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Inside the March 2003 print edition of Canadian Healthcare
Technology:
Feature Report: Electronic medical records
 Infoway’s investments
Canada Health Infoway has started making initial
investments in projects that will ultimately result in a pan-Canadian
electronic health record. In the first stages, the focus is on
interoperability.
Reducing hospital stays
Software employed at a Niagara-region hospital
allows managers to analyze the length of stay for stroke patients.
It helped them reduce the time spent in hospital to nine days
from 23 while boosting outcomes and patient satisfaction.
Wireless tech for home care
A wireless Internet solution on handheld computers
is enabling home-care nurses to check with doctors and other
wound specialists about patients, right in their homes. The application
is saving trips to emergency departments.
Perioperative system provides multiple benefits
The Isaac Walton Killam (IWK) Health Centre
in Halifax has found that a new perioperative system has provided
multiple benefits. The system, from Datex-Ohmeda, records information
before, during and after operations.
If CPOE is proven to save time and trouble, physicians will
buy into it
Although the technology has been around for
a decade or more, it’s only recently that hospital clinicians
are sitting up and taking notice of computerized physician order
entry (CPOE).
Aiming for PET in Montreal
Montreal Canadiens’ hockey star Saku
Koivu is leading the charge to acquire a PET/CT scanner at the
Montreal General Hospital. Koivu benefited from PET scans performed
in Sherbrooke, Que., and now wants to bring such technology to
his home town.
PLUS news stories, analysis, and features and more.
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Infoway begins investing in development of Pan-Canadian electronic
health records
By Andy Shaw
Maybe it’s just the nature of Canadian
news media, but when the long-awaited report from Roy Romanow’s
Commission on the Future of Health Care first burst into the
news last fall, there was no mention of what the former Saskatchewan
Premier thought might be contributed to our future well-being
by technology. Other worthy issues abounded in those early stories
in newspapers and on television. More funding needed, yes; private
versus public healthcare arguments, yes; and provincial autonomy
against federal will tensions, yes. But technology’s role,
no.
No mention that is until the Montreal-based
Canadian Health Infoway organization spotted the reference deep
in the Romanow report. In its follow-up news release, Infoway,
as it is now known for short, said in effect, aha, there it is
on page 77: “Electronic health records are one of the keys
to modernizing Canada’s health system and improving access
and outcomes for Canadians.” Also cited was a reference
buried even deeper on page 249 saying that Infoway, “..
should continue to take the lead on this initiative and be responsible
for developing a pan-Canadian electronic health record framework.”
Hardly headline positioning. And one could
have wished for more substance generally on the role of technology
in healthcare from the earnest Roy and his Commissioners. But
nonetheless, what they recommended was sufficient encouragement
for Infoway to say in its release that it would stick to its
schedule for creating: “...the foundation for interoperable
EHR solutions over the next 12 to 18 months, with a goal of having
the main components in place within five to seven years.”
Initially, Infoway has $500 million to spend
on developing a pan-Canadian EHR, announcing just before the
New Year the first of three waves of EHR investment. For starters,
Infoway is putting $21 million into seven separate projects,
split east and west and aimed at developing the “building
blocks” of an interoperable Electronic Health Record.
“Interoperability is the cornerstone
of what we are trying to do,” says Dennis Giokas,
Infoway’s chief technical officer and developer of the conceptual
architecture guiding Infoway’s investments.
Out west, Infoway is investing in two projects
in British Columbia and Saskatchewan that are building a “provider
registry”. Infoway is also backing both Capital Health of
Edmonton and the Newfoundland & Labrador Centre for Health
Information in their formerly separate efforts to create a workable
“client registry”. On its own hook, Infoway is putting
money into two other developments both geared to producing a
more detailed “blueprint” of its conceptual architecture.
Finally, Infoway has also backed further development of National
Electronic Claims Processing Standards (NeCST) already under
way as a Canadian Institute for Health Information (CIHI) initiative.
