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Inside the November/December 2006 print edition of Canadian Healthcare Technology:


Feature Report: Regional integration issues


B.C. spearheads development of disease tracking system

A trail-blazing public health surveillance system is now under development in British Columbia that will boast many leading-edge features for tracking and combating the outbreak of infectious diseases.

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Getting information to clinicians at the point-of-care

Mount Sinai Hospital, in Toronto, has made pharmaceutical information available to clinicians at the point-of-care in a variety of ways – PDAs, the hospital intranet and wireless devices.

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Wireless PDAs

Wireless PDAs – such as the BlackBerry and the Palm Treo – have been catching on among physicians. The devices combine telephones and organizers, and now are offering useful applications such as drug information and management programs.

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IHE catching on

Hospitals across Canada and the U.S. are turning to IHE profiles as a ‘standard of standards’ for connecting various systems. The benefits have been manifold, including improved patient safety and smoother project management.

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Remote access solution

The South East Regional Hospital Authority, based in Moncton, N.B., has been using a remote access solution that not only connects healthcare professionals to the hospital’s IT systems, but also plays a big part in disaster planning.


Capital Health expands EMR

Capital Health, based in Edmonton, has awarded a contract to Epic Systems for an ambulatory care EMR system. The wide-ranging solution will provide in-depth data at the point of care.


PLUS news stories, analysis, and features and more.

 

B.C. spearheads development of disease tracking system

By Jerry Zeidenberg

VICTORIA – A trail-blazing public health surveillance system is now under development in British Columbia that will boast many leading-edge features for tracking and combating the outbreak of infectious diseases.

“There’s currently no system like this anywhere else – it will be a world-leader when it’s done,” commented Clyde Macdonald, executive director of information technology for the B.C. government’s Ministry of Health.

In September, British Columbia announced it had awarded a $24.7 million contract to a consortium led by IBM Canada to design and build the advanced surveillance system. B.C. is spearheading the development of the solution, which is part of a national initiative that will be rolled out to other provinces.

While British Columbia is managing the project, every Canadian province and territory is involved. “It may be the first I.T. project in Canada that has been designed with the active participation of each province and territory,” commented Todd Kalyniuk, a partner in IBM Canada’s healthcare consulting practice. “This will ensure that the system meets the needs of partners across Canada.”

Canada Health Infoway has earmarked $100 million to help develop the technology and implement it across the country. It’s expected that the solution will be ready to install in 2007.

The surveillance system is being designed as an easy-to-use web portal that will allow public health professionals to log-on and quickly enter or access information about cases, symptoms and outcomes.

It will include advanced features for tracking outbreaks, such as links to provincial laboratory systems, which will automatically feed abnormal test results into the database. Future plans include connections to pharmacy databases, to track surges in the use of tell-tale medications and remedies. “If there’s a run on diuretics, for example, it will be monitored,” said Macdonald.

As well, the system will be able to quickly add databases and lists from multiple sources – such as airplane flight manifests or classroom student lists. In this way, if there’s a passenger who presents with signs of an infectious disease after disembarking, or a student who shows signs of a communicable disease, it will be possible for public health officials to quickly determine who else is at risk and to contact them.

Overall, the public health surveillance system will have six major components:

• communicable disease surveillance and management

• immunization

• outbreak management

• alerting

• workload management (scheduling)

• vaccine inventories and management.

The immunization component will allow physicians to keep closer tabs on the patients, especially when they have only partial records of a patient on hand. Using the centralized database in the public health system, doctors will be able to see when patients were last inoculated and if they’re due for new rounds of immunization. “Doctors will quickly be able to tell if a patient’s immunizations are up-to-date,” said Kalyniuk.

Public health planners will also be able to better organize campaigns, as they’ll be able to plot geographical areas – down to postal code areas – where local populations are in need of immunization updates.

Kalyniuk noted that the system offers interfaces to geographic information systems (GIS), which are used by most provinces. Moreover, he said the solution will make use of HL7 v.3 as a communication standard. “It will be one of the largest implementations of HL7 v.3 in Canada,” he commented.

The new surveillance system will be used by public health practitioners, including physicians, nurses, epidemiologists and government officials. Across Canada, Macdonald estimates there will be tens of thousands of users.

