INSIDE THE JULY 2005 ISSUE:
quick and easy
The workload for Canadian physicians is getting lighter – at least in
one sense. With mobile information technology gaining momentum, many
doctors are shedding weighty paper tomes for handheld computing devices
– such as Palms or Pocket PCs – to look up data about prescription
Get smart, Ontario
Smart Systems for Health Agency has been talking for years. Now, it’s
Community care via
A test of the internet for expediting healthcare has provided excellent
results in Winona, Minnesota.
Editor's note: Ubiquitous wireless, the
repercussions of Terri Schiavo.
News: Demand suddenly rises for physician IT
systems; These companies are in motion – news and views from RIM, Motion
Tech: Lenovo ThinkPadX41, Novell Linux Desktop 9, Toshiba R200
notebook, Belkin A+G wireless router, Lexmark 632 MFP.
Chatroom: Avoid strain – make use of good office
ergonomics. By Steve Reinecke
Drug references, quick and easy
Pharmaceutical databases, running on handheld
computers, are becoming popular. What are their strengths and weaknesses?.
By Saul Chernos
The workload for Canadian physicians is
getting lighter – at least in one sense. With mobile information technology
gaining momentum, many doctors are shedding weighty paper tomes for handheld
computing devices – such as Palms or Pocket PCs – to look up data about
Dr. Jay Mercer, an Ottawa general practitioner who is medical director of
the Canadian Medical Association’s web site (www.cma.ca),
says most doctors with handhelds use them for traditional calendar and
address book functions, but a fast-growing number are sourcing specialized
Hundreds of medical handbooks are available on handhelds – current
favourites include Griffith’s 5-Minute Clinical Consult and Harrison’s
Manual of Medicine. Canadian physicians are also using PDAs to access
sophisticated databases that contain a wealth of detailed, current data
about pharmaceutical products.
Physicians moving from one exam room to another can check for
contra-indications before placing patients on new medications. Doctors on
hospital rounds can prescribe with ease and confidence. When patients
inquire about side effects or medical residents ask about interactions, the
answers are a click away.
The business milieu that produces these databases is competitive. More than
a half-dozen vendors methodically comb through a never-ending stream of
product monographs, recall notices, government warnings, academic research
papers and other data before editing the information and making it
There are often subtle and not-so-subtle differences between databases. Some
are accessible by paid subscription, while others are free, supported by
sponsors or from the sale of information about users gleaned through data
mining and other forms of market research. The drug data that is available
and the method of presenting it also varies, as does platform support.
When choosing a system, physicians need to consider these factors, as well
as the quality and integrity of the data itself. “What I want,” Mercer said,
“is a team of pharmacists and physicians who are constantly reviewing the
literature to look for indications of problems with drugs or new uses for
drugs – or new dosages or new ways that a drug should be dosed.”
Ultimately, Canadian content is key. Mercer cautioned that U.S. databases
won’t necessarily recognize Canadian brands or medications used in this
country. Diclectin, prescribed for nausea during pregnancy, is available in
Canada but not south of the border and is therefore not listed in databases
that rely exclusively on U.S. sources.
Brand names can also vary from country to country. Omeprazole, used to treat
stomach acid, is known as Losec in Canada and Prilosec in the United States.
“If the Canadian drugs aren’t there,” Mercer said, “then what you have is
something that is of marginal utility because physicians are constantly
having to go back to the hard-cover books.”
Mercer and the CMA initiated an ongoing review of different products more
than a year ago before exclusively endorsing Hudson, Ohio-based Lexi-Comp.
Mercer said Lexi-Comp obtains data from Health Canada, as well from the FDA,
and agreed to cooperate with the CMA on an ongoing basis. If a CMA member
reports that a Canadian medication is not referenced or that a reference is
outdated or problematic, the CMA has Lexi-Comp’s ear and a commitment to
modify the information. “They agreed that if we found drugs that were
missing, they would endeavour to fill the holes, and they have certainly
done that,” Mercer said.