Under the provider registry banner, the BC
Ministry of Health Services will work to enhance what’s
been done so far by the Western Health Information Collaborative
and its reusable provider registry that indexes caregivers, their
roles, and their jurisdictions. In the process, the project will
assess the wisdom of conversion to HL7 Version 3 as the standard
for messaging between health information systems. In Saskatchewan,
the Infoway money will help create a re-usable “tool kit”
for provider registries that will provide registry developers
with a set of best practices found in other regions. The hoped
for upshot of both efforts is wide ranging – from reducing
the costs of deploying provider registries, to encouraging EHR
uptake, to easing maintenance, to speeding up registry software
development, and to improving security and privacy.
Client registry work in St. John’s and
Edmonton will focus also on building a registry that is reusable.
It will provide a directory of people being served within a healthcare
system. In the end, the directory should have built-in mechanisms
to “uniquely identify a patient across a diverse set of
point-of-care systems, within a region, a province or even nationwide.”
The work involves development of an interoperable enterprise
master person index (EMPI). In short, the long-term goal is to
make Canadian hospitals like a chain of cheery bars: no matter
where you go, they’ll know your name.
The architectural blueprint Infoway is developing
itself is dubbed its “IT Migration Plan” and is meant
to help the country’s regional health authorities migrate
their individual EHR set-ups to an interoperable system.
“There are three deliverables for the
Plan,” says CTO Giokas. “The
first is to understand and describe what interoperability solutions
are already implemented in various jurisdictions. You might call
that the ‘as is’ state. Then, based on that understanding,
we will drill down into our original conceptual architecture
and come up with a much more detailed ‘to be’ state.
So at that point, we’ll be able to help jurisdictions see
the gap between where they are and where we would like them to
be.”
The objective of the NeCST undertaking is
to develop a ‘to be’ state for readily exchanging health
claims information between providers and payers. It will pave
the way for future Infoway investment in drug information exchange
systems.
All of this, including two more waves of investment
will have swept over the country before summer if Infoway sticks
to its schedule.
“It’s an aggressive timetable,”
said Linda Lizotte-Macpherson, Infoway’s president and CEO.
“But it’s one that was set out in our business plan
and endorsed by all the federal, provincial, and territorial
health authorities in 2002.”
In late 2002 unfortunately, Lizotte-Macpherson
herself was temporarily felled by a back operation. However,
Infoway’s vice president of portfolio management and general
manager of Infoway’s Toronto office, Sue Hyatt, took over
as interim CEO until Lizotte-Macpherson’s expected return
this month. Hyatt’s chief task was to oversee and complete
the due diligence of deciding on who gets how much of Infoway’s
next two funding waves.
“We’ve been talking to physicians,
nurses and other members of the provider community across the
country quite a bit about what they would like to see developed
next for the EHR,” says Hyatt, “and they were very
clear with us. We were told categorically, especially by physicians,
that getting lab results was key.”
As
a result, Hyatt says Infoway’s second round of spending
will put an emphasis on developing compatible lab results systems.
Another priority identified by Infoway’s cross-country homework
will be developing common techniques for ensuring privacy and
confidentiality in the EHR.
“There are privacy projects going on
in various parts of the country but there’s been no mechanism,
no tool kits, in place for sharing that experience,” says
Hyatt.
The third and final wave of Infoway spending expected to be announced
in April will put its money on what Infoway sees as the next
two most needed components of the EHR, diagnostic imaging and
drug information.
Infoway is going confidently ahead with its
investment despite skepticism elsewhere about the feasibility
of ever developing an EHR that a whole country can share. As
Dr. Gordon Atherley pointed out in this publication last month,
efforts to establish a pan-Britain EHR are in serious disarray.
Yet Hyatt remains confident about Canada’s
direction. “We scan what’s going on internationally,
certainly. But we find it very encouraging that both the Romanow
and Kirby (Canadian Senate) reports have endorsed having an interoperable
EHR. They both recognized that Canada can be a world leader in
this field.”
Hyatt does admit that to assume such leadership
will require Canadian caregivers to become more enthusiastic
adopters of technology. “We’ve got to play catch-up
on that score,” says Hyatt. “Our caregivers do lag
behind some other countries in the uptake of technology”
They’re not technology laggards, however,
at the Toronto-based electronic Child Health Network (eCHN).
