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Inside the May 2010 print edition of Canadian Healthcare Technology:

Feature report: Electronic health records

British Columbia re-jigs its approach to the EHR
British Columbia’s auditor general was not able to find many good things to say about the province’s electronic health records project.


Leading-edge cancer treatment centre opens
Southlake Regional Health Centre, in Newmarket, Ontario, is opening a new cancer treatment centre as part of a $110 million investment in oncology programs.


High-tech cardiac research
A new, $100 million cardiac and stroke research centre in Hamilton, Ont., brings together top research teams and provides them with cutting-edge labs, offices and high-powered computing infrastructure.


Minimally invasive surgery
Montreal’s CHUM has launched a centre specializing in minimally invasive surgery for problems of the lungs, airways and esophaegus. Using endoscopic techniques, the facility has rapidly become a referral centre for Quebec.


Surgical and anesthetic information systems
Automating the heart of the hospital: They’re lowering wait times and costs, improving patient safety, and boosting physician productivity.


Perils of procurement
Hospitals must build flexibility into their requests for proposals, in case conditions change or the vendors who respond don’t offer up what’s needed. At the same time, vendors must understand why an RFP is sometimes changed or cancelled.

How to install a new lab
Hospitals in Sherbrooke, Quebec have pioneered a novel method of implementing laboratory facilities and technology. They partnered with a vendor for a complete installation, and the lab will pay for itself through productivity gains.

PLUS news stories, analysis, and features and more.


British Columbia re-jigs its approach to the EHR

By Paul Brent

British Columbia’s auditor general was not able to find many good things to say about the province’s electronic health records project. In a scathing report issued in February, he had a long list of things that have gone wrong with the five-year-old program: it’s behind schedule, over budget, not well planned and still failing to deliver promised benefits to patients, the government watchdog found.

Canada’s western-most province entered the $150-million program as part of a national, federally funded effort intended to make electronic records portable from province to province. In B.C.’s case, getting from concept to reality has been far from simple.

Originally, the B.C. Liberal government estimated an EHR program would cost $150 million, with as much as $110 million of that paid for by Ottawa. Last fall, the estimated capital cost had run up to $222 million. Originally, the B.C. government perhaps optimistically said its system would be operating by 2008; now it expects full implementation in 2013.

B.C. has yet to see most of the federal money, because payouts are based upon the provincial health ministry meeting national standards mandated by Canada Health Infoway. “Provinces usually receive 20 percent of project funding when a project agreement is signed and 30 percent after [the agency] approves project products, such as project charters and system design documents,” B.C.’s auditor general John Doyle stated in his recent report. So far, B.C. had collected only $46 million from Infoway.

“The remaining 50 percent of funding is tied to the adoption, or demonstrated use, of systems by healthcare providers. Linking 50 percent of funding to adoption provides some assurance to Infoway that electronic health record (EHR) systems are being used and is an incentive to provinces to enable adoption,” noted Doyle.

So what has gone wrong so far and what’s being done to fix it? Staff turnover, different viewing systems and the lack of a coherent implementation plan with established milestones to determine early success.

The provincial auditor identified “[t]urnover in senior management” at the health services ministry as well as the “sudden change in the assistant deputy minister” as a major cause for the EHR plan to go off the rails. In 2007, the assistant deputy minister in charge of eHealth, Ron Danderfer, left the ministry and this March was made the subject of breach of trust and fraud charges by a special prosecutor.

Danderfer played a major role in securing funding for the EHR program. “He created a significant fund flow into the ministry to develop eHealth software assets,” said Brian Shorter, a former chief information officer who is currently an independent healthcare IT consultant. “He had talked Infoway into co-funding, but he just didn’t get the (province’s) health authorities on board….Inevitably, the health authorities went off and did their own thing.” As the auditor general’s report commented, each B.C. health authority has developed or purchased its own viewer.

B.C.’s eHealth architect was forced to leave with the program far enough along that his replacement had no choice but to follow through on the original plan, said Shorter. “Any semblance of knowledge and understanding of the healthcare system and eHealth disappeared with Ron Danderfer and his troops and [his replacement] had to try and pick it up and unfortunately, it didn’t move as fast as she would like.”

