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Inside the October 2006 print edition of Canadian Healthcare Technology:


Feature Report: Developments in telehealth


Group Health Centre EMR to include local pharmacists

The Group Health Centre, a large ambulatory care facility that’s been dubbed ‘a hospital without beds’, is investing $3.5 million in a project to extend its electronic medical record system to local pharmacists.

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Atlantic Health launches region-wide EMR project

The Atlantic Health Sciences Corp., based in Saint John, N.B., has embarked on a $24 million project to upgrade its existing electronic medical record system and extend it across the region, the largest in the province.

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X-rays for orthopedics

The Royal Columbian Hospital, in New Westminster, B.C., is a partner in the research and development of 3D X-ray technology that captures images of joints while patients are standing or sitting. Traditionally, 3D X-ray images have been acquired using CT scans, with patients lying flat on their backs.

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Measuring quality

Increasingly, hospitals across Canada want to monitor the quality of their programs using computerized tools. We look at the experiences of facilities in Montreal and Halifax.

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Global physician IT

When the University of Victoria’s Dr. Denis Protti tracked the usage of clinical information systems by physicians in Europe, he discovered why European docs are much more computerized than their North American equivalents.


What is telehealth?

While telehealth projects continue to spring up across Canada, many healthcare professionals still wonder what the term means. Canadian Society of Telehealth president Dr. Richard Scott explains.


PLUS news stories, analysis, and features and more.

 

Group Health Centre EMR to include local pharmacists

By Jerry Zeidenberg

SAULT STE. MARIE, ONT. – The Group Health Centre, a large ambulatory care facility that’s been dubbed ‘a hospital without beds’, is investing $3.5 million in a project to extend its electronic medical record system to local pharmacists.

Known as EMRxtra, the program is expected to reduce medical error, boost patient safety and improve communication and collaboration among physicians and pharmacists.

In addition to GHC, partners in the plan include Canada Health Infoway, which is contributing $2 million, and the Ontario Pharmacists’ Association, which is involved in the change management component of the project. Both partner organizations are interested in the possibility of transferring the technology and methodology to other regions in the future.

For its part, the Group Health Centre has been using an electronic medical record system, supplied by Calgary-based Clinicare Corp., since 1997. More than 100 physicians and clinicians currently use the system, which has been credited with improving workflow at the facility and medical outcomes for patients.

As part of the current project, Clinicare’s software will be available to all 22 of the city’s pharmacies, ultimately giving pharmacists access – with high-level security – to the records of the patients enrolled in the EMRxtra program.

The current pilot program is expandable, and in the future could include all of the GHC’s 60,000 patients.

Tamara Shewciw, senior manager for information technology at the GHC, said that extending the system to pharmacists is expected to improve medical care in several ways.

“It will help to reduce medication errors by allowing pharmacists to have access to clinical information about patients electronically, and it will make better use of the expertise of pharmacists by including them in the circle of care.”

Tommy Cheung, director of information technology and e-Health with the Ontario Pharmacists’ Association, concurred. “In the past, pharmacists have worked blindly,” he said. “The patient arrives, the pharmacist receives the prescription, but he doesn’t know the clinical background and intent. He doesn’t know why the patient is getting the medication.

“It is very difficult for pharmacists to collaborate with physicians and other primary care providers without the IT platform,” said Cheung. “By having access to the electronic medical information, pharmacists will be able to utilize their expertise to deliver chronic disease and medication management and to help their patients to achieve better health outcomes.”

As well, “If the pharmacist knows the reason for the change, he or she might be able to recommend a more effective medication,” Shewciw added, noting that physicians aren’t always aware of the options that are available. That includes less costly alternatives for patients who aren’t covered by medication insurance.

With the permission of patients, pharmacists will be able to access patient drug profiles, current lab test results, clinical intent of prescribed medications and the patient’s care plan.

Overall, the EMRxtra solution will allow physicians and pharmacists to work together more closely than before – with pharmacists providing faster and more comprehensive decision support.

Indeed, the Clinicare system includes electronic messaging, enabling physicians and pharmacists to communicate quickly and securely.

Shewciw pointed out that communication between pharmacists and physicians does occur today, but the process is slowed by the inevitable telephone or fax delays.

