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Inside the September 2010 print edition of Canadian Healthcare Technology:

Feature Report: Regional integration issues

Interoperability still faces many hurdles, study finds
It’s often said that the power of electronic health records won’t be fully realized until healthcare providers in hospitals, long-term care centres and clinics can all share the same electronic charts. Only then will they get a full and accurate medical view of their patients.


eCHN aces interoperability
While many hospitals and health regions have been struggling for years with the problem of interoperable systems, the electronic Child Health Network has connected over 100 care providers in Ontario.


Ottawa Heart likes Lean
The University of Ottawa Heart Institute recently conducted a test of Lean methodologies in its Biomedical Engineering Department. The trial was so successful, the centre now plans to roll out Lean to other departments.


Bayshore first with HOBIC
Earlier this year, Bayshore Home Health – a home healthcare provider – started transmitting evidence-based patient data to Ontario’s Health Outcomes for Better Information and Care (HOBIC) program.


HealthAchieve and eHealth
The annual HealthAchieve conference and exhibition, held in Toronto, is gearing up with a special eHealth conference stream. It will also host more than 100 companies with electronic solutions for hospitals and clinics. We provide a quick glimpse for attendees.

PLUS news stories, analysis, and features and more.


Interoperability still faces many hurdles, study finds

By Jerry Zeidenberg

TORONTO – It’s often said that the power of electronic health records won’t be fully realized until healthcare providers in hospitals, long-term care centres and clinics can all share the same electronic charts. Only then will they get a full and accurate medical view of their patients.

Unfortunately, it appears there’s a long way to go before we reach that state of electronic nirvana. Indeed, one out of every three hospitals in Canada has trouble with interoperability of clinical systems within its own walls – never mind connecting successfully to outside providers, according to a new study conducted by Canadian Healthcare Technology magazine.

In May, the magazine polled 300 chief information officers and IT directors at hospitals across the country to find out about their level of interoperability with providers outside and within their own facilities.

Of those invited to participate, 52 completed the entire questionnaire.

A third of the respondents (33 percent) said they’re having trouble with interoperability of clinical systems within their own hospitals. According to one respondent, “[We have] multiple applications, developed separately, by different vendors, with limited ability to integrate with other systems.”

That’s been a common complaint heard anecdotally at industry conferences and informal meetings, but we believe the Canadian Healthcare Technology survey is one of the first instances of a formal poll showing the extent of the challenge across the country.

The study, titled The Communication Gap: Problems and Plans for Interoperable Systems in Canadian Hospitals, covers the following topics:

• the state of clinical interoperability within hospitals and with outside hospital organizations;

• clinical interoperability among hospitals, long-term care centres and physician practices;

• barriers to interoperability and connectivity;

• usage of various standards in hospitals;

• wireless use in hospitals today and plans for the near future;

• views of CIOs and IT directors on whether provincial eHealth programs are useful – or not;

• IT investment plans.

The full report, with tables and analysis, will be published by Canadian Healthcare Technology this fall.

To produce the interoperability survey, significant issues were first determined through telephone interviews and e-mail conversations with five hospital CIOs in different parts of the country, and with several industry executives.

What’s the cause of the interoperability troubles in hospitals? For 17.5 percent of the CIOs and IT directors, the problem stems from incompatible software; 15.9 percent blamed incompatible communication systems; 17.5 percent identified improper governance and consent systems as the culprits; and 19 percent said all of the above.

Long-term care: As a solution for improving patient flow in hospitals, it’s generally agreed that faster, more efficient placement in long-term care centres is needed. To do this, better communication among hospitals, nursing homes and other long-term care facilities would help. (Indeed, 81 percent of the CIOs and IT directors agreed that electronic communications with long-term care centres would improve patient flow.)

However, nearly 62 percent of our respondents told us their hospitals don’t communicate regularly with long-term care centres using electronic systems. What does this mean? Too often, the movement of patients is slowed down by the inefficient collection and transmission of data. Hospital staff often spend time waiting or searching for paper forms, then manually create new documents and fax them from one organization to the next. It could be so much faster and smoother if the process was done electronically using compatible software.

Interestingly, while a third of the respondents intend to connect electronically to long-term care centres in the next two years, another third have no plans do so.

