Novel children’s EHR links wide variety of providers
RICHMOND HILL, ONT. – At a time when various healthcare providers are having trouble connecting or sharing their electronic health records, the Children’s Treatment Network of Simcoe York (CTN) is showing how it can be done. The group’s breakthrough was recognized earlier in 2011 when it won an “Ingenious Award” from the Information Technology Association of Canada (ITAC).
The Simcoe York organization, with resource centres in Richmond Hill and Barrie, Ont., coordinates care for children who have multiple special needs in a large geographical region north of Toronto.
To do the job effectively, it has created a comprehensive electronic record that’s shared by service providers from over 30 different agencies.
What’s more, over 600 providers from these organizations have received training to access and use the record. The web-based system enables all members of a child’s care team to see the record and share information – which reduces the need for families to repeat their story and ensures all child and family team members are working together.
Service providers include speech and language pathologists, physiotherapists, occupational therapists, physicians, family counsellors, social workers, family support workers, early interventionists, nurses, service navigators, and others, located at various agencies, schools, and hospitals.
Kids receiving care through the Children’s Treatment Network have multiple special needs and typically have two or more service providers. Children and youth may have difficulties with communication, mobility, self care and daily living skills.
That means health and service information can wind up in many places, but the shared electronic record is able to connect it. “It’s providing the child and family team with information they can build on and supporting the development of a single plan of care,” said Louise Paul, CEO of the Children’s Treatment Network of Simcoe York. “Parents don’t have to tell their story over and over again. The record tells everyone who is on the team, what services the child is waiting for and what has already been accomplished.”
The shared record has moved some Network partners to electronic charting, while for others it does mean some duplicate entry. “Finding a way to streamline and standardize our documentation amongst the many agencies is our next challenge,” said Paul.
Using the shared electronic record, care providers are coordinating their services more closely. They’re able to see what other team members are doing, and to develop shared goals and shared accountability.
They’re even working out a common language. Previously, explained Paul, every organization would have its own way of describing a child’s strengths or needs. Now, they’re agreeing on common terms and descriptors, making communication much easier.
For the kids involved, that has meant a boost in the quality of care, as everyone is on the same page. “In the past, people would assume that a child was getting certain services.” said Paul. “Now people can see what services a child is receiving, what services they are still waiting for and which services have been discharged.”
If a child isn’t getting the attention he or she needs, that can be seen on the electronic care plan, and action can be taken. “As services become more visible to the members of the team – more kids are being identified as needing services,” said Paul. That’s leading to better treatment for children with complex needs.
Managers at partner organizations are also benefiting from the electronic system. “It has really helped them on the service planning side,” said Michelle Biehler, an occupational therapist and Director of Access at Children’s Treatment Network of Simcoe York.
“It’s allowing provider organizations to see which services the client is using, how long the service is taking, how much time providers spend travelling, how many face to face appointments and phone consultations they make and how much time they spend delivering care,” she said.
That’s giving managers much more information to improve service delivery. They’re able to determine which client group may require more time and which providers are spending time travelling. In a positive way, this information can help them to better allocate resources in order to ensure that service providers have enough time to provide direct service to children and their families.
The Children’s Treatment Network of Simcoe York uses the GoldCare electronic record, from Campana Systems of Waterloo, Ont., as the core of its system. GoldCare has assisted in the ongoing development, and the solution is hosted by the company on secure servers.
“It’s an incredibly innovative solution, and it has been created at a fraction of the cost that larger organizations are investing to produce shareable, electronic health records,” said Paula Hucko, vice president of sales and marketing at GoldCare.
Hucko said the hosted nature of the solution has been effective for the Children’s Treatment Network, as GoldCare takes care of the technical aspects of the network, while the Children’s Treatment Network focuses on delivery of clinical services.
“We ensure that they’ve got 24/7 access to the information they need for continuous care,” said Hucko. “We take care of adding users and security, upgrades and making sure the network has fast response time.”
While CTN is now enjoying considerable success with the shared electronic record, the initial buy-in from service partners was tough and has taken several years.
Indeed, the agency has been developing the electronic system since 2007, but just lately has made its biggest breakthroughs. “It’s just in the last year that things have caught on, with the partners entering a great deal of data into the system,” said Paul.
