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Inside the April 2006 print
edition of Canadian Healthcare Technology:
Feature Report: Electronic medical records
Hospitals, health regions extend use of web portals
Ontario doctors attached to York Central Hospital,
in Richmond Hill, Ont., just north of Toronto, and the associated
Southlake Regional Health Centre, in Newmarket, can now access their
very own “Portal” and do their business as never before.
RHIOs and interoperable systems are top issues at HIMSS 2006
in San Diego
We report on the flurry of activity surrounding
Regional Health Information Organizations (RHIOs) in the United
States.
READ THE STORY
ONLINE
Data quality in Ontario
An information management team has analyzed the
state of health data quality in Ontario and found many danger zones.
It’s now helping the government implement changes that will enhance
data quality and improve healthcare delivery.
Electronic health records: Preparing for the change
Change isn’t easy. Change takes time. Change often
comes with a price. Yet, things have to change.
READ THE STORY
ONLINE
Wireless long-term care
Baycrest Geriatric Health Care, in Toronto, has
implemented one of the country’s largest wireless systems in a
long-term care setting. The system consolidates voice and data in
one network and makes communication and accessing information easier
for clinicians.
Clinical decision support
With the explosion of medical knowledge in recent
years, doctors are increasingly turning to a new generation of
support systems to ensure they’re on track with diagnoses and
treatments.
Patient-friendly MRI
St. Michael’s Hospital, in Toronto, has completely
revamped its MRI department, turning a dark, basement dwelling into
a bright and appealing centre that’s reassuring to anxious patients.
PLUS news stories, analysis, and features and more.
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Hospitals, health regions extend use of web portals
By Andy Shaw
Ontario doctors attached to York Central Hospital, in Richmond Hill,
Ont., just north of Toronto, and the associated Southlake Regional
Health Centre, in Newmarket, can now access their very own “Portal” and
do their business as never before.
Said one enthusiastic York Central physician: “The portal has
streamlined my ability to see patients. I now have access to PACS, lab,
historical documents, and results all in one place. The portal is
efficient, timely, easily accessible and great to use. It has improved
my ability to look after my patients.”
Across Canada, leading-edge hospitals are establishing web-based portals
that connect systems within facilities and often link to allied
hospitals or clinics. Not only do doctors, nurses and and staff within a
facility gain access, but so do referring physicians, and in some cases,
patients, too.
That’s the case at Sunnybrook and Women’s College Health Sciences Centre,
in northern Toronto, where a pilot project is testing the use of patient
access to the hospital portal.
Veronica Maidman already has this kind of access. She and her
Toronto-based family doctor are both testing the hospital’s new chronic
care portal. They can access Ms. Maidman’s complete medical history at
Sunnybrook and Women’s – even while Maidman winters in Arizona. “It was
very disconcerting that I did not have access to my health information
while I traveled or went to see other physicians,” says Maidman.
“Gaining access the way I can now eliminates having to ask for copies of
tests and reports. I am thrilled that Sunnybrook and Women’s recognizes
the need for change and is focusing on the patient’s personal needs.”
For its part, Alberta is aiming to serve the needs of caregivers
province-wide when it introduces Alberta Netcare this spring.
It will vastly extend the web portal technology already used by
Edmonton’s Capital Health region. A systems-checking pilot for over 300
care providers in clinics and hospitals began this spring. Full rollout
should be complete this summer. That will make any Albertan’s electronic
health record (EHR) available to authorized care providers throughout
the province. By 2007, that ubiquitously accessible record will include
diagnostic images.
“Technically, we are a little bit ahead in Alberta than other
provinces,” concluded Dr. Maysan Haku-Akima, a rheumatic disease
physician at the Advanced Spinal Care Centre in Calgary. “But it’s still
comforting to know that you don’t have to be an IT graduate to use the
program.”Although the Alberta portal is unprecedented in scale, giving
physicians access to patient information via a portal is not a new idea.
Portal access by patients to the same information, however, is.
One of the early providers of portal systems, and among the most
successful, is McKesson. “We have over 50,000 physician log-ins monthly
on our clinical portal tool in Canada, and in total about two-and-a-half
million log-ins at over 400 hospitals throughout North America,” says
Ron Dunn, vice president of McKesson Canada. “It’s been widely adopted
partly because we used off-the-shelf industry standard technology. But
also because we put a face on the portal that allows our customers to
customize the look and feel of it so that it is consistent with a
clinician’s workflow. The success of that open approach has spawned
portals for other areas of healthcare.”
