It’s 11 pm: Do you know where your doctors are?

A Sudbury, Ontario doctor is behind an effort to help hospitals and clinics use computers to improve their scheduling and internal communications.

By Saul Chernos

While a schedule looks good on paper, the best paperwork can sometimes go awry when physicians work in multiple locations and swap shifts with their peers. A Sudbury, Ontario doctor who’s missed more than a few shifts himself is behind an effort to help hospitals and clinics use computers to improve their scheduling and internal communications.

Dr. Dennis Reich, a general practitioner affiliated with two clinics in this northern Ontario city, founded Chyma Systems (www.chyma.net) in 2000, inspired by his own experiences with mussed up schedules and a less than satisfactory flow of information.

“I often double-booked myself or missed a shift I was supposed to work,” Dr. Reich says, attributing much of the confusion to the use of paper for maintaining large, often complex schedules involving dozens or even hundreds of employees. “If doctors don’t have a copy with them, they can forget, and administrative staff don’t always know who’s on duty if doctors have traded shifts and not notified the front desk. The fact that physicians tend to work in multiple locations and multiple institutions makes it even more difficult.”

The web-based software, called Chyma, integrates individual physician schedules into an overall group calendar, so doctors can access and manage their own information and also see the bigger picture of an entire clinic or hospital department. Physicians who have multiple work affiliations can automatically import schedule information from each location into a single, personal calendar. Users can create guest accounts so a spouse can enter events such as evenings out or anniversaries, and assistants can input meetings. “An audit trail will document who made the changes,” Dr. Reich says. “This can be seen by schedule administrators and, when necessary, other people on that schedule.”

The original version, Chyma 1.0, included the scheduling and calendar functions, plus communications tools such as a contact manager, a system to post messages to specific individuals or the entire group, threaded-discussion areas, document-sharing options for PDFs, spreadsheets and other files, and access to Stat-Ref, an online library that includes Griffith’s 5-Minute Clinical Consult, Harrison’s Manual of Medicine, and other references. Version 2.0, released in October, enhances existing features, adds Mac compatibility and lets physicians use the same login and password to access multiple communities to which they belong.

Dr. Reich says the notion for providing these online communications tools came from his own experiences with a newsletter he started in 1999 for physicians in Sudbury. The Stethoscope, affiliated with the Sudbury and District Medical Society, promoted local medical and education-related events but lasted only a few months in paper form. “Distribution was a problem. However, we quickly realized we could put the newsletter online, so we created a national portal called Canadian Physician (www.canadianphysician.ca).”

Dr. Reich discovered his target audience was mainly interested in events close to home, and Canadian Physician morphed into Chyma. In its current form, it resembles a private internet with a grassroots look and feel. Participants need not be attached to a particular computer or location but must be an authorized member of a group. For optimum access, Dr. Reich recommends a PC with at least Windows 2000 and either Internet Explorer or Mozilla Firefox, or a Mac with a Mozilla-compatible browser (Safari is not currently supported and users could experience glitches).

Because Chyma is exclusively internal, involving only a particular community’s authorized members, users cannot send or receive e-mail to or from outside a particular community. “It’s both a strength and a weakness,” Dr. Reich concedes. “You do not have any spam coming from outside, but you won’t get any messages from people who are not part of the system.”

Privacy is a big deal. Even though the system isn’t intended to hold patient data or other highly-sensitive information, Chyma secures its own servers and employs 128-bit SSL encryption. Access is password enabled, and network administrators can manage this on a need-to-know basis.

Reich says roughly 4,000 Canadian physicians are using Chyma through their workplace. In January, some 60 Halifax physicians joined the ranks when Family Focus implemented it across its four walk-in clinics. Owner-operator Dr. Mark Fletcher oversees scheduling for the clinic’s practitioners, who work as independent contractors, and says the old paper-based system was a headache. “Doctors who traded shifts were supposed to ask the person keeping the schedule to make the switch, but they (doctors) often lost track of who they’d switched with and shifts would sometimes be missed or forgotten.”

