Women’s College: the future of ambulatory I.T.
TORONTO – Women’s College Hospital in downtown Toronto will soon move next door to its new building, an edifice that’s designed to modernize its role as a same-day healthcare centre. Along with the move will come an ambitious, out-patient charting solution not seen before in Canada – the first installation of an Epic Systems electronic patient record (EPR) in a large, ambulatory hospital.
The project has been overseen by Sam Marafioti, who in addition to his duties as vice president of corporate strategy and chief information officer for Sunnybrook Health Sciences Centre, also assumed the mantle of CIO for Women’s College Hospital.
“I took the leadership role of also being CIO at Women’s College to help them make their move next door to their new building, and strategically make sure they had the right information and communications technology infrastructure in place,” explains Marafioti. “But to be frank, I did it most of all for the chance to create Canada’s first-ever electronic patient record system designed specifically for an ambulatory hospital.”
Marafioti has a wealth of experience with electronic charting systems. He and his staff at Sunnybrook have done exemplary work with their unique “MyChart” record and “SunnyCare” system that keeps tabs on patient and clinical information throughout that sprawling hospital and its myriad departments.
But the Women’s College ambulatory EPR must do all that; then go far beyond the hospital walls and connect with every other hospital, clinic, and doctor’s office out there that its patients have been sent from or are likely to amble into.
Add to the ambulatory EPR challenge the different needs physicians working in out-patient clinics have: integration with their provincial health insurance scheme, such as OHIP in Ontario, so that they can bill for services; more continuous encounter notes; and categories of care different from or less structured than those found in traditional hospital EPRs.
Indeed, as the battle against rising healthcare and hospital costs across the country mounts, what Marafioti and Women’s College are attempting will be watched closely to see if they succeed.
In terms of funding, Canada Health Infoway will invest up to $5.9 million in the ambulatory hospital EPR at Women’s College, while the hospital will contribute at least another $5.2 million.
With that investment, Women’s College Hospital is betting on Epic Systems, a medical software company based in Verona, Wisconsin with no major installations in Canada outside of a mainly in-patient record system for the Children’s Hospital of Eastern Ontario (CHEO) in Ottawa, and a few clinics in Alberta.
In Toronto, EpicCare Ambulatory Clinical System will be the heart of the Women’s College EPR. Perhaps not so surprising a choice, however, knowing that as of March this year 100 percent of the ambulatory care practices that have reached the HIMSS Analytics Stage 6 certification are all using the Epic EPR.
“Epic is rated as number one in every survey,” says Marafioti. “They are off the Richter scale in terms of customer satisfaction. And that’s partly because they started out as an ambulatory practice and it is still run and owned by the same CEO [billionaire Judy Faulkner, who started the company in 1979].
Laura Viola, a nurse by training, and later an MBA who gained experience in academic and community hospital settings and with a major consulting firm, is the project manager for what Women’s College is officially calling its ‘ambulatory electronic patient record’ or aEPR for short.
Viola’s hospital board-of-directors-approved two-year project timeline calls for an initial roll-out by Fall 2014 of the aEPR, going live with registration and scheduling, and staged implementation of key clinical functionality including computerized order entry and structured clinical documentation.
More specifically at that time, the aEPR will have to show that it can deliver clinical value in a minimum five different fundamental functions. Among them, it must show that aEPR users can: register patients; enter encounter notes, problem lists, allergies, vital signs, or prescriptions; generate automated alerts or reminders; receive lab results or diagnostic imaging reports; access clinical reports or encounter summaries; as well as produce referral or consultation reports.
Two months later in December, Viola, Marafioti, and the aEPR project staff have a second go-live commitment to confirm that aEPR users can also access the Ontario Laboratories Information System (OLIS).
“It’s about a 24-month rollout in all, and we are confident we can do that – given first of all that we have Epic, the top EPR product in hand,” says Marafioti. “Indeed, what we are doing with Epic in the design of this new, all ambulatory care Women’s College Hospital, is not to adapt it to what the hospital does but to make EpicCare the ‘agent of change’ for the very way it provides that care. And that’s a very important concept. It’s not something that’s normally done in hospitals. Usually, an IT project is an enabler of change, but not the strategic change agent itself.”
That naturally raises the question of how well-accepted EpicCare and its manifestations are likely to be received by clinicians and caregivers using it both inside and outside of Women’s College’s shimmering new glass walls.