In fairness, as one of our CIOs pointed out, the benefits of connecting hospitals with continuing care centres have been demonstrated, but long-term care facilities themselves must also be willing to participate – something that not all of them have desired to do. They, too, must become more proactive about establishing clinical networks.

Physician practices: We were surprised to see that a vast majority of hospitals – nearly 80 percent – have connected electronically with physician clinics. Our assumption was that not much progress had been made on this front – happily, this was shown not to be the case. The CIO and IT directors noted a high degree of activity, with much more planned for the future. They’re connecting with doctors via portals and remote access, and sometimes through a mixture of both.

Standards: When we asked about various standards used in hospitals, there were some real surprises. For example, no hospital reported extensive use of Integrating the Healthcare Enterprise (IHE) profiles – despite the zealous work of organizations like HIMSS and the RSNA to promote IHE over the past 10 years. Indeed, one respondent even asked, ‘What is IHE?’

On another front, LOINC has been identified as a key standard for integrating lab systems. But only 16.7 percent of hospitals report they use LOINC to a great extent.

Certain standards have made inroads, however. HL7 v2, for example, is extensively used in 64 percent of the hospitals, while DICOM is also entrenched in 64 percent. While that’s a substantial number, one might wonder why these well-known standards aren’t even more extensively used.

Politics: Much of what’s done in healthcare I.T. is made possible only through funding, and a good portion of the manna has been dropped on hospitals by government programs. On this note, we asked our CIOs and IT directors whether the eHealth scandals of the last year have taken a toll on IT projects at their hospitals.

In response, over a quarter of them (26.9 percent) said the eHealth embarrassments have had an impact on them. Fifteen percent said it will take two to three years for their budgets to recover, while another 8.5 percent said it will take three years or more.

Asked if they thought their provincial governments had an ability to create an effective eHealth strategy, 42 percent of the respondents said not at all; 52 percent said their governments had ‘a moderate ability’; and only 6 percent checked off the ‘excellent ability’ category. So much for confidence in the government designers of a modern healthcare system.



Ontario’s eCHN shows that integration and interoperability are possible

By Andy Shaw

First lesson: integration and interoperability are not the same. The words are not synonymous; though we often use them interchangeably, which adds to the confusion. But like love and marriage, they do go together like a horse and carriage. So, any attempt to “integrate” your systems, meaning by definition combine them into one, unified whole – without your systems being able to “interoperate”, meaning exchange and make use of their information, will inevitably end up in divorce.

Of course, the ones that suffer most in a divorce are usually the children. So maybe it’s only fitting that those who have done the best job so far in healthcare of marrying integration with interoperability are those who care for sick kids. None better, nor longer, than the dedicated folks at Ontario’s eCHN, the electronic Child Health Network.

Since its inception more than 10 years ago, eCHN staff have been integrating with the rest of the province’s healthcare organizations and making their patient information systems interoperable – such that nearly 1.8 million of Ontario’s children now have an eCHN electronic paediatric health record. Those records can now be shared electronically Ontario-wide, thanks to eCHN.

Among eCHN’s other accomplishments and features:

• integrates child care data from disparate systems – including over 100 hospitals and tertiary care providers, such as children’s treatment centres, community health centres, and physicians offices – into one cohesive record;

• enables family physicians to refer and follow up on a child’s visit to a paediatric specialist;

• gives members access to a suite of paediatric care applications on the eCHN portal;

• maintains and staffs its own round-the-clock, high availability data centre;

• operates a technical and user support help desk.

It’s clear that eCHN has more than a child-like grasp on integration and interoperability. That’s very much because, from the top down, they understand the difference in the terms.

“First, we define integration as the creation of links between previously separate computer systems, applications, services or processes,” says eCHN’s chief executive officer, Andrew Szende. “As to interoperability, that’s not about making each separate resource know how the others work but about making sure they have enough common ground to reliably exchange messages without error or misunderstanding.”

Mr. Szende further adds that in defining the word integration: “…the word is normally used in the context of computing, but can apply to business processes as much as to the underlying process automation. In the past, computer integration – for example in enterprise application integration (EAI) – has typically been tightly coupled, or ‘hardwired’, making it difficult to modify in response to changing requirements. But thanks to the advent of web services and the evolution of service-oriented architectures, more agile, loosely coupled forms of integration are now starting to emerge.”

