Inside the October 2008 print
edition of Canadian Healthcare Technology:
LHINs growing up – some faster than others
Ontario’s 14 regional health authorities are now in their third year
of existence and much like toddlers, they are maturing in different
ways and at different rates. Their grasp of technology, for example,
Carestream Health has announced an innovation for the radiology
department – a wireless Digital Radiography panel that fits into a
standard X-ray bucky. It means that hospitals can convert to Digital
Radiography at about a quarter of the traditional cost.
READ THE STORY
Bell Canada is transferring technology to hospitals in eastern
Ontario that will enable them to conduct wide-ranging privacy impact
assessments – something that has been done by outside consultants,
in the past.
enhanced by telemonitoring
The STARTEL telehealth project, in Nova Scotia and New Brunswick, is
testing ways of transforming heart failure management across Canada
through the use of home-based monitoring technologies and more
READ THE STORY ONLINE
The Canada Foundation for Innovation has handed out research &
development grants to hospitals that are worth $554 million. The
lion’s share of the spoils are going to institutions in the Toronto
The BEAM TeleOphthalmology program, created in Edmonton, has been
enabling retinal ophthalmologists to remotely diagnose diseases such
as diabetic retinopathy, macular degeneration and glaucoma – with
PLUS news stories, analysis, and features and more.
Ontario’s LHINs growing up – some faster than otherst
TORONTO – Ontario’s 14 regional health authorities are now in their
third year of existence and much like toddlers, they are maturing in
different ways and at different rates. Their grasp of technology, for
example, differs widely.
That came clear at a two-day “Information Technology Within LHINs”
conference organized by Insight Information earlier this year in
Toronto. Presenters from various LHINs gave conference attendees a 2008
snapshot of their varying IT deployments – just before Ontario’s
Ministry of Health and Long-Term Care was scheduled to hand all LHINs
the results of an “Effectiveness Review” of their efforts to date.
From the review, the LHINs were to learn how ready the Ministry thinks
they are for future growth and what new strategy Ministry has divined to
By time of writing in September, however, a Ministry spokesperson could
only say that the review, which was due in June, wouldn’t be out until
“sometime this winter.”
The LHINs are also waiting for the province’s formal eHealth strategy,
which was rumoured to be ready last spring but has yet to rear its head.
Its major components are said to include Chronic Disease Management, an
electronic health record viewer for healthcare providers across the
province, and e-prescribing capabilities.
So the LHINs have been left pretty much free to toddle on independently
as they have since their inception.
Born by provincial decree only in 2005 as the lumpily-named Local Health
Integration Networks, Ontario’s LHINs have grown up so far without much
parental guidance at all. From the outset, the LHINs were allowed by the
Ministry to set their own strategy and wend their own way toward
region-wide integration. Within broad guidelines, each LHIN could pick
its own priorities, design its own eHealth pilots and projects, select
its own partners and vendors, as well as appoint its own chief executive
officer. As a result, some have grown up faster than others.
A few precocious ones such as LHINs 1 and 2 in south-west Ontario now
stand noticeably taller than their siblings when measured by their
deployment of technology. Their growth spurt started early with a
healthy grant from Canada Health Infoway in late 2003 to help the two
authorities establish a common diagnostic imaging (DI) network and
repositories they could both dip into. Today, as DI project director
Babette McRae told attendees at the Insight conference, the two LHINs
have most of that shared PACS network in place, stretching from Windsor
north up to Tobermory and east over to Cambridge. That span stands out
against the accomplishments of other slower developing LHINs, a few of
which have yet to even select a CEO.
To be fair to Ontario’s late-comer LHINs, it was not until April of last
year (2007) that the Ministry of Health gave the LHINs full authority to
get on with integrating services and technologies across their
respective regions. Yet even then the province did not fully articulate
how they should go about it. It’s almost as if the Ministry decided:
Let’s see how the kids make out on their own at first, and then we’ll
decide how to raise them after that.
Nonetheless, many of the LHIN kids are doing OK, albeit in various ways.
Most have developed some sort of eHealth strategy as a foundation for
their efforts at regional integration. Others are already on to creating
regional data warehouses that will make an electronic health record (EHR)
work. But only a few LHINs have built meaningful connections beyond
their hospitals walls and integrated their acute care facilities with
community care organizations or with family physicians in their region.