McKesson’s technology is used by York Central. It’s also employed at
Grand River Hospital in Kitchener, Ont. In partnership with McKesson,
Grand River developed a prototype portal that’s been available to Grand
River patients for nearly two years.
“The patient portal architecture is consistent with the physician
portal, so it is a nice add-on that in effect just bolts on top, yet it
is a separate entity,” says Dunn. “The kind of information the patient
has access to are things like their care team, their schedule, and their
lab results. Also the patient can access trusted databases about their
disease. So they can find out about the drugs they are taking and their
possible side effects. There’s also an area for writing a diary and
recording how they feel. So they can sit down with their physician and
use the system to review what’s happened to them since their last visit.
In addition, patients can give permission for others, including
concerned relatives who may be far away, to access their information,
including their diary.”
That’s just the kind of functionality – and then some – that Sunnybrook
and Women’s has developed on its own for Veronica Maidman’s trial run.
“To be frank, what Veronica is helping us do is develop a whole new
frontier in healthcare,” says hospital CIO Sam Marafioti. “We’d been
watching a trend particularly in the United States where the move is to
make the electronic health record more of a tool for continuing care.
Indeed, there’s a standard that’s been developed for what’s now called
the ‘continuing care record or CCR. And what that CCR does is allow all
the various stakeholders involved in a patient’s care to receive and
provide information for the continuity of that individual’s care. And we
liked those principles, given the kind of complex, chronic, and
long-term care this hospital provides.
“So we are looking at the electronic health record more broadly now. We
are moving away from it being just a record of what happens to a patient
while they are in the hospital. And we’re moving towards a record of
what happens to patients, chronic care patients in particular, who move
in and out of hospital continually.”
To that end, and with Marafioti’s guidance, Sunnybrook and Women’s began
a CCR pilot project in 2005 involving the patient Maidman. Manty Leung,
the hospital’s web services co-ordinator, developed the new record and
its availability via a web portal. Sarina Lecce, director of eHealth
Strategies & Operations, garnered clinicians from the osteoporosis
program to champion the new record and is guiding the project through
its next phases.
Late last year Marafioti, Leung, and Lecce handed the pilot over to the
osteoporosis staff and they are now making phase II operational by
seeking approvals from up to 100 patients, to put their data on the new
portal CCR record.
“We will keep our hand in and continue to help develop the record,
however,” added Marafioti. “And since we are using web technology, it is
very easy to employ an iterative process. We don’t have to create and
then re-build an entire application anymore in order to change it. We
can now put the record out there and if someone suggests a change that
everyone likes, Manty can do it overnight.”
Meanwhile, portal development at York Central and Southlake has taken
quite a different route and moved well beyond the pilot project stage.
“We have 600 physicians affiliated with our two sites and among them
there has been a 95% adoption rate of the portal,” says Diane Salois-Swallow,
CIO for both hospital organizations. “From their offices, their homes,
anywhere and anytime they can get on the internet, they can access not
only all their patient’s results and clinical information, but they can
also complete their patients charts remotely.”
That in particular, added Salois-Swallow, has proven both popular with
all staff and highly productive. Turn-around-time for chart completion
at the two hospitals has dropped dramatically. Other portal advantages
and benefits she formally cites:
• Sets the stage for responsible transition towards a paperless EHR
• Adds to efficiency and safety of care delivery by widening the
availability of results and enhancing the probabilities of informed
decision making
• Meets clinician expectations for a flexible, intuitive end-user
interface, single sign-on, and more reliable remote access, at
reasonable cost, while preserving the investment in robust underlying
HIS systems.
Informally, Salois-Swallow adds: “The key to our success so far is that
we have had very strong, IT-oriented physician leaders. Dr. Jim Boyle
and Dr. Karim Jessa, in particular, have been our physician advisors for
the portal. They have worked with other physicians to make sure it works
for all of them.”
In future, as Alberta is already doing and as Sunnybrook and Women’s has
already piloted, York Central and Southlake will push portal use to the
broader healthcare community.