In the 2010 budget, Ontario’s Ministry of Children and Youth Services announced $2.5 million in funding for 12 other Children Treatment Centres to upgrade their electronic documentation and client data base systems. Campana’s GoldCare system will be used and the company will assist in standardizing practices across Ontario’s children’s rehabilitation system.
The group of 12 Children’s Treatment Centres are working with GoldCare to develop the Children’s Rehabilitation Information System Project, or CRISP, for short. Implementation is planned for April 2012. Working collaboratively, the centres will build on the work started by CTN and all centres will benefit from shared templates and software enhancements.
That sharing should foster even greater cooperation among agencies and professional groups, said Biehler, adding that “we should see greater standardization of assessments, interventions and business processes.”
Ontario nurses using wireless systems to supervise patients at home
The conference guest speaker opened the three-day community health confab in Toronto by talking about the inefficiencies of a General Motors plant that built a variety of car axles. He pointed out that production of those axles could follow any one of 110 different “pathways” through the plant – a labyrinth of costly inefficiency.
GM’s solution? Reduce the kinds of axles produced to one kind, resulting in just one pathway.
That was music to the ears of attendees from Ontario’s 14 Community Care Access Centres (CCAC), who struggle daily with meeting their government-mandated challenge of helping thousands of Ontarians find their way through the healthcare system. It’s a system rife with hundreds of often disconnected pathways as patients make their halting way in and out of acute, community, and home care environments.
And yet, somehow those CCACs and their intrepid case managers and nursing staffs every month help over 250,000 people, including: about 3,300 transitioning to a long-term care home; another 6,200 receiving end-of-life care at home; and over 27,000 shifting from hospital to home. But not always with great efficiency, for caregivers and patients alike.
At this conference meant to help change that, Yankee simplicity met Ontario complexity. The Texas-based computer company known simply as Dell addressed the membership of its largest Canadian client, the Ontario Association of Community Care Access Centres (OACCAC), on how technology can transform community care.
“For the past few years Dell has been conducting a transformation of its own,” said David M. Zirl, PhD, the company’s healthcare and life sciences strategist, during an afternoon conference session at the waterfront Westin Hotel. “We started out, of course, as a hardware company known for its laptops and servers. But for the past five years or so we have spent an enormous amount of time with our customers, striving to understand the issues they face.”
“Particularly with our healthcare clients, we’ve been asking: What are your problems? How can we help you apply either new technology or older technology in new ways to address those problems?
The solutions and answers, said Guy Fortin, the OACCAC’s chief information and network architect and a co-presenter with Dr. Zirl, come with the advances in mobile technology. “The smartphones, the BlackBerrys, the iPads, and other tablets we have today mean that many of the tasks we do no longer need be fixed to a location.”
In short, a CCAC nurse specialized in homecare no longer needs to be in the patient’s home to provide care. Rather, as Mr. Fortin pointed out, some CCACs are already piloting a system whereby that nurse can be anywhere – watching the blood pressure or glucose results come in on his or her office or home computer screen from patients entering their own data on monitors set up in their homes; or remotely supervising the work of less costly “personal support workers”, who visit homes of patients requiring more complex care.
“A pilot is being conducted by our CCAC in southwestern Ontario, and we’ve called it the ‘E-shift Overnight Care’ project,” said Fortin. “It is part of the effort to reduce hospital visits by pediatric and palliative care patients, in particular, and delegating that care to a personal support worker.
“The current model of care is to have the registered nurse go in and be at the bedside. But complex care nurses are rare and well-qualified specialists. So naturally it’s hard to get many such nurses interested in spending night after night in patients’ homes.”
But in the E-shift project, said Fortin, just one VON nurse is linked to numerous personal support workers in the homes of patients. The support workers are equipped with iPads running a purpose-built, home care application with access to a secure web portal.
“Through the portal, the workers can share their information, not only with that overnight nurse, but also with the case worker assigned to that patient,” said Fortin.
On average, the supervising overnight nurse has four support workers on electronic tether. “This is really quite revolutionary, because we’re improving the efficiency of overnight care four-fold,” said Fortin. “As one of our hospital CEOs told us: ‘You are getting all the efficiencies of a hospital – without the overhead.’”