Dan Krinsky, Lexi-Comp’s director of business partnering and academic and
retail pharmacy sales, said more than 3,400 Canadian physicians are paying
to subscribe to Lexi-Comp’s three primary databases – Lexi Drugs, Lexi
Interact, and suites that include these two databases. He estimates that
several thousand Canadian doctors have downloaded free ‘demo’ versions, as
Lexi-Comp products include a range of databases specializing in topics such
as pediatrics, natural products and infectious diseases. “We look at
primary, secondary and some tertiary literature and textbooks to create our
monographs,” Krinsky said, describing a vetting process that scours
peer-reviewed science and weeds out opinion and second-hand interpretation.
“Even things that are published in the primary literature don’t necessarily
have the scientific methodologies that would pass our muster. We don’t just
assume that, if it’s been published in a certain journal, it’s of a high
enough quality to be included. It doesn’t necessarily make it worthy of
consideration, though we will review the information.”
Epocrates, a clinical decision-support software provider located in San
Mateo, California, offers several drug references. Its basic Rx mobile drug
and formulary guide, offered at no charge, includes adult and pediatric
dosing, cautions, contra-indications, interactions, adverse reactions, and
information for lactating patients.
The upgraded Rx Pro version, available by paid subscription, adds an
infectious disease guide and data on herbal and other ‘alternative’
medicines. Rx Pro is searchable by drug, bug and human physiology, and it
includes a medical calculator and other tools. A comprehensive Epocrates
Essentials suite bundles in other associated products, including a
laboratory test interpretation guide and disease reference guide, although
these modules can also be added individually to RxPro.
Epocrates said approximately 10,000 Canadian physicians actively use its
various database products, though not all are paid subscribers. This
includes 4,000 in Ontario, 1,925 in Quebec, 1,575 in British Columbia, 1,150
in Alberta and 1,350 in the rest of Canada. Bob Quinn, Epocrates’ chief
technology officer and vice-president of engineering, said his company plans
to add Canadian brand names. “We do not have that, yet, even though we count
quite a few Canadian users. They have been soldiering on, using the generic
drug names and mapping those to the Canadian brand names where they differ.
But this year we’ll be collecting that information.”
Greenwood Village, Colorado-based Micromedex offers mobileMDX, which
contains a drug interaction checker and a news section for alerts and
recalls, as well as data on alternative medicine, diseases and toxicology.
Micromedex marketing and product development vice-president Jay Katzen said
mobileMDX is aimed at hospital environments and has roughly 2,000 paid
subscribers in Canada, including physicians, pharmacists and nurses.
Katzen said mobileMDX includes drug information, toxicology and alternative
medicine, and has a drug interaction checker and a section for FDA notices,
drug recalls and other news. Data sources are largely American. “We don’t
cover Canadian alerts specifically at this point. We’re expanding our basic
news and alerts feature. Towards the end of this year that will include a
number of additional news and alert sites, and one of them will be Canadian
While the lack of Canadian data might be a limitation, doctors can make up
for any such deficiencies by using multiple products. PDA Consults, a
software company in Simcoe, Ontario, offers ebm2go for the Palm Pilot and
Pocket PC. A module of this software includes a database that contains drug
formularies for four Canadian provinces – British Columbia, Alberta, Ontario
and Quebec. Data for the latter is bilingual. Ebm2go lists roughly 4,000
medications, with basic information about tablet size and formulary status.
Roughly 1,400 physicians in the four provinces are registered to use the
free database, which was launched last year and is sponsored by Astra-Zeneca.
“Our product will tell you if a particular drug is covered in a particular
province and, if it is covered, the code that has to be entered on the
prescription pad,” said PDA Consults president Mark Ghesquiere, who also
works as a family physician. He sees the ebm2go formulary as complementary
to more comprehensive drug databases, particularly those which lean towards
U.S. data. “We have the formulary information that they don’t have, and they
have the drug information that we don’t have.”
Dr. Trent Dusang, a Sherwood Park, Alberta physician who practises geriatric
medicine, said he combines two databases – Epocrates Essentials and Lexi-Comp
Platinum Edition, a combination product that includes various modules – for
maximum impact. He said Lexi-Comp offers the most Canadian data and the
greatest level of detail of the programs he’s tried, whereas Epocrates is
considerably more streamlined. “Epocrates is certainly more to the point,”
Dusang said. “It gives you what you need quickly.”
There are other differences. Dusang said Epocrates database modules interact
particularly well with each other, whereas users of some competing products
need to exit one application before opening another.
