Edmonton area devises regional health information system

By Jerry Zeidenberg

The Capital Health Authority, based in Edmonton, is currently assembling a region-wide health information system that will integrate the electronic records of seven acute-care hospitals within 18 months, and a mental healthcare hospital shortly after that.

It’s an ambitious plan, and one that involves networking at least five disparate computer systems. The initial phase of the program will integrate lab, pharmaceutical and radiographic records, giving clinicians the ability to pull together a meaningful picture of the medical history of patients who may have been treated at a variety of hospitals in the Edmonton area.

Many hospitals across Canada face a similar situation as they form regional networks – their information resides in several different computer systems that are incompatible. By showing how to bridge the systems, the Capital Health Authority may create a model for other regions across the country.

“The goal is bring together information that’s pretty much in silos today, information that’s not easily accessible on a system-wide basis,” said Donna Strating, chief information officer for the Capital Health Authority. “We plan to pull together all of the patient data, from all of the sites, and present it in a standardized format.”

As an underlying technology, the Capital Health Authority is employing Oracle Corp.’s Healthcare Transaction Base (HTB), an electronic information system for the healthcare sector that was announced by the company last year. Ms. Strating says that Oracle’s system is acting as something of an integration engine, but has abilities that go beyond traditional integration products.

For example, the HTB contains a master patient index, enabling clinicians to quickly find charts and other data by plugging in patient names. It also has security systems built in, along with audit trails and workflow tools.

The system can be integrated with Oracle financial and enterprise systems, which the Capital Health Authority intends to do in the future. As it happens, the region is a heavy user of Oracle systems, and has built up a good deal of expertise in the company’s technologies. “We’ve always been an Oracle shop, and we feel their technology is very good,” said Ms. Strating.

Moreover, the Capital Health Authority plans to eventually integrate facilities and providers from across the continuum of health – namely, continuing care, home care and physician practices.

Initially, however, the region will allow these providers to view hospital information – without contributing their own records to the system – by tapping in through the Internet. They will use secure connections and software, and observe the appropriate rules and regulations regarding the confidentiality of patient information. For example, healthcare providers entering the system will do so on a ‘need to know’ basis, with the consent of patients.

This kind of access will enable referring physicians to follow the progress of their patients in hospital. It will also allow nursing homes to obtain baseline data they need to provide for the arrival of patients, or to check on medical histories.

The Capital Health Authority also intends to provide this type of data access to clinicians at northern Alberta hospitals, as many of them send patients to the Edmonton area for specialized treatment. “Thirty percent of our patients come from outside of the region,” said Ms. Strating. “We’re the referral centre for all of northern and central Alberta, as well as the Northwest Territories.”

The Edmonton area hospitals are working with Oracle and systems integrator CAP Gemini Ernst & Young to produce a system that’s to the health authority’s liking. Once this is done, the parties will enter a commercial agreement regarding its purchase or licence.

Ian Fish, Canadian healthcare director for Oracle, asserted that the Healthcare Transaction Base is something new under the sun – a healthcare information system capable of integrating a large number of users and technologies across a wide geographical area, using open standards such as HL7 Version 3.

“This is a key difference between our software solution and other large-scale, health information systems,” said Mr. Fish. “The other systems tend to use proprietary technology or data models, and have trouble integrating various hospital and community systems into a standard, non-proprietary format. They have a hard time bringing, say, lab information into a record in a meaningful way, so that you can compare – at the data level – radiology or pharmaceutical information alongside it.”

He said that Oracle is making use of HL7 Version 3 as a standard for data exchange. It’s also adopting the HL7 Reference Information Model for organizing the data.

According to Mr. Fish, in the future not only a wide variety of healthcare providers, but patients may also interact with Oracle’s system. That will be made possible by the security and database capabilities in HTB. As a result, patients will be able to update their own demographic information, or book their own appointments.

Patient involvement in their own records could also improve the quality of the care they receive and assist in region-wide planning. “There’s the whole area of follow-up and outcomes assessment that could be improved by a solution that integrates data across disparate systems, and that also gets patients to tie-into the network,” said Mr. Fish.

For example, he said it’s currently difficult to follow up on patients after their discharge from surgery. Often, physicians must wait until their patients return for a follow-up visit – which could take months. However, by using an Internet connection to the system, post-op patients could apprise their doctors and nurses of their progress each week, or even each day.

