HealthLink expands, now reaches 45 Ontario hospitals

By Andy Shaw

TORONTO – The HealthLink Clinical Data network is no longer a clinical case. Quite the contrary. HealthLink began as an experimental project linking seven Toronto hospitals that wanted to interchange their data. But its life was in jeopardy after its $6.5 million of Ministry of Economic Development funding from the Ontario government ran out.

Nor did HealthLink’s future look any healthier as a succession of general managers came and went. But the partners in the project – the founding hospitals and a group of private sector suppliers — continued their care undaunted and in 1996 all bought shares in a private HealthLink corporation.

In early 1998, the consulting firm Ernst & Young provided a business plan aimed at supplanting HealthLink’s complex government support with plain old profits. Then the Board of Directors went hunting for a corporate leader.

Now, HealthLink has data exchanging linkages with 45 hospitals and healthcare institutions around the province. Revenues are healthily brisk and even exceeding business plan projections, especially for its sale of consulting and implementation services.

Also, as of January 1, an experienced and committed Sharon Baker, late of the Ontario Hospital Association (OHA), is at the HealthLink helm as CEO. No longer is the concern: Will HealthLink survive, but now, can it keep up?

“We can’t meet the demand at the moment,” says Tracey MacArthur, HealthLink’s sales account manager at HealthLink’s downtown Toronto offices. “The demand for our interfacing group in particular has been incredible. We’ve been hiring actively but we have still had to put some business off.”

The business HealthLink is in all stems from the purpose and experience of the founders in establishing their original network. The cleverness of the business plan was to recognize that.

At start-up, HealthLink had to build a network between its original seven institutions, interface it with existing systems in each hospital and implement new technology to make that all happen. So now those are the three areas of expertise HealthLink sells to increasingly anxious and willing customers. Recently these have included hospitals in Welland, Scarborough, Kingston and Ottawa.

Aside from its services, HealthLink also offers corporate products including Internet, health card validation, and data file systems. Its easy-to-integrate clinical products include an AGFA diagnostic imaging system, a central client index, various electronic forms, and a document management system.

To keep all those going, HealthLink staff is now up to 40 people and climbing, reports MacArthur. “The bulk of them are project managers, interfacing and networking specialists. We have a very small management group here. Just about everybody is hands on.”

That suits the new CEO very nicely. Baker came to HealthLink leaving her wide-ranging job as OHA’s head of corporate services. There, she was heavily involved with OHA information technology projects – particularly helping member organizations meet the challenge of the Year 2000 millennium bug. But she says she got a lot of the smarts needed for her HealthLink position by being a waitress.

“Before the OHA, I worked for about 13 years in the private sector. I’m a Certified General Accountant and was the director of finance for a restaurant chain. But even the chain managers were expected to spend a great deal of time learning the business in the restaurants by waiting on customers,” recalls Baker. “The corporate philosophy was that customer service was first and foremost. I’ve never forgotten that experience. In fact, ‘customer first’ has become a bit of a mantra of mine.”

But in her early days on the HealthLink job, Baker says she won’t be chanting so much as listening. “First, I’m going to talk to the HealthLink staff and then to the Board to find out what opportunities and barriers they see ahead for us.”

After that things at HealthLink are likely to happen swiftly. Baker thinks the mood of the healthcare community is ripe for adopting technology at a much faster rate. For that she thanks Year 2000.

There’s nothing like a clear and visible enemy to rally the troops. We’ve had to collaborate and act quickly. So I think its more likely now that if people in one hospital see another down the street whose systems are integrated and compliant, they’re going to go down there and talk to them.

“Also, as the prices drop on systems, you’re looking less and less at a capital investment and more at a commodity purchase. Couple all that with how so much is moving onto the Internet and I think you’ll see the uptake of technology by healthcare really start to accelerate this year,” she says.

To make that uptake even faster, Baker says the information technology industry’s attitude towards its customers could use some upgrading. “Somebody once pointed out to me that only two industries call their customers ‘users’ – the IT industry and the illicit drug trade.”

So from here on in, even if a HealthLink ‘user’ is hard to find, a throng of well-served customers will likely make HealthLink thrive.

