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Inside the October 2003 print edition of Canadian Healthcare Technology:

Feature Report: Developments in telehealth

Hospital council announces new slate of e-health projects

The Ontario Hospital eHealth Council has announced support for three new projects that will help create a province-wide network of electronic health records.


Online education

Web-based CME is growing in popularity among doctors, due in part to the movement away from industry sponsored educational conferences for physicians. mdBriefCase has been a beneficiary of the trend.


Shortage of imaging technologists threatens healthcare, experts say

The situation has become a political issue in Ontario, where the opening of private MRI and CT clinics has led, according to some observers, to the “poaching” of technologists from public hospitals.


Mobile IT at Ottawa Hospital

The Ottawa Hospital has had excellent results from two pilot projects using wireless technology — a system for providing physicians with point-of-care information when treating ovarian cancer patients, and a dictation system that generates reports in hours rather than the traditional days or weeks.


Benchmarking IT projects

At a time when accountability is becoming a high-profile issue, columnist Richard Irving provides some guidelines for assessing the performance of information technology investments.

Easy-to-use monitoring

Adcom Videoconferencing plans to market the Health Buddy in Canada, a device that connects home-care patients with monitoring centres and provides communication through just four keys.

PLUS news stories, analysis, and features and more.


Hospital council announces new slate of e-health projects

By Jerry Zeidenberg

TORONTO – The Ontario Hospital eHealth Council has announced support for three new projects that will help create a province-wide network of electronic health records. The systems are aimed at giving physicians and other authorized care-providers access to a greater range of data about patients, resulting in faster and more accurate diagnoses and treatments.

The initiatives include:

• An expansion of the current e-pharma strategy to include medication information about all residents of Ontario. The existing initiative, announced last year, focuses on giving doctors access to medication data about senior citizens that’s stored in the Ontario Drug Benefit Program database. The new plan is to broaden the scope of the project, by tapping into additional sources of information such as pharmacies, to provide authorized care-givers with drug usage information about all individuals.

• A standard method of transmitting laboratory data, so there is one specification for sharing information. There are currently several projects in the works to make computerized lab information available to healthcare professionals, including a pathology system from Cancer Care Ontario, the Ontario Lab Information System and an initiative from the e-Physician Program. As well, there are plans afoot to provide physician practices with access to hospital lab results. “Rather than have four different specs, we’d like to develop one, consistent specification for all labs,” said Kurt Rose, Director of eHealth Strategies at the Ontario Hospital Association. “We want to make sure that everyone is on the same page.”

• The creation of a province-wide secure e-mail system for all Ontario healthcare providers, including the provinces 20,000 physicians, to enhance communication within the health system.

The Ontario Hospital eHealth Council was launched by the Ontario Hospital Association in 2001. The following year, the Council announced two projects as its priorities, the e-pharma system drawing on information from the ODB program database, and an electronic waiting list system for cancer patients. The e-pharma project recently won funding from the Canada Health Infoway, and Cancer Care Ontario has begun putting together pilot projects for its waiting list system, which will enable patients to better determine which provincial facilities have openings for treatment.

Sam Marafioti, Vice-Chair of the Hospital eHealth Council and Vice President, eHealth and Chief Technology Officer at Sunnybrook and Women’s Health Sciences Centre, said a request for funding the three new projects will be submitted shortly to the Ontario Ministry of Health and Long-Term Care, to obtain financing for the 2004-2005 fiscal year.

Mr. Marafioti stressed the Hospital eHealth Council, a part of the umbrella Ontario eHealth Council, favours a strategy based on the creation of regional electronic health record networks. “That’s because 80 percent to 90 percent of healthcare is delivered on a local basis,” he said, with patients moving from primary care physicians and clinics to hospitals and labs, and in some cases to nursing homes or home-care settings – all in the same community.

