CMA connects doctors and patients using new portal

By Jerry Zeidenberg

VANCOUVER – While U.S. heavyweights like Google and Microsoft are still spinning their wheels when it comes to establishing Personal Health Record systems in Canada, the Canadian Medical Association has surged ahead of the pack with an online portal for doctors and their patients.

The CMA and its subsidiary, Practice Solutions, announced the new portal, called mydoctor.ca, at a press conference in Vancouver at the beginning of April. The partners say the solution has been designed by physicians, and the goal is to improve the delivery of healthcare in Canada while simultaneously reducing pressures on overloaded doctors.

The announcement was presided over by Dr. Brian Day, president of the Canadian Medical Association, Larry Mohr, president and CEO of Practice Solutions, and Dr. Jay Mercer, medical director of CMA.ca and a well-known expert on electronic solutions in healthcare.

“Practice Solutions has built this solution because Canadian patients need better tools to manage their own health,” said Dr. Day. “Using the secure portal, patients can input and track their information, and communicate with doctors.”

In a demonstration, the team showed how users of mydoctor.ca can regularly input various types of data to monitor conditions, such as asthma or high blood pressure. Not only can physicians view the data – displayed as easy-to-read graphs – but they can also be alerted when the numbers are too high or too low.

In testing – 200 physicians across Canada have been using the system – that capability has already enabled doctors to catch problems in patients earlier than before.

Dr. Mercer described one of his own patients, a 77-year-old woman on medications whose blood pressure had dropped too far. Dr. Mercer could tell by glancing at the online graph – maintained with the assistance of her family – that her meds needed adjusting. He immediately sent message to her family asking them to bring her into his office for this purpose.

“The medication had lowered her blood pressure too much,” said Dr. Mercer. “There was a danger of her falling, due to dizziness.”

Dr. Mercer explained that the portal had allowed for improved care, as he could keep an eye on the patient’s health continuously, rather than on scheduled visits to his office.

“Important data was acquired outside my medical office, and it resulted in a decision – to alter her prescription – that likely kept her out of the hospital,” said Dr. Mercer.

It’s the tie-in with the doctor that gives mydoctor.ca portal an advantage over many other Personal Health Record (PHS) services, which have been proposed as ‘warehouses’ enabling patients to consolidate their health information.

That concept certainly has value – a patient’s data can be scattered across many sites, from hospitals and doctor’s offices to many types of therapists, and can be difficult to access when needed. A central repository of some type would go a long way to resolving this problem.

However, the CMA’s mydoctor.ca is a more active solution.

“That’s where we’re different,” said Larry Mohr, president of Practice Solutions, the CMA subsidiary that has spent several years developing the system.

“We think we’re adding value by including the active supervision and coaching of patients by their physicians.”

The system will be offered to CMA members at a cost of $240 a year; it will be up to doctors themselves whether they want to charge patients for using the system.

So far, mydoctor.ca consists of three components:

• an electronic health record;

• secure messaging;

• and tools for treating patients with chronic conditions.

At the moment, three types of chronic problems can be tracked – asthma, high blood pressure and obesity. More solutions are in the works, such as diabetes, and instruments have been tailored to work with the system so that various readings can be input by patients and tracked by caregivers.

Moreover, applications such as online prescription renewals and appointment scheduling are envisioned for the future.

It was noted that the portal is secure because it’s a closed system. “It’s not on the Internet,” asserted Mohr. He explained that the portal can only be accessed by registered doctors and patients, and that their information can’t leave the system without their permission.

Moreover, patients can house their records on the system and determine which information can be seen by various care-givers – and which information is blocked.

“The patients are really in control,” said Dr. Mercer. “We’ve given them the ability to decide who gets to see what.”

Dr. Tim Foggin, a Vancouver family physician, has been testing the mydoctor.ca portal and gave his impressions at the launch event.

“I’m looking for tools to help myself and my patients,” he said. “But the tools must be easy to use, useful, they must improve care, and they must not add work for myself or my patients.”

He endorsed mydoctor.ca because it passed all of the tests he had set for it. He noted that the portal allows him to keep closer tabs on his patients, because of the continuous monitoring of vital signs and other indicators of health. Moreover, because of the secure messaging, it has saved a lot of time and trouble for patients.

“It has saved them trips to the office,” said Dr. Foggin, who pointed out that on many occasions, a short email exchange between doctor and patient can resolve an issue.

The monitoring and communication between caregiver and patient, he said, is bringing back “personal touches to family practice. “It’s the modern-day version of a home visit,” he said.

Dr. Day observed that “better use of technology is a key plank in the CMA’s drive to improve care in Canada.” He said the mydoctor.ca system will be expanded and refined in the future.

For example, right now it’s aimed at general practitioners and not specialists. But in the years to come, features that will be of use to specialists such as himself – an orthopedic surgeon – will be added. These will include access to diagnostic images, such as CT and MRI scans.

He observed that by consolidating information, the portal will reduce the need for duplicate tests, thereby lowering costs to the healthcare system and speeding up care for patients.

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Surgeons improve results with innovative solutions

By Andy Shaw

Coast-to-coast in Canada – and at leading centres in the United States – surgical technologies are being rapidly developed. In some cases, surgeons are implementing brand new techniques that are producing stellar outcomes. In others, it’s the whole process of surgery – the movement of patients through the operating rooms – that’s being improved.

