Hospitals find fast way to implement order sets
TORONTO – PatientOrderSets.com, a web-based network that provides access to a reference library of over 470 evidence-based order sets, continues to attract new hospitals and associations. In June, the company signed up the Peterborough Regional Health Centre and six other hospitals in the Ontario Central East Local Health Integration Network.
“This is a very exciting time for our organization as we continue to expand our offerings and solutions,” said founder and CEO, Dr. Chris O’Connor. “What started out as a local innovation at Trillium Health has grown to a national initiative with over 240 organizations working together to improve patient safety and the overall quality of care.”
PatientOrderSets.com is expanding on other fronts too. In addition to the new Ontario hospitals, a recent agreement with a yet-to-be disclosed provincial government will have all 65 of its hospitals become subscribers. The state of Texas recently authorized PatientOrderSets.com to promote its service to Texas hospitals, which, if receptive, would give the company its first U.S. foothold. The Middle East and India are also target markets.
Currently, over 240 hospitals and healthcare organizations, including over 23 percent of hospitals in Canada and over 60 percent of hospitals in Ontario, use PatientOrderSets.com’s collaborative website to store, access, and compare customized order sets.
A recently announced partnership with the Registered Nurses’ Association of Ontario will grow the content offered by the company and will help in a planned move beyond the hospital segment into long-term care, complex continuing care and other segments of the healthcare continuum.
“We’re taking their Best Practice Guidelines (BPGs) and converting those into order sets,” said a spokesman for PatientOrderSets.com. “They’ll be made available toward the fall. Different packages will be rolled out over time. As we move forward with the BPGs, it will be another component of the library we are offering.”
As hospitals strive to improve outcomes and enhance patient safety, they’re increasingly turning to the use of order sets – protocols for applying the right exams and treatments to all manner of diseases and medical conditions.
Order sets consolidate the best practices and procedures for treating medical problems – from pneumonia to pre- and post-op treatments for hip fractures, and hundreds of other conditions. They serve as decision-support tools, ensuring that physicians follow the right steps in treating patients and don’t overlook necessary procedures.
One of the most heavily used order sets by clinicians is the community-acquired pneumonia admission order set, says Dr. O’Connor, who continues to work as a critical care physician in the Intensive Care Unit at Trillium Health Centre. “The utilization of order sets across the network reflects how common various conditions are, so [order sets for the treatment of] heart failure, acute coronary syndrome, COPD and stroke are all very common,” he adds. “Order sets for common surgical conditions, obstetrical order sets and emergency order sets are all used a lot.”
PatientOrderSets.com promotes itself as the only collaborative order set solution – its website being a “repository of innovation for organizations to share and learn from each other.”
Every client on the network can view every other client’s order sets. Member hospitals use the order sets developed by PatientOrderSets.com in conjunction with leading experts, as well as those prepared by other institutions when producing their own order sets – which lowers their costs and accelerates development. Members pay a monthly fee, which varies depending on the size of the institution.
“Order sets improve patient care processes that are affected by ordering, and that’s just about every process,” says Dr. O’Connor. He cites data from the Grey Bruce Health Network, an alliance of 11 hospitals headquartered in Owen Sound, Ont., which joined PatientOrderSets.com a few years ago. “They found that patients admitted with an order set spend on average one less day in hospital and, despite leaving earlier, came back 50 percent less often within the first week of discharge. A dramatic result was seen across multiple areas of care.”
Dr. O’Connor also refers to “an increasing literature showing a positive impact of implementing order sets in areas such as heart failure and sepsis.”
In particular, he points to the effectiveness of order sets in promoting adherence to best practices in venous thromboembolism (VT) prophylaxis. Adherence to best-practices has been linked to lower mortality for patients, a benefit Dr. O’Connor says drives the company.
Clinicians using PatientOrderSets.com note the effectiveness of their approach. “We see clear benefits to standardizing practices and bringing evidence-based medicine from the medical journals right to the bedside,” said Dr. Amir Ginzburg, physician director, quality and patient safety at Trillium Health. “One of the ways to do that is by bringing order sets to life.”
