Provinces pool resources and work together on computerized clinical records

By Andy Shaw

Doug Tessier is happy to report that, when it comes to developing electronic health-record systems in Canada these days, there’s “lots of stuff going on.” Tessier should know. He chairs the electronic health record (EHR) working group for the federally backed Advisory Committee on Health Information (ACHI). Both his working group and the ACHI involve the top guns for health informatics in every province and territory. For his part, Tessier is the head of Ontario’s Smart Systems for Health.

“It is still not as co-ordinated an effort as it might be, but compared to a couple of years ago, there’s a tremendous amount of collaborative activity now going on,” says Tessier. “Back then groups like WHIC (Western Health Information Collaborative) and HIA (Health Infostructure Atlantic) didn’t even exist.”

The existence of WHIC, HIA, and other similar initiatives in Ontario and Quebec has much to do with the carrot held out by the CHIPP program. All are currently vying for a share of the $80 million in federal funds being doled out through CHIPP, the Canada Health Infostructure Partnerships Program. And all have their eye too on a further $500 million to be passed along subsequently by a yet-to-be-named Crown corporation.

The seeds of all this activity were sown in a mid-1990s report to the federal government on what it should do to capitalize on the so-called Information Highway.

“That report stimulated the idea that there should be some sort of pan-Canadian electronic health record that could follow people around wherever they went in the country,” says Tessier. “It was thought that it would evolve naturally from what was being developed by each province. But it soon became clear that that was not going to happen.”

Consequently, Tessier’s EHR working group has helped to provide some much-needed direction. Its members decided on key areas where they needed agreement so they could go back to their home provinces and run with development within agreed upon guidelines.

“We saw three priorities: the need for standards, a common approach to privacy, and some agreement on technical infrastructure,” says Tessier. “We also agreed that probably the part of the technical infrastracture we needed first were (patient) registries. These didn’t have to be the same across the country but they had to interface. Beyond that we also decided we should not compete with but build on current provincial interests such as drugs, lab results, and primary care reform.”

Nor did they want to each re-invent the wheel.

“We formed HIA in 1999 and that sprang from a meeting of the Atlantic premiers who said the four provinces needed to find ways to co-operate on health information,” says Herman McQuaig who represents Prince Edward Island on the four-province HIA inititaive. “So we developed some terms of reference and had them sanctioned by the various Ministers of Health. At the outset, we felt we could take advantage of any common thinking, share best practices, and actually transfer technology.”

Announcement of the federal CHIPP initiative last year gave further impetus to the HIA group. It spent new energies on going after funds for projects that filled three common needs.

“We were all at various stages of developing one, but because we all have so many out-of-province transfers of patients we very much needed a common client registry,” explains McQuaig who is the director of health informatics for PEI’s department of health. “For the same reason, we also wanted a common PACS system to move images around. Finally, in our non-acute areas we all provide a lot of community-based care, like mental health, public -health nursing, dental, and even social services that health ministries here are responsible for. So we wanted a common case management system we all could use.”

Whether CHIPP chips in with all the dollars HIA is asking for or not, McQuaig says the region will press on with its three priorities and other common projects. However, CHIPP money will speed things up including the establishment of a joint project office for HIA in Nova Scotia.

In Alberta, there’s already a joint office for WHIC in Edmonton and a Web site (www.whic.org). Like the HIA, the Premiers and Ministers of Health from the four Western provinces as well as the Northwest Territories, the Yukon, and Nunavut spawned WHIC to “explore collaborative opportunities with respect to health infostructure initiatives.”

More than explore, WHIC, with up to $500,000 annually to sustain its secretariat, has eight projects under way and is also in hot pursuit of CHIPP grants. Like HIA, the lead of each project has been given to individual provinces that have already established expertise in that area. Alberta, for example, has the lead on the Continuing Care Electronic Health Record Initiative, one of two projects WHIC has proposed for CHIPP funding. The other is the Provider Registry where British Columbia has the lead.

Alberta is also heading up projects on health surveillance and consumer access to health information. Saskatchewan is developing a common hospital reciprocal billing system. British Columbia is running with a standard for making electronic claims as well as standards for ordering, inquiring into, and receiving the results of lab tests.

As conveyed by BC’s Ministry of Health CIO, Janet McGregor, the Ministry has spent about 11 months (3-4 person years) developing the lab test standards through extensive consultation. Public and private labs, the BC college of physicians and surgeons, the province’s centre for disease control and its cancer society have all contributed.

