Speedy lab results

From lab to computer – test results are flowing electronically and automatically.

By Saul Chernos

A patient in Kentville, Nova Scotia, with just a slightly elevated PSA, has more than his doctor to thank for catching prostate cancer at a very early stage. The province’s lab test results are almost universally available through the physician electronic medical record, and doctors using this feature are finding that it’s helping them make diagnoses they might otherwise miss.

Nova Scotia has accomplished this feat in part by having a single approved EMR vendor – Nightingale Informatix – and a single government-run lab system, which greatly simplified the interfacing process.

However, the rest of Canada is struggling to catch up. Ontario has 16 approved EMR vendors but is several years late delivering its long-promised Ontario Laboratories Information System (OLIS), which would establish a central repository to feed electronic lab data to the province’s EMR systems. Other provinces have whittled down the number of officially approved and funded EMR systems in a significant way – Alberta to three and British Columbia to four, for example – but their centralized lab information systems still remain works in progress. This means that, outside Nova Scotia, medical laboratories must continue to connect to a multiplicity of EMR systems in order to provide electronic results from their battery of blood, urine and stool tests.

For now, the relationship between physicians and labs across Canada is largely conducted by paper and fax machine. The patient, almost like an intermediary, takes a request to the lab, hands it to an attendant and rolls up a sleeve. A few days later, the lab snail-mails or faxes the results to the doctor and much sorting and filing ensue.

Times are changing, though. Maurizio Laudisa, CIO with LifeLabs, one of Canada’s largest private lab services, says paper is still the norm. However, his company maintains computer interfaces to 15 EMR systems in Ontario, including Nightingale, CliniCare, Practice Solutions and Wolf Medical, serving an estimated 3,300 physicians. LifeLabs also has interfaces with Cancer Care Ontario, Medical Laboratories of Windsor and 17 hospitals, including the transplant clinic at Toronto General Hospital, the Hospital for Sick Children, St. Catharines General Hospital, Sault Ste. Marie Area Hospital and the BC Cancer Centre.

For doctors who do not have EMR systems, LifeLabs offers connectivity via web portals: iLabLink in Ontario and, through a partnership with BC Biomedical Laboratories, Excelleris in B.C. “You can go online, sign in and view your patients’ results,” Laudisa says, describing both test result viewers as relatively similar, with some technical differences stemming from their different origins. Both run on PC and Mac and require browsers with SSL 128 encryption for security. “You can trend results for your patients,” Laudisa explains, “but it’s only for the data we provide. It’s not a viewer for any other labs.”

Physician demand for electronic lab results is growing. Some 4,500 physicians, mostly general practitioners, are registered with iLabLink in Ontario, and the system delivers 2.8 million electronic reports every year, compared with 6.5 million hard-copy LifeLabs reports. Asked when electronic reporting might overtake paper and fax, Laudisa concedes it’s difficult to estimate the rate of computer adoption by practitioners and the resulting shift to electronic reporting. “Our preference would be to eventually replace all paper reporting with electronic means, including OLIS, iLabLink, Excelleris. However, this requires the recipient to be adequately networked and system-enabled.”

One EMR system with which LifeLabs has established an interface is Nightingale on Demand, which is government-approved and funded in Ontario and Saskatchewan and is the only EMR enjoying such status with Nova Scotia’s Department of Health. “We’re an application service provider,” Nightingale CEO Sam Chebib says, describing an environment where the government hosts the data centre and physicians access patient files through the web. All labs in Nova Scotia are public, managed by the province through the hospitals, and e-Results, an electronic system that delivers test results directly to the EMR, launched in early 2007 following joint development work by the province and Nightingale.

While Nightingale on Demand is the only government-funded EMR system in Nova Scotia, with some 250 general practitioner subscribers, there are other EMR providers. These include two client-server configurations – Practimax Plus, with slightly over 100 family doctors, and Clinicare, with between 30 and 40 physicians.

Steve Anderson, IT director with Doctors Nova Scotia, which represents physicians in the province, says Practimax, the province’s largest unfunded EMR, established an interface with eResults about two years ago, and the government is working to help Clinicare modify its code to accept eResults.

Anderson adds that Doctors Nova Scotia, through an agreement with the province, offers some financing to help physicians who opt for non-funded EMR systems and is trying to convince the province to offer physicians some choice by increasing the size of its approved vendor list. He acknowledges that additional players would increase the challenges in building interfaces and creating interoperability with electronic services such as e-Results, but sees hope in standards such as HL7, which addresses the exchange of health data. “You need internationally accepted standards for these lab information systems, to manage how transactions are packaged, to be sent securely across the internet and then received and populated into the EMR,” he explains.