But inevitably many of those overnight care patients and thousands of others will still go to a hospital at some point.
“So, after they have made their way through however many different pathways that hospital has; been triaged; had their vital signs taken; and finally a doctor comes to see them,” said Dell strategist Zirl. “Then the doctor says, ‘I have diagnosed your problem,’ and gives them a set of instructions about what to do when they get back home. They may have a prescription to fill and maybe they are told to visit a rehab clinic. But the odds are at least some of those instructions will be ignored and the patient will be re-admitted 30 days later. And the ratings of the hospital go down as a result. So, how can we inject technology to improve this dysfunctional process? ” How, in other words, can we make care between hospital and home a true continuum?
The answer, said Zirl, lies in pushing easy-to-use diagnostic technology out to the patients themselves.
“But you can’t just push it out there and hope that the scale or the cuff is going to be used faithfully by the patient every day. You have to monitor that use by linking it back to a dedicated caregiver. And in order to do that you have to have a dedicated and secure healthcare delivery network, or a network that’s now called a ‘facilitated care network’.”
To Dell’s and the OACCAC’s credit, Ontario is a leader in developing facilitated care networks. Already widely deployed is CHRIS.
“That stands for Client Health Related Information System,” explained Fortin, “ and we use it for planning care, ordering, dealing with providers, monitoring patients’ progress, generating reports, billings, and assigning tasks to our case managers. We’re just now rolling it out to the last of our CCACs. So CHRIS is really at the heart of all CCAC work.”
Fortin and the OACCAC are also rolling out a CCAC document management system that will collect all clinical documents and be integrated back into CHRIS.
Similarly, moving out OACCAC-wide is a client assessment system called PointClickCare. “It does our patient contact and home care suitability assessments, and it too will be integrated with CHRIS,” said Fortin. “PointClickCare is another good example of how you can have separate networks that are dedicated to specific tasks, but which are linked by standard interfaces between them.”
Even given such admirable connectivity, both Fortin and Zirl are quick to point out that challenges remain. Not all involved in the full continuum of care between hospital and home are yet connected.
“You’ve still got unconnected groups out there like government regulators who pay for the care, the insurance and benefit organizations, the pharmacies, and the medical device companies, to name a few,” said Zirl.
And even as such groups become part of one or add their own facilitated care networks, another challenge grows.
“Security gets harder and harder to do as we get more and more outfits connected,” said Zirl. “Every time a new one gets added, it creates a security hole that we have to cover if information is to be kept confidential.”
And every portable device, be it laptop, iPad, Playbook, or Android, along with the confidential information they carry, is a potential security hole if lost or stolen.
So there are serious risks as community care goes mobile. But are they ones that can be mitigated by, you guessed it, new technology?
Zirl sees some sort of cloud-based facilitated healthcare delivery network as the answer to covering all mobile holes and preventing confidential information from leaking. “In a cloud network, there would be no actual information placed on any mobile device, so it wouldn’t matter whether it was lost or stolen. The information resides securely in a cloud and is only read from below.”
Newfoundland and Labrador planning to launch physician EMR program
CHT: What are the key health IT priorities for the next 2-3 years in Newfoundland and Labrador?
Barron: The province has recognized the need for more information system alignment and project delivery between the regional health authorities, the Centre for Health Information, and healthcare professionals. This alignment will provide a safer and more effective, standards-based health information regime province-wide.
Under the leadership of the Ministry, we are in the process of confirming all of the current or planned health information system initiatives. We’re also creating a roadmap that sets priorities, realistic timelines, and identifies interdependencies and opportunities between projects.
CHT: What major projects are currently under way in Newfoundland and Labrador?
Barron: The Centre is now deploying a state-of-the-art pharmacy network (drug information system) that will initially integrate all community pharmacies in the province. We currently have 25 percent connected, and once critical mass has been achieved, we will roll out a viewer to the regional health authorities and physicians.
This will enable safer and higher-quality front-line care at point of service areas such as emergency rooms. The information in this viewer will also support medication reconciliation in the regional health authorities.
