GoldCare enhances children’s rehab across Ontario
GoldCare, a division of Campana Systems Inc., of Waterloo, Ontario, will now be implementing its electronic health record at five Children’s Treatment Centres (CTCs) in northern Ontario. This brings the benefits of electronic charting and communication to an impressive total of 18 organizations of this kind across the province.
In August, Ontario’s Ministry of Children and Youth Services announced new funding to expand GoldCare’s platform to the five CTCs in northern Ontario, joining the 12 CTCs and a Children’s Treatment Network in southern Ontario that are already participating.
This innovative community care information management system is credited with delivering efficiencies and standardization in reporting, reducing the administrative burden on families and coordinating the availability of services across Ontario’s child rehabilitation system, ultimately leading to better outcomes.
According to Paula Hucko, chief operating officer at GoldCare, “The northern Ontario project is expected to launch this fall and will be completed within a nine-month period.”
That will leave only two of Ontario’s CTCs – both hospital-based and customers of Westwood, Massachusetts-based Meditech – outside the GoldCare network, at least for now. “This is a first for Ontario – a Ministry where one services delivery group, the CTCs, will be using a common technology and a common solution,” says Hucko.
The adoption of the GoldCare solution in Ontario began with the CTN of Simcoe York, which was formed in 2005 to improve families’ access to care by better coordinating services for 5,500 children with multiple disabilities.
By establishing CTN, services such as physiotherapy, occupational therapy, speech and language pathology, audiology, and developmental pediatrics were expanded and made available closer to home in Simcoe County and York Region.
CTN’s Single Plan of Care approach consolidated what previously had been a number of different care plans from each service provider into a single and shared plan of care, providing a common framework for setting the direction and focus of each child’s care. It also eliminates the need for a family to continually retell its story and explain its special needs and concerns to each care provider.
CTN’s shared Electronic Health Record (EHR) supports the development and monitoring of the Single Plan of Care. For families, this enables their children’s care teams – the entire circle of care – to collaborate more readily, share information and focus on the child with timely information and documentation. Through GoldCare, all team members have access to the same information and are kept informed of changes and progress. The shared EHR and collaborative approach have helped improve clients’ quality of life and outcomes.
Theresa Sanders, mother of 10-year old Jessica who has complex needs, feels the entire process and its philosophy of collaboration are responsible for improvements to her daughter’s healthcare that are “an indescribable relief for our family.”
“Team members need to be able to communicate effectively with each other and coordinate their services in order to make sure their goals are in line with each other and with the family,” she said. “This requires technology like GoldCare to enable all the team members to connect and share and come together to help the child reach his or her full potential. To know that we will never again have to face a fragmented healthcare system in Jessica’s childhood is a miracle to all of us.”
Louise Paul, CEO of CTN, acknowledges that the GoldCare solution has given her a clearer understanding of her clients. It lets her know which families are waiting for services and exactly what they’re waiting for. “So there are tremendous benefits from a case manager’s perspective, from a caregiver’s perspective, from a family’s perspective, and from the service system perspective,” she says. “We’re able to share relevant and common information with all the professionals involved in a child’s care. Our model of care and the EHR allow us to share information inter-organizationally, regardless of whether the child’s team members are staff working in the health, education and/or community sectors – it is truly a shared, integrated care plan.”
“Seeing the positive outcome of this model led the Ministry of Children and Youth Services to support moving the 12 southern Ontario treatment centres, which provide similar services to CTN, to an electronic information system that could support shared care,” commented Hucko.
A single Request for Proposal was issued for the 12 sites. For some of the sites, the project was the catalyst to upgrade their data collection systems to EHRs. Wait lists and other terms, which previously had different meanings, were standardized across the network.
All 12 southern Ontario CTCs went live on the GoldCare platform simultaneously in June 2012. One year later, more than 2,000 staff employed by the CTCs were using GoldCare daily. More than 30,000 special-needs children were being served.
GoldCare continues to enhance the solution, introducing mobile technology so the system can be accessed in the field with a mobile phone or tablet. GoldCare is also working with two sites to develop family access to the shared record through a secure family portal. “All the CTCs have expressed an interest in our portal technology,” Hucko noted.
