Inside the May 2007 print
edition of Canadian Healthcare Technology:
Feature Report: Developments in surgical
Capital Health project re-engineers patient
It doesn’t have the snappiest
name ever, but the Emergency Services & System Capacity (ESSC)
patient flow project at Capital Health Authority promises to be a
memorable landmark in the evolution of regional healthcare in
Kingston General devises pain management
Pain management after surgery
is a complex business, and patient suffering, appropriate therapies,
and the possibility of medical error are all major issues. To better
manage these challenges, Kingston General Hospital has developed
computerized systems that are leading to significant improvements.
READ THE STORY
Patient Destiny: Consumers must have access
to their health records
Just as customers accessing
their information have reduced banking industry costs, it is a
general assumption that the same will hold true in healthcare.
Hospitals use computerized strategies to
improve document workflow
If you were to measure the
number of paper-based patient charts that get distributed throughout
Kingston General Hospital (KGH) and Hotel Dieu Hospital (HDH) each
day, you might be surprised to learn just how much paper there is.
READ THE STORY
Robots with a soft touch
Canadian companies have
developed haptic feedback systems for robots, enabling surgeons who
operate the devices to ‘feel’ what the robot is touching. The
solutions have great promise for improving the accuracy of minimally
invasive surgical techniques.
Top tier medical imaging
For the first time, influential
market surveyer KLAS has included diagnostic imaging equipment in
its annual ‘Best of KLAS’ awards. We report on the winners in the
four modalities that were included — CT, MRI, CR and ultrasound.
Physicians and researchers at
the University Health Network, in Toronto, have launched a project
called GTx. It aims to speed up the development of image-guided
therapies by combining the talents of local experts.
Medica, a global gateway
We report on Medica, the
world’s largest medical technology exhibition. Held each year in
Dusseldorf, Germany, it brings together technology developers and
buyers from around the world.
PLUS news stories, analysis, and features and more.
Capital Health project re-engineers patient flow
By Andy Shaw
EDMONTON – It doesn’t have the snappiest name ever, but the Emergency
Services & System Capacity (ESSC) patient flow project at Capital Health
Authority promises to be a memorable landmark in the evolution of
regional healthcare in Canada.
The innovative ESSC project is being designed to remove the bottlenecks
restricting patient flow through a region’s resources – from emergency
rooms through acute care hospital beds to community care facilities.
Capital Health encompasses 13 integrated hospitals and numerous
community care institutions that serve about 2.6 million people in
Edmonton and its environs, as well as in northern Alberta. It has
recently added 300 hospital beds and nearly 1,000 long-term care spaces.
But that additional capacity alone was not enough to ease an increasing
pressure felt by just about every health region in Canada.
“Emergency overcrowding and the resultant backups are a longstanding
issue in Canada, and not unique to Capital Health,” says project chief
Susan Mumme, who is the vice president and chief operating officer of
Capital Health’s Regional Clinical Support Services and Integration arm.
“We tried a number of approaches in the past, but the ESSC project is a
fresh look at the problem. Rather than looking just at our facilities,
it focuses more on how patients flow through the entire system, through
the in-patient areas and out into the community.”
As they move through the system, patients touch a lot of different
bases; consequently the ESSC project does too. It is carrying out 15
different sub-projects to streamline and co-ordinate patient flow
through four key areas: Emergency Departments, Bed Management, Care
Management, and Community Care Services.
But the ESSC is not starting entirely from scratch. Rather, it is
building on an enviable infrastructure that already extends right across
“We have always had a region-wide emergency department system that
enabled us to do standardized triage, and know who to send where,” says
Capital Health CIO, Donna Strating. “But that didn’t get people out of
Emergency any faster. It only told us how big the piles were getting at
So the ESSC project began instead with a closer look at the roles and
responsibilities of those who influence and who could enhance patient
“We’re looking at new ways of our people doing things and standardizing
those processes across the region,” says project leader Mumme. “And from
there we began to look at what kind of technology we have now, such as
our Emergency System and our ADT systems (admission, discharge,
transfer) – the ones whose information might help us make better
What Mumme and her team learned from that information has been
translated into 15 ESSC “design solutions” that include new processes,
new systems, and new staff doing new kinds of work including:
• The implementation of a Full Capacity Protocol (FCP) – which is
triggered when the Emergency Department gets stretched beyond limits.
