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Edmonton vendor ushers in patient accessibility
These are early days for EMR (electronic medical records), and patients and specialists aren’t yet flocking to the web to view clinical data. However, Edmonton-based Jonoke Software Development has built a web-based portal to its system and is already seeing some early visitors.  READ MORE

Cardiology clinic uses technology to replicate
I visited Rouge Valley Cardiology in northeastern Toronto two years ago to learn how they had transformed their clinic with digital technology. A report on what I discovered appeared in the July 2006 issue of this publication. Technology has a way of advancing rapidly, so in June of this year I made arrangements to meet again with Dr. Jim Swan, the senior cardiologist and the guiding force behind his clinic’s efforts in developing and implementing leading-edge information technology. READ MORE

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Edmonton vendor ushers in patient accessibility

WebButler works with JonokeMed software, provides value to patients and doctors.

By Saul Chernos

These are early days for EMR (electronic medical records), and patients and specialists aren’t yet flocking to the web to view clinical data. However, Edmonton-based Jonoke Software Development has built a web-based portal to its system and is already seeing some early visitors.

JonokeMed EMR software started out nearly two decades ago as MediFile before rebranding three years ago. “There were too many Medi-somethings in the marketplace,” observes CEO Jody Bevan, who was a collision reconstructionist with the Edmonton Police Service before he started writing software for PCs.

Bevan launched his company in 1988 to develop custom business applications for oil companies, a museum, a food bank and other customers. The list would soon include physicians as a result of meeting a teenage programmer who had developed billing, scheduling and transcription software for his father’s medical practice. When the teenager left for college he invited Bevan to take over the software and support his father’s clinic, as well as another one using the same system. “I got to see the inner workings of these two clinics,” Bevan says. “I rewrote the software from the ground up, and made it into a full EMR.”

MediFile was basic compared to the current version of JonokeMed, which includes word processing, spreadsheet, presentation, accounting and scheduling tools. The software facilitates billing to provincial health plans, third-party insurance companies and directly to patients when needed. On the clinical side, JonokeMed accommodates lab and other test results and images, specialist reports, e-prescribing, and red-flag alerts.

WebButler is an optional module, introduced three years ago, that extends online access to patients and various healthcare providers. Using a web browser, patients can schedule appointments, review prescriptions and lab and imaging test results, and communicate with their doctor and clinic staff – all within the confines of JonokeMed.

Likewise, parents can look at their children’s records, and adult children can do the same for their elderly parents, with written permission.

“It allows a person to see what medications their parent is on without needing an appointment with the doctor,” Bevan says. Healthcare providers are key to the loop. Nursing home personnel can gain access, laboratories and radiologists can send test results and diagnostic images directly into the system, and specialists can see the results of recent blood work or X-rays and contribute their own consultation reports and notes.

The patient’s primary-care doctor wields ultimate control, deciding which patients and providers get in and what access privileges they receive. Physicians and clinic managers can receive reports and place these inside an individual medical record, or they can authorize outsiders on an individual basis.

A check-box system lets doctors confirm when they want patients to access particular files. Large clinics decide which doctors accept web bookings, and physicians can make exceptions on a patient-by-patient basis or even limit the number of appointments that are booked over the web until they see how things work out in their waiting rooms.

Everything that happens inside the system is automatically tracked and physicians are notified immediately when patients read e-mail notifications. Messages to physicians show up as clinical e-mail, and doctors can pull the patient’s electronic chart and respond. All communications are listed as web messaging encounters, creating an electronic audit trail within the EMR.

“It’s like e-mail but you get the message within the web portal so it’s secure,” Bevan explains.Bevan says an internet-enabled EMR heightens clinic efficiency, reduces unnecessary duplication of blood tests and X-rays, helps prevent harmful drug-interactions, and engages patients in their own healthcare, leading to an overall improved outcome.

“Someone who is diabetic can go on the web site, look at their lab results and see what their haemoglobin A1C or blood pressure is and what medications they should be taking. When you have this kind of participation, you get better compliance.”

With more than a dozen medical staff, the Student Health Service at the University of British Columbia has used JonokeMed since 1999 and implemented WebButler during its beta testing phase just over three years ago.

Clinic manager Kathy Brand says up to 60 students go online every day, saving students, clerical, and medical staff considerable time. The clinic also maintains four networked kiosks in the waiting area where patients can swipe their student card upon arrival.

“We’ve been able to reduce our staff by one clerical position,” Brand says. Physicians can view patient files from home or from another approved off-site location rather than coming into the clinic. The process is faster and more convenient for students, who can go online 24/7 to book or cancel appointments or view test results. Test results that don’t arrive electronically are scanned into the system. Brand appreciates the flexibility that lets clinic staff determine exactly what access the system will allow.

Doctors screen all results before approving them for posting. “You don’t want abnormal test results going to students before you’ve had a chance to speak with them.”

