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Inside the June/July 2003 print edition of Canadian
Healthcare Technology:
Feature Report: Directory of healthcare I.T. suppliers
 Ontario hospitals
enlist I.T. in battle against SARS
As doctors and nurses across Ontario rallied
together to battle the Severe Acute Respiratory Syndrome (SARS)
virus this spring, information technology professionals were
equally prepared to lend their support.
CHUS produces one of Canada’s first working healthcare
data warehouses
The Centre hospitalier universitaire de Sherbrooke
(CHUS) has a data warehouse up and running, and it’s capable
of analyzing 12-year’s worth of data that’s extracted
from the hospital’s electronic medical records.
The first pan-Canadian EHR
The Department of National Defence has started
work on an electronic health record system that will connect
its facilities across Canada and sites abroad. The large-scale
project will use Purkinje EHR software at its core.
Teaching patient safety
Unique software under development at the University
of Sherbrooke medical school, in Quebec, will allow medical students
to test diagnoses, treatments and drug orders through simulations.
Large-scale EHR in U.S.
Kaiser Permanente, the largest non-profit
HMO in the United States, has launched an electronic patient
record system that will connect 8.4 million patients and 12,000
physicians across the U.S., making it one of the largest EHR
systems in the country.
Telestroke in Ontario
Neurologist Dr. Frank Silver is part of the
NORTH Network’s new Telestroke program, which links specialists
in Southern Ontario with hospitals in the North. Patients benefit
through faster access to care.
PLUS news stories, analysis, and features and more.
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Ontario hospitals enlist I.T. in battle against SARS
By Dianne Daniel
As doctors and nurses across Ontario rallied
together to battle the Severe Acute Respiratory Syndrome (SARS)
virus this spring, another group was equally prepared to lend
its support.
Information technology professionals were also among the first
to respond to the crisis.
Within days of receiving the Ontario Ministry of Health’s
directives to limit and screen the people going through hospital
doors, the Queen’s University Anaesthesiology Informatics
Laboratory (QUAIL) team in Kingston, Ont., leveraged its experience
in Web development to produce an e-SARS screening tool.
According to QUAIL medical director Dr. David Goldstein, it took
36 hours for the team to create a Web application that cut the
screening process down from 10 to 15 minutes per person to a
matter of seconds.
“If you have anywhere from 400 to 600 people coming in on
any one shift, you can imagine the logjam,” said Dr. Goldstein,
who noted that all hospitals were required to have visitors,
patients and staff members fill out a questionnaire as they entered
the facilities. “It was taking so long, and using so much
nursing time, we said this is just not going to do.”
Another problem was identified when Dr. Goldstein randomly selected
completed questionnaires and was unable to read the signatures
of both the person cleared for entrance as well as the nurse
responsible for the screening. “So how could I track anyone
if they got sick? I couldn’t track who they were exposed
to, who exposed them, nothing.”
As part of the e-SARS initiative, QUAIL researchers created bar-coded
ID badges for every hospital employee – including medicine,
surgery, nursing, pharmacy, x-ray, lab and students – and
purchased auto-ready scanners for each entrance. They then leveraged
the wireless computing infrastructure at Kingston General and
Hotel Dieu hospitals to set up an automated screening process
at each entrance.
Upon arriving, employees swipe their bar-coded ID badge under
the scanner and the Ministry of Health questionnaire pops up
on a computer screen, time stamped and dated, and with the correct
name already filled in. The employee proceeds through the questions
on-line, entering his/her name at the end.
Because e-SARS is a Web-based tool, the information is easily
integrated between sites. This means that if an employee works
between two hospitals, the previously filled-in questionnaire
pops up, eliminating the need to repeat it.
“Not only did we achieve a significant reduction in delay,
but we also captured digital data that can now be queried,”
says Dr. Goldstein. The QUAIL team is making its tool available
to other Ontario hospitals in exchange for a donation to the
QUAIL research fund.
Another Ontario-based group sharing its expertise to help combat
SARS is the St. Thomas-Elgin General Hospital, owner of software
company Continuum solutions. The company created a mini version
of its readiness for discharge assessment tool, as well as a
version designed to deal specifically with SARS.
According to Larry Vanier and Sandie Jenkins, principals of Continuum
solutions, the software was made available to Ontario hospitals
at no charge for the duration of the SARS emergency. The goal,
said Jenkins, is to help avoid premature discharge, which would
ultimately contribute to spreading the virus.
The way the SARS Readiness Discharge tool works is simple. Once
patient information is loaded into the Windows-based system,
a screen is created for each patient that outlines 10 criteria
for safe discharge put forth by the World Health Organization.