Today, Dr. Fletcher has a lot less paperwork on his hands. “It’s taken me out of the loop as the middleman for these shift changes. It’s simplified my life.” Dr. Fletcher is hopeful missed shifts will be a relic of the paper age. “It’s a lot less likely someone isn’t going to see their name on the (web-based) schedule because there’s one page where their name is the only one there.”

Kensington Medical Clinic in Burnaby, B.C. also implemented Chyma in January. The clinic consists of 50 physicians, with up to a dozen on duty at any given time, and manager Jeremy Mickolwin says he used to update schedules monthly with Microsoft Word. “I posted copies in multiple locations around the clinic but this got confusing. Someone would change it in one location but not in the others, so everybody was checking different schedules. Doctors would sometimes not show up because they didn’t know they were scheduled.” Now, users can check schedules from home and know if any shifts have changed, and Mickolwin has less to worry about. “I can do a schedule for the entire year in advance, post it, and people can see it.”

Mickolwin says Chyma was fairly easy to implement. While system administrators can enter user data themselves either manually or using Excel spreadsheet software and a data importer within Chyma, Chyma personnel did this set-up work for the clinic. “I created an e-mail list for every doctor and sent it to our contact at Chyma. Then, a couple days later, we sat down for about an hour and I was trained on how to make schedules and do everything else. I called back two or three times to follow-up on a couple of minor glitches, but that was it.” When he was initially unable to access Chyma from his home using a Mac, he learned the system is best accessed using Mozilla, which he downloaded, rather than the more common Safari browser. Three or four of the clinic’s doctors use Macs and none has reported difficulty. Mickolwin says Chyma works well on 450 MHZ Pentium II PCs, the clinic’s oldest machines. “These are bare–bones things that just operate on the Internet. The ones up front have a bit more power because we use billing software and such, but nothing here is even close to top of the line.”

While he appreciates the access Chyma provides to online medical references, the physicians at his clinic aren’t using the discussion areas or the contact manager. They also prefer outside e-mail to internal messaging. “That might change in the future, but I think the main thing is the scheduler. The rest is just decorative.”

In Sault Ste. Marie, Ontario, Sault Area Hospital led an implementation that now encompasses much of the area’s medical community, including 10 regional health facilities and four local clinics. In early 2003, the hospital decided to centralize its core communications and documents such as policies, procedures and newsletters, says IT manager Julian Piwowarski. With 130 physicians across the city, the hospital also wanted to streamline its paper-based on-call scheduling system.

“We had an off-the-shelf package that gave us a development platform for our own web site, but we quickly outgrew it,” Piwowarski says. He discovered Chyma by chance while online, and city-wide implementation took two months, with no significant hurdles. “It’s a very light-duty intensity type application. It’s fast launching and we never have crashes connected with it.”

The system caught on – so much so that the local coroner’s office and police department have asked to be included. “We started with ten calendars for different hospital departments (plus physicians), and now the coroner asked us to put his schedule there. Now that people see a central location, they want to be there,” Piwowarski says. The Algoma Health Unit has access, for purposes of infection control, in case it needs to reach someone with particular medical skills.

Piwowarski says the contact manager replaces a bulky, awkward paper-based phone directory that constantly needed to be updated and printed, and forms are kept online and printed as needed rather than stored in bulk. “We used to stock them, and then they would go out of date before we’d use them all.” An online drug formulary replaces books that were three inches thick.

So what lies ahead for Chyma Systems? Dr. Reich and his business partners sold the company last June to Isaix Technologies, a Montreal-based technology company. “It has a strong sales infrastructure and the financial and human resource base to get the message out and take the product further,” Dr. Reich says. “We needed the infrastructure to be able to take this to the next level, and Isaix has a background in training, sales and marketing, and access to a lot of different markets that we didn’t.”

The Chyma Systems division has retained its name and personnel, and Dr. Reich – who continues as medical director – says he plans to add PDA and hand-held functionality later this year. “We’ll have an application version that will provide some of the messaging and shift-trading functionality we have online, and it will also allow offline syncing of calendars and contacts.” Stat-Ref includes the Micromedex USP DI drug reference guide, but Reich says he’s looking to offer a Canadian one.