B.C.’s Health ministry has belatedly begun tracking the progress. “As the Auditor General noted, the ministry has made significant strides in its development of the program and now has most of the mechanisms already either in place or in development to successfully deploy,” stated B.C. health minister Kevin Falcon after the auditor general’s report.

“A new Health Sector Information Management/Information Technology (IM/IT) Strategy has been endorsed and is available via the Ministry’s website,” Falcon said. “A new Tactical Plan guiding eHealth deployment has been produced and is being updated regularly, and improved eHealth reporting processes are being implemented.”

On the issue of EHR planning, the B.C. ministry last July completed the first version of a health sector IM/IT strategy which has been endorsed by the provincial eHealth Strategy Council (made up of B.C.’s six health authorities, the College of Pharmacists, the College of Physicians & Surgeons, the BC Medical Association and other health sector stakeholder organizations).

This formal strategy provides information management/information technology direction for all B.C. healthcare delivery organizations. The ministry says its strategy document will be updated annually.

With regard to the auditor general’s recommendation that the ministry develop a comprehensive plan for implementation of eHealth, the ministry states in an email that “a review of existing component plans and previous versions of integrated workplans has been carried out to identify gaps and determine requirements for a current and comprehensive plan” and that a new eHealth Director’s Forum of eHealth project managers has been created “to develop and manage against an integrated deployment plan.”

In accordance with the auditor general’s finding that the minister has to do a better job measuring program quality, completion and full costs, the ministry said its deployment plan “will include milestone targets and associated costs against which progress will be monitored and reported.”



Newmarket’s cancer centre includes many leading-edge technologies

By Neil Zeidenberg

NEWMARKET, ONT. – Many Ontario cancer patients should see their wait times dramatically reduced, thanks to the opening of the first radiation therapy centre in a heavily populated region just north of Toronto.

The Stronach Regional Cancer Centre, at Southlake Regional Health Centre in Newmarket – part of the hospital’s $110 million regional cancer program – is Ontario’s 14th radiation therapy facility. Staff at the centre expect to treat 30-40 patients daily, and up to 1,500 annually.

“Southlake’s cancer program, with the addition of radiation therapy, is designed to ensure patients receive the highest quality of care, in a timely fashion, as close to home as possible,” said Dr. Louis Balogh, vice president for cancer programs at Southlake and vice-president of Cancer Care Ontario.

Patients in York and Simcoe regions will save three hours or more travel-time to downtown Toronto by going instead to Newmarket.

Each treatment room at The Stronach Regional Cancer Centre at Southlake is equipped with leading-edge radiation technologies like Image-Guided Radiation Therapy (IGRT) and Intensity Modulated Radiation Therapy (IMRT). The suites are outfitted with video cameras and audio so the radiation team can watch and communicate with patients at all times.

The centre also benefits from the implementation of a Philips Brilliance Big Bore CT Simulator, and Elekta Infinity Linear Accelerators, also referred to as LINAC.

A CT simulator creates images that help determine the best position for the patient according to the location of their tumour. Based on these images, an appropriate treatment plan is designed that targets just the cancer cells while sparing vital organs and healthy tissue. The Linear Accelerator then delivers the actual radiation with precision to the tumour.

IGRT helps deliver the cancer treatments with higher accuracy. As with the CT Simulator, patients are positioned by the radiation team and a 3D image is created and compared to the CT simulation. Since tumors can shift slightly between treatments, computer-based calculations are applied to the data to ensure the patient is in the best possible position prior to treatment.

The cancer centre is equipped with three identical Elekta Infinity Linear Accelerators (LINACs) that are also used to deliver radiation therapy treatments. The Elekta Infinity emits a high energy X-ray that is directed at deep-seated tumours. Multiple X-ray beams at different angles are used, while special technology again helps spare surrounding tissue.

The centre has the capacity to house three additional LINACs. Based on population and the need to treat cancer, it is expected that six machines will be operational by 2012.

“This sophisticated equipment enables the healthcare team to more accurately target the area requiring treatment,” said Dr. Woodrow Wells, medical director of radiation medicine, Stronach Regional Cancer Centre. For patients, it means shorter treatment times and fewer side-effects. Treatments are painless and completed in as little as 10 minutes.

The Stronach Regional Cancer Centre is also unique in that it’s being launched in partnership with Princess Margaret Hospital, the first of its kind in Ontario.

