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Web site provides forum for Canadian EMR users to share experiencesBy Neil Zeidenberg Where do Canadian physicians go when seeking information on electronic medical records (EMR)? Where can they learn what other physicians’ are saying about specific EMR products? Until recently, any such search on the Net would only lead to American reference sites. However, a Canadian physician recently launched a new Web site where Canadian users can visit and learn from each other. CanadianEMR (http://emruser.typepad.com/canadianemr/) is an online resource for Canadian physicians and EMR users to share information and to discuss their experiences. It’s created and moderated by Dr. Alan Brookstone, a family physician and CEO of Cientis Technologies, a medical consulting company. He has written numerous articles on the use of technology in delivering healthcare. “There’s nothing like this on the Web for Canadian physicians,” says Dr. Brookstone. “I hope it encourages them to visit the site on a regular basis – becoming a meeting place for information on EMR.” CanadianEMR is a Web log where users discuss not only their successful experiences, but also the obstacles and pitfalls of EMR and its vendors. Moreover, the message board covers topics like privacy and security issues. By simply clicking on the comment link, a user can respond to what they see. Other features of the site include ‘handy tips for EMR users’ and ‘useful links.’ Dr. Brookstone believes CanadianEMR is a good resource because it’s useful to know what others are saying about EMR in their region. It’s a question that comes up frequently in discussions, but is rarely answered adequately. The Web site will have guest authors, chosen by Dr. Brookstone, speaking on a variety of topics. He has already heard from a number of ex-physicians who are eager to participate. As Dr. Brookstone explains, the site is user friendly, with no need to register a user name and password. “Visitors need only to read the postings and then comment on what they see.” Another feature, Rate Your EMR, is a general discussion and not specific to good/bad experiences. As part of the site’s code of conduct, it’s requested that comments should be constructive. Postings thought to be inappropriate will be excluded and senders may be blocked from future participation. Despite its newness, the site is garnering plenty of interest. Launched January 1st, it attracted over 1,000 hits in the first 10 days. And the site can be a huge advantage for vendors, too. “The message board will give the vendor community an opportunity for the good systems to rise to the top,” says Dr. Brookstone. Each submission is first reviewed for content and must include the writer’s contact information for verification purposes; though not all postings will be of a positive nature. “To post only the good experiences is not realistic,” says Dr. Brookstone. The Web site is updated on a daily basis. It’s also easy to manage; taking roughly 15 minutes of Dr. Brookstone’s time each day. This means he can manage the site on his lunch break. Currently, there is nobody assisting him in maintaining the site, no webmaster. “Right now, it’s maintenance free.” As far as costs go to maintain the site, it’s rather “insignificant,” about $14 per month on the high end. Says Dr. Brookstone: “The time commitment is minimal right now, though it will depend on how popular the site becomes.” BACK TO TOP OF PAGE
Leading Canadian surgeon assists U.S. space programBy Patricia Famely Dr. Mehran Anvari, a surgeon at St. Joseph’s Healthcare Hamilton, recently returned from a two-week visit to the NASA Space Centre in Houston, Tex. The telerobotics pioneer was exploring ways to extend the frontiers of medicine into space. Dr. Anvari is also the founding director of the Centre for Minimal Access Surgery (CMAS), and an expert in laparoscopic surgery. He pushed those frontiers into new territory earlier this year when he performed the world’s first hospital to hospital telerobotics-assisted surgery. Dr. Anvari, assisted by Dr. Craig McKinley in North Bay, Ont., successfully operated on a patient across 400 kilometres from his computer console in the OR department at St. Joseph’s in Hamilton. The National Aeronautics and Space Administration (NASA) is looking for that kind of skill, experience and vision as they investigate ways to deal with possible health problems faced by astronauts. NASA hopes to create systems that will enable an Earth-bound physician to perform surgery on a patient orbiting on a space station, on the moon, or even another planet. Dr. Tim Broderick, a surgeon/scientist working with NASA, invited Dr. Anvari to the Space Centre to take part in early experiments on surgery in space. Dr. Broderick was on-hand last year to watch the Hamilton-North Bay procedure that used fibre optics. “Our