Using electronic messaging is a more direct solution. “Communication becomes much faster, thanks to the messaging function in Clinicare,” said Shewciw.

Notes left by pharmacists and primary care physicians will also be accessible to other care-givers – with proper security access – giving them a better understanding of a patient’s medical status. These care-givers may include physician specialists, therapists, home care nurses, along with others. “We’re aiming at a true sharing of information, as we believe in the circle of care,” said Shewciw.

She commented that Sault Ste.-Marie physicians and pharmacists have talked about using a common electronic record for years. However, it has only become viable recently with the latest version of Clinicare, which offers advanced security features.

For example, the new system contains role-based security features, meaning that a patient can decide which providers can or cannot see his or her record. Shewciw pointed out that the program is ‘patient-centric’, and that patients will determine who can access their EMR.

The current system also contains a ‘handcuffing’ feature, which provides complete or partial access to the record, depending on the person viewing it. “A physician could be given access to the entire chart, while a physiotherapist may only need to see part of it,” said Shewciw. “Access can be fine-tuned.”

She noted that a good deal of effort will be required to set up and monitor the system. However, the GHC through this project has both the human resources and the funding to do it.

Shewciw also pointed out that pharmacists currently use their own electronic systems, and will be accessing the Clinicare system through remote access.

However, in the future, a consolidation of systems is expected.

EMRxtra will first be used in a pilot with several hundred of the GHC’s patients in two programs – the Congestive Heart Failure Program and the Vascular Intervention Program. It will then be made available to all of the centre’s patients – a community of some 60,000.

Shewciw said a patient portal is also an important part of the program. Its first phase will provide patients better access to their individual EMR, which includes their records of diagnoses and treatment, including medications and educational services, along with action scorecards that will allow patients to work towards goals on their own and with their families. A second phase would encourage patients to become more involved in their care.

“We’ve been surprised by the amount of interest in the portal,” said Shewciw. “A city newspaper wrote about it, and we’ve been flooded by calls about it since then, with people wanting to know how to sign up.” That’s a positive development, she said, indicating that patients want to take charge of their own health.

In a news release, Dr. Lewis O’Brien, physician lead for the EMRxtra project, said: “The addition of pharmacists is a natural and long overdue component of the circle of care. This program will enable me to make better use of the expertise provided by pharmacists, make more efficient use of my time and hopefully provide a more convenient and effective patient experience.”

Marc Kealey, CEO of the Ontario Pharmacists’ Association, said: “With access to an electronic system, pharmacists in Sault Ste. Marie will be able to fully collaborate with physicians and the rest of the provider team and resolve drug related issues more effectively for their patients.”

Richard Alvarez, Infoway’s president and CEO, observed: “We’re pleased to help support this initiative, which will not only help to improve the quality of care for patients of the Group Health Centre, but can also serve as a model for improving healthcare in Canada.”

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New Brunswick’s Atlantic Health Sciences Corp. launches I3 Project

By Jerry Zeidenberg

The Atlantic Health Sciences Corp., the largest healthcare system in New Brunswick, has announced a $24 million initiative to implement a region-wide electronic health record system using solutions from Eclipsys Corp.

Called the I3 Project, “the goal is to ensure integrated interdisciplinary information (I3) is collected and available in real time for the best possible care of the patient,” according to executives from the AHSC.

A critical part of the three-year-long project will be patient-safety. Features such as Computerized Physician Order Entry (CPOE), Knowledge Based Medication Administration (KBMA) and clinical documentation will provide valuable support to clinicians.

Through CPOE, Physicians will enter orders directly into the system, dramatically lowering the possibility of errors in transcription or difficulties in reading handwritten orders.

KBMA will help reduce the risk of medication administration errors through the use of bar code technology. Clinical documentation will provide a real-time source of information on the care of the patient, to give clinicians the most current data on which to make decisions.

“Patient safety is a key part of the project,” said Derrick Jardine, chief information officer for the AHSC. “Another important aspect is real-time decision support.”

Jardine explained that the new system will support various types of rules to help physicians and clinicians as they diagnose patients and authorize treatments.

Eclipsys was chosen as the solution provider after a five-month long assessment of systems from a variety of vendors. About 500 staff members at AHSC were involved in the evaluation, which began last October and included clinical scenarios and product demonstrations webcast throughout the healthcare region.