“This could lead to far better healthcare outcomes studies,” said Mr. Fish. “It would let doctors and other professionals know far sooner if their patients experience infection, pain or other problems after they’ve left the hospital.”

Dr. Thomas Jones, vice president and chief medical officer for Oracle Corp., noted that HTB has database and workflow capabilities that can be used to improve the delivery of healthcare.
For example, when a patient’s lab test arrives, the results can be automatically sent to the attending physician. If responses aren’t made within a certain period, alarms can go off and as a backup, the results can be sent to other physicians or care providers.

Workflow capabilities can also be used, for example, to automatically book the tests needed when a patient is scheduled for surgery. The system could provide the best sequence and locations for lab and diagnostic imaging tests that are required before a procedure – thereby offering the greatest convenience to the patient.

In the area of drug compliance – a major problem area for many patients and the healthcare system, in general – the HTB network could be set up to electronically send prescriptions to pharmacies (once electronic signatures for scripts are permissible in Canadian jurisdictions.)

“Using the system, the pharmacist could easily let the physician know if the patient picked up the prescription,” said Dr. Jones. “Beyond that, the system could send cell-phone reminders each day to the patient to take his or her medication. If you like, there could also be feed-back mechanisms, allowing the patient to confirm whether the medication has been taken.”

Dr. Jones observed that three other sites are currently developing large-scale information systems using Oracle’s Healthcare Transaction Base. They include a health system in Cardiff, Wales – the third largest National Health Trust in the United Kingdom; the Methodist Health Care System, based in Houston, Tex.; and the University of California at San Francisco.

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Sault hospitals connect referring physicians to information systems

By Ann-Marie Wilton

Sault Area Hospitals (SAH), located in Sault Ste. Marie, Ont., is a partnership of two acute-care hospitals – Plummer Memorial Public Hospital (public) and Sault Ste. Marie General Hospital Inc. (Catholic). We also have two satellite hospitals – one that provides emergency care 45 minutes out of town, and another that provides both in-patient and emergency care 60 minutes out of town.

Over two years ago, SAH implemented results reporting for all laboratory and diagnostic imaging patient results with the Eclipsys Sunrise Clinical Manager (SCM) system. Also included with the diagnostic imaging result interface are brief textual ECG, Holter Monitor and Stress Test interpretation results. We have recently implemented dictated documents into SCM. These implementations form the core of our Electronic Medical Record (EMR).

Part of the results-reporting project included the elimination of printing for all inpatient laboratory results until a patient is discharged. This initiative was encouraged by our care-providers to reduce paper and also eliminate duplicate charting.

A summary report of all lab results for the inpatient encounter is printed in Health Records at the time of chart completion. SAH currently has 95 percent of physicians using SCM for results reporting, along with all nursing staff, other disciplines and allied healthcare workers – basically anyone who needs access to results and patient information in order to provide care.

Significant patient information (surgical and medical history, allergies, height, weight etc.) is recorded in SCM for clinic, pre-surgical and many inpatients. This information shows across encounters in SCM, and becomes relevant to all care-providers when a patient uses the services of SAH.

With such significant data held in SCM, it became increasingly important to provide remote access to our physician offices. Most physicians in Sault Ste. Marie practice in one of four doctor buildings within the city. Therefore, it was a fairly inexpensive and easy initiative to extend a Wide Area Network to three of these buildings, in order to provide access. The fourth building, the Group Health Centre, which is a multi-disciplinary physician group practice, had previously been set up with an ISDN connection to SAH.

Until we implement the latest version of SCM, which is web-enabled, an interim solution was sought that would be cost-efficient, highly secure, and also provide the least amount of support required by the Information Technology department at SAH. Our experience in a remote access pilot taught us that as soon as we installed our virtual private network (VPN) software and the SCM client on a physician’s PC, any problems encountered by the physician or his staff on that PC became a problem for IT to solve. We wanted to avoid this if at all possible.

With recycled PCs from our nursing units and various hospital departments, we re-imaged these to be thin-clients – basically standalone PCs with only four icons to provide the simplest method of access. We also disabled all floppies and utilities in order not to encourage configuration change.