“What’s encouraging is that so far, I’ve encountered strong support and anticipation for the aEPR among the clinicians we’ll be working with at Women’s College. I sense no real resistance to change as we start out, but know that this change will be a challenge. Strong clinician support will be critical.”
The rollout nonetheless entails not only working out re-designed workflows but using as much common documentation as possible for the 50 different clinics Women’s College houses or supports, such as its walk-in after cancer care treatment clinic, or its pain management clinic, or its sports medicine clinic.
“In the end, EpicCare will be the common hub for all of them. But then will come the external connections back to hospitals like University Health Network; back to the family doctors; and back to the community care centres; back to the pharmacies; back to the labs who also have those same patients in their keep. And that connecting up is precisely what the Epic people have proven they do so well,” says Marafioti.
But Marafioti, Viola, and Women’s College have more than the singular aim of simply being a state-of-the-art ambulatory hospital. They want to be a model for the rest of Canada, if not the world.
“It’s all about fixing the problem of high cost in-patient care that we haven’t really addressed yet. But we must. It is the ultimate need we face. So in that sense, it is the last piece of the healthcare IT puzzle and I would be very proud to help put it in place,” concludes Marafioti.
Hospitals make progress in linking silos of electronic information
Mackenzie Health in Richmond Hill, Ont., and nearby Southlake Regional Health Centre, in Newmarket, are together forging ahead with a ground-breaking project to make the records of mental-health patients accessible to the various healthcare providers they encounter.
For the first time, physicians, nurses and other clinicians in the Emergency Department, outpatient clinics and inpatient departments will all have access to each other’s computerized records for mental health patients. That’s expected to improve care by dramatically improving the amount and quality of data to which care-givers have access. They will be able to make decisions with more background information, thereby improving outcomes and reducing the number of return visits to the hospitals.
“Traditionally, I.T. for mental health hasn’t been well-funded, and as a result, patient information has been very much siloed,” said Michael Martineau, vice president of B Sharp Technologies Inc., of Toronto, the company that is supplying the clinical documentation software for the project.
“This has meant that care-givers haven’t had the information they need, and patients aren’t always handled as well as they should,” added Martineau. “Too often, the patients end up back in hospital, and costs escalate.”
The new solution, called the Ambulatory Electronic Mental Health Record (AEMHR), is meant to increase the information that clinicians have available, so they’re able to improve the hand-offs of patients between healthcare team members and keep patients healthy and out of acute-care centres.
The foundation of the AEMHR is an innovative platform supplied by RelayHealth, which allows for inter-operability between any number of disparate systems. It is being used to connect the variety of ER, outpatient and inpatient systems used at the two hospitals.
In future, it will serve as the springboard for connecting even more departments at the two hospitals, providing additional record sharing. What’s more, plans are afoot to open the system to patient access, creating a personal health record for patients and their families.
The AEMHR project was awarded $1 million in funding from Canada Health Infoway, and the hospitals are also contributing cash and human resources.
Diane Salois-Swallow, chief information officer for both hospitals, explained the AEMHR project is halfway through its two-year build-out stage. It’s going well, she said, because it received immediate approval from the hospital’s clinicians.
“I thought it might be difficult to obtain their buy-in,” said Salois-Swallow, “but they immediately saw the value in it. So have the staff.”
One of the added benefits of the solution, commented Salois-Swallow, is the ability to automatically pull together synoptic reports from various physicians and clinics. In this way, the attending physician can quickly and easily produce a discharge summary and report – something that is currently time-consuming and laborious.
“This will also save the doctors from dictating, and right now, they’re often dictating two-to-three-page reports,” said Salois-Swallow. “It will save the hospitals the expense of transcribing those reports.” Currently, the hospitals spend $800,000 to $900,000 a year on transcription services, a sum that could be greatly reduced through synoptic reporting.
Salois-Swallow emphasized that mental health is the first phase of the project, but the hospitals intend to expand in many other areas. The clinical software from B Sharp, for example, will likely be used by other departments of the hospital – as well as by clinics.
The RelayHealth platform may also be extended to other partners in the healthcare community. For its part, Southlake has been selected as one of the 19 Ontario HealthLinks pilot projects, which are designed to keep teams of care-providers in synch with chronic, complex care patients – and Salois-Swallow believes the RelayHealth platform that Southlake and Mackenzie Health are utilizing is just the solution.