“It’s rare to find an arrangement where a new centre pairs with an established, internationally renowned cancer centre,” said Dr. Padraig Warde, provincial head, radiation treatment program of Cancer Care Ontario, and deputy head of radiation at Princess Margaret Hospital.

The two hospitals will collaborate on research and visits by physicians, physicists and radiation therapists.

By the time the Stronach Regional Cancer Centre at Southlake officially opens in June, it will operate three fully equipped radiation treatment rooms, a 23-chair chemotherapy unit, two multidisciplinary out-patient clinics, and space for clinical procedure, drug and equipment trials.



$100 million cardiac research centre will conduct global studies

By Jerry Zeidenberg

HAMILTON, ONT. – Hamilton Health Sciences gave a big boost to its world-leading cardiology researchers in March with the opening of a $100 million facility. The new David Braley Cardiac, Vascular and Stroke Research Institute, at the Hamilton General Hospital site, brings together two top research teams and provides them with cutting-edge laboratories, offices and high-powered computing infrastructure.

It also houses Canada’s largest biobank, which stores more than 1.8 million tissue and genetic research samples from approximately 250,000 participants globally. The new, six-storey building is named after business leader David Braley, who donated $10 million to the project.

Additional money was raised through competitive grants from the Canada Foundation for Innovation and the Canadian Institutes of Health Research.

The institute combines the Population Health Research Institute (PHRI), led by executive director Dr. Salim Yusuf, and the Thrombosis and Atherosclerosis Research Institute (TaARI), led by director Dr. Jeffrey Weitz. Working side-by-side for the first time, the two teams are conducting various tests and trials in 83 countries around the world, at 1,500 different centres.

“There’s only three places in the world that do what we do, which is cardiovascular clinical trials on a global scale,” commented Andrew Renner, director of information and communication technologies at the new centre. “There’s Oxford University, Duke University research institute, and us.”

PHRI and TaARI are expanding rapidly and together they attract more than $150 million in research funding each year. Major funders include the Canadian Institutes of Health Research, the Heart and Stroke Foundation of Ontario and several international pharmaceutical companies.

Underpinning the centre’s research and international data collection is a powerful data centre and communications network – indeed, the facility invested about $3 million in computer and telecomm equipment, including software.

“The entire network is from Cisco, with fibre everywhere,” noted Renner. There’s 200 terabytes of storage in the data centre, where NetApp storage systems are used, with redundancy at a remote back up facility.

Moreover, much thought has been put into securing the data and the networks. “We’re audited [for security] about 15 times a year, from regulatory agencies and pharmaceutical companies who want to make sure that their data is safe,” said Renner.

Researchers will benefit from an investment in 60 Dell servers and 10 Unix-based Sun servers – giving them lots of power for number crunching and 3D modelling.

“Our biggest growth area in the future will be genetic research,” said Renner, explaining that the data collected about each genetic sample can be massive. “That’s why we’re looking at such large data storage systems.”

Also important are the communication systems, as data are collected from over 80 countries, with questionnaires delivered in many languages. To make consolidating the information as easy as possible, the centre uses forms with a preponderance of check boxes, rather than text answers.

Those forms are often received as faxes, as many sites conducting research are developing countries where fax machines are popular. “Fax is still the easiest way to get information out in many countries,” said Renner.

The Braley Research Institute uses fax servers to receive these forms, outfitted with intelligent character recognition to convert the documents into computerized files.

Other interfaces include IVR, so that results can be phoned in, with voice responses in 17 different languages. The IVR system is primarily used for enrolments, so that researchers can acquire ID numbers and start the ball rolling to receive the kits they need.

For the more technologically advanced, there are also web-based interfaces.

Renner noted that the institute benefits from the ethnically diverse population of Hamilton and the surrounding region. Many of the researchers and staff speak languages in addition to English, which is an immense help when coordinating projects in countries around the globe.

According to a news release issues by Hamilton Health Sciences, “PHRI and TaARI have international reputations for innovation and excellence. PHRI conducts clinical trials in 83 countries focusing on cardiovascular disease, diabetes, obesity and the societal influences on health such as ethnicity and geography. TaARI (formerly the Henderson Research Centre) made history almost 30 years ago with the world’s first clinical trial demonstrating the effectiveness of using aspirin to prevent stroke. Since then, TaARI has become an international leader in research on vascular disease, specifically blood clots.”

