INSIDE THE APRIL 2008 ISSUE: Online PACS for independent clinics W e struggle even in this digital age in our Great War against disease and its staggering costs. At the vanguard of our attack are the country’s 2,200 independent radiology clinics that do about 50 percent of all the diagnostic imaging (DI) in Canada. Yet even when computerized with expensive picture archiving and communications (PACS) and attendant radiological information (RIS) systems, many can still only exchange images and thus ‘interoperate’ with referring physicians and hospitals via courier or the film-toting hands of their patients. The potential for inefficiencies, loss, and medical error remains high. READ MORE EMR in the land of the euro In the October 2007 issue of Technology for Doctors, we assessed the state of healthcare IT across Canada. This month, we cross the Atlantic to take the pulse of France, Germany and the United Kingdom. With these three European countries at strikingly different stages of EMR adoption, we look at their achievements, to see how they’re coping during their transitions and to examine the impact computerized management of patient records is having on quality of care. READ MORE Departments Editor’s note: What do we really know? News: Personal health records on the web; Frenzy in the aisles at HIMSS 2008; Kiosks find acceptance in the waiting room. Tech: ThinkPad X300 notebook; T1000 Vocera phone; Luminex xTag RVP. Scope: A physician’s EMR experiences in his office. By Dr. Byron Lemmex.

Online PACS for independent clinics

No up-front expenditures, reasonable monthly fees, speed acceptance.

By Andy Shaw

W e struggle even in this digital age in our Great War against disease and its staggering costs. At the vanguard of our attack are the country’s 2,200 independent radiology clinics that do about 50 percent of all the diagnostic imaging (DI) in Canada. Yet even when computerized with expensive picture archiving and communications (PACS) and attendant radiological information (RIS) systems, many can still only exchange images and thus ‘interoperate’ with referring physicians and hospitals via courier or the film-toting hands of their patients. The potential for inefficiencies, loss, and medical error remains high.

New digital weapons for those front line clinics are now at hand. Their makers promise they will boost radiologists’ productivity, speed turnaround time, shorten wait lists, reduce duplicate exams, and increase patients’ safety while bettering their outcomes.

Take the SIMMS Enterprise application, for example. SIMMS specializes in all-digital medical imaging systems that streamline both the clinical workflow and the business operations of independent radiology clinics. SIMMS Enterprise contributes, first of all, by not taking up any floor space. It exists solely online.

Radiologists and authorized referring physicians reach the SIMMS imaging system via the web. The “intelligent buffering” built into the SIMMS software enables them, after a few moments of loading, to retrieve images, data, and patient information at snappy speeds.

All of this is aimed at boosting the radiologist’s and consequently the clinic’s performance – a need David Rouhi, SIMMS co-founder and de facto CEO, has been keenly aware of since first following in his dad’s footsteps.

“My father had a clinic and he had some performance issues so, like a good son, I went in and tried to help him out,” says Rouhi at his Toronto headquarters. “I saw how the clinic operated and decided that this was the most ancient way possible of doing anything. So I looked around for software but I couldn’t find anything that would do all the things a clinic needed done.”

Rouhi also concluded that unless a clinic was doing at least $5 million of billing annually, computerizing it with RIS and PACS systems was unaffordable. So he and SIMMS co-founder Rob Goodman, along with development team leaders Nick Bratkouski and Oleg Melnikov, went on to create SIMMS Enterprise based on the ASP model. Users pay a monthly subscription fee their cash flow can handle rather than a high purchase price at the outset.

To enhance their ASP service, the company recently released the SIMMS Enterprise RadStation II application, which allows radiologists to tailor how they view and handle imaging exams. The new platform is built on the universal DICOM communication standard, so it can be integrated with any other similarly-based systems and equipment, be they in-house or elsewhere.

