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Inside the April 2007 print edition of Canadian Healthcare Technology:


Feature Report: Electronic health records


Web site will evaluate EMR systems
available to docs

Vancouver physician Dr. Alan Brookstone, left, in conjunction with doctors across Canada, will be rating EMRs, employing a five-star rating system, much like Consumer Reports.

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Interoperability the focus of HIMSS 2007 conference

The 24,700 attendees who made it to the HIMSS conference this year – after evading winter storms and flight cancellations in the American Midwest – soon confronted a blizzard of discussion about interoperability.

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Relaxing MRI

Orillia Soldiers’ Memorial Hospital has become the first in the country to install a full Ambient Experience MRI suite. The system reduces anxiety in patients, resulting in less need for sedatives and higher quality imaging.

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Interview: Matt Anderson

In a conversation with Canadian Healthcare Technology, UHN CIO Matthew Anderson discusses the biggest IT and information management challenges for his hospitals, and care facilities across Canada. At the top of the list are patient flow and patient safety.

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Faster charting

A U.S. developer of Electronic Medical Records systems is marketing its technology in Canada. Said to use a non-template approach, it can reduce the time needed to chart a full patient encounter to as little as 40 seconds.

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Telehealth in Thunder Bay

A high-speed telehealth network in Northern Ontario is saving patients air-transport trips of as much as 1,000 kilometres. It offers remote care for stroke, psychiatry, radiology, and pediatric assessments.


PLUS news stories, analysis, and features and more.

 

Web site to provide evaluations and ratings of Canada’s EMR systems

By Jerry Zeidenberg

With medical knowledge rapidly proliferating, and physicians of all stripes scrambling to keep abreast of the latest breakthroughs, how many doctors really have time to thoroughly investigate Electronic Medical Record systems?

Even when provincial authorities evaluate the systems and publish lists of provincially certified EMRs, the result can be more than a dozen ‘approved’ products. Who can spare the time to test-drive so many?

Don’t despair, help may be at hand.

Vancouver family physician and EMR expert Dr. Alan Brookstone is launching a ‘Consumer Reports’ style service on his web site, CanadianEMR, that will offer ratings of the various systems used across the country. By design, said Dr. Brookstone, it will be easy to understand and to use.

Just like Consumer Reports and its five-star rating scheme for automobiles, CanadianEMR (www.canadianemr.ca) will rank electronic medical record products using the same sort of five-level scale.

The difference is that while the consumers’ magazine and website employ expert reviewers, CanadianEMR will base its ratings on the assessments of Canadian physicians who have used the electronic charting systems. They’ll draw upon their real-world experiences to inform others of the pros and cons of various EMRs.

The performance and quality of EMRs will be based on about 15 different variables in five high-level categories, commented Dr. Brookstone. These are: purchase experience, implementation experience, support experience, usability and satisfaction with the product.

In addition, the site will aggregate information about a wide range of systems, creating a consolidated source of data. “Instead of jumping from one vendor site to another, we’ll collect the information that physicians are looking for,” said Dr. Brookstone. “It will all be available in one place.”

The CanadianEMR site will allow doctors to compare a number of systems side-by-side according to a list of criteria, such as the provinces in which a solution is available, the number of users it is designed for, whether 24/7 technical support is available, the training that’s offered, the ability to transfer data from one system to another, whether it is a local or hosted solution (or both), the standards that are employed, whether it offers interfaces to labs, X-ray clinics, pharmacies, and other functions.

Dr. Brookstone notes that not only will systems for GPs be listed and comparable, but solutions for specialists will also be included. “Specialists, like ophthalmologists, have different needs than family doctors,” he commented. “It has been especially difficult for them to find aggregated sources of information.”

Objective information about the systems and their capabilities will be supplied by the vendors themselves in a format that is easy to update and maintain. The categories will be established by a panel of clinical information system experts who are, for the most, part, practicing physicians.

“The result is that we’ll be able to speed up the whole process of accessing the information that’s needed to make a decision about which EMR to acquire,” said Dr. Brookstone. “We’ll also be able to deliver a much better informed consumer to the funding bodies,” he added, referring to the provincial groups that are subsidizing the acquisition of clinical information systems by Canadian physicians.

