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Inside the November/December 2003 print edition of Canadian Healthcare Technology:

Feature Report: Clinical decision support systems

Organizations work to improve coding of clinical data

Summing up the diagnostic discrepancies found in a data re-abstraction study done by the Ontario Ministry of Health on 10 randomly selected hospitals (four teaching, six community), one statistical slide in the presentation indicated there was a “% Error” among the coded clinical data of 65 percent!


Canadian software helps kids with prostheses

The amputee team at Bloorview MacMillan Children’s Centre, in Toronto, has developed a software solution that tracks how kids use their prosthetic arms at different stages of their lives.


Consolidation and adoption of business outlook spurs e-commerce

As more Canadian hospitals make the transition to a centralized purchasing model, there’s a growing trend to adopt electronic commerce strategies at the same time, says Nils Clausen, Country Manager, Canada, for Global Healthcare Exchange Inc. (GHX).


Decision support systems can help hospitals reduce costs and improve patient care

The term ‘clinical decision support system’ sounds mysterious, but these computerized solutions are yielding clear-cut results for many healthcare centres.


MOXXI on the move

Quebec’s innovative MOXXI project gives family physicians and other doctors access to electronic patient records and enables them to send prescriptions electronically to pharmacists. It’s now making use of wireless, mobile technology.


Computerized CDM

Computers and electronic tracking are ideal tools for Chronic Disease Management (CDM). But in order for physicians and patients to use them, the solutions must be easy to use and tailored to their workflow or lifestyles.


The Atlas project

Dartmouth College, in New Hampshire, famed for its computer science school, is home to a data mining project called Atlas that’s assessing the quality of medical care in the United States. Using the data, analysts are even able to detect fraud.

Show time

November is a busy month for healthcare trade shows and conferences. Two prominent examples are the OHA Convention in Toronto, and the Medica 2003 show in Duesseldorf, Germany.

PLUS news stories, analysis, and features and more.


Organizations work to improve coding of clinical data

By Andy Shaw

One of the presentations at a recent Ontario Hospital Association conference in Toronto could have been extremely alarming to an outsider not familiar with the complexities of coding clinical data. Summing up the diagnostic discrepancies found in a data re-abstraction study done by the Ontario Ministry of Health on 10 randomly selected hospitals (four teaching, six community), one statistical slide in the presentation indicated there was a “% Error” among the coded clinical data of 65 percent!

If this sampling were true for Canadian hospitals in general, one might hastily and erroneously conclude that a major foundation of our healthcare system – the gleaning of reliable data that guides how we practice, fund, and manage care – was dangerously cracked and flawed.

For those in the know, however, what was revealed by the Pilot Clinical Data Quality Audit, as the study was called, was not nearly so alarming. First, they point out, the choice of the word “Error” in the study summary was an unfortunate one. In the medical context the word error has a fatal ring to it, as in “medical error”. These were not medical errors that were being studied by Ontario but rather differences in the way hospital coders interpret the written records of what caregivers and clinicians did to whom when.

“What the study was really dealing with are what some call discrepancies but what we prefer to call variations in the way events are coded,” says Caroline Heick, head of data quality and classification for the Canadian Institute of Health Information (CIHI) in Ottawa. “And we know from our own CIHI studies that the discrepancy or variation rate in coding nationally is much, much lower.”

To be fair to the Ontario researchers and presenters, it should be made clear that the Ontario study was never meant to reveal any sort of statistical average for the province. Rather, it targeted coding connected with the charting of a limited number of complex clinical practices – instances where it was suspected that the discrepancy rate might be highest. The purpose, in part, was to see where remedial action was needed most.

What can be safely concluded from the Ontario study findings is that coding is less a science and far more of a craft.

Yet the study still does raise some serious questions about discrepancies. Among them: Why do they occur? What kind of discrepancies are most prevalent? And what must be done to avoid them in future?

For Heather Berry, the reason coding variations occur are largely human. Berry is health records manager for the South Bruce Grey Health Centre, a four-campus hospital centred in Walkerton, Ont.. She attended the Toronto conference and was an active participant in the audience give-and-take following the study’s presentation.

“The information the coders are working with is extremely complex, and yet, for it to be of high enough quality to be useful it has to meet some very demanding criteria,” says Berry, who then ticks off those criteria. “It has to be specific, complete, accurate, timely, relevant, current, comprehensive, and appropriate all at once.”

