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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 Mississauga-based practice.  READ MORE

Geographic tools 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 for disease.  READ MORE

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The eLabs challenge

Doctors want digital access to test results, but connecting lab systems to EMRs is a difficult task. Still, progress is being made.

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 that.”

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 organizations, etc.

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 information.”

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 the ‘broker’.

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. •



Geographic tools give doctors a new view

Geographic information systems give physicians fresh insights about the health of their patients,
wait times and outcomes.

Saul Chernos

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 periods.”

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 descending stairs.”

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 Queen’s.

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 Network.”

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 wait times.

“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 occur.

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.” •