These regional networks, however, could be connected to form a provincial network, and with further links a national system could be produced. The larger networks would enable health records to be easily transferred when patients need special care in a distant treatment centre or require attention when traveling outside their communities.

While noting that a good deal of progress is being made in the construction of electronic networks by many communities, Mr. Marafioti acknowledged that most physicians still aren’t participating in these systems. “Primary care physicians are one of the most important parts of the healthcare system, and without them, a network is like a three-legged stool that’s missing a leg,” commented Mr. Marafioti.

He said that’s why the Council is backing the creation of a province-wide e-mail network that would reach doctors, running on the Systems for Smart Health network and offering physicians connectivity to each other and to various providers in the healthcare system.

“Given the SARS crisis and the recent blackout in Ontario, we see how important it is to have a quick and secure means of communication for the doctors,” said Mr. Marafioti. “Doctors need instant information.”

He noted that a province-wide email network for healthcare professionals would provide fast transmission of alerts and treatment protocols in emergency situations. “We don’t have three years to get this up and running,” he commented. “We feel it has to be done within a year.”

Mr. Marafioti also observed that once Ontario’s 20,000 physicians are connected with an e-mail network, many other applications may become popular. “The network, with a complete physician directory, is likely to drive a lot of other applications,” he noted. “We experienced this at Sunnybrook, where we gave people the network and they started using it in many unexpected ways that improved the delivery of healthcare.”

Mr. Rose added that the proposed e-mail system would also include hospitals and other facilities. “We learned from the SARS crisis that communication is critical, for the doctors, hospitals, CCACs and for public health,” he said. “We want to fast-track the creation of a provincial healthcare email system to support our provider community.”



New wave of online educational ventures provides anywhere, anytime access

By Andy Shaw

Seems everybody these days is rushing to get involved with online medical and healthcare education. “People are all of sudden taking it very seriously,” says Greg Cook, president of mdBriefCase Inc. The company provides accredited continuing health education programs written by physicians and available online through its website.

In July, mdBriefCase entered into an exclusive partnership agreement with GlobalMedic, a Canadian Medical Association (CMA) business subsidiary that focuses on information technology and runs the CMA’s website. Canadian member doctors can access mdBriefCase courses via the CMA site.

“People are now calling us, whereas a year ago it was pretty difficult to get potential sponsors for online education,” says Cook, a 10-year veteran of the pharmaceutical business and related consulting before taking over the medical education forerunner of mdBriefCase.

Eager sponsors in numbers, ever the sign of a something that’s truly caught on, are a crucial part of the mdBriefCase-GlobalMedic deal. Companies including Pfizer, Johnson & Johnson, AstraZeneca, Boehringer Ingelheim, Aventis, Bristol Myers Squibb and Solvay Pharma, among others, have been more than generous in their grants that enable the physicians to take the mdBriefCase courses without charge.

So far, over 6,500 Canadian physicians had gone on the mdBriefCase website and completed at least one of its courses. Indeed, most of them have done more than one.

Among the 30 courses mdBriefCase offers, no one course seems to be more popular than others. That may have something to do with the fact that every course earns physicians a credit towards the CME they are all obliged to undertake every year they practice. Family physicians receive a MainPro M1 credit – a superior accreditation to M2 credits in most eyes, since those are self-reported credits.

“All our courses are M1 accredited and the criteria for that accreditation is set by the College of Family Physicians,” says Cook. “Our courses are also accredited for specialists.”

For the most part, there are no tests or examinations to prove that the knowledge gleaned by physicians has been absorbed.

“What we do have are multiple choice questions and answers. So the doctors can see how they are doing compared to other physicians, but they can do it anonymously,” says Cook.

Although there are no formal exams to gain the credit, there are a couple of online hoops that physicians must jump through which are monitored by mdBriefCase.

“One of the things required of them is that they have to have participate in an online discussion forum and we can easily check if they have,” explains Cook. “We certainly don’t monitor them constantly, but we can check to see that they have completed the various sections of their courses.”