And that takes training. The preferred coders being hired today, Berry points out, are graduates of a two-year professional health records management program. They codify information according to the World Health Organization (WHO) classifications of disease and morbid conditions. But the complexities come when patients bring with them, as so many do, more than one disease or condition. Getting the coding right for that individual is not only a personal challenge to the coder, but also crucial to the tasks of hospital bean counters, who must re-coup the costs from government of diagnosing and treating that patient.

“You could have a patient come in with the simple condition of a fractured hip,” says Berry, “But what if that patient is also a severe diabetic, a paraplegic, and morbidly obese? The treatment becomes very much different than for a simple hip fracture.”

Such complexities create what Berry calls “grey areas” in coding practices, where the basic standards are not quite specific enough to guide the coders in their interpretation of what was written down as done to the patient.

Consequently, Berry applauds the efforts of the CIHI, in particular, in conducting workshops for coders, providing them with online interpretation assistance through the CIHI website, and other initiatives the organization has taken to help standardize coding practices nationally.

There’s another source of coding inaccuracies, however, says Berry, that can only be addressed down at the hospital level.

“You’ve got to work with the doctors to ensure that what they are entering on the records is specific, complete, accurate, and meets all the other criteria I mentioned earlier in order to produce quality data,” says Berry. “They have to be educated to the importance of all this, and that’s challenging. What we have found that works here is to explain it to doctors in terms of money. We say to them that just as they must have their information complete on what they do with patients in order to be paid, so does the hospital, as well.”

A long-term solution, suggests Berry, is to make an introduction to coding practices part of a physician’s education while at medical school – showing them how to document their work accurately and thus conveniently for coders. “It’s something that will help them run their own offices once they graduate,” adds Berry.

Doctors alone of course are not the only challenge to discrepancy-free coding. Other caregivers must also be brought up to speed on the techniques for accurate record keeping.

Berry says she would also like to see more rigour on the part of hospital management in applying the standards of coding, perhaps adopting an ISO 9000 approach to data quality that other organizations, in other industries, voluntarily qualify for and adhere to. Also, as privacy regulations take hold in healthcare, there will be even more pressure on hospitals and coders to keep more and better records, she says, and hopes that government funding of coding work will be boosted appropriately.

Most of all, she adds, she’s looking forward to what will come of a data quality workshop and gathering next month in Toronto involving major players from the CIHI, the Ontario Hospital Association, the Ontario Ministry of Health and the Canadian Health Records Association among others.

“There’s a very good spirit of cooperation among these groups and a strong, shared desire to improve the quality of our data and coding,” says Berry. “It will be a very good meeting, and we will learn a lot about where we should go from here.”



New software tracks how children use their prosthesis over time

By Neil Zeidenberg

TORONTO – The amputee team at the Bloorview MacMillan Children’s Centre has developed a computer-based software solution to track how kids use their prosthetic arms at different stages in their lives.

Unlike previous studies that simply compared body-powered equipment to myoelectric devices, the PUFI software addresses the functional benefits of children’s prosthetic devices over time. It’s important, because without a thorough investigation, it’s hard to prove that one prosthesis is better than another.

“PUFI helps to determine how well kids use their prosthesis over time, as well as how valuable they consider it to be for a certain activity,” explained Sheila Hubbard, manager of the amputee team at Bloorview MacMillan.

For example, a two-year old may find it difficult to use a prosthesis for tying shoelaces, but over the course of several months or years, he or she may become quite adept at the task.

PUFI (Prosthetic Upper Extremity Functional Index) is a multiple choice computer-based questionnaire that asks how children between the ages of two and 18 fare when performing a lengthy list of two-handed tasks, such as holding a hockey stick, tying their shoelaces and doing up a zipper.

While answering the questionnaire, an animated puffin named PUFI offers encouragement, word clarification and assurance to parents and children that “they’re doing great.”

Questions asked range from very general to more task-specific, such as how they actually use their prosthetic. The data are automatically saved in the PUFI database, enabling clinicians to analyze how kids are using their prosthetics and whether more training is required.

“PUFI records all of the data and instantly gives you a full graphical report. Therapists can then sit down with parents and children, look at areas where they may be having difficulty and offer both encouragement and training,” says Hubbard.

Having such detailed analysis before them may also encourage children to use their prosthesis to perform tasks they’ve never tried before. For example, some kids may have never attempted to tie their shoelaces because their parents hadn’t encouraged them.

Moreover, having solid data to back up their findings gives developers of prosthetic devices the information they need to improve their products and to understand what’s most important to kids at different stages.