“Clearly, the portal can also be used by community care, nursing, and
research organizations,” concluded Salois-Swallow.
Elsewhere the future promises even more portal-based linkages, says
McKesson’s Ron Dunn, from the viewpoint of a company that is a leader of
the healthcare portal industry.
“As we collect more and more data, and as we regionalize our healthcare
environment, and as we no longer focus on just acute care but broaden
out into chronic and long-term care, there’s more and more of a need to
assemble that information and make it available to the patient so that
it helps them through the process of their care,” said Dunn. “But as we
do, we can go beyond physician and patient portals and develop others
that will similarly help important segments of the healthcare community
with what they have to do. For instance, we have already created a
healthcare executive portal and we’re working on a healthcare staff or
employee portal.”
As Dunn defines them, portals at their best, “present in a seamless
format meaningful data drawn from disparate sources.”
In Alberta, the sources for the provincial portal are as disparate as
Edmonton and Auckland, New Zealand. The latter is international
headquarters for Orion Systems International Ltd, which Edmonton’s
regional health authority, Capital Health, selected back in 2003 to
provide the Orion Concerto Medical Applications Portal [in conjunction
with a consortium of companies] as the platform for the region’s EHR.
The Orion-based portal, now dubbed Capital Netcare, provides authorized
users access to the records of care for all the patients who flow
through Capital Health’s 13 hospitals, nine mental health clinics, and
22 public health centres. And doing it so well, that the provincial
health department, Alberta Health and Wellness, is migrating the
browser-based record it had under development over to Orion as its new
EHR underpinnings.
Strategically, the province has re-branded the EHR it has had under way
since 2004 and is now using Netcare Portal 2006 as the means of
spreading its Orion-enhanced EHR from border to border.
“We now have over 17,000 care providers in the province who can access
records electronically. However, at last count we have about 75,000
providers in Alberta in total. So, in my mind, once we get about
two-thirds of that number using the system, we will have reached a
critical mass. Then the EHR becomes a standard of practice and not just
a set of nice-to-have tools,” says Linda Miller, the acting assistant
deputy minister for the Information Strategic Services branch at Alberta
Health and Wellness.
Tools and data that registered and authorized Alberta providers – mostly
physicians, nurses, and pharmacists connected with a healthcare facility
or a community care centre who want to – will have at their disposal via
Netcare Portal 2006 include:
• a unique pass code and a fob device for logging in
• patient list and search mechanisms in the portal that make it easy to
identify and find patients
• patient demographics and event histories for each provider’s patients
• a decision-support module that offers drug-to-drug interaction alerts
, a database of all available drugs and their common dosages, and links
to clinical guidelines from the Alberta Medical Association.
• a prescribing application
• records of prescriptions, and drugs dispensed to patients, as well as
their known allergies and intolerances
• transcribed reports including discharge summaries, text connected with
diagnostic images, procedure, operating room, and consultation notes
• lab data from the regional and provincial lab systems, displaying all
available results for the past two years
• diagnostic images (2007).
Most of this will not be new to Capital Health users, but what it will
do for them, as it will for all Netcare portal users in the rest of the
province, is to extend their reach for records beyond the borders of
their own region. So that an instance of care given to a patient up in
Fort McMurray will be immediately noted when the same patient comes in
for further care down in Lethbridge.
“We’ve been able to do this because we have I think a more collaborative
model of care in Alberta,” replies ADM Miller when asked why Alberta
will achieve a provincial EHR ahead of the rest of the country. “Our
clinicians, our pharmacists, our therapists have learned to co-operate
largely because we regionalized them over 10 years ago. And we’re
reaping the benefits of that now.”
The opportunity for the rest of the country to learn from Alberta’s
advances has made Canada Health Infoway quick to finance parts of
Alberta Netcare. It has helped fund development of the Netcare
prescribing tool. It is also, as part of a huge $189 million Infoway
investment in Alberta’s diagnostic imaging infrastructure, supporting
projects that will shape how those hard-to-manipulate images are going
to be added to the Alberta EHR.
Measuring the success of all this – or lack of it – Miller admits
remains a challenge.
“We can tell you from day one how users use the portal,” says Miller.