“Investigators at the Population Health Research Institute have made major contributions to understanding the causes of heart attack and stroke worldwide, and what can be done to prevent and treat these conditions for the benefit of millions of individuals,” said Dr. Yusuf, who is also the vice president of research and chief scientific officer at Hamilton Health Sciences. “This new research facility brings this important group together with another world class basic science team headed by Dr. Weitz. The synergy between these two teams will substantially increase the innovation and momentum of a range of different types of research activities.”



Montreal specialists establish minimally invasive surgical centre

MONTREAL – A new endoscopic airway and esophageal facility has opened at the Centre Hospitalier de l’Université de Montréal (CHUM), with an initial investment of over $1 million.

The CHUM Endoscopic Tracheobronchial and Oesophageal Centre (CETOC), located at the Notre Dame Hospital, is a minimally invasive, endoluminal diagnostic and therapeutic centre that offers diagnosis, staging and treatment for diseases of the airways, lungs, esophagus, stomach and mediastinum.

This new and innovative centre, which was opened in May of 2009 by the Division of Thoracic Surgery at the CHUM, has already treated more than 250 patients using minimally invasive techniques. Surgeons at the centre utilize the body’s natural orifices (esophagus and trachea) to perform endoscopic surgical resection, tumor targeting and ultrasound of the lung, esophagus, stomach and mediastinum.

CETOC has also become a major referral base in the province of Quebec for complex airway problems. These difficult patients are offered a multidimensional and multidisciplinary approach to the treatment of life threatening airway problems.

Using a combined approach to the airway and esophagus during simultaneous procedures, CETOC physicians are able to provide a comprehensive approach to not only the treatment of diseases in the chest, but also to palliation of esophageal cancer and tracheo-bronchial tumors.

The centre is conducting leading-edge work. “We are pioneering combined endobronchial ultrasound and endoscopic ultrasound procedures, as well as double-stenting – of the airway and esophagus –as a combined treatment for airway and esophageal disease,” said Dr. Moishe Liberman, a thoracic surgeon and director of CETOC. “We’ve received a Canada Foundation for Innovation grant for infrastructure related to our research in endoscopic technology.”

Thanks also to the support of the Thoracic Surgery Research Foundation of Montreal, CETOC has been equipped with state-of-the-art endoscopic and echoendoscopic equipment, which is benefiting the patients of Quebec every day. Patients are currently being referred from across the province for the various endoscopic procedures performed at CETOC.

Currently, four surgeons and a full-time research nurse are working at CETOC, along with clinical and research fellows and nursing and administrative staff.

The centre is running an international symposium in June which will feature new endoscopic technology and includes international speakers. More information about the event can be found at:

CETOC is not only of benefit to patients using its minimally invasive approach to patient diagnosis, staging and treatment; it also benefits the healthcare system by preventing major surgical procedures which can now be obviated using endoscopic approaches.

Patients can often be treated on an outpatient basis in a one-stop shopping approach to diagnosis, staging, treatment and palliation. This is an amazing advancement, said Dr. Liberman, and one that is especially necessary in the overburdened healthcare system in Quebec.



Surgical and anesthetic information systems: Automating the heart of the hospital

By Andy Shaw

The pilot projects have flown the coop and the tinkering is over. In their place, new industrial-strength surgical and anesthetic information systems can now be found working daily at their digital doings – lowering wait times and costs, heightening patient safety, boosting physician productivity, and even adding to hospital coffers – without any paper or even a fax machine in sight. And nowhere is this more true than in Kingston, Ontario.

Every surgical patient in the “Limestone City” is now an electronic record holder. Streaming through the city’s two hospitals – to Kingston General Hospital (KGH) for acute care and to Hotel Dieu for ambulatory work – are over 16,000 surgical patients annually. All electronically captured, scheduled, and tracked on a remarkable, home-grown surgical access system from Novari Health.

No less remarkable is a similar and also home-grown clinical anesthetic information system (CAIS) from Adjuvant Informatics that’s been breathing new life into pre-operative care at the three-hospital University Health Network (UHN) in Toronto. Dedicated nurses use a structured questionnaire to feed a powerful suite of intelligent CAIS software tools with patient data gathered at a pre-admission anesthesia clinic. The result is an electronic medical record that gives clinic staff and the operating surgeon a comprehensive “patient pre-operative assessment” of their readiness to undergo an operation. The case anesthesiologist also uses the record on the day of surgery.

