Calgary rolls out ‘e_record’ system to caregivers

By Jerry Zeidenberg

The Calgary Health Region has launched an extensive electronic health-record system that integrates more than 80 specialized systems used in its three adult acute-care hospitals, thereby creating a consolidated patient chart.

Over the past three years, the region has invested $80 million in the project, called the e_record. The system now connects the city’s three adult acute care hospitals and private labs, and as it rolls out in phases over the next four years, it will connect to all other regional hospitals, doctors offices, independent X-ray clinics, pharmacies and other care providers.

“What we’re building is an e-record that will cover the 1.2 million people in the Calgary Health Region,” said CHR’s vice president of advanced technology, Bill Trafford, in an interview with Canadian Healthcare Technology.

The main thrust of the project is to improve patient safety and enhance the quality of care delivered through the use of integrated, electronic systems.

Using connected IT systems, caregivers will have access to the information they require to make accurate decisions, right at the moment they need the data. Trafford explained, for example, that if physicians find themselves waiting for lab results, they often re-order the tests, resulting in greater costs for the healthcare system and a delay in treatment until the new results are received.

But by using the e_record system, which connects all labs in the region with the three adult acute care hospitals, results are delivered much faster. “We’ve already seen the duplication of lab tests drop significantly in the last few weeks,” said Trafford.

Rapid access to data is enabling physicians to make decisions more quickly, which in turn allows treatment of the patient to start sooner – resulting in a better experience for the patient.

Quality of care is also being enhanced by the adoption of ‘best practices’ by the various clinical units of the Calgary Health Region. Moreover, the agreed upon practices have been incorporated into the e_record system as decision supports for physicians.

“Physicians don’t want to be told what to do,” commented Trafford. “But they do want to be warned if they’re straying from the accepted path.”

Calgary’s new system not only shows them the accepted path, but it highlights the best path, as established by the most up-to-date research. And it has created best practice guidelines and order sets for an astounding 1,200 clinical areas.

“We’ve taken the region’s 10 leading lights in various clinical disciplines, and they’ve worked out the best practices in these areas,” commented Trafford. All in all, the project has drawn on the expertise of some 700 physicians and care-givers in building the order sets and e_record system.

Moreover, it’s an on-going process, since medical knowledge virtually doubles each year. As a result, the committees of physicians and care-givers will continuously review and update the system, making sure the ‘best practices’ reflect the latest information.

The decision support tools also help the region’s doctors stay current with the latest practices – when they check on the protocols for various diagnoses and therapies, they can quickly see if a previously used test or medication has changed.

And because nearly all information in the Calgary hospitals is now electronic, physicians can analyze patient therapies and outcomes much faster than before, when records were kept on paper. That’s creating an in-house source of determining best practices.

Trafford gave the example of one physician who noticed that he and his colleagues were obtaining widely varying results when prescribing the same medication. By reviewing the computerized records kept by his peers, the physician found that each of his colleagues was prescribing different doses of the medication. After a few telephone calls, the physicians agreed upon the dosage that would lead to the best results.

“That process of review and analysis, using the electronic systems, only took a couple of hours,” said Trafford. “When records were kept on paper, it would have taken days or weeks – so long, that most physicians wouldn’t have bothered.”

On the patient safety side, Trafford noted that 50 percent of errors are made in just two areas – misidentification of patients, and mistakes regarding medications.

Using a panoply of new patient safety systems, Calgary Health Region aims to take great strides on this front. Trafford commented that worldwide, there is an error rate of about 2 percent when medications are prescribed, delivered or administered. “We want to be at 0.2 by 2010,” he said.

That’s just one of the ways in which Calgary is “building a landmark capability in Canada,” commented Trafford. He believes the e_record system, and associated practices in the hospital, will make the region a healthcare leader that should be emulated by others.

For its part, decision-makers in Calgary have looked closely at several other top-performing organizations, and have modeled their own systems on their best practices.

Trafford said that three hospital groups were the key examples for Calgary Health Region: InterMountain Healthcare of Salt Lake City, Utah; the Hospital for Sick Children, in Toronto; and for cancer care, the Memorial Sloan-Kettering Cancer Center, in New York.

He noted that in U.S. quality ratings, InterMountain has consistently been a top performer for years, and the organization is known for its highly advanced decision support systems. “We’ve spent a lot of time working with them,” said Trafford, adding that Calgary has learned a great deal from Sick Kids Hospital, as well. “We’re working in a way that’s similar to them,” he observed. And in the area of oncology, where Sloan-Kettering is widely admired for its quality of care, Trafford noted that Calgary collaborated closely with the New York-based organization when developing order sets.

Trafford also said credit for the e_record system should also be given to Alberta deputy minister of health Paddy Meade, who was instrumental in keeping the project on track.