“We know how many people are signed on; how often they use it; and what
kind of data they are accessing. But for judging its overall impact on
healthcare, we need to do a better job of measuring. We do conduct
surveys and we have anecdotal evidence, however, that it’s doing good
things like reducing wait times. And we are developing a kind of
benefits-realization approach that will help us decide what we add to
the EHR. But, it’s like the spread of the fax machine. If you truly want
to measure what kind of systemic effect an innovation is having, you
have to wait until there are more than four users of it.”
So all the evidence is not in yet. But the fervent hope is in Alberta,
as it is elsewhere, that web portals will soon become a grand, new
entrance to better healthcare.
RHIOs and interoperability in the air at annual HIMSS conference
By Jerry Zeidenberg
SAN DIEGO – Talk of ‘RHIOs’ dominated the annual HIMSS conference
earlier this year, as close to 25,000 attendees discussed and analyzed
this latest trend in U.S. healthcare I.T.
With the encouragement of federal healthcare I.T. guru Dr. David Brailer
and other government leaders, medical facilities in the United States
have been busily establishing Regional Health Information Organizations,
or RHIOs (pronounced ‘reeos’.)
Observers estimate that several hundred RHIOs have been announced in the
last two years, with more emerging each week.
In many cases, such as the San Diego RHIO announced late last year (and
profiled below), healthcare providers have needed little prodding from
government authorities.
Instead, the impetus has come from local doctors. They’re eager to get
the benefits of faster, more accurate care that’s possible when
information from labs, imaging clinics, pharmacies and other centres is
instantly available through computerized networks.
The challenge, however, often lies in connecting the disparate systems
that are installed in hospitals and clinics across a city, region or
state. In many cases, the healthcare I.T. systems supplied by a single
vendor are sometimes incompatible with one another, since they run
different versions of software applications.
Various solutions are being touted, including integration engines.
Moreover, another challenge often arises – who actually runs the
healthcare network and how will the stakeholders cooperate? This issue
is commonly referred to as ‘governance’, and it’s often overlooked until
it gums up the works of the project or halts its progress entirely.
In his keynote address at the HIMSS conference, Dr. Brailer, national
coordinator for health information technology, mentioned both
interoperability and governance as key issues. Indeed, he said his group
will soon launch a research effort aimed at discovering ‘best practices’
in these areas among existing RHIOs so that others can learn from them.
“It’s time to support the maturation of our RHIOs and help them face
their various challenges,” said Dr. Brailer. “We have to be able to
support them and provide guidance for how they can be replicated across
communities.”
A contract for the best practices research was expected to be announced
in March, with the findings to be announced by September, the beginning
of the U.S. government’s fiscal year.
Dr. Brailer said there won’t be standards imposed on RHIOs, but he
believes that local networks should be able to link to a national system
that’s now under development, in order to obtain additional benefits of
connectivity.
While most care is provided locally, in some cases it may prove
beneficial to send records beyond the RHIO – for example, to specialists
in another state to examine diagnostic images or other test results.
Late last year, the Department of Health and Human Services awarded
US$18.4 million for four contracts aimed at developing prototypes for a
National Health Information Network (NHIN) architecture. The contracts
were given to four different consortia, led by Accenture, Computer
Sciences Corporation (CSC), IBM Corp., and Northrop Grumman.
In partnership with hospitals, lab, pharmacies and other healthcare
facilities, the consortia are devising standards-based networks that
include patient ID and information locator services; user authentication
and access control; and the feasibility of large-scale deployment.
In terms of interoperability, governance and replicability, the United
States might want to keep close tabs on Canada, which has been building
healthcare I.T. networks for several years. Infoway has already invested
$427 million in 141 projects across Canada. It has also developed
standards, toolkits and governance practices.
For its part, Dr. Brailer’s group has a budget of only US$61.7 million
for the current fiscal year, and is allocated US$116 million for next
year. That’s intended to fuel projects and fund research in a market 10
times the size of Canada. By closely examining what’ been accomplished
in Canada, in many cases, the Americans may avoid the problem of
re-inventing the wheel.
An excellent example of what’s driving the rise of RHIOs can be found in
San Diego itself. Announced last October and slated to start in March
2006, the San Diego Medical Information Network Exchange (SD MINE) is
the brainchild of the city’s physician community, which wanted faster
access to patient information that’s spread across facilities in the
region.
