INSIDE THE OCTOBER 2007 ISSUE:
Physician information technology across Canada is very much a work in
progress. Anchored by electronic medical record systems, and ultimately
hooked or yet to be hooked into overarching patient-based electronic
health records, physician IT is very much a product of the provincial
and territorial governments, which most directly control the purse
strings for health-related issues. But, travel across the country, and
you’ll see EMR systems, and accompanying tools that address chronic
disease management, drug prescriptions and laboratory tests, along with
digital imaging results.
Dr. Octo Barnett
After a year of polite cajoling, the Waterloo Institute of Health
Informatics managed to lure Dr. Octo Barnett north of the border to
deliver his insights concerning computer-based diagnostic support
systems. Barnett, who led the development of Massachusetts General
Hospital’s DXplain electronic medical textbook and medical reference
system, is low key and doesn’t seek publicity; perhaps one of the
reasons his industry leading decision-based systems are not used more
widely in Canada and around the world.
Editor's note: To err is human.
News: Nightingale + Cissec = improved patient
tracking; More evidence for EBM; Hello ONE Mail good-bye DVDs; Brain Age
Tech: Ultra-thin Samsung phone is big on features;
DVD helps refine joint assessment skills; Pico Pro provides security on
a stick; VisualDx, online visual decision support for GPs.
Scope: Models for achieving a better
We examine the health of IT initiatives in each of Canada’s provinces and
territories. Some are doing much better than others.
Physician information technology across
Canada is very much a work in progress. Anchored by electronic medical
record systems, and ultimately hooked or yet to be hooked into overarching
patient-based electronic health records, physician IT is very much a product
of the provincial and territorial governments, which most directly control
the purse strings for health-related issues.
But, travel across the country, and you’ll see EMR systems, and accompanying
tools that address chronic disease management, drug prescriptions and
laboratory tests, along with digital imaging results. In this issue,
Technology for Doctors gets out its stethoscope and takes the pulse of
physician IT across the country.
Nearly four years ago, the provincial health ministry announced transition
funding for primary care IT. This launched regional initiatives, with newly
created primary care groups receiving computers and EMR systems.
The Physician Information Technology Office (PITO), established in 2006 by
the British Columbia Medical Association and the provincial health ministry,
has $108 million to work with. The money will be delivered incrementally
over the next six years to physicians who undertake approved EMR systems.
While some provinces have combined application service provider and
client-server delivery models, PITO is looking solely at ASP and is
considering a shortlist of six EMR vendors, with a final decision expected
this fall. PITO is also looking for physician groups, from various practice
types, to participate as pilot sites.
“There has been a lot of work in B.C., but never at the level being
coordinated right now,” says Dr. Alan Brookstone, a primary care physician
and eHealth consultant in Richmond. He estimates about 20 percent of B.C.
physicians are using EMR, with pockets of significantly higher adoption. In
the Northern Health Region, for example, it’s close to 60 percent.
“They’re a very sophisticated community in terms of what they’re doing with
EMRs, population management and chronic disease management,” Brookstone
says, adding that the northern system is customized to meet local needs –
for example linking into the regional electronic health record through the
Prince George hospital system.
A province-wide EHR strategy, in its early stages, will impact the EMR side
of the equation. “The two are connected,” Brookstone says. “Some physicians
will be struggling with the fact that they’ve been hit with so much at the
same time. Coordination will be critical.”
The Physician Office System Program, (POSP) undertaken by the Alberta
Medical Association, Alberta Health and Wellness, and Alberta’s Regional
Health Authorities, provides more than 3,000 physicians – roughly half those
in the province – with an automated, integrated information system,
including funding and change-management resources.
A trilateral agreement, achieved this past spring and retroactive to March
2006, secures funding until March 2008 for physicians who use approved IT
products, and further negotiations could extend this. POSP plans to issue a
request for proposals for IT vendors and is developing transition plans for
doctors who want to transfer to an approved EMR vendor.