Cook counts himself and his company lucky to be in the position they are in.

“We are Canada’s number one CME website by a wide margin – both in terms of our content and the number of participants we have. We were in the print end of healthcare education to begin with, but we happened to be in the right place at the right time when we shifted to online education.”

That timing was also helped by new restrictions and guidelines that have grown around the activities of pharmaceutical companies. Their traditional practice of sponsoring weekend-long educational sessions and inviting doctors to them is now largely looked on as a no-no by regulating bodies on both the medical and pharmaceutical sides. The online courses make it easier to put the stamp of being ethical and above board on them. So growth of online courses and the numbers who take them seem inevitable. “I think the most attractive thing about them is the time they save,” says Cook. “That’s of primary importance to physicians these days, and particularly saving time at the office where they have patients waiting. They can do online courses at home. The courses usually take an hour or less to do, so they can do that while dinner is being prepared.”

Others across the land also working hard at making online learning more user friendly, both for course takers and course developers alike.

The Pan-Canadian Health Informatics Collaboratory (HIC), involving a number of Canadian universities and institutes of technology under the co-ordination of the University of Victoria, is “re-tooling” online learning in healthcare thanks to a two-year $1.6 million grant from the federally-backed CANARIE high-speed initiative (see story in Canadian Healthcare Technology, October 2002). The grant runs out at the end of this year and developers are putting the finishing touches on instruments that should eventually enhance the online learning experience enormously.

Dr. Michael Shepherd, Director of Health Informatics at Dalhousie University, for instance, leads an HIC effort that at once will make learning online more accessible, more interactive, and less expensive to set up.

“We are really working on two projects in that vein here,” says Dr. Shepherd. “The Open Text software we are using as the basis of our courseware does not have Voice-over-IP capability. So we are working on a tool or module that would allow the moderator of a course to open up the module and have everybody in groups of say, 6 to 10 people, in an educational session see each other on-screen and converse – all over the Internet.

“The other thing we are doing is building what we call a packaging piece of software. So that rather than content developers having to create a whole lesson as one big conglomerate, they can develop lessons in a modular fashion. Each module then goes into a database and is tagged. Once their sequence in the delivery of the lesson is known, then the whole lesson can very quickly be pulled together and packaged.”

As at other HIC participating schools, such work at Dalhousie involves more than just medical and healthcare specialists.

Dr. David Zitner is Dalhousie’s director of medical informatics in the faculty of medicine and is co-ordinating the efforts for the HIC of Dr. Shepherd, a library scientist by training as well as that of Greta Rasmussen from the medical faculty’s CME division who is concerning herself with online content, and Wes Robertson, an informatician with a degree in English who is working on developing better communications infrastructures for online learning.

“I learned sometime ago when I was a medical quality consultant at the Halifax Infirmary that you need access to developmental tools that are normally only available to academics,” says Dr. Zitner. “So if you’re going to solve healthcare problems with new tools you need the collaboration of people who understand both healthcare and technology.

“You need to have the faculty of medicine collaborate with the Math department and with the Computer Science department and then get contributions from the faculties of management and graduate studies. That’s exactly what we did to develop our new graduate program in healthcare informatics that we now have under way here.”

Similarly, the University of Waterloo, also an HIC collaborator, has taken the collaborative approach to its post-grad health informatics that can be taken from off campus.

The Education Program for Health Informatics Professionals (EPHIP) provides the successful student with a university-level diploma earned usually over two years and completing seven courses.

The courses are taught using audio-conferencing and Internet document conferencing. Communication with professors and collaboration with fellow students is carried out mostly by e-mail.

As the program’s director, Dominic Covvey, a full professor in Waterloo’s science faculty, wrote in our October edition, “I have tens of students who have interacted with me for as many as 60 hours and have never seen me.”

Forays into online healthcare education have gone so far that early adopters are now at that inevitable second stage of admitting to and correcting their start-up mistakes.