“The lab standards have been accepted by all the WHIC partners. Each one of course, will still have to consult their stakeholders. But we will have saved each of the other provinces and territories at least nine months of development time,” says McGregor. “Adding that up amounts to a savings of about 15-20 person years of effort.”

British Columbia has taken its electronic claims work to an even higher level. Initially a joint effort with the Insurance Corporation of BC and the workers’ compensation board, the project is being supported by all provinces and the Canadian Institute for Health Information.

To accompany BC’s health informatics initiatives, McGregor is leading the development of a research-oriented warehouse of de-personalized data that will eventually guide the province in deciding how and where it should spend money on medical services. Details of the Health Data Warehouse Project can be found after registering on the project’s Web site at http://admin.moh.hnet.bc.ca/home/health_partners.html

A few thousand “clicks” across the country but only a few computer clicks away is another site worth checking. The Newfoundland and Labrador Centre for Health Information (www.nlchi.nf.ca) is in St. John’s, a hub of health informatics development even before it became fashionable.

“We’ve had clinical information systems in our hospitals in the province reaching back to 1984,” says the Centre’s CEO, Steve O’Reilly. “And since then they’ve been expanded beyond hospitals to whole regions. But now the challenge is to connect those elaborate islands up.”

To do that, the NLCHI has made its first order of business a provincial registry that will allow healthcare consumers to be identified no matter where they roam on the Rock. Lucy McDonald, the NLCHI’s communications director, says Centre staff realized right from the start that they had to get buy-in from just about everybody to make the key to their registry, the Unique Personal Identifier (UPI), work. “We’ve done consultations and met with over 2,000 people in three years, and involved all the stakeholders.

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High-tech home-for-the-aged set to open in Ontario

By Andy Shaw

Who says vision declines with old age? It certainly doesn’t in Peterborough, Ont., where the proportion of seniors and retirees in the local population is higher than anywhere else in the province and well above the national average. Nor are vision and old age contradictory notions at the high-tech oriented Sir Sandford Fleming College on the outskirts of town. And even in town at the century-old Anson House and at the Marycrest Home for the Aged, both non-profit long-term care facilities, there’s a shared vision of what better care for our elderly will look like when it’s aided by high-tech.

That vision starts becoming a reality when officials of a partnership formed by the College’s Institute for Healthy Aging take ceremonial shovel in hand and break ground on the slopes of the Sir Sandford campus in April. Fourteen months later, a new, wired-to-the-hilt $25 million home-for-the-aged will have risen that will set a long-term care technology standard for Canada, if not the world. To be known as St. Joseph’s at Fleming, the 140,000 square-foot home will house the 42 residents of the Anson Home and the 156 residents of Marycrest, which was once part of the now-closed Sisters of St. Joseph’s Hospital. Significantly, the new home will also house the offices of the Institute for Healthy Aging.

“The number one goal we set for the Institute was to create a model long-term care facility on campus,” explains Kate Kincaid, a Sir Sandford professor and academic team leader for the Institute. “The Anson and Marycrest homes both won a competition to partner with us. The timing was good. They had both been designated Class D facilities by the Ontario government, meaning they had to be re-built anyway. So now we have a site for our combined home, and a fabulous design.”

Designed by Dunlop Architects of Toronto, the St. Joseph’s at Fleming sprawling home will back into a hill rising to just three stories in its centre hall, and flanked by two, two-story wings. Dunlop has woven spacious courtyards and walkways in between.

“There will be eight home areas in the building, all with 25 people living in each (better than the Ontario Ministry standard of 31 maximum),” says Kincaid. “Each home area will have its own living and dining rooms, and a general activity room opening onto a balcony. There will be plenty of windows and sunshine in those areas and anyone in them will see the central core and the nursing stations.”

But it is inside St. Joseph’s individual residencies where the home’s technology vision comes into focus.

“We can see a resident eventually coming into his or her room and saying ‘Open curtain’, says Jim Angel, Sir Sandford Fleming’s CIO, and who has lead the technology planning for the new home. “We’re not saying just yet that we’re going to include voice technology at the start, but it’s an example of what our aim is – and that is to make it a place where long-term care residents can have control over their own environment more than ever before.”

Kincaid says life in St. Joseph’s will live up to the high-tech expectations of future residents. “We’ll be expecting when we get there that we can still plug in our laptops, that we can still e-mail, participate in our on-line chat groups, and generally choose the technology we want to use. With technology in the room that kids can understand and play with, you’re more likely to get whole families visiting their elders. Or if you are Aunt Gertie and you want to visit with your grand-niece in Victoria, we will roll in the video conferencing cart.”