Linda Kenny is CEO of the KidsAbility Centre for Child Development, which provides rehabilitation services for special-needs children in Waterloo Region and Guelph-Wellington. She is passionately supportive of the transformation GoldCare is helping bring to children’s care across the province. “This project is a substantial achievement. To have 12 distinct organizations collaboratively agree on wide-spread standardization, common best practices and a shared platform is a real triumph.”
Kenny added, “Through the GoldCare solution, we now have an electronic record that is a complete record of each child’s experience with KidsAbility. If a child’s parents meet with two therapists, the second therapist is up to date on what the first therapist has done. That takes much of the burden for record-sharing off families.”
Kenny believes strongly this is a story that must be told and at the heart of it are children that will benefit greatly from this unique collaboration. “The potential is there for this to be a completely shared record – sector-wide – on a child’s journey.”
Canadians are steadily developing digital telepathology networks
By Gail Balfour
According to Dr. Andrew Evans, the benefits we will see from telepathology projects taking place throughout the country will go far beyond the ability to quickly share biopsy images with remote pathologists for consultation and diagnosis. This emerging technology will also have a profound impact on clinical education and research, quality assurance, accuracy and speed of diagnosis, as well as storage of data and integration with electronic health records.
“This technology is steadily evolving, with respect to scanning speed, image quality and image analysis –we are on the cusp of what you would call computer-aided diagnostics,” said Evans, Director of Telepathology at University Health Network (UHN) in Toronto.
The term telepathology refers to the digital transmission of pathology data, allowing faster and easier sharing of medical images, regardless of where the sender and recipient are located. These images are either captured from a digital camera connected to light microscope, or the pathology specimen slides are scanned to create high-resolution digital slides (or virtual slides) for transmission, analysis and storage. But this is not where the advantages end.
“Pathologists will soon be able to run algorithms on digital images and search for rare events – which normally take a long time under a microscope. A computer doesn’t get tired – it can process a huge amount of data over a long period of time, whereas the human eye fatigues. Digital pathology will also allow us to do certain things that the human eye and the light microscope simply cannot do, such as multiplex biomarker analysis on tiny biopsy samples.”
Dr. Evans is a telepathology pioneer in Canada. In 2003, Evans and his team at UHN’s Laboratory Medicine Program started investigating a digital system to address a need created when the individual hospitals within the network amalgamated and moved all of their staff pathologists to one site.
“When you take all the pathologists out of one place, you are left with few options if a surgeon at the unstaffed site needs an intra-operative pathology consultation (or frozen section): you can send the tissue to the place where all of the pathologists are, or you can send single pathologists to where the tissue is. Either way it’s a time-inefficient process. You are also one pathologist by yourself – so you don’t have the ability to show a difficult frozen section to someone else.”
Frozen sections need to be assessed by a pathologist right away, while the patient is still on the operating table. The benchmark is to have an answer back to the surgeon within 20 minutes, said Evans, so there is no time to send a physical specimen to off-site pathologists.
Today, Evans is one of the key players spearheading the Multi-Jurisdictional Telepathology (MJT) project, involving health organizations from three provinces: Ontario, Manitoba and Newfoundland, with funding from Canada Health Infoway.
The key objective of the MJT project is to establish a digital consultation network and an overall connectivity process for at least three provinces, Evans said. The hope is that this linkage will pave the way for a pan-Canadian digital network in the future.
There is also a growing emphasis on sub-specialty pathology, which creates the added challenge of getting cases to the right expert, at the right time. Digitizing the specimens into shareable images makes this type of review possible and also allows several sub-specialists to review a challenging case, regardless of where the patient, slides and pathologists are located.
Currently, each of the three provinces has moved beyond the concept phase and is reviewing RFPs for their individual hardware and software procurement. “Each province is responsible for finding the digital pathology system that will best meet their needs now and in the future. The number and type of slides that need to be scanned, the user interface and whether the system needs to be integrated into a laboratory information system (LIS) are some of the key factors to consider,” Evans said. “This will cause different provinces to explore different vendors. However, we will need to end up with a scanner agnostic or interoperable network that allows pathologists to review digital slides regardless of the scanner that was used to generate them.”