There’s also the not-so-small matter of sending lab requisitions. Physicians in Nova Scotia and elsewhere in Canada still do this the old-fashioned way. “It’s like e-prescriptions,” Anderson says. “As you can appreciate there’s an awful lot of auditing and security and encryption and process that has to be thought about when you start getting into that, and some of those systems aren’t quite ready.”

Nevertheless, Anderson is enthusiastic about the promise electronic lab results hold for doctors and patients. “This was the number-one value proposition physicians identified when we travelled around the province to engage them in the adoption of this technology,” he says. “They told us that, if we wanted them to use electronic medical records, the most important thing we could deliver was electronic lab and radiology reports.”

Lab results are automatically put in the patients chart within Nightingale on Demand, to be seen by anyone who has been given access to the data. However, the results are also put in the Nightingale On Demand “inbox” so the physician sees at a glance that new results have arrived. When physicians review their inbox, they have the option to “File to patient chart” a lab report. This action reduces clutter by removing the item from the inbox.

Dr. Mike Wadden, a family practitioner in Kentville, Nova Scotia and a Nightingale on Demand user, receives lab results and diagnostic images automatically in this fashion. “When I log in the results are in my inbox within Nightingale. I can go through them, file them in the patient’s chart, graph them against previous results, view them in tabular form, and send messages to my staff asking them to do certain tasks. What used to take two or three days to come back to me I can now access instantaneously.”

This newfound ability paid huge dividends earlier this year when one set of tests came back with a PSA reading just a tad above normal. “With a paper chart I probably wouldn’t have thought much about it,” Wadden says. “But when I graphed it, it became quite apparent to me that the levels had been increasing exponentially. I called that person in, and (subsequent tests determined) he had prostate cancer.”

In Burlington, Ontario, family physician Dr. Harpal Singh says he’s currently implementing an EMR system, and the prospect of receiving lab results electronically has been a key motivating factor. “We spend a lot of our human and financial resources, and time, trying to track down and follow results,” Singh says. “Paper is not an efficient way of processing information in the 21st Century. It’s like going to a bank machine in Peterborough, withdrawing $20, and when you return to Toronto it takes your bank a week to get the information.”

Dr. Singh says paper and fax systems are particularly inefficient because they don’t make it easy for multiple healthcare providers to know what lab tests a patient has already had. “There’s a lot of duplication of services that occurs simply because we send patients to see specialists and the specialists order tests without knowing that some of this work has already been done. You’d have a much cleaner, more cost-efficient system if everyone’s laboratory data was centralised and could be accessed by the various healthcare providers.”

While Dr. Singh will have access to electronic lab results through Nightingale on Demand’s link to LifeLabs when his clinic’s staff complete system training in September – Nightingale has interfaces up and running with 25 labs across Canada – he says he’s eager for the day the Ontario government fully rolls out OLIS, which stands to centralise and coordinate the electronic exchange of test results between the province’s labs and healthcare practitioners. Already more than a few years past its original due date and despite a political crisis that has led to changes in management and further delayed various related projects, there may be light at the end of the tunnel.

Doug Tessier, acting senior vice-president of strategy, development and delivery with eHealth Ontario, oversees OLIS as part of his agency’s mandate. He concedes that the sudden management changes following the controversies at eHealth Ontario this year have caused “very minor delays to our schedule.” He adds, though, that OLIS is already receiving test results from seven foundation adopters, including three of the province’s 12 private community labs and four hospital organizations, representing 23 of 224 hospital sites, accounting for approximately 50 percent of all lab tests in the province. Tessier adds that the labs – LifeLabs, Gamma Dynacare and CML Healthcare – are the three biggest in Ontario, and the list of hospitals features some of the province’s largest facilities, including University Health Network in Toronto and London Health Sciences Centre.

“The focus is now on getting the test results out,” Tessier says, adding that the agency plans to “turn on the tap” and begin providing data to doctors this January in the Greater Toronto Area. Tessier adds that the data will first be accessible through a portal, then over EMR systems about a year after that. “Our target over the next three years is to have 9,000 practice-based physicians, outside hospitals, who can use an EMR or a portal to get at OLIS.”