Among the RadStation II’s features:

• a customizable worklist and numerous enhanced-image display options;

• hanging protocols that automatically display images according to pre-set colour, layout, and other preferences of the radiologist;

• a history viewer for calling up and screening previous exams;

• real-time tracking of exam-generated data that helps with the assessment of that exam and the design of future exams; and

• compatibility with all the major imaging modalities.

The RadStation II and the overall Enterprise system have helped attract nearly 40 client clinics to SIMMS, with a total of close to 900 users. One of them even uses it from a seaside Mexican resort.

“We got some (Ontario) government funding, and so we quickly decided to buy a RIS and a PACS system,” explains Rita Scolieri, manager for a Brampton, Ontario company that owns and operates an independent group of seven imaging clinics. “What I liked best about the SIMMS product was that it is easy for the radiologists to report from off-site. And that meant we could attract more radiologists to come work for us.”

Scolieri also says what clinched the deal was that the RIS and PACS came bundled so she had to deal with only one vendor.

“As well, SIMMS is very user friendly. Anybody can just go in and use it. Our referring physicians also love it, because they can access it themselves and because turnaround times for radiologists’ reports back to them can be less than a day,” says Scolieri.

She wonders whether the girlfriend of one of their radiologists has similar warm feelings towards SIMMS Enterprise: “When they are supposedly off on a vacation together, he’s filing reports from their resort in Los Cabos.”

Other RIS and PACS providers have also made significant inroads into greater productivity and interoperability. Since its inception in 1995 as a spin-off of joint McGill University/Montreal General Hospital work on developing a fully-featured, DICOM-conforming and filmless PACS, Intelerad Medical Systems has built up an impressive list of Canadian and international DI clinic clients.

Among the early adopters are Merivale Medical Imaging Centre in the Ottawa area, founded by radiologist Dr. Bernard Lewandowski in the mid-1980s.

“We originally did just ultrasound. Later we added a mini-PACS, but we wanted to add X-ray and we wanted to go filmless. So we knew we needed a full-scale PACS that was DICOM compliant,” says Dr. Lewandowski. “However, PACS companies only had big systems for big hospitals at a big price.”

Lewandowski and 20-year clinic manager Alanna Racine took three years in their search for an alternative, and finally settled on Intelerad and its IntelePACS solution that also combines RIS and PACS. Their tale is telling for those who want to follow suit.

“We were a small clinic and we knew we couldn’t afford to goof up the installation,” says Dr. Lewandowski. “We knew you have more problems at first with RIS than you do with PACS, so we got our RIS right first. Once that was done we went filmless with PACS over the weekend.”

Still, improved operational efficiency was not the immediate result. “There was a lot of change management needed to help our staff adapt to and work with the technology,” says Racine. Change management in Dr. Lewandowski’s eyes is a straightforward, if lengthy process.

“First, you indeed have to have a process – one that has good information flowing to everybody who touches any file in your workflow and one that you recognize is going to have a severe impact on your organization,” says Lewandowski. “Then you manage the change by telling people you’re going to change. You explain to them why you are going to change. You get them to buy into the change. Then you get them to change. Then you keep reminding them why they changed.”

Even when most are accustomed to the new system, expect periodic change and minor upheaval, plus continuing costs, advises Lewandowski. “No one expects anyone to still work with a 486 computer, so you are going to have to pay for regular upgrades to both your computers and your software. What you save on film costs, you’ll spend on IT.”

Taking such pains is worth it, according to Racine.

“We started the clinic with just three people. By the time we discovered Intelerad, we were about 20. But the technology creates terrific efficiencies that enable you to handle a much higher volume of work. Today, our staff numbers 100.”

That growth was also helped by changes beyond clinic walls.

“Being first out of the gate was a challenge for us. Other centres and even hospitals at the time weren’t even looking at this technology. The majority of our physician referral base was quite resistant at first,” says Racine.

Times and understanding of things digital have changed significantly since Merivale’s first Intelerad installation seven years ago – one that now handles ultrasound, mammography, nuclear medicine, bone densitometry, and general X-ray.

