery phase.

Reaping the Results: Within the first few weeks of our pilot, the average acute-care stay for stroke patients plummeted from 23 days to nine, and we began to see better health outcomes and increased patient satisfaction, two facets of improved quality. Our patients were not exposed to the infections and other risks of an acute-care setting and were getting more appropriate rehab services, leading to improved physical function and fewer complications.

Not surprisingly, as soon as the pilot program ended and we stopped using InterQual Criteria for a short while, the average length of stay shot back up to 19 days, confirming that this was a program we needed to make permanent.

The pilot stroke program revealed some important systemic issues, most notably that we do not have enough alternative level of care capacity for our stroke patients once they’re ready to leave acute care. This is one of the factors behind our decision to build a new wing at our rehabilitation facility and add rehab beds at three of our largest hospitals.

The pilot also helped us understand that our health system needs areas dedicated to those patients who recover at a slower pace than most stroke patients, for whom intensive rehabilitation is out of the question. InterQual Criteria has helped us identify these patients, and we’ve now begun clustering the services these patients need and standardizing their treatment. We’re also piloting a highly aggressive and comprehensive stroke program at two of our largest hospitals.

We’re honoured that the government recognized Niagara Health System as a district stroke centre and has incorporated our criteria for moving stroke patients from acute care to a rehab setting in the formulation of its province-wide stroke strategy.

Patty Welychka, R.N., C.H.E. C.P.H.Q., is the regional director for utilization management at Niagara Health System. Craig Muir, M.D., is the chairman of the regional utilization team at Niagara Health System.

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Wireless solution allows nurses to better serve patients at bedside

By Neil Zeidenberg

Homecare nurses treating patients with chronic wounds are obtaining quick access to physicians by using a new generation of wireless handheld computers.

The systems are proving to save time and cut costs by reducing visits to hospital emergency rooms. Instead of advising patients to make the trip to hospital when a wound looks suspicious, nurses can consult woundcare specialists through the use of wireless Internet and then treat the conditions on the spot.

During a recent eight-week clinical trial at the Maple Ridge Health Unit, in Maple Ridge, B.C., WebMed Technology (www.webmedtechnology.com) provided half a dozen homecare nurses with handheld computers. The pocket-sized computers are equipped with the Sierra Wireless AirCard 750 and special wound management software.

The software, called Pixalere – a term derived from pix, meaning picture, and alere, which is Latin for nurse, or to heal – is a secure Web-based application that combines digital colour photos with a detailed description of a patient’s wounds on a customizable assessment form.

Results of the clinical trial concluded that the system would save over $180,000 per year and almost $3 million if implemented throughout the Fraser Health Authority (FHA). There was also an improvement in communication between healthcare practitioners, better use of wound-care products and a dramatic drop in heal times when supervised by a wound specialist.

“We spent a lot of time speaking to homecare nurses,” said Dr. Jonathan Burns, an emergency physician and co-founder of WebMed Technology. “We asked them what they needed at the scene in order to help communicate with people not at the scene, or to assist someone who comes the next day.

“With our system, the homecare worker visits the patient, sees the wounds, and they proceed with a brief history. They then take a visual picture of the wound using a digital camera,” added Dr. Burns.

From there, nurses can then either finish dressing the wound, or they can wirelessly send the compressed data out for immediate review.

The software has been designed to page the consulting nurse clinician or doctor on-call. The specialist or consulting nurse clinician then goes online, logs into the server, reviews the assessment, and sends instructions by e-mail back to the homecare nurse in a matter of minutes. With Pixalere, wounds can be assessed in detail such as size, shape, granulation, and odour.

Those who are benefiting from the technology include cancer, diabetes, spinal cord, vascular and cardiac patients. One patient in the trial at Maple Ridge described the experience as “like having an entire healthcare team in my living room.”

WebMed Technology also went live in Hamilton, Ont., in late January with Saint Elizabeth Health Care, an Ontario-based home-care organization. The implementation is a live-deployment of the technology and not a clinical trial. They recently finished training five frontline nurses, though eventually Saint Elizabeth Health Care hopes to have all of its nurses, including about 20 specialists, trained to use it.