That multi-use is no accident. The CAIS is meant to serve all.

“Our mission is to synthesize clinical data into meaningful knowledge that vastly improves the decision-making process for physicians, clinicians, and hospital management,” explains Adjuvant’s president and CEO, Dan Meyer. “Producing a standardized and thorough preoperative medical record achieves that goal.

“After a formal structured nursing questionnaire, the anesthetist then interviews the patient, decides about any further testing, and then suggests an anesthetic plan for the operation,” explains Mr. Meyer. “Our system then enables the physician to create a formal physician consult document and sends it immediately to the doctor performing the surgery.”

All of this, of course, can and traditionally has been done on paper. But that’s where CAIS’s electronic nature comes to the fore.

“Ensuring that all lab results and other investigations are followed up and reviewed is an error-prone and laborious task in a paper system,” says Meyer. “But an electronic system simplifies and formalizes how to handle abnormal values. Steps don’t get missed.”

The basic CAIS steps of a structured questionnaire – the physician consult, and investigation follow up – have won high approval of pre-admission clinic users at UHN.
“We just launched version 2.0 of the pre-admission software and it too has been received very well,” says Meyer. “And I think that has a lot to do with the UHN user groups who helped us develop the software. Their input really helped improve the collaboration between clerks, nurses, physicians, and administrators that is needed to operate a modern day pre-admission clinic.”

For four years, the UHN’s Dr. Scott Beattie, one of the country’s top anesthesia researchers and an expert on peri-operative outcomes has provided the vision and leadership that has facilitated the multi-million dollar project.

As it is now developed and deployed, the CAIS system has shown at UHN that it can:

• eliminate the need for transcription and dictation
• reduce lab orders and other investigations
• lower the incidence of cancelled OR bookings
• improve ICU usage
• reduce adverse events
• shorten hospital stays.

“We can validate that a large hospital can save $250,000 a year with the CAIS system,” says Adjuvant’s Meyer. “And we believe savings will increase significantly as a hospital implements new modules of the software.

All that, not surprisingly, has impressed UHN’s chief surgeon, Dr. Bryce Taylor.

“In my view, Dr. Beattie has really taken the leadership on this and made CAIS system a highly valuable tool, both for the patient and for our healthcare team. It also promises to decrease duplication, improve our accuracy, and undoubtedly better clarify risk factors for every patient undergoing surgery at UHN,” says Dr. Taylor. “But also, the more information you put into the system, the more mature and better it gets at helping you decide about what test to do next or whether the patient needs an anesthetic consultation. That’s going to be attractive to a lot of other hospitals and healthcare organizations.”

CEO Meyer at Adjuvant agrees.

“A Rand Corporation study recently estimated that in the United States, for example, healthcare spending could come down by 30 percent – if patients routinely received evidence-based care. So we believe our prognosticating, evidence-based CAIS system can be part of the solution healthcare authorities in Canada, the U.S. and worldwide are all seeking.”

Meanwhile in Kingston, the Novari Surgical Access (SA) system also has a pre-surgical module like the Adjuvant CAIS software, but the rest of the uniquely web-based system concerns itself more with work and information flowing through a hospital’s surgical care from beginning to end. At the beginning, one Novari SA “Smart Wait” module helps surgeons’ offices manage their list of upcoming cases. At the end, another module generates a mandated report to Ontario’s provincial wait-time authorities – automatically.

“It really does keep my practice organized,” says Kingston orthopaedic surgeon Dr. Davide Bardana. “I am a high volume guy. I probably handle 30 to 40 cases a month and my wait list is about 295. So that’s a lot of people to keep straight.”

Dr. Bardana, whose surgical patients include many varsity athletes from Queen’s University and Kingston high schools, says the Novari SA keeps his office on top of who should be seen, when, and it links directly with the OR booking systems at both KGH and Hotel Dieu.

“There is no paperwork or faxes flying between our office and the hospitals anymore,” says Dr. Bardana. “Everything is electronic and as a result everything, including my wait time, gets automatically documented. It is a marvellous convenience.”

Tracy Kent-Hillis at KGH shares Dr. Bardana’s enthusiasm for the system. She is KGH’s program director of surgical, perioperative, and anesthesiology, but also handles OR bookings at Hotel Dieu.

