Patient safety is linked to patient participation

By Andy Shaw

How can we engage patients to help themselves when it comes to their own care and safety?

By giving them the right tools, is the obvious answer.

That’s just what Susan King has done as head of an Ontario project to improve palliative care for the province’s cancer patients. Among them are the biblical-sounding ESAS and ISAAC, which enable patients to consistently assess their own symptoms and connect with their caregivers when needed. “We chose cancer patients because they constitute 80 percent of palliative care patients,” King told attendees of an Ontario Hospital Association seminar in January.

King’s undertaking, officially labelled the ‘Provincial Palliative Care Integration Project’, has made available to a target population of lung cancer patients in all 14 LHINs or healthcare regions throughout the province, the proven self-assessment tool ESAS (Edmonton Symptom Assessment System) that links to the clinician-accessible ISAAC (Interactive Symptom Assessment and Collection).

ISAAC can track patient symptoms over time and includes a notification function when symptom scores exceed norms. Care-givers are able to access the patient’s own ESAS scores and the clinician’s palliative performance scores from the ISAAC website to help them monitor both the perceived and prescribed levels of care.

One disease group in constant need of such safety-enhancing monitoring would be the country’s largest and most costly, the chronically ill.

Dr. Alexander Logan is doing just that at Mount Sinai Hospital in Toronto. Dr. Logan, a nephrologist, is the principal investigator for a ‘Mobile Phone-Based Remote Patient Monitoring (RPM) System for Management of Hypertension in Diabetic Patients’.

The data input devices at the patient’s end of the RPM system are a BP sleeve and a bluetooth-capable monitor that triggers a readings-laden call to the central server from the patient’s Blackberry user-interface.

Once received by the data centre server, out goes the patient’s blood pressure reports, along with alerts of any abnormally high or low readings to the physician’s office by fax. If warranted by the faxed readings, the physician can interact by phoning in a fax-on-demand request that will in turn send an automated voice mail message to the patient’s home phone (not the Blackberry).

If for example, the physician receives a fax indicating the patient’s readings are high, e.g., systolic BP>200 mm Hg or diastolic>110 mm Hg, then the patient will hear on his or her home phone: “Your blood pressure readings today were on the high side. Please measure it again for the next two days.”

Although no data are transmitted by the internet, the patient’s information is summarized on a secure web page accessible by both patient and physician. It displays daily average blood pressures for that patient, both in summary and graph forms, as well as a record of all clinical alerts generated during the previous 60 days.

In Phase II of his RPM project, Dr. Logan studied the effect the project was having on its patients. “The patients liked it,” Dr. Logan told his OHA audience. “We received 49 percent more readings than we expected, so patient adherence was high.”

Despite the RPM project’s success to date, Logan says the practice of remote patient monitoring still faces major hurdles in the way of widespread adoption by healthcare’s stakeholders.

Also he pointed to other challenges, including: no fees for participating physicians; a lack of uniform technical standards for RPM systems; not much hard evidence in yet on improved patient outcomes or how economical they are; few champions of RPM at senior levels, and a number of legal and liability issues that remain to be clarified.

Yet Dr. Logan remains highly optimistic about RPM’s future.

“In effect, the algorithms in the system that monitor the readings and generate the alerts free up time for the doctor to become more of a coach to the patient, and also enable patients to better look after themselves. So care becomes shared,” explained Dr. Logan.

For David Wiljer, PhD, enabling patients to share more in their care, be it by cell phone or other remote device, is fundamental to improving their safety. And in his ‘Putting the Patient into Patient Safety’ presentation, Dr. Wiljer pointed out that most patients have long been ready to accept technology as a tool, though their physicians may still be dragging their feet.

“We know from surveys, for example, that at least 69 percent of patients would like online charts; that 80 percent would like personalized, relevant information emailed to them after seeing their doctors; that 83 percent would like their lab test results online; and that 84 percent would like to receive electronic alerts for things like appointments and vaccinations,” Wiljer told the conference.

Wiljer should know about current patient views. He is the chair of a national working group dedicated to involving patients in their EHR. In his job as head of Knowledge Management and eHealth Innovation in radiation for both the Princess Margaret Hospital and the University Health Network, Dr. Wiljer has won several awards for his innovative initiatives that have applied informatics to patient education. His efforts have included an award-winning pilot portal that gave blood cancer patients access to their health records called, in an appropriate double entendre, Getting Results.

“The hematology clinic at Princess Margaret is a very busy place,” said Wiljer. “So we designed Getting Results to help patients better navigate their care.”

Through the portal, the patients had access to their bloodwork results, as well as algorithm-driven interpretation of those results and illuminating videos featuring Princess Margaret specialists who further explained their conditions and treatment. The portal also enabled patients to ask further questions directly of their care givers.