According to the Ontario Ministry of Health, complex care patients represent only 5 percent of the population but account for two-thirds of hospital spending. By keeping closer tabs on them, it’s believed that hospital admissions and re-admissions could be reduced.
What’s more, the RelayHealth platform could also be used in conjunction with Hospital Reports, the Ontario-based system for sending discharge summaries and other patient information directly into the EMRs of family doctors. “RelayHealth is giving us the infrastructure for many other projects,” said Salois-Swallow.
For its part, New Brunswick has had a connected system of electronic health records up-and-running for the past two years. Records at eight hospitals – seven of them using Meditech systems and another with Allscripts – are all accessible through a common viewer. The viewer – along with the interoperability software needed to integrate the systems – was supplied by Orion Health.
“Province-wide, for every hospital, we’ve been able to see patient encounters, lab results and diagnostic imaging reports ” said Cheryl Hansen, CIO for the New Brunswick Department of Health.
The next step in the provincial strategy, she commented, is to link the provincial EHR with physician EMRs, so that doctors get quick updates and reports on their patients. “We’ve heard from physicians, and they don’t want silos of information. They want easy access to labs, DI and discharge summaries.”
The ministry is currently working with the provincial medical society to start integrating the provincial EHR with physician EMRs, so there will be a two-way flow of data. Not only will hospital reports be visible from physician EMRs, but the doctor’s charting of immunizations, allergies and medications will be entered into the provincial system.
That project is currently in the early stages of its rollout. Also on the boards is a drug information system that will include electronic prescribing for physicians, with direct links into pharmacies. Work on the drug information system is scheduled to resume in April 2014 (it was delayed by provincial financial priorities) with a go-live expected in early 2015.
Another component of the ambitious plan is patient access to their own electronic records. Hansen noted the province is planning to create a patient portal, most likely in 2015. “We tested a patient portal two years ago at our tertiary rehab centre, where patients and their families were able to communicate with care-givers,” said Hansen.
Among the lessons learned through the pilot is that patients and families don’t overload staff with messages. “People were at first worried about the portal,” said Hansen. “But we found that patients and their families don’t abuse it. They found it to be very useful, as they could check on care plans and details they may have forgotten.”
Hansen said the plan is to broaden the pilot portal, rolling it out province-wide. She noted that it won’t be a disease-specific portal, as some PHRs tend to be, but will be all encompassing. “We want to have one patient portal for everything. That’s the most cost-effective way of doing things.”
In the next few years, Hansen’s team will be researching the patient portal to determine what type of information should be made available, and how it should be displayed. “We’d like to test it further, to find out what they want, what they don’t like, and how to display information in a user-friendly way.”
She also noted that because New Brunswick is a bilingual province, the system must operate in both English and French. “We have to be able to flip from one language to the other, instantly.”
Hansen stressed that having the infrastructure in place – through the Orion integration engine and repositories – is making projects like the PHR possible. It’s also the basis for sharing information among hospitals, data interchange with physicians offices, and the upcoming drug information system and e-prescribing solution. “You’ve got to have the plumbing in place before you can take on projects like this,” said Hansen. “Because it lets us do so much, the integration engine has paid for itself many times over.”
Electronic document management comes to the rescue at Grand River
After over a decade of operating in an electronic health records environment, the laboratory team at Grand River Hospital (GRH) in Kitchener, Ontario was faced with an unprecedented crisis. The situation not only had a major impact on their lab operations, but also took them back to issuing requisitions and receiving results the old-fashioned way, on paper.
On a cold Monday afternoon last spring, a major incident occurred in the Grand River Hospital lab where 80 staff were at work. In the microbiology section, a Level 3 pathogen exposure was detected in the form of a rare pathogenic fungus, Coccidioides Immitis, which can cause serious fungal disease called coccidioidomycosis.
Decisions taken in the next few hours would have far-reaching implications for patients, staff and service providers. At 6 pm that evening, the decision was made to shut down the lab completely, including all analytical equipment and computers, and provide no further access into or out of the laboratory area. GRH called in an outside provider of decontamination (decon) services and immediately re-directed all lab work that was pending for over 1,000 patients currently waiting and in the HIS/ LIS systems.
