Inside the October 2001 print edition
Canadian Healthcare Technology:
Feature Report: New developments in telehealth
tele-homecare trial launched in Maritimes
Several partners have joined forces to test a new telehealth system in
the residences of 70 Maritime-based home-care clients. Its among the largest home
telehealth project launched in Canada, and the first to make use of high-bandwidth,
Saskatchewan District Health has effectively connected 20 different
computer systems, integrating acute care hospitals and long-term care centres. An
interface engine is used, so that users can share clinical and administrative information.
Implementing a Picture Archiving and Communication System is a
large-scale project that can cause disruptions until the bugs are worked out. Once
implemented, however, a PACS can deliver major productivity improvements.
It would be extremely useful to physicians if developers of electronic
patient records would include software that automatically checks the medications
prescribed to patients during an encounter.
The NORTH network, a telehealth system that connects medical
specialists with rural delivery centres, is poised for expansion. There are major changes
planned on the technological front, as well, as the network shifts from ISDN and Switch 56
to an IP-based system.
PLUS news stories, analysis, and features and more.
High-speed tele-homecare trial launched in Maritimes
By Jerry Zeidenberg
Several partners have joined forces to test a new telehealth system in
the residences of 70 Maritime-based home-care clients. Its among the largest home
telehealth project launched in Canada, and the first to make use of high-bandwidth,
The partners call the system user friendly, as home-care
clients have just two buttons to control on and off. Theres a camera with a
sleeve cover that flips down for privacy. And familiar medical instruments, such as a
spirometer and electronic stethoscope, connect to the system using a wireless link.
The five-month-long pilot project is taking place in Halifax and
Moncton. It will allow nurses at central offices to make virtual visits to the
homes of clients, observing and speaking with patients through the videoconferencing
system. Theyll also be able to remotely control the medical instruments while
patients are using them.
The project involves We Care Health Services Inc., a privately run home
care company with 55 franchises across Canada, March Networks Inc., a multimedia
technology company with broadband solutions for home care and long-term care, Aliant
Telecom, a telecommunications provider, and CANARIE, Inc., the Ottawa-based Internet and
data communications development agency.
As well, the project will be independently assessed by Dr. Richard
Scott, an associate professor with the Health Telematics Unit at the University of
Calgary. Dr. Scott has a background in the evaluation of telehealth projects, and recently
worked with the VITAL home telehealth project in New Brunswick.
The corporate partners believe the technology can dramatically improve
the quality of care for clients and lower costs for home-care providers.
We think the technology wont replace regular visits by
nurses, instead, it will augment those visits, said Bob Webster, general manager of
March Networks, in an interview with Canadian Healthcare Technology. He explained that the
70 participants in the pilot project will continue to receive their regular visits from a
nurse, but will also participate in two video visits each week.
As a result, they will be in closer communication with their
Whats more, they will have the ability to videoconference with
the nurses on demand, if they have an emergency situation.
A nurse could recommend immediate medical attention in such cases
such as a trip to an emergency department. Alternatively, the nurse might determine
that a trip to hospital is unnecessary in certain situations, thereby saving time and
trouble for the client and medical centers.
For home care agencies, its believed that telehealth can produce
high-quality care at lower cost. Its well known that nursing shortages are a
problem across Canada, and in most parts of the world, said Webster.
Videoconferencing technology, in theory, enables agencies to provide a greater number of
visits with the nurses they have on staff.
Moreover, nurses will spend less time traveling in their cars to see
clients an unproductive use of their time. Instead, they can communicate with
patients through the videoconferencing system.
This is especially useful for geographically remote clients, such as
those in rural locations, who are difficult to visit.
We Care president John Schram said the technology is the next step in
efficient home care, and estimated that telehealth could cut the cost of delivering home
care by as much as 50 percent.
March Networks designed the equipment and is investing some $750,000 in
the pilot project to demonstrate its effectiveness. CANARIE has chipped in another
We believe theres a serious business case for this
technology, said Webster. We believe that demand for it will take off over the
next few years.
Indeed, Webster said March Networks is gearing up to start commercial
sales of the system next summer, in both Canada and the United States. Once the units are
produced in volume quantities, Webster says March Networks will be able to sell them for
about $2,000 to $2,500 each.
According to Webster, the systems are network agnostic,
meaning they work with any type of high-speed network including cable, DSL, and
The company is using an ASP model to bring down the cost for home care
agencies. Instead of selling home care providers a server with software, March Networks is
running its own servers and software from a central location.
Home care agencies tap into the server and use it connect with their
own customers using a secure, virtual private network.
Also part of the system is software that logs remote visits, and helps
the home care agency track and manage client care, staff and business issues. We
know that home care providers have a huge whack of paperwork, and were trying to
help them with this, said Webster. He said the software automates a good deal of
record keeping, and that medical data including audio and video clips are
kept on file for reference purposes. Doctors or nurses may want to go back to
it, said Webster. We also keep files from the medical instruments, so that you
can establish trends for patients.
