INSIDE THE OCTOBER 2004 ISSUE:
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.
A tale of two
Alberta’s POSP and Ontario’s ePhysician are two different approaches to
the same problems.
PACS for the
A worthwhile investment? Managers at the Burlington Ultrasound and X-ray
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
Tech: USB memory keys gain capacity and features;
Med dictionaries for the Palm; Major Windows upgrade.
Chatroom: Why Canadian MDs aren’t more
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
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
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
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
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
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
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. •
THE CONTENTS LISTING
A tale of
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
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
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
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
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
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
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
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
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
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.” •
THE CONTENTS LISTING
SUBSCRIBE - ADVERTISE -
ARCHIVES - CONTACT US