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Inside the September 2008 print edition of Canadian Healthcare Technology:


Quebec starts province-wide EHR project
The province of Quebec has officially started its $560 million Dossier de santé project, an electronic health record network that will allow 95,000 doctors, nurses and allied healthcare professionals to access the medical charts of their patients using a single viewing system.

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How to computerize your ambulatory clinics
The family practice clinic at Mount Sinai Hospital is the first of the Toronto-based medical centre’s many clinics to implement an electronic health record system. It’s also one of the first hospital-based ambulatory clinics in Canada to do so.

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Wikis for healthcare
Many minds are greater than one, in most cases. That kind of thinking is now used in online wikis. Our columnist Dr. Richard Irving proposes that Wikis be developed to improve healthcare delivery.

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Hospital lab automation
A new, front-end automation system at the Atlantic Health Sciences Corp., in New Brunswick, is speeding up results reporting, improving quality and helping the organization deal with a chronic shortage of skilled technologists. The advanced system can automatically perform up to 140 tests.

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Revolutionary CT
A new generation of computed tomography scanners has entered the hospital world. The ultra-fast systems produce extremely high-resolution images in seconds,
and greatly reduce the X-ray dose for patients.


Over-ordering DI exams?
An Ontario physician responds to a study that concluded GPs are ordering too many CTs and MRIs. Better to err on the side of caution, notes Dr. Chris Clarke, for several reasons.


PLUS news stories, analysis, and features and more.

 

Quebec starts province-wide EHR project

By Jerry Zeidenberg

QUEBEC CITY – The province of Quebec has officially started its $560 million Dossier de santé project, an electronic health record network that will allow 95,000 doctors, nurses and allied healthcare professionals to access the medical charts of their patients using a single viewing system.

The project kicked-off in May with a pilot system at a clinic in Quebec City and will roll out across the province over the next three years.

“It’s the first time in Quebec that we’ll have a complete, longitudinal view of the patient’s medical history,” commented Dr. Guy Bisson, senior clinical advisor to the Dossier’s project director, and a former professor of medicine at the University of Sherbrooke.

Dr. Bisson is currently the medical lead for xwave, which won the contract as systems integrator and project leader of Quebec’s Dossier.

Dr. Bisson explained that the Dossier de santé du Québec (DSQ) project intends to integrate existing sources of data – initially from labs, pharmacies and the provincial drug plan, and diagnostic labs – making the records available to authorized care-givers through a web-based portal.

It’s a huge integration project, and one that involves many first-of-its-kind technologies and approaches.

“This project is a milestone for Canada, as Quebec will be the first to implement the Infoway architectural blueprint on a large scale,” commented Gary Folker, managing director, business development, at xwave. “It’s also the first provincial project to use HL7 v3 messaging,” he added, referring to the leading-edge standard for communicating health data files.

For its part, xwave stands to earn $109 million as the systems integrator and project manager. Its partners include Orion, which is supplying the viewer software for the system; Oracle, whose Health Transaction Base (HTB) will be used for the first time in Canada in a large-scale project; and Bell Canada, which is providing infrastructure management and training.

Dr. Bisson noted that Quebec has a unique legal environment that requires the provincial health-record system to be created in a way that’s different from other jurisdictions in Canada.

“In Quebec, you need explicit consent of the patient to share information electronically,” he said.

As well, the data itself must be stored locally in one of 18 regions across the province. For that reason, the Dossier project is building 18 different repositories – information from various sources will be uploaded into these repositories on an ongoing basis. For example, information from 126 labs across the province will flow into the appropriate regional repository.

Nadeem Ahmed, xwave’s managing director, healthcare, said the Quebec project is likely the most complex provincial system to be launched in Canada. “It’s complex not only in terms of size, but also because of the special legal environment, the differing languages, and the challenges of integrating a diverse infrastructure.”

The initial site involves five general practitioners, as well as nurses and allied health professionals. In September, another clinic will be added – together 120 clinicians will be using the pilot system, which at that time will offer medication information, lab results and immunization data.

The province is currently creating a Quebec-wide diagnostic imaging network – when the DI repositories are established, interfaces will be created to enable physicians to access medical images. It’s expected that this will occur in mid-2009.

Already, commented Dr. Bisson, the pilot project has achieved buy-in and an enthusiastic response from the doctors. “In the past, when people talked about installing computerized records in clinics, doctors would ask, ‘why?’,” said Dr. Bisson. “Now, they’re asking when can they get more functionality, like lab and diagnostic imaging.”

