Nova Scotia aims for rapid deployment of province-wide EHR system

By Paul Brent

The decision by Nova Scotia’s health ministry to select McKesson Canada as the exclusive viewer and health record storage provider for its province-wide electronic health record system was years in the making.

The awarding of the $2.4-million contract traces back to a time when Sandra Cascadden, chief information officer for the Nova Scotia Department of Health, was CIO of the Capital Health District and was exploring the first steps to information sharing.

“We had always wanted to share information amongst the three systems that we have in the province,” said Cascadden. Provincial facilities use either Meditech Magic, Meditech Client Server or a mix of McKesson, Cerner, Agfa and GE systems in her former Capital Health District. The smaller facilities in the province use the Meditech Client Server while the IWK (Children’s) Health Centre relies on Meditech’s Magic system.

The new DI system, which can be shared province-wide, uses Agfa PACS technology. Nova Scotia currently has no electronic sharing of laboratory data, which the first phase of EHR implementation will also address.

Cascadden was part of a provincial “Joint Health Interoperability Project” which four or five years ago visited a number of U.S. facilities which had taken the McKesson Horizon Physician Portal (HPP) and overlayed it on Meditech and McKesson systems, and successfully pulled information out of those two systems into a common viewer.

“That product had always been in the forefront of our minds as we had been going through the whole electronic health record initiative,” she said. “McKesson proved that they could do it.”

That group then studied whether the McKesson HHP could meet the province’s requirements and tested it again after Canada Health Infoway laid out its requirements to validate the application. McKesson also had something of an inside track with the province because it has a policy of looking first at the products of existing vendors before seeking solutions from outside providers.

“We already have some experience with that vendor, we already have some expertise in our human resources and our skill sets, so why go outside if you don’t have to?” contends Cascadden.

That argued in favor of McKesson, as did Cascadden’s preference for a system that could, in the end, be customized by the province. And it was found that many “off the shelf” programs can be used with the HPP viewer. “If we ever want to do it on our own and customize it, I can go out on the street and buy all these products and do it myself,” she said.

Going with McKesson was also, ultimately, a money-saving decision. The Capital Health District already had the firm’s Horizon Care Record system. With the largest facility in the province already on board, the Health Department saved about $1 million in the end, estimates Ron Dunn, vice-president of McKesson Information Solutions, McKesson Canada.

The company treated that first purchase as an initial investment on the new viewing portal. “It ended up being a lot less expensive than if they had come at it for the whole thing at once,” said Dunn.

The rollout of the EHR viewing and repository system will not include any new features, at least at first, noted Dunn. “It will initially encompass a variety of existing systems, but over time it will encompass access to the complete records of patients in the province,” he said. “Today, there are few, if any other provinces that can say that. Maybe Prince Edward Island can say that. This is really going to tie all of the in-patient and out-patient care into a single viewing capability and it will tie diagnostics into it as well.”

For the current rollout phase which has Canada Health Infoway funding, Nova Scotia has set a deadline of the end of 2009 to implement the province-wide electronic health record, which includes clinicians’ main priorities: diagnostics, lab results and DI results.

“This phase is delivering on their top priorities,” said Cascadden. “The Electronic Health Record, in my mind, will never be finished. It will be a project in perpetuity, as we add new information services for cardiology, or we add new information systems for the diagnostic services, they will constantly be added in to the EHR.

As for when general practitioners, specialists and others outside the hospitals will gain access to the system, Cascadden said it depends upon the technologies they are working with. “The EHR will give the GPs and specialists a view into diagnostics, but it does not perform what an EMR would perform in their practices. It wouldn’t give them scheduling, billing, or charting, because the EMR is a view-only at this stage.

“Any physician who has an EMR, we will give them access to the EHR as soon as it is available. For those who do not have an EMR, we really do have to strategically think about which one comes first, the EHR or the EMR?”

Others on the phase one electronic records distribution list include emergency departments and pharmacists and pharmacies.

The province’s CIO has a good idea about the benefits that will accrue from implementation of the system, because of Canada Health Infoway performance measuring and monitoring guidelines.