work has significant implications for space, and as we’re the only site in the world doing this kind of work, he’s been keeping a very sharp eye on us,” said Dr. Anvari. Dr. Anvari headed south with Dr. McKinley, CSA astronaut Dr. Dave Williams and Bell Canada’s Harvey Stein – who designed the network for the telerobotic program. “The primary purpose of the trip was to be part of a series of experiments to look at the effect of zero gravity on completion of laparoscopic tasks. We used simulated environments to test the ability of the surgeon, an astronaut, and some technical staff who’d been trained to perform a variety of laparoscopic skills under zero gravity conditions,” said Dr. Anvari. “We also presented to a multi-lateral medical operations taskforce made up of the medical directors of various space agencies on telerobotic surgery and its implications for space.” Dr. Anvari said that his aim is not just to develop technology for space. “We want to develop technology that will help Canadians. Satellite technology could open many remote corners of the country which don’t have land-based facilities, yet need medical services.” There is a Canadian Space Agency (CSA) satellite outside the Charlton Ave. hospital site of St. Joseph’s Healthcare Hamilton with which Dr. Anvari is investigating the possibility of doing telerobotic surgery using satellite technology, rather than the current land-based (fibre optics) technology. The first week in Houston was taken up with experiments and on-site training. Although Dr. Anvari trained for six months prior to the visit, he needed further orientation to face the next challenge. He took off in the so-called ‘Vomit Comet’. The KC-135 plane takes its passengers on a rollercoaster ride that simulates weightlessness, or microgravity. “I trained physically to make sure that I was fit. Clearly, with the KC-135 flight, the fitter you are the more likely you are to be able to complete your task without being affected by the constant changes in gravity from 2G to zero G and the impact that has on your body. Fortunately the people in our group were fine and had no problem,” said Anvari. “It was a fantastic to experience zero gravity and see how everything feels and floats away in zero gravity. It was great to be able to get to know some of the astronauts, to get a chance to get a feel for how NASA works, and to present at a high level to the heads of the medical directories of the space agencies.” The results from the experiments are now being analyzed. BACK TO TOP OF PAGE
Voice recognition for radiology speeds up transcription turnaroundBy Andy Shaw It’s not quite out of Star Trek yet but it’s getting close. Bones (Dr. Morris Goldfinger) sits in his medical command post in the Edward Street Radiology Clinic in downtown Toronto. It’s a clinic that he founded, and is now the largest single private radiology clinic in the country. He mouse-clicks his radiological system inbox for the latest x-ray image sent his way from a satellite office in Montreal. Up comes a crystal clear, side-view image of a cranium and its connected neck bones. After a few minutes of careful study and one more click, there’s a sound cue tone for Dr. Goldfinger to begin dictating his findings. “Mandible x-ray, paragraph. The bony structures appear normal without evidence of arthritis, period,” says Dr. Goldfinger, in a normal voice and dictating the punctuation he wants in the text as he goes. Soon he’s into the technical terms of radiology that most people wouldn’t know how to spell without consulting a medical dictionary. Then he concludes: “Normal examination, period.” Another mouse click, and there are the words he’s just dictated. They appear letter perfect – even the arcane radiological terms – and are complete with correct punctuation and paragraph spacing. A quick but careful review of the text by Dr. Goldfinger follows and he sees the need for inserting a phrase. One more click at the insertion point in the text on the screen and he says “of the mandible” and instantly the words appear in the text between “examination” and the period of the last sentence. Satisfied, Dr. Goldfinger clicks a blue button on his Dictaphone PowerScribe handset and turns to speak to an observer with a satisfied, “There, it’s all done.” What was done in those few minutes represents a quiet revolution in medical dictation. Not only had Dr. Goldfinger conducted an evaluation of a remote patient but with the utmost efficiency, he had also seen, signed, and sent his findings to the referring physician via his Radiological Information System and an automated fax machine pre-loaded with physician’s addresses. That one final click also sent the Montreal image and accompanying report into an Edward Street archive, from where they can be instantly called up on his screen should the referring physician wish to talk to Dr. Goldfinger about