The UBC clinic doesn’t use all of the WebButler features, preferring to slowly introduce new features to its online service, Brand says. “When launching the online program, the Rx feature was viewed as lowest priority and therefore we originally looked past it. More than likely we will introduce the option to view Rx information this coming fall.”

For security reasons, only specialists directly employed by the clinic can access patient records off-site. Students can change demographic information such as address and telephone number, but only clerical staff can change a date of birth or health insurance information.

Dr. Ramesh Patel, a Toronto family physician, has used WebButler for nearly three years. He says that, while it clearly benefits all parties, the use of the web by outside parties to access medical data is proving slow to catch on. Only one specialist Patel deals with on a regular basis – a gynecologist – submits data to him electronically. “I’ve been trying to convince them that if they used it they wouldn’t duplicate blood-work or chest X-rays. They could see when the most recent ones were taken and they wouldn’t have to call me for information.”

The public has been equally slow to embrace web access. Patel says fewer than two percent of his patients have paid him a one-time $30 fee and registered to access their data online. “They’re slowly becoming more educated and getting more comfortable using computers and the web to access this kind of information,” Patel says, explaining that many of his patients are relatively recent immigrants. “A lot of my patients are from India, so if they travel there and want to show a test result or other report to a physician or specialist they can access this information anytime they want.”

Jody Bevan concedes that web-enablement of EMR data is slow to gain traction. While JonokeMed is installed in 150 locations, just the UBC clinic and Dr. Patel are actively using WebButler. Five other clinics are testing the optional module with selected patients.

“Physicians as a whole are a little leery,” Bevan says, adding that security is always a concern when dealing with medical data and other sensitive information. He remarks that clinic personnel need to revise their workflow in order to use the system fully, and staff are often reluctant to take on IT-supporting duties for patients who have questions. “We’re looking at ways Jonoke can provide this for clinics.”

Certainly, implementation and compatibility aren’t the juggernauts of old. Kathy Brand says Jonoke took care of transferring data to the new system and core medical staff needed just three days for training.

A JonokeMed purchase can involve the software only for clinics that want to choose and install their own hardware and network. The installation and configuration can be done by Jonoke, if desired. There is also a “Complete Solution” option under which Jonoke selects and orders the necessary computers and networking components and installs and configures everything, including JonokeMed, which runs on Mac OS 10 or Windows workstations. Clinics need a web site for WebButler, but Bevan says his company can build one.

As EMR systems gain traction in Canada, other companies are working on patient access solutions. Practice Solutions Software offers a system that accepts patient-supplied data but does not let them to access information from their chart. “We don’t yet offer a web portal for access to the EMR, but this is certainly in our development plans,” says company president Rob Thorpe.

Another player, Wolf Medical Systems, is running a patient-access pilot project at one of its B.C. clinics.“We’ve identified right away that there has to be some physician control,” says CEO Brendan Byrne. “You wouldn’t want to post information that could be distressing to a patient or for which they wouldn’t have the full context.”

For now, the Wolf system also does not allow patients direct access to their personal charts. Byrne says patients will gradually come to value online access to their medical data, but for that to happen physicians themselves will need to first embrace EMR systems.  •



Cardiology clinic uses technology to replicate

Digital technology makes opening new locations easier and less expensive.

By Issie Rabinovitch

I visited Rouge Valley Cardiology in northeastern Toronto two years ago to learn how they had transformed their clinic with digital technology. A report on what I discovered appeared in the July 2006 issue of this publication. Technology has a way of advancing rapidly, so in June of this year I made arrangements to meet again with Dr. Jim Swan, the senior cardiologist and the guiding force behind his clinic’s efforts in developing and implementing leading-edge information technology.

In 2000, Dr. Swan and his partners undertook to transform their non-invasive Stress ECG, Stress Echo and Echo lab in Scarborough, Ontario by using a single open-architecture database that would enhance patient care, reduce in-house costs and exchange information easily with other medical databases. At the same time, they wanted an architecture that could accommodate change and growth and allow them to report studies locally or remotely within minutes of study completion. The goal was to store all images and reports in electronic form, eliminating paper, tapes, and CDs in the clinic.

Looking down the road and anticipating opening new clinics, they wanted to be able to link all of their offices while also linking with hospital information systems. Eight years ago, there was no single vendor able to do everything they wanted. They worked with multiple vendors, including Prosolv, ATL, Quinton, and Philips. By the time of my first visit in 2006, they had achieved many and maybe even most of their goals.

In fact, in 2004 they became the first in the world to integrate the stress echo images, stress test PDF files, the measurements from each modality, and the header information onto one computer screen containing a single interactive report. They also developed an automatic interpreter to analyze the data and figures in the report. The interpreter generates the majority of the conclusions in the report, in a matter of seconds and with a high degree of accuracy. The conclusions of the interpreter can be supplemented or changed manually but regardless, this is a program that saves time.

It requires a minimum of work by the physician and technician to finalize the report. Typists working all day on reports have disappeared, as have all of the ECG paper, tapes, and CDs. There’s a fax server on the office network so that paper isn’t used to send the faxes that some recipients still require.