“For one out of every seven patients that steps into a physician’s
office, there isn’t enough information available for a quick decision,”
said Dr. Stephen Carson, a former Montrealer who is now the chief
medical officer of the San Diego County Medical Society Foundation.
Dr. Carson and his colleagues aim to use a computerized ‘middleware’
solution to connect the county’s 35 hospitals, 7,000 doctors, 70
community clinics, 378 pharmacies, as well as community labs, radiology
centres, nursing homes and other facilities that serve the 3 million
residents of the San Diego area.
Not in one fell swoop, by any stretch of the imagination, but over the
next few years.
Last month, as an opening salvo, the doctors were set to connect 20
hospital emergency rooms, 70 community clinics, and 200 primary care and
specialist practices.
Dr. Carson and the medical society selected Sun Microsystems as the
prime contractor for the solution. While numerous offerings were
available, cost-control and the simplicity of dealing with just one
vendor were major considerations in choosing Sun. He explained that in
other U.S. projects involving multiple vendors, cost overruns have been
experienced as consortium partners marked up their charges when changes
to the system were made.
For its part, Sun Microsystems is now a major player in the middleware
marketplace, due to its acquisition last year of SeeBeyond Technology
Corp., a leader in the integration engine and EMPI marketplace, for
US$383 million.
Dr. Carson believes the solution proposed by Sun will be easy to use.
“All doctors will need is a high-speed connection and a web browser,”
said Dr. Carson. “It works pretty much like Orbitz or Travelocity on the
web. You select what you want to know, and the system goes out and gets
it.”
He noted that there will be no centralized databases – instead, records
or views will be pulled together from various databases on an as-needed
basis. As such, no heavy investment in new storage technologies will be
required.
Wayne Owens, vice president, healthcare integration platforms for Sun
Microsystems, said the network is a relatively low-cost solution that
will save healthcare providers and insurers a good deal of money. “The
cost is less than $100,000 per hospital,” said Owens, who added that the
potential savings will amount to millions of dollars through reduced
paperwork for physicians and fewer diagnostic tests for patients.
Instead of ordering new tests because the information they need isn’t at
hand, physicians will be able to pull up patient data – in a single-view
– on the RHIO network, which uses the industry-standard HL7 protocol for
transferring healthcare data.
Additional benefits are expected through faster patient care and better
decision-making – with more comprehensive information at hand, such as
medication histories, physicians will be able to make more accurate
diagnoses and provide more effective therapies. The partners in San
Diego are also devising a clinical messaging system to track
hospitalized patients, a community-wide bridge to immunization and
diabetes registries, and a single portal for patient education.
Interoperability is one of the biggest challenges for RHIOs. It’s also a
major issue in Canada, where most provinces are currently establishing
regional health information networks.
While marketing executives from various vendors tend to make
‘interoperability’ sound easy, in actual practice, hospitals and clinics
have found it’s often quite difficult to get computer systems, software
solutions and medical devices to mesh together.
That helps explain the rise of Integrating the Healthcare Enterprise, a
joint-venture involving industrial partners and healthcare providers.
Together, they’re identifying trouble-spots when it comes to connecting
various systems. And they’re creating solutions called ‘profiles’.
Any vendor can incorporate the profiles into their own products. In
fact, the Chicago-based IHE is strongly advising hospitals to write
clauses into contracts that require vendors to conform to various IHE
profiles.
For its part, the IHE emerged out of the radiology world, and has a big
presence at the annual Radiological Society of North America (RSNA)
conference, held in Chicago each fall. However, the organization has
spread into other parts of medical I.T., including health records. It’s
now got an impressive role at the HIMSS conference, where vendors crowd
into the HIMSS pavilion to show how well their applications integrate
with those of other suppliers.
Three weeks earlier, at a January meeting in Chicago, 59 healthcare I.T.
suppliers convened for the annual IHE ‘Connectathon’. That’s where their
ability to ‘seamlessly integrate’ with other systems is actually tested,
and their ranks included major vendors like Kodak, GE Healthcare and
Philips. According to IHE spokespersons, there was roughly a 90 percent
success rate at the Connectathon. (Results are posted on the IHE web
site at www.ihe.net)
The missing 10 percent perhaps illustrates why hospitals and clinics
should demand real-world demonstrations of a product’s ability to
connect with others before they buy it. Either that, or write into their
contracts a demand for connectivity, with bottom-line financial
implications.