While many physicians stand to gain instant access to OLIS through their EMR systems when this is accomplished, some physicians might experience a downside. Ontario has 16 EMR systems that meet the current specification. But Tessier says Specification Four, the next iteration, is scheduled for this coming spring and will require systems to interface with OLIS. This could potentially result in new providers entering the playing field and current ones being removed if they do not meet the upgraded specifications. This has the potential of forcing some physicians to change EMR systems to retain government EMR funding.

While eHealth Ontario remains besieged by politics, it has good company in not yet providing an electronic path from the lab to the physician’s office. Bill Pascal, chief technology officer with the Canadian Medical Association, says all provinces have committed to building electronic reporting systems for lab results, but some are further down the road than others. “Most of them do not have their lab database up and running yet. They’ve all committed and they’re all spending money on it, so they’re moving in that direction, but we’re still some ways off.”

While the benefits are clear – for example, lives are saved when earlier diagnoses are possible – Pascal urges patience. “The bigger the IT system, the more issues you have,” he says. “If you’re trying to link one doctor’s office with one lab, it’s not a problem, but if you’re trying to link 13 labs and thousands of doctors it becomes much more complicated. The IT systems need to be much more sophisticated and you need a secure environment to make sure the information is protected. We’re learning how to do this, but it takes time to put it all in place so that it will work seamlessly.” •

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From bits of paper to just bits

Converting paper records to an electronic format is a bigger job than many clinics can do alone.

By Rosie Lombardi

Escaping the tyranny of paper is harder than most doctors imagine – even after an EMR system is implemented. Family practices often go into an EMR conversion believing they’ll finally be rid of paper going forward, and only have to worry about storing historical patient files.

But storage costs for thousands of paper patient files can be expensive. By law, family practices need to retain patient records on-site for 10 years after the last visit. To avoid these costs, many practices are scanning them to create space-saving digital records, and they often assume this task can be handled by hiring temporary staff to scan old files over the course of a few months.

“We thought we’d just scan our files as we went along, but things changed when we saw what we were up against,” says Dr. Harvey Blankenstein, a family physician at the 1100 Family Health Organization (FHO), one of several FHOs in the North York Family Health Team in Toronto.

The family practice comprised of seven doctors and six support staff implemented a Nightingale EMR system last December, and went live in February this year. The practice was also moving to a new office in August, and wanted to avoid expensive real estate costs for storage of their paper files on-site.

But there were many unexpected paper complexities in making the switch to digital EMR records. “I don’t think we really appreciated the scope of the project,” says Blankenstein. Major workflow issues quickly emerged. New paper continued to flow into the practice: laboratory reports, faxes and other medical documents that had to either be scanned or input into the EMR.

Doctors were struggling to learn how to use the new EMR program, while also compiling and inputting cumulative patient profiles. “Scanning old files doesn’t obviate the need to create and input those profiles into the EMR. You need to do both.”

The office hired a student to deal exclusively with scanning, but she was soon overwhelmed. “We were bombarding her with paper even after old charts were scanned. We had to generate new paper charts because we couldn’t keep up with scanning and inputting all the information into the EMR although the old chart was done. It all became a mammoth task.”

Most doctors have an average of 1,500 patient files each to scan, and many of these are several inches thick for longstanding patients with complex conditions. But few family practices have the high-end equipment needed to handle the job.

“We didn’t have a proper scanner for our student to do that volume,” says Blankenstein. “We had a multi-function scanner, fax and photocopy machine that we needed for our regular office tasks. If she scanned all day, then we couldn’t use it for anything else. Doing the job in-house would have entailed buying another expensive machine, but we didn’t have the office space for another piece of equipment.”

There were also some longer-term paper issues that came as a big surprise, he says. Even after the initial year-long teething pains of converting paper for an EMR are finally over, family practices need to consider that many laboratories can’t or won’t upload results digitally.

They need to either make arrangements to scan these reports on an ongoing basis, or partner with select labs that can provide information electronically.

“We assumed most labs will transmit results electronically, but we only found out after the fact that it’s not so. They’re only willing to interface with you if the volume justifies it, and nobody would give us the magic number about how much that is. They’ll send you paper results if the volume is low, and that means you’ll have to scan them into the EMR as image files instead of having the actual data. This is a big issue for us, as it’ll determine which labs we’ll direct patients to.”

Overwhelmed by all these problems, the practice decided to look outside for a document management provider to provide assistance. “It was getting to the point where we had to slow down our patient bookings.”