Implementations of the new solutions – called Eclipsys Sunrise Clinical Manager, a suite of applications that includes acute care, critical care, and emergency care – will begin in September.

Some of AHSC’s facilities previously used electronic patient record systems – coincidentally from Eclipsys. However, the existing solutions were originally installed in 1981 and are among the oldest computerized systems operating in Canada.

Not only will the new solutions offer a dramatic improvement in functionality, but they will be installed in all 13 of the AHSC’s hospitals and health centres, creating a regional EMR that can be accessed by authorized clinicians throughout the area.

As part of the solution, referring physicians and specialists in practices outside of AHSC hospitals and health centres will be able to access the electronic health record system. “Any allied physician with Internet access will be able to connect to the system,” said Jardine. “That was a requirement of the original RFP.”

Training and change management will also be important parts of the project. In fact, Jardine notes that training will account for $2 million to $3 million of the budget for the project. “Close to 3,000 staff from a variety of disciplines will be trained,” he said.

“We’re anticipating a nurse to require 10 hours of training,” he said, noting that training will be provided through a combination of e-learning, classroom and on-the-job training methods. “We’ll have trainers, mentors and super-users,” said Jardine.

The AHSC has been using solutions from Cerner for lab and pharmacy, as well as a PACS from Agfa and back-office systems from Meditech. Overall, Jardine estimates there are some 20 different systems used for various applications, including several that were developed in-house. All of these systems will need to be integrated into the new electronic health record solution.

Moreover, the AHSC will have to migrate historical information into the new system. Jardine noted that decisions still must be made regarding how far to go back into patient records when populating the new system with information.

Another important part of the implementation is a work process review. “We’re analyzing current work processes to better understand the needs of the clinicians and to see how the I3 Project can support them,” commented Jardine. A process to determine return-on-investment is also being established.

“We want to demonstrate the benefits that are obtained from the system, such as the impact on patient safety and clinician efficiency – the time a clinician spends with patients versus documenting encounters,” said Jardine. “We don’t want the measurements of success simply to be things like finishing the implementation on time.”

For its part, the Atlantic Health Sciences Corp., headquartered in Saint John, serves a patient population of 200,000 in its catchment area. In addition, it provides specialized services such as cardiology, oncology and neurology to 750,000 patients across the province.

While the system being implemented will establish a regional patient record, the data will eventually be published to a provincial repository, as part of New Brunswick’s plan to create a province-wide system of electronic patient records. “The provincial health plan through the department of e-Health envisions ‘one patient, one record’, as an important element to a comprehensive healthcare strategy for all New Brunswickers,” noted Jardine. “The I3 Project is a key step in realizing that vision.”

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Multi-functional X-ray device pioneered in New Westminster, B.C.

By Andy Shaw

Stand on your own two feet. That’s an instruction you’re not likely to hear very often in a diagnostic imaging clinic. But it is being given gently these days to orthopedic patients at the 352-bed Royal Columbian Hospital (RCH) in New Westminster, B.C. There, Philips Medical Systems, in conjunction with Royal Columbian’s radiologists and researchers, are pioneering and clinically testing a multi-purpose X-ray system called MultiDiagnost (MD) Eleva 3-D-RX, which can capture 3-D images of the knee, ankle, and other joints while patients are standing or sitting upright and thus bearing their own weight.

“Pretty much all other 3-D imaging, like CT or MRI, for example, is done with the patient lying on table or being otherwise supported,” says Peter Schable, RCH’s director of medical imaging. “But if you stand the patient up, you can see where the joint spaces are gone, or where the abrasion of the bones on each other is taking place. And those are things you can’t really see with other imaging because the joint is not bearing weight and therefore stressed.”

The hardware end of the MD Eleva in use at Royal Columbian features a large C-shaped arm that can be rotated to the horizontal position, then raised or lowered so that a patient can stand between X-ray emitting and receiving ends of the C with his or her knee exactly targeted in the middle. The subsequent 180 degree “iso-centric” rotating fluoroscopic scan of the knee done by the C arm produces an image which the still evolving Eleva software then processes. The result is a 3-D view of the joint that is detailed and natural in appearance, rather than ghost-like. It is a reconstructed but artifact-free, CT-like picture whose clarity can pinpoint pathology.