That’s where the only operational EHR in Canada that is
fully integrated and shared beyond hospital walls runs today.
The eCHN collects data from a wide variety of patient records,
imaging, and laboratory sources and integrates them into a single
view that can be called up by doctors, nurses, and other care-givers
in eight different institutions.
“It’s not yet a complete record.
We’re still working on that and adding new elements regularly.
But so far as I know it is the most advanced of its kind anywhere,”
says Andrew Szende, CEO of eCHN.
Szende says he’s hopeful that Infoway
will invest in further development of what has already been built
by eCHN.
“They’ve said they are going to
build on existing infrastructure and projects that have already
shown success,” says Szende. If they do what they say they
are going to do, then I applaud them. It would make no sense
at all to try and invent the wheel again and start experimenting
with people who are promoting vapourware.”
“If they really want to see some results
quickly, they should be looking at eCHN as a living lab,”
says Szende. “We’re open to them enhancing what we
do and letting people learn from our experience, as well as making
our network even bigger and helping other people build their
networks.”
Szende says once a network like eCHN is established,
it is readily scalable. “We could be serving 80 institutions,
ten times what we do now. All it needs is some investment.”
In Infoway’s investment announcement,
the key word to note is “interoperable”. Interoperability
is the Everest of what Infoway must conquer. The enormity of
making health record systems interoperable was made clear last
November in Düsseldorf, Germany. There an august panel of
Canadian and German medical information technology experts at
the Medica 2002 trade fair and conference laid out all they thought
must be done before the daunting peaks of interoperability are
scaled.
“With the kind of networks we have in
place around the world now, making healthcare systems able to
talk to each other will be highly complex and expensive.”
said Eugene Ingras, chief technology consultant to the Alberta
Research Council. “Because what we have in place now is
analogous to needing a separate telephone to call each country.”
Or a separate phone to call each province,
or each region, or each hospital, or each department, or each
doctor’s office you may want to share information with.
On the other hand, Dr. Sami Aita, the evangelical
founder, chairman, and CEO of Toronto-based MedcomSoft argues
persuasively there’s a cost-saving, simple short-cut to
interoperability currently being ignored in Canada by government-backed
EHR initiatives. But it has already been adopted by the no-nonsense
U.S. Department of Defense (DOD).
“After considering the alternatives available,
DOD selected the Medcin medical vocabulary from Medicomp as the
basis for its EHR,” explains Dr. Aita,” principally
because Medcin has been built up over 25 years and now provides
over 70 million links between medical terms and diagnoses, which
can then be reduced to numeric codes. So the acquisition, interpretation,
and distribution of healthcare information is enormously simplified.
You’re not trying to deal with huge, unwieldy tracts of
text, you don’t need great repositories and powerful servers,
and complex communication standards to handle and move records
around, because all you need to package up are numbers, pure
data. And it’s data that can be called up and turned back
into text or links to other sources of patient information in
a simple spreadsheet format.”
Aita says MedcomSoft’s Medcin-based spreadsheet
software is already winning plaudits from over 120 installations
the company has in North American physicians’ offices. MedcomSoft
claims to have the first medical record that numerically codifies
the entire patient encounter. Users create the record through
intelligent checklists and other spreadsheet forms. It therefore
eliminates the need for lengthy text descriptions or transcription
of dictated notes. “Also, by using a secure Web portal,”
adds Aita, “the record is scalable up to provincial, national,
and even international interoperability today.”
If that’s true, and given the enormous
investments of public funds already being slated for EHR development
of a different sort, maybe somebody should at least alert the
news department.
Shortening hospital stays of stroke patients and delivering
better care
By Patty Welychka, R.N., and Craig Muir,
M.D.
Niagara Health System, which serves a population
of 400,000 in Ontario’s Niagara region, admits nearly 700
patients a year who have suffered from strokes. With a large
baby-boom population now approaching the prime years for stroke
risk, we expect this number to climb, making this condition a
significant health and resource issue for our health system.
We knew that our stroke patients, on average,
tended to stay in acute care beds for a long time. We began to
examine these stays in the winter of 2001-2002 to determine whether
the amount of time was appropriate given their care needs.
