Inside the March 1999 print edition of
Canadian Healthcare Technology:
Feature Report: Electronic medical records
OR web site
Operating-room nurses at the Toronto Hospital have developed a unique
intranet web site that could someday streamline OR practices worldwide. The site guides
users through the set-ups for thousands of surgical procedures.
ADSL for radiology
Participants in a major pilot project in Manitoba will soon transmit
medical images over regular phone lines using ADSL technology. The $5 million dollar,
three-year project is a joint-venture partnership between the federal and Manitoba
governments and a private sector consortium led by Kodaks Cemax-Icon.
TeleMedisys Inc. is exploring ways distance monitoring can improve
management of chronic diseases. The company recently announced plans to launch a pilot
trial with cystic fibrosis patients in the Montreal area early in 1999.
Expect the Internet to soon bring us low-cost groupware. Its a
good thing, too, because traditional solutions like Lotus Notes/Domino, Microsoft Exchange
Server, and Novell GroupWise remain complex, expensive, and somewhat out of reach of
Hospitals in Ottawa are testing a region-wide solution for sharing
multi-media patient records. The Canadian-designed system provides a single point of
access to patient information, regardless of whether it is stored as paper, electronic
data, sound or video.
PLUS news stories, analysis, and features and more.
Toronto Hospital nurses develop web site
to run operating rooms more efficiently
By Andy Shaw
Three senior operating room nurses have developed a unique intranet web
site at the Toronto Hospital that could someday streamline operating room practices
worldwide. Dubbed the Peri Operative Nurses Virtual Reference Book, the site guides users
through the set ups for thousands of surgical procedures.
With the exception of buying Microsofts web authoring FrontPage
software, the Book has cost the hospital virtually nothing. And it is already saving
surgeons a bundle of wasted time and aggravation.
It really began three years ago with a conversation we had in the
hallway, recalls one of the enterprising threesome, Joyce Fleming. We had
these new PCs (that were used to record the events of every surgery) in each of our 21
operating rooms and we talked about what else we could load onto them. Fleming is
the nurse manager for the Operating Room of the Toronto Hospitals General Division.
At the time, we were having a difficulty with our surgical
service in gynecology, adds Betty Watt, another member of the web site troika.
Nurses coming onto the night shift werent always terribly familiar with the
procedures. So we said lets put them on the intranet so nurses can review them
beforehand. Watt is the nurse manager for the Operating Rooms post-operative
At that point, Daniel Ivorra, an Operating Room staff nurse, seized the
initiative. Ivorra admits to having no real IT expertise before setting out. But over the
next six months Ivorra spent most of his free time developing a template for the site.
Starting with gynecology then moving on to his own area of cardiac surgery, Ivorra
exhaustively categorized the set ups for all their procedures.
The only way to make it manageable was to group them into
categories, says Ivorra in a still detectable, south of France accent. They
may go by different names, but a lot of procedures are virtually the same. So you find one
that is the most representative and then build in links to the others.
Now, when a cardiac nurse, for instance, goes online and finds an
unfamiliar procedure, Ivorras template springs to the screen with 17 headings
Anatomy/Physiology, Room Set Up, Equipment for Anesthesia, Equipment for Surgery, Trays,
Instruments & Drapes, Hold Items, Small Items, Drugs & Irrigation, Surgeon
Preference, Count, Position, Prep, Draping, Drains & Dressing, Nursing/ Point of Care
Considerations, Care of Equipment, and Procedure Description.
Under each heading, nurses can review the selected procedures
every aspect, including the anatomy involved and a blow-by-blow description (written by a
surgeon) from skin opening to skin closing. There are even assembly instructions and
photos (taken by Ivorra with a digital camera and scanned in) for the surgical equipment
needed. An uncertain nurse can find out the preferences of each surgeon who operates in
that discipline from the sutures and patient position they use to their correct
glove size and preferred colour of gown.
Now surgeons dont have to waste time explaining over and
over again what they want, says Watt. And neither the scrub nor the
circulating nurses have to scurry around at the last minute getting things right.
To see how popular the Reference Book would be with surgeons, Ivorra,
Fleming and Watt staged a demonstration last June at an annual Toronto heart disease
Surgeons usually arent very interested in what nurses do, but we had about 95
percent of the attendees come see us, reports Watt. One Japanese surgeon was
so impressed he wanted to take our demo computer home with him.
