St. Joseph’s integrates ED documents with EHR via scanning solution
As part of a multi-phase strategy to move to an integrated electronic patient record, the 376-bed community-based teaching hospital is going live with a project to make ED paper-based charts accessible on-line. The project is the result of a two-year effort and is considered a necessary interim step on the journey towards a full-fledged electronic record.
“The reason we decided to start with Emergency is it’s a very centralized, focused chart,” says RoseAnn Pacheco, St. Joseph’s director of health records. “It is a critical department, and a lot of clinicians want to know about a patient’s ED visit.”
The project began with a comprehensive vendor selection process. Topping St. Joseph’s list of requirements were ease of use, the ability to integrate with Allscripts’ Sunrise Clinical Manager and compliance with privacy and security needs, all of which were met by Microdea Inc., of Toronto. The health centre was also pleased to work with a local vendor, says Pacheco.
Using Microdea’s Synergize for Electronic Patient Records, St. Joseph’s is scanning paper charts after patients are fully discharged from the Emergency Admissions-Discharge-Transfer (ADT) system and then making the information available hospital-wide through the familiar Sunrise Clinical Manager interface.
Rather than learning an entirely new process, clinicians simply click on a new tab in the electronic patient record, called Scanned Documents, and can access everything to do with a patient’s emergency department visit, including nurses’ notes, doctors’ notes, test results and consult notes.
“We want Sunrise Clinical Manager to be a one-stop shop for our end-users,” notes Bohdan Sadovy, project manager at St. Joseph’s. “We didn’t want them to have to leave the application and log into yet another one.”
Providing seamless integration with hospital information systems is one of Microdea’s strengths, says Colin Ruskin, the company’s vice-president of business development. “What’s unique is that we’re accommodating client needs with cost-effective, off the shelf software,” he explains. “Synergize is highly configurable, easily deployable, and is continually evolving to meet the needs of healthcare organizations.”
With 93,000 patients visiting St. Joseph’s emergency department last year, the scanning effort represents a significant volume of paper that will now be accessible on-line, eliminating the need to retrieve files from Health Records. Once the information is in Synergize, Health Records has the added advantage of controlling who has access to what, as well as what they can do with it. For example, they can restrict a chart from being printed, they can permit it to accept annotations, or they can lock it, making it impossible for anyone except those with authority to view it.
A web-enabled application, Synergize also syncs with the hospital network so that user names and passwords remain the same. “We wanted it to be a no-brainer; an application you’d be able to quickly figure your way around and I think we’ve achieved that,” says Pacheco.
One of the benefits is the ease of use of the viewer, she adds, noting that the chair of St. Joseph’s Health Records Committee, Dr. Arthur Vanek, was one of the first to use the custom tab during testing. “He just sat down and did it,” she says. Some of the features include the ability to enlarge items, view two at a time, rotate them, invert colours or zoom in and out on different sections.
Looking ahead, Pacheco hopes to replicate the scanning process in other outpatient areas that experience high volumes, like same-day surgery. For now, Health Records has made the decision not to back-scan patient records and is working on a day-forward basis. Meanwhile, scanned charts will be boxed and kept for a period of about six months before being destroyed altogether. The ongoing effort is the first step towards full on-line patient documentation, she says.
“Scanning and making our ED charts available online to clinicians is part of the foundational work that will pave the way as we move towards a complete point of care electronic patient record. Our commitment to putting patients first has even led us to rename all this work, typically understood as “eHealth”, to eCare, to better reflect how patient care will be transformed through improved processes enabled largely by technology,” says Andrew Brearton, St. Joseph’s chief information officer and chief of eCare. For more information about the eCare project please visit: www.stjoe.on.ca/about/ecare.php
‘Digital’ hospital switches on in Sault Ste. Marie
The new, 291-bed Sault Area Hospital is something unique in Ontario, and possibly in Canada – it’s a true ‘digital’ hospital in that all of its major systems are linked to its high-bandwidth computer network and can be monitored from remote locations. What’s more, these systems were all designed to work together as part of the original planning process. That’s a far cry from the usual situation, where IT is an afterthought and contractors try to adapt the completed building to accommodate the needed wired and wireless computer technology.