“Pixalere is enabling the transformation of wound care,” said Nancy Lefebre, vice president, knowledge and practice for Saint Elizabeth Health Care. “Through the use of Pixalere, and our own education and care programs, called @YourSide Companion, the client receives greater access to the specialist in a shorter period of time.

“It’s better treatment based on the evidence and best-practices.”

Moreover, Lefebre believes combining Pixalere with @YourSide Companion and their own educational programs can lead to better patient-provider satisfaction, more efficient use of wound care medical supplies, lower travel costs and fewer lengthy visits.

The product is essential, she says, in provinces like Ontario where there is a shortage of wound-care specialists.

As far as security of the data goes, WebMed uses a server that is installed behind the firewall of the hospital’s information systems. The data uses two levels of encryption and no specific patient information such as name or address is transmitted.

Dr. Burns came up with the idea for Pixalere and the home-care service when a patient arrived in the ER with second-degree burns resulting from spilling hot tea on her leg. Each round trip to the ER cost the health system almost $1,000 and about $60 from the patient’s own pocket.

Burns figured patients with minor wounds could be treated more efficiently and cost-effectively by a homecare nurse equipped with wireless technology. He and his associates set out to develop a mobile solution that would allow homecare nurses to treat patients at the scene, and if necessary, get direct access to a healthcare professional at a local hospital.

Interest in Pixalere is on the rise with requests for pilot projects coming from Saskatchewan, Alberta and B.C., as well as a few possible installations in the Toronto area.

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New perioperative system improves record-keeping, analysis and planning

By Andy Shaw

They’re breathing easier at the Isaac Walton Killam (IWK) Health Centre in Halifax these days – now that 18 new Datex-Ohmeda S5 Anesthesia Delivery Units (ADU) have come on-line, along with an additional 24 custom monitors and the ‘Deio for Anesthesia’ clinical documentation systems built into both.

First advantage: the new ADUs give good gas. Their enhanced ventilation, electronically controlled gas delivery, and agent vaporization features are pleasing not only IWK’s anesthesiologists, but also to the hospital’s bean counters for the system’s precision and cost efficiencies.

On the documentation side, the new machines and monitors, now deployed in every OR, patient pre-op interview room and post-op recovery area, are having a beneficial effect on IWK’s patients, right from the get-go.

“It’s a truly perioperative software system in that it provides electronic anesthesia documentation of patient records from beginning to end,” explains Peter Fenwick, Director of Business Development for a variety of clinical information systems supplied by Datex-Ohmeda (Canada) Inc. “Patients follow the normal procedure for being formally admitted into the hospital’s Meditech system. But when they show up for an interview with an anesthesiologist before their surgery in the pre-operative assessment clinic, that’s when the Datex-Ohmeda e-charting begins.”

A Windows-based Deio assessment module in the software interfaces with the Meditech database via an embedded integration engine, so that patients don’t have to repeat the same answers they gave on hospital entry. When the patient returns for surgery, all the patient’s pre-operative data is mirrored onto the intra-operative chart automatically. Similarly, the earlier data then all shows up on the patient’s post-operative documents.

Perhaps the most innovative aspect of the system is that during this whole process, the anesthesiologists are interacting with the Deio charting software not via a computer, but through the Datex-Ohmeda physiological monitor.

Now with nearly a year of experience on their new machines and software, the learning curve for the anesthesiologists in both the pediatric and women’s side of the merged hospital has proven to be fairly gentle, if accompanied by a little foot dragging.

“On women’s side of the hospital, where I am one of 15 anesthesiologists, we have a cross section of young, medium and older people,” says Dr. Robert Nunn, a leader of the changeover. “The medium and the older individuals were a little resistant at first (to abandon their paper charting system), but I must say that in a very short period of time everyone here came on stream because the machines are so user-friendly.”

That was one of the factors that convinced IWK to select Datex-Ohmeda and Deio (now a Datex-Ohmeda sister company) over their competitors, says Steve W. Smith, the hospital’s Director of Engineering and Facilities Services. “Our machines were 12 to 20 years old, so we wanted to replace them all. And we wanted to add an electronic record for our information management system. In the end we went with Datex-Ohmeda largely because it gave us the most integrated, comprehensive system.”