One of UHN’s technology partners for the project is GE Healthcare, which is helping to implement workflow and technology solutions around capture and transmission of pathology images. UHN worked with the company on an 18-month long concordance study to determine if the digital images were of comparable diagnostic quality as the same slides when viewed under a microscope. The study looked at more than 3,000 cases and 20,000 slides from 11 different anatomic sites, in a detailed process known as a validation study.
When trying to do something in a new way, it’s healthy to start out being a skeptic, Evans said. “You prove the new technology to yourself by looking at the same cases with both modalities to make sure what you see on the digital image matches what you see with the microscope. Ultimately, you need to make sure the diagnosis you give to a clinical colleague for the care of a patient will be the same, regardless of how you review the slides. Once you have done this you are ready to think about going live.”
Many valuable insights have come out of the UHN project, he said. “We have had real dialogue with the pathologists throughout the study, gaining their feedback and suggestions with respect to image quality and system performance. Several product iterations and design improvements were made by the engineering teams based on this feedback. And that’s about as good as it can get.” Moreover the study showed concordance between glass and digital slides.
Insights: “Pathologists look for details at the cellular level, so the equipment must capture images in full colour and at a higher magnification allowing for a much greater degree of resolution,” said Luigi Gentile, executive director of GE Healthcare’s Pathology Innovation Centre of Excellence (PICOE).
“This requirement translates into extremely large images – posing a challenge for both storage and transmission of files. At GE, we have developed proprietary technology to compress these image files, while still maintaining very high image quality, allowing for reliable streaming of images in real-time across networks,” Gentile said.
The ability to collaborate more closely with colleagues, something that is made possible by shared images, is one of the key drivers of the MJT project, said Dr. Gabor Fischer, clinical pathology associate and medical director for the Telepathology Project at Diagnostic Services of Manitoba (DSM), based in Winnipeg.
“Right now, if I have a difficult case, I have a microscope and I have a glass slide. If I am not sure about the diagnosis, what I have to do today is take that slide to a colleague who may be a few corridors away, or may be in a different building, or in a different town. There are risks associated with shipment, and there is also the issue of lost time.”
By using telepathology, however, slide images can be sent within seconds to colleagues; and two or more pathologists can view the images at the same time, to discuss the diagnosis.
Fischer pointed out that digital pathology will offer “huge benefits” on the education and research side as well.
“Today, if I want to share a case with the residents, I only have one glass slide. One of them is looking at the slide, and then when he or she is done, passes it to the next resident. So they can’t look at the same image at the same time. And it’s difficult to build a bank of interesting cases for the purposes of pathology education,” he said.
“Digital pathology allows you to scan your best cases and develop a bank online. Residents can access these and have dozens and dozens of cases they can review. You can scan the most informative, the most interesting or the most diagnostic images for the bank.”
Evans agreed, adding that this will also address a common problem found in academic centres where people do tissue-based research.
“The original glass slides get signed out of the archive and can go to somebody’s office where they might be kept for an extended period of time. The glass slides may be needed again for patient care or a second opinion, or for medico-legal reasons and problems arise if they cannot be readily found,” he said. By digitizing the slides, the original glass slides can be kept in the archive so everybody knows where they are. Digital versions of these slides can be used for research in most cases.
Fischer said another advantage digital pathology offers is precise measurement, which matters – especially in cancer cases.
“What is crucially important in many tumour resections is the distance of the margin from the tumour. Sometimes this is very difficult to measure with a microscope. It depends on what lens you are using, and what microscope. But if you use an image, the digital pathology system will measure it for you and you can even make annotations on the screen for your colleagues.”
Independent of the MJT project, there are also initiatives going on in other parts of Canada. One of the largest is taking place in eastern Québec, where more than 20 sites are updating their telepathology equipment, workflow and processes.
The aim of this project is to provide services across a large, remote region in order to avoid unnecessary patient transfer or pathologist travel. Each site is equipped with a whole slide scanner, a macroscopy station, a videoconferencing device and a case management and collaboration solution.
According to Dr. Bernard Têtu, pathologist at the Centre hospitalier universitaire de Québec (CHUQ) and medical director of the Telepathology Project for the Integrated Health University Network (IHUN), they are currently doing validation testing and using the system primarily for consultations, but are in the process of digitizing certain specimens and integrating digital pathology practices into their diagnostic workflow so it can be eventually used as a primary diagnostic tool down the road.
