New I-SITE telemedicine project screens for eye disease in Alberta

By Neil Zeidenberg

RICHMOND, B.C. – A new telemedicine project called I-SITE (Intelligent Screening of Imagery via Teleophthalmology), is using wireless technology to screen for eye disease in remote communities with a high incidence of diabetic retinopathy – a swelling of the capillaries in the retina, which if left untreated, can cause permanent blindness.

MacDonald Dettwiler and Associates —an information management firm developing the software technology – is running the project, along with its partners, the Canadian Space Agency and the University of Alberta Ophthalmology department.

Antennas have been installed at the university in Edmonton and at the clinical sites in Fort Vermillion, 700 kilometres North of Edmonton, in order to transmit and/or receive data.

To date, more than 110 people with diabetes have been screened for eye diseases using the I-SITE technology. About 25 percent of the patients screened were found to have diabetic retinopathy, and many eyes were diagnosed with different degrees of NPDR (non-proliferative diabetic retinopathy).

A total of 15 eyes have had focal laser treatment. Without detection through I-SITE, these patients would have gone blind.

Harold Zwick, PhD, project manager with MacDonald Dettwiler, explained how the technology works. “Conventionally, ophthalmologists attach a 35mm camera to the back of a fundus camera. The flash illuminates the retina, and that illumination is then captured on film.” A series of seven images are taken, spatially separated over the retina to create a diagnosis of the eye.

“What we’ve done is simply used a digital camera to capture the images in digital format. We can now pre-process these images in real-time, bundle the data together and send it either by satellite or landline to Edmonton where the diagnosis takes place.”

They are currently looking into to compressing the data so that it can be transmitted even faster.

This new technology allows an ophthalmologist to scan for eye diseases from remote locations. The I-SITE technology is particularly beneficial to small rural or First Nation communities, such as Fort Vermilion, where diabetes is three to five times higher than normal. The technology can provide better access to care, and help those affected avoid lengthy and costly travel away from the community.

“Native communities have an incidence of diabetes four times higher than the normal population, so they’re the one’s who are most in need.” Because of their remote location, “they’re also harder to get to.”

Moreover, frequent screening in remote communities can lead to early detection of diabetic retinopathy and other degenerative eye diseases. If necessary, laser surgery can be performed before it leads to blindness.

I-SITE digital imaging is just as accurate as the ‘gold standard’ of film, but the images can be processed and transmitted much more quickly, making it easier to screen for problems.

The project is being funded in part through PRECARN, a not-for-profit agency out of Ottawa that lends government assistance so long as there is collaboration between universities and industry. Participants must put up roughly 50 percent of the cost. Approximately $650,000 in funding came from PRECARN to help start up the project. The rest of the funding has come from MacDonald Dettwiler, the Canadian Space Agency and University of Alberta. To date, approximately $1.5 million has been spent to keep this project running.

Diabetes affects 6 percent of the population of North America, and left untreated, can lead to non-accident-related amputations, end-stage renal failure, impotence, hypertension, heart disease and stroke.

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MedcomSoft develops easy-to-use patient record software

By Jerry Zeidenberg

TORONTO – Despite the well-publicized benefits of electronic-patient record software, physicians have largely shunned the stuff. Researchers estimate that only 5 percent to 10 percent of North American physicians regularly use electronic medical-record systems.

Doctors commonly complain the software is too clumsy and slow – after all, they can’t start pecking out copious notes on a keyboard during a patient encounter.

Now, however, a Canadian company says it has developed software that enables physicians to log virtually every symptom, diagnosis, test and therapy during patient encounters – quickly – by using a point-and-click technique. No text entry is needed.

“You can document an encounter in 1.5 minutes instead of 15 minutes,” said Dr. Sami Aita, founder and chief executive officer of MedcomSoft Inc. of Toronto, which has developed the innovative MedWorks 3.0 software.

MedcomSoft has ambitious plans for the system, and is currently marketing the software to health systems in Canada, the United States and around the world.

Indeed, in May, MedcomSoft announced a $25 million licensing sale of the software to Mayne Nickless Ltd., the largest private healthcare service provider in Australia. The agreement allows Mayne Nickless to implement MedWorks software throughout its facilities.

The Australian organization operates 47 hospitals in five states, and also runs pathology and diagnostic imaging facilities through Mayne Nickless Diagnostic Services.