With the data accumulated so far, researchers have begun noticing certain trends such as:

• Some children start out with a myoelectric device, but due to an inability to perform certain activities in the playground, they opt for a secondary prosthesis.

• As kids grow, their needs change, so they use their prosthetics for different purposes and switch to and from functional, durable or purely cosmetic devices.

Recently, PUFI has garnered international attention with participation from 12 hospital sites around the globe. Five of the sites are in Canada, three in the United Kingdom, and one each in Australia, Holland, Sweden and Slovenia.

Last year, The Shriners Hospital for Children in the United States, a network of 22 facilities throughout North America, began using PUFI to track juvenile prosthetic usage in about 300 of its patients.

Researchers hope to add up to 100 children to the database each year, and re-evaluate the patterns from children who are already participating in the project. As well, they hope to make PUFI available on the Web. Going online would simplify the sending and receiving of data as well as provide therapists with access to the most current data.

“It’s important to not just capture the data for these kids once, but rather, to capture it over time,” says Hubbard. “When you look at someone over a period of 20 years, you’re likely to see an interesting pattern. However, if you do the same study over a shorter period the changes will be subtler.”



Consolidation and adoption of business outlook spurs e-commerce

By Dianne Daniel

As more Canadian hospitals make the transition to a centralized purchasing model, there’s a growing trend to adopt electronic commerce strategies at the same time, says Nils Clausen, Country Manager, Canada, for Global Healthcare Exchange Inc. (GHX). Already GHX’s web-based exchange has over 190 member hospitals in Canada – 95 of which are live and trading with supplier members – and, according to Clausen, all signs are pointing to increased growth in the future.

“By the end of this year we should hit an annual run rate of around $115 million in transactions for Canada,” he says. “And we see continued growth on a monthly basis as we get more hospitals trading with more suppliers.”

Clausen credits the current focus on consolidation as a key driving factor behind the push towards e-commerce, since it’s easier for hospitals to connect electronically with suppliers when product item masters and contracts are already streamlined in one central database. Equally important, though, is the opportunity for increased cost savings related to improvements in the entire materials management process.

Recent benchmarks from GHX indicate those hospitals participating in the exchange – an industry neutral utility that connects providers, suppliers, distributors and group purchasing organizations via the Internet – can expect a 25 to 40 percent reduction in errors related to the ordering process as well as a 40 to 70 percent improvement in order cycle times. There’s also a connection to enhanced patient care, by getting the right product to the right place at the right time. As well, any money saved can be used in other areas to improve patient care, he adds.

Sarah Friesen, general manager, Shared Healthcare Supply Services (SHSS) in Toronto, agrees e-commerce is catching on in Canadian hospitals. SHSS, which serves as a central purchasing facility for University Health Network, Mount Sinai and Sunnybrook & Women’s College hospitals, is currently using GHX for product purchases in its Catheterization Lab as well as in Medical Imaging.

“The system has worked well for us. We’ve achieved what we hoped we would in terms of error reduction and better control over our ordering,” says Friesen. Additional gains are being made in the lab, where handheld personal digital assistants (PDAs) are being used in conjunction with barcode technology to speed the ordering process, as well as ensure accuracy, since many items purchased for the lab are implants that need to be tracked.

“For us, the other primary objective was to get the patient care worker doing patient care, as opposed to spending their time sitting on a computer doing non-healthcare-related work,” notes Friesen. “We’re trying to find innovative ways to reduce the amount of time our patient care workers spend on material management – it’s our job, not theirs.”

Under the handheld pilot, when healthcare workers scan a product, an order is automatically created and sent to the appropriate supplier via GHX. Order information is linked to the hospital’s information system, so when the product is shipped, it can be matched against the original purchase order, receipt and invoice to ensure no errors are made.

The ultimate benefit is better control over the entire supply chain process, says Friesen. “From the patient-care side, it’s allowing us to be a lot better prepared and to be able to respond to issues a lot faster than with the manual processes we had before.”

Another group benefiting from e-commerce is the Capital District Health Authority in Halifax, which currently has nine of its major vendors trading on GHX. According to vice-president of administration Calvin Crocker, one of the main advantages of moving to an e-commerce model is the ability to pick up on pricing discrepancies, sooner rather than later. It also provides access to up-to-date information on order status, which in turn helps to improve communications between materials management staff and internal hospital customers.

