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Remote access
to patient data

Healthcare institutions are finally realizing what has been apparent in other sectors of the economy for several years; namely, that remote access to critical data is indispensable. It won’t be long before the hospitals that provide remote access to patient data, for physicians and others, will be in the majority. Physicians are getting more mobile. They work from within hospitals, private offices, and even their homes. READ MORE

A tale of two provinces
Alberta’s POSP and Ontario’s ePhysician are two different approaches to the same problems. READ MORE

PACS for the private clinic
A worthwhile investment? Managers at the Burlington Ultrasound and X-ray thought so.

Editor's note: Welcome to the inaugural edition of Technology for Doctors.
News: Write prescriptions on a Palm; telephony for busy practices; Hamilton’s Compete III; BC project manages chronic disease.
Tech: USB memory keys gain capacity and features; Med dictionaries for the Palm; Major Windows upgrade.
Chatroom: Why Canadian MDs aren’t more computerized.




Remote access to patient data

Hospitals are making valuable information available to doctors, any time, anywhere.

By Issie Rabinovitch, PhD

Healthcare institutions are finally realizing what has been apparent in other sectors of the economy for several years; namely, that remote access to critical data is indispensable. It won’t be long before the hospitals that provide remote access to patient data, for physicians and others, will be in the majority.

Physicians are getting more mobile. They work from facilities within hospitals, private medical offices, and even their homes. They need to be able to access patient data and test results at any hour of the day. Fortunately, the growth of the electronic medical record and PACS means that there is more data than ever in digital form. The growth of broadband internet access means that the responsiveness of searches and data manipulation in a remote setting can be almost as satisfying as within the four walls of a hospital.

As reported previously in Canadian Healthcare Technology, the Niagara Health System has a new high-speed fibre-optic-based network connecting its 8 hospitals on Ontario’s Niagara Peninsula. It was completed in 2004 as part of a project to build an infrastructure to support its work in creating a common electronic medical record system, including PACS.

Niagara Health standardized on Meditech software for its EMR and launched remote access for the physicians of St. Catharine’s Hospital in 2003 and for the remaining 7 hospitals in June 2004. About 20 per cent of over 500 physicians were taking advantage of remote access by summer’s end. According to Bala Kathiresan, the CIO with whom I spoke during the summer, the feedback from early adopters has been favourable. However, participation is on a voluntary basis and some doctors, especially older ones, are resistant to this development.

Although Niagara Health has standardized on Meditech software, its physicians use a variety of software in their private offices and clinics. The most common choice is EMR software from Healthscreen, a company based in St. Catharines, Ont. that claims a dominant share in the province. At the time that I spoke with Kathiresan, he was working with Healthscreen on a system to push patient discharge summaries to physicians with Healthscreen software in their offices. In this way, physicians would have the data they needed in time for the first visit by their patients after being released from hospital.

I spoke with Dr. Bruce Rosenberg, President and CEO of Healthscreen, about his work on this project and some of the obstacles that needed to be overcome. When I first spoke with him the chief problem remaining to be solved was to determine the data to include in a discharge summary. By the end of the summer he had determined that his customers wanted the capability to design custom summaries, containing just the data they needed. In order to make the Healthscreen application as easy as possible to implement, Dr. Rosenberg decided to piggyback on the modem-based communications infrastructure currently in use by labs to report their results.

By late summer, a final beta version of the Healthscreen push application was in use in several offices and drawing favourable comments. Unfortunately, it was too early for me to discuss its benefits with actual users.

I next spoke with R. J. (Rick) Salcak, director, information technology at Royal Victoria Hospital in Barrie, Ont. This is another healthcare institution that has standardized on Meditech software. Two out of every three physicians at the hospital access the EMR module on the internal network. According to Salcak, training is not an issue. New physicians receive a 15-minute orientation when they come on board and that seems to be adequate.

The number one benefit, as reported by physicians using the EMR module, is a tremendous saving of time. According to Salcak, the primary concern among non-users is that there are no benefits for them and that the hospitals are simply downloading costs to them.

Unlike Niagara Health, Royal Victoria has no specific initiative to push discharge summaries. In fact, the entire issue of remote access is being addressed differently.

Instead of providing remote access to just the EMR module, Royal Victoria has decided to use Citrix communications software to provide remote users with access to e-mail, PowerPoint presentations, and other applications they use on the internal network.

At the time I spoke with Salcak, there was a pilot group using and testing the Citrix system prior to its widespread deployment later this year. The Citrix approach to remote access is an interesting one. Applications and data reside on a server or servers in the hospital and are controlled by the remote user over a secure internet link. The amount of data going back and forth over the internet link is comparatively small. That is one reason why performance can be very good on a relatively slow internet link. Since the programs run on a powerful server, performance does not depend on the less powerful user computer. All of the processing power is provided by the server. Users control the server via the Citrix software as though they were sitting in front of it in the hospital.

The Citrix approach is not ideal for all applications. Salcak informed me that he has learned that viewing large radiology images is better done on a VPN.