To accommodate this eventuality, the project’s two biggest private sector partners, Bell Canada and Nortel Networks, will load the walls with possibility.

“We’re going to make sure first of all that the building is pre-wired to the highest possible standard and scalable,” says Ron Walker, head of the College’s applied computing and engineering services. “It will be a structured wiring scheme that will allow you to make it a building that is programmable. The wiring will enable all building systems including security systems, environmental control, lighting, telecommunications, you name it, to be under an integrated, computerized control.”

That integration will allow building systems at St. Joseph’s at Fleming to be intelligent. Says Walker: “In less sophisticated systems a breach in security might trigger an alarm, or trigger an automatic phone call. But in our case, the computer might also take other action, operating door locks, turning up lights, or opening drapes.”

Once the exact nature of the pre-wired infrastructure is set, then various technical sub-committees will get down to deciding about what applications will first start running along those wires. Med e-care of Toronto, another early partner, is set to supply clinical and administrative software. Med e-care is considered one of the leading developers of minimum data set (MDS) software for the long-term care sector. The software enables long-term care managers to effectively assess and continually evaluate residents.

Walker says the pre-wired infrastructure will enable what he terms “unobtrusive technology” to give more attentive care to residents.

“It’s obvious the wiring will help on the administrative side of the operation with information systems and patient records, and communication among the staff, but as new transducers and sensors become available we can also implement them,” says Walker. “That means residents won’t need to be constantly hooked up to monitoring devices if they are ill. We can monitor their temperature, heart beat, and respiratory rate remotely, or even do sleep research with the rooms wired the way we plan to.”

Such prospects raise two issues for the skeptical: cost and privacy. Is this going to require miles of costly optical or fibre lines? And is Big Brother going to be watching a little too closely?

Well, building funds are not likely to go into a lot of newfangled cabling, says CIO Angel, a philosopher turned computer science grad.

“Affordability is a big issue, so when you look at what you might need in the future, the best thing you can do is look at what has worked well over time in the past – and what you see is (cheap) copper wire. Even though we are always supposedly about to hit the wall with copper wire’s bandwidth capacity, it just keeps getting better and better. You get an awful lot of performance out of copper wire. Meanwhile the optical alternative is not there yet. It is not ubiquitous. So there are a lot of peripherals you might want to have that you can’t connect to it.”

Angel says the final configuration will likely embrace some fibre, optical, and for certain wireless technology (handheld PDA’s for nurses are a favourite item for discussion at planning meetings.) But good old copper wire will provide the underpinnings.

As to the potential for a Big Brother-like invasion of privacy:

“Big Sister is already watching,” says Vicki Barrow, from Marycrest, and the project manager for St. Joseph’s at Fleming. “In regular long-term care homes, nurses are constantly monitoring patients, barging into their rooms to wake them up or give them a pill or tell them when to eat. Remember, our new residents are getting older and frailer. They are staying at home longer until age 85 or so and only coming in when some sort of dementia, accident or other event occurs. So they need monitoring and care. And I think the technology we will be using will actually heighten their sense of privacy and independence.”

Through focus groups at Marycrest and Anson, both residents and staff alike have shifted from initial cynicism about their impending uprooting to outright enthusiasm, according to Ann Taylor, finance manager for Marycrest.

“The other day we had one of our 90-year-olds come into our offices asking how he could go about taking a computer course at the new home. He was clearly excited about his improved prospects for self-education,” says Taylor.

Barrow and others see the new home’s technology resources combating what she terms “learned helplessness” among residents, a common result of too much human care.

Ron Walker cites an example: “If someone can’t physically handle a remote to change TV channels, for example, we can experiment in our labs to look at how we can help the resident do that transparently.”

And Walker will have some kind of lab to do that with. While the St. Joseph’s at Fleming home is under construction, a new Sir Sandford Fleming technology wing will also be rising from the glacial moraines of the campus. The wing will house the Applied Technologies Healthy Aging Research (ATHAR) lab.

Funded by a start-up $380,000 grant from the Canadian Foundation for Innovation and matching funds from the Ontario Government, the ATHAR lab will put teams of Sir Sandford staff and third-year technology students to work on technology-improving projects for its St. Joseph’s at Fleming neighbour.

The knowledge of constantly being on the leading edge of long-term care technology is something the new home and its staff plan to share.

“One of the facilities our new home will have is a smart, wired classroom,” says Kincaid, “and we’ll use it for training both our staff and our residents.

Students from the College will also be interacting with us and the residents, so it will be a training ground for them, too. We’re also planning to network with other long-term care facilities in the province so they can learn from our experience. We plan to make a business of our educational opportunities.”