Hed be even more impressed now. Fleming says six of
Torontos 10 operating room services now have functioning templates and the remainder
are in the works. When complete, more than 7600 surgical procedures will be available in
the Reference Book.
The toughest parts of this, says Ivorra, was to get
the nurses thinking abstractly about their service so they could categorize their
To aid their thinking, a nurse heads up each services development
team and every nurse in each discipline writes up a portion of that disciplines
That breeds both camaraderie and healthy competition. And
everybody takes ownership of it, says Ivorra who alone controls the content of the
To measure just how much they value it, the Reference Books home
page tallies up the daily hits with a counter. But even without statistical proof, others
Says Bob McArthur, the hospitals director of technology transfer
and research business development, These nurses have set a terrific example for us.
Theyve applied the tools at their disposal to solve real world problems.
And the real commercial world has noticed too.
The number one operating room scheduler and documentation firm,
as well as Johnson & Johnson, have talked to us about it, reports Fleming.
But the three developers are determined not to let their software get
out of their hands at least until the Toronto Hospital project is complete. Once
weve finished with our site, we want to extend it to the Princess Margaret and
Toronto Western sites of the hospital.
Taken beyond the boundaries of the Toronto Hospital campuses, the
Reference Book could be adapted to every other hospital and become a teaching tool for
nurses world wide. But Ivorra, Fleming and Watt remain modest about their accomplishment.
What weve developed is really nothing new, says
Ivorra. Everyone knows what a web site is. Its just what we are doing with it
TeleMedisys remote monitoring targets chronic disease management
By Dianne Craig
Following its recent launch of a remote cardiac-patient monitoring
program, Telemedisys Inc. of Montreal is exploring ways that distance monitoring can
improve management of chronic diseases. The company recently announced plans to launch a
trial with cystic fibrosis patients in the Montreal area early in 1999.
Were moving into disease management, says Stephen
Maislin, president of TeleMedisys. Chronic illness is the one area the healthcare
system has difficulty in managing. People who have ongoing problems like that tend to drop
through the loop.
Much of this, he adds, is due to budget constraints that make it hard
for physicians to do what they really want to do. Another important consideration for
effective long-term disease management is patient compliance.
One reason many disease management programs fail to deliver
maximum utilization of healthcare systems and a better quality of life is because of low
compliance with treatment protocols on the patients part, says Maislin.
We aim to change this.
TeleMedisys was established in 1995 with one clear objective: to find
more cost effective and higher access methods of delivering healthcare.
For example, says Maislin, until recently, when physicians used TVs for
conferencing purposes, it was always a link with other physicians. TeleMedisys focuses on
improving the link between physicians and patients.
We wanted to build a link between patients and healthcare
professionals irrespective of where they (both) are, says Maislin.
The goal of the companys disease management and compliance
programs is to optimize clinical outcomes, reduce costs and stress on the healthcare
system, and to enhance patients quality of life.
Distance monitoring of chronic diseases offers several benefits, says
Maislin, including greater mobility since scientific data can be communicated from
anywhere in the world.
It can increase the comfort level since it keeps
remotely-based patients or healthcare professionals in touch with each other, reduces the
costs travelling to and from hospitals, cost of frequent appointments, length of hospital
We are going to be signing our first hospital for remote cardiac
monitoring soon, says Maislin. It will drop the number of days a patient
spends in hospital after an MI (myocardial infarction) by over four days.
When asked why TeleMedisys has chosen cystic fibrosis for the pilot
project, Maislin said there is a need for more attention to this serious disease. If
kids dont live in the immediate area (close to the hospital) they dont get the
same quality of care. If they develop an infection, they have to make a trip to the
hospital, incurring tremendous costs, such as overnight stays.
For patients with chronic illnesses living farther from the
hospital, the need for remote monitoring of their condition becomes even more apparent.
As the distance gets greater, so does the value of what we are trying to do,
A CD player-sized spirometer, manufactured by Cardguard of Tel Aviv,
Israel, that patients use to measure lung function is so small it can be carried anywhere.
When the patient blows into it, the spirometer calculates several
values, and then compares those with both standard values and the patients own
baseline values recorded at norm. It deviates and indicates the patients
condition according to the algorithms the physicians have developed. We relay information
back to Ste-Justine (the Montreal childrens hospital).