Macdonald noted that the solution will be among the first public health surveillance systems that’s national in scope. It will provide linkages across the country; in the future, it’s hoped that connections can be built to other countries, as well.

“Communicable diseases don’t respect international borders,” said Macdonald, who foresees the day when electronic links will be established with facilities like the Centers for Disease Control and Prevention, in Atlanta, and others around the world.

One of the difficult issues on this front, said Macdonald, is the privacy of personal data. However, progress is being made, with agreements being reached about the use and protection of personal information. As a result, it is likely only a matter of time before public health databases can be linked internationally.

Macdonald said IBM was chosen as the lead vendor after an intensive procurement process that began with nine groups bidding for the contract. “There was an international response,” he said.

IBM’s consortium partners include Scientific Technology Corp., of Tucson, Ariz., a leading developer of web-based software systems for public health applications; Science Applications International Corp., of San Diego, a systems integrator that has done work with the Centers for Disease Control and Prevention in the United States; Amaranth Consulting Group, of Victoria, B.C., which has been involved in the design of Canadian disease surveillance and public health systems for many years; and Sotern, of Brussels, Belgium, a developer of workload scheduling and management software.

For its part, IBM has extensive experience in the design and construction of healthcare I.T. networks in both Canada and the United States. The upcoming Canadian surveillance solution will also include IBM software products such as Websphere, Tivoli and DB2.

The IBM-led consortium will also tap into software developed by the federal government’s Public Health Agency of Canada, in Winnipeg. “It’s innovate software for the management of alerts,” said Kalyniuk.

At its peak, the Canadian project development team will likely number 75 to 100 people. The primary development office is in Victoria, but work is also occurring in Montreal, Ottawa, Regina, Vancouver, and several U.S. sites.

For it s part, IBM hopes to market the solution developed in Canada around the world; sales abroad will help fuel ongoing development of the surveillance system in the years ahead.

“SARS taught us that it was time to invest in a new generation of surveillance systems to track infectious diseases,” said Federal Health Minister Tony Clement, in a news release issued by the partners. “The better our information is, the better prepared we are. To fully protect the health of Canadians, we must develop the necessary tools to allow us to coordinate our responses to emerging disease threats.”

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Bringing online drug data to the point-of-care

By Sandra Kendall

As with all academic hospitals, the medical library is an essential part of Toronto’s Mount Sinai Hospital – a 472-bed acute care centre affiliated with the University of Toronto. To meet the clinical information needs of staff, Mount Sinai’s Sidney Liswood Library has assembled an electronic and print collection focused on the hospital’s clinical specialties and subspecialties. In addition, Mount Sinai’s affiliation with the University of Toronto gives clinicians access to thousands more journals and monographs. This comprehensive collection encompasses vital clinical findings physicians need for establishing diagnoses and providing evidence-based treatment options; information so vital that the library staff’s expertise at helping clinicians find it and use it makes them – and the connection they form with physicians – a key success factor in quality patient care. The point at which they converge is the patient’s bedside.

Mount Sinai’s pharmacists operate as part of an interdisciplinary care team that includes physicians, nurses and other allied health professionals as appropriate. Each unit has a dedicated pharmacist who, like the other members of the care team, can and often does provide care at the patient’s bedside.

Understanding the importance of clinical decision support data, in 1991 the MSH pharmacy department invested in Thomson Micromedex, one of the leading providers of evidence-based clinical knowledge solutions. However, they were not able to easily access this information at the bedside, where they needed it most when providing care or guidance.

There was valuable information on workstations in the pharmacy department. But pharmacists at the point of care or on call could not get to it. In fact, the on-call pharmacist was lugging home a large duffel bag full of textbooks, loose-leaf papers and a Micromedex CD-ROM to provide essential drug information to staff outside regular pharmacy hours.

One day, duffel in tow, a frustrated on-call pharmacist grumbled to me that he wished all the data in the bag could be more portable. I responded that it might, indeed, be possible for our Technology Application Unit, led by Dr. Stephen Lapinsky, to load the material onto personal digital assistant (PDA) devices.

At the time, PDAs were a new idea in healthcare. Evidence-based care data formatted for PDAs was virtually non-existent. However, the library brought pharmacy, Dr. Lapinsky and Micromedex together and the rest was beta testing.