One that has, however, is the North Simcoe Muskoka LHIN, anchored in
Barrie, a burgeoning city on the edge of cottage country north of
“We started out by doing a survey of our needs and purposely went beyond
organizations that get LHIN funding. So we included community caregivers
and our doctors in the survey too,” says the LHIN’s e-Health Lead, Rod
Burns. “Consequently, we got a clear snapshot of the whole healthcare
community’s IT capabilities and their readiness for an EHR.”
The survey revealed that only about 40 percent of the LHIN’s community
care institutions were taking advantage of the IT services such as the
secure email offered by the Ontario government’s Smart Services for
Health Agency (SSHA). Indeed, adds Burns, many in community care do not
even know what the SSHA is or does. Doctors in his LHIN on the other
hand pretty much know and are chomping at the bit to go all electronic.
“In Barrie, we have a family health team of 72 physicians, or about 85
percent of all our doctors in town, and none of them want any more
paper,” says Burns. “They don’t want to be sent faxes. What they told us
they want very clearly is an electronic interface with whatever
institution or provider they send their patients to.”
But therein lies the challenging complexity all LHINs face when trying
to interface. The North Simcoe Muskoka LHIN, for instance, has seven
family health teams, in all, who use electronic medical records (EMRs)
from four different vendors. To get what the physicians are asking for,
those EMRs must be made to interface with hospital information systems
(HIS) from two different vendors at North Simcoe Muskoka’s six
hospitals. A daunting task.
And so North Simcoe Muskoka officials decided to simplify things.
“We’ve laid out a simple roadmap to get all of our hospitals on the same
Meditech system that four of the six are on now,” says Burns. “We also
have a regional health information council that looks at how our legacy
systems in each institution can be extended and shared. That’s precisely
what we are doing now with PACS (picture archiving and communications
system), too. To have one HIS and one PACS for the entire LHIN is our
A shareable PACS for the entire province is the goal of a provincial
government effort that will eventually bind all 14 LHINS and their 148
hospitals together. The Ministry’s DI/PACS Initiative will use
repositories to make diagnostic imaging information shareable. By 2010,
the goal is that 100 percent of the images taken by Ontario hospitals
from Cornwall in the south-east to Thunder Bay in the north-west will be
digitally stored and retrievable by all authorized care providers.
For an example of system-wide connectivity, however, Canadians might
want to take a close look at the Australian experience. According to
Mark Groper, it’s perhaps the best example on earth of how a parent
health ministry should treat its children.
Groper is an executive vice-president at Emergis (now a Telus company)
and is very familiar with what South Australia – a state equivalent to a
Canadian province – has already accomplished in the direction that
Ontario seems to be heading, however haltingly. He tells of a case study
of South Australia’s 10-year-long commitment to computerizing its
caregivers, including 82 public hospitals, which can now all share their
electronic records through data repositories. And more specifically he
talks about the state’s use of the Oacis clinical information system,
configured and implemented by the consulting firm Accenture to provide a
single point of access to 4.5 million online patient records from
anywhere and by any authorized caregiver in South Australia.
“Their program has been wildly successful,” says Groper, a person not
given to over-statement. “And one of the main reasons is that they put
data warehousing early into their implementation cycle.”
Data mining of those data warehouses has enabled South Australia’s
ministry of health to measure and trumpet the benefits of
computerization and consequent integration right from the start.
“That’s brought physician, patient, and political buy-in, and so it’s
generated huge momentum as a result,” says Groper. “So much so that the
ministry of health has recently authorized another $400 million of
technology expenditures, a remarkable figure for one of Australia’s
smaller states of only about 1.5 million people.”
As Groper points out, the changes brought about by South Australia’s
investment in and integration of its clinical information system, data
warehousing, and data mining technologies are significant and highly
evident: automated discharge summaries, for example, now appear on
average within 2 days of a patient leaving hospital instead of the
previous paper-based norm of 48 days; any death following surgery is
automatically noted and analyzed, often resulting in changes of standard
procedure and saved lives of similar patients; chest pain protocols are
tracked state wide to measure the degree of compliance and consequent
outcomes; the impact of vaccines is also being monitored with the result
that one brand has been ordered off the market; and scorecard
technologies are plucking data from the depositories and measuring the
performance of individual specialists.
