Ambitious project to develop PHRs and shareable EHRs
TORONTO – In a unique partnership designed to accelerate the use of Personal Health Records and shareable, electronic medical records, 16 organizations in Ontario have joined forces to develop the Connected Health and Wellness Project.
They include private-sector companies, academic centres and hospitals. The project is fuelled by a $15.5 million contribution from the federal government, through its Federal Economic Development Agency for Southern Ontario (FedDev). In addition, the partners are chipping in another $23.3 million.
“We want to make every person be as well as they can be, and to do that, they need to be connected with their health records,” said Bill Tatham, president and CEO of NexJ, a systems integration company that is leading the effort. NexJ has created an ‘integration platform’ and engine that can connect with disparate systems and securely store data in a cloud.
But the system isn’t just a passive repository of records. Partners are devising active ‘coaching’ modules that will help people manage a variety of acute and chronic conditions. For example, it will include interactive coaching of diabetes patients, enabling them to monitor and upload information about their glucose levels and also their diet – including photos of what they have been eating.
Caregivers can respond, letting them know how those with diabetes are doing. This can help ensure that diabetics are kept on track with their care-plans, improving their health and keeping them out of emergency departments.
The partners have already completed this first application for diabetes – it was produced and tested in conjunction with York University and a medical clinic located in northwest Toronto.
Tatham explained that the system will be context sensitive, and that when patients log-in, they will be presented with options that are relevant to their particular conditions. Patients with hypertension, for example, will have buttons offering secure messaging to their care team, which may include cardiologists and nephrologists, nurses, nutritionists, home care support workers and others.
They will have access to recent and historical test results and notes. They will also be able to tap into a health library and best practices relevant to their condition.
Under development is an application allowing patients to self-schedule appointments and tests at hospitals and doctors’ offices. Both North York General Hospital in Toronto, and Southlake in Newmarket, Ont., have expressed interest in this.
“It has the potential to save them time and money,” said Tatham. “It will save them human resources they need for patient care, resources that otherwise spend a lot of time on the telephone.”
A related application that’s under development is termed eConsult, where patients fill out the forms that are needed at hospitals before they arrive. Instead, the forms are filled out online and are in the hands of hospital staff before the patients get there.
The Connected Health and Wellness Project will now add new computerized applications, and patient participation will be expanded, with rollouts across York University – an academic centre with 55,000 students – and at the North York Family Health Team, the largest family health team in Ontario. Physicians at this health team are affiliated with the nearby North York General Hospital, a community teaching hospital.
Tatham said that talks have started with the makers of major Electronic Medical Record system to create interfaces that will feed patient data into the Connected Health and Wellness Project. McMaster University’s OSCAR system, an ‘open systems’ EMR, is the first EMR organization to participate.
There are currently over 1,000 physicians using OSCAR across Canada, most of them in the province of Ontario; many of their patients will be offered access to the Connected Health platform. “This gives us a running start,” said Tatham.
The plan is to create links to hospital information systems, as well, and to lab and pharmacy systems. With permission from patients to automatically collect the data, Connected Health and Wellness Project aims to create a real-time repository of patient data pulled from a wide variety of sources.
NexJ has experience in connected data sources from integration projects it has conducted in healthcare and other industries, Tatham said. “We specialize in this kind of integration.”
Of course, the patient will have ownership of the data, and will be able to specify who can have access to the information – such as parents, children and close friends. The system will then offer caregivers a fuller picture of the patients’ health than can often be obtained.
Tatham gave an example of a situation that occurred during connectivity testing at the Royal Victoria Hospital, in Barrie, Ont. A couple brought their sick child into the emergency department, but were not able to convey the baby’s medical history to the doctors, or what medications she had been taking.
By using the Connected Wellness Platform, NexJ and the physicians were able to find out from local the EMR in a local physician practice that the baby had been a heart surgery patient at the Hospital for Sick Children in Toronto. They also found out what medications the child had been taking, enabling the emergency physicians at the Royal Vic to better determine the nature of the child’s problem and to provide safe treatment.
The Connected Health and Wellness application will be provided to the public for free. In the immediate future, the contributions of the partners will pay for the system.
Tatham said it’s likely that partners will continue contributing, and new organizations will join, because they obtain benefits that outweigh the costs.
“For the hospitals, it represents a cost-saving for them,” said Tatham, noting that healthier patients means fewer visits to their emergency rooms and wards, less waiting time and faster throughput of patients.