“Timing alone is a huge advantage. What could once take days or even weeks, now by telepathology takes less than 24 hours,” he said. “It opens up a world of possibilities.”
Agfa HealthCare, in Toronto, is one of the CHUQ’s technology partners helping to scan and validate images, establish improved workflow and to develop image management practices. According to Andy Hind, vice president of Agfa HealthCare, the benefits to digital pathology are in some ways very similar to digital imaging in radiology, but in other ways they are quite different.
“In radiology, for example, one of the biggest business benefits is that you don’t need film anymore. Essentially, hospitals were able to get rid of their large film archives,” Hind said.
“Now in digital pathology, you don’t have that same advantage, because you still have to create a slide, and you have to keep it for a certain period of time. So you are not suddenly going to get rid of the slide. Not today. But, what happens is that once you digitize that image, you are able to do all sorts of things you couldn’t do before.”
In addition, he said, there could be advantages from a multidisciplinary medical team and electronic health record perspective, to be able to see associated images of a patient all at once. “For the first time, you will be able to bring those digital pathology images together with the rest of that patient’s record.”
But despite all the obvious benefits, there remains some resistance to the technology. Pathologists are familiar and comfortable with specific equipment, and it will take time to overcome the learning curve and develop new working practices.
Dr. Evans added the profession also needs to recognize: “This technology is certainly not meant to replace pathologists, but to help us do our jobs better.”
Abbotsford physician enhances care of BC patients via telehealth
By Sharon Mah
Dr. John Pawlovich, a family physician living in Abbotsford, BC, has a thriving practice in Takla Landing, a rural and remote aboriginal community located approximately 400 km north of Prince George, BC. Like many physicians providing rural and remote healthcare, he flies or drives by 4X4 into Takla Landing once a month for a week to meet face-to-face with patients. Unlike many physicians, however, Dr. Pawlovich regularly meets with and examines these patients, and consults with Takla Landing clinic nursing staff on a daily basis from his home office via videoconference for the other three weeks of the month.
Dr. Pawlovich and Takla Landing are part of a pilot project initiated by Carrier Sekani Family Services to explore how telehealth technologies can be used to provide primary care support to isolated aboriginal communities. The project, which started in 2010, is an unmitigated success. After installing state-of-the-art videoconferencing equipment that included peripheral examination tools such as a stethoscope, an ear, nose, and throat camera, and a general exam camera, the Takla Landing healthcare team developed new processes and competencies to integrate the new technology into their daily services.
Telehealth enables nurses and physicians who are off-site to collaborate in an unconventional manner. Nurses often lead much of the care at Takla Landing and use the telehealth system to consult with Pawlovich via iPad, smartphone, or HD desktop screen and camera when a complex health issue requires a consult.
Caroline Alger, an RN who has worked at Takla Landing, notes that it is amazing to have a physician listen via telehealth to heart, lung, and bowel sounds, examine wounds, and talk to the patient to explain their symptoms and diagnosis. “It takes away the guesswork that occurs when a physician prescribes on the basis of the examining nurse’s description of symptoms and findings,” says Alger.
She notes that telehealth also helps her learn new skills and review existing competencies in patient examination and treatment. Support of healthcare services through telehealth has enabled care workers to manage more patients in-community and has reduced the number of patient transfers to acute and/or specialist care facilities elsewhere, saving money and reducing patient stress.
In addition to enhancing acute healthcare provision, telehealth also enables more optimal management of chronic diseases, allowing patients to receive proactive and preventative care from a familiar healthcare provider. “The ability to continue to directly work with a patient despite not being physically present in the community is a game changer,” says Dr. Pawlovich. Telehealth enables accessibility, reliability and continuity – the fundamental principles of primary healthcare – to occur in remote First Nations communities, leading to a strengthening of the doctor-patient relationship and ultimately, the development of trust.