FCP calls for patients to be quickly moved out of Emergency into
pre-determined areas in the inpatient units and from inpatient units out
into Community Care Services in response.
• Emergency Department Navigators – who work in the Emergency waiting
room and talk to patients and families about the Emergency process and
who ensure the triage nurse and physician are aware of any changes in
the patient’s medical condition while he or she waits.
• Comfort Care Carts – that help make a patient’s wait in Emergency more
• A Centralized Bed Hub – that helps place patients in to a clinically
• Bed Managers – who are available around the clock to decide, using bed
management software, who gets what bed and who co-ordinates transfers
between sites and facilities.
• Twice-a-day, bed conference calls connecting Capital Health’s four
largest acute care sites with community, mental health, and regional
These solutions had their origins in the first “needs assessment” phase
of the ESSC project last summer and were further refined as the project
rolled into the next “design” phase.
“We had a look at best practices around the world as a result of our
needs assessment and then we brought in staff and physicians to ask them
about the kind of processes we should support, how they would work, and
what kind of information and technology we would need to implement
them,” says Mumme.
Implementation of the solutions developed began late last fall. Charged
with getting them up and running over a 12-18 month roll-out is Jan
McGuinness, the director responsible under Mumme for Capital Health’s
“We’re using the Emergency Department’s information system to give us a
good picture of what the bed situation is at each site in real time,
says McGuinness, “and also we’re using the data from the system to help
us evaluate the changes we are making. We are really trying to make this
a data driven effort.”
One initiative whose success will be determined by the data it spawns in
particular, says McGuinness, will be the Full Capacity Protocol. “It’s
been shown elsewhere that the FCP has resulted in decreased length of
stay for patients who were admitted through the Emergency Department. So
we have developed a dashboard of data just to watch that.”
The ESSC also involves a quality of service element that’s being
elevated with the help of technology.
“For patients and their families, for example, we’re installing plasma
screens in waiting rooms that display healthcare news and updates. Or if
we had some kind of respiratory outbreak in a hospital, we will put
notices up on the screens about the etiquette they should follow,” says
McGuinness. “We are also looking at piloting a paging system, similar to
what you might have in a restaurant, for patients who are ambulatory and
who can go and get a coffee and be given a pager and be called when a
physician is available to see them.”
To effect these changes, Capital Health has engaged its Human Resources
department to set up ESSC transition teams at each of its sites, as well
as to hire new staff (the biggest budget item) for the new Bed Manager
and the Emergency Department Navigator positions.
Among the payoffs that McGuinness, Mumme, Strating and others expect
from the $10 million invested in ESSC:
• Greater patient and staff satisfaction.
• Throughput of patients to the right, clinically appropriate bed as
fast as possible.
• Business intelligence for physicians and managers, accessed through an
Oracle database portal that tells them how patient-flow changes are
affecting their areas of responsibility. The system will help them
determine whether the changes are sustainable.
• A steadier state of coverage by appropriate physicians and staff that
does not peak on weekdays and bottom out on weekends.
• A greater capacity in the Emergency Department to handle the rising
number of acute and chronic care cases stemming from an aging population
(Capital Health’s Nurse Call Centre implemented several years ago has
managed to decrease the number of low-acuity cases showing up in
• Information about the care provided by Capital Health will flow
seamlessly back to the patient’s family physician or primary care
provider in order to reduce the rate of re-admissions.
To assess the value of these expected returns on investment, Capital
Health has set up an ESSC evaluation team in co-operation with the
University of Alberta. The major measure it will evaluate, says Mumme,
is how quickly the project freed up high cost acute-care beds and moved
patients to lower cost community care beds and beyond.
Hospitals and companies develop electronic solutions to control and
By Andy Shaw
“Pain is a more terrible lord of mankind than even death itself.”