“They knew what was going to happen and did happen to them each week; they could get appointments, and they were aware of what the side effects might be of their treatment. So they knew what to prepare for and what to expect,” said Dr. Wiljer. “What we were really doing was empowering the patient to participate in their care.”

Similarly, Dr. Wiljer and an 18-member project team have a more sophisticated patient-empowering portal under way at three University Health Network sites for breast cancer patients and physicians.

With similarly clever double meaning, this one is dubbed InfoWell. It is a welcome new tool for the University Health Network’s ambitious Breast Cancer Survivorship Program.

But how do we know whether a more empowered patient is a good thing? Is the more knowledgeable patient a safer one? Or is he or she more likely to have a better outcome? Or save the health system money?

In other words, is it worth investing in the information technology, the IT, that will make the patient more informed?

Just the kind of questions that are grist for professor Kevin J. Leonard and his mill, the IMPROVE-IT Institute, that he launched in 2004 at the University of Toronto’s faculty of medicine, where he teaches health policy management and evaluation.

“Right now in healthcare, we’re investing a lot in information technology but we are not tracking what the benefits are,” Dr. Leonard told the OHA conference. “So we are busy trying to identify the metrics in order to know what to measure, including patient safety.”

One thing Dr. Leonard already knows for sure is that other industries have improved their metrics and their outcomes whenever they’ve changed their approaches to the consumer.

“In the banking industry, for instance, they’ve taken a lot of the delivery stress out of their system and improved their efficiencies enormously by deploying technology that lets the consumer do much of the work,” said Dr. Leonard.

“And now that we can do banking online and not have to go to the bank only between 10:00 and 3:00, we’d never go back to the old ways.”

Similarly, Dr. Leonard believes that certain healthcare consumers can permanently relieve much of the stress in healthcare by helping to manage their own care. And he has his eye particularly on the chronically ill, or the 3Cs (consumers with chronic conditions) as Leonard calls them.

“The 3Cs form only 30 to 40 percent of the patient population, but they account for 60 to 80 percent of our healthcare costs,” he said. “And we know that half of those costs are split 50/50 between getting care and getting information about the care.”

So any improvements in helping the 3Cs and their physicians be informed about the care they are receiving or providing should pay big benefits.

“In Canada, we spend about $50 billion on providing information such as test results, care advice, and repeat prescriptions,” said Dr. Leonard.

“So a mere 10 percent improvement in information transfer would result in savings of $5 billion.”

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CHEO develops intelligent alerting system for bedside devices

By Jerry Zeidenberg

OTTAWA – The Children’s Hospital of Eastern Ontario (CHEO) is working with the newly created Bell Canada Centre for Healthcare Innovation on a clinical decision support system that will add intelligence to the alerts received by doctors and nurses from bedside monitors. The system will have a wireless component, enabling alerts to be delivered through mobile devices.

In an environment of scarce human resources, intelligent alerts are expected to increase efficiency by sounding the appropriate alert at the right time. Moreover, the system will improve patient safety by sending alerts to doctors and nurses wherever they may be, inside the hospital or out.

It’s believed to be one of the first ‘smart’ solutions of its kind, and when completed, it will be offered as a system that can be used by other hospitals throughout the Champlain Local Health Integration Network (LHIN) and across Canada.

Numerous hospitals across Canada have installed a wireless infrastructure, and some of them have even enabled bedside devices to send information about vital signs. That enables caregivers to keep tabs on patients, wherever they may be in the hospital and by using cellular telephones, even when they’ve gone home at the end of the day.

The problem is that many new electronic devices can transmit alerts, but not every alert requires the immediate attention of a doctor or nurse.

“We are continuously improving our wireless infrastructure, to ensure that we can move all types of data off bedside monitors or other sources to handheld devices,” said Tyson Roffey, director of information services at CHEO. “But if you sent data about every problem, you’d be getting an alert every two seconds. What should really be noticed may be missed.”

On the other hand, some combinations of vital signs require prompt attention and can result in life or death situations. It’s these scenarios that ‘intelligent software’ can spot, sending immediate alarms to caregivers.

For example, a reduced oxygen level in a patient may not be low enough to sound an alert; in some cases, neither would a reduced heart rate. But when the two occur in combination, it’s important to alert caregivers immediately.

The project to create an intelligence engine for bedside monitor alerts was sparked by Dr. James King, medical director of informatics at CHEO. Dr. King received the go-ahead to develop the solution from his medical colleagues, who also saw the need for a more efficient alerting system.

The project team is expected to deliver a working model of the intelligence engine by the end of the summer. Personnel from Bell and the hospital are currently developing the system using core technology from webMethods, of Fairfax, Va.

John Anders, senior director of business development at the Bell Canada Centre for Healthcare Innovation, observed that the team is busy devising new algorithms, rules and predictive techniques for the software.