Meanwhile, Chyma Systems is courting government agencies. “We could help with pandemic preparedness. One of the things about pandemic preparedness is knowing where your human resources are,” says Dr. Reich. The company is also conducting a feasibility study to address market potential and related issues in the United States and Great Britain. “We need to determine any special needs and requirements that may be different from ours, then we’ll adjust our feature set accordingly.”

Costs depend on the size of the implementation. A hospital or other large implementation pays $2.95 to $4.95 per user per month and a one-time up-front fee of between $8,000 and $20,000, depending on its size. The up-front fee is waived for clinics, even very large ones.

“It’s a matter of the number of users and the complexity of getting the people on the system,” Dr. Reich says. “It’s to our benefit to have a clinic of 50 doctors using the system because then they push the hospitals to get on board as well. We’re going after getting good traction in the market and potentially moving into medical education and other types of revenues we can generate afterwards. The first step is getting the physician to actually use (computer) technology on a day-to-day basis.”  •

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HIMSS in San Diego

The biggest healthcare IT conference of the year was in southern California this year and it was worth the long trip from Toronto.

By Issie Rabinovitch

HIMSS06 was held February 12-16 in San Diego at the beautiful and spacious San Diego Convention Center. The annual conference and exhibition of the Healthcare Information Management and Systems Society attracted more than 25,000 attendees this year for several days of keynote addresses by national figures and celebrities, hundreds of sessions by industry leaders, and many hundreds of booths showcasing the latest products and services.

As far as information technology conferences go, 25,000 is not a huge number. Comdex at its peak in the late 1990s attracted over 200,000 visitors to Las Vegas every November. CeBIT, the mega conference that has emerged as the most important IT event of the year, brings over 450,000 visitors from Europe, North America, and the rest of the world to Hannover, Germany every March.

To place things in perspective, though, IT conferences and trade shows like CeBIT (and the now defunct Comdex) have always attracted a large percentage of non-professionals. At HIMSS06, almost everyone was either a healthcare professional involved in IT, an IT professional involved in healthcare, a vendor, or a member of the media. In many conversations during my four days at the conference, I never heard anyone say that it would be better if it were bigger. Whatever people arrived hoping to find at the show, they pretty much found it.

The opening keynote on Monday morning, February 13 was presented by Dr. David Brailer, National Health Information Technology Coordinator. Following his talk, there was a press conference in a separate room for members of the media only.

Dr. Brailer has a higher profile in the U.S. than any of his counterparts in Canada. He is a charismatic and talented individual but there are other reasons for his prominence. In April 2004, President Bush committed to a 10-year goal of providing Americans with an EMR, including prescription drug records. The following month Dr. Brailer was appointed to his current position and given the enormous task of making President Bush’s promise a reality.

President Bush continues to talk about improving healthcare using information technology, about the need to deploy IT systems to lower costs, reduce medical errors, and improve the quality of care. This subject has been in his last three State of the Union addresses and in many other speeches. On each occasion, the national spotlight falls on Dr. Brailer, since he heads up this effort.

The initiative faces the same obstacles that similar efforts in Canada face: the need to re-engineer the current paper-based workflow in healthcare and the huge upfront investments needed to reap the benefits down the road. However, with the very public backing of the President and the recognition that it is a national priority, the U.S. effort has a leg up on the Canadian one.

Dr. Brailer’s comments at his keynote were unsurprising and not particularly newsworthy but the press conference immediately after was intriguing.

In a series of increasingly hostile questions, journalists pressed Dr. Brailer on pertinent details. It seems that since his appointment, the meaning of “everyone”, as in the phrase “everyone will have an electronic medical record”, has been weakened in his speeches and interviews. According to some journalists who have been following him since May 2004, he used to mean almost everyone, over 80 percent, or the overwhelming majority. They provided quotes to substantiate their assertions. He has backtracked, it seems. While the commitment to an EMR for everyone remains in place, everyone may now mean 50 percent of the population. Perhaps even less.

Dr. Brailer was also accused of waffling on key delivery dates. Time ran out before all questions were dealt with in a way that satisfied “everyone” at the press conference.