– Dr. Albert Schweitzer
Pain can be a real a pain in the neck. Pain does have its place of
course. It serves as a warning sign for disease and injury. But beyond
that usefulness, pain doggedly persists where it’s neither wanted nor
None more so than the pain connected with surgery. To keep surgical pain
at bay, most surgical procedures involve potent local or general
anesthesia, followed often by potentially harmful, pain-numbing drugs
after the operation. As a result, surgical pain-control involves careful
pre-surgical preparation, then watchful monitoring both during and after
the procedure if the patient is to remain not just comfortable but also
safe. To that end, virtually every teaching hospital in Canada and many
others have instituted an Acute Pain Management Service (APMS) system
that is in the hands of the Anesthesiology Department, where pain
management expertise traditionally lies.
To guide it, APMS-related information, research and references abound.
The World Health Organization has issued pain management standards;
there are pain management societies, international conferences,
specialized pain medicine training, and even professional trade
journals, all devoted to combating pain. Yet it remains an elusive
enemy. Managing pain is just so complex. First one must deal with the
divergent pulls of cure and comfort. Too readily the physician
imperative of “get the X-ray first” can supersede the nurse’s plea for
pain relief for the patient. Then in the case of surgical pain, there
are all the perioperative clinical decisions to be made about where and
when and how much drug and non-drug pain killers, such as physiotherapy,
should be administered to the patient.
From the surgical patient perspective, some need more pain relief than
others. Worry can increase the pain people feel. So, part of pain
management involves patient education – to help them deal with the
details of the pills, tablets, liquids, or suppositories they must
ingest; the injections they may need; the drug pumps they must operate,
or the pain-masking relaxation and mental diversion techniques they
These complexities are rife with the potential for medical error. Small
wonder then there’s a demand for APMS systems that are managed with the
risk- and complexity-reducing capacities of computer technology.
In Canada, three notable wielders of technology are vigorously attacking
surgical pain. At Kingston General Hospital (KGH) in eastern Ontario,
Dr. David Goldstein and acute care nurse practitioner Rosemary Wilson
head a multi-disciplinary team; since 1999, they have been developing a
wireless-based APMS for the 2,500 surgical patients a year at KGH who
require pain care.
Meanwhile, in Flamborough, Ont., near Hamilton, Adjuvant Informatics
Corp. is helping their clients both at home and abroad to organize
surgical pain management with a suite of anesthesia department software
that includes an Acute Pain Service (APS) Manager module.
And in Toronto, Philips Medical Systems is working with anesthesiologist
Dr. Steven Chan, at the University Health Network (UHN), on an
ultrasound system than can block pain by guiding a needle accurately to
a local nerve and freezing it – a system that may significantly change
the whole approach to surgical pain management.
In Kingston, more than $1 million in research money and support from
government and industry have gone into the KGH’s APMS system.
“We are at version 4.1 of the software,” says Dr. Goldstein. “But the
software actually is quite uncomplicated. It simply interfaces (via a
hospital-wide Cisco 8.0211g wireless backbone) with the registration and
ADT (admission, discharge, transfer) system of the hospital, so you know
who the patient is, and where the patient is, updating immediately
whenever the patient moves. The software also interfaces with the likes
of pharmacy, imaging, EKG, and other systems to provide the information
about the patient’s condition.”
Anesthetists and other pain management clinicians at KGH can now
securely access that information held in an APMS database to also find
the patient’s care plan, lab results, notable events, consulting notes,
and even billing details from anywhere they are in the hospital. As
well, they can switch to an assessment screen on their on their computer
tablets, which lists up to 21 patient variables and 18 options for
planning patient care, such as reordering or changing medications.
This computerized APMS model has been exclusive to KGH’s anesthesiology
department, but other departments such as obstetrics/gynecology are
keenly interested in its potential, reports Dr. Goldstein. “It’s
applicable to them because it is not about the particular hardware and
software we use, it’s about how you get people and patients working
The software on board the APMS tablet fosters such co-ordination. It
generates an alert if physicians have prescribed incompatible drugs or
if the lab returns abnormal results. It also allows users to make
additional narrative comments. Finally, a built-in research function
also captures the data needed from patients participating in studies.
It is the lack of reliable data about patients and their pains that
drives the folks at Adjuvant.