He observed that hospitals and academic partners are also conducting research – devising electronic systems and testing them. The project gives them a ‘real world’ laboratory to create and fine-tune applications.
In the future, Tatham said, advertising may be added to the application – but only ads that are relevant to the patients. For diabetes patients, for example, there may be ads alerting them to price discounts on the blood glucose test strips they use.
Currently, the private sector partners in the project include NexJ Systems Inc., Oscar Service Inc., PryLynx Corp., Rogers Health Care, Research In Motion, Trivaris, Tyze Personal Networks and the Beth Israel Deaconess Medical Center (an affiliate of Harvard Medical School.)
Academic and hospital partners include York University, McMaster University, Centennial College, George Brown College, Seneca College, Centre for Global eHealth Innovation (UHN), North York General Hospital and Southlake Regional Health Centre.
York University will develop training programs for patients that will help control or improve their illnesses; the approach includes further work on the emerging Health Coach profession, in which caregivers collaborate with patients. The approach also includes incentives for patients.
Centennial College has been working on ‘gamefication’, which includes incentives for promoting usage of systems and compliance with care plans to achieve better outcomes.
Seneca is devising multimedia technology that promotes ease of use for patients when interacting with the system, while Mohawk College is working on interoperability testing.
For its part, Rogers has supplied the bandwidth needed for testing; in the future, the company hopes to roll out the system as part of a wellness program for employees.
Meanwhile, Beth Israel Deaconess, in the Boston area, proactively called and asked to join the project after learning about it. Researchers there are working on a ‘handoff’ application that ensures information is available to caregivers when patients leave one part of the healthcare system and enter another – such as when they are discharged from acute care hospitals and start receiving home care services. The goal is to reduce re-admissions to hospital, a major challenge for patients and care-givers today.
All in all, the Connected Health and Wellness program aims to make accurate and up-to-date information available to patients and their various care-givers. “Ultimately, the consumer needs to be responsible for his or her health,” said Tatham. “That’s what we’re trying to encourage.”
New approach to privacy, new programs, to propel Quebec health IT
Quebec, like the rest of the country, embarked on its electronic health journey back in 2004 with the hope that it would progress rapidly and transform the way clinicians care for their patients. Years later, though much has been accomplished, there is still a long way to go. Healthcare IT is evolving but its complex nature, coupled with competing priorities, continue to be common challenges. But with alignment amongst clinical leadership being greater than ever, Quebec is poised to accelerate the rate of deployment so patients can reap the much needed clinical benefits they are entitled to experience.
Early demonstrations of the electronic health record (EHR) in Quebec quickly changed the course regarding how this information would be captured, collected and presented to community clinicians. At the outset, Quebec passed Bill 83, which allowed the circulation of specific health information to authorized clinicians.
However, over time, it was discovered that the express consent model was an issue as were some aspects of the security model, which would have required a complete re-engineering of the security mechanisms at the institutional level.
Thus, Bill 59 was born on the last day of the last parliamentary session in June 2012. This new legislation, moving to an implied consent model, set the stage for provincial and regional campaigns aimed at informing Quebecers of their right of refusal regarding the collection of their key health information in central repositories. Based on the results of the first four regions where this was implemented, it is expected that fewer than 1 percent will exert that right.
Quebec and its clinicians are pursuing an integrated approach when it comes to electronic medical records (EMR), health information systems (HIS) and the EHR. The use of an EHR viewer is no longer considered the ultimate goal thanks to the Quebec EMR program announcement.
With this new program, primary care clinicians will be reimbursed, starting November 15, for the implementation and use of one of the upgraded EMRs sanctioned by Quebec. These EMRs have already gone through cycle one (last year) of the Quebec certification process to achieve interoperability with the drug solution, including e-prescribing, and the registries (client, provider, localization, consent, security) through the Health Information Access Layer.
Meanwhile, cycle two, integrating data from the provincial laboratory repository, is under way. It is expected that more than 4,500 clinicians will be using one of these EMR solutions within the first two years of the program, reaching a penetration of 85 percent within four years.
While these objectives may seem aggressive, some key enablers should contribute to these results. Primary care in Quebec has already been through some transformational changes through the creation of large groups of practices (GMF) whereby 2,000-3,000 physicians are already using some EMR functionalities like e-prescribing. The new program is managed by the Ministère de la Santé et des Services sociaux (MSSS) and the general practitioners association (FMOQ) plays a leadership role in all change management and promotional activities.
