Provincial health networks slowed down by the lack of new privacy legislation

By Andy Shaw

Newfoundland’s progress on a provincial health network is more than a half an hour ahead. Unlike their envious counterparts in Manitoba and Ontario, for instance, the co-operative folks at the Newfoundland and Labrador Centre for Health Information (NLCHI) are soon likely to receive funding for the provincial network’s cornerstone. It’s an electronic client registry that will give every Newfoundlander a unique patient identifier. Meanwhile in Winnipeg, information technology heads have finally come up from their Y2K fixes and they’re now telling the Health Minister what to spend money on next. Down in Toronto, well, there are more reports. The final report on restructuring Ontario’s disparate health system says an earlier report on the need for a province-wide health information network was a good thing. More encouragingly in Ottawa, there’s a permanent Info Highway office now in place working quite busily on making a national quilt out of our patchwork of provincial health information structures. But in all locales, privacy is acknowledged as the pitfall.

“Our current privacy legislation isn’t more than three pages long, says Doreen Neville, the CEO of the NLCHI in St. John’s. “And it won’t be complete enough for people concerned about the confidentiality of their information once we get to the next stage of implementing our network, the Personal Medication Dispensing History system. We’ll need the comfort of some more legislation around that.”

Concerned as others are in Ontario and Manitoba that the development of a province-wide health network might get bogged down while provincial legislators try to noodle out privacy policies to govern all electronic information sharing, Neville and the NLCHI went out to see their stakeholders.

“We wanted to develop some privacy guidelines so government people could focus on the exchanging of health information. We’d like them to carve it off from broader privacy concerns and deal with it first,” says Neville. “So we consulted with all our constituents including the provincial bar association.”

The result is a set of health information privacy guidelines the NLCHI has presented to the Newfoundland ministry of health. At the moment, NLCHI and health ministry officials are together out in the field reviewing those guidelines with stakeholders in detail.

Meanwhile in St. John’s, Steve O’Reilly, the NLCHI’s health information network project leader, has put the finishing touches to a $ 3 million dollar plan and request for funds.

“We worked with our consortium partners and took the 10,000-foot view of the unique identifier/client registry piece down to its functional requirements,” says O’Reilly. “We’ve spelled out what we need the technology to do in order to meet the business requirements. We’ve shown the costs for a number of technical options and we’ve re-assured our friends on the Hill in government that the benefits we presented in the business case are indeed there. “

The patient identifier and the second-step, $7 million medication dispensing history system are part of a notable eight-phase business plan. It won government acceptance for its proposal that the provincial health network be paid for within existing health ministry funds. The plan calls for savings created by implementing each phase of the plan to finance the next phase. The plan is being executed by the private-public partnership that put it together.

“That’s the other thing the government has been watching us for is how well our consortium has worked together,” says Bryan Eckhardt, the project leader for Manitoba-based SmartHealth, one of four private sector partners in the consortium with the NLCHI. “And the feedback we’ve been receiving from the people in the health department and at Treasury Board is that we’ve demonstrated we’re a successful partnership.”

That probably, adds O’Reilly, had a lot to with phase I of the consortium’s work on the patient identifier. It came in on time and under budget.

As a result, the consortium is likely to get go-ahead funding for Phase I shortly after the imminent federal government release of funds for its Community Health Information Partnerships (CHIP) program. An expected $80 million will be made available by CHIP to the provinces.

At the same time, Neville says she’s hopeful the Newfoundland government will approve the NLCHI as a freestanding agency. NLCHI is currently run by a board of management reporting to the Health Care Corporation of St. John’s. “Having a freestanding agency is a faster and more efficient way to develop a provincial system not only because you are freer to deal with the private sector but also because you can achieve much broader stakeholder consultation ,” says Neville. “And I’m encouraged by the fact that a number of provinces have been in touch with us about how we work and that Ontario is considering creating a freestanding organization like ours.”

Ontario, it seems, does a lot of considering. Its Health Services Restructuring Commission (HSRC) submitted its final report for the consideration of Ontario Health Minister Elizabeth Witmer in December. She’s been considering the HSRC’s interim report on an Ontario Health Information Action Plan since last February – with no action plan announced as a result. Such a long silence raises the question of whether an Ontario health network is suffering paralysis from too much analysis.

