INSIDE THE APRIL 2007 ISSUE:
The eLabs challenge
Demand for electronic transfer of lab results directly into a patient’s
electronic medical record (EMR) is growing among doctors in communities
across Canada. However, implementing this automatic ‘eLabs’ transfer of
vital information, which helps doctors make faster, better patient care
decisions, can be challenging. “One problem we’re seeing across the
country is there has not been the adoption of standards,” says Dr. Karim
Keshavjee, an EMR consultant and family physician with a part-time
add new dimension to data
In England, in the early 1850s, a wave of cholera struck with stunning
ferocity, killing thousands of people. Urban areas were pockmarked with
overcrowded houses, unsanitary slaughterhouses and decaying water and
sewage systems. They were, by modern standards, virtual welcome centres
Editor's note: Vista can make you blue.
News: Praxis EMR learns from you, gets smarter;
Cash to cut med errors is no mistake; Site rates EMR systems; Purkinje
plays the host.
Tech: The C5 Mobile Clinical Assistant is first of its kind;
Remote patient monitoring for OBGs; Recording device offers high-level
security; Mobile computing power at under three pounds.
Chatroom: Using EMR data to fight the next
pandemic. By Dr. Michelle Greiver.
The eLabs challenge
Doctors want digital access to test results, but connecting lab systems
to EMRs is a difficult task. Still, progress is
By Dianne Craig
Demand for electronic transfer of lab
results directly into a patient’s electronic medical record (EMR) is growing
among doctors in communities across Canada. However, implementing this
automatic ‘eLabs’ transfer of vital information, which helps doctors make
faster, better patient care decisions, can be challenging.
“One problem we’re seeing across the country is there has not been the
adoption of standards,” says Dr. Karim Keshavjee, an EMR consultant and
family physician with a part-time Mississauga-based practice. “Labs are a
very complex area. Ontario and B.C. are leaders in eLabs,” he notes, adding
that the government’s role is to set standards to receive and send lab
results. “But, all lab vendors have their own way of storing and
transmitting information. Because they send me the information in different
formats, most of the time, I can’t see them (interpret the results)
together,” he adds.
“A patient goes to one lab to get a blood test. And six month later goes to
a different lab to get the same tests. “Different labs use different
formats. I can’t show a trend on the computer – most computation has to be
done in my head,” explains Dr. Keshavjee.
Although vendors such as Nightingale Informatix Corp. and xwave normalize
lab results coming into their EMR software, Dr. Keshavjee emphasizes the
need for standards.
“We should not have to rely on vendors being able to ‘normalize’ data from
different formats,” says Dr. Keshavjee, who indicates the lack of standards
has even affected the ability to conduct research. “We haven’t been able to
do proper studies because the lab piece is missing. We’ve had to interpret
lab results manually,” he says.
“The important information gets to the physician and they would deal with
the lab results coming in from different sources. When we set up an account
on our ASP, the lab interfaces are already built-in,” says John Bodolai,
vice president of marketing for Nightingale Informatix Corp., of Markham,
Ont. He adds that although Nightingale software has the capability to order
lab tests, that function hasn’t been set up yet. “We can accept results
electronically,” he says. “We can also flag abnormal results, and allow the
physician to graph and trend results, such as glucose levels, over time.”
Asked how xwave is using eLabs, Nadeem Ahmed, the company’s healthcare
director, said, “MDS, for example, will send out a message in HL-7 format.
We will take that lab result, normalize it and populate the lab repository
with our EMR and then we’ll allow the physician to trend that lab result for
the individual patient and compare it against various results for the
patient population as a whole.” While many physicians are still scanning in
lab results into the patient’s EMR, he says, xwave imports results in
digital form that can be compared to previous results. It enables comparison
of measures such as average blood pressure for males between ages 40 and 45
on drug X. Also, he adds, “We span the entire continuum of care. Not many do
Currently, there are various eLab initiatives across the country, big and
small, public and private, observes Ahmed. Canada Health Infoway has funded
eLab initiatives in Newfoundland, New Brunswick, Quebec, British Columbia
and Saskatchewan. Ontario has initiated its own project.
That would be the Ontario Lab Information System (OLIS) initiative, an
integrated, province-wide system to function as ‘a single information system
allowing all laboratory test information to be electronically exchanged
among practitioners and lab service providers in Ontario.’ A key component
of Ontario’s electronic health record strategy, the OLIS clinical
repository, began receiving information last March, and is currently working
with several hospitals and two community laboratories.
Similarly, in B.C. the Provincial Laboratory Information Solution (PLIS) and
interoperable EHR initiatives will provide authorized clinicians anywhere in
B.C. electronic access to laboratory tests and results from public and
private laboratory service providers.