So in this modern “loosely coupled” era, who or what is going to exercise the tight discipline still needed to make sure one’s disparate systems dutifully and reliably establish common ground – so they can indeed exchange messages without fault?

Says Szende: “Standardized specifications go a long way towards creating this common ground where services can interact, but differences in implementation may still lead to breakdowns in communication.”

And in Ontario, they know about breakdowns! Indeed, the scandals surrounding the province’s eHealth initiatives got so heated last year there were meltdowns of entire agencies and programs aimed at both integration and interoperability.

But eCHN cooly withstood the heat. And it wasn’t the first hurdle they’d cleared in building their enviable network.

“As an organization our first obstacle to overcome was integration with Ontario’s hospitals. And as most of your readers will know, Ontario’s hospitals have dozens of different clinical information systems that collect data and store them in unique, site specific ways,” says Szende. “So eCHN built interfaces to the various vendor-provided applications and conducted detailed site specific surveys in order to successfully integrate both the data and its specific business rules into the eCHN solution.”

Still, hospitals are no peas in a pod. Integration with their idiosyncratic, and often proudly held onto systems is both a technical and human challenge. One that’s defied many an integrator, but not eCHN.

“Every hospital site had some degree of customization applied on top of the vendor-provided applications. These customizations had to be understood by the eCHN team, integrated and normalized in order to allow clinicians to view the data in a consistent manner,” says Szende. “And we admit that wasn’t easy. So for our integration efforts we used an experienced data team that had a clinical background that could interact with domain experts at the hospital sites as well as with the clinical application vendors.”

That doesn’t mean eCHN is resting on its laurels, adds Szende quickly. “Our integration effort is really a continuous one. We keep pace with member hospitals who are upgrading and updating their internal systems so we can always communicate with them in real time.”

Well and good, but how do Szende and eCHN know for sure they’re doing a the right things?

“We judge it by the enthusiastic feedback we get from our members, and most of all from clinicians,” says Szende. “They say they can rely on us, and I think that is the key to successful integration. Clinicians will not use systems that contain obsolete or error prone data.”

Another indicator of eCHN’s success is public recognition. Recently, the Hospital for Sick Children in Toronto won a “WOW Award” as Canada’s smartest IT application user in healthcare for its role in helping to develop the eCHN and being an early adopter.

Thus, endeth the first lesson.

Second lesson: Others can do the same. Take, for example, the provincially funded Children’s Treatment Network of Simcoe York, launched in 2004 and now stretching from the north end of Toronto all the way up to Georgian Bay. It has developed an “Electronic Client Record” that reaches beyond healthcare providers and integrates the electronic records of nearly 4,000 children and young people up to age 18 with the systems of over 600 children’s care workers in related fields including educational and social services.

“We sprang from the straits families found themselves in with children who needed complex care,” said Sandy Thurston, a Network founder and now the director of its planning, evaluation, and network development, at a recent show-and-tell LHIN conference in Toronto. “They needed services from such a fragmented and distant array of care providers that the parents, in addition to their own jobs, had another nearly full-time job of being their children’s case managers.”

Moving from that need, through a vision that won the support of over 50 information sharing partners, the Network now has four main features:

1. A single point of access to the care system for families with children suffering from diseases like cancer, and others requiring complex treatment

2. Ten integrated care teams of medical and other specialists available to them

3. A “single plan of care” for each child that integrates not just their healthcare support system but their community, social, school, and even recreation systems

4. An assemblage of a wide range of other child care specialists who could be called on to collaborate with Network care teams.

As a basis for all the collaboration it has engendered, the Children’s Treatment Network is using Microsoft’s SharePoint application. The Network also uses SharePoint for its Family Resource Centre, an internet portal which parents and computer savvy patients can access to share their knowledge and experience with other families and patients.

“We believe, judging from the feedback we get, that we provide as much value for patients out of the Family Resource Centre as we do from our formal care,” said Thurston.

While the Children’s Treatment Network is exemplifying community-wide integration, the electronic Children’s Health Network is sorting out which comes first: the chicken or the egg. Or rather, the fundamental question of how should integration and interoperability relate to each other? Which, in effect, should come first to your attention if you want the marriage of the two to really work?

“Originally, eCHN’s priority was integration. Now interoperability is equally important,” says CEO Szende. “We make eCHN conform to blueprints and strategies, so it can operate with other solutions. To do that we support data exchange conforming to Canada Health Infoway (CHI) preferred information access methods, such as webMethods and the publish/subscribe model that are part of the CHI Blueprint.