“The problem is that the policy process isn’t keeping up with technological change,” says Mike Moralis, a policy analyst with the Ontario Hospital Association (OHA) in Toronto. Technology has been roaring ahead, agrees Moralis, while “...we’re still making policy decisions at the same pace as we did in the 1970s.”

“You can go back to 1989 when the (Ontario) government talked about introducing Smart cards with a magnetic stripe, but nothing has yet really been put in place because the Internet has come along and changed the technology. Now there is a new pipeline,” says Moralis, “But even more importantly we haven’t been able to decide what we can put in that pipeline legally because we, like most other provinces, have no health information privacy legislation. Indeed, if you really look into it, Ontario has been struggling with this information issue since about 1974 and we’re not much further ahead now then we were then.”

One thing Ontario does know better now, thanks to the OHA, is just how much a health information network might cost.

“In all its reports the Ontario restructuring commission has not talked much about costs in any detail,” says Jim Cruickshank, a financial operations consultant with the OHA. “So we commissioned a study to put a dollar figure on the costs of restructuring. And we did that because it is the hospitals that have carried about 100 percent of the capital costs for information technology infrastructure in the past. Hospitals need to know for fundraising purposes what the figure is likely to be.

“Our study estimated that the IT restructuring costs running up to 2003 are going to be about $1.5 billion... that’s out of a total restructuring cost of about $7.8 billion. And that $1.5 billion is a much bigger figure than the ones mentioned in the restructuring commission’s reports.”

Cruickshank adds that an OHA working committee will make a full report on its cost study and the implications for an Ontario health network by early March.

“Ontario began restructuring after just about every other province, and yet in the amount of study of the subject we’ve done, Ontario has exceeded every other province in the production of paper,” observes Cruikshank.

The Ontario government’s apparent uncertainty may be evidence of an internal Cabinet debate between those who favour going ahead with high tech spending and those who want to go back and repair the bricks and mortar foundations of a crumbling healthcare system. One that now turns ambulances away at Emergency Room doors and forces cancer patients off on cross-border forays for treatment in Buffalo.

“Privacy and privatization are also paramount issues here for the government,” says Cruickshank. “The majority of people believe if you can’t put in a system that is 100 percent secure then we should not do it. And there’s also a debate whether change can be managed more cost effectively by the private sector than by the government.”

One other hope is for what might be called in other circles, a “killer app” to stir government inertia. In Ontario, some insiders see a proposed care path for cancer patients being pushed by Cancer Care Ontario as being the kind of catalyst a province needs to get on with network building.

“You need a specific system like that to be the driving force in order to get a network in place,” says Jim Kerr, head of communication information systems at Winnipeg’s Health Sciences Centre, Manitoba’s largest acute care hospital. Kerr is a member of a provincial task force that has just submitted a report summarizing all of Manitoba’s health network initiatives. The report and its next-step recommendations for extending the best of those initiatives across the province will eventually make its way to the provincial Cabinet.

What makes the report believable is Manitoba’s drug and prescription information management system, dubbed DPIM. And that’s because DPIM is already up and running.

“The application is in all the retail pharmacies in the province now and we are eventually getting it into all the health facilities across the province (DPIM went into the 800-bed Health Sciences Centre in January), says Kerr. “It means places like emergency rooms can instantly find out what medication a patient is on. That’s the kind of system we really need. One that services the patient and not just the facility.”

Kerr and his task force cohorts will also need some help from Ottawa, for they too face the potentially paralyzing concerns over invasion of personal privacy.

“We are hoping the CHIP program will help provinces sort out the privacy issue, and other issues that apply particularly to telehealth and electronic health records,” says Michel Leger, director of the consultation and collaboration division of the Office of Health and the Information Highway in the nation’s capital.

Leger’s position and office sprang from the work he and his staff did as a secretariat to the Advisory Council on Health Infostructure starting in 1997. Leger submitted the Council’s report last February to Health Minister Allan Rock. Since then, Rock won some $366 million dollars in the 1999 Federal Budget for the development of a nation-wide health info-structure. In a tri-partite effort, Health Canada, Statistics Canada and the Canadian Institute for Health Information (CIHI) have been spending some of that money developing a “Road Map” for the way ahead, funding over 30 different direction-finding projects across the land.