In addition to joining GHX, Capital District Health Authority has also signed on with a national group-purchasing program called Healthpro. Dealing with major vendors and national contracts through Healthpro makes it easier to engage in e-commerce activities, says Crocker, because those are the suppliers who are investing money to get their catalogues and pricing information on-line.

Like SHSS, Crocker would also like to trial barcode technology at some point. “What we ultimately want out of this whole e-commerce initiative is to move to a better materials management process in terms of stock and just-in-time quantities, and better sourcing,” he says. “On the finance side we want to get to a point where everything is electronic and we’re not cutting cheques.”

Both Crocker and Friesen say it is getting easier to convince executives to buy into the concept of investing in e-commerce because there’s been a shift in focus towards running a hospital like a business.

“In terms of bringing the region together and consolidating our operations,” said Crocker, “we’ve made a commitment to be as efficient as possible. We want to spend as much of our budget on the patient-care side as we can, and the only way we can become really efficient is to ensure we take advantage of the technology.”



Decision support systems can help hospitals reduce costs and improve patient care

By Andy Shaw

The term ‘clinical decision support system’ sounds mysterious, but these computerized solutions are yielding clear-cut results for many healthcare centres – perhaps nowhere more so than the University Health Network (UHN), St. Michael’s Hospital in Toronto, and at the McGill University Health Centre (MUHC) in Montreal. All three institutions are producing both clinical and financial advantages for themselves and their patients through decision-making that’s supported by a computer system that aids and abets better decision-making.

One can think of a decision support system as an “informational” application rather than simply an operational or transactional system. It can help both clinicians and healthcare managers make easier and better decisions by interpreting the information that flows from the hospital’s day-to-day transactions. And it does so with varying degrees of intelligence – either by monitoring, comparing, analyzing, forecasting or modelling the data.

At UHN, for instance, Katherine Henning, head of performance measurement, and project manager Janine Kaye, use a Misys Data Warehouse, an advanced clinical decision support application that makes sense of reams of data from an assortment of databases, including hospital records, pathology, pharmacy, physician order entry and patient satisfaction.

“We decided about two years ago to make a fundamental structural change at UHN and create a group of analysts that would support both management and clinical decision making,” says Henning. “Specifically, they help our quality teams look at data and make decisions from new and different vantage points.”

The analysts can mount those vantage points from the heights of transactional data that UHN has been collecting since 1987 on what was then a data system from Per-Se (since bought out by Misys) and which has been flowing into its enterprise data warehouse since 2000.

“We now have data coming in now from as many as 15 transactional systems,” says Kaye. “And we have about 40 people accessing that data through an Oracle reporting tool.”

Henning says there will be increasing amounts of decision supporting data available to those analysts as time goes by. “We’re only about a third of the way through the list of inputs we eventually hope to have streaming in. This year, for example, we want to integrate the operating room data set as well as nursing workload data. The nursing data, for instance, will tell us things like how many hours nurses spend with patients and what they actually do with patients during that time.”

And therein lies the biggest rub for implementers of all such decisions support systems, says Beverly Delaney, MUHC’s director of administrative informational systems.

“We use our decision support system (from Eclipsys) for all of our medical records reporting, for financial and performance analysis, for utilization management, for quality indicators, and essentially for any function that needs to look at integrated data,” says Delaney. “But the challenges we have faced in implementing all that have not been technical. We’ve rarely had a major technical issue. Most of our challenges have been cultural.”

That’s a polite way of saying that, for some time, those who input data or those who use it to interpret the data often act like unwilling horses or worse. They can be lead to the water, but they can’t always be made to drink.

“We’ve recently integrated with four other campuses,” explains Delaney. “And most of them have long histories of doing things their own way. In the process, we’ve found that the ability and willingness of people to standardize their data is the biggest challenge. And they’ve got to be willing if a decision support tool is to ever be truly useful to everybody.”

A corollary to that challenge is also the willingness of managers to use the data once they get it. Too often that a decision support tool’s output gets ignored – albeit, sometimes for good reasons: suspicions about the quality of the data.

“Auditing and validating your data is a job you cannot afford to underestimate,” says Delaney. “Data quality is a major issue with these systems.”

It’s an issue McGill has faced up to particularly on the clinical side of its decision support strategy. “We’ve been gathering clinical information for over 12 years now, and for those physicians who have been with us longest, their acceptance of the data is excellent. The best way we’ve found to build acceptance is to present clinicians with new looks at their data – and then ask them to validate the data for us. We say to them: Please tell us what is wrong with this information and help us fix it. And that has proven to be quite a successful strategy.”

