> Healthcare Technology
> Technology for Doctors
> Research Reports
> e-Newsletter




Don’t call it a bank machine
At first glance, the two large PharmaTrust MedCentre kiosks at Toronto’s Sunnybrook Hospital resemble large ATMs or other self-serve systems, but calling these integrated, medical dispensing and medication management systems ‘vending machines’ would be a grave injustice. Each kiosk employs a robotic pick system, RFID scanners, surveillance through cameras, a barcode reader, two screens and a handset. On the top screen, Cisco TelePresence enables video calls for a live counselling experience with a pharmacist, who guides and responds to patients while monitoring prescription fulfillment, dispensing, and transaction processes.  READ MORE

Improving hospital to clinic data flow
Summerville Family Health Team moves towards integrated care by streamlining services. READ MORE

Consent management
A little known lockbox provision in privacy legislation helps propel Canadian software firm into global market for consent management software.

Editor’s note: Distant worlds.
News: The view from Palm Springs – TEPR 2009.
Surge protector cuts power usage; Olympus digital camera suits Canadian weather; Acer Aspire ONE netbook computer; Ultrasound designed for point-of-care settings; Microsoft Blue-Track Explorer Mouse.
Scope: Digital dictation helps growing business. By Nadine Arpin





Don’t call it a bank machine

New PharmaTrust Interactive Kiosk dispenses pills, information sheets and advice.

By Dianne Craig

At first glance, the two large PharmaTrust MedCentre kiosks at Toronto’s Sunnybrook Hospital resemble large ATMs or other self-serve systems, but calling these integrated, medical dispensing and medication management systems ‘vending machines’ would be a grave injustice.

Each kiosk employs a robotic pick system, RFID scanners, surveillance through cameras, a barcode reader, two screens and a handset. On the top screen, Cisco TelePresence enables video calls for a live counselling experience with a pharmacist, who guides and responds to patients while monitoring prescription fulfillment, dispensing, and transaction processes.

The kiosk’s lower touchscreen allows the patient to enter and view information. More action takes place behind the scene where a drug vault, drug validation system, drug delivery system, drug labelling system, and computers for managing transactions are located.

Developed by PCA Services of Oakville, Ontario, PharmaTrust is designed for applications in hospitals, pharmacies, medical clinics and elsewhere.

The kiosks offer a convenient, alternative prescription fulfillment option for patients, and frees up pharmacists to focus on coaching patients and monitoring care.

“From the pharmacist’s perspective,” says Sara Youssef, PCA’s managing director of Pharmacy, “it assists them, and also frees them to spend time counselling the patient and providing other cognitive services, including medical checks and chronic disease management.”

Currently PharmaTrust is in the second and final stage of beta testing at Toronto’s Sunnybrook Health Sciences Centre. In the first stage, the units, in the hospital’s Family Practice clinic area, were tested without live video, but with a pharmacist present. In this stage, there is full interactivity with an on-screen pharmacist in a PCA call centre in Oakville. Initially, a pharmacist will continue to be on site.

Patient reaction has been extremely positive, says Youssef. Sunnybrook exit surveys have shown a 96% return rate. “We thought it would be a younger demographic. Over 60% of our patients during the first trial were over 50,” she adds.

The idea of bringing the pharmacist closer into the primary care loop with doctors was a key driver in PharmaTrust’s development, according to Don Waugh, PCA’s CEO. Referencing increasing incidents of adverse drug interactions, of non-compliance in taking medications, or taking too many drugs and going ‘toxic’, Waugh says, “Why does that happen?,” and answers a lot has to do with “the separation of doctors and pharmacists. When pharmacists are brought into the primary loop, everything works better, patients do better… pharmacists can follow up.”

Noting that 40% of patients stop taking their medicine, Waugh says adding the follow-up or ‘adherence’ phase is something PCA is working on, in the form of a reminder system. They want to close the loop – ensure patients are taking medications on time and with the proper doses. “We’re building a completed circle of care…managing a patient for the utilization of the medicine,” he says.

The fulfillment process begins when a patient presents at the kiosk with the doctor’s prescription and touches the lower screen. A pharmacist appears on the top screen, and prompts the patient to insert the prescription for scanning. The pharmacist sees the prescription scan and hits the coordinating drug code. Once the code is entered, the robotic pick system seeks the drug, finds it, picks it, pulls it off the storage bin, and runs it by another scanner which checks the RFID tag, as a camera enables the pharmacist to watch. Scanners check RFID tags, affixed to every product, as well as UPC codes, lot numbers and expiry dates. The drug arrives at the dispensing scale, and is checked for the gram weight. If incorrect, or if the pharmacist identifies other issues, the drug is discarded and the process restarts. Otherwise, the pharmacist releases the drug through the dispensing port, and offers counsel if needed. The kiosk’s phone handset allows patients to receive counsel in privacy.