When it comes to the equipment going into the homes of clients, Webster
said March Networks has tried to make it simple to use and unobtrusive. Instead of a
computer and monitor, a gateway box attaches to the clients TV set. A small camera
sits atop the gateway unit, with a shutter that can be flipped open or shut at the
A box of instruments including spirometer, blood pressure
monitor and electronic stethoscope is positioned nearby, but there are no cables
running to the TV or gateway box. Instead, the medical instruments use a wireless
connection to the system.
The fewer the wires, the better, said Webster. People
dont want visitors coming in and seeing a whole lot of cables and equipment lying
about. If they do, they assume the person is really in poor shape, which may not be the
By keeping it simple, we feel we will gain more user
acceptance, said Webster.
The camera runs at between 15 and 30 frames per second, enough for
real-time-video without any noticeable delays or latency, said Webster. To operate the
system, the user needs only to open a sleeve on the camera, and press a green button on
the control unit. A red button shuts things off.
The 70 participants in the trial all have chronic illnesses, such as
respiratory problems, cardiac illness or cancer. Most will be 55 to 75, which is the
typical age range for home care recipients.
For its part, We Care is proactively investing in technological
solutions to improve the delivery of home care services. The company is currently
investing over $1 million on various information technology applications.
Integration engines enable hospital networks to use best solutions
By Dianne Daniel
Integration is the buzzword as hospitals move forward with plans to
share electronic information externally with other medical centres, physician offices,
pharmacies and other community-based agencies.
But when embarking on efforts to establish a smooth flow of data from
one end of the spectrum to the other, those involved should treat integration as an
ongoing process versus a standalone project, cautions Guy Paterson, director of IT and
telecommunications for Saskatoon District Health (SDH).
Integration is not a one-time thing; its not a project that
starts and ends, notes Paterson. You do it and then its ongoing
maintenance ... How are the changes that are occurring in the organization handled as
youre getting a more complex, integrated information management system out
Since the early 1990s, SDH has chosen to make integration a core
competency of its IT department. Today, its underlying infrastructure supports the
processing of roughly 100,000 messages each day with nearly 100 per cent data accuracy.
Information is sent and received by more than 20 different computer systems within the
districts acute-care and long-term-care facilities, but as that expands to include
the community, every medical clinic, pharmacy and doctors office becomes a potential
customer as well.
To manage the complexity, the district has two full-time IT staff
devoted to integration. Monitoring tools are constantly running to alert them when an
interface process fails, via pager or e-mail, and testing is done continually.
As SDH manager of IT Perry Kjargaard puts it: With the complexity
of this web weve woven, and the demand from users, theres literally changes
requested all of the time. We employ people to manage that process.
For example, if a hospital opens a new unit, the information about that
unit has to be propagated throughout the district. Suddenly youre admitting a
patient to a bed that didnt exist before and the receiving departments need to
understand that theres a new bed there, explains Paterson. You have to
really look at the information flow from end to end, from creation to final use and
end use can be in multiple locations and for multiple purposes.
While the IT department did a lot of initial work to minimize the
amount of data manipulation required to share information among various systems, the
development of a data standards council and use of an integrated test plan have also been
key to a smooth integration process.
The initial goal was to get as close to Health Level 7 (HL7) compliance
as possible, the electronic data interchange protocol that outlines how information is
exchanged between systems. The approach at SDH is to allow each business unit to retain
control over what Paterson refers to as the transactional layer, the part that deals with
selecting best of breed software for the task at hand, whether its registering
patients, ordering lab tests, performing lab tests or reporting results. This enables
departments to choose the most cost-effective and efficient applications.
It then falls to the IT group to support the extraction of information
from those systems via an interface engine.
Our philosophy is to find the best information system to support
the needs of those business units, regardless what they are, he says. We then
look at the extraction of that data in most cases using an integration engine to
put it into some sort of repository or electronic health record, he says
That philosophy is echoed at Toronto-based electronic Child Health
Network (eCHN), a partnership among The Hospital for Sick Children, the government of
Ontario, Canada and several member organizations.
ECHN aims to electronically link hospitals, local pediatricians, home
care agencies and others that provide childrens health services.
One of the fundamental requirements we had was we didnt
want to require any of the hospitals to replace any of the information systems that they
already had in operation, notes eCHN chief executive officer Andrew Szende. We
wanted everyone to retain their autonomy and to retain the choice of buying the best of
breed information systems, the ones that they wanted.
A critical service provided by the eCHN is the Health Information
Network or HiNet, a system that enables healthcare providers to share common data in the
form of an electronic health record.