Developing the ratings and assessments for a range of EMRs will take at least six months, and Dr. Brookstone realizes that input from a large group of physicians will be required. “It doesn’t serve anyone well to have an unrepresentative sample,” he said.

As it happens, the project will benefit from a running start, since Dr. Brookstone has been operating the CanadianEMR site for the last three years. The site is one of the few in Canada with in-depth commentary by physicians about electronic health records and related issues – such as privacy and security, roadblocks to the adoption of computerized solutions in doctors’ offices, why it’s difficult to implement an EMR, comparisons of the Canadian situation with the U.S. and U.K., and more.

In addition to the thousands of monthly visitors to the site, there is a cadre of regular contributors to the CanadianEMR blog. It’s this group that Dr. Brookstone is starting with. He intends to build up their ranks with new physician recruits from around the country.

Dr. Brookstone aims to launch a prototype of the new service in May. Start-up funding has been provided by Microsoft Canada and TELUS, both of which have major healthcare market strategies. Additional corporations will be invited to sponsor the service, but in order to maintain objectivity, EMR vendors won’t be sponsors.

However, as an innovative way of earning revenue for CanadianEMR while adding value for vendors, the suppliers of clinical information systems will be able to add features to a vendor profile section of the site – such as podcasts, videos, testimonials and webcasts.

This will provide additional information for physicians who want it.

Not only will the site benefit physicians across the country by aggregating data and sharing the experiences of users. Vendors will also be able to use it as a source of market feedback, enabling them to address perceived shortcomings and improve their offerings.

According to Brookstone, “The strategy with CanadianEMR is to develop an objective and trusted resource that allows the sharing of knowledge and expertise and helps grow the entire EMR market for the benefit of physicians, vendors and funding organizations.”

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Interoperability the focus of HIMSS 2007 conference

By Jerry Zeidenberg

NEW ORLEANS – The 24,700 attendees who made it to the HIMSS conference this year – after evading winter storms and flight cancellations in the American Midwest – soon confronted a blizzard of discussion about interoperability.

The annual Healthcare Information Management Systems Society convention was held in New Orleans in late February.

While hospital CIOs and IT directors agree that computerized systems can lower runaway healthcare costs and improve medical outcomes, they’re grappling with the complications of actually connecting the clinical systems announced in recent years under the name of RHIOs – regional health information organizations.

RHIOs are aiming to connect local or regional care providers in the U.S., much like Canadian healthcare authorities are attempting to build networks of region-wide and provincial caregivers.

One of the largest providers of clinical systems in Canada is Meditech, and it, too, is heavily engaged in the drive to interoperability, said Alan Goldstein, director of Canadian marketing for Meditech. “Our biggest focus as a company is to share information across locations,” he noted, in an interview with Canadian Healthcare Technology.

And while Meditech is often chided for turning out systems that have trouble talking with others, Goldstein offers a different opinion: “We probably have more interfaces to other systems than any other provider. Interoperability is part of our strategy, so much so that we even have an interoperability group at Meditech. The non-interoperability label usually comes from the other vendors.”

Goldstein said that 80 percent to 90 percent of his Canadian customers are currently in discussions to interface their systems with others, and he estimates that 40 percent are currently engaged in connectivity projects.

Meditech played significant parts in large-scale interoperability projects, such as the development of client registries in Alberta and Newfoundland, said Goldstein. One of its bigger efforts these days is in Ontario, where it’s a participant in the Ontario Laboratory Information System (OLIS). That long-running project aims to connect all of the province’s labs, so that physicians can obtain quick and accurate results, no matter where their patients were tested.

For its part, Meditech has been moving ahead with OLIS at a rapid pace. It’s currently involved in a beta site, helping to get three sites in a multi-hospital group up and running, sending their lab data to a central repository. “We were the first company to sign an agreement for a beta project with OLIS,” said Goldstein.

Work began late last year, and the main components of the Meditech pilot are scheduled to be finished this summer. According to Goldstein, OLIS wants 50 percent of Ontario’s hospital able to send lab data to the central repository within two years. Goldstein asserted Meditech can do better than that: “There are 100 Meditech hospitals in Ontario,” said Goldstein. “We’d be able to have them all completed or well on their way in two years.”