They’re also testing various handheld units, such as devices from RIM and Motorola, to see which technology will best fit the bill for receiving messages.

While the RIM units are sleek and portable, the hospital would also like to add new bedside drug management systems in the near future, such as barcode checking, and would ideally like a device with barcode capabilities. The Motorola units, for their part, have the advantage of containing barcode readers.

“Regardless of technology, you need to be sensitive to how many different types of devices you ask the clinical staff to carry” observed Roffey. Motorola has been producing lighter units, too, such as the Q, which the hospital will also test.

Once the intelligence engine is up and running, added Roffey, CHEO will likely employ it in other applications, thereby adding automated intelligence to other computerized processes in the hospital.

CHEO’s information technology department comprises some 30 persons. The hospital also has a research institute which develops solutions, such as de- identification software, which will be used in many projects to ensure that privacy is always maintained.

Roffey said CHEO accesses a wide range of additional resources through its relationship with the Bell Canada Centre for Healthcare Innovation, which he likened to ‘one-stop shopping’. Through the centre, Bell offers up its own research resources, as well as engineers, programmers, analysts and business experts.

“We’re working on a number of projects with Bell,” commented Roffey. For example, last November CHEO awarded Bell a contract for a voice-over-IP (VoIP) conversion system throughout the hospital.

VoIP enables organizations to run their phone and computers over the same network. By operating one network instead of two, they can reduce their costs over time; it also makes it easier to integrate information between telephones and computers.

On another front, CHEO is working with the Bell Canada Centre for Healthcare Innovation to develop a set of privacy tools, including a system for conducting privacy impact assessments (PIA) for all new IT projects in the hospital. Roffey noted this will result in a significant saving.

Once we start doing it ourselves, we’ll save that money and re-invest it in patient care,” commented Roffey.

Like the intelligence engine, the upcoming privacy tool set could be disseminated across the Champlain LHIN, thereby benefiting many other hospitals. “Many people wouldn’t naturally think of Bell as a provider of privacy systems, but they have many resources at their disposal,” said Roffey. “The Bell Centre gives us a single point of contact for a large set of resources.”

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Ontario’s ICUs feed data into a province-wide information system

By Patti Enright

TORONTO – Have you ever tried making a recipe without having a way of measuring your ingredients? A dash of this, a little of that and voila… your best ‘guess-timate’ of what the dish should look like.

Not even a year ago, the same analogy could have been used to describe Ontario’s delivery of critical care. While estimates suggested that critical care accounted for as much as 10 percent of acute care bed occupancy and 34 percent of some hospitals’ budgets, there was no set of ‘measuring cups’ to actually calculate, plan for and/or assess the true impact of the care.

This changed with the arrival of the province’s Critical Care Information System (CCIS). A comprehensive initiative designed to improve access, quality and system integration in the delivery of adult and paediatric critical care services, CCIS is a key component of Ontario’s Critical Care Strategy and a part of the overall Access To Care program.

Developed and implemented on behalf of the province by Shared Information Management Services (SIMS), a Toronto-based, 13-organization information management and technology partnership focusing on health system performance, CCIS collects data on intensive care patients, the resource allocation associated with their care and the interventions deployed to address care needs, including the deployment and utilization of Critical Care Response Teams.

A first for Canada, implementation of the system began in February 2007. By December 2007, 65 hospital organizations were reporting utilization data through the one system, capturing data from 100 percent of all Level 3 adult medical/surgical Intensive Care Unit (ICU) beds in Ontario. This accounts for 52 percent of the province’s total critical care beds.

“It’s difficult to manage a complex resource such as critical care without any data on how many resources we have and how they’re currently being utilized,” said Dr. Bernard Lawless, provincial lead, critical care and trauma, Ministry of Health and Long Term Care. “Now, for the first time, and leading the way in Canada, we are measuring in real time what resources are available to critical care and improving access and quality of care for patients.”

CCIS is a secure, web-based application that integrates patient information from the electronic registration systems of participating hospitals. ICU staff update the system with information on the life support interventions that each of their patients require for their care.

The system provides hospitals, Local Health Integration Networks (LHINs) and the province with aggregated reports to inform and improve both the planning for, and operation of critical care services.

With drop down menus, report users can “drill through” content to see increasing amounts of detail as needed (e.g., average age and gender distribution in ICU patients, patient movement or bed occupancy).

SIMS collaborated with the Ministry and other organizations to develop and implement the massive project. In less than one year, CCIS had gone from an initial concept to providing data every 12 hours on patients in ICUs. Data from CCIS can identify how hospitals are using ICU resources and determine resource deficiencies by tracking real-time utilization trends. In turn, the collected information allows for a better understanding of the province’s critical care capacity and assists in resource planning and implementation.