Dr. Bisson observed that a great deal of work has gone into customizing Orion’s web-based viewer into a format that Quebec physicians and care-givers are comfortable using. Meetings have been held to determine the types of views and information that Quebec physicians want to appear automatically, and which types of data could be accessed with subsequent clicks of a mouse.

As a guiding principle, the system has been “organized from summary to detail,” with the most important information most easily accessible, he said.

Additionally, the user can further define the view, according to how he or she likes to see information.

Dr. Bisson noted that in the initial phases, the system will provide information only, and won’t have the workflow capabilities found in some electronic health record solutions. It will offer fast access to information, but the process must be initiated by the physician or care-giver. Unusual results, for example, won’t automatically be sent to caregivers – although that functionality could be built into the system in the future.

On a related front, xwave is formulating ways of including consumers in its EHR solutions, to accommodate the rising interest in personal health records (PHR).

“Consumerism is here to stay,” commented Folker. “We know there are benefits from having the patient involved in self-care. Getting the patient involved often leads to earlier detection and treatment of problems.” According to Quebec’s Ministry of Health and Social Services, the implementation of the Québec EHR is expected to bring three main benefits – improved healthcare quality, better access to services, and increased productivity among healthcare professionals, while ensuring respect for privacy and the protection of personal information.

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Mount Sinai Hospital takes lead in computerizing out-patient clinics

By Jerry Zeidenberg

TORONTO – Today, most hospitals have high-powered, computerized information systems for in-patients. But oddly enough, their out-patient clinics – such as family practice, endocrinology and cardiology – tend to rely on old-fashioned pens and paper.

Mount Sinai Hospital, a teaching hospital with over 100 out-patient clinics in downtown Toronto, has set out to change this. Earlier this year, it started using an electronic medical record system at its family practice clinic, which has 10 physicians and about 25 residents handling 30,000 patient visits a year.

It’s one of the first hospitals in the province to start computerizing its out-patient clinics.

Access to a computerized system has already made a difference in the workflow of physicians, residents and allied health professionals at the family practice clinic – formally called the Mount Sinai Academic Family Health Team, part of the Granovsky Gluskin Family Medicine Centre.

“There are many benefits,” commented Dr. David Tannenbaum, Family Physician-in-Chief at Mount Sinai Hospital. He noted that instead of paper files, which can be stored in different locations, “you’ve got all your data organized in one place.”

What’s more, because the charts are electronic, different clinicians can have access to a patient’s file at the same time – they no longer need to have the paper records right in front of them.

“You can imagine a paper chart passing around from person to person and see the inefficiencies. Now everyone involved with a patient’s care can have instant access to an accurate and up-to-date chart,” said Dr. Tannenbaum. Quick access to information is now possible for nurses, social workers, pharmacists and registered dieticians, in addition to physicians.

For its part, Mount Sinai Hospital selected a web-based solution from Nightingale Informatix, of Markham, Ont., for its clinics, called Nightingale On Demand. A selection committee was impressed with Nightingale’s knowledge of how family physicians work and interact, and appreciated the solution’s ability to be customized to meet the clinic’s needs.

Nightingale On Demand, the new solution has been connected to the hospital’s diagnostic imaging system, its lab and three other labs in the city, allowing DI and lab test results to flow quickly into the records of patients.

“From a patient safety standpoint, I’m impressed by the data flow into our EMR,” said Dr. Tannenbaum. Outside labs used to take up to a week to post results. Now it’s less than a day, sometimes even a matter of hours.

“I saw a patient at 5:30, examined his chart at 6:30, and the results from the Mount Sinai lab were already there,” he said.

The medications component of the Nightingale On Demand system allows drug interactions to be neatly identified. When a clinician adds a medication to patient’s file, the system will automatically flag it if it conflicts with a prescribed medication or allergy.

Also reassuring: doctors have become more disciplined in recording data. “The Nightingale On Demand solution has improved how we treat our patients at various points of care, from the waiting room to the pharmacy. The quality of data is better than what appears on paper because the templates force us to be more disciplined in how we record and provide information.

“And since some doctors have handwriting that is difficult to read, the pharmacists, who now receive printed prescriptions, noticed a difference right away.”

Setting up the system was no small feat, however, and actually took longer than expected. Not only was the work of creating interfaces to the hospital’s Cerner information system time-consuming and intricate, the hospital experienced a major IT staff turnover just after the project to computerize the clinics got off the ground.