It takes about two minutes of a doctors time, as opposed to the
time a visit would take. It takes just 45 seconds for the patient to transmit values to
us. And then about two or three minutes of conversation with a doctor or other health
Calls from patients participating in remote monitoring programs are
received at the TeleMedisys call centre in Montreal. The centre is staffed by cardiac
nurses, pulmonary therapists, nurses who specialize in endocrinology, and other medical
staff with specialized backgrounds.
There are three to four nurses in the centre at one time and incoming
calls are routed to the call-centre nurse best equipped to respond to that patient.
Currently, the call centres computer equipment is being upgraded.
Maislin is overseeing a shift to large, industrial 16-slot PCs from the
8-slot systems they had before. Were doing this so they will be able to
receive almost everything every form of data that could come in, says
In some cases, the spirometer alone is sufficient for remote patient
monitoring. Doctors have also expressed an interest, says Maislin, in having call-centre
nurses be able to see some of those patients face-to-face for effective assessment of
For these patients, a camera the size of a box of Kleenex will be used
for assessment in conjunction with the spirometer. The camera, made by Eight-by-Eight of
Santa Clara, Calif., simply plugs into a patients phone and TV and provides two-way
teleconferencing, so both physicians or other health professionals and patients can see
and converse with each other in real time.
We wanted to find a product that allows full lung function
testing in the home. We also wanted to find a camera that would run over regular phone
lines, so there would be no extra common costs (such as the need for extra bandwidth in
Asked whether there are any ways to measure the effectiveness of the
cystic fibrosis pilot project, Maislin said there are a number of outcomes analyses built
into the project.
Participants in the pilot project will include children who spend more
than 40 days a year in hospital and live more than 20 kilometres away from it. Fifty
patients will participate. Weve asked for the most severe patients, says
The project, which is scheduled to begin early this year, will begin as
soon as funding has been secured.
We have a partnership with Ste-Justine childrens hospital
in Montreal, says Maislin. When the pilot project is completed it will be rolled
into a regular program almost immediately.
We are trying to be of assistance to the physician but also a
benefit to the general public, says Maislin. It helps diminish complications
and provides a convenient way for patients and health care professionals to check in with
each other regularly.
TeleMedisys also intends to develop programs for diabetes and kidney
disease in the near future, says Maislin.
Its a simple concept. You dont have to build
something that does everything. We want it to enable you to go as mobile as possible, so
youre not tied to your home or your bed, says Maislin.
Telemedisys will continue to develop new remote monitoring programs,
with new capabilities, he adds. We have many more technologies to incorporate into
Integrated health networks will require patient record systems that mesh
By Andy Shaw
..Canadians want better and faster care improved
quality, speed, affordability and appropriateness.
from a Macleans magazine Dec. 7, 1998 essay by Michael Decter on healthcare
in the 2000 Millennium
Canadians began this twilight decade of the current millennium with
some 900 independent hospitals at the cornerstones of their healthcare delivery system.
But as the 1990s progressed, a mounting body of evidence showed that a good deal of care
could be provided outside of the traditional hospital, and that it could be delivered
there more efficiently and cost-effectively. As a result, predicts Toronto health
consultant and writer Michael Decter, when the new millennium dawns next year we will see
those 900-odd hospitals reduced and synthesized into 150 to 200 regional healthcare
If Decter is right, this new foundation will give us far fewer, more
specialized hospitals better integrated via technology with community-care facilities,
home-treatment services and disease-prevention programs. The hoped-for result is a
streamlined healthcare system that not only costs the taxpayer substantially less but also
sustains a healthier populace. In other words, the bet is regional integrated delivery
systems will deliver a lot more bang for the healthcare buck.
But thats not going to happen overnight. The developers of
integrated healthcare systems have to clear several big hurdles first.
To appreciate these challenges, its worth looking at an
integrated systems two great advantages. First, it enables all its providers
acute care hospitals, community clinics, physicians in private practice, home-visiting
nurses and pharmacies alike to concentrate on what they do best. And it also
enables patients to move seamlessly from one provider to another as their condition
deteriorates or improves and thus receive the most cost-effective care.
But this efficient continuum requires providers to share information
about patients securely, swiftly and cheaply. So the first challenge is to develop uniform
medical records that can be electronically stored, retrieved and moved across the region
readily. That, in turn, means healthcare institutions must make their individual computer
systems all talk to each other. These are no small tasks.