Says Douglas McVeigh, Adjuvant’s vice president of sales and marketing:
“Among the facets of the problem our APS Manager solves are inconsistent
data capture, incomplete clinical documentation and care management
plans, missing billing and paperwork, and the lack of data needed to
carry out in-depth and accurate quality assurance in a reasonable time.”
In addition, says McVeigh, the APS Manager is uniquely set up to link
with important pain management resources outside of hospital walls,
including the International Clinical Anesthesia Data Base being
established by Adjuvant to aid researchers worldwide. That capacity has
helped attract users of Adjuvant systems now operating in hospitals in
Canada, Norway, Australia, and the United Kingdom.
“We are marketing to a very receptive audience,” says Adjuvant president
Dan Meyer. “Pain has become the fifth vital sign in patient care.
Government, administration, physicians and nurses are demanding better
tools and processes to ensure that patient pain is minimal and the
therapies are safe.”
Adjuvant has made contributing to that research easier and the general
use of its products more attractive by moving their software from
client-server to a web-based platform.
“The IT department in any hospital has a very difficult task of managing
all their client computers. So if you can go into an IT department and
give them a solution that is very light weight on their current system,
as ours is, they are very happy,” says Meyer.
Other decision-makers take comfort in the software’s round-the-clock
reliability, secure user logins, full audit trails, and digital
signatures that enable complete compliance with government privacy and
Like the KGH experience, Adjuvant has found that among the biggest
boosters of its systems are those on the very front line of pain
management, the acute pain nurses.
“These nurses have undergone special training, and generally they are
very intelligent and skilled,” says Meyer. “But until now they have had
no electronic tool. They walk around with paper reference binders, but
often still can’t answer questions that are posed to them. So when they
are presented with an opportunity to use a tool that can give them
access to all the information they would ever need, they respond very
That also leads to better communication and understanding with
physicians and it pleases the hospital’s back office.
“The physicians love it because they can walk in Monday morning and get
a complete, up-to-date picture of their patients,” says Meyer. “And
hospital administrators like it because with the data the system gathers
they can do benchmarking.”
Benchmarking, of course, allows administrators to see
the performance of their services in a new, more statistically valid
light. Seeing is believing, in other words. In a more literal way, Dr.
Steven Chan at UHN is believing what he finally can see.
As head of the Regional Anesthesia and Pain Program in UHN’s Department
of Anesthesia, and an anesthesia professor at the University of Toronto,
he is an expert in a field which he admits has been seeing ‘blind’ for
some time – nerve blocking.
Nerve blocking or “regional anesthesia”, as it is formally known, can
obviate the need for general anesthetics that put the patient completely
under – resulting in much less risk to the patient and lower costs to
the healthcare system. Find the local nerve, freeze it with a needle,
and do your surgical business while the patient remains awake and pain
free, and in many cases not in hospital at all.
The problem is finding the nerve.
“It’s well known that nerve blocking has many benefits to our patients,
but this technique was under-utilized because we used to perform nerve
blocks blind in the old days,” says Dr. Chan. “But by using today’s
ultrasound we can now visualize the nerve structure. Nerve blocking
procedures are safer today because we can see vessels, pleura and other
things we do not want to put the needle into.”
Bill Bevan, the Canadian national sales manager for ultrasound at
Philips Medical Systems, says Dr. Chan and others in this burgeoning
field can now see even more.
“When they were going in blind, they knew where the nerve was supposed
to be structurally but they pretty much had to go in by feel,” explains
Bevan. “But now the resolution of ultrasound has become so good they can
actually see individual nerves inside a nerve bundle. So then
anatomically, they can say, aha, that is the particular nerve bundle
that we want. Then as they insert the needle, they can see the needle
coming in, see it hit the target, and therefore make it a safer
Through Bevan, Philips sponsors, supports, and helps equip Dr. Chan’s
12-member team of developers and researchers and also connects Dr. Chan
with Philips’ ultrasound equipment builders and designers in Seattle.
Dr. Chan regularly co-chairs international symposia and workshops for
the Association for Ultrasound Imaging in Regional Anesthesia and is
editor of the Regional Anesthesia and Pain Medicine Journal.