Dusang said he has been using Palm devices for several years for different
purposes and finds the drug reference applications extremely helpful. “With
my practice, I get lots of patients with multiple medication lists. They
will often come in with new problems and it can be a challenge to figure out
whether these are due to interactions or to older medications. I also do a
lot of house calls, and being able to have portable information is extremely
Davis Liu, a family physician in Roseville, California, who has tested and
written about handheld drug reference programs for the Medical Computing
Review (www.medicalcomputingreview.org), said products vary in many
respects, particularly in how they present information and, sometimes, their
speed in reporting new data. Many of these programs are handheld versions of
existing print drug references, while others are proprietary. The extent,
accuracy and timeliness of the content depends on the amount of time and
depth of research done by the editorial board of each handheld product.
Ultimately, Liu said, physicians should shop around, look at entire database
packages from competing providers, and then decide what might be most
suitable. “It’s a personal decision. The program vendors all (generally)
have free trials, so a physician can go ahead and download one onto their
PDA. I would encourage them to go ahead and practise with these programs in
their office and see which one fits their style. Some physicians are
detail-oriented. They want to know every little minutiae of a medication,
and they might prefer some of the more comprehensive programs. Others might
just want the lighter versions or less comprehensive ones. There’s no
Liu said he expects mobile access to data to soon become a medical norm. “It
will be indispensable. There are too many medications out there for a
clinician to really understand each one completely. Because of the
portability, convenience and the ease of a drug reference program on a
handheld, it’s almost inexcusable now for physicians not to know drug
interactions, side effects, and the latest information on the medications
they prescribe.” •
THE CONTENTS LISTING
Smart Systems for Health Agency has been talking for
years. Now, it’s taking action.
By Frank Lenk
Its mission is to make things easier
and more efficient for the medical community. And yet, the Smart Systems for
Health Agency (SSHA) continues to be a somewhat mysterious, misunderstood
body. Technology for Doctors correspondent Frank Lenk spoke with Smart
Systems’ CEO Mike Connolly, who explains that this was an almost inevitable
state of affairs… but one that’s about to change.
Evolution: According to its web site (www.ssha.ca), the SSHA is “an
operational service agency accountable to the Ministry of Health and Long
Term Care,” working on “improving the flow of patient information.”
Specifically, it is going to “build and deploy secure and reliable computer
technologies to eventually connect all 150,000 healthcare providers working
at 24,000 locations in Ontario.”
That turns out to be an even taller order than it sounds.
In 1997, a team was formed with representatives from each of the healthcare
sectors as well as from various consulting firms and technology companies
including Oracle, Microsoft, Nortel, E&Y, and Abel Computers. The purpose of
this project was to create a high level eHealth strategy.
Then the question was, how to proceed? Here’s where a crucial, far-reaching
decision was made. Rather than simply delivering quick solutions to
individual information-management problems, SSHA would instead build a
province-wide data infrastructure from the ground up.
“The recommendations from numerous people were: do not try to sell this as
infrastructure,” recalls Connolly. But he was adamant that this was the
right way to go.
And as he’d hoped, he found that politicians were actually quite accustomed
to these sorts of broad infrastructure decisions. “There was never any
debate,” says Connolly. “Every politician that looked at this, got it. They
understood that infrastructure was necessary.”
Connolly likens this approach to the building of the interstate freeway
system in the United States, or the original telephone system. It’s a big
up-front investment, but one that enables unimaginable growth and
development in the future. “You don’t accidentally get a phone system,” he
“What differentiates us in Ontario is that we’ve spent the time and thinking
on that infrastructure,” says Connolly. “To me, this is opening the door to
thousands of creative minds.”
Of course, Connolly concedes that there is a downside to following the
infrastructure route. “While you’re building it, there’s no value,” he
admits. There’s no obvious pay-off until the support system is complete and
some applications are built on it. Nor is there an obvious usage model until
the system is running. “The infrastructure provider doesn’t have the
leverage to ensure that the users are there,” says Connolly. “There is a lag
between when the infrastructure is built and when the infrastructure is
Overview: The overall goal of the SSHA, as Connolly explains it, is roughly
• To facilitate integrated, secure communications among doctors and other
constituents (hospitals, labs, pharmacies, long-term care facilities,
homecare providers, etc.) in the broader health sector.