The pharmacy network has also been designed to accept HL7 V.3 messages from electronic medical record systems for e-prescribing from physician offices. A comprehensive drug information system is the holy grail for health information technology, but it is very complex to introduce, given all of the “moving parts” in the pharmacy environment and the many potential system users.
With the collaboration and support of the pharmacists and pharmacy owners, we are hoping to have all community pharmacies on-line before the end of next year.
In addition, the regional health authorities are working with the Centre for Health Information to implement a province-wide occurrence reporting system. This system will allow standardized management of incidents at regional health authorities and allows for a roll-up at the provincial level.
CHT: What projects are planned or in the queue for the near future?
Barron: The biggest project we currently have on the books is our iEHR/Labs project. Planning for this project began in 2005-06 and its completion will result in one of the first comprehensive province-wide electronic health record infrastructures in the country. We recently completed an RFP process for the required integrated viewer technology, as well as the detailed project plan for implementation of the viewer and other technologies required for project delivery. We have secured significant funding from Canada Health Infoway towards this project and are currently going through the final provincial approval process. This project is really four projects in one: extension of the health information access layer (HIAL) used in pharmacy, provision of a configurable dynamic electronic health record viewer, creation of a robust provincial laboratory clinical repository, and the initial foray into a shared health record infrastructure.
The Centre has also worked with the Department of Health and Community Services and the RHAs to participate in a multi-jurisdictional telepathology project that includes Manitoba eHealth and the University Health Network in Ontario. The NL portion of this project is jointly funded by the DHCS and Infoway and presents an excellent opportunity to demonstrate use of distance technology to support inter-provincial delivery of specialist healthcare in the area of pathology.
Another major initiative is also under way in the area of the electronic medical record (EMR). The Centre recently released an RFP for the selection of an EMR vendor(s) that meets the requirements for integrating with the provincial EHR infrastructure. If all goes to plan, a physician office system program will be introduced by the province that will accelerate adoption of EMRs by physicians. All recent activities in this area are designed to take advantage of Infoway’s EMR funding program.
CHT: Why are these initiatives important?
Barron: Two major drivers for province-wide implementation of information technology are patient safety and access to quality care.
More complete patient specific information for clinicians certainly supports patient safety, and the completion of the EHR will provide a valuable tool that allows more complete information to be available. An added value of the EHR is that this information will be available everywhere in the province that it is required and delivered through a secure health information network. The EHR will also share certain information with EMRs, where appropriate.
In addition, Newfoundland and Labrador, like many provinces and territories, has to deal with providing healthcare delivery over a large geography that includes some very remote areas. There is a huge challenge in making specialist services available to those people living in these rural and remote areas, as well as in larger communities where specialists are hard to recruit and retain.
The telepathology initiative will bolster availability of specialist pathology services, much the same as the current provincial telehealth and PACS programs.
Telehealth has allowed specialists to see patients without either the physician or patient undertaking unnecessary travel between regions, and the PACS system has allowed remote reporting and diagnosis on patients in regions without radiologists.
The last calendar year saw over 8,500 telehealth appointments set up on a shared province-wide scheduling system and undertaken using a video conferencing infrastructure that leverages the same network used for DI/PACS and other elements of the EHR.
CHT: What are the major trends you foresee for the future?
Barron: A critical success factor for all of these initiatives is clinician adoption of information technologies at every level of the health system. We are headed towards a virtual multidisciplinary care model with the patient at the centre.
This requires quality information to be available between and throughout the full spectrum of a patient’s health provider environment.
Patients need to push their providers in this direction if they are not already on the information technology path. Patients deserve it.
The right infrastructure choices can ease healthcare consolidations
There are two primary reasons why organizations struggle with IT integration during a merger or consolidation. The first reason is complexity. In any industry – but especially in healthcare – organizations leverage a myriad of systems to provide care: clinical records, lab reports, imaging systems, diagnostic monitoring systems, human resources, financial systems, as well as various platforms, versions, models, and any number of different devices accessing the information. Trying to manage and navigate through all of it is challenging for even the most experienced IT professional.
Leisureworld was extremely fortunate that the seven long-term care homes we acquired were already using the same clinical record system and we avoided the headache of migrating all that data.
