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Inside the November/December 2007 print edition of Canadian Healthcare Technology:


Toronto Rehab launches assistive tech R&D project
Dr. Geoff Fernie, vice president of research at the Toronto Rehabilitation Institute, announces the official start of the $36 million iDAPT R&D effort. iDAPT’s 14 laboratories aim to produce technological solutions that will improve the lives of persons with disabilities.

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Sunnybrook empowers patients with personal EHR
Innovators at Sunnybrook Health Sciences Centre, in Toronto, believe that their unique ‘MyChart’ Personal Health Record could, and should, one day soon be – your chart.

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Province-wide EHR in N.B.
New Brunswick announced an investment of $36 million to kick-off its provincial electronic health record system. Over the next 10 years, the province plans to put $250 million into the project.

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If everyone agrees, then why can’t I see my record?
In late May of this year, a large percentage of the health and medical informatics community in Canada met in Quebec City for the 2007 eHealth Conference. One regular feature of this annual conference is the Great Debate. This year the debate centered on the question “should patients have unfettered access to their health information?”

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An endangered species?
Health information managers convened a meeting in Toronto to discuss their collective future – which doesn’t look bright. With the rise of electronic patient records, how does a health information manager make himself indispensible?


Point-of-care DSS
Healthcare providers are being assisted by a new generation of medical devices that offer advice and checks right at the patient’s bedside. They’re especially useful to tired or distracted care-givers, and are leading to improved patient safety.


Automated blood analysis
St. Michael’s Hospital, in Toronto, has become the first medical centre in the country to implement an automated blood-smear analysis system. The solution has reduced the time spent by skilled professionals on a repetitive task.


PLUS news stories, analysis, and features and more.

 

Large-scale R&D effort for rehab technologies announced in Toronto

By Jerry Zeidenberg

Toronto is expected to become an international hotspot for the development of assistive devices and other solutions for the handicapped, infirm and elderly, due to the official launch of iDAPT, a $36 million set of high-tech laboratories.

iDAPT, short for Intelligent Design for Adaptation, Participation and Technology, has been in the works for several years and is the brainchild of Dr. Geoff Fernie, vice president of research at the Toronto Rehabilitation Institute.

Toronto Rehab is supporting the creation of the labs, spread across three different sites in the city, as part of an overall capital redevelopment project.

Far from being isolated ivory towers, or mere test sites leading to the production of dusty academic papers, the unique R&D labs will connect an entire chain of participants needed to move useful ideas from the concept stage to commercialized products.

Working together will be academic researchers, patients, physicians, therapists, and industrial partners, all of whom will provide the insights that are necessary to produce real-world solutions aimed at improving the quality of life for people with disabling injuries or illnesses.

“At one time, the field of rehab medicine was considered a backwater,” said Dr. Fernie at a jam-packed launch event, held in the auditorium of the downtown Toronto Rehab Institute. “Now, we’ve got people wanting to come here.”

Corporate giants like Lenovo and IBM have dived into the project. So have surgeons, computer scientists, therapists and graduate students.

There’s now a sense of excitement about the rehab field, with a plethora of new tools and technologies being used to transform the lives of the disabled.

What’s more, added Dr. Fernie, there are demographic reasons behind the surging interest in rehab medicine.

Baby boomers are now hitting the age where their bodies don’t perform like they used to – but intelligent, affluent individuals aren’t willing to put themselves on the shelf because of infirmities.

“People today don’t accept the argument that you can’t get around because you’re getting older,” said Dr. Fernie. “They don’t want to spend the rest of their lives in a 200-square-foot room in a nursing home.”

He explained there are new solutions for hip fractures, falls, sleep apnea, infection control and many other incapacitating conditions or dangers that can lead to illness.

What’s more, he said, “stroke care has been revolutionized in recent times,” noting that Toronto Rehab researchers are moving ahead with thought process control over objects – something that most, until recently, assumed couldn’t be done.

Dr. Fernie explained that in addition to the graying Baby Boomers and the elderly, people of all ages have disabling accidents. Even so, “They still want to get back to things, they want to have fun.”

Indeed, Toronto Rehab estimates that over 3.6 million Canadians have a disability affecting their mobility, agility, hearing, vision or learning. Some 170,000 Canadians use manual and powered wheelchairs and scooters to get around, and about 35 percent of Canadians over the age of 75 use assistive devices.

The hardships facing these people shouldn’t be underestimated; yet, even a small improvement in the equipment can make a major difference in their day-to-day lives.