Marc LeBlanc, IWK’s Director of Information Technology, explains that during surgery the new system records every anesthesia event. Physicians no longer have to manually record every change in vital signs. Yet they can still manually enter time-stamped notes about drug use and other information, as desired.

In effect, the new system has greatly enhanced the ability of hospital anesthesiologists to practice evidence-based medicine.

“You have so much data you can now collect on intra-operative events, it opens up a whole new world of being able to print out a myriad of different reports,” says Dr Nunn. “Anything from the number of procedures per time frame, or the number performed by one surgeon or by one anesthesiologist, or comparing individual duration of procedures, drug utilization. You can use all this information for both quality control and research. The sky is really the limit.”

Under that sky also comes financial data that’s welcome in both the anesthesiology and hospital planning departments.

“Having a whole new fleet adds predictability to our budget for maintenance and upkeep,” says Nunn. “Whereas, if you were trying to replace your anaesthetic machines piecemeal, it would be much harder to predict when they were going to fail or how much it would cost to replace them.”

“The ability to print a legible record also keeps our hospital lawyers happy,” says Dr. Nunn. “Physicians and anesthesiologists are especially notorious for their illegible records. It’s also very desirable to have a neat, concise, accurate record on a chart for patient care quality control.

“In the long run, as the data builds up on practice profiles for surgeons and doctors, complications, drug use etc, you can learn and glean better methods from the data. And, as anesthesiologists get more proficient with the system, they can be more vigilant.”

Deio for Anesthesia is an eight-module package that can be implemented in whole or in part, selecting and mixing the modules as desired. The deioAssessment tool is designed for both pre-operative planning and post-operative follow-up documentation. The deioRecorder is used intra-operatively to record information at the point of care. The deioInterface links Deio to other hospital information systems. The deioWarehouse stores the information, which can then be plumbed for reports.

To make sure the data is accurate and complete, the deioValidator automatically steps in with prompts. The deioAnalyzer interprets the data. The deioServer serves to network the modules. Finally, the deioCustomizer is a configuration tool enabling users to tailor Deio outputs to their own country, provincial, regional, and hospital specifications.

IWK’s modules connect with other information systems in two ways. “On the clinical network, the anesthesia machines (including all the ADUs and the physiological monitors) are tied to the central Deio central server located in the anesthesia area,” explains LeBlanc. “That server, however, is also connected (through the deioInterface) with our main hospital backbone. And off the backbone runs the Deio assessment and archiving modules. So we have Deio running on two separate networks with their separate cabling and that protects the confidentiality and safety of the records.”

Cabling, says Smith, was one of the early challenges of converting to the Datex-Ohmeda set-up.

“You can’t just walk into an OR during normal working hours and re-wire it. You’ve got to carefully schedule work during off-hours.”

Aside from the physical set-up, security is provided by the Deio software that offers different views to Anesthesiologists, pre-op Nurses, and desk clerks, depending on their need to know and through user-specific passwords and e-signatures.

As to the future, Smith says he and LeBlanc aren’t yet satisfied with the uptake of the system by all anesthesiologists, but predicts that confidence in the new system by all users will eventually be complete. Once it is, Smith says, they may be looking at embracing other software, including a Deio system that does similar work for ICU monitoring and critical care records.

Linking their anesthesiology record keeping to other clinical information systems is also another possible step. Already, one of the Datex-Ohmeda monitors is tied to IWK’s ultrasound diagnostic imaging system. Meanwhile, within the current arrangement, Dr. Nunn sees new software templates emerging specific to different pediatric and women’s procedures, speeding both the input and interpretation of the electronic data. “Our goal, of course, is to go toward the complete electronic health record (EHR),” says LeBlanc.

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If CPOE is proven to save time and trouble, physicians will buy into it

By Dianne Daniel

Although the technology has been around for a decade or more, it’s only recently that hospital clinicians are sitting up and taking notice of computerized physician order entry (CPOE). As study after study continues to indicate improved quality of care and increased time savings following a successful CPOE implementation, physicians – who by their very nature rely on evidence to support decisions – are beginning to realize that CPOE is a technology they can no longer choose to ignore, says Hoda Sayed-Friel, director of physician and clinical systems for Westwood, Mass.-based Medical Information Technology inc. (Meditech).