“Before the project began, we didn’t know how many critical care beds we had in Ontario – let alone who occupied them or how acute they were,” said Rachel Solomon, director, health system integrations, SIMS. “Now, knowing this information from as recently as half a day ago offers us invaluable information in the event of a surge, such as SARS.”

CCIS provides information to hospitals, LHINs and the government to support “systems-thinking” on the use of provincial critical care resources and how critical care is thought about, planned for and delivered as an 1,800 bed provincial resource.

Once fully implemented, the system will:

• Provide real-time resource utilization data, potentially saving lives by supporting efforts to get the right people, in the right beds, at the right time;

• Help improve access to critical care by combining CCIS information with data from CritiCall, Ontario’s existing critical care bed and resource registry;

• Reduce inefficiencies by helping healthcare organizations and the province work collaboratively to quickly identify and address inefficiencies in the system;

• Improve patient safety by allowing for ICU resource comparisons across the system, focusing coaching teams on areas requiring improvement;

• Provide key information for LHIN Critical Care Leaders as they work to ensure ICUs across LHINs are coordinated.

Earlier this year, the CCIS team kicked off the next phase of the project – this time working to capture information from all specialty ICUs in the province, such as pediatric, burn and cardio-vascular ICUs. An updated version of CCIS is also scheduled for release in 2008 with additional user-friendly enhancements and continued improvements to data quality.

As the system evolves, CCIS represents the most comprehensive database of information on critically ill patients and critical care units in the province.

“If a major medical crisis like SARS was to ever occur again, critical care staff would be able to know what’s happening and act more quickly to address any issues,” added Solomon.

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Quebec surgeon uses telementoring to teach laparoscopic skills

By Andy Shaw

When it comes to discussing telemedicine in Quebec, Dr. Richard Ratelle likes making small talk. Laparoscopic small, that is.

“We know from studies that right across Canada, not very much is taught in medical schools, nor in residency, about laparoscopic surgery. And, of course, older surgeons weren’t schooled in it at all. Yet, minimally invasive laparoscopic techniques are being used more and more, both in general surgery and in specialties,” says Dr. Ratelle. “Urologists and now gynecologists, for instance, are increasingly turning to laparoscopy; so we need to teach them how to use it properly.”

A colorectal and general surgeon at downtown Montreal’s Saint-Luc hospital, Dr. Ratelle has also addressed the need for dissemination of new techniques and has emerged as Quebec’s premier laparoscopic ‘telementor’.

“I began working about three years ago with Dr. (Mehran) Anvari, in Hamilton at McMaster University, who is perhaps the best known surgeon in Canada for his telemedicine work. Together, we developed this concept of telementoring,” explains Dr. Ratelle.

Responsible for the general surgical teaching program at the multi-hospital Centre Hospitalier de l’Université de Montréal (CHUM), Dr. Ratelle now shares his expertise province wide from his Saint-Luc office, via a Tandberg teleconferencing suite.

From the patient’s point of view, argues Dr. Ratelle, the benefits include:

• having access to specialized surgical care locally

• avoiding transport to a remote centre of surgical expertise

• remaining in contact with their local and known care givers

• experiencing less chance of a medical error because the local surgeon is being guided by an expert.

For the local general surgeon, Dr. Ratelle says expert-guided telementoring means he or she can now offer a sub-specialty that previously may not have been available in the community.

Also, that local surgeon can master new techniques in an optimal environment (i.e., in their own hospital and without leaving town or disrupting their normal practice.) There are benefits, too, at the other end of the system for the telementor: the convenience of simply returning to your office – as Dr. Ratelle does – to share your expertise makes good use of the specialist’s time; it keeps expert surgeons actively involved in spreading competence in their respective specialities; and in order to do that, they too don’t need to leave town.

Or at least not as often.

“A couple of times a month I still do go out and teach surgeons laparoscopic surgery first hand,” says Dr. Ratelle. “But even after you help a surgeon with five or six cases, it is still not enough for them to master the technique. So you need to keep teaching and mentoring them. Now, right from my desk here I can do that. I can in effect be with them right in the operating room, showing them where to go, and discussing what to do, but I don’t need
to travel. ”

What is travelling – and at light speed – are the images moving between Dr. Ratelle and a protégé surgeon in Chicoutimi, say, over Quebec’s healthcare backbone RTSS network.

“I may spend five hours with that surgeon during the operation, but what I don’t have to spend is the four hours to drive to Chicoutimi and the four hours to drive back,” says Dr. Ratelle.

Still, getting surgeons up to speed on laparoscopic methods requires some time. “It takes about 10 to 15 mentoring sessions with a surgeon before they have mastered their particular laparoscopic technique,” says Dr. Ratelle. “But once they have, they can mentor others.

“This way, I think we can raise the percentage of operations done laparoscopically throughout the province,” he says. “Right now in Quebec, only about 20 percent of colorectal operations are laparoscopic. I think we can get that up to 50 or 60 percent.”

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