The Budget also provided funding for an on-going collaboration and consultation effort with the provinces that Leger now directs. Since it set up shop in June, Leger’s office has convened meetings of a now permanent advisory committee on health info-structure. It consists of all the provincial and territorial CIOs.

“We currently are merging a blueprint document we developed last fall for all the key elements needed in a health info-structure with another piece of work we did called a ‘Current State Assessment’,” says Leger. “From that we will be able to do a comparison of what is going on in the provinces and do a ‘Gap Analysis’ of what is missing and where.” Leger’s advisory committee has also struck three other work groups, the most important of the moment is the one working on privacy.

“I think the protection of personal health information is what’s uppermost in most Canadians’ minds about all this,” says Leger. “So we are looking at how legislation in each jurisdiction can evolve and allow the free flow of information between them but with due respect for privacy.”

Leger says his privacy group will be working on this crucial challenge for the next few months and can’t predict when they will finish.

But he already concludes: “I don’t think it will ever be one piece of legislation. I think what we can achieve, however, is agreement on a common set of principles.”

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Sunnybrook re-engineers its materials management

By Jerry Zeidenberg

TORONTO – Sunnybrook and Women’s College Health Sciences Centre – which spends approximately $207 million of its $450 million operating budget on supplies and expenses – has launched an ambitious program to reduce its supply processing costs by 50 percent through improved technologies and management techniques.

The savings could very well amount to millions of dollars each year, and could be re-invested back into clinical programs.

Sunnybrook is at the forefront of an emerging trend in which hospitals are implementing new management systems and technologies to streamline their supply-chain procedures.

In an era of government funding cutbacks and increased demands for services by the public, healthcare providers are now seeking ways to become more cost-effective organizations, both on the clinical and business side of their operations.

Several hospitals are now working with the Efficient Healthcare Consumer Response (EHCR) program, which is associated with the Toronto-based Electronic Commerce Council of Canada. The EHCR is made up of hospitals, consultants and vendors, and aims to use electronic technologies and new management techniques to dramatically cut operating costs at medical centres. Sunnybrook plans to join the EHCR in the near future.

As part of its own solution, Sunnybrook recently installed enterprise software from GEAC Corp., to help keep better track of many business functions, to improve the flow of information and to automate many supply chain functions.

“Technology will be a huge enabler,” said Sarah Friesen, director of materials management at Sunnybrook. However, she noted that supply chain management is a complex task, and that it will take time for staff members to explore the functionality of the new, computerized system and to become familiar with it.

Sunnybrook recently studied its supply chain operations and discovered many areas that could be improved. For example, it was found that clinicians are spending up to 50 percent of their time on materials management functions, which equates to $16 million annually.

“They’re directly calling vendors and saying we need a particular kind of wheelchair, or they’re going to the stores because they don’t have supplies they need on carts,” said Janet Huber, vice president of Sunnybrook and chief operating officer of the Orthopaedic & Arthritic Institute, which is now part of Sunnybrook.

She pointed out that much of the time spent by clinicians on materials management could be re-directed to patient care, if the right processes were to be implemented.

At a recent presentation given by Huber and Friesen – at an Institute for International Research conference – Huber outlined several other trouble spots. It was found that 15 percent of the products coming into Sunnybrook’s three campuses have no known destination. “Nobody knows who ordered them or where they’re going to,” said Huber, explaining that the “rogue” products often remain in limbo at the loading docks because they’re improperly labeled and the receivers don’t know where to send them. In most cases, they’ve been ordered by frustrated clinicians who can’t find what they need on carts or in their departments.

Moreover, there is currently a high error rate in documentation of received goods, such as mistakes made in quantity, pricing, or addressing for delivery within the hospital. Often, the mistakes mean that the goods cannot be properly received.

At the same time, Sunnybrook has identified many opportunities for improving processes and lowering operating costs.

It believes that inventory management costs can be lowered by 29 percent, order management by 80 percent, and transportation/distribution costs by 68 percent by using new systems and technologies.

Moreover, Huber said that inventory levels could be reduced by 80 percent (through just-in-time processes), and that the hospital could become “paperless” with 90 percent of its trading partners. The centre also aims to reduce product obsolescence by 80 percent and reduce total supply process costs by 50 percent.

Currently, many stores items are on hand for over six months, leading to obsolescence issues “because of expiry dates and changing clinical practices,” said Friesen.