Sir Sandford Fleming’s networking and computing experience is already well recognized. It’s hubless, fully-switched 100 Megabit to the desktop network is unequalled in Canadian educational circles and links five campuses stretching from Lindsay to Haliburton. It services 15,000 user accounts. The College’s Pentium III 450 Mhz desktops give it the highest computer to student ratio in the land.

St. Joseph’s at Fleming’s developers are counting on that reputation to help raise the $25 million dollars needed to build their vision – through drives organized by both the St. Joseph’s and the Sir Sandford Fleming foundations. “We don’t get any provincial money for our home until the doors open,” says Barrow.

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Capital Health Region ready to begin large-scale I.T. systems project

By Neil Zeidenberg

VICTORIA, B.C. – The Capital Health Region (CHR) will invest approximately $53 million to replace nearly all of its clinical systems (laboratory, pharmacy, radiology, and patient management, ER, community health), as well as its administrative information systems (human resources, payroll, general accounting, and materials management) and decision support systems.

The region announced that it has chosen Sierra Systems Group Inc., a systems integrator and business-consulting firm, as its implementation partner for the four-year project.

The region will merge its decision support systems by creating an enterprise data warehouse and a comprehensive analytical tool kit that will result in a management desktop portal on CHR’s Intranet.

“The Capital Health Region was faced with having to integrate both its clinical and administrative information systems from the six organizations that came together to form the new health region,” said Brian Shorter, chief information officer of the CHR. “Sierra Systems was instrumental to our success in planning a solution to this formidable problem.”

Under the partnership, Sierra is responsible for project support, including methodologies for project management, as well as training, risk management and analytical support to the CHR, an alliance which provides hospital, community, home, environmental and public health services, including education and prevention, to 340,000 residents living in the capital region of Vancouver Island.

As an indication of the size of the implementation, it’s expected that the internal network will consist of about 3,700 access terminals. The new systems will serve the needs of about 6,000 staff and 700 physicians (from specialists, diagnosticians to family practitioners) covering services in the whole region. “We want the family physician to be able to reach the systems through their own desktop,” explained Shorter.

To meet its core clinical information systems needs, the CHR will be implementing the Cerner integrated suite of application software.

“Cerner was chosen because they were price competitive, they had a fully integrated product, and there is a significant degree of flexibility in how the system is set up so that it matches local operating needs,” explained Shorter.

The Cerner product also has a single clinical data repository and a sophisticated tool for physicians to view the repository in various ways.

Using high-speed Wide Area Network connections, CHR will deploy the Cerner system to 26 sites within the region using Citrix software, a server-based technology that runs enterprise applications on any device over any connection.

“By being web-enabled, we’re hoping to use the features to help make our laboratories more business competitive with higher levels of customer service,” explained Shorter. Moreover, they will provide Internet access to physicians, enabling them to review patient information from any location in British Columbia.

Sierra’s relationship with the Capital Health Region dates back to 1984. “Between 1984 and 1996, we provided them with various levels of support, including the implementation of all of the applications that were implemented at that time,” said Bill Thomson, vice president and branch manager at Sierra Systems.

Thomson believes the four-year deal represents an excellent opportunity to continue the relationship with the CHR as it evolves. Sierra has a proven track record with the organization in delivering in various capacities over a span of nearly two decades, and doing that within the province. Implementation of the systems will be happening in three phases over the next three and one-half years, starting with the pharmaceutical system in May 2001.

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Many Canadian hospitals just starting to tackle supply chain issues

By Dianne Daniel

The supply chain function in Canadian hospitals may finally be gaining the attention of senior management, but there’s a long way to go before it moves from the basics to a more sophisticated system based on the latest technology, says John Raskob, a senior manager at Toronto-based Deloitte & Touche Solutions.

“Most hospitals right now are still about 15 – some as high as 20 – years behind other industries in terms of sophistication,” says Raskob. “The biggest issue is that approximately 70 percent of Ontario hospitals are in a deficit position and supply chain is usually one of the last functions to get funded.”

Although Raskob concedes the supply chain function is earning a higher corporate profile, the reality is that most healthcare facilities are so busy dealing with the consolidation of disparate computer systems due to mergers that they haven’t been able to attain even the most basic task of product standardization. “I’ve heard claims of 50 percent standardized, but I’d say the average is less than 25 percent,” notes Raskob.

One hurdle is that hospitals have typically focused on material management (the management of internal resources) and have difficulty making the transition to the broader scope of supply chain management. The challenge is to encompass the entire sequence of events that takes place from procuring of a product to placing it in the hands of an end-user, and with up to 12,000 stock items at the average hospital, that’s no small task, says Raskob.