“We had to do that when we were building the PACS across the province, everything from physician surveys about, ‘How much time has this saved you?’ and ‘Are you able to do this more efficiently?’ etc.,” Cascadden said. “We have done it before, so we know the types of things we need to do.”

She is confident that her department will reach the end-of-2009 deadline. “We have been thinking and doing and planning this for a long time.

“The partners we have, McKesson, Initiate and folks at Sun, are good strong companies and there is a lot in it for them, too, for us to make it.”

Moreover, “Nova Scotia is a really great size to be able to do things from a provincial perspective,” said Cascadden. “The fact is, we have been able to achieve provincial rollouts before, as with our Agfa PACS. We’re already in a good position in that we only have to integrate three hospital systems, and we have no private labs.

“So we are in a much, much better situation than a lot of the other jurisdictions to actually be able to pull this off.”

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CMA president backs physician IT, sees the need for new approaches

Dr. Brian Day notes that family doctors and specialists are essentially small business owners who face a free market for expenses and a fixed market for earnings. No wonder they’re slow to invest in computers.

Dr. Brian Day, an orthopedic surgeon and award winner for his research and innovations in arthroscopic surgery, has been called “Dr. Profit” for his outspoken advocacy of privatizing more of the Canadian healthcare system. Agree with him or not, Dr. Day speaks of what he knows. After BC government funding cuts had drastically reduced his operating hours in the 1990s, Dr. Day founded the Cambie Surgery Centre in Vancouver, a for-profit hospital which sees about 5,000 private patients a year. Day is both the Centre’s medical director and one of its 40 shareholders. Less well known about this soft spoken, Liverpool, England-born advocate is a career-long passion for what computers can do for healthcare. CHT Contributing Editor, Andy Shaw, recently visited President Day in his Vancouver consulting office.

CHT: Dr. Day, judging from what I see on your desk, and unlike how other Canadian physicians are sometimes described, you’re clearly not a Luddite when it comes to computers?

Day: That’s true. I started with computers back in the 1970s. It was a Radio Shack Tandy. Then later, together with Myles Clough, who was a resident, we wrote a paper on electronic medical records (EMRs) in 1980. I also had a summer student when we graduated to an Apple II. He got so intrigued he went down to Bellevue (in Washington state, the headquarters of the world’s largest software company) and has since retired as a Microsoft millionaire. Maybe I should have gone with him. And a few years back, I was CEO of a company that was going to develop EMRs but that did not work out. So, I guess I have just been ahead of my time.

CHT: What about your peers in Canada? By comparison to countries in Europe and elsewhere, where the uptake of computers by physicians is 90 percent or better, Canadian doctors are trailing the pack aren’t they?

Day: Well, we just did a national physician’s survey of the CMA, and 26 percent of our doctors now have electronic medical records. That’s progress, but it’s not good enough. Another survey from the OECD (Organisation for Economic Co-operation and Development, with 30 member countries) tells us that our spending on IT in our hospitals is only a third of the OECD average.
So we are backward in our spending. Our governments have just not fully recognized how important to healthcare information technology is. But I have to add that the CMA has done so. Our subsidiary, CMA Holdings, has a company called Practice Solutions that offers an electronic medical record system to doctors. We’ve also been talking to major software and communications companies about the possibilities for collaboration in this area. So as an organization, the CMA is definitely interested in IT.

CHT: What about from the family physicians’ point of view? What’s the barrier in their eyes?

Day: It’s partly an economic one. Physicians in Canada, for the most part, are small businesses that are placed in a very awkward position. On the one side, as small businesses they are exposed to a free market when it comes to their expenses – but they face a relatively fixed market for their earnings. Now, for them to upgrade their offices to an EMR requires both a capital expense and additional ongoing operating costs. The major benefits of that expense will go to the government and to patient care rather than to physicians. So there is no financial incentive for them. Governments here and there have come up with some financing to encourage doctors to invest in IT, but they need to step solidly forward and offer consistently available financing.

CHT: Does it work that way elsewhere?