Carestream offers ‘low-cost’ DR solution with wireless detector
ROCHESTER, N.Y. – Carestream Health has announced a cost-effective
innovation for the Digital Radiography marketplace – a wireless DR
detector panel that can be used with existing X-ray machines to replace
the film that’s still widely used in hospitals and clinics.
Carestream’s new wireless X-ray panel slides into the ‘bucky’ that’s
used to hold a film cassette.
There’s a startling difference in workflow between traditional
film-based radiology and the digital version. Using X-ray machines and
film, technologists must carry the film cassette to a machine for
developing, and then ship the images to a radiologist for reading – a
process that can take anywhere from minutes to hours.
By contrast, the wireless DR panel transmits the image to a workstation
or PACS, where they’re ready for a radiologist to work with in a matter
And captured digitally in this way, the images can be manipulated with
electronic tools by physicians, resulting in higher-quality readings and
potentially better outcomes for patients.
The impact on workflow – and patient throughput – in hospitals and
clinics could be enormous, according to Carestream. With increasing
demand for X-rays in populations around the world on the one hand, and a
simultaneous shortage of skilled technologists to operate machines on
the other, a solution that speeds up the flow of patients through an
X-ray department is much desired.
While DR has offered faster throughput for many years, it has been
financially out of reach for most organizations. Indeed, according to
stats from Carestream, there are 200,000 general X-ray rooms around the
world, but only 6 percent of them have DR.
“DR has been too expensive,” commented Todd Minnigh, worldwide director
of marketing for digital radiography at Carestream. He estimates that it
costs up to $650,000 to outfit an X-ray room with standard Digital
Radiography equipment. In comparison, the DRX-1 system that’s being
released by Carestream will sell for approximately $125,000.
“At this price, you could convert four rooms to wireless DR for the
price of a one-room, dual detector DR suite,” said Minnigh.
He noted that another technology, Computed Radiology (CR), is less
expensive than traditional DR, but “you don’t get the benefits of DR
workflow with it.”
That’s because CR uses a cassette that must be moved from the exam table
or wall stand to a machine for processing – essentially the same,
awkward manouver as with film, although the processing is somewhat
faster and CR converts the images into electronic format for viewing in
With the wireless DR panel, by contrast, the detector can stay where it
is, and it will transmit high-quality preview images in less than five
seconds. In 15 seconds, the panel is ready to send another image.
The detector panel contains a battery, and each battery can power up to
90 exposures. The batteries snap in and out of the panel, so that a
technologist can replace a spent battery with a fresh one, without
disrupting the flow of patients through the suite.
According to Carestream, a battery replacement can be done in less than
a minute. Recharging a battery takes three hours, and a re-charger can
hold up to three batteries.
Carestream has had the DRX-1 under development for about two years. It
expects to start selling the system – currently a work in progress – in
the first quarter of 2009.
The system will be demonstrated at the upcoming Radiological Society of
North America conference in Chicago. While other companies have been
working on wireless DR panels, Minnigh said this is the first one that
fits the dimensions of standard X-ray buckys.
That means it’s easy to upgrade rooms to DR – you simply replace the
X-ray cassette with the wireless panel. And in the off chance that the
wireless system is out of commission, you can substitute a film cassette
or a CR panel until the DR system is back online.
“No modifications to existing X-ray systems are needed and facilities
can continue to use the bucky with CR or film-based cassettes, if
desired,” said Diana Nole, president, digital medical solutions at
Carestream health. “In addition, the wireless functionality of the DRX-1
can improve efficiency by allowing a much more flexible workflow to meet
the specialized needs of each individual facility.”
According to the company, the DRX-1 can be used in general radiology,
trauma, orthopaedics and virtually all other X-ray exams.
The system is being sold with one panel, which can be inserted into a
table bucky or upright stand, as needed. But Minnigh noted that each
DRX-1 console can support up to three wireless panels. Additional panels
will cost approximately $100,000 each.
Image quality is at 139 um pixel pitch, the company said. The panels are
durable, and have been designed to sustain a drop from three feet.
They’re expected to handle about 56,000 exposures a year, with a
lifespan of seven to eight years.
Privacy of electronic records enhanced using masking techniques
By Pat Jeselon and Ruth Yeo
Some say there is no need to be concerned about
personal privacy, as we have none anyway. Others express great concern
that our personal privacy is being constantly and consistently eroded.