Finally, and this is the really tough part judging from the early
going, care providers in a region must agree on how their system will function and see
clearly what the benefits to them and their patients will be if the system is even
to get off the ground.
Thats why Ken Lawless was surprised. Lawless is executive
director of the Ottawa Life Sciences Council (OLSC). It is the facilitator for one of the
countrys most vigorous and sophisticated efforts at developing a regional healthcare
Right from the outset of our project just over 18 months ago, I
was surprised by how all our partners pretty well had a common vision of what it would
look like and what the benefits would be, said Lawless in a recent interview.
The OLSC is the co-ordinating body for the Ottawa Community Health
Information Partnership, OCHIP for short. OCHIP is a consortium of 20 healthcare providers
and organizations including the Ottawa Hospital, the University of Ottawa Heart Institute
and several private sector suppliers. Currently funded by the Ottawa regional government,
OCHIP is charged with revamping the Ottawa-Carleton Regions healthcare delivery
system. By next year, Lawless expects OCHIP to become a self-sustaining not-for profit
But OCHIP began as a regional project in April of 1997 on the heels of
an Ontario government healthcare restructuring report. The report noted that Ottawa
hospitals had made a significant investment in technology, but that it was not well
integrated across the region. Formally, OCHIPs consequent aim is to provide the
Ottawa area with a secure integrated regional electronic patient information system
that links providers, educators and researchers throughout the Regions system.
Informally, OCHIP states its common vision much more eloquently and
memorably on an OLSC web site (www.olsc.ca) page entitled Imagine. It is an
ideal every regional health system might well strive for and reads:
Mr. Jones is 45 years old, a successful businessman in the prime of
his life. He has just eaten lunch and is walking along in a local shopping mall and
develops heaviness in his chest and thinks he has indigestion. He stops at the drug store
for some antacid.
He speaks to the pharmacist who hears his complaints. Mr. Jones is
starting to feel disoriented. The pharmacist, with Mr. Jones permission, retrieves
his electronic record to discover that he is a known heart patient.
The pharmacist directs him to go to the urgent care clinic, which
is in the mall and alerts the clinic electronically that Mr. Jones is coming. Jones allows
the clinic nurse to access his regional electronic chart and his primary care
physicians charted notes. The nurse discovers that Mr. Jones is a known high-risk
patient with a past history of coronary disease and refers him immediately to the clinic
physician who orders an electronic ECG to discover evolving changes of a heart attack.
Through the facility of video teleconferencing, the physician
reaches the cardiologist on call who reviews the findings and the new ECG, which is
available to him over the network. He agrees with the diagnosis, orders the transfer and
arranges for the angiographic suite to be prepared to receive Mr. Jones directly. Mr.
Jones is transported directly to the Heart Institute angiographic suite where he is
assessed and is shown to have an acute occlusion of his left anterior descending coronary
artery which is successfully opened with a newly developed thrombolytic agent undergoing
Mr Jones symptoms are relieved, he undergoes angioplasty and
stenting the next day and he is discharged from hospital after 2 days. Prior to discharge,
Mr. Jones and his family participated in a comprehensive coronary education program. His
family physician and home care providers are notified electronically of the admission and
The time from the onset of Mr Joness symptoms to the
diagnosis in the community clinic was 30 minutes. The time from onset of symptoms to
definitive therapy was 90 minutes.
A few days later, Mr. Joness primary care physician reviews
Mr. Joness lab, ECG, and cardiology notes in the patients electronic record.
Mr. Jones recounts the benefits of his experiences:
prevention of life threatening heart damage
reduced length of stay in hospital
avoidance of costly duplication of tests and traumatic surgery
efficient use of community based health care resources across the continuum from
the pharmacist to the home care provider
elimination of delay due to multiple assessments at different facilities which
could have delayed his ultimate treatment at the Heart Institute if his history had not
The Institutes Utilization Management Committee reviewed the
costs associated with this episode of care as part of an ongoing study to increase
efficiency and reduce costs. The data was also made available to the clinical
epidemiologists for their study of cardiac care clinical outcomes.
Our partners in OCHIP are all anxious to see this happen
here, says Lawless who adds that the partners are equally realistic about how to
make it happen. Theyre doing it one step at a time.