He notes that order sets enable pre-scripted safety enhancements to patient care, such as ensuring that immobile patients receive blood-thinners to prevent clots in their legs, that might otherwise get overlooked. “If you put that front and centre on an order set, suddenly the compliance with that evidence-based safe practice goes up by degrees of magnitude.”
Doug Moynihan, the CEO of Atikokan General, a 41-bed hospital in northwestern Ontario, says, “We’ve been quite pleased with PatientOrderSets.com. It allows us to speed up the time to get treatment ready for the patient. Once the physician makes the diagnosis and enters the information into the system, then immediately in the lab, in the pharmacy and on the nursing floor, they now know what needs to be done to treat the patient. The speed with which information can move is faster and it helps us reduce the potential for errors.” For its part, Atikokan General has utilized 223 of the available order sets.
Foothills Hospital pioneers use of real-time medical coding in Alberta
CALGARY – In one of Canada’s first implementations of real-time medical coding, the ICU at Foothills Medical Centre has completed a six-month pilot project that tested the use of concurrent coding to arrive at a more extensive and accurate picture of patient problems, diagnoses and other medical information.
Dr. David Zygun, ICU Medical Director at Foothills Medical Centre in Calgary, led the project, which concluded March 31, 2012. He believes the new system will soon be adopted by other Alberta hospital ICUs, with transferability to other departments.
Under the old system, physicians entered their diagnoses for coding retrospectively, after their patients had been discharged. As a result, “We didn’t have very rich data,” said Dr. Zygun. “We were happy if we could just get the initial diagnosis entered.”
Using the new method, coding takes place while the patients are still in hospital. “We felt that a real-time interaction would be the best way to capture the most accurate data and have it in a timely fashion.”
In the pilot-project, the coders (Health Information Management professionals) interact with the critical scenario in real-time – conducting concurrent coding, an approach that promises to yield much richer data, such as more extensive diagnostic information.
In this scenario, coders are available to discuss with the healthcare providers exactly what is happening with the patient and then code it accurately.
Foothills ICU divided the project into two units – a cardiovascular post-surgical unit and a multi-system ICU, as a way of including different types of patient populations. The six-month pilot proceeded on a randomized and blind basis, so that the doctors didn’t know if the cases were coded concurrently or after discharge.
3M Codefinder Software, the application used by coders to quickly and accurately code and group diagnoses, played a key role in the pilot. It has long managed the complex rules and terminology of ICD-10 CA and CCI—the alphanumeric codes affixed to every diagnosis, treatment and procedure. 3M Codefinder, however, was reconfigured for the pilot-project so it would provide a concurrent coding workflow, said Lili Levesque, Western Account Manager for 3M Health Information Systems (HIS).
3M HIS also provides the database, 3M Health Data Management (HDM) System, into which the abstract is integrated.
Moreover, Foothills ICU had a new scoring system, Apache IV, which introduced a new coding system that serves as a prognostic and length-of-stay predictor for the ICU specifically. “The electronic interface allowed us to do not only the traditional ICD-10 codes but Apache diagnosis as well,” said Dr. Zygun. “We’d been using an Apache II version in our old system, but the goal was to upgrade, so we researched prognostic scoring systems that had diagnostic codes attached to them and we implemented those codes in our concurrent coding project. “
Concurrent coding has not previously been performed in Canadian ICUs routinely, says Dr. Zygun. “There are perceived cost barriers,” he explained. Part of his project is to understand how much more time is required of coders and the level of electronic resources needed to do it concurrently. “I think people have not adopted this process,” said Dr. Zygun, “because they do not truly understand what added value could come out of this. Or they don’t foresee that it would be of significant value relative to perceived costs.”
Dr. Zygun’s team, which included 17 ICU physicians, feels differently. They are persuaded the timeliness and richness of data, through concurrent coding and the related electronic interface that feeds the database in real-time, has significant benefits for patients.
In particular, concurrent coding leads to more information for physicians and care-givers as patients make their way through different parts of the healthcare system.
“We know that in transfers of care, there is always a loss of information. We’re hoping[through the use of real-time coding] that the amount is absolutely minimized. So things which happened six hours ago, six weeks ago or six months ago are always available to healthcare providers to understand the patient’s course.”