his interpretation of the image. The click also triggered the Edward Street clinic’s accounting software that then automatically prepared a bill to Ontario’s health insurance plan, OHIP, for Dr. Goldfinger’s services. All that took just minutes for a process that even two years ago, before voice transcription technology had matured, might have taken days. “We used to dictate on audio tapes and send them to our typists, so you wouldn’t even see your report for review, editing, and approval for at least four or five hours,” says Dr. Goldfinger. “Then, even what you’d fixed, signed and sent off the report, if the referring physician called back, you’d often end up scrambling to find it on some clerk’s desk in a stack waiting to be filed.” With the Dictaphone system running the Edward Street show for a year now, that’s all gone – including all five of the clinic’s typists and half the clerical staff. “The system gives us a very productive infrastructure. Overall we’ve been able to reduce our staff while carrying out the same amount of work,” says Dr. Goldfinger. And that’s a prodigious amount of work. Dr. Goldfinger estimates he and the other four full-time radiologists and a couple of part-timers at his clinic (with the help of five servers and a full-time IT staffer in the back rooms) pump out over 500 interpretations and reports a day. All handled as neatly and digitally as the demonstration Dr. Goldfinger gave above. “Without the people we used to need, we have a very economical infrastructure, so expanding it doesn’t cost much. That’s why last year we were able to open another Toronto clinic,” he says. Getting up to speed on the new system for newcomers is not difficult, either. It took about two hours for each radiologist to “train” PowerScribe to recognize the quirks of their individual voices. Then over the course of another month, the system learns on its own to better understand what the dictating rad is saying. “After the first two hours of training, the system was remarkably accurate,” says Dr. Goldfinger. “After we hit that first month threshold, it became incredibly accurate.” The dramatic rise in computer processing power has helped improve the quality of voice transcription, says Don Fallati, Dictaphone’s U.S.-based vice president. “But more than anything else it is the ‘language modelling’ we do at Dictaphone and work so hard at. And in this case we applied that modelling specifically to radiology so that the system would recognize or quickly learn to recognize all its specialist terms.” As good as it is, there’s at least an awareness challenge that goes with greater adoption of voice transcription by the healthcare community. “I think a lot of physicians in the past may have experimented with dictation and transcription using off the shelf software that wasn’t adapted to their profession, and they consequently found it wanting. But many doctors aren’t aware of the dramatic improvements there have been in the technology over the last 18-24 months,” says Duncan Salt, General Manager of Dictaphone Canada in Mississauga, Ont. “Considering the millions of dollars that healthcare is spending each year on manual transcription, it’s time for doctors to re-visit their computer, I think, to see how things could be improved.” Judging by Dictaphone sales of PowerScribe, especially in Ontario, some radiologists have indeed been heeding the advice and re-visiting their keyboards and microphones. “There are some areas in the Maritimes and out in BC that have shown strong interest in our systems, but Ontario is clearly the leader in adoption,” says Ben Hebb, Dictaphone Canada’s head of sales for Ontario, (and the person who gave the demonstration of PowerScribe that Dr. Goldfinger admits bowled him over). “We could soon have upwards of 15 installations in Ontario, and they range in size from the smallest clinics to the largest hospitals.” BACK TO TOP OF PAGE
ASP model for dictation/transcription means faster service at SouthlakeBy Dianne Daniel Southlake Regional Health Centre has stepped into the Web world as the first Canadian hospital to use a dictation transcription service from MedQuist Canada that leverages an Internet-based application service provider (ASP) model. The Newmarket, Ont.