Day: Yes. In Britain, for instance, family physicians are not paid on a fee-for-service basis. They don’t operate a private office as doctors do here. The facility in which they practice is owned by the health authority. So when they get new information technology it is funded for them. And that springs from an understanding on the part of government there that it is cheaper to invest in information technology than not to invest in it.

CHT: Why is IT such a good investment?

Day: For one thing, we have 24,000 avoidable deaths a year in our hospitals, many of which might be the result of lack of information, lack of data, and mistakes made in transferring information. All that leaves caregivers without the knowledge they need to give proper care. For example, a big story in the Vancouver papers here recently told how the paper record of positive test results in a mammogram had gone missing for two years. That’s an information transfer issue and we’re performing very badly on that particular score at the moment without IT.

CHT: The universal EHR supposedly will fix problems like that. What’s your view of the pan-Canadian EHR?

Day: There are three components to any health record: one is the hospital or institutional record; then there is the doctor’s office record; and also there is what Microsoft and others are pushing – the patient-based record. So the main challenge in Canada is to somehow get those three talking together and brought in line with each other. The CMA wants to get involved and help make that happen. One part of that challenge that we can help with is that there is a lot of distrust amongst physicians right now over the confidentiality issue. They are concerned that patient information, particularly any stored on line by an application service provider, can be hacked into.

CHT: As a physician yourself how do you feel about that?

Day: If I have a history of heart disease and I happen to be on vacation in Paris, France, it would be good, if I have a sudden chest pain, that the cardiologist over there can look at my ECGs and other records. So we’re wondering if there is a role for the Canadian Medical Association here – because of the distrust I mentioned. What people are worried about most is who stores the information. It may be that a body like the CMA could be involved as the “storage vault” or a central storage agency. I think doctors and patients may not trust government, and they may not trust a private technology company to store their information, but I think they are likely to trust the CMA.

CHT: Claude Castonguay’s report has just come out in Quebec. Its recommendations suggesting greater privatization of the healthcare system have hit the headlines across the country. But less noticed was its calling for more IT in healthcare. What do you make of that part of the report? Did it say anything new?

Day: Well Andy, Castonguay’s report was supposed to be de-politicized through having each provincial political party involved equally in preparing the report. Unfortunately, after its release, it has become politicized. The report rejects the status quo. Some of the media ignored significant and important proposals. Filling the “IT gap” was one of those, but other recommendations, such as patient-focused funding, dealing with the reality of unsustainable cost increases, and calls for increased accountability and responsibility were significant and constructive recommendations.

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Vancouver project allows access to electronic care plans and records

By Michelle Perrault

VANCOUVER – A new initiative, launched in January by Vancouver Coastal Health, uses innovative technologies and processes to provide whole teams of caregivers with access to the electronic records and care plans of their patients.

The CDM Care Connectivity Program is a two-year pilot project aimed at increasing system capacity and reducing demands on acute care services as a progressive step towards Primary Health Care system redesign.

The project makes use of a comprehensive, team-based approach, with primary care physicians as key players. It also encourages a more proactive patient.

At the core of this effort is the ability to share information across the care continuum, giving physicians quick access to data and enabling patients to obtain the appropriate services and support, when and where needed.

“Incomplete patient information is a significant challenge facing family physicians when caring for highly acute patients with multiple chronic conditions,” explains Dr. Garey Mazowita, head of the department of family practice at Providence Healthcare and medical director for the CDM Care Connectivity Pilot.

“This project addresses the gap by providing family physicians in their offices with electronic access to patient care plans, health records and other information to support care planning and decision making,” said Dr. Mazowita. “It can be as simple as being alerted when a patient has been admitted to hospital or finding out what medications they were prescribed upon discharge.

“This information enables us to follow-up more effectively and prevent the patient from ending up back in the emergency department, which is all too often the case.”

The CDM Care Connectivity pilot brings together family physicians, specialists, chronic disease nurses and other providers in a collaborative approach that is focused on developing and implementing:

• Shared Care Model – a team of clinicians working from and contributing to a single electronic care plan for each patient.

• CareConnect, VCH’s Electronic Health Record – enabling authorized family physicians access to CareConnect remotely, linking them directly to a shared care plan, patient-centric data and clinical information such as lab results, transcribed reports and health system encounters.