For example, the Ontario Hospital Association launched an online service called Healplex last year (see Canadian Healthcare Technology, March 2002) in the hope that hospital administrators and other staff would take courses in great numbers. But they didn’t. So the OHA pulled the plug this year and is at least temporarily shifting its remote education emphasis to videoconferencing.

“What happened with Healplex is that we essentially took it off because our market place surveys showed us that it was too expensive,” says Robert Houlden, director of educational services for the OHA. “It was very much subscription based and you couldn’t pick off separate courses.”

Holden says Healplex also had an image problem.

“It was set up as a separate company and people didn’t really associate it with the OHA. So it didn’t resonate with our members very well. We’ll no doubt return to some kind of online education but this time we’ll likely keep it under the OHA brand.”



Shortage of imaging technologists threatens healthcare, experts say

By Andy Shaw

There’s been much hue and cry in Ontario lately, in case you missed it, about the “poaching” of MRI and CT technologists by the province’s newly minted private imaging clinics. This summer, the Toronto Star newspaper in a number of articles drew attention to examples of robbing Peter to pay Paul – including how the University Health Network, the country’s largest conglomeration of publicly supported acute care, had to scale back its hours for MRI because of the loss of several technologists to a private clinic, one sanctioned by the Ontario Government.

Those stories in turn stirred up the Loyal Opposition and other government critics to call for the Premier’s resignation, the Minister of Health’s head and the padlocking of the clinics.

The fury, of course, stemmed from the original notion that the entrepreneurial clinics would increase the province’s dreadful lack of imaging capacity, not diminish it. The carrot that the Government hung out to attract entrepreneurs into the field and help fill the void included the admonishment not to “steal” technologists from the public system. However, it was a stipulation that not only proved unenforceable, but flew in the face of the very supply and-demand economics Conservative governments champion. It was also offensive to the technologists themselves, who indirectly were being told they shouldn’t go looking for better pay, more convenient hours, or perhaps more interesting jobs that the private clinics might offer.

So this summer in Ontario, aside from SARS, the West Nile virus, and the Great Power Blackout, the poaching of radiological talent was seen as a big healthcare problem.

But poaching is not the problem, says Normand Laberge, the chief executive officer of the Canadian Association of Radiologists (CAR). The root problem is the process – the privatization process Ontario evidently blindly chose.

“Nova Scotia went through the same poaching problem the year before. We told Ernie Eves (the Ontario Premier) and Tony Clement (the Health Minister) that Nova Scotia was the example, that the same thing would happen in Ontario and that it would not be to the advantage of anybody. Of course, they’re thinking the health system is not sustainable, so they have to go private. But in this case, it is sustainable if the approach is properly organized and administered.”

There is, luckily says Laberge, another example province where things diagnostic are properly organized and administered, but which Ontario unfortunately also chose to ignore.

“Alberta does not have a poaching problem, and yet in a way it is far more privatized than the systems in Nova Scotia or Ontario,” says Laberge. “In Alberta, the radiologists and the technicians are not employees of the hospitals or the clinics. They are a separate corporate entity that is hired by the hospitals and clinics to manage their diagnostic imaging departments.”

In effect, the Alberta healthcare system has “outsourced” diagnostic imaging to an entrepreneurial group that supplies services to both public and private users. That group allocates which radiologists and technologists go where, and consequently there is no stealing of one from the other.

A sustainable integrated model, in short, compared to what Laberge terms a disastrous one in Ontario that is bound to crash. “What Ontario has done by creating private clinics that are not part of the system is equivalent to putting on a car a front wheel that can’t be steered.”

He sees the competition for scarce diagnostic imaging staff created by the private clinics not only driving up salaries, but healthcare costs generally, without reducing the imaging backlog. To retain their staff, Laberge reasons, hospitals will have to increase wages or bow to inevitable demands of their best people to match the weekdays-only, daytime-only and other job perks the private clinics offer – creating a need to hire more staff to fill the other hours a hospital must work that a clinic doesn’t.