It’s the goal of iDAPT to make many such improvements, small and large.

Perhaps the centerpiece of the iDAPT project, which includes 14 different labs, is a state-of-the-art, subterranean facility called CEAL – the Challenging Environment Assessment Laboratory. Built deep below the Toronto Rehab Centre, CEAL will consist of a giant hydraulic simulator that can generate winter-like conditions, including ice, snow, gusty winds and slopes.

Resembling a huge flight-simulator from the aviation industry, the machine will enable researchers to test people’s balance in inclement weather conditions – something the disabled would have to contend with during the Canadian winter.

A motion simulator will allow researchers to test people’s balance under these conditions, enabling them to refine and improve the devices they’re developing.

Another large lab will consist of a typical hospital patient-care room, but it will include an overhead catwalk for observation. This lab will devise new solutions to reduce or eliminate injuries to caregivers who are looking after the elderly or infirm in hospitals or nursing homes.

A modest, single-storey house serves as a lab where researchers can develop artificial intelligence and smart home technologies. These solutions will be of immense help to people with dementia and other disabilities, allowing them to live as independently as possible.

And a movement evaluation lab is advancing research on treatments for paralysis from stroke and spinal cord injury.

A fast-paced video presentation showed Dr. Fernie visiting a couple other iDAPT labs. In one, he visits the centre’s ‘swallowing lab’, which investigates how people with an inability to correctly swallow can waste away, choke or swallow food into their lungs, potentially causing pneumonia. It’s one of a few such labs in the world, and it’s doing ground-breaking work.

Captured on video, Dr. Fernie also visited iDAPT’s industrial design and rapid-prototyping labs. Here, designers and students transform ideas into real-world products, making them useful and attractive.

The devices can be quickly produced for testing as prototypes by a computerized milling machine and lathe system – all state-of-the-art.

Some of the iDAPT labs are currently open with research under way. The centerpiece CEAL facility, along with several others, won’t be ready until 2011, when Toronto Rehab’s own capital redevelopment is expected to be complete.

About $14 million of iDAPT’s $36 million budget has been supplied by the Canada Foundation for Innovation. Speaking at the October launch, CFI president and CEO Dr. Eliot Phillipson called iDAPT a “highly creative and imaginative undertaking… with substantial societal benefits.” He continued by saying, “It will result in new knowledge, ideas, technology transfer, and an improvement in the quality of life for Canadians with disabilities.”

Mark Rochon, Toronto Rehab’s president and CEO, commented that the $36 million investment in iDAPT is the largest investment ever made in Canada in rehab technology.

At the iDAPT launch, one of the speakers made his comments from his wheelchair. John Shepherd is a Harvard MBA student who suffered a catastrophic car crash. “Four-and-a-half years ago, I broke my neck,” said Shepherd. But the well-spoken student hasn’t let that derail his career plans, and is well on his way to completing his studies at the Ivy league university.

The former Toronto Rehab patient is also involved in iDAPT as a project consultant. His advice for researchers and industrial partners currently developing solutions is to listen closely to the users of the devices – people who have ‘skin in the game’ and the best knowledge of whether something is useful, or whether it could be further improved.

“We’re the consumers of assistive devices,” said Shepherd. “We have the expertise, and this expertise needs to be brought into the R&D process. Consumers have a role to play in the research enterprise.”

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Sunnybrook empowers patients with personal EHR

By Andy Shaw

Innovators at Sunnybrook Health Sciences Centre, in Toronto, believe that their unique ‘MyChart’ Personal Health Record could, and should, one day soon be – your chart.

All Sunnybrook patients are offered the web-based MyChart to not only view their record of diagnoses, treatments, and test results, but also to help create, manage, and in effect, own their own personal health record.

Developed relatively inexpensively in less than a year, Sunnybrook is now extending MyChart beyond its sprawling campuses to care agencies in the surrounding community and, if its developers have their way, to the rest of the province and the country.

“We only spent about $150,000, mostly on staff costs to develop it, so we don’t need to recoup our costs and we can therefore offer MyChart to other users at no expense,” says Sam Marafioti, Sunnybrook’s vice president of corporate strategy and development, as well as its CIO. “Now, we know there are other personal electronic health record systems out there, but none that we’ve seen is really a complete health record. MyChart is.”