The information shared includes lab results, dictated summaries and
images, all of which is intended to provide a continuum of care, linking home care to
community agency to regional pediatric centre to a childrens hospital.
Like Saskatoon District Health, the eCHN relies on HL7 messaging
standards to ensure smooth data transfers.
While member hospitals usually have an interface engine in place to
make outgoing data compliant with the standard, the eCHN uses the Health Data Network
(HDN) from IBM Canada Ltd. on top of that to pull the information together into one
According to Dr. John Edmonds, eCHNs network specialist, once the
machines on either end understand what it is theyre sending and receiving, the next
step is to normalize the data.
For example, hospitals may use different names for the same lab test.
When the information arrives at HiNet, the IBM HDN software needs to know they refer to
the same thing so that the information gets put into the right `slot, he says.
Another layer of sophistication is required in the software to ensure
the reference range for the lab test is displayed correctly, he adds. The reference
range is different for different ages of kids. The software needs to know how old the
child is, what am I going to display as normal now and what was normal when the test was
Like SDH, the electronic Child Health Network has a team devoted to
managing change, called its MED team for Medical Entities Dictionary. The group
continually looks at lab tests coming in from different places and has discussions about
the best way to handle the information. Its not something thats
static, notes Edmonds.
In operation since October, 2000, HiNet allows users to call up an
integrated view of a childs health record that indicates the most recent test
results as well as the patient history.
Members of the network retain ownership and control of their own
patient records, but a copy is mirrored in HiNet in real-time so that the most current
information is always available to everyone without the risk of one member making
an unwanted change to another members record, says Szende.
Current eCHN members include Toronto-based St. Josephs Health
Centre, Saint Elizabeth Health Care (a home care provider), Orillia Soldiers
Memorial Hospital, Rouge Valley Health System, Bloorview MacMillan Childrens Centre,
of Toronto, and The Credit Valley Hospital, in Mississauga, Ont., as well as roughly 20
Information is transmitted via private T1 or leased fibre lines for
privacy and security, although Dr. Edmonds is quick to point out the electronic records
are much more secure than the paper versions shared normally.
At the moment a health record department will send out a paper
chart, but once we send it by fax or mail, we have no control over how its
distributed, he says. With the electronic version we can keep track of who
looks at it.
Complete commitment, strategic plan key to PACS implementations
By Issie Rabinovitch, PhD
When General Electric Medical Systems Information Technologies recently
hosted a one-day press event at their headquarters in Milwaukee, I decided to attend. As
GEMS racks up US$9 billion in sales annually and invests US$900 million in R&D per
year, it cannot be ignored. Im happy to report that the mini-conference exceeded my
The day was fast paced, with numerous presentations by GEMS executives,
partners, and customers. The quality was uniformly high, with a few exceptions, but the
best presentation (in my opinion) was entitled Essentials for a successful
enterprise PACS implementation, by Neil D.Johnson, M.D. Hes the Chief Medical
Advisor, Clinical Informatics, at Childrens Hospital Center, Cincinnati.
What distinguished this PACS presentation from others I have attended
was the experience of the presenter. Dr. Johnson has been involved with his
institutions PACS project since the earliest planning stages, and is still involved
day-to-day more than a year after full implementation.
A native of Australia, Dr. Johnson was both a pediatric radiologist in
that country as well as an entrepreneur in healthcare technology before moving to the
United States. He has authored numerous peer-reviewed publications and made presentations
around the world. He is a member of many professional associations, and serves on several
national committees. His main clinical focus is vascular and interventional radiology.
Over a decade ago, he brought this unique blend of experience to his
job at Cincinnati Childrens, a leading U. S. pediatric institution. It is a 350-bed
hospital with seven linked outpatient centers about 20 miles or more away. It performs a
total of 148,000 radiology exams and has 375,000 outpatient visits per year.
Dr. Johnson led the centers development of a PACS (picture
archiving and communications system) to replace film used in radiological procedures. The
hospital began planning its PACS in 1998, and the undertaking involved 50 people from
numerous functional areas.
The RFP stage was reached in January 1999, vendor selection in July,
contracting in August, and implementation commenced in December of that year. He told the
team that this is the biggest thing we will ever do, and in retrospect, he
doesnt think he overstated the case. The PACS project was a major disruption in
everyones life, and actually lead to a revolt at one stage, which Dr. Johnson dealt
The PACS at Cincinnati Childrens replaced a system of radiology
film transportation between facilities by truck. It has helped the hospital approach its
ideal of any film, anywhere, anytime. According to Dr. Johnson, the key to
success included a strategic plan, a complete commitment to a filmless environment, and
careful selection of vendors for what was assumed to be a 15 or 20-year marriage.