“All hospitals are at some stage of digitizing now. Physicians, especially those recently out of school, are more tech-savvy these days. They have no problem accessing our images online. One of our goals this year is to completely eliminate any paper in our process,” says Racine.

“In order to go paperless, you need to have very good co-operation between your RIS and your PACS,” adds Lewandowski. “We are upgrading our RIS now because one thing we have learned is that your RIS should be the brains of your whole system.”

The brains at Agfa HealthCare agree. They have put a RIS system at the centre of Agfa’s “IMPAX for Imaging Centers” solution that’s designed specifically for managing single or multi-site clinics. Using the RIS in IMPAX referring physicians can request an appointment via a web-based interface. Built into the RIS is software that manages document workflow. In addition to its PACS imaging features, IMPAX offers tools for patient registration, worklist management, interpretation and dictation, report approval and distribution, and billing. Its ‘Practice Analysis Reporting’ feature graphs the referrals, revenue, and other productivity measures of the business.

“The functionality of the product in an independent imaging centre needs to be the same as if you were in the hospital,” says Dave Wilson, who heads up marketing for the Americas at Agfa HealthCare. “Radiologists are radiologists no matter where they work. They need the previous history of the patient, the associated tests, and other patient-specific information all at hand.”

Unfortunately, as the volume of data accelerates its growth, what’s now at hand is soon to get out of hand.

“There’s a tidal wave of information coming,” said Ross Mitchell at last fall’s RSNA conference in Chicago. He’s the founding scientist of the Calgary Scientific Medical Group. “First of all, there is more and more imaging being done in healthcare. At the show last year, Philips announced a 256-slice CT and Toshiba came out with a 320-slice CT. Compared with what today’s 64-slice machines produce, we’re looking at a quadrupling of the data.”

Calgary Scientific is a spin-off based on Mitchell’s imaging research done at the University of Calgary. It sells software to OEMs that enhances the images their machines produce and speeds access to them.

“Even if you are in a major teaching hospital, seeing that information tidal wave coming is intimidating. If you are in an independent clinic, it’s downright scary,” said Mitchell. “What are you going to do with all that data?”

A partial answer is provided by Calgary Scientific’s software, which abstracts only the data a specific disease-hunting radiologist needs from an image. At the RSNA 2007 show, the company announced an agreement with American Medical Sales (AMS), a PACS vendor that targets independent clinics.

John McColl, a veteran of the Christie Group in Montreal that handles Fuji, thinks an answer to the coming flood lies in the massive regional data repositories being championed by Canada Health
Infoway.

“Infoway’s interest of course is what the data repositories can do for a pan-Canadian EHR,” says McColl. “But there can’t be a complete EHR unless the images from independent clinics are also in those repositories.”

The good news, according to McColl, is that as RIS/PACS systems become more affordable and thus more prevalent, we’ll be taking another step towards a national EHR. The bad news is that many smaller clinics will need financial help if they are to be RIS/PACS capable. Clinics big and small will face the technical challenge of transmitting data to those repositories.

Infoway, by law, can’t fund private imaging clinics directly, as it does public health facilities. Happily, British Columbia, Saskatchewan, and Quebec all have funding programs in place to help independent clinics computerize. Ontario, for its part, offers occasional one-time financing for imaging equipment.

Where Infoway can help, says McColl, is to continue its work on the IHE ‘profiles’ aimed at helping clinics to share their images and radiological information.

In a paper called “The Road to Interoperability”, Infoway describes an interoperability “profile” called the “Cross-enterprise Document Sharing for Imaging” or XDS-I for short. Infoway sees XDS-I as “a milestone in the drive to build a common pan-Canadian EHR architecture.”

Infoway developed XDS-I in co-operation with the international IHE (Integrating the Healthcare Enterprise) volunteer group that fosters clinical information and radiological image sharing through the use of established standards such as HL7 and DICOM. HL7 is the standard used to communicate radiologist’s reports and other text emanating from a RIS, while DICOM standardizes image transmission.