What MyChart users at Sunnybrook can access or do with MyChart is impressive:

• see and keep records of their care at Sunnybrook, including all test results, such as labs, CT and MRI reports gathered by the hospital’s electronic patient record (EPR) system;

• store and amend personal and family health information, including symptoms, diets, exercise programs, allergies, medication history, and emergency contacts;

• add care provided by other care teams including private clinics;

• view clinic visit notes;

• request and schedule appointments;

• request prescription refills;

• maintain and add to a name-and-address book of caregivers, physicians, labs, and clinics;

• keep a personal diary;

• message physicians and clinic administrators who indicate they accept electronic messages;

• complete online questionnaires;

• find links to frequently asked questions (FAQs), procedure descriptions, videos, events, and other content provided by Sunnybrook that is specific to their diseases.

In addition, Sunnybrook patients can grant online access to some or all of their MyChart record to family, primary care givers, community care centres, pharmacists, and others.

“We like to tell the story of the 84-year-old farmer we call Percy. He gave access to his offspring who live some distance away, and who were concerned about his health after he fell off a roof while repairing it. But with them monitoring his medications, appointments, and other care carefully via the Internet, it’s enabled Percy to continue living on and tending his farm independently,” says Sarina Cheng, the director of eHealth strategies and operations at Sunnybrook. “In another case, one of our patients in palliative care gave access to their power-of-attorney, which is something we hadn’t thought of, but it makes a lot of sense.”

Technically, Cheng and her development team built MyChart with off-the-shelf applications, including Adobe’s ColdFusion MX 7, Flex 2.0, and Flash 8 software. Microsoft Internet Information Server 6.0 hosts the MyChart site, while its database runs on Sybase 12.5, held by a Microsoft SQL 2000 server. To guarantee security, MyChart uses Microsoft Windows 2003 Active Directory for authentication and Verisign certificates for encryption. The latter is the same system used by Canadian banks.

The benefits of MyChart, say Marafioti and Cheng, are not limited to Sunnybrook patients. Staff are also experiencing improvements:

• no disruption to their current ways of doing things;

• a reduction in the number of phone calls and forms needed for referrals and consultations with frequent-user patients;

• streamlining of workflow, thanks to MyChart’s appointment scheduler;

• a better informed, more readily treatable patient who has read MyChart’s educational content and FAQs;

• and soon, for all 12,000 full and part-time staff members, the use of MyChart for their own personal health records.

All that has given Sunnybrook the confidence to offer MyChart to others. Patients, or “clients” as many community care agencies prefer to call those they serve, with the Senior Peoples’ Resources in North Toronto Inc. (SPRINT), a non-profit home healthcare agency, are also now in control of their own records.

“I think what’s important to stress about MyChart is not just the access to information it gives, but also the integration of care,” says Sandy Seary McKinstry, a senior director at SPRINT.

“That’s especially important to community care providers who are more numerous and more active in clients lives than their counterparts in hospitals are,” says Seary McKinstry. “MyChart allows us to know more about our clients, share their information, and thus provide them with better overall service.”

Back at Sunnybrook, Marafioti and Cheng are continuing to adapt MyChart to better suit different Sunnybrook departments and sufferers of specific diseases. In the process, there have been lessons learned.

“The patient often gets test results before the physician has found the time to look at them. So they can be quickly on the phone to the physician’s office looking for an explanation of the results. And that’s probably a good thing in most instances,” says Marafioti.

“But in really sensitive cases, such as the pathology results from a biopsy that could spell cancer, perhaps it isn’t,” he adds. “In one instance, for example, a patient saw the results of a test and concluded that their condition had worsened – when it in fact it had improved.

“So our oncologists asked us if we could build in a time delay for certain results before the patients sees them, enabling the physician to make the call to the patient first if needed. So for oncology, we have built that time delay in.”

Concludes Cheng: “MyChart helps with education, access, monitoring, tracking, wait times and can be expanded to include all personal health data, status, and medical history for an entire family – even pets, if one chooses.

“It’s interactive, not a viewer. MyChart is a personal communication and management tool for the health consumer and it is at its most powerful for the continuity of care outside of hospitals. MyChart keeps the primary care physicians, community services and other care providers informed and it enables patients to have all their information at their finger tips at all times – sharing it when they choose.”  

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‘One Patient, One Record’ system ready for take-off in New Brunswick

By Jerry Zeidenberg

The province of New Brunswick announced in September that it will invest $35.9 million over the next three years to establish a province-wide electronic health record system.

Canada Health Infoway will contribute $18.2 million to the project, with the remaining $17.7 million coming from the province.