For example, they have to be without a fever for 48 hours, their
cough must be resolving and their chest x-ray must show improvement.
Each day, a healthcare worker fills in the electronic form with
updated information, marking “yes,” “no”
or “not applicable” for each one. When every question
is answered with a “yes” or “not applicable,”
a patient can safely be discharged.
As Jenkins points out, the tool can be tailored to any discharge
criteria, making it applicable to other situations as well. It
can also be used to produce reports for statistical analysis.
“SARS prompted us to send it out in a mini version,”
she said. “Right now, we have readiness-for-discharge tools
for medical/surgical patients, psychiatric patients and pediatric
patients as well. We decided to focus down and give them this
mini piece of it, as well.”
Continuum solutions included an HL7 ADT interface with the SARS
Readiness For Discharge Assessment software. The interface tool,
called Transmed, is supplied by Artificial Intelligence in Medicine,
and has also been available on a cost-free basis to aid in the
fight against SARS.
At the Baycrest Centre for Geriatric Care in Toronto, lending
a hand was also the focus of the 20-member I.T. department, who
discovered several innovative ways to help out. During the initial
weeks of the virus outbreak, the centre’s 800-bed hospital
facility went into protective lockdown mode, limiting access
to essential personnel only.
According to Baycrest Centre director of information technology
Stephen Tucker, the I.T. team was so moved by instances where
family members were prevented from seeing each other, they quickly
came up with ways to help. “On the way in, there was this
elderly gentleman waving to his wife up on the third floor,”
notes Tucker. “It was touching, an elderly gentleman waving
to his little bride and he can’t be in there with her.”
The I.T. team decided to leverage its existing wireless infrastructure
in order to set up two-way teleconferencing. They purchased four
D-Link cameras, which were integrated into existing movable computer
carts and offered family members the ability to communicate with
their loved ones through scheduled meetings.
The family members could use their own home computers and schedule
a meeting via a password-protected Web site, or they could use
one of two hospital computers provided at two entrances. The
ability to see their loved ones while talking on the phone proved
so valuable, Tucker says, the centre planned to continue the
service even after the emergency ended.
CHUS produces one of Canada’s first working healthcare
data warehouses
SHERBROOKE, QUE. – Many hospitals and
health regions in Canada are planning to develop a data warehouse,
but the Centre hospitalier universitaire de Sherbrooke (CHUS)
has actually gone ahead and done it. They’ve now got a warehouse
up and running, capable of analyzing 12-year’s worth of
data that’s extracted from the hospital’s electronic
medical records.
The system, which has been built using data warehousing software
from Sand Technology of Montreal, extracts information from clinical
and will soon draw on financial databases, as well.
Information is automatically converted into standardized, coded
data using SNOMED, ICD-9, DRG and other systems. The data are
encrypted and de-identified (no patient names are used), and
researchers and other healthcare professionals can be assigned
varying levels of access to the information.
“There are very few data warehouses in North America that
can do this sort of thing,” commented Dr. Andrew Grant,
a medical professor at the University of Sherbrooke and director
of the research project.
He explained that the system enables researchers and planners
to gain a better understanding of current medical practices.
In this way, they hope to improve outcomes and reduce costs.
For example, the system could be used to graphically show how
diagnostic tests are being requested. Dr. Grant noted that sometimes
in routine tests normal values can be returned with a frequency
that might suggest that some of the tests weren’t essential.
Physicians wouldn’t be asked to stop ordering tests, “but
we can ask people to be more discriminating, especially in routine
situations,” commented Dr. Grant, who added that the system
“pinpoints possible problem areas to think about.”
The warehouse enables researchers to perform:
• Epidemiological and longitudinal
studies;
• Health/risk indicator analysis;
• Outcome studies and clinical decision analysis;
• Development of models of resource management;
• Medico-economic analyses.
Sherbrooke’s new data warehouse is part of the IRIS-Q (Infostructure
de recherche intégrée en santé du Québec)
project. The goal of IRIS-Q is to put clinical data warehouses
in place at four university hospital centres in the province
of Quebec, to link them and make the data accessible via a single
web portal by 2006.
The Canada Foundation for Innovation is funding IRIS-Q with $28
million. Of that, $3.2 million was awarded to the Sherbrooke
portion of the project, which is known as CIRESSS (Centre informatisé
de recherche évaluative en services et soins de santé.)