-based facility signed-on to MedQuist’s DocQment Enterprise Platform (DEP) in September 2003, and according to Anthony Reddick, Southlake manager of health information and decision support, the most noticeable change since then has been the speed of service. “The glory is that turnaround time has improved with this system,” says Reddick. He notes that the goal of the new system was a turnaround time of 24 hours. “They’re beating those time lines, based on what I’ve been hearing back from the physicians.” Prior to choosing the MedQuist DEP service, Southlake was managing its own in-house transcription system, which Reddick refers to as antiquated. Transcriptionists were supplied by MedQuist and worked from home, but the hospital had reached a point where it was necessary to upgrade its equipment in order to support ongoing dictation. Rather than investing in another hardware solution, Southlake decided to look at outsourcing as an option. “Like most hospitals, we’re tight for IT capital,” says Reddick. “So to have an approach that would allow us to convert dictation to an operational cost has its benefits.” With MedQuist’s DEP, everything required to handle medical dictation is supplied to Southlake, including a gateway PC and server. Physicians create voice files, which are sent on to MedQuist’s regional data centre in Alpharetta, Ga., over a toll-free line. Files are then captured in the centre’s Oracle database, where they’re matched to Southlake’s Admission/Discharge/Transfer (ADT) system through a real-time, HL7 interface, so that patient demographics can automatically be inserted. From there, files are available over a secure Internet connection to trained medical transcriptionists, who use PCs to access and transcribe the notes. “Now that they’re dictating into our data centre, with just a click of a few buttons we can have a thousand transcriptionists able to access their voices,” comments MedQuist national project manager Jim Wheeler, who led the implementation. One of the biggest changes, he adds, is that the number of available transcriptionists is no longer tied to the number of available ports on the in-house dictation system. Another significant change is in how the notes are returned to Southlake. With the old system, medical staff didn’t have on-line access to dictated notes. With DEP, using proprietary technology for printing and viewing of documents, returned notes can be printed or viewed on any floor, station or printer in the hospital, or viewed remotely as long as a physician already has secure outside access to the hospital. According to Reddick, the ability to print from more than one location was a key factor for Southlake. Before deciding to outsource its medical dictation, the hospital surveyed other sites to determine any shortcomings and found that the need for distributed printing was mentioned repeatedly. “I spoke to a number of hospitals and looked where they fell down,” say Reddick. “And one of the things was they couldn’t get documents to print where they needed them to print.” Reddick encourages any facility considering an ASP model to do its homework and look at what has gone wrong at other outsourced sites. For example, Southlake also ensured a high level of detail in its contract with MedQuist, because it could “see where other hospitals got burned because they didn’t investigate that thoroughly.” As MedQuist Canada director of operations Carey Silverstein explains, the first step in providing the ASP platform is a discovery process, during which MedQuist determines the needs and wants of a hospital, such as expectations, requirements and timelines. From there, the company produces a detailed project plan, so that a client hospital knows exactly what’s going to happen every week until the go-live date. Part of that plan involves customizing the solution so that it interfaces to existing hospital information systems. “With this system we were able to give Southlake exactly what they wanted,” says Silverstein. “In the past, the dictation and transcription industry has consisted of a lot of canned applications, but here, we have a lot of flexibility with what we’re offering.” For Silverstein, the transition to an ASP model for transcription is as big a leap as the move from cassette-based to digital dictation. “The community is very cognizant of what’s happening, and the feedback we’re hearing from the majority of our clients is that they no longer want to purchase hardware anymore,” he says. MedQuist Canada, based in Concord, Ont., is currently transcribing 30 million lines of dictation annually. The intention is to migrate all of its current customer hospitals onto the ASP model in 2004 and then branch out to new clients next year. As soon as a critical mass is reached, the company plans to launch a Canadian-based data centre in the Toronto region, so that voice files no longer have to cross the border. At Southlake, future plans include the addition of speech recognition capabilities, as well as autofaxing support for dictated documents, all of which are currently offered by MedQuist. Meanwhile, all dictation for health records, excluding diagnostic imaging, lab and pathology, which are handled in-house using the MedQuist platform, will continue to be outsourced. “I’m kind of embarrassed when I talk to peer hospitals that are having so much grief, and they’re weeks and months behind with their on-site transcription,” says Reddick. “Right now, it’s just something that functions so effortlessly here.”