“There’s (eLabs) activity happening at multiple levels,” says Dr. Brookstone.
“At the national level, it’s happening with InfoWay to make sure the
standards are there. At the provincial level, we have provincial EHRs that
are in evolution – where there is functionality for lab results. In B.C.,for
example, they are developing IEHR – Interoperable Electronic Health Records
and PLIS. But the Alberta solution is a little bit ahead. They are
investigating the ability to first select the results they would like to
have delivered into the EMR before having them delivered,” he adds.
“Physicians want information delivered directly to the EMR but they want to
be selective. They don’t want everything delivered to the EMR,” notes Dr.
Brookstone. “For example, if you go to an intensive care unit there may be
30 arterial blood gas readings but do physicians want that in the EMR?
Probably not. It’s part of the care of the patient in the facility. They
want results regarding monitoring of cancer markers, renal functions, etc.
Physicians want more control – they want the ability to be selective so they
can choose the results that go into the EMR,” he add. This ability to select
is a key part of the eLabs initiative developed for Alberta.
Dr. Allen Ausford is a family physician based in Edmonton and a founding
member of the team involved in developing Alberta’s province-wide project.
It is focused on engaging cooperation from a wide range of stakeholders,
including doctors, labs, health regions, hospitals, pharma and medical
The Alberta approach uses EMRs and wider-ranging EHRs together to provide
doctors with the information they need while enabling them to be selective
about test results they receive. “EMRs and EHRs are both equally important.
On the lab side, we’ve made it possible for doctors to select which test
results they want,” says Dr. Ausford, adding, “It’s all about the context.
If you don’t understand the context of when the tests were ordered, you
don’t want to receive the results.”
The Alberta EHR, a province-wide record called Netcare, aggregates
information from all nine Alberta Health Regions and offers a subset of
pertinent summary information on a patient. It carries a lab repository,
imaging, reports, consultations and text summaries regarding procedure-based
things like pulmonary function studies.
“Capital Health, for example, sends all lab information directly to my EMR.
Whatever I checked off on the EHR the night before will be delivered to my
EMR,” says Dr. Ausford. If a patient took a test that the doctor didn’t
order, or it (the order) wasn’t cc’d to him, he can see from the EHR that
the test has taken place and whether the results are relevant to the
information he needs to care for that patient. He can ‘tick off’ the ones he
wants sent to his EMR, as well as any additional information he might want.
While the EMR gets a direct feed of all results ordered by that doctor, the
EHR includes results from tests not ordered by that doctor, as well as other
possibly relevant patient information.
“That’s why we don’t merge the EHR into the EMR,” says Dr. Ausford,
explaining that the separation enables doctors to be selective and avoid
being overloaded with lab information not relevant to the case at hand.
Asked about the challenges his team faced in getting this system up and
running, Dr. Ausford said there are several challenges. “You have to have
clinical data repositories in place. You need cooperation between the health
regions, labs, medical and pharmacy associations, regulatory bodies, and
health and wellness organizations, as well as the legislation, as we have
from Alberta’s Health Information Act. It’s important that people want to
work together. There will be political issues and concerns with patient
security, so they will have to be addressed, but, he emphasizes, getting
everyone to work together, and agree that if a situation arises where a
standard is not in place, it wouldn’t prevent the exchange of data.
“If you wait for a standard to be completely locked down, it will never
happen,” says Dr. Ausford. “There are so many areas you need to agree on. In
Alberta we’ve agreed on some standards, and if standards aren’t in place,
we’ve agreed we won’t let the lack of standards keep us from sharing
In addition to the provincial level, there are eLabs initiatives going on at
the regional and local levels in Canada. At the regional level, for example,
says Dr. Brookstone, “In Vancouver the Coastal Health Authority is working
to provide view functionality with potential in the future to have direct
interfaces to physicians’ EMRs from the regional lab system.”
At the local level, says Dr. Brookstone, “groups of physicians are
approaching either a private or hospital lab to get those results directly
into their EMR.”
“We see that as an emerging trend,” notes Bodolai, referring to the addition
of hospitals to the company’s ASP system. “We have a good platform for
adding the hospitals – a community-based platform, so it is easier for us,”
he says, adding that Nightingale recently signed an agreement to do the same
thing for physicians in the Ottawa area. We will be integrating into the
hospital system so we can provide lab and other clinical information for the
physicians. We worked with the physicians in the area and very closely with
the hospital to set this up.” In Nova Scotia, Nightingale accepts lab
results from the eight health regions and over 35 hospitals.
“We take a feed of those results and put them into our EMR,” he says. In the
Grey/Bruce region of Ontario, a number of physicians use Nightingale’s ASP
system for receiving results from different labs. “Last year, physicians in
the area requested the addition of Grey/Bruce hospitals so they could get
hospital labs, diagnostics, imaging reports. They get a feed of the lab
results,” says Bodolai.