If the hospital stays appeared longer than
designated by benchmarks, we needed to investigate the reasons
for overstays and create solutions for optimizing the care plans
for these patients. Our goal was simple: to improve the quality
of care we provide to our stroke patients.
Learning from the Past: When we launched our three-month pilot program for
stroke at Welland Hospital, a facility with 169 acute care beds,
stroke patients were staying an average of 23 days. We were fairly
certain it was too long, but we weren’t sure of the reasons
behind the long stays.
To conduct an objective analysis, we needed:
• A standard for how long each patient
should stay in the acute care setting before being relocated
to a less medically intensive milieu
• The ability to pinpoint and track the
specific reasons for any delays in our processes of care
• The ability to determine the most appropriate
next level of care based on appropriate criteria
We turned to McKesson’s InterQual Criteria,
an evidence-based clinical decision support tool that we have
used since 1997 for a variety of quality and utilization initiatives
throughout the health system. We applied it to an earlier project
at the Greater Niagara General Hospital in Niagara Falls, where
the government had mandated the elimination of 45 beds over a
one-year period.
To intelligently reduce our number of beds,
we applied InterQual Criteria for Acute Care and were able discern
at what point our patients should have been transitioned from
acute care to another care level or been discharged. We discovered
that two-thirds of the overstays occurred because we had no appropriate
alternative setting for the patients once they were stable enough
to leave acute care.
Over the past few years, information like
this has helped us gain a system-wide understanding of our bed
needs across all levels of care.
Further, using the software form of InterQual
Criteria to perform reviews enabled us to delineate the reasons
for delays related to internal workflow. With very precise data
in hand, we could make the changes necessary to eliminate those
delays. Ultimately, we were successful in meeting the Ontario
government’s directive, recognizing savings of $8 million
to $9 million a year.
Launching the Stroke Program: At Welland Hospital, we first conducted an InterQual
review of 176 patient days over a one-month period, determining
that patients had spent 74 of those days in acute care beds unnecessarily.
Then we began probing into the reasons, also using the criteria.
We discovered that many of our patients were
medically stable and ready to move to a less intense level of
care somewhere between day six and day ten. But because we weren’t
flagging these patients for transfer, they lingered in the acute
setting for up to two additional weeks.
Once we began applying InterQual Criteria,
we began to see common scenarios. For example: it’s day
eight of a patient’s stay in acute care, and he has been
recovering quite well. Alerted to this fact by his nurses, the
case manager appears on the floor, accompanied by her laptop
loaded with the criteria.
She reviews the patient’s case and validates
that he meets the criteria for transfer to a rehab setting. When
the patient’s physician makes her rounds, the case manager
asks her for an order to move the patient to rehab. It’s
granted, and the patient moves the following day to begin the
next recovery phase.
Reaping the Results: Within
the first few weeks of our pilot, the average acute-care stay
for stroke patients plummeted from 23 days to nine, and we began
to see better health outcomes and increased patient satisfaction,
two facets of improved quality. Our patients were not exposed
to the infections and other risks of an acute-care setting and
were getting more appropriate rehab services, leading to improved
physical function and fewer complications.
Not surprisingly, as soon as the pilot program
ended and we stopped using InterQual Criteria for a short while,
the average length of stay shot back up to 19 days, confirming
that this was a program we needed to make permanent.
The pilot stroke program revealed some important
systemic issues, most notably that we do not have enough alternative
level of care capacity for our stroke patients once they’re
ready to leave acute care. This is one of the factors behind
our decision to build a new wing at our rehabilitation facility
and add rehab beds at three of our largest hospitals.
The pilot also helped us understand that our
health system needs areas dedicated to those patients who recover
at a slower pace than most stroke patients, for whom intensive
rehabilitation is out of the question. InterQual Criteria has
helped us identify these patients, and we’ve now begun clustering
the services these patients need and standardizing their treatment.
We’re also piloting a highly aggressive and comprehensive
stroke program at two of our largest hospitals.