“Physicians do act on evidence; if you show them evidence, they will come,” notes Sayed-Friel, adding one of her company’s goals is to help hospitals find proof that CPOE is advantageous. “One of the things we help our customers do is understand their environment and where they’re having errors in a written system. We actually go in there and look at the pharmacy log to figure out where they’re having problems.”

Problems can range from ordering the wrong drug or wrong dosage to misreading intentions or receiving incomplete orders. CPOE systems make improvements in these areas by alerting physicians to drug allergies, drug-drug interactions or drug-medication interactions at the time of ordering, by presenting a knowledge base of common drugs and dosages and by eliminating the ambiguity of handwritten orders.

While reducing medical error is the most widespread reason to adopt the technology, others include greater efficiency, better sharing of information and the appeal of having clinicians, pharmacists, lab technicians and nurses all working from the same electronic record.

“Right now, the physicians think of the medication orders as what’s written on the medication order sheet, the pharmacists think of the medication order as what’s in their free-standing computer system and the nursing staff as what’s written on their paper medication administration record,” says Dr. Glen Geiger, director of the Centre for Applied Health Informatics at Toronto’s Sunnybrook & Women’s College Health Sciences Centre. “In a (computerized) model, the technology is binding everyone into a single unified view of a patient’s medication list. Any changes by any party become visible to the other parties – something that’s not really achievable in a paper world.”

Sunnybrook & Women’s is moving forward with plans to adopt CPOE and is currently in the process of configuring its existing clinical workstation and pharmacy order entry technology for what Dr. Geiger describes as the “e-medication process.” Much of the back-end work has to do with deciding on the correct default dosage for medications, ensuring medications are identified correctly and consistently, deciding which alerting functions should be used, and providing support for complex orders.

The intent is that once a drug is selected in the computerized system, a physician will be presented with the normal dosage and then allowed to make changes or review alerts. Complex orders such as an insulin sliding scale that includes a whole series of insulin doses will be handled automatically – a feature Dr. Geiger says will help to gain physician buy-in to the technology since it saves time. Once entered, orders will automatically be sent to the pharmacy system for review and dispensing, and then to an electronic medication administration record (EMAR) that will provide a dynamic list of all active medications for nursing staff to administer.

When configuring alerts – flags that pop up as reminders or warnings at the time a drug is ordered – Sunnybrook & Women’s is following the 80/20 rule, he adds, referring to the fact that a small number of alerts probably represent the bulk of the value. “Clear evidence about what is a tolerated level of alerting doesn’t exist, but you can certainly find guidelines suggesting which alerts appear to be high yield.”

Julie Simpson, director, information services at Ottawa-based Queensway-Carleton Hospital says configuring rules or alerts into a CPOE is a bit of a balancing act. “You have to walk that fine line between being safe, but not driving people so crazy they want to turn it off,” she says.

Queensway-Carleton recently embarked on a three-phase plan to implement a full suite of clinical and financial applications from Meditech. The third part of the $4-million project, scheduled to go live by April, 2005, includes CPOE and electronic clinical documentation.

While Simpson believes the hospital has enough “in-house champions” to ensure the CPOE implementation is a success, she stresses the importance of maintaining open lines of communication with clinicians and ensuring their participation in the project from beginning to end. Some steps the hospital has taken include getting three physicians to sit on the project steering committee, building good will by dealing with other identified needs (such as adding more network access points in the physician lounge) and convincing clinicians that CPOE is not an additional clerical task, but simply a more efficient tool than paper.

“Once you start touching a keyboard, it’s perceived as a clerical skill, whereas sitting and writing your notes on a chart is not,” says Simpson. “Part of our job is to point out you’re swapping one task for another, not necessarily adding clerical time.”

Perception is clearly a hindering factor to adoption of CPOE, adds Meditech’s Sayed-Friel. So much so, that the company actually changed the name of its product line from physician order entry to ‘provider order management’ in order to remove any clerical connotation. To assist hospitals in defining alerts, the company has also announced plans to provide a sample catalogue created by polling its North American customer base and validated by physicians.

On the horizon, Sayed-Friel expects to see remote access as a key selling point for CPOE implementations, since physicians will want to access the system via mobile devices. She also expects to see greater interest in physician documentation as well as in computerized ordering for ambulatory environments.

 

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