One problem some are encountering, according to Dr. Brookstone, is that many
lab systems are custom built for a specific need. As a result, he says, a
custom interface may need to be built to deliver the results into the EMR.
“The advantage of a provincial system is that if the vendors customized
their software, the system acts as a third-party broker which doesn’t
actually hold information but transmits it from the lab through a standard
interface to the EMR. The EMR only has to build one standard interface to
One of the problems now, he says, is that “whenever there’s an upgrade to
the software there’s also an upgrade to the interface.”
“The important thing is there is work taking place at many levels, and it
becomes costly to support multiple interfaces. Although physicians want
results delivered directly into their EMR, they need to be careful to
consider what they want or they will get spammed. They don’t want to get
every single lab result. They want some control so they can select the labs
they want,” says Dr. Brookstone.
While the Alberta model, with its selective options, serves to support the
idea that cooperation between different stakeholders in a province goes a
long way toward enabling an effective eLabs deployment, the call for
standards can be heard across the country.
“Lets get this thing the way it’s supposed to be so all the functionality
works in predictable ways you can count on,” says Dr. Keshavjee. •
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Geographic tools give doctors a new view
Geographic information systems give physicians fresh insights about the
health of their patients,
wait times and outcomes.
In England, in the early 1850s, a wave
of cholera struck with stunning ferocity, killing thousands of people. Urban
areas were pockmarked with overcrowded houses, unsanitary slaughterhouses
and decaying water and sewage systems. They were, by modern standards,
virtual welcome centres for disease.
Dr. John Snow, a London anesthesiologist, tracked one particular outbreak,
marking fatalities building-by-building on large-scale city maps. Coupled
with exhaustive interviews and walkabouts, the mapping proved illuminating,
leading Snow quickly to his culprit, smack in the middle of Soho – a
badly-polluted Broad Street Pump used for drinking water.
Fast forward to a post-Y2K world, and it’s evident that Snow effectively
pioneered the use of geographical data to track illness and manage the
delivery of healthcare. Thanks to modern-day computer software, digital
mapping and tracking systems, a ubiquitous internet, and lightweight,
portable devices, medical researchers are spared exhaustive rounds and can
analyze complex information with ease.
Led by Dr. Sean Doherty, associate professor of geography and environmental
studies at Wilfrid Laurier University in Waterloo, Ont., and Dr. Paul Oh,
medical director of the cardiac program at the Toronto Rehabilitation
Institute, researchers are using GPS-supported tools to monitor the daily
activities of 50 diabetic patients in Toronto, including travel, exercise
and overall health conditions. The aim is to probe the effect of
environmental and lifestyle factors such as air quality, stress and
inactivity on blood-glucose levels.
“Our goal is to assist patients in the self-management of their disease and
help caregivers in assessing lifestyle factors associated with their
patients,” Doherty explains. “We hope to show there is a great potential for
monitoring and for providing a summary of patients’ daily lives over long
The study involves multiple partnerships. Research in Motion has supplied
GPS-enabled BlackBerry handsets, Telus has provided network bandwidth, and
Medtronic has contributed Continuous Glucose Monitoring Systems to log
glucose levels every five minutes for up to 72 hours at a time. Standard
Register’s ExpeData Digital Writing Solution uses a digital pen to capture
handwritten dietary logs, transferring the information to the user’s
handset, and an interactive application from Life:WIRE allows data to be
gathered and analyzed, and results presented, using a mobile device or Web
interface. Researchers are also using purchased Bluetooth-enabled heart rate
monitors and three-axis accelerometers, both of which communicate directly
to the BlackBerry devices.
However, the heart of the system is the software, which is designed to
aggregate the data into information relevant to physicians. The software
records a patient’s GPS co-ordinates at regular intervals and uses
geo-spatial mapping to provide details of activities and trips, activity
locations and modes of travel.
“It can tell where you moved, where you stayed still and where you went into
buildings, and it can often tell the mode of travel – whether you were
walking or in a car,” Doherty says, explaining that the system can interface
with GIS mapping systems to pinpont the location of buildings and roads. The
result is a diary of a person’s movements, although there are some
limitations, such as difficulty in penetrating buildings.
“That’s the next frontier,” Doherty says. “GPS devices are increasingly
getting better signals indoors, and in several years we may be able to more
accurately track what you’re doing in a building – say climbing or
At the Toronto Rehabilitation Institute, Dr. Paul Oh says the project
introduced him to geographic tools, and he anticipates a potential though
limited role for the technology in the future.
“It can be one of the tools that we’ll see in the future, especially as
these sorts of devices become more entrenched in our daily lives, as
cellphones become GPS-enabled – things like that.”