Founded in 1971, Leisureworld Senior Care Corporation is the third largest long-term care provider in Ontario. Leisureworld owns and manages 26 long-term care homes, one independent living home, and one retirement home. It cares for approximately 4,300 residents in its long-term care homes and employs over 5,000 employees.
Data migration from one system to another is possible, but it really depends on the vendors and technologies. Often times the data integrity can’t be fully guaranteed so organizations elect to migrate a smaller portion of the data.
It is common practice for financial systems to simply import balance forward information rather than migrating databases. This leaves organizations in a situation where they must maintain the original system for historical reporting.
The second, and probably the larger issue, is the mind-blowing amount of data we have to manage today – a challenge that is increased with a merger or acquisition.
In the healthcare industry, the move to electronic medical records (EMR) has compounded the amount of data that has to be managed and accessed. To complicate matters even more, many of these legacy EMR systems sit within separate silos and are incompatible. Currently, there are various initiatives, like Ontario’s ConnectingGTA initiative, which will share data by leveraging existing data sources such as disparate repositories and registries, and make patient data available securely– anywhere, anytime – to doctors and clinicians across the care continuum.
When integrating and consolidating enormous amounts of data, you need a lot of processing power and bandwidth. As the vice president of information systems at Leisureworld, I’ve led the IT integration effort for one merger in the last year, and there was an acquisition in the year before I joined Leisureworld.
These mergers brought Leisureworld multiple systems and servers, some new and some legacy. At one point, there was a possible need to upgrade 26 servers, which represented a $175,000 investment, and did not include the potential cost of adding bandwidth.
We needed to consolidate and integrate our expanded IT infrastructure to manage our costs and centralize IT management, but performance of the wide area network (WAN) was also a concern.
It quickly became apparent that WAN optimization technology would become a critical component of our integration efforts. We installed Riverbed Steelhead appliances to enable consolidation of end-of-life servers at our 26 homes, and accelerate key applications like email and clinical applications.
We were also able to backup data centrally and safely to an offsite disaster recovery (DR) site and avoid costly bandwidth upgrades to our remote sites. We successfully consolidated these disparate systems, and avoided an estimated $500,000 in bandwidth upgrades in 2009 and 2010.
Even with WAN accelerators, the need to upgrade from DSL and Cable Internet is a reality.
Once our initial network concerns were dealt with, we were able to look for more economical bandwidth solutions. Leisureworld began to investigate wireless WAN technology and eventually tested a synchronous 5 mb/s connection provided by TeraGo networks.
The service has been up and running for over a year and we have it installed at 16 locations. The price is lower than what the traditional fibre optic providers can match and also provides protection from fibre optic cables being severed as the system is redundant and fully wireless. This keeps integration costs down where service is available and has been remarkably stable.
Post-merger IT integration can be a difficult, long-term and an expensive proposition, but with a solid infrastructure in place, your organization can be nimble and well prepared for expansion or consolidation.
Daniel Neufeld, vice president of information systems, Leisureworld Senior Care Corporation.
Social networking websites and the privacy of health information
When the COACH Privacy and Security Experts Group convened this past September to discuss our approach to updating COACH’s Guidelines for the Protection of Health Information, we decided to introduce a section covering a number of new trends and issues. Considerations and recommendations when using social networking sites, from both a personal and professional user’s perspective, are included in this section. Here are some highlights of the recommendations in the recently released 2011 Guidelines.
The use of social networking sites continues to grow in popularity, and with the recent entry of Google into the market it shows no signs of tailing off. The ability to connect or reconnect with friends, family, or colleagues online can be quite compelling. In fact, millions of people around the world are now using sites such as Facebook, Twitter, and LinkedIn on a daily, hourly, or by-the-minute basis to share information.
Organizations are also starting to embrace these sites as a medium for obtaining information to support recruiting, for staff or client education, and even for internal information sharing. Unfortunately, for many of these sites, the concept of privacy is often an afterthought.
By focusing on providing users with engaging ways to communicate (and, in some cases, finding ways of tracking and monetizing the data being generated by these interactions) many social networking sites have actually made it extremely difficult for users to understand the privacy risks associated with their actions and the information they post online.