“We are also using the MD Eleva to examine the cervical spine and bones in the neck,” says Schable. “And you can see even subtle changes to the articulating surfaces of the neck when it is flexed or extended, again while the patient is standing or sitting up.”

In addition, Philips and Royal Columbian are watching how the MD Eleva system performs in other spinal imaging circumstances where load bearing is not important, but having the fine detail of a CT-like image is.

“We’re using the MD Eleva to assess the results of verboplasty procedures that cement vertebrae into position,” explains Schable. “The advantage it has over CT is that you can see 3D volumetric images of what you’ve done while the patient is still on the operating table and while you’re doing the procedure. So the patient doesn’t have to move off to another suite for imaging.”

Such efficiency and flexibility is important to the mission of RCH. Though not a specialist orthopedic hospital, it is the main trauma and emergency hospital, as well as a cardiology, vascular, and neurology centre, for the entire Fraser Health Authority, which serves some 1.5 million people living in the lower mainland.

“You can use the MD Eleva both as a radiographic and as a fluoroscopic unit and can also be used for interventional radiology procedures,” says Schable. “So beside our high-end (cardiovascular) imaging suite we have built a multi-functional room where we can use the Eleva to do a broad range of less complicated imaging and interventional tasks – especially ones which don’t need to tie up an operating room. That multifunctional room also provides back-up for us as a referral centre for Fraser Health. So, all in all, I would say that the Eleva helps us reduce hospital stays, speed up recovery time, and generally gives us a better way of doing things for the specialist physicians, nurses, and technologists who run our radiology department.”

But it is more the range of RCH’s resident minds that caused Philips Medical Systems, based in Bothwell, Wash., to look not too far north across the border and choose the Royal Columbian to put the MD Eleva system through its first paces.

“The Royal Columbian has been a very good partner for Philips for several years and we’ve done a number of things with them in the past to help evaluate and test our products,” says Scott Burkhart, general X-ray vice president for Philips North America.

“So we’ve seen how their staff has the curious spirit and the focus needed to think of things that have not been done before and therefore to do good research,” says Burkhart. “They are also very easy to work with. So when we wanted to test this new 3D multifunctional system, it was a very natural thing to turn to them. We knew they could help us sort out what the clinical issues were.”

Royal Columbian staff first saw the MD Eleva two years ago, when it was demonstrated by Philips a the Radiological Society of North America (RSNA) show in Chicago, and marvelled at what Burkhart describes as its “Swiss army knife” flexibility.

“It can be used for orthopedics, pain management, vascular exams, electro-physiology, to name a few,” says Burkhart. “And that’s part of the problem for us. People wonder: What is this thing? Aside from telling them it’s a Swiss army knife, I say the killer app it has is the ability to produce CT-quality images in 3D. And I also think 3D imaging will broaden into other forms of imaging, and eventually comparing interchangeable images of all modalities in 3D will become the norm.”

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Continuous assessments enable hospitals to change, measure quality

By Dianne Daniel

Most people are familiar with the adage, “If it ain’t broke, don’t fix it.” But how many ever stop to consider the opposite scenario: “If I don’t know it’s broken, how can I fix it?”

Quality co-ordinator Elsa Salomon does.

For more than 12 years, Salomon has been evaluating patient satisfaction at the Centre Hospitalier de l’Université de Montréal (CHUM), as a way of helping hospital decision-makers. Based on the premise that “you can’t improve what you don’t measure,” the information collected is used to implement quality improvements that keep the hospital aligned with its core values.

Key to the hospital’s assessment program is determining what questions to ask in the first place. “You do not ask a question that you’re not ready to hear the answer to,” says Salomon, using the example that if patients are asked to rate satisfaction with hospital operating hours, then administrators must be prepared to address it. “Are you willing – or able – to do something about it? If the answer is no, then don’t ask the question,” she says.

Working with an on-line, web-based surveying tool from Montreal-based Agili-T Health Solutions Inc., CHUM conducts one major assessment of patient satisfaction every five years, as well as 12 to 15 surveys each year that are more specific in nature. To date, the majority of surveys have been paper-based, but the hospital is moving towards using computer kiosks and handheld devices at the bedside, says Salomon.

The Agili-T tool, called Androfact, offers a bank of validated questions prepared in collaboration with the University of Montreal and the Greater Montreal Regional Health Board. The questions are designed to measure different dimensions of healthcare delivery.