There is also plenty of opportunity for rationalizing the number of vendors and products that Sunnybrook works with. While the medical centre currently has up to 8,054 vendors, 154 of them represent 80 percent of the purchases made by Sunnybrook. As well, the centre purchases syringes from 19 different vendors, catheters from 25 vendors and gloves from five vendors. “There’s lots of duplicate product coming in, and there’s no knowledge [on the part of staff members] that the same product from different vendors is coming into different units,” said Huber.

Liana Scott, logistics services manager with Source Medical and a committee member with the Canadian EHCR initiative, noted that 48 percent of the processing costs in the healthcare supply chain were found to be avoidable ($11 billion out of a total of $23 billion), according to a key U.S. study.

She said the Canadian situation does not completely parallel that of the United States, but that in all likelihood, considerable savings can be found in this country, too.

Solutions for achieving these cost reductions will involve:
• Inventory management control systems.
• Continuous replenishment processes.
• Product packaging and handling.
• Contract/pricing administration.
• Purchase order payment.
• Sales-activated settlement.
• Electronic product information.
• Point of use data capture.
• Electronic customer information.

Key tactical enablers will include information technologies and activity-based costing, while strategic enablers will rely upon partnerships and alliances and change management plans.

A pilot project has recently been launched at the Ottawa Hospital, and preliminary results should be available in six months, Scott said.

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Mount Sinai Hospital provides medical expertise to AmericasDoctor.com

TORONTO – Mount Sinai Hospital has become the first Canadian sponsor of AmericasDoctor.com, a web site that offers 24-hours-a-day advice to patients anywhere in the world. The site (found at www.americasdoctor.com) also offers regularly scheduled “chats” with leading medical specialists, enabling the public to pose questions on a wide variety of diseases, diagnostic techniques and treatments.

“We realized that the public is looking for good, reliable healthcare information,” said Fran McBride, communications director for Mount Sinai Hospital. “AmericasDoctor is a fast-growing site with information that’s approved by physicians.”

She said “the idea is to bring our expertise to a topic.” According to McBride, AmericasDoctor enables Mount Sinai Hospital to spread its knowledge on a global basis. That promotes the hospital and the services that it offers.

“It will help build our international reputation, which also helps us recruit top staff and researchers,” said McBride. “As well, we’re not averse to attracting out-of-country patients.”

She said the hospital has renowned programs in cancer care, perinatology, orthopedic surgery, genetic research, and others.

As part of its agreement with AmericasDoctor, each month at least one physician from Mount Sinai Hospital will participate in an online chat. At the time this article was written, Mount Sinai Hospital physicians had participated in seven sessions, including chats on colon cancer, jaw-joint reconstruction surgery, and high blood pressure treatments for pregnant women.

There is a fee to become a sponsor of AmericasDoctor, but McBride did not wish to disclose the financial terms of the agreement.

AmericasDoctor.com began operation in September 1998. The company claims to operate the only medical/health Internet site offering private, real-time, one-on-one chats with board-certified, board-eligible physicians 24 hours a day, seven days a week, at no cost to the consumer.

In addition, AmericasDoctor.com offers consumers online medical library and reference resources, information about health and medical communities that target specific diseases and conditions, and health products and services through its Medical Shopping Mall.

It also offers health news that is updated regularly throughout the day, volunteer opportunities in various clinical trials through its relationships with Contract Research Organizations (CROs), along with CenterWatch, a leading publisher of clinical trial information.

On a related note, Data General, a division of EMC Corp. announced that it has teamed with HealthGate Data Corp., a supplier of online medical content, to provide the Ontario-based Chatham-Kent Health Alliance with HealthGate’s CHOICE. The solution is said to bring personalized medical content to the hospital’s local community via its Web site.

Chatham-Kent Health Alliance is a partnership between the Public General Hospital (PGH) and St. Joseph’s Hospital (SJH) in Chatham, and Sydenham District Hospital (SDH) in Wallaceburg.