Soon there will be more data to validate, as Delaney and MUHC press ahead with creating new and more useful vantage points for its decision makers.

“We’ve decided to roll out the latest ‘Gold’ version of the Eclipsys (Sunrise Decision Support Manager) product,” says Delaney. “It offers a Web-based piece of the application that will give our users faster access to the data through our intranet and will also simplify the data for them. We’re in the very early stages of this, but eventually our quality advisors and other expert users of the system will be able to create views of the information specifically for targeted users. Take for example, our obstetrical mission team. They will be able to access views of their particular obstetrical patient population and that population’s use of things like diagnostic services, or the number of their returns to Emergency after discharge, for instance, and whatever else that interests that particular mission team. And it will give them tailored information both about the quality and the use of their services.”

Still, as Delaney is quick to admit, and as Michael Stewart at St. Mike’s hospital in Toronto agrees, the beauty of that data very much lies in the eye of the beholder.
“Pharmacy is a classic example of how people view information differently,” says Stewart, who is the hospital’s decision support director. “They may buy morphine from their vendor, for instance, that costs them say 35 cents. But looked at from a hospital-wide point of view, that morphine may in total cost us 65 cents – taking into account the hidden costs of the purchaser who bought it, the transport person and receiver on the shipping dock who handled it.

“Costs, in other words, that don’t appear on the invoice. So you have to have a mechanism built into your decision support system, as we now, that allows you to reconcile those two different views.”

More challenging yet, adds Stewart, is the attitude of users that can so easily turn sour.

“There’s a particular problem in healthcare when data is not as good as it can be. We have a lot of scientists and scientific-thinking people in healthcare, so when it comes to data, they don’t expect ‘nearly right’. If they find one patient they think has wrong information, then it tends to invalidate the rest of the data. In other environments, people are happy with a 95 percent accuracy rate, but here in healthcare, it has to be 99.9 percent.”

The challenge for the future, says Stewart, is to establish “confidence limits” in the accuracy of a decision support system’s data. Says Stewart: “Systems can be made 100 percent accurate, but there is usually a very high financial cost connected with that perfect accuracy.”

Stewart says a more productive approach, and one which St. Mike’s is pursuing, is to offer decision makers more views of the same information, so that one bad apple does not spoil the whole data barrel.

One way to do that, advises Stewart, is to provide more links to concurrent utilization review. “One such tool we have, for example, is used by our nurses who can come on shift and ask: Why is this patient still in hospital? It allows them to see what are the lab test results, or other bottlenecks that are holding patient care up. If you tie that view into hospital management systems, then management can really start to come to grips with workflow and costs. If MRI says they need another machine, for instance, that creates a challenging decision for management. They inevitably wonder: Is it just because MRI wants to be state of the art? But if you can pull up data for management that says: By not having that new MRI machine we will have 50 patients a week who are waiting four more days and that are each costing us $500 a day – then its easier for them to make a more informed decision about spending several million dollars on a new MRI.”

Providing more multi-faceted views of their transactional data is where St. Mike’s is doing some real decision-support groundbreaking.

“We are the only hospital I am aware of, for instance, that does care costing for all of its outpatient visits,” says Stewart. “So our fully-costed patient visits include 30,000 in-patients, 60,000 emergency patients, and now 500,000 ambulatory or out-patients whose visits are also fully costed.”

It is with such cross-department numbers that modern day decision support systems can truly shine, says a man who should know, Kevin McCole, vice president of sales, decision support for Eclipsys in Chicago. A veteran of decision support systems stretching back to 1990, and work experience with PSI, an Eclipsys predecessor, McCole says he has stayed in the field because of a philosophy that to this day still rings true for him and Eclipsys.

“In the 1980s, there was really no tool that really could measure the hospital as a business,” says McCole. “Hospitals were managed back then by departments. But a hospital’s process, costs, and efficiencies really run more along service lines that cross over departmental boundaries as a patient progresses through its care. So if open heart surgery, for example, went up by 25 percent, say, there was no real way of knowing what that would mean to other departments.”

But decision support systems can make a serious difference to not only the efficiency of the hospital, but to the care of the patient.

“We’ve had the advantage in the United States of being forced by our billing systems to pay much more attention to cost per case analysis, and so we’ve been quicker to adopt and embrace decision support systems that can give us that information,” says McCole. “But it’s clear now from numerous studies that such systems can produce an extremely significant reduction in a patient’s length of stay in hospital, as well as among other benefits their surgical complications.”