Fabien de Lorenzi, associate director of research at CHUS, explains
that while the Per-Sé electronic patient record system
in use at the Centre for the past 12 years excels at meeting
the day-to-day information management requirements of the hospital,
it was not designed to respond to the complex queries researchers
wanted to ask.
He added that, “the heavy workload on the system arising
from day-to-day hospital operations meant that researchers’
complex queries have to be slotted for execution only during
evenings and weekends, which meant the system was rarely used
for research purposes.”
The current solution, the SAND Patient Record Analytic Server,
allows researchers to ask questions of the data that were practically
impossible before, and in particular allows clinical data and
medical notes to be queried at the same time.
The SAND Patient Record Analytic Server gives researchers at
CHUS the ability to access more than 500,000 electronic patient
files and more than 3 million medical notes and reports per year.
All data are held in a greatly simplified data model — reduced
from 1,200 tables in the operational system to 11 re-grouped
tables.
Canada’s military starts on large-scale electronic patient
record project
By Andy Shaw
If ultimate I.T. challenges are your cup of
tea, here’s one to ponder:
Please provide us with an electronic health record (EHR) system
that:
• maintains comprehensive health records for 50,000 to 60,000
of our people, including their drug and dental care, no matter
where they move (and they move frequently);
• is available to our care-givers and patients alike, 24x7
in our one hospital and 27 out-patient clinics across the country,
as well as our constantly changing missions abroad and even aboard
our ships at sea;
• uses commercially available software and decision-support
tools that have been proven reliable from trustworthy suppliers;
• is bilingual;
• most importantly, is so secure that not even the most
skilled hackers of any potential enemy of ours can crack it;
• and finally, integrates all this into one easy-to-use,
readily maintained, future proofed, and bug-free EHR that works
without fail from the first day it is rolled out.
Such was the formidable nature of the criteria set forth by the
Department of National Defence (DND) in a Request For Proposal
(RFP) for an EHR that will underpin the healthcare of all of
Canada’s fighting men and women in both the regular and
reserve arms of the Canadian Forces.
Like the business of the Forces themselves, this massive undertaking
is not a job for the faint of heart. Yet, nine prime bidders
all responded to the RFP. In the end, the nod went in February
this year to Lockheed-Martin Canada to deliver a state-of-the-art
EHR, dubbed the Canadian Forces Health Information System (CFHIS).
But why Lockheed-Martin? The builder of fighter jets, smart bombs,
cruise missiles, and naval frigates, among other major weapons
systems? And a company with little experience in healthcare?
“That’s true about our healthcare experience per se,
but obviously the DND selectors agreed with us that it was a
secondary consideration. Rather, it is our strengths that are
most needed by this project — specifically our general familiarity
with the military and most importantly of all, our expertise
at large-scale systems integration,” said Alan Steele, now
Lockheed Martin Canada’s project manager for the CFHIS in
Ottawa.
Steele’s qualifications include just the right amount of
grey hair, he says, grown from facing the challenges of 18 years
of project management for DND, including the highly successful
Canadian Frigate Program that produced Canada’s widely envied
fleet of modern warships.
This time, Steele will oversee a multi-year contract worth at
least $56 million that calls for a test-as-you-go, phased implementation
of the CFHIS. The first three phases of design, testing, and
roll-out will stretch over five years.
Steele and a project team of both military and civilian personnel
are co-ordinating the work of the initial five subcontractors:
Dinmar Consulting, Purkinje Inc., SCC Soft Computer Consultants,
Calculus Informatique, and Adstra Systems Inc.
“This is a rather unusual set-up. It’s a very, very
large systems integration project for one thing,” says Richard
Johnstone, senior functional analyst on the project for Dinmar.
“Also what’s unusual is that this is an EHR to be used
in widespread clinics and deployed abroad. The third distinguishing
feature is how much energy and thoroughness is going to go into
protecting privacy and security. Of course, the military has
a special concern about that. It can’t ever let an enemy
know the state of health of its troops.”
Johnstone was part of an earlier team that developed the multi-server,
Citrix-based enterprise architecture plan for the CFHIS, an initiative
that stretches back to 1998 when DND first committed funds to
develop a Forces-wide EHR. This time around, he will lead the
contribution of Dinmar, which brings much healthcare experience
to the project. Dinmar claims it is the largest independent provider
in Canada of I.T. consulting services in the healthcare sector.
Purkinje, based in Montreal, will bring the software nuts and
bolts of the actual electronic health record. Its bilingual Dossier
clinical notes/EHR product enables both physicians and clinical
assistants to make keyboard entries into a single on-screen document.
On “civvy street”, Purkinje already has a user base
of 1,100 clinics.