In 2002, MSH rolled out a hand-held, portable computer support

system for the on-call pharmacist. It contained a newly developed PDA-enabled version of the evidence-based drug data, an electronic version of the hospital formulary handbook, hospital contact addresses and medical calculators to help adjust dosages for patients with kidney or liver problems. This information was updated regularly by synchronizing the PDAs with a desktop computer. This gave MSH mobility at the point of care and continuous access to the data needed for clinical decision support.

The success of the pharmacy department’s on-call program begged the question: Wouldn’t clinical decision support information be valuable to other clinicians, too? The answer seemed clear. Again, working with pharmacy and the vendor, the library brought the data up on the hospital intranet, making it available to the entire MSH community.

However, though definitely an improvement over books, intranet access alone didn’t completely solve the point-of-care decision-making problem. Like pharmacists, physicians and nurses don’t always have access to computers – and thus, the information on them – at patients’ bedsides. Yet, in this age of electronic intelligence, clinicians simply don’t make decisions without evidence. They rely on it and they expect it.

So, once again, MSH turned to mobile devices, this time loading the data on laptops and wireless rounding carts, in addition to PDAs. The library established a link on the hospital’s intranet to download these tools to portable devices, giving physicians and nurses easy access to patient treatment information when and where they needed it.

It has made a decided difference. Recently, a patient presented with an infection by a multi-drug resistant organism. The infection required treatment with meropenem. However, as the patient had allergies to penicillin and ceftriaxone, there was potential for an allergic reaction to other antibiotics. PDA access to the database allowed the care team to quickly assess the risk and find another way to administer the drug that minimized the chance of potential anaphylaxis.

Data when physicians need it is improving patient care at MSH. And what’s good for Mount Sinai could be good for the Greater Toronto Area (GTA), and perhaps even the province of Ontario.

In clinical information, as in life, you get what you pay for. Data has a price and best-practice knowledge is an investment. Yet, not all GTA hospitals have made this investment. Part of the reason is cost.

In Ontario, each hospital purchases or licenses such resources as Micromedex independently. In addition, because the data resides on single PCs in one or two locations, pharmacists are often the only allied health professionals with access. However, with the advent of Local Health Integrated Networks (LHINs), now is the time for Ontario to do something about that.

By centralizing the annual subscriptions held by departments such as pharmacy in the teaching, partially affiliated and community hospitals, the GTA could expand access to valuable drug data to other allied health professionals both within hospitals that have it and to hospitals that don’t. The benefits of data sharing would be significant in terms of safety and costs.

Access to such an authoritative tool for assessing harm could mean a reduction in medication errors. For those hospitals already paying for access, centralized licensing would produce economies of scale that could streamline processes to improve efficiency and facilitate group purchasing, reducing costs.

And GTA-wide access is just the beginning. A province-wide site license would expand access even more, making desktop and mobile access to the best evidence-based drug referencing tools a reality at even the most remote hospitals. In Nova Scotia, New Brunswick and Saskatchewan, similar information initiatives are under way. Ontario, the last of Canada’s provinces to introduce regionalized healthcare services, could benefit by following suit.

Centralizing annual subscriptions assures standardized, seamless and affordable access to evidence-based drug references for those who benefit from it and those that might. The outcome is the right data in the hands of the right people at the right place to make the right decisions.

Sandra Kendall, BA, MLS, is Director, Library Services, at Mount Sinai Hospital in Toronto.

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Wireless drug alerting solutions are making waves with physicians

By Dianne Daniel

For years Dr. Andrew Thompson has relied on electronic medical references in order to check dosing information and drug interactions when prescribing medications for his patients. What’s different these days is that instead of juggling both a cell phone and a personal digital assistant (PDA) in his lab coat pocket, the London, Ont.-based specialist in internal medicine is using one device for everything, including his phone, e-mail, and on-line reference guides.

About six months ago, Dr. Thompson began to use a Blackberry 8700 from Waterloo, Ont.-based Research in Motion (RIM) Inc. The most significant change apart from the integrated voice and data features, he says, is that instead of having to synch with his computer to ensure the information on his handheld is up to date, he now receives automatic updates wirelessly.