Chronic disease management is part of the package, accessible largely
through the primary care networks of family physicians, nurses and other
healthcare professionals that were established as part of the funding
process. Physicians can use their EMR systems to track patients with
diabetes and review lab information. “Chronic disease management is still
very much in evolution and kind of piecemeal but is moving forward because
of the primary care networks,” explains Dr. Heidi Fell, a family doctor who
serves as a physician resource to POSP on a contract basis.
The provincial EHR, Alberta Netcare, offers physicians access to lab and
diagnostic imaging reports from sources in some locations, and the province
is working to make this more complete.
Alberta Health and Wellness, meanwhile, is developing communication
protocols between the EMR, physicians’ offices, and the provincial EHR, so
that up-to-date Pharmaceutical Information Network patient profiles can be
made available province-wide. PIN launched earlier this year in a limited
way, and some test clinics have been approved. “If it passes it will be
rolled out in a more general fashion later on,” Fell says.
The Saskatchewan Medical Association and the province have developed a plan
that would see the government offer some funding for a province-wide EMR,
and some work has already proceeded, piecemeal, on the nitty-gritty.
The province has established a web-based viewer physicians can use to
connect electronically to a prescription database maintained through the
Saskatchewan Pharmaceutical Plan, which links all pharmacies in the
province. Dr. Bill Haver, who sits on the Saskatchewan Medical Association’s
information technology committee, compares this effort with Alberta’s PIP,
where doctors can review a patient’s prescription history and retrieve some
online interaction data. The next phase, he says, will let physicians
interface with the database through their EMR.
Another key project is developing a laboratory repository to offer a single
province-wide interface for test results. “It won’t matter how many
different labs are out there, they would all have patient information in a
central database,” Haver explains.
Meanwhile, the provincial Health Quality Council has started to integrate
clinical practice guidelines for chronic conditions such as diabetes and
coronary artery disease, with a web-based interface to import data. A couple
of clinics have developed an electronic interface to collect the data within
their own EMR systems and then file it electronically with the Council.
Haver says roughly 10 to 15 percent of Saskatchewan physicians are using the
EMR as their primary chart. The biggest challenge he sees to further
adoption is convincing physicians – who are in short supply and feeling the
effects of a heavy workload – that the technology can help boost efficiency.
Nearly three years ago, the province launched Manitoba Approach to Primary
Care, and the Physician Integrated Network project emerged from this last
Four family practice clinics are participating as demonstration sites to
explore change-management and other adoption and operational issues. One
area of interest is chronic disease. Each group practice has selected two
conditions, such as hypertension or diabetes, to track quality indicators.
Dr. Diamond Kassum, chief medical information officer with Manitoba eHealth,
says that upon completion of this initial phase, the government anticipates
extending the initiative to additional group practices and include new kinds
Recently, Manitoba launched the Primary Care Information Systems Strategy,
with a view to completion in 2008. The province is tracking other
jurisdictions, including British Columbia and Alberta, to study EMR
adoption. “We’re looking at the criteria for selecting EMRs,” Kassum says.
“We’re going to move towards a request for proposals just like these other
places, to create a short list of vendors that would fit our criteria.”
Manitoba is also working with Canada Health Infoway’s peer-to-peer network
to identify early adopters who might agree to mentor doctors less familiar
with the technology.
Kassum says roughly 10 to 20 percent of the province’s family doctors have
EMR systems and money is a key issue. “We don’t have the funding envelope,
so we don’t know what the government is prepared to support.”
OntarioMD, a subsidiary of the Ontario Medical Association that receives
provincial money, is coordinating efforts to build a province-wide EMR and
related systems. OntarioMD CEO Brian Forster says about 1,200 primary care
physicians have implemented funded EMRs, with a current target of 2,700.
That’s from a field of roughly 17,500 specialist and family physicians.
Forster says primary care doctors must join family health groups to be
eligible, and specialists aren’t yet included.
The EMRs that OntarioMD currently funds through its Primary Care IT program
can receive test results from some major commercial laboratories. Further
application and specification work needs to be done through the Ontario
Laboratories Information System prior to a fuller roll-out.