We’re honoured that the government recognized
Niagara Health System as a district stroke centre and has incorporated
our criteria for moving stroke patients from acute care to a
rehab setting in the formulation of its province-wide stroke
strategy.
Patty Welychka, R.N., C.H.E. C.P.H.Q.,
is the regional director for utilization management at Niagara
Health System. Craig Muir, M.D., is the chairman of the regional
utilization team at Niagara Health System.
Wireless solution allows nurses to better serve patients
at bedside
By Neil Zeidenberg
Homecare nurses treating patients with chronic
wounds are obtaining quick access to physicians by using a new
generation of wireless handheld computers.
The systems are proving to save time and cut
costs by reducing visits to hospital emergency rooms. Instead
of advising patients to make the trip to hospital when a wound
looks suspicious, nurses can consult woundcare specialists through
the use of wireless Internet and then treat the conditions on
the spot.
During a recent eight-week clinical trial
at the Maple Ridge Health Unit, in Maple Ridge, B.C., WebMed
Technology (www.webmedtechnology.com)
provided half a dozen homecare nurses with handheld computers.
The pocket-sized computers are equipped with the Sierra Wireless
AirCard 750 and special wound management software.
The software, called Pixalere – a term
derived from pix, meaning picture, and alere, which is Latin
for nurse, or to heal – is a secure Web-based application
that combines digital colour photos with a detailed description
of a patient’s wounds on a customizable assessment form.
Results of the clinical trial concluded that
the system would save over $180,000 per year and almost $3 million
if implemented throughout the Fraser Health Authority (FHA).
There was also an improvement in communication between healthcare
practitioners, better use of wound-care products and a dramatic
drop in heal times when supervised by a wound specialist.
“We spent a lot of time speaking to homecare
nurses,” said Dr. Jonathan Burns, an emergency physician
and co-founder of WebMed Technology. “We asked them what
they needed at the scene in order to help communicate with people
not at the scene, or to assist someone who comes the next day.
“With our system, the homecare worker
visits the patient, sees the wounds, and they proceed with a
brief history. They then take a visual picture of the wound using
a digital camera,” added Dr. Burns.
From there, nurses can then either finish
dressing the wound, or they can wirelessly send the compressed
data out for immediate review.
The software has been designed to page the
consulting nurse clinician or doctor on-call. The specialist
or consulting nurse clinician then goes online, logs into the
server, reviews the assessment, and sends instructions by e-mail
back to the homecare nurse in a matter of minutes. With Pixalere,
wounds can be assessed in detail such as size, shape, granulation,
and odour.
Those who are benefiting from the technology
include cancer, diabetes, spinal cord, vascular and cardiac patients.
One patient in the trial at Maple Ridge described the experience
as “like having an entire healthcare team in my living room.”
WebMed Technology also went live in Hamilton,
Ont., in late January with Saint Elizabeth Health Care, an Ontario-based
home-care organization. The implementation is a live-deployment
of the technology and not a clinical trial. They recently finished
training five frontline nurses, though eventually Saint Elizabeth
Health Care hopes to have all of its nurses, including about
20 specialists, trained to use it.
“Pixalere is enabling the transformation
of wound care,” said Nancy Lefebre, vice president, knowledge
and practice for Saint Elizabeth Health Care. “Through the
use of Pixalere, and our own education and care programs, called
@YourSide Companion, the client receives greater access to the
specialist in a shorter period of time.
“It’s better treatment based on
the evidence and best-practices.”
Moreover, Lefebre believes combining Pixalere
with @YourSide Companion and their own educational programs can
lead to better patient-provider satisfaction, more efficient
use of wound care medical supplies, lower travel costs and fewer
lengthy visits.
The product is essential, she says, in provinces
like Ontario where there is a shortage of wound-care specialists.
As far as security of the data goes, WebMed
uses a server that is installed behind the firewall of the hospital’s
information systems. The data uses two levels of encryption and
no specific patient information such as name or address is transmitted.
Dr. Burns came up with the idea for Pixalere
and the home-care service when a patient arrived in the ER with
second-degree burns resulting from spilling hot tea on her leg.
Each round trip to the ER cost the health system almost $1,000
and about $60 from the patient’s own pocket.