The success of the Takla Landing pilot project has led to further investigation about the effectiveness of telehealth in supporting specialist care. “We’re now offering several specialties within Takla Landing, including general surgery, thoracic surgery, infectious disease care, nephrology, addictions, HIV and AIDS, dermatology, and cardiology,” notes Dr. Pawlovich. While complex treatments may not take place at the community health clinic, local healthcare staff and telehealth both play key roles in managing and supporting the patient through the process. For example, Dr. Pawlovich and clinic nurses have managed simple surgical pre- and post-operative exams in-community by videoconferencing with the specialist.
While the anecdotal reports of telehealth use in Takla Landing are glowing, Dr. Pawlovich is interested in bolstering these reports with evidence. He has enlisted the help of Dr. Kendall Ho, founding director of the University of British Columbia Faculty of Medicine’s eHealth Strategy Office, to evaluate both the Takla Landing telehealth pilot project data, as well as all subsequent telehealth-delivered primary care services in the community. “We hope to use the evaluation to further support – in specific ways – improvements to access, quality of care, and productivity over time,” says Dr. Ho. “We intend to use the evaluation to characterize patterns of good practice of telehealth in primary care through this initiative.” Drs. Ho and Pawlovich will begin evaluating the data later this year and will release their findings in 2014.
The emerging First Nations Health Authority (FNHA) is very interested in the outcomes of the Takla Landing pilot project and has initiated a Telehealth Expansion Project that plans to fully launch by the end of 2013. This project will create the opportunity for a large number of aboriginal communities to get involved with telehealth when they’re able and ready to do so.
The Telehealth Expansion Project will utilize a comprehensive mapping and matching exercise based on community-identified priorities to connect first nations communities with needed health services. As each community’s priorities are unique and the mapping and matching process is still ongoing, the FNHA cannot yet specify which services will be provided at each site. However, broad clinical service areas that will be targeted include: mental health and addictions; maternal health; diabetes/chronic disease management; and, HIV/AIDS (clinical, mental health and wellness services). When the FNHA assumes full jurisdiction over first nations health in British Columbia in October, it will release further information about the specific communities that are ready to engage in the Telehealth Expansion Project.
Dr. Pawlovich is cautious about referring to telehealth as a cure-all for addressing gaps in aboriginal health. He cautions that communities should assess what services are currently available and explore how telehealth will improve those services.
There are other challenges facing remote and rural aboriginal communities wishing to augment their healthcare programs with telehealth technologies.
Telehealth is heavily reliant on internet connectivity and requires a great deal of bandwidth to function properly. In regions of B.C. that do not have access to high speed connectivity, acquiring this bandwidth can be difficult and costly. Videoconferencing equipment, too, can also be expensive. However, Dr. Pawlovich feels that the rapid evolution of mobile technologies will likely bring such barriers down over time.
Sharon Mah manages communications for the Rural Coordination Centre of BC (rccbc.ca), a group seeking to improve rural health in British Columbia through the coordination of health education, advocacy, and community partnerships.
Canadian technology makes patients partners in their own healthcare
By Steven D. Freedman, MD, PhD and Dr. Camilia R. Martin, MD MS
BOSTON – Now, more than ever, patients are demanding a bigger role in the management of their health. With endless access to computerized information and consumer technologies that keep the flow of data nearly constant, patients now expect the same level of engagement from their healthcare practitioners.
No longer will office visits with long waits between tests and follow-up be the norm. Patients and their families are looking to become partners in an ongoing and interactive care plan. This is a challenge for a healthcare system rooted in one-way information dissemination from doctor to patient.
Currently underway at the Beth Israel Deaconess Medical Center, a teaching hospital of the Harvard Medical School in Boston, is a clinical study based on “Passport to TRUST,” a new healthcare initiative that provides each patient with their very own interactive health “passport.”
Using technology from NexJ Systems known as NexJ Transitional Care Management, this people-centered approach to healthcare gives patients a “digitized care plan” that enhances shared decision-making between them and their doctors. It also allows easier handoffs between physicians and non-MDs/nurses for improved follow-up and monitoring of care beyond the office visit.
Today, most healthcare providers suffer from a lack of structure in their dialogue with patients, and standardization at the point of care. This one-way form of communication from doctor to patient limits shared decision-making, and the lack of a clear step-by-step plan and timeline in the patient’s journey to wellness leads to fragmented care, poor follow-up and an inability for patients to readily communicate with their physician.