Despite what many see as Ontario’s privatization boondoggle, others see at least a silver lining in it, including Dr. Renate Krakauer, president and CEO of The Michener Institute for Applied Health Sciences in Toronto. It trains and supplies the province with its radiology technologists, both diagnostic and therapeutic.

“I think the newspapers have made too much of so-called poaching. It’s not really the human resources issue it’s made out to be,” says Dr. Krakauer, who adds that with additional funding supplied by the province earlier in the year, she expects the Institute will be able to train many more diagnostic imaging technologists, at least on the MRI side of things.

Indeed, Michener Institute staff see the private clinics as breathing fresh air and more career chances into what was becoming a moribund profession.

“After Ontario re-structured its hospital system, there were really no opportunities for advancement or growth or promotion within organizations for our people,” says Nicole Harnett, the dean of diagnostic imaging and therapy at Michener. “So they got tired of their jobs. They saw them as dead ends and they were leaving the imaging profession.”

But the growing demand for MRI technologists, in particular, now accelerated by private clinic demands for them, has been re-invigorating. MRI training is a post-diploma program, meaning those that take it already have certification as some sort of radiological technologist and are generally leaving behind a vacant job.

“We do need to fill those lower level jobs, but MRI training is at least keeping people in the imaging department. We are no longer losing them like we used to,” says Harnett.

To fill the extra demand for MRI’s, Michener trained an extra cohort of technologists this year.

“We usually run two MRI programs every year, producing about 40 graduates, but our labour market analysis told us we would need about 60 to meet the needs of the province, so we ran an additional program,” says Lorraine Ramsay, Michener’s chair of advanced imaging. “We received about $350,000 from the government to help out with that extra group, but that doesn’t really cover all the costs.”

Michener officials wish there was similar hope and support for other disciplines.

“Imaging technology has been receiving all the publicity but there are shortages in the other modalities that we also train here,” says Krakauer. “Nuclear medicine and radiation therapy are particularly in need. But we have not been funded to increase the class size in either and that is a concern for us.”

A Michener study released late last year, for example, predicts that by 2007 the province will be short nearly 300 nuclear medicine technologists.

Such a shortfall of technologists echoes a larger, country-wide dearth of the higher radiological skills. According to a human resources study conducted by CAR, Canada has a ratio of one physician radiologist for every 18,000 of its citizens while our own federal government recommends there should be a radiologist for every 13,000 people. By next year, the study predicted, Canada would be short some 500 radiologists. What’s worse is that while the number of diagnostic images that need to be interpreted by radiologists is rising by as much as 5 percent a year (despite technologist shortages and thanks largely to an aging population), the average age of the radiologists is also rising. Already some 10 percent are continuing their practices past the age of 65, and retirements are expected to accelerate in the next few years.



Ottawa Hospital tests wireless charting and dictation applications

By Dianne Daniel

For physicians working in the Ottawa Hospital’s gynecologic oncology program, instant access to accurate and up-to-date patient information in a clinical setting has moved from wish list to reality following the launch of a wireless pilot project this summer.

Using Microsoft Windows Server 2003 and .NET connection software, along with database management software from SysteMagic Software Solutions Inc., the hospital has created a patient data collection and analysis system intended to assist doctors and researchers as they work to find a cure and to improve treatment for ovarian cancer in Canadian women.

According to Dr. Tien Le, associate professor of gynecologic oncology at the University of Ottawa, the program currently sees between 30 and 40 women at its weekly cancer clinic, including both new and follow-up patients. The goal of the newly designed system, called GOSOCS for Gynecology-Oncology Services Ovarian Cancer System, is to put the most complete patient information into the hands of physicians, pharmacists, nurses, social workers and other healthcare professionals involved in the ongoing care of cancer patients.