“It was purpose-built this way from the ground up,” commented Jeff Weeks, chief information officer at the hospital, who explained that the general contractor, Ellis Don, worked closely with Cisco Systems and integrator FlexITy Solutions to design a hospital in which all of the systems meshed. “The key feature is that IT is used to integrate everything,” said Weeks.
The integrated systems include lighting, heating and air conditioning, security and building controls. As well, Ellis Don has supplied bedside computer terminals for accessing clinical data and for patient entertainment; and an enterprise-wide WiFi network reaches every nook and cranny of the facility. The surgical suites are all wired with high-speed video connections for teaching and remote consultations with specialists at other centres.
Even the smallest annoyances can be monitored and remedied over the network. “If a lot of sun is hitting the south side of the building and heating it up, for example, we can monitor and easily adjust the temperature while leaving the north side alone,” commented Weeks, noting that this provides a much more comfortable environment for patients and staff alike.
For clinical staff, the bedside terminals should make a significant difference. They enable nurses to input their notes right at the point-of-care, instead of searching for pen and paper and entering data back at the nursing station. Physicians can call up charts and diagnostic images on the terminals and when needed, they can show test results and images to patients.
Patients themselves can use the bedside systems to access the web – the high-powered network can easily support applications like video conversations with friends and relatives via Skype, along with TV and phone calls.
The Sault Area Hospital uses Meditech as its main information system, with an Agfa PACS for diagnostic imaging. It has implemented a ‘paperless’ pharmacy, in which all orders are scanned and computerized.
Weeks noted that the hospital is currently putting together order sets, which will prepare it for its next big clinical IT project, computerized provider order entry (CPOE). That’s on the agenda for the end of year, or perhaps next year, depending on the state of readiness in the organization. “We don’t want to swallow the ocean,” quipped Weeks. “We’re already pretty busy with all of the new systems.”
Another big help for nurses – and patients – are the 250 wireless phones that are being used by nurses throughout the organization. They’re replacing an older nurse-call system that sent alerts to a central console; now, nurses receive alerts and messages from patients on the phones, anywhere in the building. That enables them to respond much faster when patients need attention.
The phones are also able to sound alarms and alerts from patient monitoring systems – letting nurses know when patients are in distress or when equipment needs a re-set.
Peter Stavropoulos, CEO of FlexITy, the project integrator, noted that the wireless system is able to support multiple virtual networks and just about any IP device. That includes the new wave of smartphones that are becoming popular with physicians and other clinicians. “We’ve tested all of them – iPhones, BlackBerrys, Motorola, Android phones. The network can support them all.” That should come in handy as doctors and nurses ask for access to the hospital information systems through their smartphones.
What’s also noteworthy and ready for prime time in the hospital is the RFID system. Stavropoulos observed that a good deal of work was put into the system to track equipment and even patients, if the hospital desires. “We’ve integrated eight or nine technologies to create the RFID system,” he said. “The result is that it can detect the location of a piece of equipment to within a foot.”
He explained that such a level of precision is crucial, because in a hospital, a difference of just six feet can put you in another room entirely. “Other systems can’t find devices down to this level of accuracy,” asserted Stavropoulos. “Ours can.”
That will likely result in savings of time and money, commented Brantz Myers, director of business development for Cisco Canada. “Hospitals tend to over-provision expensive transfusion pumps and other pieces of equipment because they can’t be found when they’re needed.” But using RFID, those missing devices can be found quickly and easily. As a result, less stockpiling of equipment is needed.
The RFID system could be used in the future for such applications as preventing the abduction of babies, added Myers. “You can create rules to detect when a baby is being moved without proper authority,” he said, explaining that when an infant is moved at the wrong time or outside of a given area, alerts can go off and security systems can be mobilized.
Myers commented that the hospital’s high-speed, medical grade network extends right into the six operating rooms, where it can be attached to a variety of cameras and scopes. “If surgeons want a remote consult, they can bring in a remote specialist in the middle of an operation. Cameras will give a view of the room, and they can give the remote specialists images of the patient, including views through endoscopes.”
He noted that connections from the hospital to other organizations will be made through eHealth Ontario’s high-speed network.