Too often, patients leave their physician’s office unsure of what’s wrong with them and uncertain of what they themselves can do to get better. Even when a patient is given instructions on how to improve their health, often the physician has no insight into whether the patient is actually following the assigned care plan until the next office visit.
Thanks to a partnership with NexJ Systems, a Toronto-based provider of cloud-based software delivering enterprise relationship management solutions to the healthcare, financial services and insurance industries, Beth Israel Deaconess is embarking on creating a digitized bidirectional care plan between the patient and physician that can outline potential causes of the presenting problem, justify how tests and treatments would change management, define timelines for follow-up, address the patient’s thoughts and concerns, and access the latest info in real-time with the patient to define best practices through trusted content.
As an example of a Passport to TRUST careplan for a patient presenting with abdominal pain, potential causes are listed such as ulcer, irritable bowel syndrome, pancreatitis and inflammatory bowel disease. Tests and treatments are then outlined which in this example may include a trial of an acid blocker; if no better in two weeks, then Donnatal twice per day to treat for irritable bowel syndrome; if still no better, will obtain an MRI scan to assess for pancreatitis; if MRI is normal, will then proceed to colonoscopy to determine if the abdominal pain is due to inflammatory bowel disease.
Red flags/triggers that should prompt an immediate call are detailed, and the patient’s thoughts and concerns, such as “Do you think I could have cancer?” are elicited in the care-plan. This step-wise care-plan can now be viewed by the patient’s family or medical advocate (if so desired by the patient) and by other members of the patient’s healthcare team allowing for coordination of this patient’s medical care across time and providers.
By utilizing NexJ Transitional Care Management, what we’re really doing with Passport to TRUST is embracing the reality that multiple parties contribute to the patient’s care, and their plan of care. Therefore, we’re enabling the personal care plan to be shared across the healthcare continuum, not just with those caregivers any organization chooses, but all of the caregivers and advocates the patient is choosing to rely upon.
The result is that all parties are on the same page, and because any provider who is using NexJ Transitional Care Management can edit and track the personal care plan, it can evolve as needed during the patient’s journey. Best of all, through NexJ Connected Wellness, the electronic care plan is accessible on the web or through mobile devices at any time through the patient’s personal account.
The patient also has the option to print their care plan, or the ability to electronically share the personal care plan with anyone in their circle of care – friends, family, advocates, and health care providers.
When patients share their plans with their care teams, it encourages collaborative care. As a result, the office visit is now a forum for shared decision-making as patients become informed partners in their care. Patient lifestyles, thoughts and concerns are easily addressed and always reviewed, minimizing premature diagnostic anchoring.
By creating a stepwise longitudinal care plan to enhance patient activation, we are truly improving health outcomes. The results of Beth Israel Deaconess’ patient satisfaction and shared decision-making pilot – a survey of 108 patients and seven physicians – showed that 96 percent of patients were satisfied with their physician using Passport to TRUST versus 38 percent satisfaction with their doctor visit before Passport to TRUST was introduced.
In addition, 97 percent of our patients found the written summary of the plan to address their concerns “very helpful”, and 69 percent of the patients shared this written summary with family and/or friends. And, for us personally, we saw about an 80 percent reduction in the number of patient phone calls regarding concerns and questions.
Effectively supporting patients during transitions in care and reducing re-admission rates requires improving communications between providers and their patients and giving patients the information they need to understand their condition and treatment plan.
Through the creation of lay-language care plans, we can now provide patients with the information they need about their conditions, what treatments they have had to date, next steps in their care plans, what to do in case of adverse events, and notes for their next visits. Having this information easily accessible gives patients added care and comfort away from their doctors, and, most significantly, it contributes to reducing unnecessary hospital re-admissions and any associated penalties.
Steven D. Freedman, M.D., Ph.D., is Director of the Pancreas Center at Beth Israel Deaconess Medical Center and Professor of Medicine at Harvard Medical School, Boston. Camilia R. Martin, M.D., M.S., is an Assistant Professor of Pediatrics at Harvard Medical School, and Director for Cross-Disciplinary Research Partnerships in the Division of Translational Research at Beth Israel Deaconess Medical Center, Boston.
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