“We’re pretty proud to be associated with one of the world leaders of
this rapidly emerging field,” says Bevan.
As with all emerging fields, though, they come with their challenges.
For Dr. Chan it is overcoming the differing mindsets that separate two
medical specialties. “With anesthesiologists, you have the challenge of
convincing them to learn a brand new technique.”
For Dr. Goldstein at KGH and Adjuvant Informatics, there are few studies
yet which show the return on investment (ROI) likely from APMS systems.
Goldstein does point to one study that said the use of hand-held APMS
computers in the post-operative acute pain management ward reduced the
time required to see each patient by 30 percent.
Elsewhere, an eight-month study of a wireless APMS system in use at
three nursing units of the Nebraska Medical Center indicated that it
averted 157 medical errors, which translated into a projected
cost-avoidance to the hospital of $712,000.
In terms of how much you need to invest in order to gain such potential
returns, KGH and Adjuvant Informatics are at different ends of the
scale. Goldstein and KGH are offering their APMS software to other
hospitals for free – with the buyer picking up the costs of having a KGH-approved
third party install, adapt, and maintain the system. Meanwhile, Adjuvant
is offering their applications at an up-front cost – but one that
includes installation and maintenance and which, says marketing manager
McVeigh, will deliver $160,000 to $240,000 in savings and thus pay for
itself in less than six months.
However the market responds to these and Dr. Chan’s pain saving
techniques, their prospect remains highly promising: no longer will
surgical pain, at least, be able to lord it over us.
Patient Destiny: Consumers must have access to their health records
By Kevin J. Leonard and David Wiljer
Just as customers accessing their information have
reduced banking industry costs, it is a general assumption that the same
will hold true in healthcare. As more patients bypass the “hands-on”
personal method and obtain information for themselves, it is estimated
that great savings will be gained, and consequently, a tremendous amount
of strain will be removed from the system.
However, very seldom is patient information (e.g., the specific results
of diagnostic tests) ever shared with the patient. As a result, it is
very difficult for patients to enter a dialogue with their doctors about
treatment, because the healthcare provider is the only one with the
information. One truism seems to be constantly ignored: It is impossible
for patients to manage their health without the requisite information!
This is not just a passing fad or part of a catchy slogan, but rather a
conclusion that is based on a number of logical premises, outlined as
Times have changed: This may not appear to be all that insightful, at
first glance, but this premise contains very important building blocks.
We are no longer in an era where businesses and governments tell people
what to do and when. The rise in consumerism has created the demand from
the public for better information and better service. The public wants
information in the way they want it, when they want it. We have rapidly
progressed through the Information Age into a “Knowledge Era”.
Information that is meaningless to consumers has no value. In the next
20 years, the industries that will be successful will be the ones that
can take advantage of technology and deliver pertinent information,
which is “targeted knowledge” channeled down to the individual consumer.
Patients are at the centre of healthcare: We have seen many Hospital
Mission statements echoing this same message – changing to
patient-centered care. However, this ‘mantra’ has not been firmly
understood or appreciated. Without the patient, there is no need for
healthcare professionals. The patient is the one constant throughout all
of the healthcare system.
What patients do want, and will demand, is better information about the
system, about who does what services, and about how well they perform
these services. Answers to these questions will allow consumers to make
informed decisions surrounding their care.
Patients want access to their own patient information – and they want to
be able to understand what it is that they are reading. In particular,
they want to know more about their illness or disease, and they want
information on treatment options and success rates. Often, they would
like to get in touch with other patients to exchange experiences and to
get advice. After all, it is only when they interact with other patients
that they get real information about what they are going, or will go,
Ultimately, patients are the decision makers: When patients are faced
with difficult healthcare questions, they seek advice – from their
doctors, other health professionals, and their own personal network.
Even though the physician will provide the best medical support,
ultimately, it is the patient who has to decide whether they want this
drug treatment or that surgery.
It is understood that not all patients may have the maturity or
cognitive ability to comprehend the decisions that they have to make.
Many caregivers have used this argument to withhold information; but, in
actuality, this rebuttal only applies to a small percentage – perhaps,
to 20 percent of our population. The remaining 80 percent have the
ability and the right to make their own decisions. What they lack is the
medical background in order to facilitate all the information and to
process it in order to make an informed choice.