Burns figured patients with minor wounds could
be treated more efficiently and cost-effectively by a homecare
nurse equipped with wireless technology. He and his associates
set out to develop a mobile solution that would allow homecare
nurses to treat patients at the scene, and if necessary, get
direct access to a healthcare professional at a local hospital.
Interest in Pixalere is on the rise with requests
for pilot projects coming from Saskatchewan, Alberta and B.C.,
as well as a few possible installations in the Toronto area.
New perioperative system improves record-keeping, analysis
and planning
By Andy Shaw
They’re breathing easier at the Isaac
Walton Killam (IWK) Health Centre in Halifax these days –
now that 18 new Datex-Ohmeda S5 Anesthesia Delivery Units (ADU)
have come on-line, along with an additional 24 custom monitors
and the ‘Deio for Anesthesia’ clinical documentation
systems built into both.
First advantage: the new ADUs give good gas.
Their enhanced ventilation, electronically controlled gas delivery,
and agent vaporization features are pleasing not only IWK’s
anesthesiologists, but also to the hospital’s bean counters
for the system’s precision and cost efficiencies.
On the documentation side, the new machines
and monitors, now deployed in every OR, patient pre-op interview
room and post-op recovery area, are having a beneficial effect
on IWK’s patients, right from the get-go.
“It’s a truly perioperative software
system in that it provides electronic anesthesia documentation
of patient records from beginning to end,” explains Peter
Fenwick, Director of Business Development for a variety of clinical
information systems supplied by Datex-Ohmeda (Canada) Inc. “Patients
follow the normal procedure for being formally admitted into
the hospital’s Meditech system. But when they show up for
an interview with an anesthesiologist before their surgery in
the pre-operative assessment clinic, that’s when the Datex-Ohmeda
e-charting begins.”
A Windows-based Deio assessment module in
the software interfaces with the Meditech database via an embedded
integration engine, so that patients don’t have to repeat
the same answers they gave on hospital entry. When the patient
returns for surgery, all the patient’s pre-operative data
is mirrored onto the intra-operative chart automatically. Similarly,
the earlier data then all shows up on the patient’s post-operative
documents.
Perhaps the most innovative aspect of the
system is that during this whole process, the anesthesiologists
are interacting with the Deio charting software not via a computer,
but through the Datex-Ohmeda physiological monitor.
Now with nearly a year of experience on their
new machines and software, the learning curve for the anesthesiologists
in both the pediatric and women’s side of the merged hospital
has proven to be fairly gentle, if accompanied by a little foot
dragging.
“On women’s side of the hospital,
where I am one of 15 anesthesiologists, we have a cross section
of young, medium and older people,” says Dr. Robert Nunn,
a leader of the changeover. “The medium and the older individuals
were a little resistant at first (to abandon their paper charting
system), but I must say that in a very short period of time everyone
here came on stream because the machines are so user-friendly.”
That was one of the factors that convinced
IWK to select Datex-Ohmeda and Deio (now a Datex-Ohmeda sister
company) over their competitors, says Steve W. Smith, the hospital’s
Director of Engineering and Facilities Services. “Our machines
were 12 to 20 years old, so we wanted to replace them all. And
we wanted to add an electronic record for our information management
system. In the end we went with Datex-Ohmeda largely because
it gave us the most integrated, comprehensive system.”
Marc LeBlanc, IWK’s Director of Information
Technology, explains that during surgery the new system records
every anesthesia event. Physicians no longer have to manually
record every change in vital signs. Yet they can still manually
enter time-stamped notes about drug use and other information,
as desired.
In effect, the new system has greatly enhanced
the ability of hospital anesthesiologists to practice evidence-based
medicine.
“You have so much data you can now collect
on intra-operative events, it opens up a whole new world of being
able to print out a myriad of different reports,” says Dr
Nunn. “Anything from the number of procedures per time frame,
or the number performed by one surgeon or by one anesthesiologist,
or comparing individual duration of procedures, drug utilization.
You can use all this information for both quality control and
research. The sky is really the limit.”