McCole says politely that he thinks that Canada is still lagging in its use of such tools, but was impressed recently by a healthcare costing conference in Edmonton he attended.

“There were a lot of people there who wanted to get a better handle on this whole topic and I think it shows the Canadian market is becoming a lot more sophisticated.”

For Michael Stewart at St. Mike’s, there’s also a gap to be closed in decision support systems between what he terms his “Cadillac” system and the Volkswagen or smaller systems of the community care centers his hospital’s patients also encounter. And at McGill, the gaps that will always need closing are between people.

“There is really only one way to make decision support systems effective,” concludes MUHC’s Delaney. “You’ve got to go from department to department and from person to person until everyone feels accountable to each other for the data in the system and the way the information is used.”



Wireless handheld computers enable doctors to prescribe at point of care

By Neil Zeidenberg

MOXXI has gone mobile. The innovative Montreal-based pilot project that has given physicians electronic access to the medication histories of patients, and enables them to send scripts directly to pharmacies, started off by using standard desktop PCs.

But physicians are often on the go, and the current phase of the ‘Medical Office of the 21st Century’, aka MOXXI, is enabling doctors to use wireless iPAQs to receive and send drug-related information.

“The beauty of this system is that doctors can change the prescription on the spot, while the patient is still present,” explains Dr. Robyn Tamblyn, director of the MOXXI project.

The iPAQ Pocket PCs are equipped with Sierra Wireless AirCards – high-speed wide-area-network cards that connect to the Bell Mobility IX system. Physicians can use the handheld computers to access patient charts and to send drug prescriptions electronically to pharmacies, where the scripts are automatically integrated into the pharmacy software.

Dr. Tamblyn explained that in Quebec, pharmacists can accept electronic prescriptions. “Physicians and pharmacists here established standards for what would constitute an acceptable electronic prescription,” she said. “The digital signature here is legal,” a development she believes will be adopted by other provinces and by the United States.

The MOXXI project originally started in 1996 using standard PCs; the addition of wireless iPAQs began in January 2003. The mobile devices are said to require less training than desktop solutions, and support in the field is better since any problems experienced by doctors can now be monitored via the wireless technology.

“We can actually see where they’re having troubles entering data, how often they’re using it and provide strategic support for physicians having difficulty,” said Dr. Tamblyn. “It provides a technical solution that’s much easier to support and it’s easier to use for doctors in the field.”

MOXXI currently connects 30 physicians, about 12,000 patients and 31 pharmacies in Montreal. The pharmacies are all located near the physician practices.

“We tried to set it up so that no matter what pharmacy the patient visited, the system would be able to retrieve electronic prescriptions and send information about prescriptions dispensed,” Dr. Tamblyn explained. Patients can essentially pick and choose on a moment’s notice which pharmacy they go to. And since it’s electronic, pharmacists don’t receive illegible handwritten prescriptions, but encrypted documents with all of the information they need.

Initially, physicians enter prescriptions onto a wireless keypad. The data is sent to the MOXXI servers by cellular network where the drug and dosage is reviewed and compared to the patient’s current medication. MOXXI then sends information back to the physician regarding the medication ordered, including proper dosage and any risks associated with that drug. “Pharmacists are delighted they don’t have to fuss over what the prescription is,” says Dr. Tamblyn. “The physicians find the drug profile incredibly valuable, especially for patients taking many different medications.” The drug profile shows physicians a list of what drugs their patients are on and from whom it was prescribed.

To date, MOXXI’s accomplishments include a 19 percent reduction in the rate of medication errors; development of a technology that can be readily used by busy primary care physicians, and a technological model that makes it possible to support them; the capacity to integrate information from both the private pharmacies and the public insurer so physicians can look at all drugs being prescribed and dispensed to their patients.

Despite all the achievements, there is room for improvement. Number one is the memory capacity of the iPAQ in terms of its performance. It needs to be faster. Electronic prescribing is certainly faster when you’re writing many prescriptions, but for a single prescription, it’s slower than writing by hand. That’s because they’re currently using a 56k modem.

“In order to make this a more functional system, they need a more powerful handheld device and high-speed wireless,” says Dr. Tamblyn. Additionally, doctors have requested interfaces with the lab so they get their lab results automatically on the iPAQ, and the capacity to dictate into the iPAQ to record their notes.