“It’s one source for everything and I don’t have to remember to charge two devices,” adds Dr. Thompson, who says with his busy lifestyle it’s easy to forget. “It’s kind of a dumb reality, but it’s there. How many times have I picked up my (PDA) and it’s been dead.”

Dr. Thompson is among a growing number of physicians who rely on wireless devices in their medical practice. Over the years he’s used everything from a clunky Sanyo organizer to a Palm Pilot with a stylus, and says at first he was hesitant to switch to the Blackberry, a relative newcomer to the market.

“The Palm entrenched itself early on in this space,” notes Jeff McDowell, vice-president, global alliances at RIM, “so they have the advantage of existing for a longer period of time.”

Over the course of the last year, however, RIM has turned its attention to the healthcare arena and now has eight independent software vendors offering medical references and on-line functionality for its Blackberry devices, including two guides used by Dr. Thompson: the Tarascon Pharmacopoeia and Sanford Guide for Antimicrobial Medicine. According to McDowell, the company is aiming to leverage its enterprise experience in the healthcare space.

“In the last year it’s become clear to us that everything we’ve done that was important for enterprises is as important, if not more important, in the healthcare environment,” he says. “We’re not just an individual user platform, we’re something a hospital can invest in from a strategy perspective.”

The intent is to get software vendors to take existing information written for other electronic means – normally accessed via a web browser – and work with the Blackberry open development environment to create a Blackberry version based on a Java client. While the web-based versions will work on a Blackberry, it’s the Java client that enables software vendors to add more functionality such as caching of data, automatic updates and easier access to databases, notes McDowell. Once a Blackberry version is created, it will operate on any Blackberry device, from the newly announced Pearl to the more robust 8700.

RIM is also working with legislative groups and different hospital communities to ensure it understands the unique requirements of healthcare professionals. For example, the robust security features that are necessary for compliance with privacy legislation are inherent in the Blackberry platform, making it easier for hospitals to consider it as part of an enterprise-wide mobile strategy.

Lexi-Comp Inc. of Hudson, Ohio, is one of the eight software vendors currently supporting the Blackberry. A beta program of Lexi-Comp ON-HAND software was expected to be complete in October, and Dr. Tina Go, an epilepsy fellow in the Department of Neurology at Toronto’s Hospital for Sick Children, was one of the first to jump on board.

According to Dr. Go, the user interface for the Lexi-Comp software is easy to navigate on the Blackberry and there’s no need to open multiple databases when looking for drug doses and interactions. “With the Blackberry version… you can type in the name of a drug and get a choice of adult or pediatric dose,” she explains.

Dr. Go had been using a Blackberry as her cell phone and e-mail/web browser device for about two years, but also carried a Palm in order to access the Lexi-Comp drug database and medical references she needs for her clinical work. “For four months now I’ve been using my Blackberry and leaving my Palm at home,” she says. “It’s my phone, e-mail, PDA – everything.”

Moving to “all-in-one” devices is a growing trend among physicians, says Zak Bhamani, associate principal, market strategy, for Telus Business Solutions. In June, 2006, Telus launched the first solution under its Wireless Physician program: Epocrates Essential on the Palm Treo 650. Like RIM, Telus is also taking a deeper look at the wireless needs of the healthcare sector.

“We thought in order to start adding value immediately, let’s go with something they already know and already love,” says Bhamani, noting that Epocrates on a Palm came up as “almost a mainstay” in the Canadian physician community when Telus researched the market. Like the Blackberry platform, the Telus version of Epocrates offers automatic updates so doctors no longer have to worry about downloading and synching, as well as access to e-mail, calendars and schedulers. It also features a newer version of the software that supports Canadian drug names.

“The Palm Treo 650 takes all of the things they were doing on their Palm to the next level,” says Bhamani. “We’re giving them more functionality, but avoiding the whole pain of adoption.”

Dr. Alan Brookstone, head of the Richmond Physician User Group in British Columbia, has signed up for the Telus Wireless Physician and is using the Palm Treo 650 as both his cell phone and PDA. The advantage, he says, is that he has the device with him at all times and can quickly access a current summarized database of drug information when needed, or refer to services like Lexi-Comp’s Lexi-Interact on the web. He also uses it to quickly review alerts, asking for more detailed information to be sent to his e-mail address.