Changing vendors sooner than 15 years, according to Dr. Johnson, is a
prospect too horrible to contemplate. Therefore, the PACS supplier must be a stable
company with long-term vision and commitment, substantial resources for development, and
an aggressive approach to upgrades. Dr. Johnson and Cincinnati Childrens chose GEMS,
but there are other vendors that fit the profile. In Dr. Johnsons view, smaller
companies are more likely to disappear, and are therefore a dangerous choice.
A PACS is a BIG Information System, the emphasis being Dr.
Johnsons. It is more than just being filmless. He made the point, several times,
that having the ability to pass images around (image distribution) isnt all there is
Whenever he reads about institutions that claim to have installed a
PACS within a few weeks, he is absolutely confident that they have simply accomplished
something far more limited. Installing a PACS takes more than weeks or months.
At Cincinnati Childrens, 90 percent of reports are signed off
within 24 hours. If a report is marked as urgent, it is handled within one hour. Some film
is still used, but every image is available in digital form.
There are some radiology procedures at outpatient clinics that require
a radiologist to be in attendance. Until PACS, these physicians would only read a few
pictures per day, but now they can be far more productive, since they can read pictures
that were taken anywhere. Wherever the doctor is, including at home, he or she can read
the film. The PACS solution provides after hours service, uniform service, any place, any
There is a national shortage of pediatric radiologists, with over 100
advertised positions currently unfilled. Dr. Johnson mentioned the case of a city in the
U.S., comparable in population to Cincinnati, that was about to lose all of its pediatric
radiologists in a labour dispute. The hospitals in that city were considering outsourcing
the work to Cincinnati Childrens, whose efficient PACS gives them the capacity to
handle this extra work.
Dr. Johnson also had some valuable tips on working with consultants. He
admitted that his experiences in Australia with consultants had been less than successful,
but his experiences in the U.S. were decidedly more favourable.
According to Dr. Johnson, consultants can be very valuable in
implementing a PACS, especially if they are neither part time nor beginners, if they have
national experience and are part of a team with multiple skills. Dr. Johnson has found
that consultants are most valuable for project organization and discipline.
Issie Rabinovitch, PhD, is a Toronto-based computer consultant.
Doctors offices would benefit from automatic drug checking
By Dr. Alan Brookstone
Canadas aging population is creating a poly-pharmacy nightmare
for physicians across a range of clinical specialties. One of my greatest frustrations in
family practice is my inability to easily detect or predict dangerous drug interactions
particularly in my elderly patients who are on multiple medications.
The number of pharmaceutical products on the market makes it virtually
impossible to predict serious drug interactions given the constraints of time and the
limited information that is available at the point-of-care.
The average consultation time for an office visit is 10 minutes, and
even though tools such as Palm-based ePocrates qRx 4.0 provide drug interaction checking
capability, using my Palm during the office visit requires that I have to double-task.
During an average consultation I have to take a history, examine my
patient, develop a diagnosis and treatment plan and write a prescription. As a result, I
have little time available to perform a drug interaction check to look for potential side
To be useful, this information should be automatically and
transparently presented to me as part of the patient encounter.
The patient medication profile needs to be resident in my clinical
record system without the need to re-input any information other than a change in dosage
or the addition of a new medication at the time of the clinical interaction. Anything less
is too cumbersome.
As a result, I depend to a large degree on my clinical knowledge, my
intuition and the friendly local pharmacist, who calls my office all too frequently to
confirm a medication dosage or warn of a potential interaction with another medication.
How do they do it? Through sophisticated drug databases that
automatically prompt the pharmacist with respect to potential interactions based on a
patient medication profile.
According to an August 2001 National Post news article, it is estimated
that approximately 5,000 to 10,000 Canadians are dying per year due to medical errors.
This number is approximately one-tenth of that reported in the United
States and is in proportion to similar studies in the UK and Australia. Electronic Medical
Record systems are an important means for reducing office based prescribing errors.
In a medical office, time is the greatest limiting factor for
physicians. If a tool does not integrate into the daily patient workflow, is difficult to
use, is not instantaneous in response or adds to workload, it is simply not going to be
Physician offices currently lack the technology necessary to detect
adverse drug interactions and suggest possible alternatives. As a result, we cannot take
advantage of technology to attack this problem because the majority of physicians run
purely paper-based medical offices.
Standalone tools do not work, as they require a change in workflow in
order to be adopted by physicians and provide limited end user benefit. Therefore, I
strongly believe that adoption of a physician-based electronic record management system
will require a more complete solution than that which is currently available.
Implementation will also require considerable workflow re-engineering
in order to be acceptable to the physician user.
Features will need to include immediate access to clinical data and
flexibility in the mechanism of data entry including keyboard, voice recognition and
handwriting recognition. I strongly believe that physicians require a solution that
applies to every aspect of daily workflow.
Dr. Alan Brookstone is a physician based in Richmond, B.C.