GPS isn’t the only tool for high-tech geographical analysis. In eastern
Ontario, medical researchers and practitioners are using Geographic
Information Systems to open new doorways for understanding and treating
illnesses ranging from SARS to cardiovascular disease.
Using the Vascular Health Promotion Network (VHPN), an internet-based
patient management system, researchers at Queen’s University have teamed up
with several hospitals and Cissec Corporation, a private software developer
specializing in medical data management, to look at the role geography plays
in terms of risk factors and treatment.
The GIS component of the VHPN lets doctors, administrators and researchers
map patients by multiple factors. The entry of postal codes, using only the
first three characters to protect privacy, lets researchers analyze medical
conditions, wait-time issues and patient outcomes on a geographic basis. The
GIS software can even map within a hospital or other building, helping
improve the understanding how contagious diseases and acute medical events
play out in varying milieus.
“We’ve linked multiple data sources together so that we can collate data and
bring meaning to it,” says Stephen LaHaye, medical director of the
Southeastern Ontario Vascular Disease Prevention and Research Centre at
The GIS component proved useful during an outbreak of salmonella a year ago.
Provincial health officials wanted to pinpoint a cause, but by the time
people presented to emergency rooms with symptoms, too much time had lapsed
and they couldn’t remember what they had eaten.
“Our system picked up an outbreak of a viral gastro illness within 24 hours
of the initial sentinel outbreak,” LaHaye says. “We were able to get to
those people and conclude that it was salmonella from bean sprouts.”
LaHaye says GIS tools can help caregivers and researchers catch outbreaks
early. “We know there are a couple areas people tend to present early when
they fall ill – to their drug store to buy over-the-counter remedies, and to
hospital emergency rooms. So we’re linking to pharmacies to look at
over-the-counter sales of medications patients use before they become sick
enough that they present to emergency rooms. We’re also linking to
elementary schools because children tend to be the ones who propagate a lot
of epidemics. By looking at absenteeism rates, we can see early spikes and
start to predict outbreaks of epidemics.”
Early successes in detecting food and airborne illnesses can be applied to
other forms of disease.
“Because we can plot data over time, we’ve noticed a seasonal variation to
strokes, which I don’t think anyone has really recognized before,” LaHaye
says. “We’re able to link the stroke data with data from the Weather
LaHaye says caregivers can link chronic care data with syndromics data. “We
think the stroke outbreaks, if you want to call it that, follow closely
behind flu outbreaks, and now we have the ability to link these two
databases together through the Internet.”
GIS systems can be plugged into any digital data source. Consequently, data
can be gathered and mapped from a facility management point of view,
enabling staff to predict possible flu outbreaks in hospitals and helping
them cope with wait times and temporary staff shortages.
Local health information networks in eastern Ontario are using GIS
technology to manage stroke and cardiac patients. Researchers have also used
spatial mapping to plot real-time data into simulators to probe hospital
“We found a definite correlation between proximity to a hospital and wait
times,” Cissec CEO Mike Rimmer said. “We noticed some people were waiting
longer than others and discovered that people who live further from the
hospital – say 30 to 40 kilometres from a hospital – actually enjoy shorter
wait times than people who live right next to one.”
During follow-up interviews, researchers learned that sympathetic booking
clerks felt badly that some people had to travel a considerable distance for
tests and therefore scheduled them sooner, sometimes the same day.
Rimmer says he has high hopes for the future of geographic analysis. “We
have a substantial amount to learn in data management, which is what this is
– taking data that is in itself meaningless and shaping and managing it for
a very clear picture of what is happening. Then, you can focus on what you
need to do to address a problem.”
Bill Pascal, chief technology officer at the Canadian Medical Association,
says geographic and tracking technologies are already being used in other
industries, including fleet management and retail, and are bound to catch on
in healthcare, particularly for patients with multiple, chronic or high-risk
conditions, and also in areas relating to prevention.
“It can help ensure that the activity a patient is following fits the
healthcare path the physician has sent the patient on,” Pascal says. “It’s a
two-way flow, not only the doctor seeing things but the patient and doctor
working together to make sure that what’s happening is happening in the way
best to support the patient to improve or minimize issues.”
Pascal says the ability to use mapping functions to track disease outbreaks
and identify possible sources and common dimensions would enable public
health professionals to act more quickly and effectively when outbreaks
However, he has one overarching concern: privacy.
“One has to be very careful with how technology is used. People need to know
how you’re going to use it, and you need all sorts of controls around who
gets to see the data and for what purposes.”
Electronic monitoring, and any data that comes out of it, should fall into
the same category as information that is maintained in a patient’s
electronic health or medical record, Pascal says. “We have to manage the
privacy side so we don’t scare people off for the wrong reasons.” •
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