On another front, Meditech has started to deploy the Integrating the Healthcare Enterprise (IHE) standard for document exchange, a profile knows as XDS. “We’ve been delivering it, and we can link systems using it,” said Goldstein. He noted, however, that Meditech is not an IHE sponsor company and does not participate in its ‘Connectathons’. Nevertheless, he added, it is still employing the connectivity solutions created by IHE.

Emergis, pardon the pun, is emerging as a major player when it comes to health IT interoperability. The Montreal-based company recently acquired Dinmar and its Oacis suite of Electronic Health Record solutions – which were developed from the start with interoperability in mind, according to the firm. But Emergis also has expertise in many other areas, including high-volume transaction processing in the insurance and pharmaceutical businesses, as well as networks and security.

Its technology is at the heart of the provincial health IT system in Newfoundland and Labrador, where it’s supplying the electronic ‘bus’ that will link all of the components of the provincial EHR – including the client registry and EMPI, provider registry, drug and lab information systems, medical imaging system and the clinical data repository.

“We’re on track to have the first (Infoway) blueprint version 2, HL7 version 3 HIAL in Canada,” said John Hawkins, vice president of professional services for Emergis.

All of those fancy acronyms are shorthand for Infoway’s vision of a core architecture that will allow the hundreds of healthcare systems used in Canada to send and receive information from one another.

As such, the Newfoundland bus could very well serve as the model for projects across the country, as Infoway is a proponent of replicable systems.

Emergis is active in a number of other integration projects, including the EMPI in eastern Ontario that’s easing data exchange among regional hospitals.

Moreover, the company recently won a contract to supply its Oacis EHR to six hospitals in Montreal, in addition with the eight hospitals that make up the McGill University Health Centre and the Centre Hospitalier de la Universite de Montreal, a project that’s sure to require a good measure of integration.

In a slightly different twist on the interoperability theme, Emergis will soon release a solution that enables a community to create its own health IT network at an affordable price. “It can link doctors’ offices, hospitals, labs, pharmacists and others, and it includes security,” said Hawkins, adding that a chain of pharmacies is currently using it.

On a somewhat different front, the multi-faceted Emergis is getting ready to market a pharmaceutical decision support system, which it currently sells in Quebec, to the rest of Canada. “It’s very successful in Quebec,” said Helene Chartier, vice president of marketing. “Many pharmacies use it, and now PDA vendors are selling the solution to doctors.”

However, the system is in French, which has limited its usage in North America. Once an English translation is completed, it will be marketed to pharmacies and physicians outside Quebec.

One of the leaders of the interoperability movement is a group called Integrating the Healthcare Enterprise (IHE), a volunteer-led organization based in Chicago. (See www.ihe.net) It took up an impressive amount of real estate on the show floor at HIMSS, where an array of vendors demonstrated how they’ve built IHE ‘profiles’ into their solutions. By doing so, data from one vendor’s system can be sent and understood by another vendor’s system – which in the past has been a big problem.

At a press conference, spokesman Michael Glickman observed that the IHE creates solutions to real-world problems by creating ‘profiles’ – essentially, commonly accepted methods of getting the job done. The most pressing problems are suggested by end-users, such as hospital managers. Solutions to the problems are arrived at collectively, by the users and vendors of technological products. They’re then tested at an annual gathering called the ‘Connectathon’.

To date, there are eight ‘domains’ or areas in which the IHE focuses its work: Cardiology; Eye Care; IT Infrastructure; Laboratory; Patient Care Coordination; Patient Care Devices; Radiology (including Mammography and Nuclear Medicine; and Quality (which was just added.)

Soon, said Glickman, the IHE intends to start working on solutions for Endoscopy and Pharmacy.

As well, the group plans to start documenting the uptake of IHE profiles by healthcare users. This will enable it to measure the usage of its solutions and gauge its own organizational effectiveness.

For its part, Agfa HealthCare continues to expand out of the radiology department and across the enterprise with new solutions.

Recently, it reaffirmed its drive into the hospital portal business with the announcement of three more Ontario customers, in addition to the three portals it has already constructed for hospital groups in partnership with Medseek.

Not only do the portals provide an entry into hospital systems for physicians and other caregivers, but they also offer ‘single view’ access to all of the disparate systems that a caregiver may need to access.

