INSIDE THE OCTOBER 2008 ISSUE:
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.
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.
Editor’s note: Satirical web sites
amuse. They may even educate and instruct.
News: Nightingale upgrades its patient portal;
Quebec starts province-wide EMR project; Ontario reports EMR usage stats
by vendor; Alberta selects vendors.
Tech: BlackBerry Curve 8330 smartphone; Samsung
multi-function printers; Ultramobile Panasonic Toughbook CF-U1 PC; Adobe
Acrobat 9 family of products.
Scope: Why doctors order lots of CT and MR
scans. By Chris Clark, MD
Edmonton vendor ushers in patient
WebButler works with JonokeMed software, provides value to patients and
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
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
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
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
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
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. •
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Cardiology clinic uses technology to
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
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
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
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
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