If there is anything in need of tweaking at the moment, Weeks said it would be the cellular phone reception within the hospital. “Cellular coverage is one of the headaches right now,” he said. The solution will likely be an in-building cellular system consisting of additional antennas and access points.
Nunavut improves patient care with its new electronic health record
The effort has been fuelled by a $13.7 million investment, of which $7.8 million was contributed by Canada Health Infoway.
There are enormous challenges in this EHR project – to start, Nunavut comprises an enormous land mass with few roads. It has shortages of doctors and nurses, and about the coldest weather in the country. Nonetheless, medical care must be delivered to 32,000 residents – come rain, sleet or snow storm.
Transportation is by snowmobile, SUV and cargo plane. “If we need to send a patient to a specialist, we have to send them by plane, which adds an incredible cost to providing healthcare services,” said Martin Joy, manager, information systems, Department of Health & Social Services (DHSS).
“We’re also unique in that our healthcare model is fully integrated, with all care managed by the Department of Health & Social Services (DHSS),” said Joy. “That includes public health, home care, primary care; out-patient clinics, mental health and acute care.
In Nunavut, many communities are without a doctor – in these cases, when possible, care is often delivered by nurse practitioners.
And the satellite-based infrastructure can’t sustain an electronic health record. “So the government of Nunavut is rolling out a wide-area network upgrade over the next year and a half, which coincides with deployment of the EHR,” said Joy.
The aim of the Nunavut EHR project is to provide residents with a complete health record, one that follows them throughout the entire continuum of care. A Meditech health information system is being utilized, which will help track all patient data and integrate with technologies like Picture Archiving and Communication System (PACS) and diagnostic modalities such as computed radiography and computed tomography (CT).
In Phase I, existing pharmacy, laboratory, and patient registration systems were replaced and health records, territorial-wide patient scheduling, diagnostic imaging and non-medication management order entry for physicians and clinicians were implemented, in acute-care as well as in ambulatory care areas, including public health, home care, and mental health.
Workflow analysis and system build were completed by late 2010. Training began in January 2011, and the go-live of the first four sites in Iqaluit and Cambridge Bay occurred in February, with the implementation teams working out glitches and providing ongoing support post go-live to ensure sustainability. These sites were chosen because they’re the only ones that could manage the bandwidth necessary to run the EHR.
“We’re connecting the hospital in Iqaluit and the two Regional Health Centres in Rankin Inlet and Cambridge Bay with the Health Centres in communities as small as 100 to 150 people, and as few as two staff nurses,” said David Shearing-Wittig, senior consultant and project manager with Toronto-based Healthtech Consultants, the company hired to provide overall implementation project and change management, as well as specific subject matter expertise necessary to plan, build and roll out the applications with Nunavut’s iEHR team.
As of February 7th, patient demographic information such as chart number, age and sex for the majority of the 32,000 residents had been entered into the EHR.
In phase II, scheduled to start later this year, “We’ll be implementing clinical documentation, CPOE, medication management, including bedside medication verification,” said Joy.
Phase II also includes full clinical documentation – prescription writing, medication management, and provider documentation. “And we’ll be implementing CT and diagnostic imaging into all the communities to take advantage of the PACS,” added Joy.
Staff are already starting to see some of the benefits of an electronic health record. “Clinicians in Cambridge Bay have commented on the improved access to patient information” said Terri LeFort, vice president at Healthtech Consultants. “When seeing a patient in a follow-up appointment, being able to see the previous diagnostic tests that were ordered and the results provides better clinical decision making.”
And there’s been a dramatic reduction in wait-times from the typical three to four weeks down to a few hours, as pointed out by Karen Shearing-Wittig, senior vice president at Healthtech Consultants, “We’re seeing that it’s possible to reduce the turnaround time for a DI exam from a couple of weeks to a few days. That’s an excellent return on investment.”
That’s also an incredible achievement – in any climate.
The rise and fall of HL7: The current standard is not going to last
The rise and fall of HL7. That might seem an unusual comment from the CEO of a company that’s supposed to be an HL7 middleware vendor. But times are changing and HL7 is not where I see our future. Standards do not exist in a vacuum. To be successful, standards must address market needs and solve real problems.
There are plenty of standards which are not worth the paper they are printed on because are not sufficiently useful or practical.