Curiously, Dinmar will help Lockheed-Martin integrate the Purkinje
record even though Dinmar itself markets the well-known OACIS
health record. “It’s an acquisition Dinmar has made
only fairly recently,” explains Johnstone, who further points
out that Dinmar was included by Lockheed-Martin not for its products
but for its general experience and expertise with healthcare
I.T. systems.
“We are pleased to be working on a project of such prominence
and scale,” noted Mark Groper, Dinmar’s CEO. “Our
history of focusing solely on the provision of healthcare technology
solutions is well-suited to the complexity of the CFHIS project.”
SCC Soft Computer Consultants will provide an ancillary suite
of laboratory, radiology, and pharmacy systems, with partner
Calculus Informatique of Montreal ensuring that they are all
bilingual.
Adstra Systems of Toronto will contribute its dental charting
and dental imaging management systems.
Lockheed-Martin will orchestrate the contributions of these players
to the CFHIS, first on a rigorous, proof-of-concept test-bed
located at the National Defence Medical Centre (NDMC) in Ottawa
— all under the watchful eye of the “customer”,
represented by Lieutenant Colonel Jim Kirkland, DND’s senior
staff officer for health services informatics. He will be aided
by DND’s own project manager, Bill Brittain. For those systems
and contributors who pass the test, there will be yet another
proving ground when the CFHIS will be placed in two pilot sites,
likely at Canadian Forces clinics in Esquimalt, B.C. and Edmonton.
“We began work on this in 2002 even before we formally picked
Lockheed-Martin. So now we’re six months down range and
have about 30 contractors already in NDMC. We have been consulting
DND healthcare providers all along to make sure we’re going
to provide what they need and can use. The test-bed, all the
hardware, and all the out-of-the-box applications installed.
And we are configuring the security solution,” says Lt.
Col. Kirkland, who is a former pharmacist turned manager with
24 years of health services work in the Canadian Forces logged
so far.
“For security, we will be using PKI (public key infrastructure)
to support our EHR, which I think will be a first in government.
And the EHR will run over our defence wide area network, our
virtual private network,” says Kirkland. “All the applications
will be PKI-enabled using Entrust products, and I don’t
think there is much of that going on yet anywhere else. To integrate
all the applications together we are using E*Gate software. That
will give us HL7 interfaces for messaging and a common look and
feel to the applications.”
Kaiser Permanente’s EPR will reach 8.4 million patients
across the U.S.
By Andy Shaw
It’s big, it’s bold, and, in about
three years, this electronic patient record (EPR) system promises
to be bountiful. Kaiser Permanente, the USA’s largest not-for-profit
health maintenance organization (HMO), is investing US$1.8 billion
into an EPR program that uses software from Epic Systems Corp.
The record will service all 8.4 million of Kaiser Permanente’s
members, along with its 12,000 physicians and 100,000 other caregivers
in all eight of the HMO’s semi-independent regions across
the United States.
When the EPR roll-out is complete in 2006, both Kaiser patients
and staff will have password protected access to what promises
to be the biggest patient database in the world and one that’s
rich with best practices for members and caregivers alike.
Kaiser Permanente, headquartered in Oakland, Calif., announced
in February that it would adopt an EPR from Epic Systems, based
in Madison, Wisconsin, for all Kaiser’s 29 hospitals and
423 medical offices spread across nine states as well as the
District of Columbia. It was a dramatic and somewhat surprising
decision. For a decade Kaiser had been developing its own EPR
with the help of IBM. But even though the work with Big Blue
had produced a functional EPR, Kaiser was heading towards $1
billion in costs and at least a five-year-long rollout.
Kaiser Permanente’s new CEO decided that was going to be
too expensive and too long. Soon after, Kaiser executives made
a convincing business case for shelving it and writing the expense
off. Then, in a competitive bid process, Kaiser turned and picked
the Epic alternative.
“When George Halvorson arrived last year as the new CEO,
he saw right away that the EPR was going to be our single largest
capital expenditure,” explains Dr. Andrew Wiesenthal, executive
director of the umbrella Permanente Federation and who is quarterbacking
the Epic deployment. “So he said he wanted to make sure
we were on the right path and asked us, along with a number of
consultants, to re-examine what was available in the marketplace.”
Dr. Wiesenthal says that when Kaiser Permanente had first looked
for an EPR in the late 1980s, there simply was none – at
least not one scalable enough to handle the caseload of even
one Kaiser Permanente region, never mind the whole outfit. Then
in the 1990s, its Northwest region (second largest behind California)
found and adopted an Epic EPR for its half-million members.