In due course, the system will also provide secure access to patients, so they can communicate with their caregivers, book appointments electronically, and access their records, thereby enabling them to keep tabs on their own results and progress. “We’re creating a very big cultural shift,” commented Trafford. “We’re creating a partnership between doctors, nurses, caregivers and patients.”

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Ontario’s Smart Systems for Health critiqued, aims for turnaround

By Jerry Zeidenberg

TORONTO – On the topic of Ontario’s Smart Systems for Health Agency (SSHA), there’s lots of bad news. But there are positive developments, as well.

First, the bad news. An operational review of SSHA, conducted by Deloitte Consulting and made public in January, found the organization to be a poor performer in just about every area it looked at. To put it bluntly, you could say the SSHA was misfiring on all six cylinders.

After spending $458 million of taxpayers’ money (counting the current fiscal year), the SSHA has created products that its users – hospitals, community care providers and doctors – consider to be of poor quality and ineffective. They also feel the SSHA’s service delivery levels are low.

Moreover, the reviewers at Deloitte concluded that SSHA functioned with inadequate strategic planning and project management, had serious governance and accountability problems, and provided little measurement of return-on-investment.

The 100-page operational review can be accessed at www.ssha.on.ca

On the other hand, there’s some good news, too: the caustic operational review may have jolted the SSHA – and its overseer, the Ministry of Health – into making the changes needed to become an effective provider of eHealth products and services.

“As a board of directors, and as management, we accept the review and its findings,” said Mike Lauber, the acting CEO of Smart Systems for Health Agency. “We’re taking the work of Deloitte and using it to transform the organization. The review is now our roadmap – we’re going to take its recommendations. We’re going to implement the industry’s best practices.”

While SSHA was formally launched in 2002, Lauber didn’t come on board until December 2005, when he was appointed its chairman. By the spring of 2006, he urged the underperforming organization to commission an independent, operational review, as a first step on the road to improvement. “I suggested it, and nobody resisted,” said Lauber, a chartered accountant by training, and a former partner in KPMG’s audit and consulting practice. He also served as ombudsman for the banking industry, investigating and resolving customer disputes.

A new board of directors was appointed last spring, and by the fall of 2006 the previous CEO had departed, and Lauber shifted from his role as chairman to that of acting CEO. (In late February, William Albino was appointed as the new CEO; Lauber returned to his role as chairman.)

Lauber acknowledged that in the past, it was difficult to obtain information from the SSHA about its spending and overall performance, but as part of its current transformation, a new era of transparency will be initiated. The first step on that front was making the operational review public – something that didn’t have to be done.

“Our goal is operate at the standard of a TSX (Toronto Stock Exchange) listed company,” said Lauber, with regular and rigorous reporting, along with high standards of corporate governance and accountability.

To help implement the operational turnaround, moreover, a change management office has been formed. It will assist the various parts of SSHA, which now employs 300 people, as it puts ‘best practices’ into place. Over the next six months, SSHA is focusing on four major areas:

• Project management. SSHA is aiming to improve its time controls and budget management. As well, it’s putting an integrated, enterprise-wide approach to project management in place. “Project management has tended to be silo-based at SSHA,” said Lauber. “We’re building a unified approach, so that projects are coordinated and use the same methods.”

• Data centre improvements. While a great deal has been invested in two data centres, they haven’t used best industry practices – for example, advanced automation for problem detection and automated reporting to clients. These and other practices are currently being installed, as part of a project called Setting the Course on the Operational Road to Excellence (SCORE). “In six to eight months, we’ll have reached a good operational standard,” said Lauber.

• Financial controls and expertise. SSHA is bringing in a Chief Financial Officer. It is also implementing much more sophisticated financial systems and reporting procedures. “We want to be able to tell, at any time, how much it’s costing us to run a particular application, like OLIS (the upcoming Ontario Laboratory Information System) or an EHR,” said Lauber.

He commented that, “General Motors knows down to a tenth of a cent what it costs to put a bumper on a car – we should know our costs, too.”

On a related note, when asked about rumours of runaway costs in the past, and overly large payouts to consultants, Lauber asserted that Deloitte found no signs of “inappropriate use of funds” – nor did professional firms in three previous accounting audits. He added that SSHA made heavy use of consultants in its early days to launch the organization and implement infrastructure, and paid standard consulting fees, but the agency has changed course and is now almost entirely staffed by its own employees.

• Strengthening human resources. “We may well hire an executive level human resources director, because HR is such a critical issue here,” said Lauber. He explained that as an I.T. organization, SSHA is competing for highly skilled programmers, engineers, analysts and managers. “It’s a huge talent management issue. I.T. professionals are mobile and in great demand. We’re competing with banks and industry for them.”

Lauber said an environment must be developed at SSHA that encourages people to stay and develop their careers. “You want to slow down the turnover.”