In Halifax, for instance, Brain Repair Centre chair Dr. Ivar Mendez has helped make neurosurgery more orderly, planned and precise by adding two biomedical engineers to his operating room team.

“We need them nowadays because computer and imaging technology has become such an integral part of working on the brain and the spine,” says Dr. Mendez.

The engineers ensure the calibration of technological aids remain accurate, thereby allowing the surgeons to first plan, then find their way, and next make their exacting cuts – all with greater confidence.

“Now we can reach areas that were unreachable before, or take care of tumours that were so complex we couldn’t treat them before,” he says.

Never-done-before treatment of brain and spinal disorders is also being advanced at the Brain Repair Centre using a new-age technique that Mendez and staff call “Deep Brain Stimulation” – a therapy that also demands well-planned, image-guided navigation.

“In Deep Brain Stimulation, we are integrating electronic systems with organic matter,” says Dr. Mendez. “We insert small electrodes into the brain and deliver electrical current to specific areas that are the root of Parkinson’s disease and other movement abnormalities.”

Such electronic intrusions can have dramatic effect, often instantly stopping tremors that have shaken patients for years.

Deep Brain Stimulation by nature is also systematic.

“We do this kind of surgery in a virtual environment with a computer first,” explains Dr. Mendez. “So we can first plan the areas where the probe is going to enter the brain, the trajectory of the probe through the brain and the target we want to reach. Then, when that’s all done, the data are transferred to a special frame around the patient’s head and then we do the actual operation.”

In addition to computerization and imaging technologies, new biological approaches are in the works.

“What we’ve done mostly until now is to go into the brain to take out a tumour or to clip off an aneurysm. Today, what we are working on is not taking out but adding new cells to the brain – stem cells and others which when properly placed can repair the circuits that have been damaged either by disease or injury,” says Dr. Mendez. “So, here in Halifax we have developed micro-injector systems that are controlled by computers and can place cells in any part of the brain we choose. I believe this kind of cell therapy is going to be a very important part of our future.”

New therapies also loom large in the future at the Vancouver General Hospital, where Dr. Anthony Papp and his team are pioneering the use of ‘hydro surgery’. Dr. Papp is the medical director of the BC Professional Firefighters’ Burn Unit at VGH and a world-leading expert in the use of what, in effect, is a salt water-driven scalpel.

“Our hydro surgery system is a Versajet machine that consists of a console that pumps saline into a hand piece. It has at its head both a suction opening and a very powerful, tangential water jet,” explains Dr. Papp. “You can set the power of the jet from 1 to 10 and make it work like a blade. So you can clean up wounds in very difficult anatomical areas where a blade might not reach, plus you remove less tissue at a time. Also, whatever blood there is, or dead tissue that you’ve removed, it can all be sucked out right away.”

This unprecedented cleanliness of the wound bed, and the thin-slice precision of the water jet, results in healthier dermis, the major layer of skin. So healing is faster and the disfiguring scarring associated with burns is reduced to a minimum, improving the whole process of care.

“In the past, burn patient dressings were taken down every day, sometimes two or three times a day, to clean the wounds and then apply new dressings. So, you were torturing the patients daily,” says Dr. Papp. “Now by using hydro surgery, the wounds are so clean we can put a dressing on that lasts a week. That means if a burn takes two weeks to heal, we only do two dressing changes, instead of 20 or more as we did before.”

The beneficial impact that has on the whole system of looking after burn victims is significant. The demands on nursing time, the need for pain control, and hospital stays are all decreased.

Says Dr. Papp: “Once patients are treated, they can go home and then just come back to the burn clinic once a week for a dressing change. It makes life way easier for everyone.”

Another innovative therapy – also involving water – that’s under development by Dr. Papp might also be applied to burn victims. Eventually, it could also make the treatment of cardiac and transplant patients easier and more systematic.

Dr. Papp is beginning a study using a “di-electric measurement” tool.

“It’s a device that has a probe you put in contact with the burned skin and it sends out a painless electromagnetic wave into the different layers of tissue underneath,” he explains. “It gives you information about the amount of water being held by those different layers. That in turn tells you how deep the burn is.”

Knowing the depth of the burn is crucial to the timing of treatment. Today, it can take up to 72 hours before the burn depth is known and surgical treatment can begin. Animal lab tests have shown that the di-electric probe can determine burn depth within 8 hours. So Dr. Papp estimates the burn unit could save VGH and the burn victim another two days of hospitalization.

“But also, let’s say you are in the ICU (intensive care unit) after cardiac surgery and they are giving you huge amounts of fluids, or say you’ve got renal failure and you are in dialysis, a non-invasive de-electric probe could tell whether your fluid load is at the right level,” says Dr. Papp.

While Dr. Papp continues his hydro surgery research and development at VGH, the hospital is also equipping itself with the latest in surgical robots. Last fall, VGH joined the handful of Canadian hospitals that fully employ robotic technology in the surgical care of urology, cardiac, and gynecology patients. Two large private donations totalling $4.5 million will support a three-year project that is centred on the purchase of a da Vinci S High Definition surgical system and attendant implementation and training, costing a total of $6.5 million.

Meanwhile, at the University Health Network, in Toronto, there’s a push to incorporate technology into the surgical departments. But it is information technology that’s the main focus.