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Provincial pharmaceutical systems move beyond claims processing

By Dianne Craig

Originally conceived to automate claims processing and check drug interactions, provincial pharmacy systems are quickly becoming an effective warning device against all risks of adverse drug reactions, a comprehensive profiler of patients’ drug history, and a key link between doctors, pharmacists and patients both in and out of the pharmacy.

Also, while there are differences among Canadian provinces regarding the focus and direction of their systems, each provincial health department is working to improve patient treatment and keep pace with advances in drug therapies. The importance of checking all aspects of potential drug interactions alone has increased as many new drugs are introduced.

CNN recently reported that “deaths by accidental poisoning through mistakes in medication more than doubled between 1983 and 1993,” according to a study conducted by the University of San Diego and reported in the British journal Lancet.

Most provincial pharmacy systems were launched within the last two or three years. While Ontario was one of the first to create a computerized network, Prince Edward Island, which just recently introduced its system, and British Columbia have some of the newest innovations.

Moreover, doctors and provincial health managers are not the only people driving demand for new innovations to existing pharmacy systems. “Pharmacists want more detail. They want to be able to identify drug interactions as well as the duration between fills – to find out for example, how long the drug is active in your system,” says Cheryl Taschuk, manager of B.C.’s Pharmanet system. In B.C., she adds, they are currently studying a California model that applies different categories and durations of drugs to a specific category of drugs. It would allow them, for example, to compare the effects of five days of Imitrex with three days of Tylenol and one day of eye drops.

B.C. is also moving quickly to bring its Pharmanet system to doctors’ offices for point-of-prescription patient and drug checks, and into hospital emergency rooms to provide an at-a-glance patient drug profile and drug interaction database.

“This will help emergency room physicians to prescribe better,” says William Mercer, senior manager of B.C.’s Pharmanet system. “For example, it will help prevent double-doctoring (obtaining the same prescription from two different doctors).”

“In doctors’ offices, B.C.’s system would be available in a (read-only) basis. They would need the history of the patients based on what prescriptions were actually filled – not just those that were prescribed,” says Taschuk.

To test the system, B.C. Pharmanet connected the system to 15 hospital emergency rooms last year, and 12 completed the trial. The Ministry of Health is now rolling out the program across the province on a voluntary basis.

In the pilot, security was a major concern. “We hooked up a dozen ERs. We wanted to make sure we defined access procedures, and to ensure we thought of everything regarding security and confidentiality. We must keep medical profiles confidential and be able to challenge inappropriate log-ons.”

B.C. is planning a trial that would give private physicians access to the Pharmanet system. The test may consist of about 100 sites.

For its part, Manitoba is launching trial programs to bring its Pharmacare system into hospital emergency rooms, according to the provincial Ministry of Health’s Pharmacists’ Consultant Jack Rosentreter. There are also pilot projects going on in Quebec and Nova Scotia linking those provinces’ systems to doctors’ offices.

We have a pilot project going on in one area of the province making Pharmacare available to physicians,” says Emily Somers, manager of drug programs for Nova Scotia’s Department of Health. “We want to have it all linked – all physicians and pharmacies.”

In most provinces, all pharmacies are connected to a computer pharmacy system. In B.C. it is mandatory for all pharmacies to be hooked into the Pharmanet system. Every prescription for every person in the province is entered into Pharmanet.

“It’s likely that other provinces only record the prescriptions they are paying for or are contributing to the cost of,” says Taschuk. For example, while Ontario’s Drug Programs’ adjudication server processes claims for over 2,500 pharmacies and boasts a fast five-second response time, not all Ontario pharmacies are hooked up since they do not all bill the Ontario Drug Benefits Program.

In Nova Scotia, all pharmacies – approximately 215 – are connected to the pharmacy system, but currently it only tracks prescriptions that the Department of Health pays for, including those filled under the seniors’ Pharmacare program, and those filled under the low-income family benefits program. “We will move to have it track all prescriptions,” says Somers.