According to Stella Skerlec, Infoway’s head of Registries, Infostructure and Diagnostic Imaging, “The DICOM standard ensures that an imaging machine packages its data in a way that can be understood by another machine, but to be truly interoperable, the DICOM data needs an additional ‘wrapper’ around it that directs where the image is going.”

Skerlec says XDS-I adoption is occurring around the globe. At the HIMSS Interoperability Showcase in February 2007, more than 60 vendors had XDS-I-enabled systems on display.

British Columbia, Alberta, Saskatchewan, Ontario, and Quebec have all declared XDS-I ‘stable-for-use’. In those provinces, XDS-I compliance is now mandatory for any RFPs issued by government-backed buyers. Not surprisingly, Infoway has also made XDS-I a must in any project it funds.

The Infoway paper concludes by saying that XDS-I will provide all users with “...the ability to instantly locate, access and share X-rays, ultrasounds, CT images and MRIs among all points of service…”

At that stage, a major battle on the imaging front will have been won. •

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EMR in the land of the euro

Electronic medical records and healthcare IT in three key countries: France, Germany, and the UK.

By Saul Chernos

In the October 2007 issue of Technology for Doctors, we assessed the state of healthcare IT across Canada. This month, we cross the Atlantic to take the pulse of France, Germany and the United Kingdom. With these three European countries at strikingly different stages of EMR adoption, we look at their achievements, to see how they’re coping during their transitions and to examine the impact computerized management of patient records is having on quality of care.

Of the three countries, the UK leads in the adoption of the EMR, followed by Germany and France in that order. In terms of the effectiveness of the overall healthcare systems, as determined by the World Health Organization and others, the order would seem to be reversed.

The UK has spent massively to enable the adoption of the EMR. The Commonwealth Fund, a New-York City-based foundation devoted to healthcare issues, reported last year that 89 percent of primary-care doctors surveyed in the U.K. reported having EMR systems in their offices, and other, more recent estimates peg the number at close to 100 percent.

“It’s pretty much universal in the U.K., now,” says Dr. Shaun O’Hanlon, who works part-time as a cardiologist in Guildford, England and is clinical design director with EMIS, the largest EMR provider in the U.K. “You get the odd physician who doesn’t want to use them and likes their old paper records, but very few people could run their business now without an EMR.”

The key, O’Hanlon says, has been linking EMR systems to compensation. Physician salaries are partly dependent on meeting targets around patient care. Clinical management systems are widely used for scheduling and billing but most physicians also use them to detail clinical contacts, create printed prescriptions with barcodes, refer patients to specialists, and view and archive electronic images such as X-rays. The government requires general practitioners to supply performance statistics and that is difficult to do without the use of an EMR.

The U.K. has made particular gains in chronic disease management. “We’ve traditionally had a fairly high mortality rate from conditions such as diabetes and ischemic heart disease, and a moderately high degree of mortality from asthma,” O’Hanlon says.

Through a program called Health of the Nation, physicians can collect data within their EMR systems. This provides valuable data during patient visits and helps drive physician awareness of chronic conditions.

O’Hanlon continued, “There are EMR tools out there to assist clinicians with patient interventions and treatment. If you look at the quality care indicators over the last five years, you’ll see many more people with blood pressure under control and lower cholesterol, and over the next 10 years we expect a substantial reduction in mortality from those illnesses. Practices realized that they needed to have registers of all patients with certain illnesses and that they needed to record information coming in from the laboratories, in a way that it could be easily retrieved.”

Still, despite the U.K.’s successes, the EMR ramp-up has experienced challenge and controversy. Richard Granger, who oversaw implementation work as chief executive with the Connecting for Health program of the National Health Service, resigned last year amid press reports that the ten-year, Cdn$24.3-billion project was two years behind schedule and having trouble updating and integrating disparate legacy systems. Granger was himself quoted saying he had hoped for ‘calmer waters’ for the project.