According to Agfa, it does this using a federated model – meaning that information stays in its original location and is accessed on an ‘as needed’ basis, instead of being aggregated in a central repository.

“Other vendors provide portals, but in many cases, they can only access their own applications,” said Saravana Rajan, business development manager for Agfa HealthCare, based in Toronto.

Rajan explained that other vendors may offer access to disparate systems, but they do it by collecting all of the data in a repository. “That’s 90 percent more expensive than our solution,” said Rajan. And it’s difficult to keep the data in the central database up to date.

“We pull the data together in real-time, when the physician needs it,” said Rajan. “It’s always up-to-date. And we know that physicians would rather have no information than old information.”

Andrew Giles, Agfa HealthCare’s marketing manager for enterprise solutions, commented that Agfa can put together a portal for a 200-bed hospital in as little as three months. “We’ve got interfaces ready for 150 different systems,” he said. “These include the most widely used systems in healthcare.”

On a related note, Agfa will soon start marketing its own Electronic Health Record system in Canada, using the the Orbis system that it acquired from a European vendor.

According to Agfa, Orbis is widely used in Europe, and includes all of the components needed in a hospital or health region – such as lab, pharmacy, notes, orders, and many others.

Asked whether another EHR can make it in a marketplace that’s already saturated with vendors, Giles replied that many hospitals are getting ready to upgrade their systems, and that includes scrapping obsolete solutions.

“Our research shows that many hospitals are planning to replace their legacy systems in 2009-2010,” said Giles. “They’re searching for better systems, and some that have our Impax PACS have already expressed an interest in Orbis.”

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New approach improves patients’ MRI experience at Orillia hospital

Stephen Leacock would be proud. Soldiers’ Memorial Hospital in Orillia, Ontario – the town Leacock affectionately and humorously cast as Mariposa in his classic Sunshine Sketches of a Little Town – is quite literally letting more sun shine into what can be the dark experience of undergoing a magnetic resonance (MR) examination.

As part of an $83 million expansion, Soldiers’ Memorial has built an enlightened imaging unit that is the first in Canada to fully envelop itself in the “Philips Ambient Experience”. The centrepiece of the new Philips suite is a state-of-the art Achieva 1.5 Tesla MR machine. But more importantly, to both patient and radiologists, the experience of passing through its powerful magnet will be as pleasant and relaxing as it can be.

The Ambient Experience suite enables patients to exercise a good deal of control over their environment. The patient can select their choice of themes from a Wi-Fi touch pad before entering the examination room, they can select its artificial lighting within a wide range of soothing pastels. They can pick music to accompany projected scenes of mountains, lakes, underwater seascapes, and other calming images to play on the walls and ceilings. The idea is that by giving patients a greater sense of comfort and control over their experience they will be more at ease, less sedation will be needed, and superior imaging will result.

What’s more, in Orillia, the imaging suite is not buried in the window-less confines of the basement as it is traditionally in other hospitals. Rather, it is at ground-level, and on the suite’s roof, a circle of skylights above the imaging waiting rooms lets the sunshine pour in.

But the light dawned on Soldiers’ Memorial’s CEO, Bernie D. Schmidt about the wisdom of making the experience of imaging more ambient some time ago.

“Before coming here to Soldiers’, I was at the Children’s Hospital of Eastern Ontario and there we were concerned about sedation rates for diagnostic imaging. So I wondered how we would handle it here in Orillia because we have a huge regional pediatric population,” says Schmidt. “Then when we visited the RSNA conference in Chicago we saw the Ambient Experience display at the Philips booth.”

Schmidt also learned that a Chicago-area children’s hospital had experienced a significant drop in sedation rates as a result of converting its imaging areas to an Ambient Experience suite.

“So both for our younger patients and for older ones, who might be claustrophobic or anxious and who could benefit from having more control, we went with Philips – partly because it is the only vendor out there that provides this fully ambient background,” says Schmidt.

“We chose Philips first of all because of the excellence of their equipment, but the Ambient Experience aspect of it was also very important because it fit right in with our aim to make the hospital much more patient focused,” says David Lafleche, the director of diagnostic imaging.

But chief radiologist Dr. Mark Swanson, wasn’t so sure about all that, at least at the outset. “I admit I asked at the beginning. ‘Why would we want to spend money on something that’s just decoration? But as I discovered, it is much more than that. A lot of the people we examine, especially the elderly, aren’t coming here under full power. They’re sick or they’re anxious. But we know now that if they are made to feel better, we can get better images.”