Also, the real-time codes would make it easier to track emerging pandemics such as the H1N1 flu, where ICU responders had to set up systems to quickly understand the epidemiology of these conditions and how they’re affecting ICU resources. Standard retrospective coding wouldn’t allow that, because even if the charts could be coded within 60 days, that turn-around is not timely enough to understand the impact on hospital resources.
Concurrent coding may turn out to be somewhat more expensive than traditional coding. After all, it may cost more for coders to review charts while a patient is in hospital and make updates over a period of days or weeks than to code an entire chart retrospectively. As well, there are likely to be upfront charges for informatics.
Yet, real-time coding may translate into larger cost savings for the healthcare system as patient outcomes improve. And few can argue with investing in systems that prolong or save the lives of patients.
“If you get better data that more accurately reflects your patients, and this information feeds into patient care so that we don’t automatically lose information, then,” said Dr. Zygun, “in my mind the marginal additional costs will be well justified.”
Manitoba eHealth advances use of EHR, EMR, change management
Manitoba eHealth continues in its goal of connecting the right information to the right healthcare provider at the right time. Our last report on the progress in Manitoba focused on the introduction of eChart Manitoba, its provincial electronic health record system.
Running parallel to the eChart implementation is the province’s successful EMR Adoption Program. Our feature this month will highlight both of these initiatives and provide some insight into how a small province has accomplished so much in just a few years.
Roger Girard, CIO, Manitoba eHealth noted, “As we introduce new clinical systems, we are finding that our customers are fully engaged and demanding more. Our challenge will be to continue to plan carefully and use our resources efficiently.”
EChart Manitoba: In December 2010, Manitoba went live with a provincial electronic health record system called eChart Manitoba. The original goal of having 30 sites live with eChart Manitoba by July 30, 2011 was met and since that time, 68 emergency departments and primary care clinics are now live with the solution. In addition, more sources of information are now available to healthcare professionals through eChart Manitoba.
All Manitobans have the right to know who has viewed their information, to see and receive a copy of their information in eChart Manitoba and to hide their information from the view of anyone using eChart Manitoba through a disclosure directive. To date, 28 individuals have requested a disclosure directive, up from six a year-and-a-half ago.
Feedback from users of the system is positive. Users believe that eChart takes away the “detective work” that a physician sometimes has to do in a paper chart world. They have stated that eChart gives them a clearer picture of what is going on with a patient, which can help reduce risk in their patient care. Users believe that eChart can provide a quicker response to queries about a patient’s medication or lab result. For example, we’ve seen over 10,000 domain views just for the month of May.
“With the initial successes and lessons learned, we are now looking for ways to increase the rate of deployment of eChart Manitoba, so that there is more access to healthcare providers and their patients all across the province,” said Liz Loewen, Director, Coordination of Care, Manitoba eHealth.
“We are now preparing to leverage the health information access layer infrastructure to introduce a new service, delivery of provincial labs and DI reports to ordering provider EMRs. This will improve workflow and increase the return on the EMR investment for these clinics,” she said.
The new service, called eHealth_hub, will use a certification process to ensure connecting sites meet minimum standards for interoperability. “This new certification process will set the standard for future systems that link EMRs to services provided by Manitoba eHealth,” said Loewen.
EMR Adoption Program going strong: The EMR Adoption Program’s goal is funding to help 1,000 community-based physicians and nurse practitioners implement EMRs in their respective practices. By October 2013, 63 percent of family doctors in Manitoba will be using a Manitoba Approved EMR.
Manitoba eHealth has worked on a number of initiatives to ensure EMRs continue to spread across the province. Established in 2008, the organization’s Primary Care Information Systems (PCIS) Office supports the adoption and effective use of EMRs.
Focusing its efforts on community physicians and primary care providers in Manitoba, the PCIS Office backs several initiatives that improve the delivery of healthcare, all of which manage the ongoing relationship with approved EMR vendors and provide support mechanisms to help clinics select, acquire and implement a system.
First, the PCIS Office is responsible for recognition and administration of the relationship with Manitoba’s approved EMR vendors. “We have an agreement with the Province of Manitoba, and our role is to administer the master standing agreement between the province and the EMR vendors,” said Michael Haip, Manager, PCIS Office, Manitoba eHealth.