Together, Chatham-Kent Health Alliance serves the medical needs of 110,000 people in the municipality of Chatham-Kent, South Lambton and Walpole Island. With a staff of 1,200 caring for over 173,000 inpatients, outpatients and emergency patients annually Chatham-Kent Health Alliance is the third largest employer in the area. Chatham-Kent can be found on the Internet at http://www.ckha.on.ca/

HealthGate’s CHOICE solution (Comprehensive Health Online Information Center for the Enterprise) is said to integrate medical content from over 300 key publishers to customers’ Web sites. Chatham-Kent’s site features information on parenting, wellness, fitness and medical conditions, and contains a resource of medical databases for physicians to use for reference and/or educational purposes.

By using HealthGate’s customized CHOICE solution, the Health Alliance hopes to draw a larger audience to its Web site and develop a closer relationship with its physicians and members of the community, in addition to keeping them informed about the health services Chatham-Kent provides.

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Amid controversy, Alberta passes new health-information legislation

By Jerry Zeidenberg

In the face of protests from the Alberta Medical Association, opposition politicians and local newspapers, the Alberta government has passed a new Health Information Act, joining Saskatchewan and Manitoba as the first provinces to do so.

Also known as Bill 40, the legislation updates laws that are 15 to 20 years old. According to the government, the new act modernizes the guidelines for health records in a system that has moved from being hospital-centric to one that is composed of a continuum of care. Patient information is now contained in many different locations – including family practices, hospitals, health authorities and clinics, along with community health-centres and home-care organizations.

“Files are scattered in many places, and patients were having trouble accessing their information,” said Susan McManus, a spokesperson for Alberta Health and Wellness, the government department. Under the new legislation, patients will have the right to go directly to their doctors and ask to see what information is in their files, and inquire as to where the information has been sent. They will also have the right to request to have inaccurate information in their files corrected.

As well, according to the government, Bill 40 provides rules and regulations for the handling of patient records in today’s environment of ubiquitous computers and data networks, which potentially make the information easier to collect and transmit.

While the critics claim the legislation allows information to be transferred without a patient’s knowledge, and for purposes that he or she may be unaware of, the government asserts that Bill 40 provides “strong and clear rules for the protection of personal health information.”

According to Health and Wellness Minister Halvar Jonson, “Bill 40 safeguards the privacy and confidentiality of an individual’s health information and maintains the importance of the patient-physician relationship.“It requires that each Albertan be given access to their personal information upon request and prescribes strict rules for the collection, use, access and disclosure of health information.”

The legislation was developed over the past three years through consultations with stakeholders such as the AMA, the College of Family Physicians, the College of Physicians and Surgeons, the Alberta Pharmaceutical Association, and the Office of the Information and Privacy Commissioner.

Copies of the legislation are available on-line at www.health.gov.ab.ca

According to the government, Bill 40 contains the following protections:

• Custodians (such as physicians, pharmacists, hospitals) have the primary responsibility for protecting and safeguarding health information, including personal health care numbers.

• There are clear rules for collecting, using and disclosing any health information that identifies individuals. Disclosure of information can occur with consent, except for restricted circumstances, such as: where family members of seriously ill individuals are informed so that treatment decisions can be made; to respond to a court order; or to prevent imminent danger to the health of another person.

• There are rules governing who receives what type of information. Disclosure of health information does not necessarily mean full access to all medical files.

• Individual patient consent must be given before any personal health information can be transmitted electronically.

• Health organizations and professionals have the responsibility to ensure that there is adequate security for information stored electronically. New systems development and combining or linking information will be monitored and controlled.

• The Information and Privacy Commissioner plays a key role in the legislation by reviewing decisions, doing investigations, providing advice and resolving disputes. The Commissioner is independent from the government, the regional health authorities and other bodies.

• A full privacy impact assessment is required by the Privacy Commissioner, if the Minister of Health requests health information from custodians that is not already authorized in law.

• There are strong penalties – fines of up to $50,000 can be levied to an individual or organization found to be in violation of the legislation.

Said Health Minister Jonson: “Prior to the Health Information Act, there were no comprehensive rules in legislation that ensured an individual’s right to access their own health information or that protected this important information.”

Bill 40 was passed in the Alberta legislature last November. It has not yet been implemented.

Last fall, the Alberta Medical Association lambasted the act, taking out advertisements in major newspapers and charging that under Bill 40:

• Details of medical, diagnostic, treatment or care information about patients may be disclosed without consent, and against doctors’ wishes.

• That if a patient gives consent for an electronic record to be seen by doctors, that non-physicians could have access to it.

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