For Maida Jerej, Soldiers’ Memorial’s head MRI technologist, anything that makes the imaging suite look and feel less like a procedure room is highly welcome. “When you can pick a scene and walk into it, whether it is a beach scene or cartoons for kids, and especially if they can bring in a disc and have their own music playing, it makes patients feel this is going to be OK and that I can make it through there.”

And they will be going through in some numbers. Sharon Burkhart, the director of public affairs at Soldiers’ Memorial, says the new MRI suite, when fully functional by the latter part of 2007, will provide 3,380 scans per year. “It will initially be funded to run during regular business hours Monday to Friday, plus emergencies at all other times,” she adds.

The Achieva 1.5T scanner that’s at the core of the suite will complement a 64-slice CT scanner recently acquired with Ontario Health Ministry help. Together with the addition of new digital radiology equipment, the combination will lift Soldiers’ Memorial to the status of being a regional centre of excellence for diagnostic imaging in middle Ontario.

“As a radiologist, this all means we will be able to see finer anatomy,” says Dr. Swanson. “We’ll now be able to see the spinal cord, rather than just the canal, for example. So we’ll be able to get closer to the diagnostic truth.”

Next milestone for diagnostic imaging head Lafleche will be the selection and integration of a PACS system that will tie all the hospital’s imaging modalities together. “Then the images will come to the radiologists, rather than the radiologists having to go to the various modalities to see them.”

To make this progress and the Ambient Experience happen, CEO Schmidt had to go to his Board of Directors and the hospital’s fund-raising foundation for approvals of the $7.4 million overall upgrading of Soldiers’ Memorial’s diagnostic imaging. “Because of the extra technology involved, the Ambient Experience suite is more expensive. But by the time we were done with our presentations and Board discussions about implementing it fully, they were excited and absolutely committed to making it happen,” says Schmidt. “Indeed, they felt the Ambient Experience part would help us attract more dollars.”

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CIO Matt Anderson: Patient flow and safety are the key issues
There are other challenges, but getting patients through swiftly and safely are top of mind.

Talk about a multi-tasker. Among the IT hats Matthew Anderson wears are: Vice-President and Chief Information Officer (CIO) of the huge University Health Network (UHN) in Toronto as well as the CIO for North York Community Care Access Centre, St. John’s Rehabilitation Hospital, Toronto Community Care Access Centre, Toronto Rehabilitation Institute, and West Park Healthcare Centre.

Also, he is the E-Health Lead for Toronto Central Local Health Information Network (LHIN). All that and the father of two young children, too, Matt Anderson has been recognized nationally for managing somehow to get things done. In 2005, he was named CIO of the Year at the Canadian Information Productivity Awards, held in partnership with CIO Canada magazine.

CHT Contributing Editor Andy Shaw caught up recently with Anderson in his UHN offices in downtown Toronto to talk about where all that multi-tasking is leading.

CHT: Matt, no doubt you have a lot of them, but can you talk about what your most important goals are these days?

Anderson: Well Andy, I guess that depends in part on what hat I am wearing. But they are all kind of related, and most of them centre on integration. The difference in the hats is really just a different perspective of the same whole. And that has to do with how we are integrating the health system and how we are improving services as a result.

The particular lenses we’re looking through are: Access: how are we improving access to healthcare – often measured from an Emergency Department perspective, and that’s a pretty hot topic these days. And really part of that is Wait Times, for both unscheduled events that you typically encounter in “Emerg” and for scheduled events such as hip and knee replacements.

Then while you’re doing that, there’s Safety. How do you protect and improve patient safety while you’re improving access and reducing wait times? So they are pretty lofty goals.

CHT: Given those high goals, then, what would you say you’re trying to get your IT systems to do, to help you achieve them?

Anderson: If you had to boil it down to two words, they would be flow and safety. On the flow side, referral systems, particularly in the LHIN context, are a priority so that we can eliminate the faxing and the other paperwork that go with referrals. But we’re also taking it a step further and trying to get to resource management systems – like the very impressive systems that are already running in places like Victoria and Calgary, and to some degree at the NHS in Britain.