The four icons we provided on the desktop were for SCM login, Internet Explorer, SAH internal e-mail and SAH intranet. Our Internet Explorer denies access to specific web sites and limits some incoming mail. Our intranet provides online access to all hospital policies, procedures and newsletters, a telephone directory, current emergency physician on-call schedule, and links to medical libraries. We purchased ink jet printers, power bars and the terminal server licenses we needed for each physician install.

To connect each building to the SAH LAN, we purchased Soho Firewall, Microsoft Terminal Server 2000, switches and UPSs. We negotiated with a local computer vendor to install each office for a flat rate of $79. We also negotiated with the same vendor to provide the monthly Internet connection fee and hardware support for each physician office for a flat rate of $35 a month. This eliminated the need to find resources within IT to either install or support our remote users, which would have posed scheduling problems since our staff consists of only four technicians and our current compliment of hardware within the four sites is already at greater than 500 PCs.

The remote access physicians who maintained offices outside of the main doctor buildings were connected via Watchguard’s VPN client and a Linksys router/switch that is capable of NATing (network address translation) to provide a secure connection. The same four icons were put on their thin-client desktops. The $35 monthly flat rate for Internet connection and hardware support had been factored in for connection of these offices also. Our goal was to provide the same service to every physician in our community for one price.

The combination of terminal server, VPN and firewall provides the highest level of security for SAH. The terminal server provides video and keyboard entry so data stays within the SAH walls. The VPN ensures the data being sent is secure since it is encapsulated between the firewalls at each end, so a third-party cannot see in. The firewall eliminates the remote access PC being a back door to the SAH network.

Along with the hardware install we also ensured our SAH policies supported remote access to our clinical application. In addition to providing remote access to physicians, we knew we also wanted their office staff online, to eliminate the frequent phones calls required to our diagnostic departments for missing results.

Since these people are not employees of SAH, our policies had to support their access to our systems, and clearly define lines of responsibility and the consequence for a breach of confidentiality.

Phase One of our remote access project has been to connect interested physicians within the city limits. Over 80 percent of our physicians came aboard on day one, with many more following soon after project initiation. A handful of physicians are waiting for Physician Order Entry (POE) to be implemented prior to needing remote access.

Phase Two of the project is to extend remote access to regional patient-care facilities, since much of the diagnostic work for their patients is performed at SAH.

We also anticipate connecting our physicians at home, as we have received many requests for this application. Our timeline for Phase Two completion is over the next couple of years.

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Low-cost system said to boost revenue for doctors, enhance patient care

By Jerry Zeidenberg

You’d think Canada’s 60,000 doctors – arguably the country’s brightest minds – would be the earliest adopters of computers. In reality, the opposite is true. According to the Canadian Medical Association, only 14 percent of doctors in physician practices have computerized the clinical and business sides of their work. Indeed, doctors are among the least automated professionals in the country.

The reason? To date, specialized practice management systems have been too expensive, offer little in the way of financial or clinical payback, and require too much time for maintenance and upgrades.

Things may soon change, as software companies address these concerns.

Already this year, Cogient Corp., a Toronto-based developer of clinical practice management software, has made several breakthroughs in the doctors’ office marketplace. In May, the company announced a $600,000 contract with Urgent Care Canada, a company establishing large, multi-disciplinary clinics in under serviced settings.

A month earlier, Cogient announced that Toronto-based Edward Street Radiology, the largest private radiology practice in Canada, signed a contract to implement the company’s software at its two locations. Some 45 radiologists and technologists will be using the software.

Also in April, Cogient became one of the first companies to obtain a standing offer contract with the Alberta Physician Office System Program (POSP). The $15 million Alberta program is seeking to computerize doctors’ offices throughout the province, and the government is working with the Alberta Medical Association to validate software that can be offered to clinics and doctors.

For its part, Cogient has devised a solution that’s relatively inexpensive, and offers physicians the chance to actually improve the financial performance of their practices while enhancing clinical results. “We’re not trying to get doctors to change the way they practice medicine,” said John Soloninka, president and COO of Cogient. “We’re providing doctors with something that’s low cost, will save them time and earn them more money while improving clinical outcomes.”

Instead of asking doctors to pay cash up-front for a package of hardware and software, Cogient’s Application Service Provider (ASP) model charges 50 cents for each patient visit. For the average doctor, that works out to $3,000 or $4,000 a year.