Under that sky also comes financial data that’s
welcome in both the anesthesiology and hospital planning departments.
“Having a whole new fleet adds predictability
to our budget for maintenance and upkeep,” says Nunn. “Whereas,
if you were trying to replace your anaesthetic machines piecemeal,
it would be much harder to predict when they were going to fail
or how much it would cost to replace them.”
“The ability to print a legible record
also keeps our hospital lawyers happy,” says Dr. Nunn. “Physicians
and anesthesiologists are especially notorious for their illegible
records. It’s also very desirable to have a neat, concise,
accurate record on a chart for patient care quality control.
“In the long run, as the data builds
up on practice profiles for surgeons and doctors, complications,
drug use etc, you can learn and glean better methods from the
data. And, as anesthesiologists get more proficient with the
system, they can be more vigilant.”
Deio for Anesthesia is an eight-module package
that can be implemented in whole or in part, selecting and mixing
the modules as desired. The deioAssessment tool is designed for
both pre-operative planning and post-operative follow-up documentation.
The deioRecorder is used intra-operatively to record information
at the point of care. The deioInterface links Deio to other hospital
information systems. The deioWarehouse stores the information,
which can then be plumbed for reports.
To make sure the data is accurate and complete,
the deioValidator automatically steps in with prompts. The deioAnalyzer
interprets the data. The deioServer serves to network the modules.
Finally, the deioCustomizer is a configuration tool enabling
users to tailor Deio outputs to their own country, provincial,
regional, and hospital specifications.
IWK’s modules connect with other information
systems in two ways. “On the clinical network, the anesthesia
machines (including all the ADUs and the physiological monitors)
are tied to the central Deio central server located in the anesthesia
area,” explains LeBlanc. “That server, however, is
also connected (through the deioInterface) with our main hospital
backbone. And off the backbone runs the Deio assessment and archiving
modules. So we have Deio running on two separate networks with
their separate cabling and that protects the confidentiality
and safety of the records.”
Cabling, says Smith, was one of the early
challenges of converting to the Datex-Ohmeda set-up.
“You can’t just walk into an OR
during normal working hours and re-wire it. You’ve got to
carefully schedule work during off-hours.”
Aside from the physical set-up, security is
provided by the Deio software that offers different views to
Anesthesiologists, pre-op Nurses, and desk clerks, depending
on their need to know and through user-specific passwords and
e-signatures.
As to the future, Smith says he and LeBlanc
aren’t yet satisfied with the uptake of the system by all
anesthesiologists, but predicts that confidence in the new system
by all users will eventually be complete. Once it is, Smith says,
they may be looking at embracing other software, including a
Deio system that does similar work for ICU monitoring and critical
care records.
Linking their anesthesiology record keeping
to other clinical information systems is also another possible
step. Already, one of the Datex-Ohmeda monitors is tied to IWK’s
ultrasound diagnostic imaging system. Meanwhile, within the current
arrangement, Dr. Nunn sees new software templates emerging specific
to different pediatric and women’s procedures, speeding
both the input and interpretation of the electronic data. “Our
goal, of course, is to go toward the complete electronic health
record (EHR),” says LeBlanc.
If CPOE is proven to save time and trouble, physicians will
buy into it
By Dianne Daniel
Although the technology has been around for
a decade or more, it’s only recently that hospital clinicians
are sitting up and taking notice of computerized physician order
entry (CPOE). As study after study continues to indicate improved
quality of care and increased time savings following a successful
CPOE implementation, physicians – who by their very nature
rely on evidence to support decisions – are beginning to
realize that CPOE is a technology they can no longer choose to
ignore, says Hoda Sayed-Friel, director of physician and clinical
systems for Westwood, Mass.-based Medical Information Technology
inc. (Meditech).
“Physicians do act on evidence; if you show them evidence,
they will come,” notes Sayed-Friel, adding one of her company’s
goals is to help hospitals find proof that CPOE is advantageous.
“One of the things we help our customers do is understand
their environment and where they’re having errors in a written
system. We actually go in there and look at the pharmacy log
to figure out where they’re having problems.”