The subject matter covers everything required to monitor a patient experience, from accessibility to outcomes, including wait times, how easy it is to get around, the attitudes of physicians, the technical quality of care and the quality of the food.

When preparing a survey, users like CHUM simply point and click on existing questions, selecting those that best suit their needs.

“It’s like a pantry; you know what you need and you put it all into your pantry and then, depending on the recipe that you want to make, you get the necessary ingredients,” says Salomon. “Agili-T furnishes the basic information and analysis that are necessary to start your improvement process.”

Androfact is offered using an application service provider (ASP) licensing model, with prices varying from $7,500 to $60,000 per year depending on variables such as the number of surveys conducted, the number of question modules (or banks) used and how many reports are made. The company provides a fully hosted, secure, hardware infrastructure as well as the software and, according to Agili-T president Richard Pridham, new product releases are available every six weeks.

Unlike market research firms that conduct surveys as an outsourced service, usually as a one-time endeavour, Androfact enables healthcare organizations to personalize the process of obtaining feedback, keeping it in-house at a price than enables a continual flow of information.

“Our customers don’t have to be experts in creating surveys,” notes Pridham. “They log onto the system and literally pick and choose from among the questions we offer.”

As hospital or health-region users select their questions, a corresponding database is automatically generated. Once the answers are entered – either manually or by scanning – results are analyzed.

The reports available through Androfact provide a weighted satisfaction value that can then be used to determine where improvements need to be made. “We provide the business intelligence aspect to help them figure out what the data means, so they can determine whether or not they’re meeting patient expectations,” explains Pridham.

For example, one team at CHUM has used the survey process as a way to assess several changes implemented over a five-year period. By asking the same questions each year, they were able to assess which changes had the most impact on patient satisfaction. Eventually, Salomon would like to extend this type of analysis among teams as well.

“Instead of a team evaluating their personal best, they should be able to start looking at it from one team to another, willing to compare and willing to benchmark,” she notes.

Internal benchmarking is an area the Izaak Walton Killiam (IWK) Health Centre in Halifax is hoping to get into once it begins to use the Androfact tool this fall. According to manager of quality Brenda MacDonald, the facility has been distributing paper-based questionnaires for several years in order to obtain patient feedback and currently uses 16 in-house developed surveys geared to 16 separate service areas.

Although it maintains a database of the information collected, it hasn’t been able to compare results because the questions aren’t standardized.

Moving to the validated questions available in Androfact will change that, says MacDonald. “Using standardized questions throughout the organization gives you the ability to pool your results,” she says. “We currently can’t do that.”

In addition to moving to the web-based service, IWK is also looking to improve how surveys are disseminated. In addition to the labour-intensive process of sending out paper-based questionnaires, the health centre will be using Androfact to launch a survey on its website this fall and is also considering the use of computer kiosks in common areas or patient lounges. “Some will still prefer paper,” notes MacDonald. “But the Internet is much more available now and is the way to go.”

In order to reach as wide an audience as possible, IWK will be tapping into the multilingual capabilities in Androfact, offering its English questions in French, Arabic and other languages at the click of a button, says MacDonald. “Everything we’ve done to date has been English, and we know the patients and families we serve don’t always speak English,” she says. “Using the validated question banks … allows us to be more inclusive.”

Both Salomon and MacDonald are adamant the information gleaned from patient satisfaction surveys is crucial to improving service quality. At IWK, several themes have emerged from survey responses over the years, resulting in lasting improvements. For example, new moms consistently indicated the information they received about breastfeeding was inconsistent and confusing. As a result, the hospital provided nursing staff with an education module outlining current best practices so that messaging would be more consistent.

Another theme indicated that hospital signage wasn’t sufficient and that patients were having difficulty finding their way around, leading to the implementation of a new signage system that’s still “work in progress” says MacDonald.

Unlike system-wide surveys – typically population or accountability studies – the information collected using Androfact is site-specific, department-specific and even change-specific, enabling quality managers to address the issues that really matter at the front lines, says Pridham.

“We provide a way to drill down and get feedback at the departmental level on an ongoing basis and to do it effectively and efficiently without absorbing major costs,” he says. “We then deliver that feedback inside the organization to those on the front lines who can bring about change.

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