What I witnessed at the press conference reminded me of similar exchanges at events and conferences in Canada. Politicians, political appointees, and government bureaucrats use language creatively and can be difficult to pin down, no matter how simple the questions. That seems to be the same in both countries.

While journalists may be passionate about issues like the e-health record for the masses and promises surrounding its deployment, the American public at large seems to know little and cares less. A few days before Dr. Brailer’s keynote, IDC’s Health Industry Insights released the results of a survey of 1,095 consumers. They found that 70 percent of respondents were unaware of the U.S. government initiative we’ve been discussing here. Respondents, regardless of their level of awareness, were divided when asked if the government will meet this goal, with 45 percent confident and 43 percent not confident.

“Consumers are both unaware of this Federal initiative and skeptical of the value proposition associated with digital health care,” said Marc Holland, program director of healthcare provider research at Health Industry Insights and author of the report.

The IDC report contains many other interesting conclusions, but the key message is clear. If you want to get the public behind any serious and expensive healthcare IT initiatives, if you want to ignite enthusiasm, count on doing a lot of work for many, many years. It’s a sobering message and applies to Canada as much as it does to the U. S.

For a change of pace, I decided to visit some booths of interest and focus for a while on technology rather than politics and policy.

Intel has produced a new architecture for mobile computers to succeed Centrino. The most radical new feature is CPUs with two processors on the same die. The older architecture boosted performance by increasing the clock speed of the processor. Somewhere around 3.6 GHz it became clear that this approach couldn’t continue. Processors running at that speed and higher were using too much power and generating too much heat.

The new designs are referred to as Core Duo and they offer tremendous benefits – better battery life (by virtue of lower power usage) and better performance. Users of notebooks and tablet PCs built on this Intel platform will notice improved multitasking. Running intensive processes in the background on a computer with a conventional CPU can use nearly 100 percent of the capacity and make the computer seem sluggish.

If you’ve tried to use a word processor while a backup or a virus scan was taking place, you have experienced this phenomenon. With a Core Duo processor, the background processes will run on one core and the foreground applications will run smoothly on the other. I tried the new Toshiba M400 at HIMSS but there will soon be Core Duo models from all manufacturers, big and small.

I finally got to try Vocera’s instant voice communications system at their booth. Vocera products are in use in many industries, but they suit the needs of healthcare particularly well.

The system consists of software running on a Windows server and a wearable communications badge that weighs two ounces and can be worn like a memory key or clipped onto clothing. As the photograph shows, there is no apparent means of “dialing” a call. That’s because everything is done by voice. The badge is controlled by natural spoken commands. It’s as easy to setup a conference call as it is to call one person. If desired, you can send a text message or alert to the LCD screen on the back of the badge. The system requires a Wi-Fi network, which is already present in many hospitals and clinics.

The demo was thoroughly convincing to me. The Vocera system is already in use in Canadian healthcare. We hope to profile some of these installations in a future issue of Technology for Doctors.

Lexmark demonstrated several of their new multifunction printers. These MFPs don’t so much introduce new features as enhance features that already existed on the models they supersede.

These MFPs are able to print forms stored on a server and populate these forms with patient data. These tasks are performed while standing at the printer and choosing the desired forms and patients from the upgraded control panel. A computer is not required.

The previous generation of Lexmark MFPs could do this too but the new units have much bigger and brighter control panels and a better user interface. It is now easier for busy and stressed users to specify and print forms in this way. The ability to also scan, fax, and copy documents is a plus and these functions were demonstrated in a simulation involving a patient, doctor, and phamacist with the latter receiving a prescription by fax and questioning the dosage.

As I continued to tour the showfloor, it became clear that the number and variety of EMR software vendors continues to grow. We reported in the January issue that EMIS, the dominant vendor in the UK with more than half that country’s market, was setting up shop in Canada. Until we covered that story in T4D, I had never heard of EMIS. That kind of experience was repeated at HIMSS06.