While the EMR adoption rate is close to 100 percent in the U.K., it’s in the single digits in France. The use of computers for billing and administrative tasks among French physicians is ubiquitous, but only a small proportion have clinical EMR capability. Kiran John, who recently joined SCIOinspire Corp, a Pittsbugh, Penn.-based healthcare informatics provider, as Marketing and Research Consultant, says data he gathered in 2006 while working for Frost & Sullivan show 6.2 percent of primary care doctors’ offices in France had these capabilities.

There is a trial in progress that involves roughly 2,500 family physicians and 38,000 patients. It is the seed that is designed to grow into a national web-based Electronic Health Record, the dossier médical personnel (DMP). The government’s goal of rolling this out in all hospitals and clinics by the end of 2008, already a delay of plans announced in 2004, no longer seems feasible.

As well as delivering patient care and patient safety benefits, the French government has estimated that the DMP will eliminate fraud costing between 2 and 3 billion Euros annually. However, the forecasting institute OPECST estimates that the cost of implementing the DMP in all French hospitals, clinics, and physician offices may exceed 10 billion Euros.

Dr. David Koff, chief radiologist with Hamilton Health Sciences, used to practice in France. He continues to follow medical issues there as a founding member of IHE Canada, a non-profit organization with global ties that facilitates the adoption of IT standards in healthcare, says government progress in France towards an EMR has been slow.

Close to a decade ago, an early predecessor emerged in the form of a chip-embedded health card which doctors would process at each medical appointment, allowing the doctor to be paid and the patient to be reimbursed for any up-front expenses such as those covered by private insurers. The government soon decided to embed key patient medical information in the cards, but it became clear the cards could not store more than a limited amount of data. In 2004, the government announced plans for the nationwide DMP, but the trial was launched only last summer.

“The government selected a number of test clinics and doctors who agreed to participate, and they’re involving patients who are also willing,” Koff says.

The trial is minuscule when compared with the country’s population of 64 million, but Koff offers some early praise, particularly for the system’s tendencies to support patient rights and freedoms. Patients currently enjoy full control over their records, including the ability to deny access to physicians who represent insurance companies or other interests that aren’t necessarily those of the patient. In France, the patient even owns the images.

The government has also opted for decentralized hosting. Just as people choose their cell phone provider, patients will choose the host and access their record electronically from any computer. “The government wanted it to be an open system rather than constrained that way,” Koff says. Data is encrypted, and each time information is updated it is dated and signed by the author, letting patients track the entire process and add their own comments. As the government moves forward, he adds, one challenge will be establishing common guidelines and ensuring compliance.

In terms of EMR capabilities, Germany lies somewhere between the U.K. and France, with the Commonwealth Fund reporting that 42 percent of primary-care physicians have such systems. Cathy Schoen, the report’s lead author, says Germany has been strong in the area of nationwide chronic disease management. The group’s report elaborates, explaining that German doctors said they routinely give chronically ill patients written instructions to help them manage their care at home. “These responses might reflect Germany’s national disease management initiatives, which put a premium on physicians’ ability to identify, monitor, and manage care for patients with chronic diseases,” the study authors wrote.

While France, Germany, and the U.K. differ widely in their rate of EMR implementation, their respective success in actual healthcare delivery is a different story. Despite its low position on the EMR totem pole, France is widely recognized as having one of the world’s top-performing medical systems.

“They compare favourably internationally in terms of child health and low infant mortality, as well as longevity,” says Paul Dutton, an associate professor of history at Northern Arizona University who compared the French and U.S. medical systems in his recent book,
Differential Diagnoses. He says popular support for patient rights and arms-length government involvement stems from a strong sense of physicians as professionals bound only to the service of their patients, and a value placed on patient confidentiality.

While the French government works towards national implementation of the DMP, patient records and images for the most part continue to be maintained the old-fashioned way. Dutton says, however, that the government is working to consolidate some of these records. Patients are given a booklet which lists vaccinations and other key data. They are supposed to take it with them to medical appointments so that the physician can consult it and update it if necessary. Not all patients choose to do this, however.