• To give physicians electronic access to medical information (research
results, discussion forums, etc.).
• To help doctors use information technology in their day-to-day practices.
These broad goals are manifested in a number of projects currently under
Secure Email: Right from the start, the top item on everybody’s eHealth wish
list seemed to be secure email. Reasonably enough, that’s where the SSHA
plans to start.
“Email is the first thing we’re going to try getting the docs interested
in,” says Connolly. However, he adds that this isn’t just email, but a
complete messaging system including calendar scheduling, support for
portable devices such as the BlackBerry, directory services, and more.
“Email is the backbone of it,” he explains.
Of course doctors who work at larger institutions already have their own
internal email. The SSHA project will connect these individual networks, as
well as smaller institutions and individual doctor practices, into a single
“federated” environment. “We’re basically putting the whole health sector
into a common directory,” says Connolly.
Email will be encrypted from end to end. “As long as I’m sending to someone
inside this directory, it’s secure.” Mail won’t initially be encrypted when
sent to outside addresses, but that too is on the roadmap. “We’re hoping to
provide that service shortly.”
Connolly noted that several institutions were already connected as part of
an SSHA pilot project. These include the University Health Network (UHN),
the Toronto Community Care Access Centre (CCAC) and Saint Elizabeth Health
Integrating the entire province presents many difficulties. “Even directory
synchronization, where we initially thought it would be easy – it’s not,”
says Connolly. The idea is to have a single directory that can manage login
and authentication for all users of the SSHA infrastructure.
Ensuring trust is one obvious problem: “How do I know who you are, to some
significant level of trust?” Connolly asks. These kinds of problems have
been solved in the corporate world, but SSHA must develop solutions in a
very different province-wide environment.
Once users are authenticated, managing the entire directory, given the
complex and changing roles adopted by each individual, presents an equally
formidable challenge. “On the surface this looks quite simple,” says
Connolly. “But it’s never actually been solved in our type of health-care
However, Connolly notes that the work is getting done, and systems will be
available for use within a matter of months.
Clinical Management Systems (CMS): A SSHA project of comparable, if not
greater interest to doctors is referred to as Clinical Management Systems
Connolly estimates that only 5 percent of doctors are using computers for
clinical systems, such as electronic patient records. This seems to be a
widely-held view although there are other estimates as high as 10 percent.
CMS will make available state-of-the-art management software, in an effort
to get all practices fully automated.
There will be two CMS streams.
• Commercial software will be available from independent vendors, who will
be certified by Ontario.MD (a subsidiary of the OMA, part of the Primary
Care IT program). There may be funding available to assist with purchase;
for example, eligible primary care renewal groups.
• A specific suite of software will be made available as a joint venture
between SSHA and the Ontario.MD web portal (www.ontariomd.ca). This will be
based on the application service provider (ASP) model; the actual software
will reside on a central SSHA server and be accessed by doctors via a secure
In the latter case, the ASP vendor would come into the office, set up
hardware and train staff. Data will reside in SSHA’s highly secure data
center, properly backed up and protected with no worry for doctors. Doctors
will pay on a monthly basis.
According to Connolly, the SSHA software suite is being provided under
sub-contract by “a truly world-class vendor,” selected by tender through the
Ontario Medical Association (OMA) on behalf of the Ministry of Health.
Connolly reports that contract negotiations are “almost complete,” with full
availability expected late this year.
Although doctors may initially be concerned about allowing patient data to
reside on the SSHA systems, Connolly emphasizes that security is a primary
goal. He points out that by law, the SSHA isn’t allowed to give out
information even to the government. “We have no access to the data
ourselves,” he notes.
Private High-availability Network: Both email and clinical management
software are tangible benefits that should soon flow out of the SSHA
initiative. However, the most far-reaching component of all is the network
infrastructure itself. In effect, the SSHA is building a sort of private
medical Internet, an independent high-performance network connecting all
healthcare providers in the province.
With Internet connectivity almost a given across Ontario, the SSHA network
might seem redundant. But Connolly cautions that the Internet today isn’t
secure enough, reliable enough or fast enough for critical healthcare
The CMS project is a good example. With the ASP model, all user interaction
runs over the net, back to the central server. Thus, it’s vital that the
connection be consistently fast and reliable. “I can’t type something in and
sit there and wait,” notes Connolly.