The e-prescribing cycle initiated at the EMR level would not be complete without the integration of the pharmacists’ back office systems. The two main solutions used in more than 90 percent of Quebec community pharmacies are already upgraded and ready to be deployed on a bigger scale so that pharmacists can retrieve e-prescriptions created by clinicians.
The number of e-prescriptions is growing rapidly in the central repository with physicians using one of the upgraded EMRs. The deployment is progressing with a concerted approach between medical clinics and surrounding pharmacies. However, the complexity of balancing the needs of physicians and pharmacists in this integrated approach has slowed the project thus far. The use cases, however, are proving to be so compelling that the connection of all pharmacies should be complete by 2014-2015.
Points of acute care in Quebec, especially the community ones, have been slow to deploy a complete HIS beyond the traditional laboratory, pharmacy and diagnostic imaging system due to lack of financing and availability of French-language commercial solutions.
Some of the university health centres have reached Level 4 of the EMRAM adoption model of HIMSS Analytics, but most of the institutions are still at Level 3 or below. For many years, only the university health centres were seriously implementing these solutions, but that movement has increased substantially with most of the regions now involved in the implementation of such clinical systems.
The regions were mandated by the MSSS to implement a unique solution within each territory, enticing the regional agencies to work collaboratively with its institutions and clinical leaders. Some of these regions are also planning on upgrading their HIS to become interoperable with the EHR specifically to access data from the drug, diagnostic imaging or laboratory provincial domains.
Both diagnostic imaging and laboratory domains are progressing with the archiving of images and reports and the connection of public labs. In fact, the archiving in one of the three diagnostic imaging repositories (DI-r) of all images taken in public facilities will be completed by the end of 2012 with the private ones starting and planned to be completed the following year.
The Quebec teams are at work to resolve the challenges encountered in achieving complete interoperability, using the XDSi registry, between heterogeneous PACS and DI-r technologies.
The connection of public sites to the unique laboratory repository is progressing slowly, with Quebec City slated as the first region to be complete by the end of the year, which will make up 20 percent of the overall provincial volume. When complete, this solution will complement the existing regional hubs, allowing the distribution of lab results to ordering physicians.
Quebec’s sustained efforts have resulted in the successful installation of a vaccine inventory management module at the provincial, regional and local levels. The installation of an immunization registry is planned for the beginning of 2013 in the first pilot region, with a full deployment later in the New Year.
Regarding telehealth solutions, the creation of four coordination centres managed by the University Integrated Health Networks (Réseau universitaire intégré de services) has crystalized the efforts which were often led by isolated champions. These new centres were able to create a network of more than 900 telehealth stations throughout Quebec. The demand and offerings for these specialized services are now growing rapidly.
Louise Beauchesne is Executive Regional Director (Quebec), Canada Health Infoway.
For patient safety, obey the “10 rights” of medication administration
By Cheryl D. Parker, PhD, RN-BC, FHIMSS
All nurses are taught the “five rights of medication administration” during their basic nursing education. These are: right patient, right route, right dose, right time and right medication. For over 35 years, this memory aid has helped nurses to both avoid medication errors and to promote the desired patient outcomes.
While the “five rights” are still required, there has been recent discussion in the profession about adding additional “rights” to the list to accommodate additional crucial steps nurses must consider as the nursing practice has evolved and documentation requirements have increased. These new “rights” consist of:
Right documentation: Are both the medication and patient condition being documented properly at administration? Documentation showing that providers followed the appropriate administration protocols can both improve patient safety and reduce liability.
Technology can help encourage proper documentation by utilizing automated medication alerts and reminders to document vital signs, lot numbers and other details before administration.
Right reason: Is the proper medication being given to the patient? For example, if a patient is receiving insulin, does he or she have diabetes?
After confirming the original five rights of medication administration, nurses could still give a patient a drug for the wrong reason. A fundamental question must be, “Why is this patient receiving this medication?” If the drug is a blood thinner, for example, does the patient have cardiovascular problems?
Right form: Even the right medication administered in the right route could cause an adverse event if given in the wrong form.
Medications come in many varieties – pills, IVs, suppositories, patches, etc. – and each form has its own unique attributes, such as absorption time. Acetaminophen can be administered as a liquid, pill or suppository, while ibuprofen can be administered intravenously. It is imperative to note that identical medications in their different forms can cause different reactions, even if the dose is correct.