Problems can range from ordering the wrong drug or wrong dosage
to misreading intentions or receiving incomplete orders. CPOE
systems make improvements in these areas by alerting physicians
to drug allergies, drug-drug interactions or drug-medication
interactions at the time of ordering, by presenting a knowledge
base of common drugs and dosages and by eliminating the ambiguity
of handwritten orders.
While reducing medical error is the most widespread reason to
adopt the technology, others include greater efficiency, better
sharing of information and the appeal of having clinicians, pharmacists,
lab technicians and nurses all working from the same electronic
record.
“Right now, the physicians think of the medication orders
as what’s written on the medication order sheet, the pharmacists
think of the medication order as what’s in their free-standing
computer system and the nursing staff as what’s written
on their paper medication administration record,” says Dr.
Glen Geiger, director of the Centre for Applied Health Informatics
at Toronto’s Sunnybrook & Women’s College Health
Sciences Centre. “In a (computerized) model, the technology
is binding everyone into a single unified view of a patient’s
medication list. Any changes by any party become visible to the
other parties – something that’s not really achievable
in a paper world.”
Sunnybrook & Women’s is moving forward with plans to
adopt CPOE and is currently in the process of configuring its
existing clinical workstation and pharmacy order entry technology
for what Dr. Geiger describes as the “e-medication process.”
Much of the back-end work has to do with deciding on the correct
default dosage for medications, ensuring medications are identified
correctly and consistently, deciding which alerting functions
should be used, and providing support for complex orders.
The intent is that once a drug is selected in the computerized
system, a physician will be presented with the normal dosage
and then allowed to make changes or review alerts. Complex orders
such as an insulin sliding scale that includes a whole series
of insulin doses will be handled automatically – a feature
Dr. Geiger says will help to gain physician buy-in to the technology
since it saves time. Once entered, orders will automatically
be sent to the pharmacy system for review and dispensing, and
then to an electronic medication administration record (EMAR)
that will provide a dynamic list of all active medications for
nursing staff to administer.
When configuring alerts – flags that pop up as reminders
or warnings at the time a drug is ordered – Sunnybrook &
Women’s is following the 80/20 rule, he adds, referring
to the fact that a small number of alerts probably represent
the bulk of the value. “Clear evidence about what is a tolerated
level of alerting doesn’t exist, but you can certainly find
guidelines suggesting which alerts appear to be high yield.”
Julie Simpson, director, information services at Ottawa-based
Queensway-Carleton Hospital says configuring rules or alerts
into a CPOE is a bit of a balancing act. “You have to walk
that fine line between being safe, but not driving people so
crazy they want to turn it off,” she says.
Queensway-Carleton recently embarked on a three-phase plan to
implement a full suite of clinical and financial applications
from Meditech. The third part of the $4-million project, scheduled
to go live by April, 2005, includes CPOE and electronic clinical
documentation.
While Simpson believes the hospital has enough “in-house
champions” to ensure the CPOE implementation is a success,
she stresses the importance of maintaining open lines of communication
with clinicians and ensuring their participation in the project
from beginning to end. Some steps the hospital has taken include
getting three physicians to sit on the project steering committee,
building good will by dealing with other identified needs (such
as adding more network access points in the physician lounge)
and convincing clinicians that CPOE is not an additional clerical
task, but simply a more efficient tool than paper.
“Once you start touching a keyboard, it’s perceived
as a clerical skill, whereas sitting and writing your notes on
a chart is not,” says Simpson. “Part of our job is
to point out you’re swapping one task for another, not necessarily
adding clerical time.”
Perception is clearly a hindering factor to adoption of CPOE,
adds Meditech’s Sayed-Friel. So much so, that the company
actually changed the name of its product line from physician
order entry to ‘provider order management’ in order
to remove any clerical connotation. To assist hospitals in defining
alerts, the company has also announced plans to provide a sample
catalogue created by polling its North American customer base
and validated by physicians.
On the horizon, Sayed-Friel expects to see remote access as a
key selling point for CPOE implementations, since physicians
will want to access the system via mobile devices. She also expects
to see greater interest in physician documentation as well as
in computerized ordering for ambulatory environments.
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