Another major aim is to keep data absolutely private. The SSHA network will
be inaccessible from the Internet, so sensitive patient information simply
can’t leak out. Internet access will be provided, of course, but this will
be handled centrally, through a single airtight gateway.
SSHA will provide hardware and the ‘last-mile’ connection to doctors’
offices. By building its own system, SSHA will have complete control. It can
monitor all the connections, and will have its own routers and firewalls in
doctor’s offices as well as larger organizations.
However, SSHA will use existing phone lines, cable connections, etc., for
most of the backbone connections. “The vast majority of doctors and
healthcare providers have broadband service available in their area,” notes
Connolly. SSHA will piggyback on this installed connectivity.
“We have vendor of record arrangements with six network service providers,”
Connolly notes. Where no existing broadband connection is available, there
are other ways, such as satellite or wireless.
“Initially, the work was focused on getting the major institutions
connected.” That work is largely complete, and SSHA is moving to the next
phase. “In the next two to three years, there will be a huge focus on
doctors,” says Connolly. “There’s a variety of ways we’re looking at
bringing docs onto the system.”
Other Projects: Although the two projects already mentioned will have the
greatest impact, SSHA is involved in several other significant projects.
For example, there’s the Ontario Laboratory Information System (OLIS), which
will not only handle electronic distribution of current lab results, but
also give access to a history of previous results. According to Connolly,
the OLIS project is well under way, and scheduled to “go live” in 2006.
Also notable is the Integrated Public Health Information System, which is
currently being implemented. It will connect all of Ontario’s Public Health
Units, and also provide public health information to doctors’ offices as
A major potential application is quarantine management, obviously spurred by
the SARS outbreak. Connolly notes that prior to SARS, there hadn’t been a
major quarantine for fifty years, so the systems to deal with such a
situation didn’t exist. This new service should remedy the situation.
“Ontario should be proud of its reaction to the SARS outbreak and its
subsequent preparation for future pandemics,” says Connolly. “We are now
among the best-prepared jurisdictions,”
Roll-Out: While SSHA has spent much of its energies thus far building broad
foundations, specific services are due to go live at various times through
the rest of this year.
“The way we’re doing this is primarily geographic,” says Connolly. “Our
philosophy is you’ve got to have somebody to talk to.” And that “somebody”
is most likely to be another individual or organization in your immediate
SSHA is trying to get “communities of interest” to be its agents. “We’re
funding them to help us,” says Connolly.
An early experimental installation has been up and running for about two
years in Chatham-Kent. But the first large-scale roll-out is now taking
place across the Ottawa area. A similar project will be undertaken in the
“We’re working with the OMA to get this all sorted and out the door, to get
a lot of docs in very quickly,” says Connolly.
Other types of institutions will present more of a challenge. For example,
connecting to pharmacies, large and small, presents a unique set of
“We’re dealing with pharmacies to try and get them on,” says Connolly. He
notes that the small pharmacies are easy, while the larger ones, with
pre-existing data systems of their own, present more of a challenge.
However, the problems are being solved, and Connolly expects pharmacies to
go live within several months. “It’s intended to be this year,” he says,
Infrastructure: “Ontario has spent a significant amount of intellectual
capital on the infrastructure component,” Connolly notes. Others, he says,
haven’t come to grips with this side of the problem. He admits that some
provinces are ahead of Ontario on specific applications. For example, B.C.
emergency rooms have had electronic access to pharmacy data for two to three
years already. A similar system is in the works for Ontario later this year.
However, Connolly feels that Ontario will come out ahead in the long run by
taking the slower, ground-up route. “On the infrastructure, I suggest that
Ontario is at the forefront of the technology,” says Connolly. As various
services roll out on that infrastructure platform in the coming months,
Ontario should assume a leadership role in delivery as well. •
THE CONTENTS LISTING
care via the internet
A test of the internet for expediting healthcare has
provided excellent results in Winona, Minnesota. Can Canadian communities
duplicate the experience?