If you walk into office of the UHN’s chief surgeon, Dr. Bryce Taylor, you might expect to see his wall lined with university degrees, family snapshots, vacation photos, and other memorabilia. But not a head-and-shoulders shot of Matt Anderson, UHN chief information officer, beaming beatifically out at all who enter.

(Editor’s note: At press time, it was announced that Matt Anderson had been appointed CEO of the Toronto Central Local Health Integration Network – in recognition of his leadership qualities at the UHN.)

“There’s a reason why Matt’s picture is on my wall, and I am on his, because to me, our biggest way forward in surgery is to be able to document, to be able to record what we do – and to make the patient’s experience more efficient by the deliberate, organized sequential capture of data,” says Dr. Taylor.

“We’ve put together a plan which I hope is going to be embraced by Matt’s group and we call it SPIRES,” says Dr. Taylor, as he pulls out a schematic of UHN’s end-to-end surgical process.

“I like acronyms, and this one especially, because we are really going to be pushing it,” says Dr. Taylor. “SPIRES stands for Surgical Programs Information Retrieval and Enabling System. And it reflects just how much we think of IT in our surgical planning.”

Taylor says about a year ago, he began analyzing UHN’s surgical workflow and patient care from end to end.

“It starts with patient referral, to the surgeon’s office, to pre-admission, admission, operating room, PACU (post-anesthetic care unit), surgical admission, in-patient unit, and then the follow-up visit,” comments Dr. Taylor, who says he was originally motivated to become more systematic when Ontario first announced its plans to battle the province’s overly long wait times.

“When the wait times project came on, the secretaries would book one of our cases and then go over to the wait time system and book it again. And I knew they were going to hate us if that continued. So about four years ago, I said we have to develop a system where you can electronically book a case and at the same time populate the data required by the wait time system – and we called the electronic document we now use for that our ‘e-form’.

The UHN e-form imposed a new discipline on the scheduling of patients and importantly, the surgeons who operate on them.

“So now, the surgeons’ secretaries can’t book a case until they book the date of consultation, the decision to operate, the date of operation and so on down the line of our whole process,” says Dr. Taylor.

Giving direction as to what and how they want things done, in no uncertain terms, is not new to chief surgeons, of course – especially ones who have been star quarterbacks, as Bryce Taylor was in the 1960s for the University of Toronto Blues, then a football powerhouse.

“I gave our surgeons a choice, because you always have to give people a choice,” says the still commanding Taylor. “I said, you can either use the (e-form) system to book your case – or you don’t operate here. That was their choice.”

Not surprisingly, concludes Taylor, things get done they way he likes them now, that is, electronically, and the secretaries, he reports, are happy, too.

As part of what’s now his SPIRES initiative, Dr. Taylor has borrowed a technique from the auto industry called Value Stream Mapping, or VSM for short.

“Toyota uses VSM, and what you do is get a whole lot of people involved in your production process together and first talk about your process,” explains Dr. Taylor. “Then you look at and dissect every little thing that happens in it. Finally, you produce from all that information what’s called a ‘spaghetti diagram’ of your complete process. And what you inevitably find is that your process is too convoluted and inefficient. So then, what we did was to ask our group for suggestions as to how we can make our patient flow more efficient, more manageable and less mistake prone.”

Based on those suggestions, as Dr. Taylor explains, the next step is to select one segment of that convoluted VSM map and apply agreed-upon suggestions for streamlining that part of the process. This step is referred to as a “Rapid Improvement Event” or RIE.

“In the RIE, you create changes in the map that can be monitored and measured for their effect,” says Dr. Taylor. “And that is where Matt and his staff have helped us tremendously, in the peri-operative mapping of what happens to patients before and after their operations. And I think, as a result, we’re making the patients feel that they are being treated in the way they want to be treated.”

Similarly, in Boston, process has become primary – especially inside the OR. As the Center for Integration of Medicine & Innovative Technology (CIMIT), a collaborative of teaching hospitals in the Boston area has noted:

“Traditional operating rooms are inefficient and overcrowded. Patient data are not integrated and displayed to caregivers in a timely fashion, and turnover time between cases is lengthy.”

Seeking to change that is a CIMIT-backed project at Massachusetts General Hospital (MGH) dubbed the “Operating Room of the Future” (ORF). The ORF at MGH is no mere vision of what might be. It’s a real OR that even has a history.

Launched in 2002 by CIMIT, the ORF experiences a steady flow of patients undergoing both minimally invasive and open surgery – but all the while the ORF is also “…a living laboratory that explores new technology platforms and systems of care.” In doing so, the ORF puts a premium on “…accurate data capture and analysis, multidisciplinary teamwork, and thoughtful integration of technology.”

Thoughtful is the key word – thoughtful enough to reject even the hottest new technologies, if they don’t cut the mustard in the ORF.

“Yes, we’ve killed a couple,” admits one of the ORF’s three project leaders, Dr. Warren Sandberg, with a gentle laugh. “Within our own context – and that may be different than another hospital down the road – but within the ORF, we had high hopes for sophisticated supply cabinets that would allow us to update our inventory as we removed items from the cabinet.

“But it didn’t work out for us, for a couple of reasons. First, people did not reliably log the removal of items from the cabinet. So we tried to address that with RFID tags. But the tags we had then were expensive and big. Often the tag cost more than what it was identifying and it could also obscure the label – so you didn’t know what you were taking out of the cabinet.”