During the process patients are also prompted to scan benefit cards. The bottom screen reveals what, if anything, they must pay. Once payment is accepted via debit, credit or cash, receipts and drug information sheets are printed.

According to PCA’s COO Peter Suma, there has been a perception in retail environments that patients can’t chat with pharmacists. “We have seen patients come in just to have a conversation with the pharmacist,” he says.

In the call centre, pharmacists monitor screens for video counselling, a view of the fulfillment process, the patient’s touchscreen and other pharmacy management information. “We provide pharmacists,” says Waugh. Alternatively, PCA can set up a call centre for clients who own a kiosk and have their own pharmacists.

The units are stocked with drugs relating to doctors’ prescribing preferences. Kiosks hold about 330 SKUs and contain only commonly prescribed medicines. Asked about security risks, Paul Wilson, PCA’s Vice President, Corporate Communications, says narcotics are not stocked in the systems. According to Youssef, some narcotics may be stocked in the future, but only in a hospital emergency setting. “The encryption in our software is higher than that used by the chartered banks,” adds Wilson.

While Sunnybrook’s Dr. Sharon Domb, medical director of the department of family and community medicine, feels it is early to assess the kiosk since it is “just getting started”, she adds “it is very exciting technology and potentially has great utilization in the future.” Dr. Domb also thinks the PharmaTrust kiosk will be particularly applicable in remote communities, where a pharmacy isn’t available.

A second test site will be added during the first quarter of 2009 at the Toronto-based Albany Medical Clinic. As with Sunnybrook, a pharmacist will be on site during the initial trial.

Several enhancements to PharmaTrust are in development. While handwritten prescriptions are currently read by the pharmacist, prescriptions with a barcode corresponding to each drug will soon be printable from a doctor’s computer screen so the bar code reader can scan the prescription. Also, says Suma, laptops will be rolled out to doctors at Sunnybrook later this year enabling them to make TelePresence video or sound-only calls to the on-screen pharmacist. The kiosk video screen will also be capable of becoming a split-screen if, for example, the pharmacist wants to make a call to the doctor. Also, doctors will be able to use the laptops to create the prescription and send it to the prescribing system for pickup.

“So the pharmacist is a pushbutton away, both for the patient, and the doctor,” says Suma.

The PharmaTrust project at Sunnybrook has come to the attention of David Caplan, Ontario’s Minister of Health and Long-Term Care. Since his appointment in June 2008, he has made known his interest in healthcare IT and his belief in its value. In November 2008, during a speech to the Canadian Club in Toronto, he acknowledged that Ontario hasn’t moved as quickly as he would like in this area but that “by 2015, every Ontarian will have an electronic health record.”

One of the three clinical priorities announced last year by the Ontario government is to implement online management of prescription medications in order to minimize preventable adverse drug events. The minister was curious to see how the PharmaTrust technology might further these goals.

Early in March, during a visit to Sunnybrook, he was briefed by Sarah Youssef (see cover). She explained how the technology integrated the pharmacist more effectively into the healthcare team. He also got some first-hand experience with one of the MedCentres. •



Improving hospital to clinic data flow

Summerville Family Health Team moves towards integrated care by streamlining services.

By Issie Rabinovitch

Summerville Family Health Team is a four-site healthcare clinic whose 24 physicians provide services to upwards of 30,000 patients in the west end of Toronto and Mississauga. All Summerville physicians have privileges at the nearby 750-bed Trillium Health Centre, and refer patients to its two sites for treatment. There is a significant exchange of data between Trillium and Summerville, and prior to the completion of a major project in March 2008, a paper divide existed between the two that slowed down communication and created redundancy.

“A patient goes for an X-ray at the hospital,” explains Summerville’s Dr. David Daien. “The radiologist looks at the X-ray in a digital format, dictates information into the X-ray system – then transfers the whole thing onto paper to send to the patient’s physician, who, despite having an EMR at his end, has to scan and convert the information back into some sort of digital format for electronic storage. It doesn’t make sense.”

Now, with the implementation of xwave’s clinical management system (called xwaveEMR as of February 2009) and its integration with existing IT infrastructure at Trillium, Summerville’s four clinics receive an average of 1,700 messages from Trillium per week – everything from discharge summaries and consultation notes to pathology reports and diagnostic imaging results.

All the information is digital. David Daien estimates that the time spent scanning at Summerville has decreased by 50 percent. This represents a savings of two to three hours per site every day.

“Part of what’s made this work so well is that it’s integrated 100 percent into our workflow,” he says. “Doctors don’t have to remember to open an application or download an update; the information is delivered directly into their EMR. Consequently, no specific training, above and beyond the training required to learn the EMR in the first instance, was required for the hospital integration project.”