The latter concern is frequently cited amongst those individuals who
worry that the electronic health record (EHR) will wipe-out whatever
remaining privacy we have in today’s world of Facebook.
In a recent survey conducted for Infoway and the Office of the Privacy
Commissioner of Canada, 88 percent of Canadians support the EHR. The
poll showed nearly two-thirds of Canadians believe there are few types
of personal information that are more important for privacy laws to
protect than personal health information. Of those Canadians surveyed
who support the EHR, the following was also reported:
• Canadians want to ensure that privacy and security safeguards are in
place to protect their health information.
• 77 percent would like audit trails that document access to their
health information, and 74 per cent want strong penalties for
• 66 percent of Canadians want clear privacy policies to protect their
• A majority of Canadians (55 percent) would like to be able to hide or
mask sensitive information contained in their record.
The basic benefit of the EHR is to provide healthcare providers with
up-to-date relevant personal health information on the patients for whom
they are providing care. The basic risk of the EHR is that an
individual’s personal information could be accessed by authorized users
who do not have a professional relationship with the individual.
The challenge faced by privacy specialists is to find a pragmatic
balance between enabling access to personal information for healthcare
providers, on the one hand, while providing patients with a degree of
control over who can access the information in their EHR, on the other
The “need to know” principle is the basic tenet of the majority of
access control programs. Notwithstanding the issue of establishing what
is “need to know” rather than “nice to know” or “helpful to know”,
roles-based access control (RBAC) is a worthy approach to ensuring that
only those who need to have access to a patient’s information in the EHR
are permitted to do so. Most hospitals are good examples of RBAC at
The patient-provider relationship is based on trust and healthcare
professionals are well aware of their responsibilities to hold in
confidence any personal information their patients may disclose to them.
However, there are frequent instances where personal information is
disclosed; not through the original healthcare provider, but because
another provider accesses the person’s information outside the
patient-provider relationship. Privacy breaches of celebrities (remember
George Clooney?) by staff are not uncommon, but neither are those of
everyday citizens by healthcare providers who are ex-spouses, next-door-neighbours,
or a relative of the patient (such as the September 2005 privacy breach
at the Ottawa Hospital).
Consent directives give the individual the ability to place a “mask” on
all or some of their personal information in the EHR.
Authorized users are thus precluded from accessing that person’s EHR
unless the person gives their consent. Often, consent takes the form of
a keyword that when entered into the EHR system temporarily lifts the
mask, enabling the healthcare provider to access the information.
Canadian jurisdictions are entering into legislative or policy
consideration of consent directives in response to this public concern.
Ontario’s health information privacy legislation (PHIPA) supports this
concept, as does BC’s “E-Health Act”. New Brunswick and Nova Scotia are
also contemplating the use of consent directives, and a recent ruling by
the Alberta Privacy Commissioner requires the implementation of consent
directives in that province. PEI has already introduced masking
functionality into its EHR.
All this is good, but some myths still persist.
For example, some believe that masking personal information in a record
will put the patient at risk by preventing a healthcare provider from
having full access to all available personal information about the
patient. In reality, masking functionality is always counter-balanced
with un-masking functionality.
Similarly, there are those who think that electronic health records will
destroy the patient-provider relationship because of the inherent
privacy risks. Privacy risks do exist with an EHR, as the distributed
environment upon which the EHR is premised increases the risk of privacy
violation. But it also provides protections that the paper-based record
system cannot: access control based on “need to know”; audit logs and
alerts; consistent implementation of security technologies; and consent
directives that enable masking.
Privacy gone? We think not.
Pat Jeselon, MBA, CMC, is an eHealth Privacy Consultant working in
BC, Ontario, Nunavut and Atlantic Canada. She is President of Pat
Jeselon & Associates Consulting. Ruth Yeo, BSc Health Information
Sciences, is an eHealth Privacy Consultant working in BC. She is
President of Hourglass Consulting.
STARTEL takes heart failure management into patients’ homes
Capital Health is pilot testing Nova Scotia’s first
home telehealth venture through STARTEL, a multi-year research project
that aims to transform heart failure management across Canada – from
crisis response to proactive intervention.