Complicated standards can be pushed for a while, but ultimately, the market rejects them. Even governments will ultimately reject complicated standards, through a democratic correction process – although they usually waste a fair amount of other people’s money along the way.
So back to HL7. Why was it successful?
Version 2.X of HL7 solved a very big problem for many people in healthcare IT back in the 1990s. It replaced a lot of ad hoc data sharing mechanisms used in the industry at the time.
Nevertheless, it is a lie when a vendor tries to claim they are “HL7 compliant”. The term is meaningless.
The best any vendor can ever do is provide a stream of messages with fields that map adequately to most of the data from their application.
HL7 interfaces always end up being a thin wrapper around the structure of the database of the application which feeds them. The standardization comes about because there are common ways of structuring a lot of the data. The pain comes from areas where it is unclear how to structure the data.
HL7 is working on creating the ultimate solution for healthcare interoperability – the Reference Information Model (RIM), which underlies the structure of version 3 (v3) of HL7. I think that effort is doomed to fail for these reasons:
1. There is no such thing as a single optimal data model to serve all purposes. A formal data model is always going be a square peg going into a round hole.
2. There is substantial academic criticism of the RIM that points to semantic inconsistency within the model itself.
3. It is creating complicated standards which are expensive to implement.
The only organizations spending money on v3 are governments and some big corporations like Oracle, which based its healthcare transaction base (HTB) on it. Oracle salespeople can sell ice to eskimos but I have not heard a lot of great success stories for that product.
Now let us fast-forward to what I think will become the future, JSON based web services over HTTPS. Let us look at the benefits:
1. HTTPS with authentication is analogous to LLP – only it comes with authentication and security baked in.
3. JSON data names and values give good suggestions on places to look for data.
Hmmm. Notice something? The value is just what HL7 offers. In fact, a lot more since these are very mainstream technologies that extend far beyond just the healthcare market.
That is why I am not betting the future of my company on HL7. Our value was never really as an HL7 implementation tool. The value our tools provide is the wiggle room we provide for our customers to handle the incompatibilities that occur with real world data.
Our new Iguana Translator is all about making it easy to grab data from anywhere – be it HL7, X12, XML, JSON, databases or web services and making it easy to munch, transform and consume that data.
That is the future I am betting on.
Eliot Muir is CEO of iNTERFACEWARE, based in Toronto. The company’s web site is at: www.interfaceware.com/canhealth
Across Canada, physicians and researchers develop new types of surgical robots
That’s also true of laparoscopic and other minimally invasive techniques, but image-guided, robot-assisted surgeons, robo-surgeons, have further advantages: they have much finer control over their surgical instruments; tremors that naturally occur even in the hands of the steadiest surgeons are filtered out by the robot’s software; they get a far better view of where their instruments are exactly at the moment and where they are headed next.
Also, robo-surgeons sit down on the job at the robotic console. With no need to stand they don’t tire as quickly. And the surgical robot itself tires not at all. So rotating teams of surgeons can use it continuously. Finally, no other minimally invasive technology can perform at a distance, say from a surgeon sitting in Hamilton, Ontario while operating on a patient in North Bay, some 415 kilometres away, up-province.
That’s just what Dr. Mehran Anvari did before anyone else in the world, back in 2003, building on the research into robotic technologies and techniques he began in 1995. Now the head of the federally backed Centre for Surgical Invention & Innovation (CSII) in Hamilton, Dr. Anvari and his Centre are considered among robotic surgery world leaders. But they are not alone in Canada.
Consider for example:
• In October last year, physicians from McGill University were the first to ever use a surgical robot, the market-leading, American-made daVinci robot in combination with “McSleepy,” the world’s first anesthesia robot, to perform an operation on a prostatectomy patient at Montreal General Hospital.
• Titan Medical Inc., of Toronto, is currently developing a next generation 4-armed robotic surgical system called Amadeus for operating rooms of the future. Built-in communications software will put expert surgeons “in the room” with patients no matter how far apart they are. Amadeus’s advanced haptic or force-feedback technology will keep its robo-surgeon users aware of just how hard they’re pulling on tissue or sutures.