• Electronic Medical Record – used by the chronic disease nurse to collect medical histories, care plans, health targets and other patient-specific information. This information is used to create a Shared Care Plan for the patient and incorporates access to multi-disease protocols.

• Chronic Disease Nursing Role – nurses working with family physicians to proactively manage and support complex patients, using the Electronic Medical Record system as a key tool for collecting and sharing information with other health providers through the Shared Care Plan.

• 24/7 Telecare Service – provided by HealthLine Services of BC, patients have one number to call for round-the-clock assistance. The service links them to healthcare professionals who are trained to support patients with multiple chronic diseases and are available to provide advice when needed. They can proactively provide medication reminders, patient education, and counseling.

• Privacy/Access Standards – addressing the policies and processes protecting patient confidentiality and ensuring clinicians have appropriate access to information when and where required to support patient care.

“We know that patients with more than one chronic illness need more time and attention from their family doctors and require hospitalization more often than other patient groups,” said Dr. Heather Manson, Vancouver Coastal Health vice president and project sponsor for the CDM Care Connectivity Pilot.

“Our expectation is that by proactively managing these patients with a shared care model that emphasizes patient self-management and health promotion, we will reduce demands on the acute care system and improve the quality of life for these patients,” said Dr. Manson.

A cornerstone of the CDM Care Connectivity Pilot is the ability for clinicians to get access to the information they need. For example, when patients call the telehealth number, they are connected to nurses who can access their electronic care plans and provide advice and support. If a patient arrives in the emergency department, the attending physician can access this information via CareConnect.

“Timely access to information supports better decision making, which drives utilization of healthcare services,” explained Greg Feltmate, VCH chief information officer. “Without this information, most health professionals are limited in what they can do outside of the hospital setting. The CDM Care Connectivity Pilot is an opportunity to demonstrate the clinical value of technology at it relates specifically to patient care and to the health system overall.”

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Online patient records arouse interest at the 2008 HIMSS conference

By Jerry Zeidenberg

ORLANDO, FLA. – It was Google’s first appearance at the annual HIMSS conference in February, and the company was showing off the ‘beta’ version of its new product – Google Health.

As if exhibiting were a last-minute idea, the company had a modest booth that was nearly lost in a sea of giant corporate pavilions. That didn’t stop the attendees – maybe they located it through some kind of online search engine.

In the end, there was a crowd spilling over at the Google booth each day, eager to get a peek at the mock-up of its new online system

The masses were also found at Microsoft and Revolution Health, both of which have thrown their hats into the Personal Health Record (PHR) arena.

That’s one way of judging what the hot topics and trends are at a trade show – just follow the crowds. And attendees at the Healthcare Information Management and Systems Society conference were excited about PHRs.

There have been many who’ve pooh-poohed the idea of online, personal health records – essentially web-accessed, electronic health records that are controlled by patients. But PHRs are sparking a great deal of discussion, and companies, hospitals and patients are quickly moving into this new field.

Representatives from Canada Health Infoway were close observers of the PHR phenom at HIMSS, checking out the systems and talking with Google and Microsoft executives, among others.

The general consensus is that services like Google Health and Microsoft HealthVault still have a long way to go – especially when it comes to setting up shop in Canada and understanding the nuances of provincial privacy laws and EHR practices. But at the same time, the folks at Infoway realize that once internet titans like Google and Microsoft are involved, many others will follow and public awareness about online records is bound to be raised.

The momentum is certainly there. One of the educational sessions at HIMSS noted the existence of at least 120 online PHR services. Former America On-line (AOL) co-founder Steve Case is operating one of the biggies – it’s called Revolution Health, and Case gave one of the keynotes at the conference. For its part, Revolution Health already claims to have become the top healthcare site in the U.S. According to Case, “Revolution Health Network is now the largest health property on the Internet. Less than one year after launching, the Revolution Health Network generated 256 million page views in January, enabling it to pass WebMD.”