On a related front, at their HIMSS pavilion, the IHE demonstrated
innovative and useful solutions, including the Cross-Enterprise Document
Sharing for Imaging profile (XDSi), which creates pointers to patient
images across facilities and organizations, enabling doctors to obtain
all of a patient’s studies, no matter the location. For example, using
XDSi, radiology, cardiology and endoscopy images, from different sites,
can all be linked in a patient record. It’s a solution that was
developed in Montreal, with the involvement of Canada Health Infoway,
and was inaugurated a year ago. This year, it has been implemented into
products by 27 different suppliers.
As well, the IHE has devised a solution called Patient Identifier
Cross-referencing (PIX) for improving the performance of patient
registries and Enterprise Master Patient Indexes. It, too, was being
demonstrated at the IHE pavilion at HIMSS.
On the connectivity theme, various vendors at HIMSS demonstrated how
they’re integrating different pieces of the hospital into the electronic
patient record.
Welch Allyn (www.welchallyn.com),
a well-known maker of equipment for doctors’ offices and hospitals,
showed a new application called Connex that automatically charts the
vital signs of patients on ‘low acuity’ hospital floors. While ICUs are
already high-tech, with sophisticated monitoring equipment alerting
doctors and nurses, other areas of the hospital still rely on a nurse to
monitor as many as 20 patients at a time using paper charts.
Often enough, nurses are grabbing scraps of paper, scribbling readings
of vital signs, and keeping the notes in their pockets. Later, they
input the data into computers at a nursing station.
“We studied the workflow of nurses in low-acuity settings for three
years,” said Tom McCall, vice president with Welch Allyn. “We found over
20 areas of possible error as nurses track vital signs, including
misidentifying patients in their notes. There are also lots of
inefficiencies and wasted time when they’re making notes and keying in
the data later.” He said the new system eliminates about five hours of
data transcription a day, per floor.
Using Welch Allyn devices, the solution electronically grabs the data –
such as pulse, blood pressure, temperature and blood oxygen levels – and
charts it on a monitor. The system has 10 different ways of displaying
abnormal information, including red highlights, exclamation points and
red boxes. The HL7-based solution will map to other EMRs, said McCall,
such as Cerner or McKesson charting systems.
With the explosion of medical knowledge in recent years, it has been
difficult for physicians and nurses to keep up with the latest diagnoses
and therapies. Hence the growing importance of clinical decision support
systems.
Several companies announced developments in this area:
• Epocrates Inc., provider of mobile and desktop clinical applications,
launched Epocrates SxDx, a disease diagnosis and treatment reference and
symptom assessment tool. The company developed the application, which
provides diagnostic support to physicians, in collaboration with the
Massachusetts General Hospital’s Laboratory of Computer Science.
It runs on mobile devices, including personal digital assistants, and
allows healthcare professionals to enter patient symptoms and findings
to generate a clinically useful diagnosis index to the Epocrates disease
reference.
Additional information can be found at
www.epocrates.com
• Ovid Technologies, a Wolters Kluwer company, announced the launch of
ClinicalResource@Ovid, a new point-of-care tool that gives medical
professionals quick access to peer-reviewed, evidence-based information.
ClinicalResource@Ovid integrates key resources, including diagnosis and
treatment guidelines provided by Clin-eguide; expert-authored disease
monographs from the 5-Minute Consult Database; up-to-date drug and
pharmaceutical information from Facts & Comparisons, including data on
natural products; bibliographic data from the National Library of
Medicine’s MEDLINE database; and detailed patient handouts that address
over 4,000 adult, pediatric, senior, and women’s health topics.
According to the company, ClinicalResource@Ovid provides Ovid current
customers with one-click access to all of their subscribed Ovid book,
journal, and EBMR resources. (www.wkhealth.com)
• Roiled by the SARS outbreak, and now anxious about avian flu, Canadian
hospitals may be interested in TheraDoc, an expert system dealing with
infectious diseases. Produced by a Salt Lake City company of the same
name, TheraDoc is now installed in 43 U.S. hospitals in 22 states. They
range from Johns Hopkins Hospital in Baltimore to a small, rural
hospital in Arkansas. According to company president Stanley Pestotnik,
sales have been doubling each year, and some Canadian hospitals have
been making inquiries.