“With the limited information about the level of contamination and exposure available at the time, we were abundantly cautious,” said Vince D’Mello, administrative director of laboratory medicine for GRH and St. Mary’s General Hospital. “Our priority was to act with the highest level of caution to prevent any member of staff or patients or service providers from being exposed” to the pathogen.
By 9 pm, a temporary lab was set up in a different area of the hospital with an entirely different set of processes to enable specimens to be received, processed and directed manually to five alternate labs – located within a 150 km radius – that had offered their services. Sister facility St. Mary’s General Hospital (about five kilometers away) quickly took on much of the work, processing specimens promptly and returning results to GRH on paper. Courier services shuttled between the sites at 15 to 30 minute intervals.
All 80 staff members in the lab that afternoon were potentially exposed to the pathogen. Local public health authorities and the Ontario Ministry of Health and Long-Term Care became involved. Adhering to the protocols of the decon services provider, each staff member had to proceed outside to the above-ground parking garage where a specially designed shower and catch basin system had been rapidly deployed. Cold spray downs and harsh scrubbings were administered to each person to ensure staff safety.
The GRH lab processes specimens for approximately 1,000 patients per day, with the average patient requiring work in all five major disciplines: biochemistry, haematology, blood bank, pathology and microbiology. With each patient typically coming in with a minimum of three requisitions, the resulting volume was 20,000 pieces of paper per week. Not only did the lab have to continue providing service during the crisis, but they also had to comply with the quality and regulatory standards (e.g. for patients’ health records, retention of records, result reporting) required by Ontario Lab Accreditation and Accreditation Canada programs.
GRH had to account for each order requisition, confirm that the results were received, and ensure that the patients’ physicians were notified in a timely manner. Shutting down the physical lab meant that there would be no access to the patient’s laboratory investigation information in McKesson Horizon Lab laboratory information system while the decontamination procedures were carried out. No computer access meant no electronic requisitions and no electronic test results – leading to paper, paper and more paper.
During the decontamination process the entire lab area was considered contaminated so access was highly restricted. Four staff members volunteered to re-enter the infected area that week, including core lab manager Sonia Hall. Dressed in full-cover protective hazmat suits, the group retrieved data from some of the analyzers and inspected sensitive optical-type equipment to ensure that it was properly shut down and could be decontaminated in a safe manner.
By that night, results began coming in on hardcopy paper or through fax from the different labs. With clinical or lab users having no access to their GRH lab computer system elsewhere in the hospital, a statement would be entered into the patient records simply noting that the lab tests had been conducted at a specific lab location, time and date. It was then up to temporary clerical staff (hired over the coming days) to sort, file and retrieve requested results from a rapidly growing stack of boxes.
Test results were faxed to the ordering unit or clinician. All the critical results were called to the ordering unit or clinicians in timely manner as per hospital policy. Even with diligent effort, during the crisis papers occasionally got misplaced or misfiled. Within days, 60 boxes of paper had been filled, representing approximately 120,000 pages.
The GRH team identified that a different solution was going to be needed to effectively manage this interim process. An outsourced provider of document conversion services – Salumatics Inc., of Mississauga, Ont. – was brought in two weeks after the exposure to remove the overflowing boxes to their secure production facility, scan each piece of paper, index the results to the correct patient, and upload the images into the web-based document management system SaluVision. Demographic data from the scanned images was matched to the unique patient number.
“In some cases, images had to be duplicated multiple times so that different types of tests performed by different sections of the lab for the same patient could be searched, and results located in a timely manner,” explained Ken Crowell, director of conversion solutions for Salumatics. After the initial backlog was cleared, GRH continued to send one box per day for scanning and conversion to digital images, with the images turned around and viewable in less than 24 hours.
Results continued to come back from different labs on different days. With still no computer access to the lab software system at the two week mark, GRH set up an interim solution to give lab personnel and physicians access via Lotus Links to look up results in SaluVision.
“We had very little time to train all hospital staff,” noted Keyur Dixit, GRH and St. Mary’s manager for integrated quality and point of care testing. ”We ran a few training sessions for laboratory staff via webinar, and we updated hospital communications daily.”