Most physicians have computers, paid for partly from their own pockets and partly through government funding, including some of the proceeds of a one-Euro surcharge French citizens pay for every medical visit. While doctors are not required per se to have computers, it is necessary to use them to process patient insurance claims through both state-run and private supplemental insurance plans.

“Physicians really need to have computers in order for patients to be reimbursed by the national health insurance. It’s their bread and butter. If patients can’t get reimbursed, the practices aren’t viable, so it’s a de facto law,” says Dutton.

Excepting the small national EMR trial, there is little sharing of data. Dr. Koff says more than a few private radiology labs and clinics provide images on CD to patients, but French hospitals are in the process of going filmless.

Still, France remains well respected for providing a high level of healthcare. Koff attributes this success not to anything electronic but to basic access. “You don’t have wait lists. Everything is fast. You can get an MRI the next day at a private clinic and it’s fully paid for by the government.” Koff says French doctors are able to charge beyond the government flat rate and be compensated through private insurers, and many private clinics offer high-end diagnostic tools as well as surgery and other forms of treatment. “You don’t have to wait two years to get a hip replacement – you can get one when you need it and the government funds this completely.”

For all its successes, the French healthcare system isn’t perfect. Paul Dutton says the mix of public and private clinics, a complex insurance system, and rules that allow doctors in certain circumstances to negotiate fee schedules above and beyond state fees has left some inequality in the system. “There’s this constant tension between liberty and equality,” Dutton explains. However, he says this balances out somewhat in that private supplemental insurance policies often cover a portion of the added costs, as well as covering a roughly 30 percent portion of routine patient medical expenses that is generally not covered by the state health plan.

The 2007 Euro-Canadian Health Consumer Index confirms France’s generally-high position, ranking it third in a field of 30 contenders, behind Austria and the Netherlands. “France has one of the best healthcare systems in Europe from a consumer point of view,” says Johan Hjertqvist of the Brussels-based Health Consumer Powerhouse, a European think-tank specializing in healthcare issues and an Index cosponsor. “France is a top competitor, generally speaking, when it comes to outcomes quality, access to care, short waiting times, consumer choice, consumer influence, and so on. However, there are some deficits, like the slow implementation of new drugs.”

Germany fared well, placing fifth, while the U.K. was 17th, not far ahead of Canada’s 23rd-place finish. “Germany has quite good access, low waiting times, a fairly generous system that covers a lot of different treatments, and good access to pharmaceuticals,” Hjertqvist says.

Hjertqvist referred questions about Germany to his organization’s German specialist, Arne Björnberg, who said that the country has a large number of small hospitals, which makes it difficult for the country to compete for quality on an international scale. Germany’s population is just 36 percent greater than the population of the U.K., but it has twice as many hospitals.

“Small hospitals in Germany generally don’t specialize or concentrate on individual specialities,” Björnberg said. “It is very difficult for a 150-bed general hospital to be first class at everything, as the generally acknowledged condition for becoming really good at a certain condition is that the hospital gets to treat a lot of that condition.” He adds that Germany is currently en route to financing all hospitals on a common price scale, which could potentially lead to a major shake-up in the German hospital system, with hospitals merging or specializing, or doing both, to survive.

Ironically, the U.K. performed well in terms of digital record-keeping, ranking with top performers such as Denmark, Finland and the Netherlands, while France and Germany landed well behind some of their European counterparts in adopting national EMR systems. However, Johan Hjertqvist attributed the U.K.’s overall low-ranking to factors such as lengthy waiting lists, a high infection rate, and somewhat poor health outcomes despite relatively high spending, per capita, on healthcare compared to other countries.

So, will integrated patient record and related information systems enhance actual healthcare outcomes and performance? Is this how governments should be spending their billions on healthcare? “I would be careful to draw conclusions here,” Hjertqvist says. “As the systems develop over the next few years, we may be able to make more specific judgements.” •

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