For his part, Dr. Aita is a French-trained emergency-room physician who notes that doctors shouldn’t be faulted for refusing to adopt patient-record software in the past. “We shouldn’t blame them for not using computers, because they never received the proper tools,” he said. “Most of the systems require months of training, they need too much text input, and they don’t have multimedia capabilities.”

According to MedcomSoft, not only is MedWorks easy to use, but it contains enough intelligence to prompt doctors on the questions that should be asked as part of a full diagnosis, what tests should be ordered and the potential therapies that are available.

It also automatically converts the encounter notes into commonly used medical codes – such as ICD-9 and CPT-4 – which are needed for reporting and billing. As such, it automates work that is otherwise time-consuming and expensive.

For doctors in the United States, the software offers the ability to automatically generate Health Care Financing Administration (HCFA) compliant E&M codes – an important feature, since Medicare claims in the U.S. must meet stringent requirements.

At the core of the MedWorks software is the Medcin system, a unique database created by Medicomp Systems Inc. of Chantilly, Va. Over the past 25 years, the company has worked with physicians and scientists at major centres such as Cornell, Harvard and Johns Hopkins to compile and logically link virtually every human disease, symptom, test, diagnosis and therapy into a computerized table format.

The Medcin researchers have assigned a numerical code to each of these data elements, creating a number-based system for medicine. That’s why text entry isn’t required on the part of the physicians using the system.

Instead, doctors can point-and-click their way through a diagnosis, with the software automatically displaying symptoms, tests and therapies that are logically connected. In this way, patient encounters can be quickly documented.

The Medcin researchers have captured more than 150,000 data elements in this way, creating some five million connections among them.

However, because of the built-in intelligence, users aren’t overwhelmed by a mass of information. They’re only presented with items that are clinically relevant.

For example, certain symptoms, diagnoses and therapies will appear for a 70-year old smoker complaining about a cough. By contrast, different data elements are logically linked to a three-year-old with a persistent cough.

For its part, MedcomSoft is first into the market with a comprehensive system based on Medicomp’s database technology, which it has licensed. “We’re the first company to create a complete electronic medical record that uses the Medcin database,” said Dr. Aita. “We created the first engine in the world capable of driving the Medcin nomenclature.”

Medicomp updates the nomenclature every three months, adding developments such as new tests and therapies.

Surrounding the Medicomp engine, MedcomSoft has built what it’s calling a user-friendly system with many additional features that improve the clinical performance of doctors and entire health regions.

For example, physicians can track the results of tests and therapies in groups of patients, essentially conducting their own outcomes analysis. Dr. Aita says this sort of data mining can be done on a larger scale, as well. Results could be collated in a hospital or an entire health region.

“You can look at the data and see whether six days in hospital is better than seven for a hip replacement,” said Dr. Aita. “You can determine whether home care is better for some chronic diseases, and whether ventalin is better than other drugs.”

He added that, “Every doctor or hospital can collect their own stats and do the data mining. And it’s all codified in formats like ICD-9 or CPT-4.”

The software is web-enabled, and can run on common browsers like Internet Explorer or Netscape Navigator.

Doctors can use this capability to give patients access to their medical records, whether they’re at home or travelling in other parts of the world.

The information can be accessed on mobile technologies, such as the new cellular phones that display several lines of alphanumeric text.

“A patient on vacation in Florida could phone in to the web site, access his health record, and get a list of his medications,” said Dr. Aita. This might be particularly helpful if the patient needs medical attention while on holidays or when working abroad.

Hosting the medical record could become a new source of income for the physician, said Dr. Aita. They doctor could charge a relatively small fee, say $50 per year, to keep the patient’s record on a web site. If a doctor enlists 2,000 patients, it could be worth $100,000 annually in extra fees. “There is now a payback for the physician,” said Dr. Aita.

The web-based system can also help make the doctor’s office more efficient. It can be connected to labs to order diagnostics tests and to obtain quick results – via e-mail rather than over the telephone or fax.

What’s more, the software can display all kinds of images, including surgical photos, x-ray files, and angiogram movies.

Patients could request prescription renewals via e-mail, and doctors might be able to quickly authorize such refills with pharmacists who are part of a network. Dr. Aita said discussions in Canada are under way with the major drug chains.

And because the MedWorks system can be built with protocols – routine questions for various ailments – GPs and specialists can let assistants handle much of the preliminary questioning of patients that typically slows down the doctor.