The money will be used to put the essential building blocks in place for the ‘One Patient, One Record’ (OPOR) system. The core components, as announced, will consist of:

• an Interoperable Electronic Health Record. The Interoperable Electronic Health Record is considered a foundation piece for the One Patient One Record (OPOR) system. It will provide the infrastructure and functionality required to link, capture, store and view relevant patient information.

• a Client Registry. The Client Registry system is essentially the one-patient component of the OPOR system. With this system, each patient will have a unique provincial identifier that will tie together patient information from various clinical systems.

• a Provider Registry. The Provider Registry system will contain information on healthcare providers in the province.

• and a Provincial Diagnostic Imaging Repository. The Provincial Diagnostic Imaging Repository will consolidate a patient’s diagnostic imaging reports and images for procedures such as X-rays, CT scans, ultrasounds and MRIs, into a provincial repository.

The Department of Health has signed agreements with Initiate Systems Inc. for a Client Registry solution ($1.9 million over two years) and Orion Health for the Interoperable Electronic Health Record and Provider Registry systems ($4 million over three years).

A third contract awarded to xwave for system integration and maintenance services is worth $5.6 million over three years. The contract to create a diagnostic imaging repository has been awarded to Agfa Inc., in the amount of $9 million over two years.

Change management and training programs will also account for a large measure of the investment. And as Canada’s only officially bilingual province, New Brunswick is committed to developing solutions that work in both English and French.

“These systems are key building blocks along the journey to a complete electronic health record that will ultimately link all patient information from across the healthcare system – from hospitals, from your family doctor, from your local pharmacy and elsewhere,” said Mike Murphy, New Brunswick’s health minister.

In terms of architecture, the province doesn’t intend to pioneer new technologies or methodologies; instead, it wants to implement time-tested solutions that have a track record.

It’s hewing closely to Infoway’s standards and solutions, and it has watched carefully as other jurisdictions – Alberta and British Columbia, in particular – have gotten their own province-wide programs off the ground.

“We’re not the first to do this, but we’re going to catch up quickly to the other provinces,” said Gordon Gilman, assistant deputy minister for corporate services. “We’re a small province, which makes things easier in many ways. We think we can catch up to the others in two or three years.”

Many of New Brunswick’s hospitals are already sophisticated users of electronic health records. However, the OPOR system will provide a large measure of interoperability between the hospital systems, which are provided by many different vendors and often lack an ability to talk to one another.

The electronic health record from Orion will act as a kind of umbrella solution, accepting information from all systems and providing a viewer to healthcare providers across the province.

Carole Sharp, assistant director for projects, corporate services, at the New Brunswick government, said that a central repository will be established, housing patient data from disparate sources that will result in a comprehensive single record for each person in the province.

Healthcare organizations will keep ownership of their data, but some of it will be sent to the repository. “That will allow doctors and nurses across the province to use a viewer to see an integrated record,” she said. Sharp noted that not all data will be sent to the central repository, only that which doctors, nurses and other healthcare professionals consider to be essential.

For its part, xwave will provide system-integrator services, tying together the various solutions so that disparate systems mesh in the repository viewer.

“xwave has over 30 years experience in building healthcare systems,” said Paula Hatty, account executive with the company. “We’ve created client registries and we’ve played a key role in developing the patient wait time system in Ontario.”

Gary Folker, managing director of clinical management systems at xwave, commented that the company is well-versed in interoperability issues and Infoway’s blueprint for the design and construction of healthcare systems.

“We’re also experienced in project management, and we’re well-positioned to keep things on time and to deliver the best solution.”

Gilman commented that in addition to the four core projects, New Brunswick has also embarked on a Prescription Drug Monitoring Program, which will collect pharmaceutical prescription information at the point of dispensing – that is, at the province’s pharmacies.

The program will track dispensing of some six or seven drugs – such as oxycontin – that have been sources of concern in New Brunswick and other provinces. “We’re going to monitor selected drugs that appear to be problematic,” said Gilman. “We’ll likely share information with addiction services and police forces.”

The province has completed an RFP for the Prescription Drug Monitoring Program, and expects to select a vendor before the end of the year.

Moreover, New Brunswick will be implementing a full-scale pharmaceutical monitoring program, which will deliver information to health service providers at the point of care.

It will track the drug history of patients, provide physicians with drug interaction information and allergy warnings, in a bid to improve patient safety and the effectiveness of therapies.

Gilman noted that New Brunswick is currently in the planning stages of the project, and that planning is being conducted in conjunction with the province of Nova Scotia. “They’re developing the same kind of system, so why not do the planning together?,” Gilman commented.