The company’s clinical practice management solution is called ClinicalLogic. Its ASP approach means the servers and software are housed off-site in a centralized, secure data center. There’s little in the way of capital costs – all that a doctor’s office needs is a reasonably up-to-date computer and a fast Internet connection.

By maintaining the software at a data centre, doctors aren’t turned into computer geeks who end up spending countless hours tweaking their computers and interfaces. Instead, the time-consuming maintenance tasks and software upgrades are performed by Cogient at its data facility.

Physicians might be concerned about the security of the data, since it is housed at an off-site data centre. But according to Soloninka, Cogient has invested $2 million in its data center on security, redundancy and backup systems.

What’s more, Cogient can provide physicians with regular downloads of their data – just so they can have records on hand, as well. According to Soloninka, while Cogient manages the data centre, the data belongs to the practice.

ClinicalLogic appears to be a comprehensive EMR and practice management package that covers everything from front office patient scheduling and billing, to real-time health card validation, as well as charting the physician-patient encounter.

Cogient has created links to commercial labs such as Gamma/Dynacare and Canadian Medical Labs, enabling lab results to be sent electronically to the doctor as soon as the practice office goes online.

Some of the most attractive features of ClinicalLogic reside in its ability to boost income for clinics. According to Soloninka, eliminating missed charges, reducing OHIP rejections, trapping invalid OHIP cards and increasing third party collections alone can lead to 15-25 percent in additional revenue.

The system also generates codes for billing, supports real-time EDT claim submission and line-item reconciliation, and virtually eliminates mistakes that arise due to incorrect billing, said Soloninka.

Cogient’s director of marketing, Bekhe Purkis, said the security provisions built into the Web-based ClinicalLogic provide doctors with the ability to access the system from a variety of locations.

Physicians can see their patients while at the clinic, hospital or home, call up patient charts, and also submit claims using the ClinicalLogic program. “You log into the Internet, using either your thumb-print or a secure login from any Internet location, and you have instantaneous access to your practice,” she said.

Cogient is a strategic partner of Hewlett-Packard (Canada) Ltd. According to Bob Miller, HP’s healthcare and education business development manager, there has been noticeable growth recently in the physician I.T. marketplace. “Doctors are under severe cost pressures, and they’re seeking ways to improve the performance of their practices,” said Miller. “They’re looking at ways of improving the tracking and management of their clinical encounters, and they’re trying to speed up the turnaround for billing.” In addition, there has been “significant uptake in the growth of mobile computing among physicians,” said Miller. This has included solutions ranging from handheld computers – such as the Jornada and iPAQ – to linking these devices with satellite phones for emergency encounters in the North.

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IT disaster-recovery requires technological expertise, human relations skills

By Stephen Tucker

Last December, the information technology team at Baycrest Centre was conducting routine maintenance on the network when a cable on a principal server came loose. When it was replaced, it triggered a scrub of the hard drive’s primary index field. This caused the corruption of more than 180 gigabytes of data.

While patient and accounting information were not affected by the problems on this particular server, more than 900 Baycrest personnel faced the loss of years of data. This included PhD dissertations, book manuscripts, presentations, reports, general files, correspondence, prescription and hearing aide billing information, and much more.

A massive four-week disaster recovery effort ensued. This effort cost more than $80,000 and involved the equivalent of 1,000 worker days to correct. In the end, we recovered all but 14 days of data. I learned more in that month about handling a disaster than I did in a year on the job. This is the story of an IT disaster and many of the important lessons learned during recovery.

No one knew our new backup system was faulty: Earlier in 2001, we installed a new backup system. The system tested perfectly before installation. We did not know, however, that when the new system went live, human error caused a critical fault. It wasn’t until we went to restore the corrupted information that we discovered we did not have a functional backup. All the data stored on 12 hard drives of the affected server were seemingly lost.

We immediately contacted a data recovery service, hoping the picture wasn’t as bleak as it looked. The hard drives were a total loss, but the disaster recovery technicians were able to recover the information stored on tape. That was the good news. The bad news was that taking the recovered data and restoring it to users was going to be a nightmare.