By mimicking an infectious disease expert, TheraDoc helps physicians,
pharmacists and nurses with the diagnosis of infectious diseases. It
also helps them make better decisions about drug therapies.
“Every doctor treats infectious diseases, but most have very little
background in microbiology or antibiotic therapies,” said Pestotnik,
whose company exhibited at HIMSS. “Most doctors have spent a semester on
these topics in medical schools. There are very few physicians who
understand them well, aside from infectious disease specialists.
“But there are not many infectious disease experts,” he added, “compared
with other specialists, like cardiologists and nephrologists.”
Pestotnik said that’s why a system like TheraDoc can help most
physicians – especially in this day and age, when doctors and other
health professionals are expecting to see new and unusual infections.
Significantly, TheraDoc can be used in disease surveillance systems. It
was used for this very purpose at the 2002 Winter Olympics in Salt Lake
City, where it detected an outbreak of influenza, allowing health
officials to take early action. See
www.theradoc.com for additional information.
Ontario’s info management group aims at better data and health
results
By Jerry Zeidenberg
TORONTO – You can’t manage what you can’t measure.
And you’re really in trouble if your measurements are inaccurate, late
or non-existent. With all of these problems plaguing the collection of
healthcare data in Ontario – including dead patients who were
re-admitted to hospitals (at least on paper) – the province established
a Health Results Team in late 2004. Its information management group,
headed by University of Toronto academic Dr. Adalsteinn Brown, has taken
concrete steps to help rectify the situation.
• To ensure that its proposed changes are rooted in solid research, the
team has finished a massive data quality report, which will soon be
available on the Ontario Ministry of Health’s web site. “It’s the
largest study of its kind ever done in Canada, if not the world,” said
Helen Whittome, a member of Dr. Brown’s information management group.
She noted the survey had excellent cooperation from Ontario’s hospitals,
with a 96 percent response rate.
• Actions have been taken to improve the quality of coding. Whittome
noted that quality improvement workshops have already been held in seven
regions of the province for acute and ambulatory care providers. Results
have been quick to emerge – soon after the workshops were held, there
were 1,400 re-submissions of data to the Canadian Institute for Health
Information.
• A software ‘wizard’ for health indicator calculations, developed for
hospitals by the Hospital Report Research Collaborative, is being
upgraded to help hospitals produce better data. “We are in the process
of augmenting this tool with data quality indicators that were used at
the data quality improvement sessions so hospitals can use it to clean
up their data at the source,” said Whittome.
• An online registry of ‘best practices’ for data collection and
management will soon be available. “It will show what hospitals are
doing in many areas, like case costing or how to complete charts in the
best possible way,” commented Whittome. She said that already, some 80
to 100 examples of new processes or techniques have been collected for
the registry. It’s important that word of these improvements gets
around, however, so that best practices become shared practices, said
Whittome.
Collecting and presenting this type of data is an important step. An
additional task, asserted Jeremy Veillard, also a member of Dr. Brown’s
team, “is translating data into specific outcome measures to drive
performance improvement.”
Veillard previously worked at the World Health Organization, which
conducted a high-profile ranking of the healthcare performance and
status of 191 countries. In it, France gained the top ranking, while
Canada checked in at number 30.
Veillard noted that after the study was published, many countries wanted
to know how they could improve. The WHO conducted its own work to
address this issue, drawing a good deal of information from the case of
the Veteran’s Administration (VA) in the United States, which
dramatically improved its delivery of care and patient satisfaction
levels in the 1990s under the direction of Dr. Kenneth Kizer, while
simultaneously reducing its costs.
Veillard observed that by focusing on 18 indicators, across the system,
the VA was able to make significant improvements. These indicators
included major disease states, such as diabetes and cervical cancer.
Ontario is now going through a similar process with the development of
core sets of indicators and scorecards that are designed to measure
performance in a number of areas.
Dr. Brown, who was recently appointed Assistant Deputy Minister for
Health System Strategy for the Ministry of Health, points out that the
presence of such rankings tends to spur improved performance. He
explains that when the VA started to reveal outcomes, performance
improved dramatically. “Within three years, the VA had implemented
client health records and were generating revenue.”