He observed that it’s much easier to bring experts to the Maritimes for meetings once, rather than to request visits to different Atlantic provinces on separate occasions. While the One Patient One Record project is, for the most part, starting with large organizations such as hospitals, the long-range plan is to include all healthcare providers, such as doctors’ offices and clinics.

“The ultimate goal is to connect all sources of patient information,” said Gilman. “That includes public health, mental health services, doctors’ offices and others.” That will require additional investments in new systems. Indeed, the province estimates it will need to invest some $250 million in eHealth over the next 10 years.

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If everyone agrees, then why can’t I see my record?

By Kevin Leonard, PhD

In late May of this year, a large percentage of the health and medical informatics community in Canada met in Quebec City for the 2007 eHealth Conference. One regular feature of this annual conference is the Great Debate. This year the debate centered on the question “should patients have unfettered access to their health information?” I was very fortunate to be invited to be one of the debaters – on the pro side.

Before the debate even took place, the audience, of about 800 attendees, were asked whether they agreed or disagreed with the debate question. It was estimated at the time that approximately 90-95 percent of the delegates responded in favour – yes, patients should have access to their health information! And this was before the debate even started.

If so many people agree, then why can’t I see my record today? What is the hold-up? What is stopping us from moving ahead in a direction where there is overwhelming support – and this support is coming from healthcare professionals?

These are great questions that have been asked before, and we know that the answers are not that straight-forward. One major reason is seemingly banal, but overpowering: our delivery system has not accepted the idea of patient access to their own medical records.

I know, how can this be? Is this not in direct contradiction to what was stated in the preceding paragraphs? Well, yes and no.

In the abstract, yes it makes perfect sense that patients should have full access to all of their health information. In an era where consumers are becoming more involved in most every other aspects of their lives, it is reasonable to assume that the same consumers would want the same powers and freedom while managing their healthcare.

However, dealing with one patient at a time, considering the very nature of the contents of a PHR (patient or personal health record), addressing issues surrounding relevancy and privacy, the acceptance of full patient access is not as readily forthcoming. More specifically, the resistance is not, for the most part, technology-based but rather driven by a health system infrastructure and culture that cannot change… at least the way it is structured today. In other words, the system will not change until a number of issues are addressed. Below, I outline three.

First, the healthcare culture, certainly when it comes to dealing with patients, has been operating for generations with a paternalistic view. The consensus is that most patients cannot be trusted to manage their own care.

To some degree, this perspective is warranted. Further, some patients appear to even go out of their way to provide evidence in order to support this thinking. Smoking is one obvious case where there is widespread poor health management by patients.

However, it must be emphasized that this is not the case for all patients. There are many patients with chronic illness who truly want to be more actively involved and empowered. I know that, as a patient, I want to know all the facts no matter how tough they may be to deal with; sometimes understanding the situation does indeed make it easier to accept.

Second, the reimbursement structure within the Canadian healthcare system does not motivate doctors (certainly not general practitioners) to provide medical records access to their patients. While doctors most assuredly want their patients to be informed, so as to improve their health outcomes, in the end, there really is no reason to spend much time or effort, not to mention funds, to provide this access.

In fact, one could argue, that the system today actually promotes and reinforces an environment of face-to-face, one-to-one, healthcare information delivery (as opposed to electronic communication) by creating a simple payment formula – fee for service (i.e., see a patient, submit a claim).

If patients get access to information through electronic means, there will be fewer patient visits – no ifs, ands or buts! That is one of the major benefits of IT – fewer visits, lower costs overall. While it is true that the benefits of eHealth go well beyond the financial (i.e., patient safety, increased efficiencies), this is still an important consideration that needs to be addressed. In the end, what would motivate a clinician to earn less money?

Third, it is not yet an accepted fact that patients having access to their own health information improves their health outcomes. The research is still going on “in the labs”, but each month there is more and more evidence demonstrating that the empowered patient is healthier.

So, where does that leave us? It would appear that no matter how much IT development has taken place, or how much system interoperability is created or informatics training is done, I won’t get to see my record until:

1. The overall system appreciates the role of the patient as an individual and as a key stakeholder who must become active in healthcare system management.

2. The financial framework begins to motivate clinicians to support patients’ migration to feasible access of their own health information.

3. More research is funded to prove the hypothesis that informed patients are healthier.

Kevin Leonard, MBA, PhD, CMA, is an Associate Professor, Faculty of Medicine, University of Toronto.

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