“All our regions had recognized the need for patient-record
automation. Some were heading down the path of internal development
working with IBM, as we were at the time in Colorado, while others
went looking outside,” says Dr. Wiesenthal. “But by
the late 1990s, Kaiser Permanente recognized that it should make
a unified effort. Of course, we were all aware of what was happening
in the Northwest, but we made the decision to go with an internal
IBM solution largely because we thought it would be more scalable.”
However, when directed by their new boss to look again, Wiesenthal
says they found the marketplace had changed. “It was very
clear that the market had matured and that Epic had evolved its
EPR’s functions, technical capabilities, and robustness
substantially. It was also developing faster than our EPR and
we saw it would pass ours by. It’s what happens when a company
directs all their energies into their product. We were happy
with what we had done (with IBM). There was nothing broken about
it. It was working but it was clear that we would be left with
something that wasn’t the best.”
What’s more, the Epic record was proven. So it needed no
long-running trials or pilots – only careful adaptation
to the legacy systems and idiosyncrasies of the seven other Kaiser
Permanente regions.
The Epic system includes a full medical record, physician order
entry, clinical decision support, scheduling, and billing modules.
Through a Web portal, the client-server based system will be
open to patients to create and update their own personal health
pages, request appointments, ask for prescription refills, and
otherwise communicate with their care providers.
All this will function in an encrypted environment and provide
secure access around the clock. Patients and caregivers gain
access according to strict rules set for their roles. They can
delve into medical histories, test results, diagnostic imaging,
prescription information, and up-to-date medical sciences information
to the extent authorized. Caregivers will be able to practice
evidence-based medicine drawing on the aggregate data of the
central EPR repository and benefit from built-in checks against
medical errors.
Challenges of rolling all this out, says Dr. Wiesenthal, include
getting the data definitions right in the final configuration.
So, while there will be no pilot projects per se, there will
be some unit testing of these definitions. That’s all to
be done by September, when delivery to each of the regions is
scheduled to begin. During the transition to the common record,
each region will keep its legacy systems up and running, and
will independently deploy differing parts of the Epic system
as suits their situation.
“One of the great advantages of the Epic system, is that
it is highly configurable and adaptable to the local circumstances,”
says Dr. Wiesenthal.
Nonetheless, when asked how do you manage such a huge and variable
deployment, Dr. Wiesenthal replied: “Really carefully.”
With a implementation project team that will rise at Kaiser Permanente
headquarters to as many as 200 people and involve as many as
1,500 when counting those in the field, Dr. Wiesenthal says the
hardest part for them all will be training and support. “We
face a lot of resource allocation issues in terms of getting
people in the right places at the right time. We have to put
a lot of time, energy, and effort into appropriately training
people and supporting them as they implement this software. Otherwise,
you run the risk of failure, and we don’t intend to do that.”
That job will be made somewhat easier by the nature of the network
Epic will function on, and Epic’s track record in the Northwest
and in Georgia, where some of the Epic modules have also been
in use.
“We have a private network running on T1 lines already in
place. So we don’t have to build a new one, and we don’t
have any telecom issues to deal with in the roll-out as a result,”
says Dr. Wiesenthal.
Perhaps more importantly, ever since the Northwest region began
piloting the EPR system in Oregon back in 1994, Kaiser Permanente
has actively encouraged and sought detailed feedback from physicians
and other caregivers. It has made a study of gaining user “buy-in”
and made many modifications following caregiver input.
Judith Faulkner, CEO and founder of Epic Systems Corp., likes
the emphasis Kaiser Permanente has give to such collaboration.
“Kaiser Permanente’s vision offers significant advantages
for providers and patients alike, especially in sharing information
across locations and over time,” says Faulkner. She goes
on to point out that users can gain secure and instant access
to EPR information at every point-of-care which, in turn, encourages
providers and patients to collaborate more and thus streamline
the care process.
Those benefits and others have not gone unnoticed internationally,
says Dr. Wiesenthal. “We’ve had several hundred visitors
here from Britain, for example, after an article appeared in
a medical journal over there. It concluded that a patient being
looked after by Kaiser Permanente would be a lot better off than
one being looked after by their National Health Service.”
So far, no Canadian visitors in any numbers have shown up. But
maybe they should. Dr. Wiesenthal says that despite the fundamental
differences between the privately driven U.S. healthcare and
taxpayer-driven Canadian model, there’s no reason why the
Epic system, given its proven flexibility, couldn’t be adapted
to a public healthcare system.
“I think they could learn something from what we are doing,”
concludes Dr. Wiesenthal.
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