“Our team took that approach because we wanted to be compliant with the Blueprint’s electronic health record (EHR) principles,” adds Szende. “We also implemented a service-oriented architecture that makes it easier to interoperate with provincial services and products as they become available.

“As a result, eCHN is currently a flexible, open, scalable and interoperable EHR solution. So if and when the Ontario Laboratory Information System (OLIS) goes live, for example, we’ll be able to interoperate with them and exchange OLIS lab results. We’re also looking forward to hooking up with other provincial services, such as patient and provider registries, when they become available.”

Lesson three: you can do it too. And you don’t have to do it all by yourselves. Not only do you have the shining examples of the eCHN and the Children’s Treatment Network before you, there’s money out there, or at least the promise of it. And not just from provincial coffers.



Lean approach scores high marks in trial at the University of Ottawa Heart Institute

By Rosie Lombardi

Lean is a concept that’s floating around in hospital circles, but there’s a lot of uncertainty about what it means exactly or how disruptive it may be.

“I’d heard comments about it and people seem to have some trepidation about it,” says Timothy Zakutney, Manager of the Biomedical Engineering Department at the University of Ottawa Heart Institute (UOHI). “But the more I learned about it, the more fascinated I became to try it.”

To evaluate Lean’s benefits, Zakutney made a convincing case to hospital executives to have his area serve as a test-bed for the potential implementation of Lean throughout the UOHI.

Although he has a high-functioning team of eight staff dedicated to maintaining and repairing VADs, heart lung systems, echocardiography, ventilators and other technology, he says there was room for improvement. “Engineers are pack rats, and the area was getting cluttered with tools, parts and equipment. We needed to make the workspace more efficient to help us focus on tasks from initiation to completion.”

Infection control is another issue that is gaining more urgency in hospitals. “Not having an orderly, tidy workspace makes infection control challenging. I wanted to make it a safer environment for staff.”

The central question he asked staff to consider in rethinking their processes was: What minimal tools are needed to get the job done based on the urgency, frequency and severity of tasks?

The team then moved into the next phase, working with GE Healthcare Lean workflow specialists to develop solutions. “There was a lot of data gathering and observation of staff by GE Healthcare to analyze existing performance, in addition to spaghetti diagramming and process simulations.”

Simulating processes with the help of an external facilitator applies Lean thinking and gets staff to take an objective look at what they do, says Michčle de Montigny, a GE Healthcare consultant who worked with the UOHI team. “We go through simulations and ask staff: Show me how you would repair a ventilator. Walk me through the steps. Lay out the tools and parts you need.”

Zakutney says this part can be emotionally challenging, but is one of the most valuable aspects of Lean in helping staff optimize their work areas. “It’s about exposing the way you work and opening yourself up to new and better ways to get work done. People react differently to this, which is why Lean is ultimately about changing human behaviour. Having external experts to help you through is useful, and GE Healthcare is great at recognizing at what level people are in this emotional roller coaster.”

During the implementation phase, the team worked hard to clean-up, sort and standardize, all within the period of one week. “We went through every desk, nook and cranny and sorted all the components. Then we literally scrubbed everything down with the help of housekeeping, and put back only the needed tools and equipment in a standardized order. ”

The final and most important phase of the Lean effort was the sustainability piece, says Zakutney. “After we put everything in order, we started implementing checklists, so that going forward, we would maintain everything we had accomplished.”

The consensus-building that’s part of the Lean approach was hugely important. “The big thing for me as the manager is that the staff took on the responsibility of decision-making. This engaged them in the process and facilitated the success of the project.”

The project was completed in May 2010. While Zakutney says he plans to collect and analyze six months of data to determine the measurable benefits, there are already some clear improvements that he has observed. “People have a greater feeling of control over their workload, and they’re working smarter because they’re spending less time searching for things.”

The VP of Finance at the UOHI was supportive throughout the project, and was pleased with the results and sense of pride it fostered in staff. “So we’re going on the Lean journey and will be moving forward with applying Lean in our diagnostic imaging area,” say Zakutney. “And we’re exploring implementation in our clinical services, our discharge management processes, and on our nursing units.”