Toronto-based SLM Software’s claims solution, currently in use in PEI, Manitoba and Nova Scotia, is based on the AUTUM object-oriented program. According to SLM executive Matthew Soong, all provinces are using Oracle-based open systems on UNIX servers configured to suit their needs. Manitoba is using servers from IBM, Nova Scotia is using Sun Microsystems servers and PEI is using Digital Equipment servers.

According to Cathy Hamilton of Ontario’s Drug Benefits Program, Ontario is using Tandem servers. Nova Scotia is currently working with SLM on a number of enhancements to the software for use in that province.

While there are several databases from which to choose for checking drug interactions, all provinces are currently using a First Databank solution, says Soong.

According to B.C. Pharmanet’s Taschuk, “First Databank is the most popular drug interaction checking mechanism in the world.” First Databank uses an external board of doctors, pharmacists, and research people to obtain the algorithms.

Since the provinces are using First Databank, they all have access to essentially the same drug interaction information. The feeds from First Databank are frequently updated to ensure they incorporate the latest data. Even though they have a strong source of drug interaction information, the provinces still see room for improvement and are looking for ways to augment and enhance the information received from the databank.

“There’s not enough good information available,” comments Hamilton.

“We believe we need more information about drug interaction, so we’re looking at ways we can adapt other systems for use within our Pharmanet system,” says B.C.’s Taschuk, referring, for example, to the California model B.C. is studying.

In addition to the need for more information on how different categories of drugs interact over certain durations – as in the California system – there is also a desire for other types of drug information.

Somers says that Nova Scotia’s plans for its pharmacy system include getting its formulary list of drugs available as a reference tool on the system. That would provide information regarding cost, how the drugs should be used, and how they fit into therapy.

“We recently added criteria for use of ‘special authority’ drugs such as second-line antibiotics like ciprofloxacin. The pharmacist enters in criteria codes and sends them straight to us. We introduced this because we found the time required to send paper documentation back and forth (in order to have the drugs dispensed) was not acceptable,” says Somers.

There are some differences in the way provinces use drug interaction information and develop drug profiles of individuals.

In B.C., pharmacists can request one of three drug profiles, according to Malva Peters, Pharmanet’s coordinator. “They can request a full profile history of up to 14 months, a profile of the last 15 prescriptions, or simply a profile of prescriptions an individual has had filled at other pharmacies,” says Peters. “We also return warnings of drug-to-drug interactions and drug to prior adverse reactions.

“We also return a duplicate ingredients warning – for example to check whether codeine or another analgesic had been prescribed in a duplicate therapy. We return warnings regarding refill compliance to check whether a prescription is being refilled too soon or too late.

“We check duration of therapy prescribed, so we know, for example, that 30 days would be too long if it was for an antibiotic prescription. The system also checks dosage levels to ensure the prescription is not too high or too low.”

While Nova Scotia’s system picks up drug interaction information, the province is not currently sending it back to the pharmacies. Pharmacies are doing that through their own software.

“No pharmacy has a complete patient profile. We’re trying to set it up so the messages we send back to the pharmacies are meaningful.

For example, we send some specific warnings regarding early refills, and whether someone has ordered the same drug from two different pharmacies,” says Somers.

“It’s a new system and there are things we want to do to make it better,” she says. “We have physicians and pharmacists that assist us in making changes to ensure the system works for physicians. Right now, we’re concerned about getting the right drugs to the right patients.”

Like the other provinces, Ontario and Manitoba check for double-doctoring, which has become a cause for concern in recent years. “Ontario maintains a history for each recipient on the Ontario Drug Program and checks for things like double-doctoring and drugs with potential to be misused,” says Hamilton.

When B.C.’s Pharmanet system detects misuse or fraud through double-doctoring, the province reacts by restricting that individual to one doctor/one pharmacist to prevent fraud from recurring.

PEI wants to establish a drug profile for all residents of the province and have it done right at point-of-prescription at the doctor’s office, according to Soong.

“They have a vision they call ‘all drugs, all people,” he says, in reference to the province’s desire for improved accessibility.

“That’s our vision too,” agrees B.C.’s Mercer. According to Soong, British Columbia is probably most diligent about collecting drug profiles at this moment. “Even non-residents must have a profile to get drugs,” he says.