Separately, Practice Solutions Web Services, a subsidiary of the Canadian
Medical Association, has begun implementing a web-based chronic disease
management toolkit in Ontario and is looking to expand it elsewhere in
Canada starting this fall.
“We’re piloting it in Ontario,” explains Dr. Jay Mercer, a family physician
in Ottawa and medical director with Practice Solutions. “I have patients in
their late 80s who are tracking their blood pressure online on a regular
basis and allowing me to look at it. I can open a browser in my EMR, do a
screen capture, and drop the data right into my EMR as a picture. The next
step will be to be able to pull data directly into the EMR.”
In 2002, Quebec established a line of annual funding to create family
physician groups. The province provided a technology platform, including a
server for each group, a computer and software for each doctor, and drug
prescription, lab order and chronic disease management tools, and also
covered costs for nursing and secretarial salaries and ongoing technology
needs such as high-speed Internet. In return, the government required the
groups to maintain walk-in clinics seven days a week and offer collaborative
care for patients with chronic conditions.
As a result, physicians have secure electronic access to their offices,
clinics and local hospitals. “They can see lab tests even when they’re
travelling,” explains Jean-Francois Rancourt, a family doctor in Montmagny.
The provincial EMR includes prescription capability, but doctors currently
print paper copies for patients to fill. Rancourt expects the province will
spend more than $560 million to implement the EHR and further develop
electronic lab test, pharmaceutical and other record-keeping capabilities
over the next three years.
With roughly 130 physician groups on board, the province hopes for 300 in
about three years. However, Rancourt says many physicians in Quebec work
alone and the province has already landed the early adopters. “The remainder
will be hard to assemble because there won’t be as much interest or demand,
but these groups are the future of front-line medicine in Quebec.”
Between 2003 and 2005, when the province opened its seven community health
centres, it committed to setting up EMRs in all of them. Some sites are now
fully implemented and doctors are able to use this EMR for purposes such as
chronic disease management and viewing lab results maintained by the
regional health authorities.
Separately, a few primary physicians have their own office EMRs, and some
enjoy varying levels of integration with their regional health authorities.
“It’s not a very integrated strategy right now,” explains Bronwyn Davies,
director of primary healthcare with the provincial health department. “The
current provincial eHealth strategy is trying to bring all of that
Davies says the government plans to establish a prescription monitoring
program as part of a provincial addiction strategy, with a view to helping
healthcare providers address prescription drug abuse. The province also
plans to eventually let EMR systems feed into the overall electronic health
Also under way are assorted, individual projects. Several general
practitioners are reviewing decision-support tools such as those used in
B.C. for chronic disease management. Another study involves the use of EMR
to help primary care physicians in the clinical management of diabetes.
Dr. Gerald Maloney, president of the New Brunswick Medical Society, says the
current health minister seems particularly keen to establish a common
patient record. “In the past there hasn’t been much initiative from the
government in that way,” Maloney says. “The government wants to make it
province-wide and select the system that will allow all of the
provincial-owned establishments to be on one record.” Maloney adds that
government funding and support are key.
When Nova Scotia launched its province-wide EMR, the service was offered
through application service provider and client-server models. Now, with
near-ubiquitous access to high-speed Internet, it’s almost entirely ASP.
“With an ASP model, it’s like their phone – they contract for the system and
the service,” explains Sandra Cascadden, chief information officer with the
Nova Scotia Department of Health.
The province is working to roll out EMRs to as many physicians as possible.
Cascadden says the province has 260 primary care doctors and 89 primary
health clinics on board, close to one-third of the way to full usage. To
ramp up adoption, the province is providing funding for transitional costs
exclusive of hardware and has enhanced Health Information Technology
Services (HITS-NS) to offer support.
Cascadden says the vision is for a province-wide system rather than multiple
islands of information and health service systems that do the same thing.
Family doctors who use provincially-sanctioned EMR systems can, for example,
access lab and diagnostic imaging results and other data.