“We helped Novari design the system so that surgeons could get past managing their wait lists in inefficient, mechanical ways, including reminder notes stuck in their back pockets,” says Kent-Hillis. “With Novari they can tell at a glance how long their patients have been waiting to see them. It also provides “urgency scores” of how ill the patient is, if they’ve cancelled a booking, or what kind of testing they need.

“That has eliminated most of the paper in their offices, but most importantly to us is their access to the electronic booking forms for our operating rooms. So both the workflows of the surgeons and ours have improved.”

So have KGH’s and Hotel Dieu’s cash flows.

“From an administrative perspective, Novari keeps me informed about our volumes. We have contracts that stipulate we must meet certain volumes of procedures, and it lets me know how near or far off we are from those commitments. Before Novari, I had no way of knowing that with a paper-based system until operations and cases were completed,” says Kent-Hillis.

From a patient’s perspective, Novari can also bring some comfort.

“I can look at what we call ‘acquisition rates’ and use Novari to do up custom reports about them,” explains Kent-Hillis. “If we are interested in prostate cancer waits, for example, I can see how many patients we’ve acquired and are waiting, as well as what the trend has been for the previous six months. Then we can make adjustments to our OR schedules.”

There is another financial benefit to using Novari, though it was unintentional, according to John Sinclair, Novari Health’s director of business development.

“We didn’t develop the product with this in mind, but in Ontario and I believe in British Columbia now too, the provincial health ministries have set aside a pool of money to help shorten the longest surgical wait lists, such as hip replacements. In other words, they’re saying we’ll give you thousands of dollars more for each one if you’ll do more hips. So now, people like Tracy can look at their own hip-replacement lists and re-allocate time in the ORs to give the orthopaedic surgeons an extra block of time every two weeks, say. So it’s another way of maximizing hospital revenue.”

As valuable as that may be, the Novari SA, developed with the help of Queen’s University medical staff and researchers including Dr. Bardana, also boosts something that’s invaluable – patient safety.

“Dr. Bardana has told me that he also values the system because it doesn’t allow patients to get lost,” says Mr. Sinclair. “Let’s say after he has seen you that he has put you down for a procedure in OR in three months time. But now you are two-and-a-half months out and you are not yet on the OR schedule. When Dr. Bardana’s assistant logs on that day, she’ll get an alert saying she needs to confirm an OR booking for you.”

Also, Sinclair points out, the Novari SA “knows” if you had to cancel a booking because of illness or a bad snowstorm, for example, and it raises you up automatically to a higher priority in the wait list.

This sophistication of a small company’s software has not escaped the notice of the larger healthcare organizations.

“We’re certainly in a space with some big fish,” says Sinclair. “We have relationships with IBM, GE, and Sierra Systems among others. Novari SA can interface with existing hospital OR systems to include McKesson, GE and others. We’ve also had a number of visitors to Kingston and expressions of interest from providers in the United States.”

American visitors see the Novari SA in quite a different light.

“For them, wait lists are not really a concern. They see it more as a loyalty and revenue tool,” says Sinclair. “If there are two surgery centres in town and one of them makes booking patients for surgery electronic and thus so much easier than the other, then that’s the centre that you’re most likely to send your surgical work to.”

This is not to say that in the 1976 Olympic Yachting city of Kingston, that getting Novari SA widely accepted was all smooth sailing.

“Skepticism was certainly one of our challenges,” says KGH’s Kent-Hillis. “There was a fear that the system would create additional work for physician’s offices. So we established a number of champions and involved the doctors’ medical advisory council. Starting five years ago, it took another two years for the last doctor to come on board. But now we have all the surgeons in Kingston on the system.”

Dr. Bardana was not among those that needed much work to convince.

“Because the system documents everything, when I say to officials that I need more resources, they can’t tell me: ‘Oh, you’re just saying that.’. I can show them up-to-the-minute numbers connected with my work, because they are right at hand from Novari. So there’s no argument,” said Dr. Bardana over his cell phone recently as he walked home to wife and children over Kingston’s limestone pathways.

En route, he added: “Now I wish we could roll out a similar system for our clinical appointments. We handle our surgical appointments with Novari but for our clinical appointments, we still use paper and a three-ring binder. So I use both systems – but I know which one is by far the best.”