“I can see this type of wireless capability being very useful with public health alerts,” he notes.

Bhamani expects to see an evolution of the wireless programs for healthcare in the future as new devices continue to come onto the market.

Dyan Conrad, director of product management at the Canadian Pharmacists Association (CPhA), agrees. “We’re going to be looking at the evolution of the technology and adapting our content to make sure we keep up,” says Conrad, adding that integrated devices like the Palm Treo 650 and Blackberry are “coming on fast.”

The CPhA’s eTherapeutics clinical decision support software has a Mobile Companion that supports Palm and Pocket PC handheld devices, and offers access to drug information tables as well as a link to Lexi-Comp’s Lexi-Interact to check for drug interactions. Right now there is no support for the Blackberry. According to Conrad, automatic updates are available to Pocket PC users via IBM’s WebSphere Everyplace Access technology, while Palm users still need to hot synch with a desktop computer in order to receive updates.

In terms of future developments, she expects to see mobile solutions extended to include access to electronic medical records and hospital information systems as well. “Physicians don’t want to log into multiple applications,” says Conrad. “For us it would mean developing relationships with EMR vendors. We’re aware of who’s out there and we’re looking at technically how we can tie the content together.”

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Use of IHE profiles eases network integration and spurs patient safety

By Jerry Zeidenberg

TORONTO – Not only can I.T. standards help connect various healthcare systems and make the bits and bytes work effectively, but they can also speed up the project management that’s needed to put all of the pieces together. When the Thames Valley Digital Imaging Network, in southwestern Ontario, employed IHE profiles to help mesh the radiology systems of eight different hospital corporations, the use of standards accelerated and smoothed the whole process of project management.

“It took away the emotion,” said Beth Goodhew, managing consultant with Peninsula Consulting Group, which assisted the Thames Valley Hospitals with the large-scale project.

As a result, the project managers didn’t get bogged down in arguments about which method of connecting systems was best. Once they decided what their priorities were, the ways of doing it were pretty well mapped out by the IHE profiles – which are standard methodologies for solving real-world problems.

“It wasn’t a matter of how site A does it, or how site B does it – it’s how the IHE does it,” said Goodhew, who spoke at a recent conference on standards organized by the IHE and ITAC Ontario.

“IHE gave us the means to conduct discussions without finger-pointing,” said Goodhew. “And that drove decision-making and productivity.”

IHE – short for Integrating the Healthcare Enterprise – is a movement that emerged out of the radiology world, to help connect diagnostic imaging systems. But it’s now extending to cardiology, laboratories, pharmacies and throughout the healthcare enterprise.

Based in Chicago but gaining adherents around the world, IHE is made up of healthcare professionals in hospitals and clinics, consultants and vendors. Together, they’re devising ideal methods of getting disparate IT systems to talk to each other, thereby promoting organizational efficiency and patient safety.

Essentially, the IHE members are taking existing standards such as HL7 v3, DICOM and others, and creating ‘profiles’, which are set methods of accomplishing specific tasks. These tasks include scheduled workflow, patient information reconciliation and the consistent presentation of images, among others.

Last year, IHE Canada was launched. Its web site can be viewed at www.ihe-canada.com.

At the IHE/ITAC Ontario workshop on standards, Goodhew noted that IHE profiles helped the Thames Valley Digital Imaging Network integrate the PACS networks at eight sites in southwestern Ontario in just two years. The first phase of the project, connecting the eight hospital radiology departments, was completed in December 2005.

The sites include the London Health Sciences Centre and St. Joseph’s Health Centre, both in London. These two large teaching institutions produce 50 percent of the 750,000 DI exams produced annually by the group. The remaining exams are generated by six outlying community facilities.

Together, the group has 55 radiologists, 10 residents and eight nuclear medicine physicians. Over 200 systems were connected as part of the project.

In the first year of the project, sites in London were connected; and with the lessons learned, the six other sites were all connected in the second year.

The key IHE profiles used were scheduled workflow (“the basis of radiology,” said Goodhew); patient information reconciliation (“the key to data integrity”); consistent presentation of images; and charge posting (billing systems.)

Also providing insights at the IHE/ITAC Ontario conference was Dr. Nogah Haramati, a leader in the IHE movement and chief of radiology at Montefiore Medical Center, a New York teaching hospital with 1,400 beds. It has 100 radiologists and handles 450,000 diagnostic exams annually.