In addition to taking stock, looking to the future can also provide the
kind of information that is needed to guide the development of policy
and healthcare decisions that will stand the test of time.
“Where will we be a generation from now?” asked team member Matt Norton,
noting that our position 20 years from now will determine our needs for
human resources, education, training and equipment. But Norton said the
picture can be continually refined through the use of innovative
methodologies such as long-range scenario planning. This methodology has
been increasingly recognized over the last decade as a useful tool for
guiding decisions with long-range implications in highly complex sectors
like healthcare. “We are currently testing this methodology in the
field, in collaboration with the Specialized Paediatric Coordinating
Council. The objective is to develop a series of long-range planning
models to help predict the future need for specialized paediatric
services in Ontario.”
Electronic health records: Preparing for the change
By Jerry M. Garcia
Change isn’t easy. Change takes time. Change often
comes with a price. Yet, things have to change.
Unlike the private sector, like a large bank, the healthcare system has
more emotion at stake when it comes to technological changes such as
electronic healthcare records (eHR). And as electronic healthcare
records mandates enter into Canada’s healthcare system, change
management will play a huge role in its successful design, delivery and
deployment.
In the end, the success of eHR is built by and with people and not just
with technology. Most clinicians will not simply adopt technology
because it has been dropped on their desks. If you can confidently prove
that this technology will help provide better patient care, then
clinicians will embrace it.
Involve them early, involve them often: The one thing for certain in the
change to eHR will be the long-term journey. To ensure this journey is
successful, one of the most important steps is ensuring that your
organization and the proposed technology change are aligned.
Don’t just seek out only the champions, but also the detractors to
change. Also, you will need to seek out the influencers and opinion
leaders in the organization. A high level of collaboration with all
those invested in eHR is important to ensure no future animosities to
the technology. Clinicians tend to be more forgiving of the system’s
imperfections, and the bit of extra time it may take to use, if they
were involved in its design and implementation from the beginning.
Prove the value: Always keep in mind that the motivators for caregivers
are the desire to give quality care to patients. In implementing eHR and
its processes and technology, there is no stronger motivator for
physician support than a clear demonstration that this will help them
take better care of their patients.
Acknowledge the barriers: Realistically, despite the claims of vendors,
eHR takes more time than handling pieces of paper, although it reduces
the clerical functions of other clinical staff. Physicians have three
kinds of interaction with clinical information system:
• Access to results
• Electronic documentation
• Order entry
For instance, experience has shown that the real challenge in gaining
physician acceptance of a clinical information system is in reducing the
perceived time to conduct a transaction.
Find your pathways: Showing respect for active resisters to eHR is an
effective strategy, even though there are costs involved in providing a
parallel pathway. The parallel pathway should not be so attractive as to
cause defections from the groups adopting the new tools, but hospitals
that fail to provide a workaround for resisting change often learn that
clinicians have built them themselves. Sometimes it may involve simply
finding champions who will work with technophobic clinicians to print
out lab tests and patient records.
Continuously show improvement: Electronic healthcare records are a never
ending process. Continuous improvement of the system is required to
retain clinicians previously recruited. Expectations evolve and change
over time. In one example, a client with a clinical information system
in place for seven years initially had 60 to 70 percent of its
physicians agreeing that the system brought value to them personally.
Hospitals with eHR implementations that have been most successful at not
just recruiting, but retaining, clinical users have built disciplined
and formal communications models around the experience of using the
tools. eHR deployment – everything from application design to placement
of workstations – must be constantly re-evaluated for new expectations,
innovation and evolving needs.
Physicians will adopt change in clinical processes and technology if
they believe it will help them provide better care for their patients.
Ensuring that clinicians’ interests and concerns are adequately
addressed will go a long way in ensuring the eHR’s successful journey.
Jerry M. Garcia is managing partner, Health and Life Sciences,
Accenture, in Toronto. Additional content for this article was provided
by Healthcare Technology, Volume 3: Steps Toward Developing an
Electronic Health Record, article entitled; “Securing Physician
Adaptation and Adoption of eHR”, by Manuel Lowenhaupt, M.D., Lawrence M.
Hanrahan, M.D., M.B.A., and Scott J. Cullen, M.D., Accenture.
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