The best analogy I can offer is this: Vandals go to a public library and tear out every page of every book and then scatter the pages. Your job is to reassemble all the pages in the right order, in the right books, in the least amount of time. That was the task ahead of us. We eventually did this. It wasn’t easy, but it was enlightening.

Lessons learned from IT disaster recovery: The first lesson we learned, and this may be the most important thing, is that a disaster recovery effort must have an effective internal communication component. We were in a triage situation. Through frequent communication, we were able to determine which departments needed the fastest response. In the meantime, we let the staff know why we were making specific recovery choices.

Had we simply been working to fix the technical problems without actively communicating through e-mail, phone, in-person meetings with each department, frequent communications with senior management, and later on through newsletter copy, we would not have been as effective. Communication is a two way process. Through frequent communication, we plowed through the critical files, to the important ones, to the “glad its back stuff.”

As long as our users were aware of what was happening, they offered us as much patience and understanding as one would hope under the circumstances. They continued to help direct us to the critical areas. Once things settled down, our communications tapered off. That was when the users started to make increased demands. We realized we had to keep active communications in place all the way to the end of the recovery process.

More lessons learned: The disaster occurred during Christmas season, when many people were off, including those in the financial department. The disaster recovery consultants wanted more than $25,000 before they would begin the data recovery process. It was the middle of the night, and we did not have access to that kind of money. Eventually I was able to convince them to start work. The second lesson we learned is to line up important suppliers before the disaster strikes and have established lines of credit.

The third lesson we learned is to have backup equipment on site that can be rushed into service. Our test server was available, but it did not have 180 gigabytes of memory. We now have a server ready and able for disaster relief duty.

The fourth lesson: employees must take breaks. Our team worked the first 36 hours straight. We arranged for hotel accommodations, where people rested and then came back to work. As the disaster recovery effort continued on for several weeks, people did not cut back from extremely long days. They wore down and began making mistakes. I saw firsthand that people can’t work long hours for an extended period of time and remain at peak efficiency. No matter how committed the people are, they will begin to falter.

In addition to fatigue, the staff exhibited outsized feelings of worry and guilt. We worked with the HR department to help staff understand and cope with these feelings. We subsequently gave staff members a week off to disconnect from the pressures of work and recover peace of mind.

During the height of the recovery operation, we arranged with an outside consulting firm to bring in 11 people, including a project manager, to augment our team. It cost more than $20,000. This taught us our fifth lesson – there is a limit to how fast you can bring in outside help. We had to instruct the auxiliaries in the basics of our network, and we could only do this at a relatively slow pace due to other staff commitments. The expected relief from added hands did not arrive as fast as we hoped. We now have an orientation program prepared. This will enable us to bring helpers on board much more quickly.

When you send your disaster-recovery team out to various areas of the organization, you start to develop problems of overlap, which generates confusion. Basically it is a management issue of who is doing what, when, and why.

This taught us our sixth lesson – have a task management strategy in place. We developed a fan-out program to enhance the recovery effort. Fan-out teams were assigned to specific locations. These teams worked with the users to uncover the most critical problems and then to work down the priority list.

Stephen Tucker is Director, Information Technology, at Baycrest Centre for Geriatric Care in Toronto.

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Heart Institute uses Internet to transfer records swiftly and securely

By Ranald McGillis

As one of two Regional Cardiac Care Coordinators at the University of Ottawa Heart Institute (UOHI), Lorna Bickerton has her work cut out for her. Lorna and colleague Pat Doucette oversee the administration of records for cardiac patients at the UOHI and the 35 Eastern Ontario hospitals whose patients are referred to the Institute. All those referrals and subsequent assessments, responses and updates generate vast amounts of paperwork, a considerable portion of it redundant.

“For every patient, every referral, there are phone calls and faxes,” says Bickerton. “You call referring physicians. You phone in assessment results to hospitals. You send a fax – then follow up with a phone call to be sure the fax was received. And you’re communicating with the referring physicians, the assessing physicians, the patients, and the families of patients – that’s an awful lot of calling and faxing. At any one time, you can have multiple copies of a single document floating around.”

It won’t be long, however, before the sea of paper will be reduced to a trickle – and redundancy eliminated almost completely. Bickerton and Doucette will be among the hundreds of healthcare workers in Eastern Ontario to benefit from RASCHR: the Regionally Accessible Secure Cardiac Health Records system.