The office manager, Sherri Weisz, took the lead on the project and did the due diligence

needed to gather information about several providers’ offerings, and in organizing meetings with the physicians to evaluate it. After short-listing the top three, the practice settled on Toronto-based DocuDavit Solutions Inc.

“We chose them because they’re willing to store paper files in addition to scanning them, and were flexible about working with our schedules and coming up with financial arrangements that allow us to amortize the costs over a few years,” says Blankenstein.

“For us, the costs were reasonable, as we could spread them out and it was more cost-effective than buying a scanner and hiring a student, which would have taken more time, and we still would have needed to store the paper.”


Don’t DIY

The 1100 Family Health Organization’s experience is fairly typical, says Sid Soil, president of DocuDavit Solutions. “Many doctors come to us after getting frustrated with doing the job themselves. We take their paper away and empty their offices.”

Document management companies use commercial scanning equipment with proprietary software that barcodes the paper files to speed up scanning, says Soil. “It’s possible for a student to do a competent job, but we can do 1,500 files in a week or two, versus an entire summer.” In addition, higher quality results can be achieved, as documents can be enhanced so writing is larger, blacker and more legible, and providers have quality assurance processes in place to catch errors.

Many doctors’ offices seek external providers right off the bat, but some come after they’ve started the job themselves, says Elan Eisen, president of Record Storage and Retrieval Services Inc. (RSRS), another Toronto-based document management provider that was short-listed for the project. “In scans done by students, we find pages from one file mixed with others in almost every project. Often we have to start from scratch and redo their files, which makes the job even more costly.”

A key issue doctors frequently overlook when using their own office equipment is that searchable PDF files can only be produced if they use the optical character recognition (OCR) features, says Soil. “Many don’t scan with OCR because it requires an extra step and slows things down.” Unfortunately, this produces image files instead of readable characters, which makes it impossible to use search software to automatically find keywords within a particular file. “We use our search features all the time – a file can have hundreds of pages,” says Dr. Blankenstein.

Even with OCR, it’s not possible to feed data from a patient’s scanned historical record directly into the corresponding EMR record, says Soil. PDF files are typically appended to the EMR system as a separate application that runs on the side but can be opened with a click. “Most EMR vendors don’t want doctors putting in tons of historical patient information as it bogs down the system,” says Eisen.

Some offices opt to store both paper and electronic records with DocuDavit so that they have back-up if the server is down, says Soil.

Eisen says some offices without an EMR in place are scanning their files to support a future transition. “Many are waiting for government funding, but they don’t have room for all their mounting paper. They do it as a first step to an EMR.” Pediatricians are also scanning their paper records to avoid storage costs, as they must store them for up to 28 years, and specialists are using document management software with scanned records as an alternative, since most EMR systems are designed for family practices and are unsuitable for their areas.

A new issue is emerging as more and more doctors implement disparate EMR systems, says Soil. “If a patient leaves one doctor’s office with an EMR to go to another with a different EMR, you have to pass on both the paper historical file and electronic file. But it’s expensive to convert the EMR record, so it’s easier to print it. You always have to create paper.”

For both vendors, ball park costs for a basic scanning project are about $6,000 for a typical doctor’s load of 1,500 historical patient records, or about $120 per box for about 50 boxes.


Paper logistics

There are many project management issues to consider in organizing files for scanning by an external provider so that workflow isn’t affected, says office manager Sherri Weisz.

The participation of an office coordinator is essential, notes Soil. DocuDavit picks up paper files from doctors’ offices and works with their schedules so scanning coincides with their vacation schedules, upcoming patient visits and so on. “They often provide us with access to their online calendars, or e-mail us to let us know they need certain patient files scanned.” The company also provides a hybrid service, storing an office’s paper patient records, and scanning and uploading them to their EMR on demand.

Even with DocuDavit’s assistance, managing the logistics of scanning and uploading 7,000 historical patient files for the 1100 Family Health Organization required a great deal of administrative effort, says Weisz.

“It was a massive task going through the charts, putting them in boxes and sending them off, because you need to log them all. It’s your responsibility to know which charts left your office. We also went through each chart quickly to ensure everything was in order before boxing it. It took five staff members an entire weekend to go through, label and log the 50 boxes we prepared for our first doctor. Our secretaries did lots of overtime during this project.”

The effort was further complicated by delays in setting up the EMR system, which was implemented in December but didn’t go live until February. “This threw our schedule off for the scanning, because we started it in December. But by the time our EMR was up and running two months later, we had a lot of catch-up charts to scan too, and we wound up with two PDFs for some patients.”