Of course, SSHA will have to deal with other problems, as well. For example, it faces criticism that it has built infrastructure that few are using – secure e-mail is a case in point. The Deloitte review notes that of 60,000 secure email boxes that have been installed since 2003, only one-third are in active use.

Part of the problem is that not enough storage space has been allotted to the mailboxes for applications like receiving and storing diagnostic images, which take up a great deal of room.

However, Lauber asserted that the size of the email boxes is currently being increased. In addition, he said a rollout to Ontario physicians is currently under way, and that the usage numbers will soon increase.

Finally, he observed that many doctors simply aren’t using email to consult with their peers; instead, they’re still relying on the telephone. It’s only a matter of time, he said, before their work practices change. “It’s much like ATMs or the fax machine,” said Lauber, noting there was resistance to them at first, but then sudden acceptance once a tipping point was reached.

And while the Deloitte review paints a largely negative picture of SSHA, Lauber says he doesn’t totally agree with its assessment, stating the organization has strengths as well as weaknesses.

“There has been a lot accomplished,” said Lauber. “We’ve built data centres, a reliable network, we host applications and secure email is now rolling out.

“The major applications will only appear in the next two to three years,” he continued, citing provincial lab, drug and imaging solutions as the prime examples. “But they wouldn’t be possible if we didn’t do the planning or build the infrastructure.”

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Clinical connectivity advances at Hamilton Health

HAMILTON, ONT. – Dr. Justin deBeer, an orthopedic surgeon at Hamilton Health Sciences, was halfway around the world in Taipei, Taiwan but wanted to be able to keep tabs on his inpatients back in Canada. What in the past would have been a next to impossible proposition was actually done quickly and easily thanks to ClinicalConnect – a web-based portal for physicians that brings together data from three of the hospital’s most commonly used clinical software systems in an electronic health record format.

Hamilton Health Sciences worked with Medseek to design and implement the ClinicalConnect portal, but also engaged physicians from a variety of disciplines to offer input and drive the creation of the final product. Since Meditech is the most widely used information system at Hamilton Health Sciences, it was the first to be merged into the ClinicalConnect environment. ClinicalConnect offers a user-friendly view of the Meditech information, which ranges from admission information to lab results, and allows physicians to view the information simply by signing on to ClinicalConnect.

The next step involved adding views of patient records, stored in a system called Sovera. Currently the charts are scanned and merely displayed through ClinicalConnect, however, the portal does allow physicians to view the information and also indicates the number of chart deficiencies that need to be resolved. By the end of this year, physicians will be able to access Sovera directly through ClinicalConnect, which will enable them to interact with patient information in real time and directly resolve any chart deficiencies.

In the future, physicians will have the option to e-edit and e-sign Meditech-based charts in the portal, and the updates will be passed back to the Meditech system. When this feature is available in the portal, it will also be available via PDAs.

Adding PACS to the system proved to be a tremendous enhancement, since it enables physicians to view X-rays from the same system that houses other clinical information about their patients. And by signing on to one system, physicians can access and interact with all of this information. They can also customize their views and pick and choose which information they want to see and when.

“Our ClinicalConnect portal gives physicians and other clinicians secure, real-time access to electronic patient records. Whether they are at the hospital or elsewhere, our physicians can quickly access all clinical reports, lab results, PACS images, pharmacy medication lists and much more,” said Dale Anderson, information and communications technology manager of projects and e-Health solutions at Hamilton Health Sciences.

Already, more than 900 physicians, nurses and other clinicians at the hospital and within the surrounding communities are using the system. Many physicians, particularly those in family practice, have noticed improved communication as a result of ClinicalConnect, since the information is updated in real time and they have access to detail about tests, medications, and other particulars that may affect their patients, even after they have been discharged from the hospital.

As Hamilton Health Sciences expands the wireless network within its four sites, ClinicalConnect will become even more valuable. Already, some physicians have been piloting wireless applications of the system on PDAs in certain areas of the hospital. They’ve got access to all available patient information when they are seeing the patient. Patients are also able to ask questions about particular tests and procedures when they are with their doctor and do not have to wait for results to be retrieved from another computer or system.

For Dr. deBeer, remote access to patient information through ClinicalConnect enabled him to use Internet access on the computer in his Taipei hotel room to call up the patient’s information, including X-ray images and blood work, to check up on his hospital patients. Noting that physicians are always pressed for time and routinely required to travel as part of their practice or for educational purposes, Dr. deBeer is confident ClinicalConnect is adding value for physicians and their patients.

“Now regardless of where we are in the world, we don’t ever have to leave patients behind,” he said.

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Radiologists and referring physicians need to work more closely

Normand Laberge is chief executive officer of the Montreal-based Canadian Association of Radiologists. CHT writer and contributing editor Andy Shaw interviewed Mr. Laberge in Chicago, at the recent Radiological Society of North America (RSNA) annual conference.