In addition to working with vendors, the PCIS Office also coordinates programming like the EMR Adoption Program, a Manitoba and Canada Health Infoway-funded initiative to drive adoption and utilization of EMRs.
The EMR Adoption Program has met with great success over the past year, with more than 900 physicians and nurse practitioners already signing a funding agreement with Manitoba eHealth. “Implementing a provincially approved EMR is a step in the right direction for primary care clinicians and will enable access to a more integrated view of their patient information,” said Wilma Arsenault, Director, Strategy and Primary Care at Manitoba eHealth.
Manitoba eHealth is also focusing on upgrades that will provide a number of enhancements to EMRs, increasing their interoperability with other sources of health information. In the first stage of upgrades, users will see improved access to eChart Manitoba.
“We are integrating a launch button into the EMRs so users are able to launch directly into eChart Manitoba and identify the appropriate patient,” said Haip, adding the first stage will also provide a mechanism for delivering both diagnostic imaging and lab results. “We are actively involved in conformance testing with our vendors, and are trending to pilot the new functionality with clinics by end of summer 2012, with general release thereafter.”
In addition to working with approved EMR vendors and heading the EMR Adoption Program, the PCIS Office also runs the Manitoba Peer-to-Peer Network, which acts as a resource for those who are looking to improve the management of patient care with an EMR system.
Within the network, Manitoba peer leaders act as coaches and advisors, offering advice on everything from understanding the benefits of an EMR to selecting a vendor and product to actually implementing the system. Other services offered by the Peer-to-Peer Network include peer collaboration and education sessions, EMR site clinic visits – during which peer leaders host other healthcare professionals at their clinics with demonstrations, tours and open dialogue – and peer coaching, which consists of small-group education sessions that help clinics optimize EMR use.
In the future, the PCIS Office and Manitoba eHealth will continue their efforts to further EMR adoption and use. As for long-term goals, Manitoba Health, along with Manitoba eHealth, is working closely with Canada Health Infoway on EMR standards and certification.
This article was prepared by Manitoba eHealth. For more information, please visit www.manitoba-ehealth.ca.
BC makes use of IT systems to support healthcare integration
By Andy Shaw
Like many provincial governments across Canada, British Columbia was rocked by an eHealth scandal three years ago. Many wondered if BC’s eHealth efforts would be put on the back burner. Happily, that didn’t happen – in the wake of the scandal, the BC government quietly began to right its healthcare ship with a revitalized and ambitious eHealth strategy and program. Launched by the BC Ministry of Health in 2010 with the publication of its “Health Sector Information Management/Information Technology Strategy” document, the strategy laid out a three-year plan of integration and priorities for doing more in healthcare with less through integrated electronic means. And so far, so good, it seems.
While BC was one of the top spenders on healthcare in the year 2001, “By 2011, we had dropped to ninth amongst the provinces in per capita healthcare spending,” says respirologist Dr. David Ostrow, the president and CEO of Vancouver Coastal Health, one of six regional health authorities blanketing BC. “And yet by all accounts we are still meeting targets for designated procedures as set by the federal and provincial governments. I attribute much of this to the development of our now partially integrated health systems.”
What largely keeps those systems from being completely integrated is the absence of most of the province’s doctors. “Unlike fully integrated systems in Europe and some in the United States, we, like the rest of the country, do not integrate physician care with the rest of the health system,” says Dr. Ostrow.
However, BC’s eHealth initiatives, which now include a drive to bring more physicians into the electronic fold, are fully integrated at the leadership level. Dr. Ostrow sits on a 21-member eHealth Strategy Council that includes top officials from the Ministry of Health, from all six health authorities, from the BC pharmacy and physician/surgeon colleges, and from the native health council among others. Collectively they have taken up the mantel of driving BC’s eHealth strategy and integration forward, on momentum others have created for them in the past.
“BC has been a leader in eHealth and its integration for the last 10 to 15 years,” says Michael Nusbaum, president of his own consulting company and active in the healthcare informatics field for three decades. “It really all started with something called HealthNet BC. It introduced a whole array of services that facilitated the collection, harmonization, and distribution of information that facilitated healthcare delivery in the province.”