Scheduled for launch at the UOHI in May 2002, RASCHR will use the Internet to link the Institute with 12 regional hospitals, enabling the transmission of cardiac-patient information over a secure Virtual Private Network (VPN). In a system such as this, security is critical.

“As anyone in healthcare knows, the laws surrounding patient confidentiality and information privacy are strict,” says Dr. Shu Tim Cheung, Chief Information Officer at the UOHI. “If patient information were not secure, there would be a lack of confidence not only in patient record-keeping but in healthcare as a whole.”

RASCHR is a CHIPP initiative (Canadian Health Infostructure Partnerships Program) and, as such, has received $1.5 million in government funding along with equivalent support from project partners.

The project lead on RASCHR is Canadian IT-services company xwave. xwave has built secure directories for organizations such as the Department of National Defence, and Public Works and Government Services Canada. The company has also built secure, wireless communication systems for several police forces including the RCMP.

“Some kinds of information – healthcare records included – are particularly sensitive,” says Michael Martineau, xwave’s director of business development. “We had to be certain this system was airtight.”

Supporting the system is a centralized, reusable security infrastructure provided by Bell Canada, another partner in the RASCHR project. Based on Public Key Infrastructure (PKI) technology, Bell’s infrastructure is used by customers such as UOHI who need to protect sensitive and confidential information as it traverses the Internet.

Rather than build such a sophisticated security infrastructure from scratch, RASCHR is leveraging Bell’s significant investment in the existing system, as well as the company’s extensive security expertise.

To further ensure a high level of security, the system architecture was built in three layers. At the front end is the web layer – the only part of the system accessible to healthcare workers. Second is the application layer – the layer that contains the system’s programming instructions. At the back end is the data layer – the database of patient information. And there are firewalls between each.

“It would be nearly impossible,” says Martineau, “for anyone to get through those layers and firewalls and tap into that database.”

Bell’s PKI technology will be used to encrypt information being transmitted, and will allow only users with registered digital certificates to decrypt it. In addition, every person who uses the system will be assigned one of four clearance levels that will determine the extent to which the user can probe patient records. And users will also be audited; the system will track their queries and identify the person who last modified a patient record.

When RASCHR is fully operational and all 12 regional facilities are connected, the transfer of cardiac-patient information will be faster, more efficient and more accurate. With security covered, healthcare professionals will enjoy the significant patient benefits.

“It’ll enhance patient-care big time,” says Dr. Catherine Greenough, an internist at Arnprior and District Memorial Hospital, one of the facilities that will be linked through RASCHR. “Right now, we’re running to the medical labs. We’re running to the echo labs. We’re running to the floors. The fax machine is going non-stop – all in an effort to either track down or relay information. I can’t wait to be able to hop on a computer, punch in an ID number and get all that information in one spot.”

Lorna Bickerton at the UOHI points out that as well as being efficient, RASCHR is also user-friendly. “The new system mimics our old system, which means, for instance, that people who aren’t inclined to fill out forms in the first place won’t have to acquaint themselves with new ones.” Bickerton also likes the fact that the system allows users to track patient referrals. “The system will provide notification of when a referral has been received, when it’s being assessed, and what the outcome is.”

While Bickerton acknowledges people’s concerns about the security of medical information being relayed over the Internet, she points out that in many respects, RASCHR helps improve security. “Right now we’re having to send information in faxed documents – documents that sit in fax machines in open offices. That’s not an ideal way to send patient records.”

Catherine Greenough agrees. “There’s no question that security is vital. But truth is, you walk into any hospital ward – particularly in the evening when there are fewer nurses around – and you could probably at some point find the opportunity to crack open a chart and have a read.” She adds, “I think that while security is on everyone’s lips these days, what’s really going to matter more to them on a day-to-day basis is availability: will the system be up and running 24/7?”

xwave’s Michael Martineau says yes, indeed. “Remember those three layers of architecture? We’ve built redundancy into each of them. There are multiple web servers, multiple application servers, and two database layers. If one server or layer goes down, the other automatically kicks in.”

“This system is going to provide us with a more effective means of tracking our cardiac patients – and eventually, I’m certain, all patients,” says Lorna Bickerton. “They will be much better cared for as a result.”

Ranald McGillis is Vice President, Central Business Unit, for xwave.

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