• For just over a year now, the Hospital for Sick Children (SickKids) in Toronto has been putting a $10 million federal grant to work to further develop its “KidsArm” robotic surgical, the first of its kind in paediatric care. The hospital’s Centre for Image-Guided Innovation & Therapeutic Intervention is preparing the KidsArm for commercialization with the help of MacDonald, Dettwiler and Associates Ltd. (MDA) and Philips Canada among other companies. KidsArm will be able to work in small and delicate spaces to perform, its developers say, procedures such as suturing a baby’s tiny vessels 10 times faster than an unaided surgeon.
• IMRIS Inc., of Winnipeg, early last year bought out a Calgary company and its magnetic-resonance (MR) compatible neurosurgical robot and partnered with MDA to bring their “NeuroArm” to surgical world markets.
Dr. Anvari and his team at the CSII, backed by $14.8 million from Ottawa, are currently working on a number of robotic projects.
“At the top of our list is an image-guided system for the earlier detection and treatment of breast cancer,” says Dr. Anvari. “If everything goes well, we will have the system in use within the next two or three years. But we have other robotic applications in development ranging from spinal to trauma to micro surgery.”
The CSII’s Bone Drilling Machine is a product of Dr. Anvari’s and his staff’s know-how with robotic devices and MDA’s experience at building them, first of all for the aerospace industry. The jointly developed surgical robot will use pre-operative images, from a CT scan for example, combined with real-time sensory feedback, to automatically drill pilot holes in the spine for vertebral pedicle screws, without any damage to the spinal canal.
When perfected, the hope is the Bone Drilling Machine will be spun off to a separate company or otherwise made ready for world-wide sales.
“That commercialization is what we are focusing on, and it is one of the main reasons that we got our federal grant. It is what the Government of Canada is focusing on, too. Commercial acceleration, it’s called,” says Dr. Anvari. “Our job is to make innovations like the Bone Drilling Machine viable products. One that we have shepherded through the so-called ‘Valley of Death’ that causes so many good ideas to die before they get to the other side. We will get it to the point in that journey where a private company is going to look at it and say, gee-whiz, I think we will take this device and run with it.”
Among other devices Dr. Anvari hopes will have the same gee-whiz effect is what the CSII has dubbed the Margin Machine. For more reasons than one, there’s a need for better and faster distinction between malignant and healthy tissue. Knowing precisely where the margin is between them will help surgeons automatically make better decisions while they operate as to what should be cut, and where.
Making that distinction of margins more quickly will be particularly helpful to breast cancer patients and their doctors, who now often wait agonizingly long times before they know for sure what the nature and true size of the lesion is.
All of which keeps Dr. Anvari enthused more than 15 years after he started down the robotic surgery path: “I think it is a very exciting time in history and particularly in Canada. It’s wonderful for our country to be leading in a field where we are truly applying information technology – and it is really IT that robotic surgery is enabled by – to change the way that surgery is going to be both offered by clinicians and accessed by patients in future.”
Meanwhile, the promise of a surgical robot that can operate without generating interference in and around an MR magnet may well open up a whole new world of image-guided surgery.
“We are continuing to move forward with our robotics program, “says Brad Woods, director of corporate communications for Winnipeg-based IMRIS. “There is a clinical trial under way at Calgary’s Foothills Hospital, where we’ve got a robot integrated into an IMRISneuro suite. So we are working in close collaboration with the physicians there as we advance the robot towards commercialization.”
Until shown otherwise, Woods believes that the IMRIS surgical robot is the only one in the world that a surgeon can use together with a high-field MR scanner in the operating room: “The capabilities of the system are such that they really enhance the surgeon’s precision at performing microsurgery and biopsy-stereotaxy procedures on the brain. As well, it enables less invasive procedures generally.”
Of course, IMRIS’s MR compatible robot is not doing all that by itself. It’s got inside help.
“It has elaborate software controls that we have developed, to keep the planning of the intervention, the execution of the actual surgery and above all, patient safety top of mind,” says Woods.
Functionally, the robot features two arms that can manipulate non-magnetic and therefore MR-compatible surgical tools with great accuracy at the microscopic level – and doing all that as they are being controlled by the surgeon operating from a remote workstation.
“What the surgeon sees are three-dimensional images of both the brain and the surgical tools. The system provides what’s called ‘haptic feedback’ or in layman’s terms, a sense of touch, so that the surgeon can effectively feel through the robot and its tools, even very small anatomy,” says Woods.