Nevertheless, the work continued and the family practice clinic now has connectivity with many of the HIS components. Chief among these is Admissions, Discharge and Transfer (ADT), which shares key patient demographics with the family practice clinic.

“The demographics and case ID information are very important, and it’s critical that everything is precise,” said Dr. Tannenbaum. “You can’t have errors in this data, and it took several months to sort out some of the issues and get the interfaces right.”

All of the preliminary work, however, has set the stage for other hospital clinics to computerize. This in turn will help the family practice clinic, as it will make it easier to share information with the clinics visited by patients – such as nutrition and fertility.

As it stands now, other clinics and in-patient departments can theoretically obtain access to the family practice records, using Citrix remote access systems. But this would require setting up security and access privileges for various care-givers.

Communication will be easier once more clinics have the Nightingale system up and running.

Dr. Tannenbaum noted that better communication with the data systems in other hospitals would also be useful, as “many of our patients go to other hospitals in emergencies.” As a result, a good deal of patient information is scattered around the city.

Better communication would also help out on the research side, says Dr. Tannenbaum, who is also an associate professor of medicine at the University of Toronto. As well as training residents who graduate from U of T’s medical school, the family practice clinic is heavily engaged in research studies.

He noted that 10 family practice clinics at sites across the city are working together on research, and connectivity through electronic records would greatly ease the task.

The researchers are tracking patient data, sorting out trends and establishing best practices for quality outcomes.

On a related front, Dr. Tannenbaum sees patient involvement and self-management as huge issues in the near future, with patients gaining access to their electronic records. “It’s the next big hurdle,” said Dr. Tannenbaum.

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Is there a healthcare Wiki in your future?

By Richard Irving, PhD

In 2001, Jimmy Wales invented Wikipedia, which has now grown into the world’s largest online, free encyclopedia and is available in over 100 languages. The basis of a Wiki is user-generated and maintained content. Wikipedia is largely open in that any user can create an entry. A system of dedicated volunteers constantly monitors content and removes offensive or defamatory content and corrects errors.

However, the Wiki concept of mass on-line user collaboration is being used as the basis for many innovative organizations. For more information, check out Wikinomics, a recent book by Don Tapscott and Anthony Williams.

Using the free Wiki search tool ALOT, I received 581,000 hits for the term “health wiki”. If you go to www.wikia.com/wiki/Health, you will find a list of a wide variety of Wikis from diabetes to sleep apnea.

Now, I have a request to make of you, dear reader. Can you identify how we might use the concept of a Wiki to facilitate the development of a low cost, high-quality integrated healthcare system? As a start, here are some of my ideas. Yours will be better:

• Create a survey Wiki by and for healthcare IT professionals, where survey questions can be identified, refined and where surveys can be generated, analyzed and the results reported.

• Create an IT problems Wiki, where healthcare IT professionals can raise problems and issues and solicit comments from similar professionals across Canada.

• Create a best practices Wiki, where healthcare professionals can post interesting and innovative solutions they have developed.

• Create an academic Wiki for the presentation of new and interesting ideas from the global literature on healthcare IT. This could be combined with a blog where academics and selected professionals could debate the merits of these ideas. (I am currently working on a blog of books I heave read that I hope to have up in the fall).

• Create a healthcare advocacy Wiki where IT professionals and others can raise system wide issues.

• Create an anonymous Wiki to deal with the gap between government pronouncements and the front-line reality.

• Create Wikis for clinicians to discuss treatment details with other clinicians.

• Create drug Wikis, where patients can post information on effectiveness and side effects.

Most of these ideas assume that the Wikis are restricted to a professional group such as healthcare IT professionals or clinicians, but perhaps not all should be that restrictive. Deciding who can post and who can view the posts is a major design issue. Perhaps many of those ideas I proposed already exist. If so, we need an index to these sites.

Please send me your ideas and comments. If I get enough of them, I will publish a selection in a subsequent column. I won’t mention your name, but will at least acknowledge that the ideas aren’t mine. Let’s see if this small experiment in mass collaboration will work. I need your ideas and comments by September 30th. Who knows, perhaps we’ll start something worthwhile. I can be reached at rirving at ssb.yorku.ca.

Richard Irving, PhD, is an associate professor of management science at the Schulich School of Business, at York University, in Toronto.