Weisz also tracked the costs, which she says were almost double what they’d originally estimated. DocuDavit’s basic scanning costs are a nickel per page, but many charts have more pages than they appear to at first glance. “There are lots of two-sided reports, sticky notes, telephone messages and so on in files.”

A great deal of her time was spent figuring out the logistics in accordance with a doctor’s schedule and preferences. “How many files will you send, when will you send them, and in what order? We decided to handle one doctor’s files at a time, as there’s no way we could deal with 7,000 files at once.”

A small office with one or two doctors and one support staff would be overwhelmed by the task, she says. “The secretary needs to deal with everyday business, so it would be impossible to do during the day – they would need to do it after hours or hire extra staff.”

To avoid headaches, the timing of an EMR implementation and scanning of back records should be carefully planned to coincide, Weisz says. “I strongly recommend that once the decision is made to go live with an EMR system, not another piece of paper goes into a patient’s chart.”  •

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A tool patients can use to track cancer risk

Radiation Passport 1.0 for the iPod Touch/iPhone.

By Mark Otto Baerlocher, MD

I recently teamed up with my brother, a programmer with Tidal Pool Software Inc., to create an application for the iPhone and iPod Touch. We called it “Radiation Passport”; it allows patients to record and track their radiation exposure from medical exams and procedures.

Before I describe the thinking behind this application and my reasons for believing it’s important, I’d like to offer some information on radiation.

Radiation that we all are exposed to comes from two primary sources – background and medical. The most significant source of background radiation is radon. Most people are exposed to more medical radiation but fortunately, it is possible to control this kind of exposure. The primary purpose of Radiation Passport is to increase awareness among patients about the potential risks of medical radiation and to give them a tool to monitor and evaluate exposure.

The use of radiation in medicine has enabled tremendous advances in both the diagnosis and treatment of diseases. This is particularly true in the fields of radiology, interventional radiology, interventional cardiology, and radiation oncology. The use of procedures involving radiation has grown at a rapid rate. CT alone has roughly doubled every two years since the mid 1980s.

However, with this increased use of X-ray, CT, nuclear medicine exams, fluoroscopy, and other such procedures, comes the increased risk of radiation-induced cancer. A controversial paper published in 2007 in the New England Journal of Medicine by Drs. Brenner and Hall estimated that, at current CT scan levels, 1.5 to 2 percent of all cancers in the United States may be attributable to radiation from CT studies alone.

There are numerous models by which cancer risk due to radiation can be estimated; the authoritative BEIR (Biological Effects of Ionizing Radiation) committee currently assumes an ‘LNT’ model (Linear, Non-Threshold). That is, any amount of radiation, regardless of size, is associated with some cancer-induction risk, and this risk response is linear overall. A given exam taken twice gives you twice the estimated risk, and risks are assumed to be cumulative over your lifetime.

When physicians request procedures for patients that utilize ionizing radiation, the assumption is that the potential benefit (diagnosis, treatment) outweighs the potential risk of cancer induction. Unfortunately, estimates based on published studies imply that up to one-third of CT scans may be unnecessary.

The use of a radiation passport to enable patients to track their exposure to medical radiation has been advocated. That’s what Radiation Passport does, and more.

Users enter the type and date of their exam/procedure and the application records the information and assigns the estimated radiation exposure. Patients need to track each of their imaging and imaging-related sessions, including the body part involved.

The radiation exposure is computed for all exams and procedures entered in the passport and an estimate of the cancer risk due to this exposure is calculated. Patients can also write notes (for example, reminders to follow-up on a radiology exam). A key feature of the application is its ability to estimate the risk of developing cancer by undergoing the next procedure (involving radiation) that their doctor or dentist prescribes. Physicians may also use the application to determine the estimated cancer risks for a specific exam or procedure they are considering, so that the patient can make an informed decision.

For example, if a young woman suffered from kidney stone disease, and had undergone several CT scans in the past for this reason, an emergency physician might be less inclined to perform a CT scan the next time she presented to the hospital for presumed kidney stone disease if the physician had this information.

Further information about Radiation Passport may be found at: http://www.tidalpool.ca/radiationpassport/index.html

The program itself may be downloaded for $2.99 from the iTunes store. We would be very interested to hear any comment/suggestions/advice for future versions on how to make this more useful to both physicians and patients.

Mark Otto Baerlocher, MD, is a radiology resident in Toronto.  •

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