Mr. Nusbaum cites the examples that built an early reputation for BC eHealth excellence, including a province-wide client registry, a provider registry, and PharmaNet, which securely links all BC pharmacies. More recently, adds Nusbaum, BC’s far-flung telehealth system has also earned the province kudos.
“The telehealth network has produced excellent examples of the benefits of telehealth. And one of them is that telehealth requires provincial co-ordination, which is a good thing. Also, there has been a lot of intelligent thinking of how telehealth services get linked into broader-based eHealth services. Specifically, telehealth can help make the use of electronic health records ubiquitous.”
That’s just a natural evolution of what telehealth can do for healthcare integration, says Nusbaum. “Information content that is managed and transmitted by telehealth clearly has the same content and is already in the digital format needed by the electronic health record.”
Nusbaum is even more impressed by what the BC health ministry has done by way of empowering is regional health authorities.
“One of the cleverest things the BC government has done was to take the eHealth program, which traditionally belongs to a Ministry of Health, and in effect push the program out to the regional health authorities,” explains Nusbaum. “So it has delegated responsibility for eHealth to those authorities. And the government has done that with the intent, I think, of now freeing the Ministry of Health to concentrate on policy while the individual authorities take on the tactical tasks of implementing eHealth programs.”
The hope for Nusbaum and others is that more localized responsibility for eHealth will bring new energy to eHealth implementation, which wherever it is being pushed solely by a central authority, tends to grow sluggish.
Nusbaum points to a unique BC initiative that’s a prime example of the good that can come from putting money and decision making into regional hands. “It’s a program that’s been going on for some while called the ‘Lower Mainland Consolidation’. And that LMC involves four health authorities serving all the people in and around Vancouver. These are independent governance organizations that are coming together to form a collaborative and share their services. It’s an opportunity for integration that I’ve never seen the likes of anywhere else in the country.
“And here’s the kind of thing I mean. Together they can say: (Vancouver) Coastal you are going to take responsibility for diagnostic imaging in all our area health authorities. So the staff in radiology at the other authorities are going to be transferred to you and you are going to operate them as a whole. And then say to an another health authority: you get Labs; and yet another agrees to take on Admitting, etc., etc. It’s an experiment, but I think a lot of good things can come from it.”
Phil Barker, one of the architects of that unique you-do-this model agrees. Mr. Barker is the vice president of information management for Fraser Health, one of the four collaborating LMC authorities. He also sits on the eHealth Strategy Council.
“The initiative really began in 2009 when the CEOs of those four authorities agreed to consolidate a list of about 15-20 common activities, most of them support services of one kind or another, but several are clinical support,” says Barker, “and that was everything from facilities management to capital planning to diagnostic imaging, quite a broad spectrum.”
Barker says that cost-savings and other economic benefits were the prime goals of this consolidation. But he thinks an even greater long-term advantages will accrue from the on-going standardization of activities resulting in both better quality control and improved patient care.
As part of that move toward consolidation, the LMC brain trust also had the wisdom to create a guiding light.
“We call it the IM-IT Design Authority,” says Barker. “The role of the Design Authority is to essentially oversee the planning and design and in some cases, implementation of cross-healthcare organization IM-IT initiatives – especially the ones where our technical architectures and more importantly, our information architectures, may be different from one health authority to another. So the Design Authority looks at each initiative to find a congruent solution or to find money for a new solution.”
Barker reports that two of the more notable solutions have been to work out a shared PACS system for all LMC authorities, as well as a shared bio-medical engineering solution for a common computerized maintenance management system.
Just as importantly, Barker feels, the Design Authority has also developed a series of “information management architecture principles”. These are simple rules-of-thumb that help Design Authority reviewers and planners think their way through integration’s so often very complex challenges.
“We have developed principles about organizational design; we have principles around applications and the selection of tools; we have principles around selection and management of technologies; and we have principles around the gathering and distribution of data and clinical information,” says Barker. “The principles have proven to be extremely helpful even though they are expressed quite simply like this, for example: Data have a single source of truth.”
So, how do all these eHealth goings on behind the scenes affect the performance of those actually out front delivering patient care?