PRINCE EDWARD ISLAND
All 200 primary care physicians bill electronically, and most use their
billing software for scheduling, but less than a dozen doctors have
implemented actual EMRs.
However, PEI is working on its Clinical Information System. This
hospital-based electronic health record includes components such as pharmacy
and lab tests, though only from within the hospitals. There is no outside
physician access, according to Dr. William Walker, a Summerside surgeon who
is a liaison and trainer with the project. Walker says the PEI government is
also working on an electronic drug information system. Currently it is in
trial with a handful of physician offices, and the province is busy linking
in community pharmacies.
The drug system functions mainly as a medication information system but will
eventually be linked into the provincial EHR system, Walker says. He adds
that the drug and clinical information systems will also eventually be
connected with each other and, ultimately, with physicians in their offices.
NEWFOUNDLAND AND LABRADOR
In 2006, the government began laying the groundwork for province-wide EMR,
engaging 25 physicians in four clinics in a trial. Mike Barron, CEO of the
Newfoundland and Labrador Centre for Health Information, a provincial Crown
corporation, says consultations with key stakeholders are planned to develop
a strategy for building a system that complements the provincial EHR, which
is currently under development.
Some doctors already access electronic lab results and other patient data
through their regional health authorities, but Barron says this information
does not yet constitute a complete patient record. The province is also
working on a drug information system that will include all community
pharmacies and present a consolidated view of patient drug histories. A
future phase would allow physicians to e-prescribe even if they don’t have
an EMR. “That’s a little bit different than what’s going on in certain other
jurisdictions,” Barron says.
Funding is key. Barron says the provincial government needs to know details
such as the overall scope of the project and associated costs. “That’s
essentially what we’re doing right now. The provincial strategic plan will
indicate what overall investment will be required, and from there the
government can determine what portion of that investment, if any, they feel
Two EMR pilot project sites, with a dozen doctors, are completed in
Yellowknife and Hay River. These are now implemented, and the NWT is looking
to extend service to all of its 65 doctors.
The two clinics are using EMR tools that include digital charting systems.
Dr. Ewan Affleck, medical director of Yellowknife Health and Social
Services, says the NWT government has helped with funding and support and
hired him to assist with territory-wide implementation.
He says that, because almost all physicians are salaried government
employees it should be relatively easy to bring them on board. On the other
hand, the territory is challenging, with 42,000 patients spread over 1.17
million square kilometres. “An EMR has to work in clinics, nursing stations,
outreach clinics, and mobile settings,” he says, adding that an ASP model is
imperative because servers are difficult to maintain across such geography.
Most physicians in this territory are based at Baffin Regional Hospital,
where they are accessing electronic client and laboratory information. Nancy
Campbell, a spokesperson for the Nunavut Department of Health and Social
Services in Iqaluit, says an online pharmacy resource and hospital drug
information system will soon be available, as well.
“An eHealth strategy has been developed,” Campbell says. “One of its goals
is to allow healthcare practitioners to share information across the
territory by linking the regional hospital with remote community health
centres and referral centres outside of Nunavut.”
One large clinic in Whitehorse, which accounts for nearly half the
territory’s billing transactions, has its own EMR, but the Yukon itself does
not yet have a system in place. For now, the territory is building back-end
infrastructure and watching developments in Alberta and British Columbia.
“We’d like to be able to learn from the work that’s being invested by others
in the process,” says Chris Bookless, manager of information systems and CIO
for the Yukon Department of Health and Social Services. “We’re anxious to
see how standards in terms of the level of interoperability play out in the
The Yukon is implementing a new engine for pharmacy programs and medical
claims. “In the future we’ll move towards enabling e-prescribing, but we
have interim steps to take first,” Bookless says. “We’re dealing with some
more fundamental basic building blocks. At the moment, we have a focus on
telehealth because of our rural-remote population base.” •
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Dr. Octo Barnett chats
Distinguished physician and healthcare IT pioneer discusses diagnostic
support systems and more.