The Montefiore Medical Center has multiple off-site clinics and a data centre located 30 miles away from the main site. Dr. Haramati explained that since the terrorist catastrophe of 9/11, his hospital has been de-centralizing services and sites as a disaster planning strategy.

Dr. Haramati asserted that the use of IHE profiles at the organization has resulted in a multitude of benefits. Among them, he said, “are patient safety issues, to look at just the low-hanging fruit.”

He noted that by implementing the IHE’s patient information reconciliation (PIR) profile, rather than using free typing of patient names and identifiers, the hospital has virtually eliminated the misidentification of patients.

“PIR is very important to us,” said Dr. Haramati. “We need it because people make mistakes. They’ll pick the wrong name from a worklist. A tech will take a man’s name from the worklist and put a woman on the table. It happens – they’re only human.

“But the IHE profile can catch this,” he said.

At another point in the conference, when audience members were asking questions of panelists, a company rep noted that the process of building standards like IHE profiles into their systems will cost money. He wanted to know how much hospital executives are willing to pay for such efforts.

Dr. Haramati – who urges hospitals to demand in contracts that I.T. and radiology suppliers build IHE profiles into their solutions – acknowledged there are costs to vendors. However, he said that at his hospital, they’re willing to join with the other healthcare providers to create a list of top IHE requirements. “We’ll go along with them,” he said. In this way, vendors aren’t working in numerous directions to please individual clients, but are creating solutions that can be used by a large group of customers.

Dennis Giokas, chief technology officer for Canada Health Infoway, asserted that “standards will play a key role in interoperability,” and in getting the myriad of healthcare systems across regions talking to each other. He estimated there are some 40,000 healthcare I.T. systems across Canada – an enormous systems integration project.

He pointed out that integration is a complex task, as to obtain real value from interconnectivity, it will involve not just standard information models, data types and terminologies, but semantic abilities among computers, as well. “So that information can be understood when it is exchanged,” he said.

Giokas observed that by the time Canada Health Infoway finishes its initial mandate in 2009, it will have spent $50 million on standards creation and promotion. Its total budget for spurring the rise of electronic records and networks in Canada is $1.2 billion.

However, Giokas said an investment on the order of $10 billion will be needed to create a completely integrated system, with much more than $50 million spent on standards. He said it’s far better for organizations to work through Infoway on the creation and dissemination of standards than to try creating I.T. standards for themselves – which may work in their hospital or community, but not necessarily in their greater region or province.

One audience member asked whether it’s worth investing in standards or shareable electronic patient records, at all, based on the premise that most care is delivered locally and that records wouldn’t have to travel very far.

Giokas answered that a good deal of care actually requires patients to travel considerable distances, and that interoperable records could help them immensely. He quickly mentioned three examples – the Maritimes, where patients throughout the region will often travel to Halifax for specialized treatment; the Electronic Children's Health Network (eCHN) in Ontario, which connects pediatric patients and their caregivers across the province to specialists in Toronto; and Capital Health in Edmonton, which includes several tertiary-care centres that regularly treat thousands of patients traveling from British Columbia, Yukon, the Northwest Territories and Nunavut.

David Koff, a radiologist at Sunnybrook Health Sciences Centre, in Toronto, noted that interoperability is desperately needed in I.T. systems. Many physicians simply won’t use computers, even today, as it’s too difficult to access the information they need from disparate systems.

“We’ve got 170 different software systems at our institution,” said Dr. Koff. “A lot are old, and they don’t communicate. Perhaps we are victims of our early enthusiasm with computers.”

Because of this communication gap, many doctors don’t bother. “If they have to go through different systems, log-in each time and work with different GUIs, change their passwords every five days for each of them – no way, it won’t happen.”

It must be much easier to access information, he said, with seamless integration between disparate systems. This could be done, in the future, at least, through the use of commonly accepted standards.

Dr. Koff said the roadblocks are not just technological, however, as some doctors still have a psychological aversion to computers.

“Some think computers are a waste of time, and won’t use a keyboard.” He asserted that “we must educate the users,” about the benefits of clinical systems. “We need strong leadership,” he said.

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