A Virtual Private Network (VPN) allows a remote user to login to the hospital’s internal network over an internet connection. The VPN encrypts the data traffic in both directions. The image file is downloaded to the remote computer and manipulated there. In the Citrix approach the image file is loaded into the memory of the server, which takes less time. However, there is smoother scrolling and quicker screen updates with the VPN approach, which is mostly used by radiologists while they are on call during off hours.

Here is Salcak’s response to my request for more details:

“The VPN connection is not necessarily faster. The issue relates to manipulating a PACS image that may be 75Mb in size. With the VPN connection the entire image is downloaded and resides on the hard drive of the remote computer. When the radiologist manipulates the image for interpretation, the only bottleneck is the performance of the remote PC.

In the Citrix scenario, the image file resides on an application server in our computer room. As a result image manipulation is jerky and much slower as the remote user is only getting screen updates of the image over the Internet. Normal data applications work exceedingly well with Citrix.”

Finally, Salcak mentioned that he has received numerous requests from doctors that want to download patient data into their office systems. The problem he is grappling with is that many of them have substandard systems.

The final stop of my virtual journey was at an Oacis. Oacis is now a division of Dinmar, a Canadian information technology company specializing in healthcare applications and based in Kanata, Ont. In 2000 Dinmar purchased Oacis, a pioneering American company, largely for its EMR product. Oacis introduced a remote login capability in the mid-90s and after its acquisition in 2000, a client/server version and a Java-based web version.

One of the strengths of Oacis software is that it works well on wireless - there is now access via wireless handheld devices and Tablet PCs. Oacis is in use at Sunnybrook and Women’s in Toronto, which is establishing the groundwork for a campus-wide process for mobile device connectivity to patient data stored in its Oacis data.

The Ottawa Hospital is also working on their mobile computing process and procedures with Oacis. They have installed their wireless infrastructure and are now testing devices at that site. Oacis is working with other large Canadian institutions that cannot be named at this time.

For many physicians, wireless access to patient data from anywhere at any time is the ultimate form of remote access. These Oacis projects and others featuring wireless technology will be covered in future articles. •



A tale of two provinces

Alberta’s POSP and Ontario’s ePhysician are two different approaches to the same problems.
By Joaquim P. Menezes

Both have broadly the same goals and similar components: physician IT funding, clinical management delivery, and transition/change management support.

But the resemblance between Ontario’s ePhysician Program and Alberta’s Physician Office Systems Program (POSP) ends there.

While their objectives are similar, the two programs have evoked very different responses from the physician communities they serve. POSP was well received from the very beginning; there has been and continues to be confusion – and a great deal of controversy – surrounding the ePhysician project.

Alberta’s POSP was designated in 2001 as a joint initiative between the Alberta Medical Association (AMA), Alberta Health and Wellness (AHW), and Alberta’s Regional Health Authorities (RHAs). Among other things, this program offers financial support to physicians to set up an effective office IT infrastructure that is integrated with province’s health information system.

Despite initial challenges, the program got an enthusiastic response. Around 1,500 of the nearly 6,000 physicians in the province signed up in the first phase, which ran October 2001 to March 2003.

Monthly disbursements to physicians were guided by three key tenets: equity, physician involvement, and placing information systems at the point of care.

“In keeping with the equity principle, we wanted funding to be made available to any physician in any geographical area, committed to the program’s agenda,” said Dr. Fraser Armstrong, an Edmonton-based family physician actively involved in designing and implementing POSP.

As funds were limited, program managers adopted a phased release format, picking recipients through a lottery system. Lotteries were run nearly every month, and by the end of the first phase almost all of the 1,500 applicants were accepted.

To ensure a meaningful level of commitment, physicians had to pay 30 per cent of the office automation costs, while the grant covered 70 per cent.

Armstrong said funds were made available to help with patient care rather than with business processes (such as better billing). “Basically, we wanted to influence the way we deliver care with systems implemented at the point of care.”

He cited how this works in his own practice. “Let’s say a patient of mine afflicted with multiple complications – diabetes, ischemic heart disease, and high-blood pressure – shows up in emergency. The person is likely to be on 15 different drugs. Previously, if I was asked to provide a medication list, I’d have to scour through a thick file. Now I can pull up the patient’s past medical history, drug lists, lab tests, allergies, the works – with just a mouse click.”

This capability proved very useful to Armstrong during the recent recall of Serzone, an anti-depressant medication Bristol-Myers Squibb pulled off market shelves after it was linked to several cases of massive liver failure. “There are four physicians in my office,” Armstrong said. “The day the recall was announced we searched our database, came up with 10 patients on the drug, phoned them, and had them discontinue immediately.” He said this feat would have been next to impossible if his office maintained only paper records. “Imagine trying to manually sift through 40,000 paper charts to locate who is on Serzone!”

According to Armstrong, the POSP program owes its success to a combination of factors: an effective program management office (PMO), the linkage of funding to definite outcomes, and the strong involvement of all stakeholders – physicians, the government, and the vendor community.