While RFID technology has at least temporarily fallen out of favour at the ORF, other new approaches that have passed the test are not necessarily high tech, including ceiling booms and “parallel processing”.

“When we opened the project six years ago, the feeling was that ceiling booms were nice, but a kind of expensive indulgence that didn’t provide any core functionality,” says Dr. Sandberg. “But minimally invasive surgery requires a lot more equipment – like pumps, camera controllers and light sources – than you would use for traditional surgery, and it all has to be close to the patient. Until the advent of the ceiling boom, that equipment tended to be rolled around on big trolleys about the size and shape of a refrigerator.”

In addition to blocking easy movement within the ORF, those rolling hulks all had to be set up and plugged in, in different ways for each operation and patient.

“So it was a tremendous amount of work for the nursing team to configure all that equipment, and that created conflict with their primary responsibility of looking after patients, not equipment,” says Dr. Sandberg. “But by putting all the equipment on booms, you can move it around to where it needs to go very easily, by just pushing a button.”

Would that moving patients around thoughtfully was as easy. “In a traditional operating room; the room is set up, the anesthesia team brings the patient into the room, the patient is anesthetized, surgery happens, the patient emerges from anesthesia and is then wheeled out. Finally, the OR is cleaned and set up again,” says Dr. Sandberg. “That’s a linear process – one activity follows the other.”

But in the parallel processing model that the ORF has instituted, activities happen at the same time.

“For instance, the anesthesia team anesthetizes the patient in an induction room separate from the ORF, while it is being set up.” says Sandberg. “That sounds simple enough, but we found it has a rather remarkable effect. We found that people don’t hurry in that mode. Both the anesthetists and the nursing team in the OR know they will wait for each other and only roll the patient in when both the patient and the OR are truly ready.”

With no time spent anesthetizing patients in the OR, more operations can be scheduled each day. “Several other centres have copied our ORF model, because our research has shown that the additional throughput and subsequent higher revenues it generates more than outweighs the cost of building a separate room for the anesthetists,” says Dr. Sandberg.

In the Canadian setting, more efficient throughput would translate into reduced waiting times for surgery. Similarly, the ORF has doubled up the processes of patient information and the reporting of surgery carried out on the patient.

“A perioperative nurse staffs the induction room, where she assembles all there is to know about that patient. But she also staffs the recovery room, where the patient comes out of anesthetic and where she compiles our surgical reports,” says Dr. Sandberg. “She also comes into the OR and can see for herself what’s happened to a patient beforehand and even ask questions of the surgeons. So, little time is spent [by clinical staff] making reports while we’re trying to get the operating room ready for the next case.”

In other words, the process has reduced non-operative time in the ORF to a minimum. “In most university hospitals in the United States, the average non-operative time in an operating room is about 65 minutes,” says Dr. Sandberg. “In the OR of the Future model, we can reduce that by 50 percent.”

Meanwhile, the ORF does indeed apply the computer to a number of its processes – including what Dr. Sandberg terms “automatic process monitoring and process control.”

“We are striving to put the right information in front of the right people, just before they need it, says Dr. Sandberg. “We are very heavily invested in electronic documentation – so that everyone looking after the patient is sharing the same information about that patient. Sounds easy, but it is difficult to do. So at the ORF, right now, we’re working very hard on making that happen.”

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New report examines strengths and potential problem areas of RFID

By Andy Shaw

Dianne Beattie, CIO and VP of Information Management at the London Health Sciences hospitals in southwestern Ontario, succinctly noted the value of RFID technology at a recent conference in Toronto.

“We were considering buying 700 new infusion pumps that we felt were badly needed and that were going to cost us about $7 million,” Beattie told the audience. “We realized that by using RFID and knowing where they all would be at all times, we would need far fewer pumps. And so we saved ourselves a half-million dollars.”

Beattie said they are not tagging people yet at London Health Sciences, but that the experience with RFID so far is encouraging them that way.

Beattie made it clear that RFID, implemented the right way, can have dramatic clinical and economic benefits for hospitals – which in Canada are all cash-strapped and are desperately seeking the biggest bang for their investment dollars.

Beattie was speaking at the event with Paul Tsaparis, head of Hewlett Packard Canada, and Ann Cavoukian, Ontario’s Information and Privacy Commissioner. They braved a wintry day in March and took to the stage together at the MaRS Centre in downtown Toronto to formally launch a joint report on Radio Frequency Identification (RFID) technology. The report, RFID and Privacy: Guidance for Health-Care Providers, is intended to answer questions about what some have seen as a questionable healthcare technology.

CEO Tsaparis opened the breakfast briefing head-on, facing up to the questions the pithy 33-page report strove to answer. Commissioner Cavoukian followed with illustrative RFID tales stemming from her own experience as a patient. HP Canada’s Chief Technology Officer (CTO), Victor Garcia, co-author of the report along with Cavoukian, then outlined the benefits RFID users have experienced in other countries. A small chorus of RFID supporters and observers followed with insightful comments. The show then closed with an on-stage panel discussion involving all the players.

In short, here are the questions about RFID as Tsaparis and the report posed them, followed by a terse summation of what the report and its presenters gave as answers.

What, asked Tsaparis for openers, are the general implications of using RFID technology in healthcare? Enormous efficiency, cost and life-saving benefits providing caution is exercised.