These systems match patient need to resources. A mental health facility, for example, would post on such a system that it has the capacity to accept the following types of patients. So when you are doing a referral back here at a general hospital and you’re looking for a bed or a service, you put in your need and the system says here is where it is available. And then you do the referral.

And again from an access and safety perspective we are looking at chronic disease management. The particular push we have been making is on diabetes. So we have multiple proposals into the Ministry of Health to help fund an effort that is GTA-wide. That takes time, but there are aspects of it we are moving on now, such as the referral system.

I would say my third priority is UHN’s own safety agenda. We have spent a fair amount of time looking at medication errors, but now we are starting to shift our focus a bit to infection.

CHT: So along those lines, what do you feel have been your biggest accomplishments to date?

Anderson: I’d say one of them certainly is Toronto’s Community Care Access Centre (CCAC). And there, instead of coming up first with an internal strategy that would get them to an electronic chart, etc., we started from outside at our connection points with the Centre instead. So we now have automated tools for referral into the CCAC and we have automated tools for referral out of the CCAC. There is still paper in between, but we’ll soon have that gap closed, too.

Here at UHN’s end, we’re proud too of the low-cost e-referral system we’ve set up. So often a lot of the folks who show up in our Emerg do not need to be admitted. But they can’t go home without some form of support. So we put a little algorithm into our computer system that says – when a patient comes in and registers in Emerg, if the following things are true about them – fire a notification off to the CCAC.

Similarly, we have a link to the CCAC database. If we have a patient show up who is already a client of the CCAC, the system automatically fires off a notification to the CCAC, too.

So what we are doing is very rapidly engaging community resources. And what we’ve found is a four-fold increase in the number of patients who are eligible for care under the CCAC. We’re getting people out of Emerg faster and seeing a whole new cohort getting care in their homes. That’s been very exciting.

CHT: Well that certainly smoothes out and quickens the flow of your unscheduled events. What about your scheduled events?

Anderson: We have a terrific physician-leader at UHN, Dr. Nizar Mahomed, who identified an overuse of rehabilitation facilities in the Toronto area by people who have had a hip or knee replacement. In the paper world, if it is not closely monitored, about 90 percent of the patients go to a rehab hospital and only 10 percent to the CCAC for care afterward, when the ratio should be about 50/50. We took Nizar’s algorithm and also put it into our hospital information system. So that at pre-admission when patients come in, the system says, okay, this patient should be streamed to rehab or this patient should be streamed to community care. And right there, they will book all the patient’s downstream appointments.

And of course, we are proud to be part of the Provincial wait times system that was implemented by Sarah Kramer. That system has been a catalyst for a series of quality and access improvements.

CHT: No doubt though you are still facing challenges. What would you say are the most pressing?

Anderson: There is nothing new in it, but funding is always a challenge. However, there are encouraging signs in Ontario. Certainly the investment in wait-time improvement has been great on a whole bunch of fronts, including raising awareness of what an e-Health strategy can do.

The beauty of wait times is that it underscores the need to tie IT investment to clinical and business outcomes. It’s a shining example of how you move an e-Health agenda forward.

Also in Ontario, we’ve got the LHINs in place, but we’re not truly regionalized yet. We’re still working with hospital boards that do not always have the incentive to think regionally. However, we are experiencing a shift in focus because of the LHINs, and that is when the benefits of things like e-referral systems are realized.

One of the biggest challenges we face, however, is not the technology but the unwritten local rules doctors and nurses use to communicate with each other. They are so different from place to place. So to deal with that from a workflow perspective is a continuing challenge.

And perhaps the greatest challenge is finding skilled IT staff. The competition for them is just unbelievable.

CHT: When you do find the IT staff and the systems you need, how do you measure your return on investing in them?

Anderson: Most of the ROI is rarely measured in financial terms these days. Mostly it is measured either in terms of the safety benefit or the flow benefit. On the safety side, we look at things like transcription errors. On the flow side, it would be factors like how many days a patient is occupying a hospital bed when they are simply waiting to move on. We also measure wait times in Emerg, as well as the number of patients who are admitted but who are still sitting in Emerg.

CHT: So what does the future hold?