“Instead of the doctor asking about history and symptoms for 15 minutes, the assistant can go through the list, which can be reviewed by the physician afterward,” said Dr. Aita.

For example, a pediatrician may spend much time asking patients and parents about fevers. These questions could be asked by an assistant.

MedcomSoft is currently creating its own “accelerator protocols” for a variety of specialties, the first of which is orthopedics.

Overall, the MedWorks software is built on Microsoft Office and NT. MedcomSoft is not a newcomer to the world of electronic patient records. In the mid-1990s, it released its first version of MedWorks – without the Medcin engine. The software is currently used by some 400 doctors, clinics and hospital departments in Ontario.

With the new version, however, the company is clearly shooting for the international marketplace. From a business point of view, it’s very attractive to license the software to U.S. healthcare systems, which typically employ hundreds and even thousands of doctors in a single organization.

As well, MedcomSoft will be marketing the software in Canada, where it will provide doctors with long sought after clinical and financial advantages, asserted Dr. Aita. “The software has major medical benefits,” he said, “and it gives doctors an incentive for investing in computer systems.”

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Ontario budget: more money for health IT, but standards go missing

By Andy Shaw

The recent Ontario budget allocates significant sums of money to improve the province’s health information structure. But the former head of Ontario’s healthcare restructuring commission, whose report prompted the expenditures, is less than impressed.

The Ontario Budget 2000, announced in May by Finance Minister Ernie Eves, provides cash for four major IT initiatives in Ontario healthcare:

• $4 million additional funding for the expansion of a children’s health information network now connecting five southern Ontario hospitals.

• $45 million to bring a telephone triage service piloted in Northern Ontario to the greater Toronto area (GTA).

• $150 million in one-time funding for the hardware and software needed to link up 200 physicians in an around-the-clock primary care network.

• $500 million matching funding for the Ontario Innovation Trust that provides grants to universities, laboratories, and other research centres for high technology of all kinds.

“These are all very good things to do,” says Dr. Duncan Sinclair, the recently retired head of Ontario’s Health Services Restructuring Commission (HSRC) “But they are not going to be very effective. The government has missed the fundamental issue that we gave heavy emphasis to in our report. To make these investments work, we said Ontario needed to create a strategy that would allow health data to be moved province wide. In order for that to happen all these new installations must be compatible with each other. But right now they’re not, because we’ve failed to develop common standards for them. And standards development has not been funded.”

What has been funded is the electronic Child Health Network (eCHN). It now connects the pediatric services of the Hospital for Sick Children, St. Joseph’s Health Centre, and St. Elizabeth Healthcare in Toronto with the Rouge Valley-Centenary Health Centre in Scarborough and Soldiers’ Memorial Hospital in Orillia. According to Horace St. Aubny, an economist with the Ontario finance department, the $4 million dollars promised to the eCHN in this year’s budget tops up the $7.5 million already given it in the 1998 Budget. That totals a $11.5 million Ontario government contribution to the $15 million dollar project, designed to improve information sharing among healthcare providers to children.

Specifically, the eCHN is meant to reduce duplication of tests and assessments, distribute clinical information rapidly to healthcare providers, and give access to information about a child’s care to his or her parents. Under development with the assistance of IBM Canada Ltd., the eCHN is slated to eventually connect up 32 institutions and about 500 pediatric physicians.

The $45 million set aside for a toll-free telephone triage system for the GTA is designed to reduce the crush of patients jamming Toronto area hospital emergency rooms. Like systems already established in New Brunswick, Quebec, and British Columbia, the triage system would give concerned callers critical information about their condition they might otherwise have sought by showing up at the hospital or their doctor’s office. Callers will be connected with experienced nurses who will have a database of diagnostic and other medical information at their fingertips. They can then make an informed referral to the most appropriate healthcare provider for that caller.

The Ontario finance department’s St. Aubny says the project will likely get under way this summer, funded by the $20 million promised in the Budget for its start-up.

The $150 million set aside for Ontario’s primary care network is testament to the success of pilot projects throughout the province. Patients who register with the network through their doctors will have 24-hour-a-day, 7-day-a-week access to expert care providers. With the new funds, 200 physicians will have the right computer gear in their offices to quickly share patient medical and medication histories.