It is our belief that in the healthcare system of the future, we will
see physicians (and other professionals) act as advisors to patients,
rather than the old model, where patients are told what to do. Gone will
be the day where patients will feel that they are not free to question
facts or to seek options.
Decision-makers need information: It is well understood in information
theory, and in the decision analysis literature, that decision-makers
need information to assist in making any decision. It then becomes clear
that we must get the critical information to the patient in order for
them to make informed decisions. This means that the focal point of the
healthcare system of the future must be on the patient record, since
that is the only point where all the data reside. In order to move the
data and information around efficiently, it is obvious as well that this
record will have to be in an electronic form.
Conclusion: Patients must be able to access their health records and
other patient information if they are to make informed and effective
decisions about their health management. Consequently, it is impossible
for patients to manage their health without this requisite information!
Access to records improves satisfaction for lung transplant
Over 40 percent of patients have
at least one chronic illness, accounting for nearly two thirds of all
medical expenditures. Because of their long timeframe and high attendant
costs over time, chronic illnesses lend themselves to electronically
mediated self-management tools. Prototypes of web-based,
patient-centered Information and Decision Support Tools have been
demonstrated to improve self-management of illness and enhance
understanding of the complications of poorly controlled disease.
Patients living with chronic illness are also more likely to use health
information than their healthier counterparts, although each chronic
illness has specific, recognizable challenges for affected patients in
symptom comprehension, information management, task fulfillment and
It is our hypothesis that leadership will come from these chronically
ill patients (either individually or within a group) by demanding better
access to health system and service information. In recent research, we
interviewed patients on a number of “access to information” issues.
Unfortunately, asking patients (or computer end-users or stakeholders)
what information they would like to receive is not efficacious due to
the fact that end-users are normally not well versed in “system
What stakeholders are very good at, however, is identifying
functionality they would “like to have” at the moment that they
experience it. As a result, we have engaged different groups of patients
suffering from a chronic condition. In this instance, we present results
on post-lung transplant patients in both passive (survey interview) and
active (simulation) environments to elicit their needs and wants. (This
group was analyzed due to accessibility, however, it is believed that
many of the findings are applicable across a number of illnesses or
Almost two-thirds of these lung transplant patients (63 percent) had
seen some portion of their medical record (most commonly blood work or
X-ray results) and a similar percentage believed a personal medical
record would help them manage their personal healthcare. The most common
reason respondents wanted access to their medical chart was to enhance
their understanding of their medical condition. This desire to have
further access to personal medical information was expressed despite a
comprehensive patient education program provided by the transplant
program, and despite the fact a high degree of patients felt they were
provided with an adequate degree of information upon discharge from
hospital. As a whole, this group appears to have a high level of
interest in their medical information and can be described as active
participants in their care.
The patients were then asked what they believe would be the most
valuable aspect of having access to their medical information.
Respondents were encouraged to check all that apply:
• 57 percent of patients believe that access to their medical
information would help enhance their understanding of their medical
• 13 percent of patients indicated that access to their medical
information would help ensure the information was available to their
• 13 percent of patients felt access to this information was important
in case of an emergency.
Further, over 60 percent of patients believe that having access to
information about the medical care that they receive would help in
managing their healthcare while at home. The difference in the phrasing
of each question may illustrate the importance patients’ place on
information necessary for self-management over information about their
hospital stay. Sixty percent of patients believe that if they were
provided with their medical record, they themselves and their family
physician would use it the most. Related to the use of the patient’s
medical record, 73 percent of respondents did not have any concerns
about a family physician, family members or other medical specialists
having access to their record.
Patients were also given the chance to choose what type of information
from the hospital they would find useful to help manage their care at
home The most popular choice was the lab test and results (67 percent)
followed by a summary of their medical history, medication information
(history and current), contact information (specialists and emergency
contacts) and blood pressure/ temperature charts. Family and personal
history and height/weight charts were not strongly endorsed. Only 17
percent of all respondents felt the inclusion of an allergy history was
necessary in their personal health record. Given a choice, 63 percent of
patients would want this information as a paper copy. Other preferences
included CD (13 percent), secure Internet (13 percent), and other
storage device (10 percent). Forty-seven percent of respondents
indicated that they would find it useful to have the entire lung
transplant manual in an electronic format.