Nancy MacLeod, director of material management at the Queen Elizabeth II Health Sciences Centre (QEII) in Halifax knows firsthand just how difficult it is. Three years ago, when five facilities merged into one to create the QEII, she was faced with five separate inventories that needed to become one.

“The duplication of the number of products was extraordinary,” says MacLeod, adding that involving clinicians in the decision-making process was important. “We went through a very labour-intensive process with clinicians, identifying what we could eliminate. It was a huge piece of the equation. If they don’t buy in, you’re not going to get anywhere.”

One method that worked was to take a team approach. For example, duplicate products would be set up in a room and throughout the day, physicians would review the products and make a selection, adding comments as to why one particular product was acceptable and another wasn’t. In a very democratic process, the product preferred by the majority would win and if most people said either would do, the least expensive one was chosen.

According to MacLeod, education and communication were key throughout the process. Vendors were invited to the hospital to provide an in-service on products that were changing and any time a change was made, notices would be sent out in either memo, newsletter or e-mail form. No change is too small to announce, she adds.

“Something we may perceive as simple – we’re changing wipes, for example – you would think would be no big deal, but it can be a huge deal,” she comments. “For the people who are used to the one that was a certain size and felt a certain way, if you change it without telling them it causes a lot of grief that you don’t need.”

In addition to standardization, another concept several hospitals are grappling with is performance measurement. Budgetary constraints are shifting the focus more to the bottom line and that means finding ways to measure and report on the performance of the supply chain.

“We need to begin to manage the purchase of products more like they do in private industry, where you are purchasing based on a combination of quality, price and performance,” says Sarah Friesen, director, supply chain services, at Toronto’s Sunnybrook & Women’s College Health Sciences Centre (S&W).

Working with Deloitte & Touche Solutions, S&W has developed a score card it is now using to measure its financial, internal and supplier performance. The card uses 20 indicators – items such as on-time delivery, fill rate or percent of invoices that come in without a purchase order – to report on performance. Some of the data is collected automatically via links to the hospital’s Geac SmartStream enterprise resource planning (ERP) system while the rest is collected manually.

The goal is to use the information to produce reports that will ultimately aid in purchase decisions. “We will use the reports to see which suppliers are performing well and who’s not and then take that into consideration when we’re out to tender,” says Friesen.

Once products are standardized and a performance measurement program is in place, hospitals can start to benefit from technology improvements for supply chain management. The notion of Web-based procurement is one area everyone is investigating. Yet, according to Raskob, even though larger organizations are thinking of it and partnering with possible providers, very little is actually happening.

“In our blue sky world, we have electronic catalogues that nurses in the units can click on and click their quantities, and electronically send that to the manufacturer,” says QEII’s MacLeod. “That’s where we would love to be and what we hope Web technology will do for us a few years down the road.”

Implementing an integrated ERP system is also an advantage when it comes to good supply chain management. Raskob points out that whether or not they include a supply chain or material management module, most ERP implementations will at least provide the basic purchasing and inventory data required such as stock locators, cycle counts or physical year-end counts.

At S&W, Friesen suggests a good handheld computer system for cart replenishment and fulfillment that interfaces to an ERP system is also important. Like MacLeod, she is also looking to Web technology and an on-line catalogue to streamline the purchasing process even further.

“Right now the catalogues we have are all paper catalogues and they’re very inconsistent,” says Friesen. “There’s no consistency in the nomenclature and naming conventions so that’s one of the things we’re going to be working on.”

One effort under way is the Efficient Healthcare Consumer Response (EHCR), a group headed by Nigel Wood from the Electronic Commerce Council of Canada. The EHCR hopes to introduce universal product numbers (UPNs) for healthcare stock items similar to how the grocery industry operates. Not only will standard barcodes make it easier to do business over the Internet, since all catalogues would use standard product numbers, but it would also make the entire inventory process more efficient by supporting the use of scanning equipment.

Raskob, MacLeod and Friesen are in agreement that standard barcodes will have a positive impact on hospital supply chain practices. They also know that it will be a matter of years before anything happens.

“The lack of a standard UPN in healthcare is holding us back from being able to use scanning technology,” says MacLeod, who also sees standard barcodes as critical if on-line catalogues and marketplaces are going to be successful. “For two-ply gauze right now every company has its own number so we can’t go on the Internet and search for a product number, we have to go company by company.

“But if there was a standard code for a product, we could click on the Internet, find the five companies who sell it and send out our tender.”

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