STARTEL is putting sophisticated monitoring and communications equipment
into 100 heart failure patient’s homes across Nova Scotia and New
Brunswick, in partnership with the Atlantic Health Sciences Corporation.
Patients check in daily, using the equipment to record their weight,
heart rate and blood pressure measurements and send them to a central
station, where experienced heart failure nurses interpret the data. The
nurses monitor the patients’ input and contact them immediately if the
results indicate a problem is brewing.
“In essence, we’re taking the heart function clinic into people’s homes,
with added benefits,” says Michelle Currie, Capital Health’s STARTEL
project coordinator. As she notes, there is only a handful of heart
function clinics in the province. “It’s difficult for many patients to
travel to these clinics – they may be a long distance from home, and
some patients may be too ill or lack the resources to get to the clinic
easily or often.”
Unlike ‘bricks and mortar’ heart function clinics, STARTEL provides
patients with daily professional monitoring of their key disease
indicators. It also provides them with ongoing education, through
scheduled bi-weekly telephone or videoconference ‘clinical visits’ with
The nurses work closely with cardiologists, as well as the patients’
family doctors, to adjust the patients’ care plan as needed. They also
stay in close contact with patients to ensure patients understand and
follow their treatment – so they may potentially avoid crisis
“One of STARTEL’s unique elements is the inclusion of the primary care
physician,” says Dr. Jonathan Howlett, the Capital Health cardiologist
who developed the project. “We send patients’ bi-weekly reports to their
physicians, to keep them in the loop and give them a say in their
patients’ cardiac care. We also notify them of any non-cardiac problems
the patient may be having, so they can follow up. We’re creating
specialist-primary care teams, as opposed to parallel and possibly
conflicting care from two isolated groups.”
After an initial assessment at the QEII Health Sciences Centre for
patients in Nova Scotia or the Saint John Regional Hospital for those
patients in New Brunswick, patients enrolled in STARTEL are assigned to
a control group or the home telehealth group for a one-year period.
Half of this group receives a video-equipped device and half receives a
device with audio only. The researchers want to learn which device is
most effective, and how patients in the telehealth group fare compared
to those who receive the ‘usual’ care from their family doctor and heart
“We are using blood work to determine changes in kidney function, fluid
retention, hemoglobin, clotting factors and other heart failure
indicators,” notes Ms. Currie. “At the same time, we’re reviewing health
records to see how many visits patients made to their family doctor or
local emergency department, and whether or not they were hospitalized
for their heart failure symptoms. This will give us a clear picture of
the benefits and cost-effectiveness of the home telehealth system.”
Canada Health Infoway and AstraZeneca Canada are the major funders of
this research project; with contributions from NB Heart and Stroke, as
well. Dr. Howlett envisions STARTEL will roll into a clinical program –
and not just in Nova Scotia and New Brunswick.
With shortages of nurses, family doctors and specialists across the
nation, the STARTEL approach offers a way to extend the reach of limited
resources, while providing proactive health care. The ultimate aim:
healthier heart failure patients, at home, not in hospital.
How does STARTEL work? Let’s look at the experience of a patient
enrolled in the program. Each morning, Vere Brydon’s STARTEL
heart-health monitoring device chimes a greeting and asks him how he’s
feeling. That’s his cue to go to the unit and touch the screen to enter
his answer – the same, better, or worse than yesterday.
The voice then asks him to take his blood pressure with the attached
cuff, providing step-by-step instructions, and displaying the score on
the screen. After weighing himself on the attached scale and entering
some more information, he presses the spot on the screen that sends his
report to the hospital, where STARTEL project coordinator Michelle
Currie and/or heart failure nurse Kim Bentley reviews it.
At 85, Mr. Brydon has seen his share of heart troubles. The WWII veteran
had his first of more than a dozen heart attacks at the age of 44. He’s
since had a quadruple bypass, several stents, and now a
re-synchronization defibrillator (pacemaker). He lives independently in
spite of his heart failure, and credits STARTEL with a newfound peace of
“Being in this project gives you confidence,” says Mr. Brydon, the first
Nova Scotian patient to receive a STARTEL device. “It’s like having a
nurse in the house who can take your blood pressure anytime. It makes
you feel a lot more comfortable.” Yet his main motivation for joining
the study was to help others in the future. “This is the kind of
research that will help keep people independent, and out of hospital or
nursing homes, longer. It’s a wonderful program.”