Shaw: Normand, clearly the tremendous advances in imaging technology over the past few years are influencing the practice of radiology. With higher resolution, more imaging modalities, and most recently, much more government funding for new imaging equipment – what has all this meant to Canadian radiologists?

Laberge: Canadian radiologists lobbied hard to ensure our hospitals remained up-to-date in imaging technology and can be proud of that accomplishment. They also stepped up to the plate when the system asked them to focus on productivity. We’ve come to a stage in the evolution of our healthcare system, however, where radiologists need now to put the emphasis on quality in order to ensure that they remain respected as professionals. If radiologists don’t emphasize the professional quality and value-added aspects of the work they do, there’s a danger they could put themselves out of business.

Shaw: That’s surprising to hear, can you explain a bit more about being professional? What’s the problem?

Laberge: Imaging equipment is available to all physicians on an unprecedented level. At the same time, we’re not producing enough radiologists to meet the growing demand for medical imaging. Studies clearly show that not all imaging tests ordered are the most appropriate. As professionals, it is our duty to develop ways to ensure our healthcare system avoids inappropriate tests and the costs associated.

Shaw: How so?

Laberge: Canadian radiologists need to move beyond the simple interpretation of images. The imaging process is a six-step job. As professionals, radiologists must be involved in the entire process, from the time the examination is considered for a patient, until the time the final report is discussed with his physician. If there’s a certain amount of resistance to the idea of greater involvement, it’s because radiologists traditionally don’t like to be gatekeepers. But they’re the experts here. They’re best placed to advise patients and their doctors on which tests are the most appropriate. So it is their duty to be involved.

Shaw: Can you describe those steps briefly?

Laberge: The very first step involves judging the appropriateness of a test ordered by a physician, given what he or she is looking for. The second step involves scheduling. Some patients can wait, others can’t. Helping to manage the demand and the constant trade-off that must be made between access to and quality of care is part of the professional responsibility of radiologists. But even then, they’re not ready to view images yet. The third stage involves the relevant protocols. Are you going to use a contrast agent? What kind of views will you do? Radiologists must become directly involved in determining the use of protocols based on evidence and in the development of standardized best practices.

Shaw: So now, as the radiologist, am I finally ready to do the exam?

Laberge: Yes, and it is only at this fourth stage that the exam is performed. But radiologists are also responsible for quality control. You maintain the equipment, you pay attention to the workflow in the department, and you supervise the technologists. Most importantly, you make sure you are using the right level of radiation for each individual case. This is critical and another professional responsibility of being a radiologist.

Next, at stage five, comes the interpretation of images and production of a report. But this should not be the last step; there is a sixth one, which is communication. You need to be available to discuss your findings and the appropriate follow up with referring physicians and not leave it to them to simply read a report. Consultation between physicians and radiologists is fundamental in ensuring quality care to Canadian patients.

Being a true radiologist means direct involvement at each of these six stages.

Shaw: And if I don’t do them?

Laberge: Let me give you an example: In such a case, the cardiologist who wants a CT or an ultrasound done will be much more likely to just go ahead, have the imaging tests done and interpret the results on his own. Because radiologists are not providing the kind of full value-added, the six-step service I’ve just described, a real danger exists that their role will eventually be seen as non-essential and the healthcare system and its patients would be much the poorer for it. We need to go back to emphasizing professionalism in our industry not only for its continued existence, but to ensure that Canadians from coast-to-coast benefit from the value it adds to their quality of care.

Shaw: Speaking of cost-cutting, what’s been the impact of outsourcing? Teleradiology now makes it quite possible, for instance, for images to be interpreted in India relatively inexpensively overnight and sent back to the hospital with a report by the next morning. So we’ve seen the rise of companies who do that, like Nighthawk.

Laberge: There is nothing wrong, per se, with outsourcing an interpretation by teleradiology. For obvious job protection reasons it is preferable to have this done within Canada, but as we’ve seen, the interpretation of imaging is just one step of the medical act. Now who takes care of the other steps? You still need a radiologist, even if you are going to sub-contract a portion of the work, otherwise it would be misleading to say that the entire medical act has been covered.

Shaw: If successful, and radiology starts to be done the right and responsible way in today’s circumstances, where do you think it can head tomorrow?

Laberge: Already, in some institutions, the first place trauma patients go is not to Emergency but to Radiology. Imaging is rapidly becoming a cornerstone of healthcare. You can’t treat if the diagnosis is not done and this is our turf. We have evolved from what was just radiology, to diagnostic imaging, and now on to what’s more appropriately called with the addition of Interventional Radiology “medical imaging”. In other words, as radiologists we are involved before, during, and after. And that is a hell of a responsibility. That is why we’re making professionalism an issue.

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