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Drug references,
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 drugs. READ MORE

Get smart, Ontario
Smart Systems for Health Agency has been talking for years. Now, it’s taking action. READ MORE

Community care via the internet
A test of the internet for expediting healthcare has provided excellent results in Winona, Minnesota. READ MORE

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 Computing.
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 prescription drugs.

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 medical data.

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 available.

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 well.

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 information.”

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 valuable.”

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 one-size-fits-all.”

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.” •



Get smart, Ontario

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 asserts.

“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 used.”

Overview: The overall goal of the SSHA, as Connolly explains it, is roughly threefold:

• 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 way.

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 Care.

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 environment, adequately.”

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 (CMS).

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 network connection.

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 applications.

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 needed.

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 geographic area.

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 Toronto area.

“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 problems.

“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, very firmly.

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. •



Community 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 EMR.

“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 the hospital.”

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. •