I attended an AGFA briefing on ORBIS, the EMR product they acquired in 2005 by purchasing GWI, a German vendor of healthcare information systems and the Electronic Patient Record. AGFA claims that ORBIS has 500,000 users in Europe, more than any other system.

I heard about ORBIS for the first time during the briefing. Its customer base is almost entirely in Germany, Austria, Switzerland and France. It seems to be unknown outside those countries. No one I asked at the conference, even vendors of similar software, had ever heard of ORBIS. It’s interesting that new contenders are emerging on a regular basis. I think it says that, even though there are many companies doing good business with their healthcare information systems, there isn’t a player dominant enough to scare off new investment. Another interesting detail about ORBIS is the expected release date in the North American market – 2008. I think the message there is that Agfa wants its loyal customers to know that a worthy AGFA solution is on the way and to adjust their plans accordingly and to wait for it.

I spent some time with Medsphere, a much different kind of company than AGFA with a much different kind of healthcare management solution. The company was founded in 2002 but it wasn't until November 2005 that Medsphere appointed Dr. Ken Kizer as CEO and Chairman of the Board. Therein lies an interesting story.

During the two decades prior to joining Medsphere, Dr. Kizer held some very influential public positions. In particular, from 1994 to 1999, he was Undersecretary for Health in the U.S. Department of Veterans Affairs (VA). In effect, Dr. Kizer was the CEO of the VA healthcare system, the largest healthcare provider in the U.S., with an annual budget in excess of $20 billion, approximately 200,000 employees, and more than 1,300 sites of care.

In that capacity, Dr. Kizer spearheaded major changes at the VA, including the system-wide implementation of an electronic health record with a bar code medication component. The software that was developed under his leadership is called VistA, for Veteran Health Information Systems and Technology Architecture.

A few years ago it was realized that the millions of line of code that were written for VistA (and subsequent upgrades) could be requested from the government under the Freedom of Information Act. It wasn't long before companies were formed to exploit the obvious business possibilities.

Medsphere is probably the best-known of the growing number of companies that provide services for VistA. Medsphere has ported VistA to Linux and other operating systems. It has also removed some of the aspects of VistA that aren't relevant outside of veterans' healthcare and launched its version at HIMSS under the name OpenVista.

To make clear the meaning of “open source”, Medsphere was giving away the software on CD to anyone that wanted it. The software is easily competitive with anything out there. It is comprehensive and integrated and has an easy-to-use graphical user interface. The core system is sometimes enhanced with proprietary modules that are not free. Regardless, the software costs of an OpenVista implementation are either essentially zero or just very low.

Midland Memorial Hospital in Texas, a 371-bed hospital spread across three campuses but operated as a single organization, was one of the earliest institutions to evaluate a move to open source software based on VistA. Talks with Medsphere began in 2003 and by early 2005 actual implementation work began. Some applications went live in late 2005 and most of the system should be in place by this summer. The hospital's information systems director estimates that the total cost by then should be $7.1 million, less than half the total costs of an implementation using commercial software.

According to Medsphere, the implementation costs of OpenVista are somewhat lower, the software costs are dramatically lower, and the total costs range between one-third and one-half of the total costs of a "proprietary" solution.

Medsphere OpenVista is available in two flavours: Enterprise and Clinic. The Clinic version consists of modules needed in small offices and multi-specialty clinics.

Other companies are working on the VistA-Office Electronic Health Record (VOE) project with the Veterans Health Administration to develop an office version of VistA.

VOE is targeted for use in clinics and small physician offices. It retains many functions of the VistA system but is enhanced in such areas as office patient registration, reporting of quality measures, and printing/faxing of prescriptions. It won't happen overnight, but open source is going to have a tremendous impact on healthcare.

Secure e-mail is another product category that I follow closely. I saw more than a handful of worthy contenders but rather than discuss their features in any detail I would like to pass on the hottest tip I heard at HIMSS.

During a demo of a mail product at the booth of a major vendor, I asked about marketing plans in Canada. I was told that negotiations were taking place with major ISPs, such as cable and phone companies. Deals are likely to be made later this year and secure mail will be available to subscribers, possibly on the same basis as virus and spam scanning. In other words, free. •

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