The computerized system has caused operating costs to drop and has reduced the time to produce the final report to a matter of a few minutes. What did all this cost, I wondered? According to Dr. Swan, “The cost to do all this, including the software, network, IT in-house support and hardware was around $45,000 in 2004. It did not include the time or costs of the cardiologist manager to implement the program. In 2004, the lab was doing approximately 30 studies per day and the cost of the first stage we recovered in 10 months. After that we only had the costs of the software yearly maintenance and our own in-house IT costs, which combined were significantly lower than our previous typist costs and material operating costs. The advantages of digital were apparent from the start and improved the quality of the care in our clinic dramatically and no one wanted to go back to our old ways.”

In 2006, the clinic added its first echo machine with 3-dimensional echo capability and in December 2007, it added a second. Integrating these machines into the software required some work. In 2008, they expanded their technology with the addition of strain and speckle tracking to the software. By end of the summer, they were successfully integrating 3D, Strain and Speckle Tracking into their viewing thumbnails, database and reporting structure.

The clinic is working on adding a 3D section to the auto interpreter but until that is done, the doctors and technicians have been using drop downs in the existing module to complete the 3D portion of the report. “The volume of studies in the Toronto lab is now 45 studies per day and the reports are sent to the referring physician the same day or the following morning. We have the capability of generating a final report within four minutes post study, if need be,” added Dr. Swan.

Prior to the implementation of this digital system, the clinic was doing approximately 30 studies per day in the lab.

Dr. Swan referred to the “Toronto lab” in his remarks, and that’s because in December 2007, he and his partners opened an office in Collingwood, Ontario with two treadmills and one Echo machine. The technology developed for the Toronto clinic made it possible to get the Collingwood office up and running in an efficient manner. A reporting station was installed on the same kind of network as in the Toronto office but there was no separate server or database. Instead of storing data on their own network, the Collingwood office used a high-speed internet connection to access the Toronto server.

This approach saved time and a lot of money. Making the Collingwood reporting station a node on the Toronto network saved about $15,000 (cost of a server license) and made setting up the Collingwood office much easier than it would have been otherwise.

“We have used this set up for the last 10 months successfully. Most of our cardiologists have reporting software on their lap top and all they have to do to report is plug in somewhere on the network in Toronto or Collingwood and they can see the images and do their reports. They can read reports from Toronto in Collingwood or vice versa with ease and also can report from home studies done in Toronto or Collingwood using their lap top or desktop computer. This technology has been welcomed by the patients and the referring physicians in the Collingwood community.”

“The costs in Collingwood had been very reasonable, making it possible to add a second state-of-the art echocardiogram machine in September. This will increase the volume of studies per day from 15 to around 30.”

In August, another office was opened in Pickering following the template that proved successful for Collingwood. Additional modalities (clear cardiology and peripheral Doppler) were added at the Pickering site, necessitating some integration work that was completed in September.

There are additional costs in setting up the Pickering site related to the peripheral Doppler license and the licensing of the nuclear cardiology reader.

In the few weeks that the Pickering office has been active, efficiency levels have improved. Reports are going out the same day or no later than the following morning. The automatic interpreter has new algorithms to accommodate the nuclear and peripheral Doppler studies in addition to 3D echo and speckled tracking and strain. The added technology isn’t requiring much extra time from the physician or technician. “The structure that we have set up at Pickering allows us to grow the site at a very reasonable cost and the same holds true for Collingwood,” offers Dr. Swan.

At the heart of the system RVC has developed for its growing number of clinics is Prosolv CardioVascular, a web-based, vendor- and hardware-neutral, software system to which Dr. Swan attributes much of RVC’s success. Two years ago ProSolv, based in Indiana, was acquired by FujiFilm. ProSolv software is used at over 350 hospitals and clinics in North America including The Cleveland Clinic and The Mayo Clinic but just four sites in Canada, the largest being the Montreal Heart Institute and Rouge Valley Cardiology and its satellite offices.

When asked for particulars about what his clinics did differently than others using ProSolv, Dr. Swan focused on the use of the automatic interpreter where RVC has been at the forefront. RVC has led the customization of the automatic interpreter in Prosolv to separate the different levels of severity of valvular heart disease, analyze and grade systolic and diastolic function, assess left ventricular hypertrophy and prosthetic valves, integrate the stress test result and Duke Treadmill score into the final report, and assess right-sided heart pressures. RVC is currently expanding their algorithm to analyze the data from 3D echo, strain and speckle tracking. The algorithm uses current accepted national and international cardiology guidelines with minor modifications.

The development and use of the technology described here is a success story in every sense, including financially. The system has allowed Rouge Valley Cardiology to better serve its patients as well as to expand, quickly and profitably, to Collingwood, Pickering, and Ajax (later this year). Dr. Swan is more than willing to share the valuable lessons he has learned along the way. •