The survey indicates that lung transplant patients are interested in
accessing their personal health information to support their health
management. At the time of the survey, well over half of the sample
group was connected to the Internet and according to the literature, it
can be expected they are accessing health information through that
medium. This desire stems from increased self-reliance in the management
of personal health and the desire to take a more active role in the
medical decision-making process. While the effect that this information
may have on patient health outcomes is not clear, access to personal
health information is associated with improved patient satisfaction. As
patients move to a more self-reliant role in the management of their
health, the demand for personalized information will only increase.
Conclusions: We must begin to put pressure on the system to support
patients in gaining access to their own health information. As presented
herein, this is needed and soon will be demanded. Ultimately, this
inevitability has been framed by the term Patient Destiny, where
patients are actively involved in all healthcare decision-making. This
is an infeasible proposition in a paper-based system, which means we
must move to more Electronic Health Records or EHRs. Since patient
access to individual healthcare provider organizations’ health record
systems appears to be almost as unviable, due to limitations in data
format, unique patient identifiers and system constraints, one appealing
approach is to follow the path whereby patients interface with their
health-related information across the many providers in a Web 2.0
A web-based patient interface between consumers and the health system
could help patients search for quality information and link them to
resources that address their needs. In detail, the benefits for the
consumers could be as follows:
• Obtain quality health information, quickly and efficiently, based on
personal and contextual needs;
• Access an up-to-date consumer health directory with listings and
satisfaction ratings of trusted healthcare providers in Canada and
• Connect with like-minded users to share health experiences, knowledge
• Allow consumers to use monitoring tools to manage active lifestyles
and primary healthcare conditions such as blood pressure, weight and
• Provide a pathway to their own health information and expectations;
• Design a reward system for their investment in health, well-being and
where health-conscience behaviour is rewarded within a ‘point
In essence, a health sector-wide strategy of patient awareness and
education is now required. All consumers of healthcare – the healthy and
the ill – need to be presented with a forum for a comprehensive
discussion on healthcare, one that deals with the trends of rising
consumerism and greater expectations relating to information access and
delivery. We must promote an “effective and coordinated consumerism”
perspective within healthcare. Hopefully, this will provide an incentive
to all consumers to become more involved in their own care and health
management and to demand more from health providers.
Kevin J. Leonard is Associate Professor
in the Dept of Health Policy, Management & Evaluation, University of
Toronto. David Wiljer is Director, Knowledge Management and Innovation,
at Princess Margaret Hospital, University Health Network, Toronto.
Hospitals use computerized strategies to improve document workflow
By Dianne Daniel
If you were to measure the number of paper-based patient charts that get
distributed throughout Kingston General Hospital (KGH) and Hotel Dieu
Hospital (HDH) each day, you might be surprised to learn just how much
paper there is.
“People conceptually understand that there’s some activity, but even
those in the hospital don’t quite grasp the order of magnitude,” says
Eldon Dutcher, project manager, patient records improvements, at
Kingston, Ont.-based KGH. “We estimate that 78.7 feet of (stacked) paper
is handled every morning.”
Over the course of a year, that amounts to nearly 1,700 feet of paper –
almost the height of the CN Tower in Toronto – despite the fact that
both hospitals are currently using an integrated electronic patient
chart. “We’re in a hybrid situation,” notes Dutcher. “We have an
electronic chart… but unfortunately there’s also a lot of paper.”
Some of that paper stems from emergency room visits, or ambulatory and
outpatient clinic appointments, while the rest consists of handwritten
nurse or physician notes, as well as reports generated by existing
clinical information systems.
While there are projects under way to transition to electronic
documents, Dutcher expects it will take anywhere from five to 10 years
before a completely electronic chart is implemented.
In the meantime, the hospitals are launching a short-term strategy to
reduce paper by using the Computerized Patient Record (CPR) and Media
Manager products from Raleigh, N.C.-based Misys Healthcare Systems,
along with Synergize, a document imaging and indexing system from
Richmond, Hill, Ont.-based Microdea Inc.