Dictation technology produces transcribed reports within minutesBy Neil Zeidenberg TORONTO – Physicians can now dictate their notes into a Palm handheld computer as they see patients, upload the sound file into their desktop PC and watch as their voice notes are quickly converted into text reports. The new dictation/transcription application, called VoiceMD, is available through Toronto-based VoicePC Inc. (www.voicePC.ca) It includes special software that dramatically improves the sound-recording quality on a Palm handheld computer. And using voice-to-text conversion, it also enables doctors to produce medical reports in minutes, instead of hours or days when using a dictation service. “Doctors don’t need to wait 24 to 48 hours to have the transcription sent back to them,” says Waleed Qirbi, president of VoicePC. “Instead it takes 24 to 48 seconds to have their five-minute dictation transcribed from the Palm in front of them. This means the file can be completed, signed, and printed the same day. It gives instant results.” Physicians can beam their files wirelessly to a desktop PC by using the new Palm Tungsten computers, or they can upload files in the traditional manner by simply placing their handheld into a cradle and transferring the report. A secretary or assistant can then scroll through the file, correcting any obvious errors. Making the review process easier is that the physician’s voice overlay remains embedded over the text, providing audio confirmation for the secretary during her review. The physician can then quickly scan the report and sign-off. VoicePC offers hardware and software bundles that include licensed voice software from ScanSoft. Also available are over 30 templates providing speech vocabularies for a wide-range of medical specialties, such as neurology, endocrinology, oncology, and urology. The Palm computer enables physicians to carry patient records, decision support tools and a dictation machine all in one lightweight device. Unlike heavier notebook computers, which can drain their batteries in two hours, a Palm can last significantly longer on a single charge. What is more is that users are even able to recharge at a much faster rate than a standard laptop. This translates into less downtime for a Palm handheld in comparison to a notebook computer. “We’ve moved into the Palm and Tablet PC market,” says Qirbi. “But the Tablet has been more cumbersome and expensive, making it the second or third choice for doctors.” Price-wise, a Tablet PC with headset, 1GB of RAM, Dragon NaturallySpeaking Medical software, and enhanced recording software has a purchase price of approximately $5,000. However, a Palm with the same bundle is closer to $1,500. All voice-recognition software will make mistakes – users can expect an error rate of about 5 percent. But VoicePC makes errors fairly easy to correct. While on the desktop and using a headset, the user identifies misspelled words and, via voice commands, asks the system to either delete or fix the word. The system does have the ability to adapt to the intonation and inflections of the user. “The more it’s used, the more accurate it becomes,” explains Nicholette Williams, an account manager for VoicePC. “And with fewer errors to fix, and record turnaround time, the need for transcriptionists can be eliminated.” For many doctors, clinics and hospitals that outsource their transcription services, that could translate into substantial financial savings. It also gives users more control over when their patient files are completed. The first time the software is used, the user simply reads along with a dialogue box which highlights as words are recognized. For most VoicePC users, this means simply having the computer highlight each word as it is spoken. This creates an initial user vocabulary, which eventually results in the user being able to convert voice to text on-screen in real time. With language models now available in multiple languages, VoicePC Computers are available in both English and French. VoicePC also provides training with the delivery of every system. This ensures the client is comfortable using it from the start. Qirbi notes that without basic training, most people become frustrated and quit because they don’t know how to use voice-recognition software properly. Even worse, out of the box, most voice recognition systems don’t work well because the PCs on which they run have not been optimized for the application. “Our systems are customized specifically for use with voice recognition software,” said Qirbi. “We know the product works because we build the product and test the product to ensure that every system is ready for use upon delivery.” Waleed Qirbi was born in Ottawa, and is an MBA graduate of the Joseph L. Rotman School of Management in Toronto. He also has a BA in political science from the University of Western Ontario. While studying for his MBA, the discovery of a brain tumour affected all but 15 percent of his vision. It was in his return to complete his MBA that he was exposed to voice-recognition technology. After gaining experience with the systems, Qirbi decided to create new applications for others – such as physicians. He believes the timing is right for the VoiceMD line of products, as Palm computers are popular among physicians and the voice dictation system provides a low-cost solution that dramatically reduces waiting times for reports and increases a doctor’s effectiveness.
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