One of the first things we did was to bring in a consultant group
that had experience establishing similar systems elsewhere, explains Lawless.
It was an American firm, the First Consulting Group. It had helped set up 17 systems
in the United States. And they recommended we not try to do it all at once but take a
OCHIPs first operational module was the Integrated Clinical
Information System (ICIS) announced last fall and currently being used and evaluated by
the Womens Breast Health Centre on the Civic Campus of the Ottawa Hospital. ICIS
allows large volumes of patient records and diagnostic information to be stored, accessed
and viewed securely by healthcare providers across multiple sites. Partners in ICIS
include JetForm Corp., Newbridge Networks, and Oracle Corp.
But at the heart of ICIS is Canadian-designed software from another
partner, Mainsource (formerly PARJplus) Software Corp. of Ottawa. Its Multimedia Clinical
Document Management System (MCDMS) provides a single point of access to patient
information regardless of whether it is stored as paper, electronic data, sound or video.
MCDMS is an electronic repository that can store an unlimited number of
medical records and deliver them within hospitals and beyond to outside clinics,
doctors offices and even eventually to homes. The repository and system at work in
the Womens Breast Health Centre handles patients scanned bar-coded charts, lab
results, transcriptions and discharge summaries.
Integrated with the Ottawa Hospital Civic Campus diagnostic and
hospital information systems, the MCDMS-driven ICIS will also soon be able to store,
retrieve and convey voice notes, graphics, x-ray, MRI and other images as well as short
video clips connected with a patients record. (A similar system is also operational
across town at the National Defence Medical Centre, although the two are not yet linked.)
To make this work, the MCDMS sits on a hardware configuration of a
Digital Alpha server 4100, a StorageWorks Raid array and a Digital optical jukebox. A
Mainsource desktop program integrates the software combination of JetForms
electronic forms and an Oracle database.
The JetForm software generates the form. It is then filled in,
printed, bar-coded and scanned back into the system, explains Paul Duff, vice
president of sales and marketing for Mainsource. Then we use Oracle as a tool to
figure out where that form and all other data we enter should be stored in the
When clinicians retrieve data from the Health Centres repository,
the records travel along the hospitals Newbridge ATM local and wide area networks to
15 workstations at the Civic Campus. Eventually users will be able to access the
repository from some 300 workstations spread across all three Civic, General and Riverside
campuses of the Ottawa Hospital, says Ray Berringer, district manager for Newbridge.
When they are at that stage, theyll be ready to use
InTempo, our workflow tool, says Pam Ferenbach, an account executive with JetForm.
That means users will not only be able to store and retrieve them, but actually be
able to move patient forms around for approval or digital signature.
Elsewhere, other regions are taking different approaches. In Winnipeg,
for example, Jim Kerr, divisional director for Communications and Information Services
with the Health Sciences Centre, reports that the regional Winnipeg Health Authority is
joining up a dozen or more of its providers into a regional system.
But even though its eventual goal too is rapid and secure distribution
of patient information, Winnipegs initial focus will be on the other end of the
integrated healthcare spectrum analysis of outcomes.
Were developing a universal database or repository and
giving users an Oracle tool-set to tap into it, explains Kerr. They can learn
how to use the tool-sets within an hour and can start designing their own datamart right
after that. The datamarts allow users to query the repository for information thats
specific to their interests. So if someone at the Health Ministry, for example, wants to
find out or keep tabs on, say, how many women between the ages of 25 and 40 were treated
for the flu this winter, they can.
Such custom reports were possible to create in the past, but to
generate them, that might take our Health Sciences information system up to three months.
With our new set-up, users themselves can generate the reports in three minutes. So
were starting out by first solving that old conundrum about technology leaving you
information rich and knowledge poor.
In another variant on regional system development, Ontarios
HealthLink is taking a different tack. Originally a provincial government-funded project
to link seven Toronto area hospitals, it was forced early on to solve another challenge to
developing regional healthcare delivery systems. What to do when start-up government
dollars dry up? Unlike its counterparts in Ottawa and Winnipeg,
HealthLink receives no funding from a regional authority. So it has
turned its own expertise into a self-sustaining moneymaker. Unlike OCHIP, for example,
HealthLink sells consulting and implementation services to hospitals wanting to set up
their own internal information systems as a prelude to interfacing externally with a wider