What’s more, the surgeon’s work is not interrupted by the patient being shifted back and forth between traditional optical imaging devices and MR imaging. The IMRIS robot can operate without causing interference within the bore of a high-field scanner.
“That means the surgeon can have a constant view, including the structure and physiological information that MR provides, to see past where the surgical instruments are currently and also where the surgeon is headed with them next,” explains Woods.
The company first introduced its flagship IMRISneuro to world markets in 2005; its systems have gone on to be adopted around the world, including sales to five of the top 10 hospitals in the United States as ranked by US News & World report last year.
In Germany, IMRIS’s world-wide reputation for innovation in the neurosurgical, cardiovascular, and neurovascular markets preceded a first-ever installation this March of the IMRISneuro suite in Europe, at the University Hospital Tübingen in Germany, just south of Stuttgart.
At the time, neurosurgeon Dr. G.C. Feigl, the head of the hospital’s Center for Interoperative Imaging Technologies declared: “After several months of intense planning and construction we are very proud that the first state of the art iMRI unit of its kind in Europe with a mobile 1.5T magnet will be opened in our Department on April 15.”
Noted in the news release for that inaugural installation was what the IMRISneuro suite does for the hospital and its patients: “Clinical workflow and access to the patient is not impacted and the MR scanner is removed completely from the operating room when imaging is complete. This ensures a high degree of safety for both the patient and the surgical environment.”
But IMRIS did not rest on those laurels.
“In late 2009, we launched two innovations, IMRIScardio and IMRISNV, which combine the capabilities of MR and fluoroscopy in a single integrated suite,” says Woods. “We designed IMRIScardio to assist clinicians with interventional cardiovascular procedures including atrial fibrillation and structural heart disorders. IMRISNV is designed for the neurovascular market and specifically, stroke management.
But IMRIS has kept its MR eye on more than just passive imaging.
“For the past three years, we have also been very active in advancing our solution for radiation therapy,” says Woods. “In 2010 we had advanced it to the point of entering a partnership with Varian Medical. It’s the world leader in radiotherapy products for cancer treatments.
“The product we are planning jointly combines IMRIS’s MR imaging platform with Varian’s TrueBeam linear accelerator. The aim, quite literally, is to help clinicians target tumours more precisely for more effective treatment while reducing the damage to surrounding healthy tissue.”
The actual future of robotic surgery, however, remains to be seen. One barrier to making robo-surgeons of all those who wield a scalpel is the current high cost of robotic surgical systems, which can run to well over $1 million each. Feasibility studies have been done and are still underway that are trying to determine whether such an investment is worth the return.
Also there is a fairly steep learning curve associated with robotic systems, meaning surgeons may have to operate on a dozen patients or more before they are adapted to robotic ways. That, plus other training on the system, may mean at the outset that robotic operations take twice as long as traditional surgery, tying up surgical units and staff for longer, and prolonging the time in which patients are under anesthesia.
Of course, when it comes to surgical robotics, we are still in the early days. It’s quite likely that robots will in the future be integrated into operating rooms and that medical students will learn to use them as part of their initial training. At that point, they will be regarded as just another piece of standard OR equipment.
U.S. spurs e-prescribing activity through ‘meaningful use’ incentives
“Physicians and nurses are really only going to use it if the content matches their clinical processes,” Michael Hansen, CEO of medical content publisher Elsevier Health Sciences, said at February’s Healthcare Information and Management Systems Society (HIMSS) conference in Orlando, Fla.
The U.S. Office of the National Coordinator for Health Information Technology has been pushing health IT vendors to improve drug alerts as part of the national incentive program that will pay doctors and hospitals bonuses of an estimated $27 billion (U.S.) for “meaningful use” of electronic health records (EHRs) over the next seven years.
The first stage of meaningful use, which covers the first two years of a provider’s participation in the incentive program, calls on hospitals and individual providers alike to implement one CDS rule, which may include medication management. They’ll also have to enter medication orders electronically for at least 30 percent of patients to qualify. It’s likely that the CDS and CPOE requirements will grow in subsequent stages, starting in 2013.