By Paul Brent
After a year of polite cajoling, the
Waterloo Institute of Health Informatics managed to lure Dr. Octo Barnett
north of the border
to deliver his insights concerning computer-based diagnostic support
Barnett, who led the development of Massachusetts General Hospital’s DXplain
electronic medical textbook and medical reference system, is low key and
doesn’t seek publicity; perhaps one of the reasons his industry leading
decision-based systems are not used more widely in Canada and around the
“He is not a person to get on a plane and lecture on this stuff. It took us
a year,” said Dominic Covvey, professor and director of the Waterloo
Institute for Health Informatics Research. “He doesn’t trumpet what he has
done and he doesn’t like to travel. And yet, the only way you promote these
things is to get out there.”
Reluctant or not, Barnett is a persuasive salesman of DXplain, or his more
recent computer creation, the six-year-old Primary Care Office Insite (PCOI)
website. In the case of PCOI, whenever he wants to demonstrate its worth, he
cites a recent survey that found more than 40% of physicians using the
PC-based information system save at least 25 minutes a day.
“When I show it to the hospital administration there is never a question
about funding,” said Barnett, a senior physician at MGH and the senior
scientific director at the hospital’s Laboratory of Computer Science. He’s
also a professor of medicine at Harvard Medical School. By his calculations
the PCOI system can save the equivalent of three or four full-time
physicians, or about $1-million in annual costs, for a typical hospital.
While hospital brass may like the possible savings from the physician’s
electronic helper, it has been embraced by more than 9,000 healthcare users
because of its utility and ease of navigation. Think of it as a system for
physicians created by physicians. Intended for time-pressed primary care
physicians, specialists and nurses (its three biggest users), the PCOI
system is designed for routine patient care incorporating features such as
patient care guidelines, therapy information, educational material for
patients and paperwork support.
The older DXplain diagnostic support system, in use for the past 15 years,
has approximately 50,000 users, Barnett estimates. (MGH does not provide
specific data on DXplain usage because it does not want to be seen to be
promoting it in a commercial way). Hospitals, institutions and clinics pay
between $1,000 and $8,000 for full access to the system but the biggest
source of users comes through Merck’s Medicus website, which offers a free
DXplain portal for individual Medicus subscribers.
Essentially an electronic medical textbook and medical reference system,
MGH’s DXplain system interprets a set of clinical findings such as signs,
symptoms and lab data, and produces a ranked list of possible diagnoses.
DXplain’s reach has grown with the expanding capabilities of the Internet.
DXplain has had limited use in Canada. It was tried and abandoned in New
Brunswick about a decade ago and Barnett knows of no current Canadian users
of the diagnostic platform currently.
Waterloo’s Covvey, who has known Barnett for more than three decades, aims
to change that soon. This fall, Covvey expects to begin a trial program with
OntarioMD designed to get up to 500 physicians to use DXplain. “[DXplain]
seems to be one of the great survivors in the field,” said Covvey. “There
have been many efforts in the diagnostic area, many of which have kind of
“The problem with other diagnosis systems is they quickly get to the border
of what they do; you can make glaucoma diagnosis but nothing else,” Covvey
said. “DXplain is attempting this mass approach of looking at thousands of
possible explanations and seems to do it very well.”
While there are a number of good medical databases for specific diseases or
conditions, Barnett said there are few systems that analyze symptoms. Those
that are trying to do that, such as MD Consult and the U.K.-based Isabel
software, utilize a textbook-based search to attempt to find answers for a
particular set of symptoms.
Though less capable than PCOI, DXplain has nonetheless proven to be easier
to export. “It is not geared to an individual hospital; it is geared to what
is the nature of the diagnostic process that one goes through in working up
PCIO, a “just in time” clinical knowledge system, is intended to respond to
a patient’s specific medical problem. Barnett gives as an example whether a
50-year old male with no urinary symptoms should receive a PSA test. The
first screen that a physician would encounter is a list of nine information
resources: primary care guidelines which comprises about 800 staff-written
recommendations on specific conditions, written patient information and
instructions, drug insurance information, pharmacy locations, insurer’s drug
formularies, an electronic drawer of 57 forms, medical calculators (obesity,
smoking etc.), a clinical access guide and patient letters which can
automatically generate a letter containing lab test values and includes
paragraphs to interpret those values.