Bayshore the first home care organization to transmit HOBIC data

By Leigh Popov

In April of this year, Bayshore Home Health became the first home care organization to electronically transmit patient-centered, evidence-based clinical health data to Ontario’s Health Outcomes for Better Information and Care (HOBIC) initiative.

According to the Ontario government, “The ability to collect and produce more accurate and comprehensive information and make it available for decision-making is essential to the transformation of our health system. This information will help us understand the impact of nursing and other disciplines on a patient’s health.”

HOBIC’s mandate is to implement Ontario-wide, standardized collection of patient health outcomes, staffing and quality of work life information reflecting a variety of disciplines, including nursing.

HOBIC provides valid, reliable information that is patient-centred, evidence based, outcome-focused and comparable across all sectors. HOBIC has already made significant inroads in the acute care sector, and has seen good adoption in hospitals within the province.

We decided to engage with the HOBIC initiative because it made perfect sense for our organization as we transition from traditional to evidence-based clinical practices. Although HOBIC’s roots were in Ontario, it has now become a national initiative. As a national nursing organization, Bayshore recognized the value of applying the same evidence-based, outcome-focused principles of the HOBIC model across our organization.

From a business standpoint it was a pragmatic choice. In aligning with HOBIC we could leverage existing resources and research rather than reinvent this body of knowledge ourselves, and in the process have to redesign and redeploy our systems. In other words, we chose not to reinvent the wheel.

Our progress: Our work on the HOBIC project started late fall 2009. The first order was to make changes to our electronic forms to accommodate HOBIC data elements. In doing so, we added certain fields and developed a special assessment which our field nurses could fill out at the community point of care.

Next came development of two interfaces: one from our clinical management system to our middleware platform; a second from the middleware to HOBIC directly. We believed using a three-tier architecture option was a more efficient approach in this case, since the technology was already in place and we could realize the added benefit of repurposing the inbound clinical data to our own clinical data repository as well as to HOBIC.

Interface development, testing and debugging, activation and training of field staff continued through to March 2010, with rollout happening in the second half of the month.

Bayshore Home Health nurses use a secure mobile electronic charting application in the field. Nurses immediately started filling out the assessments which were then automatically transferred to HOBIC. At the same time, they were given access to the HOBIC database on the same devices in the field for review, assessment and possible adjustment of care plans to enable the best possible outcomes for clients.

Lessons learned: In achieving our goals, we worked with a number of partners on both the implementation and development sides of the initiative. These partners included vendors of clinical management systems who assisted in the data extraction and adaptation for electronic form delivery, interface development specialists who ensured the successful execution through the middleware architecture, and HOBIC’s technical solutions group who assisted with testing and validation.

Data field mapping is a large component of interfacing and makes each interface unique. This was certainly the case here, however, we were still able to draw on the experience of others to help in this implementation.

For example, we looked at HOBIC’s numerous implementations in the acute care sector and their technology partners as a resource for addressing such fundamental issues and processes as communication protocols and exception/error handling. Error handling specifically can be problematic if working out for the first time. HOBIC’s experience here helped make the troubleshooting and validation process run smoothly.

Results: For many organizations such as ours, a successful transition to HOBIC does not require radical infrastructure change. At Bayshore, the technology requirements were largely focused on the connection element, as well as internal training, project management and perhaps most importantly, change management support.

With the healthcare sector challenged by rising demand and costs, we firmly believe that wide deployment and proper use of HOBIC will drive costs down through improved outcomes. A more integrated model of care can also reduce duplication not only in each vertical sector, but also across sectors in the greater health system.

Although the Province is still in the early stages of database building, the population and trending data gathered through HOBIC will prove invaluable in supporting the healthcare system moving forward. The data provided will also help organizations such as Bayshore expand efficiencies throughout our nationwide system, regardless of location.

Having strong, measurable data provides a strong foundation for effective evaluation and decision-making at the system, organizational and client levels. We believe that taking these initial steps with HOBIC today will bring us closer to the goal of quality, patient-centered, evidence-based care.

Leigh Popov is Chief Information Officer at Bayshore Home Health where he is responsible for delivering vision and thought leadership in design, development and support of all eHealth, administrative and other electronic communication systems. Leigh holds a Masters degree in Business Administration from Queen’s University in Kingston (Ontario). Bayshore Home Health has more than 50 home care offices, 20 community care clinics and 8,000 employees.