“What we’d like to be able to do is retrieve information quickly in the clinical setting when we encounter a patient, so that appropriate decision making can be made regarding patient management,” says Dr. Le.

As part of the pilot, physicians are using handheld and tablet PCs to access the hospital’s computer network, and ultimately, the GOSOCS database. Not only are they able to retrieve the most current patient data available, but they can also input their own notes while seeing a patient, which are then automatically updated in the database. The value, says Dr. Le, is that physicians are better equipped to deal with patient needs as they arise. “If a patient has a concern from a psychological perspective, I can address it from the clinic,” he explains, “rather than waiting to go back to my office and placing a call to the social worker to determine what the concerns are.”

At press time, the Ottawa Hospital was ready to complete the last phase of GOSOCS, involving the installation of an 802.11 wireless network with wireless access points throughout the hospital, so physicians can access the database “live” as opposed to using PC docking stations to synchronize data. According to Dr. Le, the pilot is mainly taking place at the Ottawa General campus, but the plan is to extend it to include all hospitals in Ontario involved in the treatment of ovarian cancer.

What makes GOSOCS portable between environments is its use of XML Web services on the client side, so that data collection remains device independent while the Internet can be leveraged on the backend. “Hospitals have so many different types of computing services, from a myriad of vendors. Putting in place a Web services interface was not only a great solution for this specific project, but it also gave us a framework for healthcare from a proof-of-concept standpoint,” says Ben Watson, senior project manager, Web services at Mississauga, Ont.-based Microsoft Canada Co. “... If we can prove that we can deliver multiple customized patient reports at the hospital level while standardizing the data on the backend, then I think we’ll have a huge win in terms of what people can leverage for future healthcare projects.”

It appears Ottawa Hospital is one place where wireless technology will continue to play a significant role in the future. In the Department of Medicine, for example, a group of physicians are currently using mobile dictation services provided by Accentus Inc. of Ottawa, following the successful completion of a pilot project in March.

As Dr. Doug Smith, the department’s deputy chairman explains, physicians dictate into handheld PCs or personal digital assistants (PDA) and then send the voice files to Accentus via PC docking stations. Within four hours, the completed medical transcription is returned in a format that is compatible with any word processor as well as the hospital’s electronic health record system, OACIS. In addition to the rapid turnaround time, the main benefit is that doctors can use one device for multiple purposes, says Dr. Smith.

“The only thing that makes this different from the Dictaphone is that it combines the dictating capability with my agenda, e-mail and contact list,” he says. “Ultimately what we are looking for is one device that will allow you to do all of that, plus be your cell phone and pager, but we’re not quite there yet.”

Dr. Bill Cameron, professor of medicine and infectious diseases at the University of Ottawa, was one of the first physicians at Ottawa Hospital to use the Accentus mobile dictation service. Unlike other doctors who were already using a handheld computer, Dr. Cameron was introduced to the technology for the first time through Accentus. While it did take a few weeks to become accustomed to the device, he says he has no desire to return to his previous method of using a recorder for dictation.

“I think it’s neophobia; we don’t like something that’s different because we don’t understand its workings,” says Dr. Cameron. “Now I just see it (the mobile device) as a black box – I speak into it and back comes a letter.”

Both Dr. Cameron and Dr. Smith envision a time in the future when the mobile dictation service will be able to leverage the hospital’s investment in a wireless network, allowing physicians to dictate on the fly as opposed to using docking stations. Notes Dr. Smith. “I know we’re heading in that direction.”

Since the pilot in March, 15 Department of Medicine physicians have signed up for the service and more are expected to follow. The main reason for increased interest in the mobile dictation service is that it facilitates the concept of the electronic patient record, which remains a major thrust for the department, says Dr. Smith.

“If a patient came into the emergency and was seen by a resident, rather than writing a handwritten note, they could dictate into this technology and it would actually appear on the chart within hours rather than days or weeks,” he says.