What are the privacy implications of using RFID? It depends whether you’re hanging RFID tags on things or people.

Is it acceptable privacy-wise for you to tag and track medical equipment? Absolutely.

Is it similarly acceptable for you to tag and track patients? Yes, providing you take precautions.

Finally, beyond tagging equipment and patients, can your use of RFID be a threat to your patient’s privacy or security in any other way? Yes, if careless RFID data gathering enables unauthorized snoops to put 2 + 2 together about patients.

Wisely, both its launch-day advocates and the RFID and Privacy report took pains to answer two more questions that were more fundamental:

What is RFID? And what is privacy?

“RFID,” said the report, “is a contact-less technology that uses radio frequency signals to transmit and receive data wirelessly, from a distance, from RFID tags or transponders to RFID readers.”

Like other information technologies, Tsaparis pointed out, RFID enables users to “capture, manage, and act upon reliable data.” And therefore, it inherently has the potential to do both good in the right hands and evil in the wrong ones.

Users of RFID, including some 400 hospitals in the United States, as CTO Garcia pointed out, are using the technology in various ways to answer:

• What do we own by way of equipment and other tangible assets?

• Where are all those assets right now and where have they been?

• What and who are authentic, including caregivers and drugs?

• What should never be separated from each other, including surgical instruments left in patients?

• What’s the right prescription, the right drug dosage, and the right timing for this patient or tripping an alert when they appear not to be?

• Who can go where with what so that, for instance, a hospital can allow access to babies only to RFID-tagged maternity room nurses or mothers and limit how far they can roam?

With such functionality, said Tsaparis, RFID should be seen as a highly strategic asset to a hospital, but he acknowledges it also can be thought of as a liability. “I have to admit that when people think of RFID, their minds tend to go to that sense of liability.”

Enter Cavoukian, stage left, armed with her X-ray slides of her own broken and now pinned shoulder, to answer, What’s privacy? And to explain how it can safeguard against RFID liabilities.

First, though, she pointed out what privacy is not, or more specifically, as guardian of the peoples’ privacy in Ontario, what she’s not concerned about when RFID tags are being slapped on.

“If you’re tagging things, surgical items, sponges, scissors and the like, be my guest,” said Cavoukian, as she showed an X-ray image of a patient with a pair of scissors sewn securely inside. “There are enormous benefits to preventing that, and you can do so without concern for privacy.”

But tagging a person, that’s definitely a concern.

Privacy as Cavoukian and the RFID and Privacy report see it is:

“…the right of an individual to exercise control over the collection, use, disclosure and retention of his or her personal information.”

Further, the personal information that people have the right to control is defined very broadly: “Almost any information, if linked to an identifiable individual, can become personal in nature, be it biographical, biological, genealogical, historical, transactional, locational, relational, computational, vocational, or reputational.”

That clear legal right and wide-ranging definition are enshrined in Ontario in a law Cavoukian helped to create in 2004 called the Personal Health Information Protection Act. It’s similar, it should be noted, to personal health information laws in other Canadian jurisdictions. So proceed with caution, advised Cavoukian, when applying RFID to your human assets.

What you need to do at the outset, she advised, is to conduct a ‘Privacy Impact Assessment’ or PIA, while proudly waving a PIA template developed by her office specifically for RFID, which was due for release at the end of March.

“It will help you identify the risks of RFID if you are contemplating implementing it and show you the best way to protect against them,” said Cavoukian. “We walk you through the planning steps, the architecture, and the IT options you have.”

Where even the best laid RFID plans can run into trouble is in what Cavoukian described as a third “grey area” that lies between tagging people and tagging things. It is, she said, the hardest of the three to address.

“It comes up when you start tagging things that are associated with people,” said Cavoukian. “Like a badge on a doctor, or on a patient, or on a piece of equipment, or on a drug. Individually, these tags do not carry or communicate any personal information. But if the data is leaked, it can be linked together in a way that becomes personal information and therefore a privacy concern.”

HP CTO Garcia later cited, as an example, a situation where RFID tagging showed that a clinical specialist, certain drugs, and a kidney machine were all in a certain patient’s room. That could signal to a snooping insurance company, the media, or other unauthorized parties that the patient was suffering from renal failure.

The lessons are clear: Don’t collect or aggregate this kind of data if you don’t need to. And practice ‘data minimization’ wherever possible.

Examples of benefits to RFID users who had done just that were part of the worldly CTO Garcia’s presentation and talk.

“It’s been our experience at HP, first of all, that hospitals may carry as much as 25 percent too much inventory and that RFID can help them reduce that. It can increase the efficiency of their inventory management,” said Garcia.

“And we also know that RFID-enabled equipment tracking and tracing can save as much as a third of staff time needed to look for equipment like laptops or handhelds. An ROI study of a hospital in Richmond, Virginia showed that it had paid for its $250,000 RFID system in 18 months.”

Continued Garcia: “RFID has also proven to be a very useful safety tool because it can differentiate automatically and consistently between products or drugs that may sound alike, such as Celebrex and Cerebryx, but which treat very different conditions, with very different effects.”

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The three Rs of medical quality: Reminder, Record and Review

By Clayton L. Reynolds, MD

To date, most physicians in clinics and hospitals have delivered healthcare in a non-standardized fashion. The range of treatments applied to particular diseases can be quite wide – and the clinical outcomes rather varied.