Barnett said MGH’s system has gained rapid physician adoption because it
tackled workflow support giving users a quick and easy way to access forms
and patient letters to educate them about their specific conditions. The
other initial selling point was the creation of a formulary database to
allow physicians to determine what particular drugs were insured by
different insurance providers.
The quick adoption of the PCOI system was also facilitated by the appearance
of computer terminals on virtually every physician’s desk at Massachusetts
General. This was key because physicians simply don’t have the time to walk
down a hallway to access a database. It has to be at their fingertips. “The
PCOI system requires that I have very good technology available, a computer
on a doctor’s desk and a printer right there,” said Barnett.
The heart of the PCOI offering is the patient care guidelines, which are
drawn up by MGH’s medical advisory board. As a group, it adds on average
three guidelines per week to the current list of about 800. New guidelines
are based upon users’ requests. “It is not a system that someone comes
around and says, ‘You use it.’ It is a system that they really did help
develop and help modify.” While PCOI’s creators have had little difficulty
encouraging experts to contribute to the patient guideline storehouse,
getting those same experts to update their submissions when new information
constantly comes up has proven problematic. MGH aims to have all its
guidelines updated after one year and currently achieves that goal only
about 80% of the time.
Nevertheless, giving PCOI’s users a sense of ownership has paid off. The
most recent paper-based survey on the system’s usefulness yielded a 77%
participation rate. “You get a 77% return from practicing physicians, you
have got something,” said Barnett. On a scale of one to five, those
participating in the survey gave the PCOI system an average score of 4.7 in
terms of utility.
Usage statistics back that up. It was found that over a six-month span, 98%
of primary care users at Massachusetts General had used the PCOI network and
in the most recent two-month period measured, 94% had used it.
Adoption has quickly moved beyond the confines of its home hospital. Without
any recruitment efforts on Mass General’s part, the system has been adopted
by 12 hospitals in the state. The largest outside user, the Brigham and
Women’s Hospital, has nearly 1900 enrolled users, a fact Barnett marvels at.
“We have never done any publicity over there, never introduced it to them,
never asked them to join the committee.” The only requirements for those
interested in using PCOI is that they are part of MGH’s Partners Intranet
and part of a hospital or clinic, since it won’t be licensed to individual
doctors. “We are never quite sure if we should (recruit) or not. It may be
that we should, but without the resources, we just haven’t done that.”
That doesn’t mean that PCOI could easily be exported to other parts of the
U.S. or Canada. “There’s the idea that Canada is much more standardized than
the United States. I doubt it, but each hospital would have to have the type
of leadership that would listen to its users and say, ‘What is it about this
that we should have in the system?’”
As an experiment, MGH tried and failed to install and operate PCOI in three
hospitals in some of the most deprived areas of the U.S.: one on an Indian
reservation in Arizona, another an inner city hospital with few doctors or
resources, and the third a community hospital in northern Maine. “It worked
partially,” explained Barnett. “Nobody had the time, or the energy to put
forth the effort to try and make it fit for their own purposes, their own
A vast and complicated system that helps as much with a particular
hospital’s idiosyncratic back office functions as it does patient diagnoses,
successful transplantation means more than computers on every doctor’s desk.
“It is not just the technology, it is also the type of environment, type of
leadership and type of support,” he said. “To be useful it has to really
reflect the nature and the characteristics of the particular hospital.”
Sobered by the failure to transplant PCOI, Massachusetts General is in no
hurry to attempt it again. To do it right, the system would have to be
custom-adapted for any interested institution. With a staff of two
programmers in addition to Barnett, three part-time medical editors and a
non-medical editor, MGH simply does not have the staff resources to
aggressively license the system, whether it wanted to or not, which sounds a
lot like its history with DXplain. •
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