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Toffler: Expect a move towards self-care and home-based healthcare

By Jerry Zeidenberg

TORONTO – Just as the explosive growth of computers in households is making possible a revolution in home banking, shopping and education, a good deal of healthcare is about to shift into the home, says futurist Alvin Toffler.

“There’s a movement towards ‘self-care’ that’s based on the vast amount of information available to patients,” said Toffler, speaking at the Ontario Hospital Association conference in November.

The celebrated author of Future Shock and the Third Wave said, “we’re on the edge of a return of power to the home.”

He noted that shake-ups in healthcare won’t stand apart from other massive social and economic upheavals, but will be an offshoot of them – which is why he links healthcare to developments such as home banking and shopping.

Toffler asserted that many of the PCs installed in households are more powerful than units used in businesses.

As part of a keynote speech, Toffler quickly outlined his theory of three waves of civilization, and explained how healthcare differed in each one of them. In a nutshell, he divides the past into:

• the First Wave, an agrarian revolution that began 10,000 years ago;

• the ‘Second Wave’ industrial era that was launched 200 years ago;

• and the current ‘Third Wave’ society that is driven by information and its transmission belts – things like computers, telecom lines and the Internet.

Asserting that a cult of secrecy used to surround medical knowledge – Toffler claims that’s why Latin was widely used in medicine during the industrial age – patients can now become well versed about particular ailments by conducting research on the World Wide Web and through Internet news groups.

“Secrecy? Forget it,” said Toffler. “Medical knowledge is becoming de-secretized, and many patients are better informed about particular ailments than their doctors. What they want is a medical consultant, not a dictator.”

Social attitudes are changing at the same time, he said. “The doctor is no longer God, and the patient will have much more responsibility for his health.”

Aside from electronic sources of information, new information will be available in traditional forms. “Often it will mean going to a bookstore and getting something off the shelf on pharmaceuticals for $10,” he continued. “It’s not going to bankrupt anyone – that’s less than the cost of a couple of movie tickets.”

The communications revolution is also pushing the home healthcare trend, as use of the Internet grows and electronic infrastructure is vastly improved. These improvements include higher bandwidth telecom lines and a rapid proliferation of communications satellites orbiting the Earth.

All of this affects not just the collection of health information, but treatment, too.

Toffler observed that while patients once languished in factory-like hospitals, they can now obtain a wide variety of treatments in their homes, along with monitoring systems. A new wave of instruments and devices, powered by microchips and the telecommunications network, is making this possible.

In many cases, patients can take drugs, infusions, oxygen, and be monitored at home using remote control devices. In the future, they could be given electronic implants. “Tiny devices, the size of a grain of rice, could send out signals to the doctor’s office about your body, about hormone levels and other conditions,” said Toffler.

Overall, there’s a shift away from the ‘factory’ model of the industrial revolution, to a more decentralized approach to treatment and convalescence.

What’s more, “during the industrial revolution, there was an impersonalization of relations between doctors and patients,” said Toffler. “There were many innovations designed to speed patients through the healthcare factory – the hospital – more quickly.”

Now, he asserted, healthcare is becoming more personalized. “I suggest we not use the factory as a paradigm for healthcare,” said Toffler.

Technology is also making possible the customization of medical treatments, a shift away from the “one-size-fits-all” medicine of the industrial era. For example, using genetic screening and therapies, drug regimens could be tailored for specific individuals.

He cited opinions that 10 percent to 40 percent of patients don’t respond to the drugs they are given. But using new molecular gene technologies, “you could tell genetically what a patient will respond to, and customize the medication.”

Toffler had some criticism for the medical profession, contending that many doctors in hospitals don’t communicate well among themselves.

“Often in hospitals, doctors don’t know why other doctors did something – and they often don’t know who the other doctors are.” He said that communications technologies could help resolve this problem.

But he added that doctors need more direct contact with each other. “They need I.T., but they also need face-to-face contact with each other. It gives them an added dimension.”

Toffler explained that with face-to-face communication, physicians can credit and evaluate information. “You obtain connotative information this way, not just denotative information. For example, you can tell if the other doctor is an alcoholic, or if he is having a bad day.

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