It has been argued, with good reason, that evidence-based medicine would reduce that variation, and would result in better outcomes and overall improvement in the quality of healthcare. In this article, I suggest that incorporating clinical practice guidelines – a form of evidence-based medicine – directly into Electronic Medical Record systems would lead to dramatic improvements in healthcare quality.

In brief, the electronic medical record can be a boon as we try to apply, use and evaluate the effectiveness of clinical practice guidelines (CPGs). The EMR cannot replace the process of construction of the CPG, but it can make their distribution much easier and more complete than a paper-based system.

Through integration with the EMR, clinical practice guidelines can be made available in a uniform way throughout a clinic – with a single version disseminated to all caregivers. That immediately eliminates a major problem with paper documents – namely, they tend to circulate in multiple versions, many of which are out-of-date.

Any EMR could be customized to display clinical guidelines, using a ‘dashboard’ approach and word processing and spreadsheet programs. Moreover, as providers employ the EMR in their daily use of CPGs, they can send messages by internal email to the clinic managers, who can make appropriate use of comments to revise and improve the CPG. As a result, there is quick and continuous feedback that allows clinics to develop the most effective guidelines.

Chart reviews: A curious thing happened in 1999 that brought me to a new understanding of the relationships among several facets of quality of care.

I had done a medical chart review on patients with hypertension. The review showed poor compliance with the criteria that I had used in setting up the review.

Discussion with the providers in my department revealed that poor compliance was linked to poor knowledge of the guidelines. In fact, the guidelines had never been presented to the providers in my department!

We easily concluded that the guidelines should be presented to all members; they should be available to everyone at all times while seeing clinic patients; and the providers should record relevant aspects of their care of patients with hypertension. Then, and only then, could one apply a meaningful review to check compliance.

Having seen these factors at work, I developed the theory of the ‘Three Rs’ of healthcare quality – Reminder, Record and Review. While initially devised through my experience with the hypertension review, the process could be easily applied to any and all patient encounters.

Theory of the three Rs: Right off the bat, a clinical practice guideline serves as a Reminder to the provider of what actions are required for particular patients or groups of patients. The provider performs the work (i.e., follows the guideline) and enters the information in the medical Record. Then a Review of the recorded data is performed to see if the guideline was followed.

Clinical application of the theory: Now, to understand how this theory applies to all aspects of patient care, I had to change my idea of what a clinical practice guideline is. It isn’t simply a set of cookbook rules put out by a national organization.

Instead, a clinical practice guideline is any rule that a clinician uses to determine the management of any aspect of a patient’s care under any given set of circumstances.

A clinical practice guideline can be formal or informal. It can be written or verbal. It may be old or recent. It can be explicit or implicit. A CPG can be valid or invalid. A CPG can include elements pertaining to the evaluation of patients and their problems, recording of data and management of patient populations and their medically related problems.

In short, a clinical practice guideline exists for every clinical decision the healthcare provider makes.

Let me give two brief examples:

• A provider encounters a patient with anxiety, goiter, low serum TSH and normal serum free T4. The provider decides that the patient has hyperthyroidism and starts treatment with anti-thyroid medication.

The clinical practice guideline followed in this example is that a patient with symptoms of hyperthyroidism, goiter and low TSH (even with a normal free T4) has hyperthyroidism and should be treated.

• A provider encounters a patient with anxiety, goiter, low serum TSH and normal serum free T4. The provider orders a serum free T3 measurement.

The clinical practice guideline being followed in this example is that a patient with symptoms of hyperthyroidism, goiter, low TSH and normal free T4 is not diagnosed to have hyperthyroidism (and hence should not be treated with anti-thyroid medication) until at least one of the serum thyroid hormones is shown to be elevated. This CPG uses the concept of ‘subclinical hyperthyroidism’ and recommends that no anti-thyroid treatment be instituted if the two circulating thyroid hormones are within normal range at the time of testing.

Ideally, providers must be informed which of the two stated clinical practice guidelines is to be followed in their clinics. Thereafter, providers can be held to the stated CPG.

Administrative application of the theory: There are several steps in the process of implementation of any clinical practice guideline:

• construction of the CPG and agreement on its wording;

• distribution of the CPG;

• ascertaining that the text of the CPG is available for use by providers at all times;

• performance of reviews, for evaluation of compliance with the CPG;

• distribution and discussion of results of reviews; and

• modification of the CPG and reiteration of steps 1 through 5.

Ironically, each of these steps is also a barrier to the implementation of the CPG. Who is to construct the CPG and what published data should be used? How should the CPG be distributed, considering that the CPG may apply to providers in a variety of clinics? Whose job should it be to monitor the availability of the CPG in a particular clinic? Who should perform the reviews for compliance? How should the review results be displayed and discussed with the providers? Who determines that a modification of the CPG is necessary and carries out the changes?

As any provider who has done chart reviews can attest, reviews of paper-based medical records are time-consuming, inefficient, error-prone and frustrating. Let’s see how computerization can help.

The role of the Electronic Medical Record: The EMR can make available the clinical practice guidelines in full text or as a summary, and in a diagnosis-specific presentation. The EMR can be used to modify an official version of a CPG to conform with local conditions.