In reply, Vancouver Coastal Health CEO, Dr. David Ostrow first reviews BC eHealth’s three clear aims: “The first aim is to give us access to integrated, longitudinal, patient centric clinical information. The second goal is to enable care delivery and communication across the continuum. And the third is to deliver care at a distance.”
Dr. Ostrow points to elements – either operational now or soon to be for all BC hospitals – including shared consultation reports, community care overviews, acute care discharge summaries, medications, diagnostic images and associated reports, lab results, and immunizations.
Under the care delivery and communication aim come appointment scheduling, notifications, medication management, ordering of tests, care planning, and referrals. Services underway or planned for the goal of care delivery at a distance there are tele-mental health, tele-thoracic and oncology services, phone consultation, web consultation, tele-radiology, tele-pathology, tele-trauma, and continuing professional education.
In terms of milestones to be reached in the near-term, Dr. Ostrow says that by 2013 next year there will be a universally shared laboratory reporting system from all public and private labs and province-wide extension of a standard imaging e-Viewer. The next year, 2014, will see a completion of EMR-EHR integration among hospitals, the lab reporting system, and PharmaNet.
But those admirable accomplishments are not the end of the road, Dr. Ostrow readily admits. “We still do have significant healthcare challenges, like discrepancies between health outcomes in certain populations. We also do not have a robust comprehensive strategy to deal with the complex aging population, but as a whole, like the rest of Canada, our overall health outcomes are improving.”
Still, among even those who admire BC’s eHealth advances, there are some who would like to see it advancing and improving health outcomes at a faster rate.
“We’ve had a brilliant start but things have slowed down out here now,” said one respected healthcare observer who declined to be named. “I see a lot of planning going on, and its good planning, but I don’t think British Columbia is making the actual progress in implementing those plans that it could be.”
The sticks in the BC mud many think are the family doctors, specialists and other physicians in individual practices. Like their counterparts in other parts of the country, they’ve been slow to make their record-keeping digital. To set up an electronic medical record EMR system for their offices, in other words. And without electronically shareable medical records, eHealth planners know there can never be complete healthcare integration in BC, or anywhere else.
But it’s not that BC isn’t trying.
“There is a very active program in the province to facilitate the deployment of EMRs to physicians,” says consultant Nusbaum. “It’s run by the provincially backed PITO (Physician Information Technology Office). It’s like OntarioMD and similar efforts in other provinces. Now PITO has had some real successes and it is deepening the penetration of the EMR no doubt. But the essential problem still is that physician offices are largely independent from the various provincial health authorities.”
Nusbaum is fully aware of the exceptions to this rule. “There are some physician groups now that are part of a health authority and there is no question about them using EMRs. In many instances, they use the same tools as the authority.” But even those physicians who are independent and who do have an EMR system in their offices, still have a problem.
“They are using independent systems and so that becomes an issue of interoperability,” says Nusbaum. “Now technically, interoperability is not so big a problem as is the business relationship between the physicians and the health authorities and especially the trust between the two.”
Likely no one in the province understands this dynamic better than Dr. Alan Brookstone, who is both a family physician in Richmond, BC and a widely respected “practice efficiency” consultant to other doctors and their offices.
“Like most provinces, we’ve had great success in getting early adopters to take up the EMR, but for the majority of later adopters among physicians it is a much, much tougher sell,” says Dr. Brookstone. “So the EMR uptake in BC has been slower than anticipated and slower than I would like to see it.” says Dr. Brookstone. “Also there’s been a lot of emphasis to standardize on big, functional systems – such as Vancouver Coastal Health has done in moving exclusively to the Cerner product for their health information system. But now I think the focus should shift to making the EMR also part of the standard of care.”
Dr. Brookstone, a South African by origin, is aware of how other countries have met this challenge, including England, which has tied the need for reporting to EMR use. “In effect, the National Health Service over there said if you don’t use a standardized EMR for reporting to us, you don’t get paid.”
Dr. Brookstone doesn’t think such a heavy hand is needed in British Columbia. “We need to shift focus from the big picture down to the granular challenge of making the EMR work. As physicians, we need to be able to send a referral, receive a prescription, do medication reconciliation with ease from our offices. Once we make information exchange flow like that, then I think we will see a big jump in EMR adoption.”
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