“Finding the results in SaluVision was much faster than searching the temporary boxes,” added Sonia Hall. “We could search by name, accession number, test date, plus easily track the pendings and query the physician accordingly.” The ability to monitor where the tests were among the five different outside labs, and track results coming back, gained the lab team crucial efficiencies. The decon services provider was well versed in procedures for decontaminating the sensitive analytical equipment inside the lab. Using a solution of 6 percent hydrogen peroxide, they followed a predictable, effective process to clean the entire lab and all equipment. Many items and materials could not be cleaned and had to be disposed of: paper, binders, fabric furniture, purses, jewelry, clothing, cork boards, ceiling tiles.
The situation was critical, time sensitive, and fraught with ethical challenges. As Vince D’Mello said: “All of our decisions were made within an established ethical framework in relation to patients, staff and recovery of operations. In an acute care setting, most of our patients are critical, so lab results had to be available in a timely manner.” With the assistance of outside laboratories to process the tests, decontamination experts, document conversion specialists, and the dedication of the lab team, the GRH lab has resumed normal operations and now runs most of their daily operation electronically. They’re back in business.
Smartphone-based medical devices are empowering patients: Topol
By Jerry Zeidenberg
NEW ORLEANS – By refusing to relinquish information to patients, physicians and administrators with old-school mentalities are inadvertently sabotaging the healthcare system, causing it to spin out of control financially.
Keeping information and decision-making from patients is also producing poor medical outcomes.
That was the message of physician, author and futurist Dr. Eric Topol, a keynote speaker at the annual HIMSS conference, held earlier this year in New Orleans.
Dr. Topol noted with dismay that many physicians resist sharing information. Often patients must fight to gain access to their files in physician practices and hospitals, which safeguard the information with a labyrinth of rules and regulations.
“Should patients get access to their lab results,” he asked rhetorically. “How can you even ask that?” he thundered. “It’s their lab results.”
And he pointed to a recent poll that found 68 percent of US physicians refuse to use e-mail with their patients. “To me, that’s a problem,” he said.
Dr. Topol referred to the recent Time magazine issue containing a long essay about the high-spending U.S. health system, which consumes over 17 percent of GDP. That compares with 9-10 percent in most other industrialized countries.
In contrast, healthcare costs could be vastly reduced by keeping patients out of hospitals, which could be done, asserted Dr. Topol, by putting more information and decision-making power in the hands of consumers.
With the power of smartphones and other technologies, he said, patients are able to conduct a good deal of medicine on their own.
“It’s a whole new way of doing medicine,” said Dr. Topol, adding that, “The smartphone has exceeded any other technology for market penetration.
“Collectively, smartphones have changed our lives.”
He joked that we’re all so absorbed by our smartphones that a new species has emerged – homo distractus.
On a more serious note, he displayed a host of gadgets that all plugged into his iPhone – including an electrocardiogram device, a diabetes meter, a blood pressure wristband, a vital signs detector and a sleep sensor.
“Why go to a hospital’s sleep lab when you can do it at home,” he asked. “Who could sleep normally in a hospital lab?” he asked, to great laughter from the audience.
He also pointed out that devices are available to digitize the voice – to determine moods – which can be used for treating depression. And products are already appearing that use the iPhone as a ‘lab on a chip’, enabling patients to do their own lab assays.
Eye exams can be performed through smartphones, and parents can also take photos of their children’s ear drums to determine if they’re infected.
All of this, he observed, can help keep patients out of the acute-care centres – helping to reduce the exploding costs of healthcare.
“We don’t want people in hospitals,” said Dr. Topol. “We can now do so much from our homes, except for operating rooms.”
He added that keeping patients out of hospital also helps them avoid nosocomial infections and hospital-based medical errors – two major dangers and sources of illness and death.
What’s more, data from patients using various therapies could be collated in this age of ‘big data’, to determine the most effective drugs. He observed that currently, many medications are used for whole populations of patients, but end up benefitting only a small percentage of them.
With supercomputers like IBM’s Watson, however, data could be collected from smartphones and parsed to determine which types of patients benefit from certain therapies, and which ones don’t. That, too, could eliminate wasted spending from the health system.
On the other hand, Dr. Topol didn’t address whether patients are skilled enough to use medical devices that are connected to smartphones and to accurately interpret the results. It remains to be seen whether most consumers have the ability to use new, smartphone-based tools without underestimating or overplaying the extent of their medical problems.
Still, he did observe that some physicians may be stonewalling when it comes to offering patients a bigger role in their medical care because they fear a reduction in the part they will play.
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