The site is at www.revolutionhealth.com

The idea of PHRs, despite the obstacles they face, is not so far-fetched. Sunnybrook Health Sciences Centre, in Toronto, has already launched something along these lines, called MyChart. It allows a patient to access his or her health records – drawn from the hospital’s own EHR – over the Internet. As a result, the patient has access to the information 24/7, wherever he or she might be.

Other Canadian hospitals have launched portals that also offer access to patient records, but most are incipient efforts that offer a slice of the hospital’s data.

For its part, Google is talking about building upon these models and allowing patients to aggregate their data from a wider variety of sources – with records from one or more hospitals that may house the patient’s data, along with information from labs, pharmacies and clinics. That way, patients could have a complete and up-to-date chart, all in one place.

Google plans to do it in a ‘virtual’ manner – data would stay put wherever it is physically housed, in hospitals, labs or clinics. But it would be pulled together by an integration engine, as needed. This is the Travelocity model – the travel booking service that calls up the latest rates and locations for hotels, plane fares and vacations from various databases, according to the needs of the user.

The snag? Healthcare data is notoriously complex, and tying databases together in this fashion may be the easy part. What’s difficult is getting the data to work together in common formats.

(For a deeper discussion of this problem, see our report in this issue on Kitchener-Waterloo’s regional cardiac database. Linking 10 different databases in real-time was easy, compared with collating the data types in a meaningful way.)

That’s assuming, of course, that electronic databases are available. In both Canada and the United States, many providers have yet to computerize their patient records. Most hospitals may be doing it, but how many doctor’s offices have shareable electronic data? In this country, possibly 20 percent, according to recent studies.

And just look at how long it has taken the Ontario Lab Information System to link laboratory results – after years of tinkering, it’s still in pilot mode.

Still, the clever young minds at Google are forging ahead. And in the long run, they just might accomplish what they’ve set out to do.

Already, they’ve struck up their own pilot project with the Cleveland Clinic to test Google Health. Like Sunnybrook, the Cleveland Clinic also uses MyChart. And as part of the project with Google, up to 10,000 patients will gain a Google Health account, which will be populated with MyChart data and information from the patients’ other caregivers.

Microsoft, on the other hand, is taking a somewhat different approach with its HealthVault product. Intead of creating a virtual record, the Bellevue, Wash.-based software giant is offering the means to store all of a patient’s health information in centralized repositories, or ‘vaults’.

What’s more, it sees the HealthVault as a platform that can be used by various partners – such as medical device manufacturers, as well as hospitals, associations and other organizations. So far, more than 40 partners have signed on or expressed solid interest.

And in a fascinating move for a company that has jealously guarded its technology in the past, Microsoft is now opening up much of the HealthVault system to partners, to make it easier to devise linkages and new solutions. (During the HIMSS conference, news came out that Microsoft was being slapped with a $1.3 billion fine for defying a previous European Union order to open up its technology to developers. Microsoft executives at HIMSS asserted that they’ve mended their ways.)

The advantage of working closely with medical device manufacturers, and others, is soon apparent. Once you’ve got medical device developers on board, you can collect data such as vital signs in real-time, and house if for up-to-date analysis and reference.

Chronic care patients could wear monitors that automatically upload data to a HealthVault. Patients, their families, and their professional caregivers could regularly check the results over time – and armed with alerts or trendline data, take a more proactive approach to the patient’s data than ever before.

Theoretically, this could translate into marvellous medical outcomes. One recent British study, for example, showed that when diabetic patients managed just a 1 percent drop in their glycemic HA1C hemoglobin level through consistent self care, diabetes-related deaths declined by 21 percent; strokes dropped 12 percent; and peripheral vascular disease that can lead to leg amputation sunk by a whopping 43 percent.

Of course, the Microsoft methodology has its problems, too. For example, where are the data ‘vaults’ to be located? Who is to be liable for the data in case of a breach or unauthorized use?

Microsoft executives say they’re interested in expanding the system to Canada, and currently, they’re conducting a careful study of the privacy laws in each province. “We don’t want to launch in just one province,” says Grad Conn, senior director of product marketing, Microsoft Health Solutions Group. “When we’re ready to go, we’d like to do a national rollout.”

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