The EMR has the capability of line item display, an important feature for those CPGs which have multiple elements – witness the need for A1c, urine albumin/creatinine ratio and lipid measurement on different time schedules in diabetics. And the EMR can use a dashboard display, to show the provider what elements of a CPG are up-to-date for a particular patient at any given date of clinic visit.

The EMR can easily handle requirements for diagnostic or therapeutic procedures and act as a clinical decision support system. For example, when a provider orders a CT of the head, an icon can appear, indicating the guidelines for appropriate ordering of a CT scan (e.g., the Canadian Rules for CT Scan of Head in Trauma Patients), are available for viewing. The provider will have the option of viewing or not viewing the guideline and of not following all elements of the guideline, even when viewed.

In the instance in which the provider elects not to follow the guideline or any particular element thereof, the provider can be asked to give an explanation. In this way, each user becomes part of a CPG virtual development team. Over a period of time, the guidelines become more relevant to day-to-day practice. Real clinical outcomes (not just simple statistical data such as the percentage of female patients over 50 years of age who have had a mammogram) can be tracked and related to the use of specific guidelines.

EMR-enabled display of CPG-related data: Two dimensions of the display of CPG-related data have already emerged.

The first dimension uses the ‘dashboard’ metaphor. Patient-specific information is projected onto the computer screen when the healthcare provider is either seeing the patient or perusing the chart for adherence to the elements of the CPG. The dashboard will reveal current line-item information that details those elements of the CPG which have and have not been met. The provider can then order the missing elements.

Usually, this process will be carried out by medical staff, although others can be trained to perform this task. This information would not normally be accessible to any third party.

The second dimension involves the export of data derived from completed CPGs to a word processor or spreadsheet program. The data can then be redacted, manipulated and collated for transfer to the province (or third-party payor in the U.S.) for reimbursement. Financial incentive programs based on compliance with specific disease-related CPGs are in effect in the United States as ‘Pay for Performance’ and in British Columbia as ‘Expanded Full Service Family Practice Condition-based Payments’.

The British Columbia Medical Association, in collaboration with the British Columbia provincial government, has established its program to incentivize general practitioners and family physicians to comply with three specific CPGs.

Quoting from their brochure: “This incentive program is aimed at supporting high quality management of congestive heart failure, diabetes and hypertension. Physicians will now receive an annual payment for each patient with diabetes and/or congestive heart failure whose clinical management is consistent with recommendations in the BC Clinical Practice Guidelines. In addition, an annual $50 incentive payment is now available for BC Clinical Practice Guidelines treatment of hypertension where this care is not part of treating diabetes or congestive heart failure.”

Both Pay for Performance and Expanded Full Service Family Practice financial incentive programs would benefit from application of the new theory. In order for providers to comply with the line-item CPGs, they must know what the elements of each CPG (the Reminder) are, and they must be able to document which elements have been met (the Record). Then they must be able to export the provider-specific, patient-specific and CPG-specific information for use by third party payers (the Review).

In British Columbia, the physicians use Flow Sheets to remind themselves of the elements of the CPG. Data related to each element (e.g., hemoglobin A1c in the management of diabetes) are entered into the flow sheet (the Record). The Reminder and the Record are one and the same. The third part of my theory refers to Reviews of such data. While I see no mention of a Review mechanism in the BC document, it is likely that eventually, such a mechanism will be instituted.

Quality of healthcare and this theory: If quality in the healthcare field means, ‘Doing the right thing at the right time to the right patient or population and using the right resources,’ then application of the theory of the three Rs will be highly beneficial in ensuring and documenting high quality of care.

The theory of the three Rs helps guide the process of CPG construction, implementation, evaluation and improvement. The clinical practice guideline is the Reminder of what to do; the written case is the Record of what was done; and the Review matches each of the other two elements of the theory. These three Rs are identical. When used in an integrated fashion, they represent the vanguard of improvement in quality of healthcare.

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Affordable digital radiography solution at rural Alberta hospital

By Andy Shaw

Tourists passing by Vegreville, Alberta know it best for the exquisitely patterned, yet giant, 5,000-pound Ukrainian Easter Egg towering nearly four stories high over the Trans-Canada Highway at the edge of town. But radiologists and diagnostic imaging directors among those travellers should stop in for a look-see at something not nearly so obvious, but equally impressive to its users – the state-of-the-art digital radiography (DR) installation at the small St. Joseph’s General Hospital.

For about a year now, the DR system from Imaging Dynamics Co. (IDC), in Calgary, has transformed diagnostic imaging at the 25-bed community hospital into what its users say is a filmless, cassette-less, and mostly paperless wonder.

“It has done a lot for both our imaging staff and our patient care, but it’s our radiologist, Dr. Bernard Caplan, who is thrilled with it most,” says St. Joseph’s director of diagnostic imaging Ellen Johnstone. “He says the images from our IDC system are not only the best he’s ever seen, but because of the efficiencies of the system, before Dr. Caplan leaves at the end of each of the four days a week he spends with us, he has reported on all the imaging we did that day. So, referring physicians can get Dr. Caplan’s reports not within 48 or 72 hours as in the past, but now within 12 hours or less.”

IDC, specializing solely in affordable digital radiography systems, began as a little Calgary company that could. Established in the early 1990s, IDC has taken on the giants of the medical imaging industry and in lone cowboy-style ridden its patented DR technology and Charge Coupled Device (CCD) cameras to 38 countries, including China.