The $500 million Ontario Budget contribution to the Ontario Innovation Trust (OIT) is not purely for information technology, St. Aubny points out. The independent trust funds a wide range of equipment and technologies that help advance medical research. OIT matches grants from the Canada Foundation for Innovation, a corresponding federal program. The 1999 Federal Budget announced $200 million for the Canada Foundation and then the 2000 Federal Budget added another $900 million. Hospitals, universities, colleges, and other research institutes must apply and survive a screening process to gain the grants. But applications to help fund new computer systems for research environments will be considered.

Considering all that available money, however, Dr. Sinclair says Ontario is still missing the point.

“I believe we only have a window of opportunity and that window is closing fast,” says Dr. Sinclair. “The large hospital groups in Ontario are all developing their own networks and they are all based on proprietary technology. There are no standards in place to link them so they can share information. And I think within six to eight months those systems will be so large that the cost of then making them compatible will be absolutely prohibitive.”

Asked why he thought the Ontario government appeared to miss a main thrust of his commission’s report, Dr. Sinclair replied. “It’s not sexy. The government believes it can’t sell a long-term concept like the need for standards to the public. Right now it’s addressing the short-run problems of healthcare that are in the news. And in that sense the government may be right. If you said to most people on the street today that what we need to do right now is to spend a lot of money on developing a proper health information infrastructure, they would probably look at you as if you were from another planet.”

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New web-based scheduling software optimizes the delivery of services

By Jerry Zeidenberg

Scheduling patient examinations, tests and treatment is a challenge for every hospital.

However, it’s even more difficult at the University Health Network, due to the wide range of procedures going on and the high volume of patients arriving each day.

In a bid to ensure the smoothest possible flow of patients and an optimal management of equipment, the UHN – an amalgamation of the Toronto General, Toronto Western and Princess Margaret hospitals – is now testing a new form of enterprise-wide, scheduling software.

“The UHN has 3.3 million bookable events a year,” commented Dave Harestad, CEO of eOptimize.com, the Vancouver, B.C. company that is producing the software selected for the pilot project in Toronto. He noted that UHN is one of the busiest and most complex hospitals in the country, and if the software works there, it’ll work pretty much anywhere.

Unlike most of the scheduling software that’s on the market today, eOptimize.com’s product coordinates resources across the whole enterprise, not just for individual departments.

It also makes use of sophisticated mathematics to model complex relationships between people, services, equipment, locations and other resources in the hospital system.

As Harestad puts it, the software is used “to better model the relationships that exist between all constituents of the delivery process.”

For example, a gastroscopy may be broken down into a number of various events, such as pre- and post-procedure events such as lab work and follow-up visits. Using the eoptimize software, all of these events can be brought up at once and booked on the computer system.

By contrast, older methods of scheduling across departments required “a lot of checking and time spent on the telephone,” said Harestad.

He noted that when arrangements are made over the telephone, there’s a lot of time spent on hold, or waiting for the appropriate person to be paged, along with call backs and confirmations. According to Harestad, the eOptimize.com system speeds-up this whole process by giving care providers a better picture of the enterprise when scheduling events. In addition, it offers access for patients to schedule their own procedures – when hospitals are ready to allow this.

“You and I will be able to go online to book our own non-critical healthcare services from our homes, offices or wireless devices, much like we do with banking, shopping and brokerage services,” said Harestad.

Currently, the pilot project at the UHN is targeting the cardiology department, across two sites.

Unlike many previous forms of scheduling software, eOptimize is entirely Web-based. What’s more, it uses the mathematics of optimization to determine how to bring people, rooms, and equipment together in the best fashion.

“You can conceivably have hundreds or even thousands of constraints on a scheduling problem,” said Harestad. “When you consider a scenario whereby event A cannot occur within three hours of event B, and each event needs multiple resources, each with their own availabilities and constraints, you suddenly have a pretty complex problem on your hands,” said Harestad.

“Add in the fact that the patient has indicated he is unavailable on Tuesdays and Thursdays, and the problem gets that much more tricky.”

EOptimize.com was started last year by Harestad, Barry Baker and Karen Hawkins, each of whom previously worked at clinical software companies.

As well as maximizing the use of a hospital’s resources, “We’re also concerned with issues of patient satisfaction,” said Harestad. “You don’t want to have people sitting and waiting for care. You really don’t want to book every patient for 9 am, and let them sit and wait for the next available opening.”

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