The goal, explains Dutcher, is to capture any paper documents deemed
“likely to be referred to in future visits.” The information is then
scanned and indexed, and associated with the appropriate “event” in the
Patient Care System (Kingston’s implementation of the Misys CPR), using
Media Manager and barcodes to ensure a perfect match. Remaining paper
documents will continue to be stored with the paper charts.
“This is an interim step, a means to drive immediate benefit so
clinicians can more readily have access to information without waiting,”
says Dutcher. “Capturing an image is less than optimal, but it’s a
rational next step.”
As part of its workflow analysis, KGH and HDH have uncovered close to
900 unique document types that are potential candidates for scanning.
When they go live with their scanning effort in June, physicians will be
able to access scanned images from the same chart review screen they’re
currently using in PCS, with the added advantage of being able to zoom
in on any text or handwriting that may be unclear.
In addition to an anticipated reduction in paper consumption and
printing costs, Dutcher is also expecting a 30 percent reduction in
labour costs. Having more information readily available at the point of
care will also improve patient outcomes, he says.
“What if you were to arrive at Emergency, unconscious, with no visible
signs of trauma? The doctor’s essentially working in the blind,” he
says. “It can take up to 20 minutes to get that paper chart to a
physician. Time is life; if we had that information on-line, perhaps we
would know of some pre-existing condition.” That, of course, could make
a significant difference in the patient’s medical outcome.
It’s all about creating intelligent workflow, says Avril Cardoso,
manager of application services, information systems, at Credit Valley
Hospital in Mississauga, Ont. As part of a project called EDDIE, short
for Electronic Data and Documentation Integrated Everywhere, the
hospital has set a standard that any patient-centric documents must have
a barcode and will be centrally managed using electronic forms software
from Alpharetta, Ga.-based Optio Software Inc.
“Physicians really like having the bar-coded form because they have more
confidence that the correct documents will be attached to the right
patient,” she says.
Like KGH and HDH, Credit Valley is using scanning and indexing to
improve productivity in its health information management department.
But the current focus is on patient registration.
“Registration is a very hot topic because it’s the first touch point
with patients,” says Cardoso, noting that as more information flows
throughout the hospital electronically, the more important it is to
According to Cardoso, the hospital was encountering many issues with
workflow management in its registration areas, primarily because
registration takes place in over 40 different locations, including six
off-site areas. Moreover, registration is staffed by a mix of full-time
and part-time employees who don’t always follow the right procedures.
In particular, bills were occasionally being sent to the wrong address,
health card information was incorrect, and patient demographics were
Using the Boston Workstation from Boston Software Systems Inc. of
Sherborn, Mass., Credit Valley Hospital has found a way to automate its
registration workflow using rules-based scripting. The Windows-based
tool is embedded into the hospital’s registration system where it serves
as a sort of “electronic manager,” intervening with pop-up messages
whenever a particular process isn’t being followed.
To date the hospital has programmed 35 rules into the Boston Workstation
system and it plans to include 10 to 15 more.
Examples include rules that ensure a patient’s provincial health card is
swiped to verify name, date of birth, gender and health card number;
that the address entered matches the listing in a Canada Post database;
and that certain fields are not bypassed as a patient is registering.
“At first (administrators) were a little nervous about ‘big brother is
watching,’” notes Cardoso. “However, we tried to give back a little by
filling in information automatically that they would normally have had
to do manually.”
“I think more and more hospitals are seeing this as a real opportunity,”
notes Margaret Mayer, director of marketing at Boston Software Systems.
“It really goes to patient safety for them.”
At Credit Valley Hospital, for example, the Boston Workstation allows
the hospital to be more “intelligent” by capturing data, such as
allergic reactions and religious beliefs, at the time of registration
and feeding that information to other on-line systems.
As Cardoso explains, certain religions don’t allow the use of blood
products, so having that information available as part of an electronic
chart helps to prevent someone from receiving an unwanted treatment
The patient menu system is also fully automated so that any patient food
allergies are automatically fed to the kitchen, where every ingredient
is monitored to prevent the wrong food being served.