Dr. Daien continues, “If you know how to use our EMR then you know how to manage documents received via this interface. We encountered some challenges regarding duplicate records that can occur as documents progress from draft to final status. We also needed to arrange that documents intended for our Nurse Practitioners were delivered to them directly to support their full scope of practice. ”

The recently-renamed xwaveEMR is the first application service provider (ASP) solution of its kind to be provincially certified and funding-eligible under Ontario’s physician IT program. Physicians can access it as a fully-managed, web-based service, subscribing to it on a pay-by-month basis and receiving it via a highly secure, high-speed managed private network – ONE Network – by eHealth Ontario, itself recently renamed (from Smart Systems for Health Agency).

“The ASP offering is one of the reasons we chose xwave,” says Daien, adding that along with the benefits of web-based anytime-anywhere secure access, the solution’s management by xwave makes adoption and maintenance easier than it typically would be with a stand-alone EMR.

The CMS software itself is GE Healthcare’s Centricity, used by 30,000 clinicians worldwide; xwave is first to bring Centricity into Canada, customizing it for Ontario physicians. The solution provides users with complete patient records, multi-physician and multi-site scheduling, billing and patient registration; and features such as automatic drug interaction alerts, reminders for routine screening, online health-card validation, standardized patient-encounter forms for chronic diseases, and family health team (FHT) reporting templates.

“Part of having better care is having more integrated care,” says David Daien. “We didn’t want to create electronic silos.”

Trillium had already invested in Health Information Access Layer (HIAL) infrastructure as part of its vision of a Community Care Services Model – a model that connects patients and their health records to the healthcare professionals who comprise each patient’s “health team.” This model is built to standards such as Health Level 7 (HL7) and complies with Infoway’s mandated architecture.

xwave was able to leverage this infrastructure by building an interface to it that collects and sorts information related to Summerville patients, then ‘pushes’ the data to the EMR inboxes of the appropriate Summerville physicians; they prefer this to the alternative ‘pull’ model which requires them to retrieve the information.

The solution is completely transparent at Trillium’s end – “Staff there would never know there’s been any change made,” says Dr. Daien. At Summerville, information is received in real-time.

While Daien acknowledges the learning curve associated with adopting the new EMR technology, he says that the project’s biggest challenge has been not the technology itself but understanding the workflow around it.

“You need to understand the lifecycle of a document,” he says, explaining that without the proper planning, physicians could receive too much information, or unnecessary multiple versions of a document. The xwave interface has been designed to gather patient data in a way that ensures Summerville physicians are getting the information they need.

“Overall we’re very pleased with the integration,” says Daien. “xwave’s skills were solid.”

Another factor that has contributed to the success of the project is Trillium’s cooperation and commitment to integrated healthcare. In 2005, Trillium launched a $100 million, seven-year initiative called THINK – Transforming Health Care into Integrated Networks of Knowledge. The HIAL infrastructure is part of the THINK agenda.

“Once you have the core infrastructure in place, the rest becomes easier,” says Benoît Long, VP, chief information officer and chief marketing officer at Trillium Health Centre. “When you’ve made the investment in HIAL – when you’ve taken that standards-based approach – all the components are reuseable, re-deployable. There’s a very high degree of interoperability.”

Previously equipped with nine scheduling and billing systems and three distinct EMRs, Summerville’s 24 physicians now have one system that, spanning four physical locations, manages all clinical activity. The xwave interface receives patient messages from the Trillium HIAL and maps them to the physicians’ in boxes in the Summerville EMR, automatically storing a copy of the messages directly in the patient’s electronic chart. Should a patient leave the practice, David Daien points out, the patient’s information is no longer retrieved.

Since the project’s completion in March 2008, tens of thousands of messages have been relayed, dramatically improving the speed and efficiency of information delivery from one facility to the other. Summerville physicians are notified the minute their patients are admitted to Trillium and the moment they are discharged. Document travel time has been shortened from days to minutes, and the constant paper-shuffling so endemic to healthcare has been reduced.

The integration in fact has earned Trillium a Government of Ontario Merit Award; the awards are given annually to recognize public-sector organizations and individuals for their commitment and contribution to improving public service in Ontario.

In March 2008, Dr. Daien stated that the next step was to make the system bi-directional, so that Summerville can send information to the hospital, sharing patients’ allergy information, problem lists and medication lists. Unfortunately, there has been no progress on that yet, since the resources have not been available due to competing priorities. It is still on the wish list.

E-prescribing presents another opportunity to improve the healthcare system and save time, but it is not available in Ontario, with the exception of 2 pilot projects sponsored by the MOHLTC (Ministry of Health and Long-Term Care).

According to Dr. Daien, “We enter all prescriptions in the EMR and print them out and give them to patients.”

Daien is an ardent advocate of the enabling qualities of healthcare IT, and believes that if we improve access to information, the Ontario healthcare system will improve.

“How is it that you can use the Internet to book a trip to Australia but you can’t use it to book an appointment with your family doctor?” he asks rhetorically, then adds, “We’re now dealing with a generation of patients who are regularly using this kind of technology, and will expect that their physicians are using it too.”  •