IDC’s X-series of DR products competes successfully for cost and quality-conscious imaging buyers not only looking for medical applications, but also those in orthopaedic, chiropractic, and veterinary markets.

IDC’s selling points are the significant advantages DR systems generally have over film-based radiography and computed radiography (CR) systems:

• DR involves no environmentally unfriendly or costly chemicals, nor any office space-hogging storage of processed film;

• DR generates high resolution X-ray images with low radiation dose; and

• DR’s digital camera CCD technology has stood the test of the universe’s toughest proving grounds – aboard other imaging devices including the Hubble space telescope and the Mars rovers.

If there is any drawback to DR, it is the quality of the image is only as good as the quality of the software that’s interpreting the images produced by the CCD camera detectors. Something researchers and developers at IDC are keenly aware of.

“The quality of our images is really IDC’s hallmark,” says IDC’s Seattle-based vice-president of western sales, Rex Harmon.

The IDC X-Series imaging technology can produce over 16,384 shades of gray working with the CCD’s 16 megapixel images, which are digitized at 14 bits per pixel. In addition, the software ensures that each pixel is filled out to its fullest. The result is that low radiation dosages are producing high resolutions – quickly.

“DR is faster than CR because unlike CR, there is no handling of cassettes. You take your picture. You see it immediately. You say, yah, that one’s OK. You take your next picture, and so on,” says Johnstone. “By the time you get the patient off the table or away from the chest stand, and you open the door for them to leave, the radiologist already has the image.”

And that’s good not only for Dr. Caplan’s day, but also for St. Joseph’s patients.

“DR has improved patient care, and that’s because the studies are now done in a more timely fashion,” says Johnstone. “Once the image has been taken, it is moved onto PACS, and as soon as it is on PACS, the radiologist can simply refresh his screen and the image opens up for him right away. That makes for faster diagnosis, too, because he can call up previous images either from DR or CR.”

But even though IDC is an Alberta company, it had to compete for the Vegreville deal before Johnstone and ultimately Janeen Miskew, Alberta’s East Central Health Region’s director of diagnostic imaging, gave it the nod.

“We did a week-long North American tour, on both sides of the border, looking at other installations and other suppliers before we made the final decision,” says Miskew. “One of the reasons we like the IDC unit, in particular, is that it has two detectors,” explains Johnstone. “One detector is in the table and one in the chest stand. That means you don’t have to pull it out of the table and push it in the chest stand and vice versa, as you have to do with some other manufacturers. And there’s lots of up and down mobility in both the table and the chest stand. The chest stand, for instance, can be swivelled around and become an extra table. So that means if you are working with someone in a wheelchair and you need to image their feet, you can get the chest plate down very low and they can just put their feet on it.”

What also got IDC’s foot in the door was its price. Though figures for the sale aren’t public, IDC’s Harmon says, “We set out generally to come close in price not to other DR systems, but to CR systems, which are less costly. If we had come in with a $500,000 or more DR solution for Vegreville, they wouldn’t have been able to afford it. And in fact, ours cost them quite a bit less than that.”

Even so, St. Joseph’s had to do some innovative wheeling and dealing – especially since the equipment in its CR room was barely a year old.

“We were able to pass that CR room on to a smaller clinic that very much liked what we had. And what we earned from that sale was added to my budget, so we could buy the DR room from IDC,” says Johnstone.

Changing from CR to DR workflow proved challenging at first, but was manageable in the end, according to Johnstone. “The IDC system has several things we were used to with our previous equipment. For instance, it can track. In other words, if you move the plate, the X-ray head will track with it. So that saves the technicians a lot of time when they are working with difficult-to-position patients. It’s also easier on their bodies and there are fewer strain injuries.”

St. Joseph’s six licensed imaging technicians, including Johnstone, provide service from 7:30 in the morning until 11:00 at night. Its patients from Vegreville itself are largely an older group, but a wide range of ages come in from the surrounding area. St. Joseph’s, along with the larger, more extensively equipped centre in Camrose, are the only two bastions of imaging in the sprawling East Central Health Region.

“As a region, the DR system has saved us a ton of money,” says East Central’s imaging boss Miskew. “So it will eventually pay for itself. First, there are no more chemical or film costs or courier costs. Also, we may have a critically ill patient in Vegreville, but the GP or physician there may not be quite sure. So we can phone our radiologist in Camrose, have him look at the images we have in Vegreville (thanks to an enviable region-wide PACS) and determine whether we need to send them to Camrose to have a CT scan done. If not, we are saving money on ambulance trips and putting less stress on the patients by not making them travel until we’re sure it’s necessary. Being able to do an instant consult like that is a huge saving in rural Alberta, where we have very long distances between our hospitals.”

Despite its success in Vegreville, there are no immediate plans for spreading the benefits of DR further in the region. That will come hopefully, says Miskew, when East Central’s installed CR systems eventually need replacement. But IDC itself has bigger hopes and plans.

“If, as Canada Health Infoway wants, we are all to have a true electronic health record, then the diagnostic imaging as part of that EHR will have to be digital,” observes IDC’s Harmon. “”And though we now have all these different modalities, don’t forget that it’s still radiography, or general X-ray that accounts for over 60 percent of all imaging done in Canada. So we’re going to need to equip our hospitals and clinics with digital radiography systems that are affordable.”

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