By Dianne Daniel
There are untold delays in healthcare:
A patient with high cholesterol has just been to the lab for a blood test,
and now must wait days for a result. Another has a prescription that’s about
to run out and needs a refill – he delays seeing the doctor because of the
hassle of booking an appointment. So does another patient, who isn’t feeling
well and needs a check-up. Meanwhile, his condition worsens.
If you’re a resident of Winona, Minn., a picturesque community of about
27,000 nestled on the banks of the Mississippi River, taking action in any
of the above scenarios is as easy as logging on to the internet, says Dr.
William Davis, a family practice physician and chief medical information
officer for Winona Health, the community’s 99-bed hospital.
Four years ago, the hospital embarked on a project to design and develop a
Web portal that would give residents access to personal health records (PHRs).
The intent was to provide a secure on-line tool that could help patients
manage their healthcare. When area physicians were presented with the idea,
says Dr. Davis, the effort grew to include an electronic medical record (EMR),
as well – one that would enable healthcare practitioners to collect and
share patient data on-line.
“We started backwards in some ways,” says Dr. Davis, “because we started
with the idea of a Web portal and patient contact, whereas most physicians
and hospitals would start with an electronic medical record and then think
about expanding it.”
The project was driven by three partners: Winona Health, Cerner Corp. of
Kansas City, Mo., and Hiawatha Broadband Communications. According to a
March 2002 article in American Medical News, Cerner chose Winona as a test
site for its internet-based IQHealth product line because “it was small, it
had a single health system, it had a small number of physicians and it had a
fibre optic network already in place” – a network built by a local
educational foundation that connects all schools and universities, as well
as the hospital. In addition, resident internet usage exceeded the national
average by 20 percent.
Today, through the Winona Health Online PHR system, residents are able to
create personal health profiles; assess their current state of wellness;
request prescription refills; obtain drug information; or, receive lab and
test results. Meanwhile, physicians at Winona Health, Winona Clinic (a
35-doctor multi-specialty group), Family Medicine of Winona (Dr. Davis’s
four-doctor practice), Lake Winona Manor Nursing Home and Watkins Manor
Assisted Living, are all sharing patient information via an integrated EMR.
With the exception of a handful of doctors and a few private nursing homes,
just about every doctor in Winona is participating in the joint effort, says
Dr. Davis. While the PHR and EMR remain separate Web-based initiatives – the
first targeting consumers and the second targeting physicians – future plans
call for the two to be integrated, he adds.
Transitioning from a paper-based world wasn’t easy, says Winona Health
director of information systems Rod Hughbanks. For one thing, the group
started out attempting to build an interface between the newer Cerner
products and its existing information and billing systems, which also had a
lab and radiology component. “We learned the hard way that that was a
challenge,” says Hughbanks, noting they ran into problems trying to ensure
the disparate systems were integrated. “We lost confidence in our data.”
Another challenge was trying to keep patients separate, points out Dr.
Davis. “When you have different registration systems, it’s possible to
duplicate people very easily, and of course, that leads to confusion.”
To simplify the transition, Winona Health decided to standardize on one
software platform, and in March 2003 went live with 16 Cerner applications,
including Power Chart, an acute care electronic medical record (EMR); Power
Chart Office, an EMR designed for physicians; and IQHealth, the personal
health record or PHR piece. The applications and accompanying patient
records are supported through Cerner’s Remote Hosting Option, allowing
Winona Health to take advantage of a protected data centre and 24-hour
monitoring – services that would be cost-prohibitive for the group to
provide on its own, says Hughbanks.
Although physicians aren’t paying for the IQHealth piece – which is
available to residents free of charge – they did join the hospital in
signing a multi-year, multimillion-dollar contract for Cerner’s EMR
products, reports American Medical News. To keep costs down, Winona Health
devised a pricing model that essentially allows the hospital to contract out
software services to area physicians and nursing homes for a monthly fee,
based on the number of practitioners at each location. Meanwhile, physicians
are responsible for providing their own computers and internet access.
Access to Winona Health’s EMR requires two sets of passwords and is
protected using role-based security. An audit trail is also maintained,
explains Dr. Davis. “Every time someone touches a record to look at it, the
system records who did it, and you have to declare your role,” he says,
noting “role” could be physician, consultant, record viewer or on call. “If
people are inappropriately looking at records, they’re terminated.”
