Cross-country check-up

We examine the health of IT initiatives in each of Canada’s provinces and territories. Some are doing much better than others.

By Saul Chernos

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.

BRITISH COLUMBIA

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.”

ALBERTA

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.

SASKATCHEWAN

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.

MANITOBA

Nearly three years ago, the province launched Manitoba Approach to Primary Care, and the Physician Integrated Network project emerged from this last year.

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 of information.

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.”

ONTARIO

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.”

QUEBEC

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.”

NEW BRUNSWICK

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 together.”

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 record.

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.

NOVA SCOTIA

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 comfortable subsidizing.”

NORTHWEST TERRITORIES

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.

NUNAVUT

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.”

YUKON

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 longer term.”

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 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.

“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 died off.

“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 a patient.”

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 uses.”

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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