Right response: If a medication is given to decrease nausea or pain, did it work as expected? This is a somewhat trickier “right,” since not all medications cause an immediately noticeable response. Assessing the response to a drug administration, however, is crucial to avoiding adverse events and readmissions. If determining a response is not possible during a patient’s encounter, then post-encounter follow-up is necessary.
Right patient education: Does the patient understand why he or she is receiving the medication, what side effects to watch for, which side effects to report immediately and what actions to avoid?
In days past, most patients accepted physicians’ orders without question. Today, that passive model of healthcare has been replaced by initiatives that encourage patients to become active participants in their care. Nurses are on the front lines of this important shift, and access to the EHR and patient education materials at the patient bedside can help to assist and inform their patients.
Electronic Medication Administration Record (eMAR) and Barcoded Medication Administration (BCMA) systems have helped nurses follow the five original rights, and while technology cannot replace good clinical judgment, it can assist nurses with the five new rights, as well.
With the help of technological tools, five additional “rights” can supplement the original protocol to help healthcare facilities improve patient safety and ensure better outcomes.
Cheryl D. Parker, PhD, RN-BC, FHIMSS, is chief nursing informatics officer for Rubbermaid Medical Solutions and is a contributing MSN instructor for Walden University.
Lessons from the eHealth Ontario diabetes fiasco
By Richard Irving, PhD
The cancellation of a $46.2 million contract for a diabetes registry has the political opposition, pundits and reporters once again raising questions about the management of e-health in Ontario. I believe that many of the critics are missing the point. This is a fiasco, but not in the manner portrayed in the media. Simply put, this seems to me to be a failure of project management.
In considering the project it is important to note that the CHAOS reports produced every few years by the Standish Group consistently show low IT project success rates ranging from 28 percent in 2000 to 32 percent in 2008.
Furthermore, the same series of studies show failure rates for the same period ranging between 44 percent and 53 percent.
There are some who challenge the CHAOS findings, and I agree that the CHAOS reports may overstate the problem. However even if they overestimate project failure rates by half, a 20-25 percent failure rate is still unacceptable; particularly since this is across all sizes and durations of IT projects.
It is well established in the IT literature that as the durations of IT projects increase beyond one year and the cost of the project exceeds $1 million the probability of success falls dramatically. All the eHealth Ontario projects making the headlines have been multi-year, multi-million dollar projects where the basic probability of success is low. Consequently, we see some dramatic failures of these projects.
Large government projects often face a further hurdle to success. That hurdle is the lack of flexibility built into the contracting process. In a large private organization, there is often the ability to change requirements and project direction in response to changing circumstances. (In CHAOS terms this would be a “Challenged Project”, but that might be okay if the benefits are worth the changes).
Large government contracts are usually less flexible. There are good reasons for this lack of flexibility, but this rigidity increases the risks that IT projects may produce obsolete or marginally useful end-products. Political issues also cloud the chances of success.
A recent book, ‘Reinventing Project Management’, by Aaron Shenhar and Dov Dvir, provides insight into how the management of these complex projects may be improved so that the risks of failure are reduced. They describe a four dimensional NTCP model based on Novelty, Technology, Pace and Complexity. While space prevents a complete description of the NTCP model here, I will comment briefly on how this model may apply to the problem of the diabetes registry.
In so far as I understand the project, the diabetes registry was a derivative application of known technology. This means that it used well-established technologies which can be described as medium-level technology. The pace of the project seems appropriate, but the complexity was likely much higher than anticipated – and thus the delays. Shenhar and Dvir would likely classify the project complexity as a systems project. That is a project where “there is a complex collection of … subsystems jointly performing multiple functions to meet a specific operational need.” To successfully manage these projects one needs at least:
• a good grasp of systems thinking and systems modeling;
• a broad skills range and proper interface management;
• the ability to evolve specifications over time;
• high levels of configuration control and management;
• significant user involvement; and
• high levels of cooperation and coordination with the client and key stakeholders.
My guess is that the project was formulated without proper regard for the complexity involved and that a combination of weak initial specifications, contractual rigidity and under-estimation of the risk of failure, all contributed to the failure of this project. Finally, I believe that e-health projects will continue to fail until more sophisticated project management systems and better contracting processes are put in place.
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