According to Janice Turek, a registered nurse who serves as Winona Health’s
eHealth specialist, one of the most onerous tasks in moving to a
community-wide EMR was getting physicians to agree on what the record should
look like. Depending on areas of specialty, everyone had a different idea as
to what the primary view should be, she says.
“We did have some difficulty coming up with an agreement,” admits Turek,
adding that lack of experience using an EMR added to the challenge. “Even to
this day, I’d say it’s probably not the view that everybody is happy with.”
Nevertheless, Dr. Davis credits the resulting electronic medical record and
patient personal health record for improving the way he and his colleagues
practice medicine. From his exam room he can now generate prescriptions,
view x-rays and complete his notes while a patient is sitting in front of
him. “When you work in a paper world, information is frequently hard to find
and often takes hours to days, depending on how easy it is to retrieve,” he
says. “… In our practice, we’ve experienced significant improvement in terms
of our billing and income, just because we’re doing a much better job of
documenting and coding visits.”
Both initiatives have also improved communication between physicians and
patients, he adds. For example, patients can log into Winona Health’s secure
Web portal in order to view test results – a PHR feature that has proven
particularly useful to diabetic patients who need to closely monitor glucose
levels. The electronic flow of information has also reduced incidents of
system abuse and made it easier to detect patients who “doctor shop,” says
Dr. Davis, since physicians now have access to prior test results via the
“I’ll see a patient and say I think you have a hernia and you need to have
it fixed,” he says. “I’ll send them down the road to the surgeon and I don’t
have to send a letter anymore, the surgeon can simply look at my last note.”
According to Jim Shave, president of Cerner Canada, there are many aspects
to Winona Health Online that interest Canadian communities as they continue
to grapple with how to connect multiple stages of care in the pursuit of an
electronic health record. Despite his efforts to promote the concept,
however, he says he hasn’t had much success in generating a Canadian version
of Winona, “largely because most organizations are still struggling with
getting some basic infrastructure in place.”
Those who have visited or learned of the community usually give it a very
positive endorsement and express a genuine interest in wanting to do
something similar, he says. But without high-level backing at the regional
health authority or government level, it’s unlikely to occur. “What I have
really struggled with, quite honestly, is the business model to make
something like this work,” says Shave. “If you can keep a patient out of the
emergency unnecessarily or out of the physician’s office unnecessarily, who
overall has the benefit? Who funds something like this? Is it the physician,
the consumer or the healthcare organization?”
If the Ontario Hospital eHealth Council’s definition is any indication, some
Canadians may be on the road to replicating Winona, despite those
As its web site states, the council is attempting to move towards a new
model of care. It defines eHealth as “a consumer-centred model of healthcare
where stakeholders collaborate, utilizing information communication
technologies including internet technologies to manage health, arrange,
deliver, and account for care, and manage the healthcare system.”
In Winona, that already appears to be the case. Although it took more than
four years to get to the point where physicians and residents are actually
beginning to use the electronic records, Turek points out that the
possibilities moving forward are “endless.”
Currently in the throes of a software version upgrade, the group plans to
implement computerized physician order entry (CPOE) as the next big step in
expanding its EMR. Right now, orders are handwritten and entered into the
computerized system via unit secretaries.
On the PHR side, it hopes to develop a health inventory that patients can
fill out electronically prior to visiting a clinic.
“The health inventory is a report that will be threefold,” says Turek. “It
will be for the provider to view and save to the electronic medical record;
it will be a record for the patient to keep; and, it will also provide some
aggregate information for employer groups in the area looking at the risks
of their employees.”
While Winona may be unique in that a good percentage of its residents have
internet access, key to successful endorsement of the PHR, she adds, is good
planning. “We tried to identify some of the population that maybe would not
have access – like our rural population, senior citizens or people who could
not afford computers,” says Turek. “We then set kiosks out in the community
in key places – senior homes, the YMCA, library, public health, clinics and
It also helps that residents have access to a fibre optic network, with more
than one company offering telephone, data, cable and internet services to
keep costs down. Similar high-speed access may not be so easy to replicate
in other communities, yet it definitely improves the overall experience of
accessing healthcare information on-line.
“It’s a whole different way of thinking within the healthcare community,”
says Turek. •
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