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Lab automation at Atlantic Health Sciences streamlines processing

By Dianne Daniel

Doing more with less isn’t just a cliché at Atlantic Health Sciences Corp.’s (AHSC’s) medical laboratory in Saint John. The multi-facility regional health authority in New Brunswick completed the implementation of a “front-end” lab automation system at Saint John Regional Hospital in March, the latest piece in its integrated lab strategy, and is currently reaping the benefits of several process improvements, says Ian Watson, administrative director, laboratory medicine.

“The big efficiency for us is achieving our lean objective in terms of reducing unnecessary steps and procedures,” notes Watson.

Like many laboratory environments across Canada, AHSC is dealing with a decreasing supply of technologists while the number of tests performed each year is increasing five to 10 percent on average. “That’s been the driver, to see how we can optimize our shop so we can take advantage of the skills and knowledge of our technologists…instead of managing the more manual aspects of specimen processing,” he says.

The front-end automation piece is the Modular Pre-Analytics (MPA) system from Roche Diagnostics, of Basel, Switzerland, with Canadian headquarters in Laval, Que. A robotic system that measures more than 20 feet long and resembles a miniature assembly line, the MPA handles the preparatory work of spinning blood samples in a centrifuge, safely uncapping them, and aliquoting them (separating them into smaller samples so that more than one test can be conducted).

The original sample is then recapped and archived in a storage rack while the smaller samples continue down the line to existing automated testing equipment or, in some cases, are transferred to a medical lab technologist for manual testing, depending on the information contained in the original barcode label.

With 2,000 samples arriving on-site each day, the MPA is allowing the medical lab to maintain its service in the face of a labour shortage, says chief technologist, chemistry, Susan Buckley. “We’re aggressively recruiting, but so is everybody else in Canada,” she says. “This is allowing us to sustain and even build to offer more; if we didn’t have automation, we wouldn’t be able to do that.”

In addition to relieving medical technologists of the repetitive and labour intensive tasks of centrifugation, uncapping and capping samples, the MPA system is contributing to a shorter turnaround time by streamlining the entire process. As Buckley explains, when technologists were preparing samples manually, it was more efficient to work on batches of 30 to 50 at a time, whereas the automated instrument works continuously on smaller batches, “levelling out those peaks and troughs of work being congested.”

By reducing the need for human intervention, it also removes the possibility for samples to “be forgotten” in the centrifuge and, because it automatically rejects samples that don’t meet an objective set of benchmarks, it reduces the potential for subjectivity to come into play in a technologist’s interpretation.

Other benefits include a decreased likelihood for repetitive stress injury due to uncapping and recapping, reduced exposure to biohazard samples, as well as less upfront work for the central receiving area which can now concentrate on ensuring the correct specimens have arrived, are appropriately labelled and correctly identified before they go onto the MPA. The MPA is also integrated with the AHSC’s lab information system so that any tests performed are automatically “tagged” to a patient record and the location of the original sample is recorded so that it can easily be retrieved if further testing or verification is required.

“One thing we didn’t want to do was paint the picture that we were seeking automation in order to reduce our staffing complement – that wasn’t the objective,” points out Watson. “It was about redeploying our resources so they could do the important part of their work.”

Jacques Laporte, Roche Diagnostics’ corporate manager, integrated healthcare solutions, says the trend across Canada is that the lack of skilled technologists is prompting medical laboratories to examine their processes and look for areas that can be consolidated. Prior to implementing the MPA system, for example, AHSC automated its backend testing processes using the Roche Modular Analytics Serum Work Area to consolidate its clinical chemistry testing (such as glucose levels, liver function, cardiac markers and cholesterol) and immunoassay testing (hormone levels such as PSA, FSH, LH and Beta HCG) under one area, eliminating the need for two blood samples to be drawn at the start.

“At the end of the day there’s the same amount of work to be done, but instead of handling two separate tubes on two separate systems by two separate people with two separate sets of skills, you have one person handling one combined system with one tube,” he says. The hospital saves on tubes and manpower, and with fewer samples to manage, the process is faster and less prone to error.

In fact, Laporte would argue that automation projects are more about process improvement than robotics. “If we don’t look at process first, than what we find is they’ve just automated chaos,” he says.

According to Buckley, AHSC’s lab is still in the process of “tweaking” the MPA system and “getting staff used to working with it” but the initial feedback is positive. The automated solution is used for blood testing and some urine analysis, and the hospital is considering adding technology that will enable the system to identify those samples that need to be referred to an outside lab, automatically sending them to a default “buffer” zone.

“I never thought in my career I would see a piece of equipment that can do what this does,” she says. “I’ve been working for 35 years and it’s really quite something.”

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