So it’s no surprise that medication management, CPOE and clinical decision support were popular topics at HIMSS, the world’s largest health IT event – even among those from outside the U.S.
Dr. Karim Jessa, director of medical informatics at York Central Hospital in Richmond Hill, Ont., came to Orlando looking for ways to improve medication safety. York Central, which uses McKesson’s Horizon Meds Manager for pharmacy order entry, is just beginning to install CPOE house-wide, an effort that could take two to three years to complete. “In Canada, CPOE hasn’t been at the forefront,” Dr. Jessa said.
He hopes to leverage expertise from nearby North York General Hospital and Toronto East General Hospital, both of which have installed Cerner CPOE systems already. But he had more to learn, so he made the trip to HIMSS in part to attend Elsevier’s launch of its Smart Content Initiative, featuring a new classification system that’s intended to bring clinical knowledge closer to the point of care.
So far, York Central has created some order sets, mostly on paper. “Eventually we will be able to embed alerts at the point of care as our CPOE project rolls out,” said Dr. Jessa, who practices emergency medicine.
The new Elsevier approach integrates content into EHRs and presents what Dr. Jonathan Teich, Elsevier’s chief medical informatics officer, called “digital nuggets of information.” Exclamation points on the EHR screen shows where new information might be available.
Numerous vendors at HIMSS also talked about avoiding a side effect of CDS gone amok, namely alert fatigue that causes physicians to tune out.
“Information has to be consistent and current,” said Dr. Teich, who still sees patients one night a week in the emergency department of Brigham and Women’s Hospital in Boston. In the context of medication management, CDS has to keep up with new literature on off-label uses, as well as drug approvals and recalls.
One HIMSS session actually focused on improving safety in the scheduling and administration of medication orders at Brigham and Women’s, though that was among the hematology and oncology populations.
In that case, the hospital set up a Web-based chemotherapy ordering system, then linked it to the pharmacy system and re-worked order entry processes to improve on the existing electronic medication administration record (eMAR). The new eMAR provides warnings when chemo agents are administered out of sequence and when the nurse doesn’t electronically verify the drug label at the bedside.
After three years and US$3 million devoted to improving the eMAR in chemotherapy, Brigham and Women’s was set to extend the system to the neonatal intensive care unit and newborn well-baby area in April. Eventually, the hospital will roll out the design to all inpatient wards and integrate the system with smart infusion pumps.
Mobile and wireless technology are helping to transform medication management, too. Charles J. Still, project manager of information systems for Southwestern Vermont Health Care and a health IT consultant, gave a presentation at HIMSS in which he noted that it’s virtually impossible to make bedside medication scanning work without a reliable wireless network in the hospital.
On the show floor, healthcare analytics firm NaviNet introduced NaviNet Mobile Connect, a mobile communications platform designed by former Apple developers in order to integrate messaging from health insurers and disease management companies into clinical workflow. (In the U.S., doctors and patients alike often ignore such messages, in part because they don’t trust commercial health plans.)
At the heart of NaviNet Mobile Connect is technology from Prematics, an e-prescribing vendor that NaviNet bought late last year. NaviNet Chief Medical Officer Dr. S. Michael Ross, who came over from Prematics, said that 90 percent of primary care encounters involve at least one prescription, offering a perfect opportunity to provide educational material to patients.
“E-prescribing’s a Trojan horse for us,” Ross said. “E-prescribing gets you into a provider workflow.”
With the system, case managers from insurance companies and other plan sponsors – large employers in the U.S. spend billions on health benefits for their workers – can send clinical messages before the physician generates a prescription, Ross said, to make sure that patients get the right drugs.
Real-time integration with e-prescribing data hub Surescripts lets patients know at the time the doctor writes a script exactly how much they will owe at the pharmacy and can automatically substitute generic versions of drugs if the prescriber sets it that way. Patients leave the office with a printout, including an area with a clearly marked “sponsored” message with adherence information.
Just as importantly, the NaviNet system offers two-way communication, so the physician can “close the loop” by telling the payer if a recommended procedure or consultation was, was not or will be done. “It gets the message volume to stop,” Ross said.
“You’ll get more patient behaviour change if it comes from the physician,” added Scott Rybak, NaviNet vice president of business development and partner management.
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