It has become such a concern that the Privacy Commissioner of Canada recently released a report discussing this very issue. While the report focuses primarily upon Canadians’ personal use of social networking sites, it also includes discussion of the implications of corporate use of these sites, including the observation that, “In addition to the personal risks…social networking can pose risks to the reputations of businesses. Companies may be responsible for improper disclosures, and whole institutions [could be] thrown into disrepute.”
Regardless of whether you are accessing these sites on your own, or on behalf of your organization, there are numerous risks associated with their use. Here are a few recommendations to help you manage these risks.
Read the user agreements: Almost all social networking sites will require users to establish an account before using the service. When establishing an account with a site, many users simply agree to the terms and conditions set out in the site’s User Agreement without paying any attention to what the site claims to be doing with the information they provide and post. Since many of these sites offer their services for free, they will often share information (about users and their use of the site) with “third parties” as a means of generating revenues. Also, some sites will claim ownership of any information posted on their service, including photos and videos.
Before registering with a site, take the time to read the User Agreement (or Terms) to see how they plan to use the information you provide or generate. From a corporate perspective, organizations may want to have their legal counsel review these terms and conditions prior to allowing staff to register.
Master the privacy controls: Some social networking sites have tried, or have been forced to address privacy concerns by adding features to let users control how their personal information and postings are shared. Many of these features were not designed into the original site, but were added after the fact, so they can be difficult to use. Further, the default settings for many of these features are sometimes oriented more toward the sharing of information and less toward preserving privacy.
Invest some time getting to know the privacy controls provided on the social networking sites you use. Organizations may want to do likewise, and provide all corporate users with a formal guideline explaining these features and indicating how they should be configured to ensure privacy.
Consider that postings may be seen by everyone, indefinitely
Regardless of how many of the provided security controls have been activated, once information is posted a user can never know who will see it, and for how long it will be available online. Some sites share and accept content from other sites to attract more users, and due to the nature of how content on the Internet is archived, there is no way to control or know for how long a posting will remain online.
Care must be taken to maintain the privacy of all when posting information and interacting with others. For example, a seemingly innocent comment about seeing a friend or colleague at a social function who is dealing with a rare terminal illness, when combined with other information such as your location (available in your site profile) could effectively identify the friend to some readers.
Always consider who may be viewing your online communications, and always re-read posts in their entirety before sending them. Once something is posted there will be little chance of removing or retracting it from a site.
Understand the implications of your actions online: Organizations should consider their relationship with a social networking site to be analogous to their relationship with more mainstream media. Do employees have free reign to make comments on behalf of the organization on radio, television or in the print media? If they do, are they allowed to speak without any sort of guidance or preparation?
Organizations should provide all staff who use social networking sites with policies and a code of conduct for all online interactions, and ensure that they know they are expected to follow it. A remark made in poor taste online may not only impact the reputation of that user, but also the company with which they are associated.
For businesses, make it a team effort:
An organization may assign multiple staff with the responsibility for accessing social networking sites on its behalf. Human resources staff may be using these sites to support recruiting, marketing staff may be using them to reach new or existing customers, and staff in other departments may be using them for research purposes. Not all staff who are accessing these sites may be posting information, but they should all be monitoring what is being posted by and about their organization. As the Privacy Commissioner of Canada observed, one poorly considered posting online could very quickly bring an organization into disrepute.
Final thoughts: Social networking sites can offer a powerful and efficient way to exchange information online. However, as with any sufficiently powerful tools, there are risks associated with their use. By considering the provided recommendations, and educating yourself and your staff about the issues involved with using these sites, you can mitigate the risks. Find out how a site works, try to determine how it makes money from its services, and learn how to protect yourself or your staff. When posting anything online consider the rights of others, and keep in mind that you will never know who else may see it and for how long it may remain online.
The COACH Guidelines for the Protection of Health Information is a resource to assist the healthcare sector with protecting the personal health information they require to do their work. The 2011 edition is available as a textbook or eBook from www.coachorg.com or the COACH office, firstname.lastname@example.org, phone 1-888-253-8554 or 1-416-494-9324.
Greg Lypowy, MHI, is an Associate Partner with the Barrington Consulting Group in Halifax, Nova Scotia, where he helps organizations plan, implement, and assess the privacy of health related systems and programs.
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