The PMO manages everything from funds distribution and change management to the evaluation/review process. It works closely with physicians in the program, ensures they have done a readiness assessment, gets them to sign a declaration that they are meeting outcomes, and conducts onsite audits after implementation.

The vendor community, Armstrong said, has also responded, mounting an effective engagement mechanism through a trade organization called CHITTA (Canadian Healthcare Information Technology Trade Association). CHITTA nominated representatives from member companies to sit on various POSP committees. This allowed vendors to contribute their expertise and ensure their solutions aligned with emerging physician needs.

While Physician IT funding defines Alberta’s POSP, it’s one element in Ontario’s ePhysician project (ePP) – a joint initiative of the Ontario Medical Association (OMA) and the provincial Ministry of Health and Long-Term Care.

In addition to physician funding incentives, ePP includes transition support and a portal. It also offers physicians the option of accessing clinical management systems (CMS) via an ASP-type model.

The portal – OntarioMD.ca – is perhaps the only non-controversial aspect of the program.

As of spring 2004, all 27,000 Ontario doctors could register for this interactive portal that provides access to the latest health news, journals, alerts, a drug database and much more. OntarioMD.ca is being hosted at data centres managed by Smart Systems for Health – an Ontario government agency with a mandate to create a province-wide IT infrastructure for electronic communication among Ontario’s health service providers.

“I think the portal is a wonderful idea,” said Dr. Douglas Mark, a family physician and president of the Coalition of Ontario Family Physicians (COFP). “To have access to diverse medical resources and information is the way of the future for us.”

However, Dr. Mark and several other COFP members have a few bones to pick with the other aspects of Ontario’s ePP, especially its IT funding component.

Currently, for physicians to get IT funds through ePP they must become members of an eligible primary health group. For instance, family physicians have to join a Family Health Network (FHN) and work as a team. It’s not the teamwork that worries many family doctors, but that FHN membership forces them into an “unacceptable” compensation structure that’s largely, though not entirely, salary-based.

“Instead of fee-for-service, FHNs are heavily weighted on capitation-type funding,” said Mark. He said a modified fee-for-service deal was being offered as an option, but even that left family physicians holding the short end of the stick. “The modified version puts caps on patient visit compensation. So if a particular patient has a chronic condition and comes in ten times a year, you get paid only for one or two of those visits.”

The extent of dissatisfaction among family physicians with FHN membership clauses became clear following a poll conducted by COFP in 2002. Of 1,350 Ontario family physicians who participated, 98 percent rejected the content of the FHN template agreements.

Mark explains why. “The contract had no details on the physician IT program – the page supposed to deal with this topic was blank. It had no mechanism to settle physician-government disputes, no negotiation clauses, no fixed term, and no end dates. As a contract it failed miserably.”

In addition, Mark claimed most CMS vendors were “prevented” from participating in the program. “In Alberta, any software vendor can develop products that meet the criteria. Everything is open and transparent. Ontario has narrowed it down to a few vendors and shut out the rest.”

Some fault the ePhysician program for its “ambiguity”. “No one really understands how it works,” said Dr. Dennis Reich, president of the Sudbury and District Medical Society, and a COFP member. “If you’re a family physician, want to be part of this program and get funding, you would be hard pressed to figure out whom to talk to.”

Some of these claims were refuted by Glenn Holder, executive lead, Ontario Physician IT program.

He said physicians involved in the program’s “primary care pilots” – around 250 of them – have received funding. In Ontario, he added, a “conformance testing” program was introduced for vendors of clinical systems. “Vendors have already gone through a process of functional, usability and integration testing. Their tools have been evaluated for everything – ability to integrate with labs, secure messaging, compatibility with shareable EHRs and more.”

According to the Ontario Family Health Networks web site, 13 local CMS products from 12 vendors have been certified. According to Holder, these applications will also be available to physicians via an ASP-type model sometime this fall. He said an approved CMS application will be hosted by SSHA at its data centres, and physicians will be able to subscribe to the ASP service just as they would to cable TV, by paying a monthly fee. “It’s truly turnkey,” Holder said. “With it comes technology, support, and backup for recovery. So doctors can focus on using the application instead of worrying about installing and operating the technology themselves.”

The Ontario and Alberta projects provide useful lessons for the future, showing what’s needed to design office system programs for physicians.

They demonstrate how important physician involvement is to the success of such initiatives, according to Dr. Alan Brookstone. He is a Richmond, B.C.-based family physician who chairs the Richmond Physician’s IT User Group and has presented at numerous conferences to physicians, medical personnel, and healthcare groups.

“If you want clinicians to use your systems,” Brookstone says, “you must have them intimately involved in all phases of the project – from design to implementation to evaluation. That, it seems, has happened more comprehensively in Alberta.”

He warns against placing highly structured requirements around what physicians need to do to adopt the technology. “The more restricted you make entry to the program, the less success you will have.” •