Anderson: Some of the referral systems we’ve built we’ll be replacing eventually with more robust, commercial products, no doubt. But our early versions gave us proof of concept and immediate results that were clear to everybody. I wish other change-management systems we put in were as easy to gain approval as those.

Our medication-order entry program is moving ahead. We’ve got it in play at UHN and at a few other SIMS partner organizations. But it is challenging and it is expensive. Nobody’s software is perfect. Yet the results are undeniable. We have reduced transcription errors to virtually zero, for instance, because nobody is trying to read the doctor’s handwriting anymore.

But overall, we have to look at the sustainability of the healthcare system, and even whether it’s going to be here 10 years from now. Certainly, with e-referrals and other systems in place, we can still squeeze out some inefficiency from the supply side of the equation.

But sooner or later, we’re going to have to seriously address the demand side. And chronic disease management does address the demand side. We have to find ways, for instance, to have fewer diabetics develop kidney failures or require amputations. Prevention and disease management is really the future. And when I look out West and see the great stuff Capital Health in Edmonton is doing with a fully regionalized model working on the demand side, you can see that they are already away to the races.

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Non-template approach to the EMR results in faster patient charting

By Jerry Zeidenberg

Just when you thought there was nothing new under the sun in the EMR universe, a Los Angeles-based company is bringing a system to Canada that enables physicians to chart a medical encounter in as little as 40 seconds. According to the company, that includes an entire SOAP note – made up of Subjective and Objective observations, an Assessment and Plan, along with billing instructions and referrals, if needed.

Skeptical?

We were too. But because Infor-Med Corp. (www.infor-med.com) claims to have over 5,000 physician users of its Praxis EMR in the United States, we took it more seriously. Moreover, Praxis has now made a Canadian beachhead in Victoria, B.C., where it’s used by Dr. Clayton Reynolds – a Newfoundland-born endocrinologist who served as the long-time head of quality for three Los Angeles hospitals before moving back to Canada.

As Dr. Reynolds puts it, Praxis uses a “bass-ackward” method of inputting data, explaining that the system actually takes longer to use at first, but quickly becomes faster as you populate it with data.

That’s because it works on the principle of similar cases – that most cases you see in a day are quite similar. So when you build up a body of cases, symptoms, drugs and other variables, you can use a previous encounter – already populated with many variables – as the basis for the new patient’s encounter note.

When you’ve built up a body of cases, it’s much faster to remove data from a note than to construct a wholly new note for an encounter. Instead of entering a mass of data for each patient visit, you simply recall the most similar case on the screen, and remove unnecessary items or add a few that are peculiar to the current patient. As the company points out in an online demo, “Once you enter a medication or diagnosis, you never have to enter it again.”

So for example, when a patient presents with an inflamed pharynx and other symptoms, and you suspect acute pharyngitis and may prescribe erythromycin, you can tap an E into the drug section, and all cases where you previously prescribed erythromycin will come up.

With another tap, you select pharyngitis, and all of these cases are highlighted. Pick one of them, preferably the ‘closest encounter’, and you’ve got the basis for the new note – of course, you can change the variables, where applicable. For instance, the current patient may have had the sore throat for three days instead of the previous patient’s five days, and may have moderate inflammation rather than severe, and so on.

Infor-Med claims that as you work with the system, you can quickly bring down the time needed to complete an encounter note – from three or four minutes per patient to just 40 seconds, in a matter of weeks.

Dr. Reynolds, who also works as a tester and advisor for Infor-Med, stresses that unlike other EMRs, Praxis does not use templates. Templates require you to work through pick lists, and the pick lists are not so easy to alter. It’s also time-consuming to run through these menus, and they require the physician to do the same amount of work for every encounter.

By contrast, the Praxis EMR reduces the amount of work as you go along – the more terms and keywords in the system, the company says, the faster it is to generate complete and accurate notes.

Unlike templates, moreover, the Praxis EMR is said to allow physicians to work in their own way. “Templates assume there’s one best way to do medicine, but medicine is as much an art as a science, and physicians all have their own way of doing medicine,” says Dr. Reynolds. Instead of being forced through a pre-set list of variables in templates, you’re able to create your own lists in Praxis. You can click on any symptom, test, drug or variable to bring up a list of cases, which included a particular keyword, and use the ‘closest encounter’ as the basis for your new assessment and care plan.

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