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Inside the March 1999 print edition of
Canadian Healthcare Technology:

Feature Report: Electronic medical records

OR web site

Operating-room nurses at the Toronto Hospital have developed a unique intranet web site that could someday streamline OR practices worldwide. The site guides users through the set-ups for thousands of surgical procedures.


ADSL for radiology

Participants in a major pilot project in Manitoba will soon transmit medical images over regular phone lines using ADSL technology. The $5 million dollar, three-year project is a joint-venture partnership between the federal and Manitoba governments and a private sector consortium led by Kodak’s Cemax-Icon.


TeleMedisys Inc. is exploring ways distance monitoring can improve management of chronic diseases. The company recently announced plans to launch a pilot trial with cystic fibrosis patients in the Montreal area early in 1999.


Tech trends

Expect the Internet to soon bring us low-cost groupware. It’s a good thing, too, because traditional solutions like Lotus Notes/Domino, Microsoft Exchange Server, and Novell GroupWise remain complex, expensive, and somewhat out of reach of smaller organizations.

Region-wide EMR

Hospitals in Ottawa are testing a region-wide solution for sharing multi-media patient records. The Canadian-designed system provides a single point of access to patient information, regardless of whether it is stored as paper, electronic data, sound or video.


PLUS news stories, analysis, and features and more.


Toronto Hospital nurses develop web site
to run operating rooms more efficiently

By Andy Shaw

Three senior operating room nurses have developed a unique intranet web site at the Toronto Hospital that could someday streamline operating room practices worldwide. Dubbed the Peri Operative Nurses Virtual Reference Book, the site guides users through the set ups for thousands of surgical procedures.

With the exception of buying Microsoft’s web authoring FrontPage software, the Book has cost the hospital virtually nothing. And it is already saving surgeons a bundle of wasted time and aggravation.

“It really began three years ago with a conversation we had in the hallway,” recalls one of the enterprising threesome, Joyce Fleming. “We had these new PCs (that were used to record the events of every surgery) in each of our 21 operating rooms and we talked about what else we could load onto them.” Fleming is the nurse manager for the Operating Room of the Toronto Hospital’s General Division.

“At the time, we were having a difficulty with our surgical service in gynecology,” adds Betty Watt, another member of the web site troika. “Nurses coming onto the night shift weren’t always terribly familiar with the procedures. So we said let’s put them on the intranet so nurses can review them beforehand.” Watt is the nurse manager for the Operating Room’s post-operative care unit.

At that point, Daniel Ivorra, an Operating Room staff nurse, seized the initiative. Ivorra admits to having no real IT expertise before setting out. But over the next six months Ivorra spent most of his free time developing a template for the site. Starting with gynecology then moving on to his own area of cardiac surgery, Ivorra exhaustively categorized the set ups for all their procedures.

“The only way to make it manageable was to group them into categories,” says Ivorra in a still detectable, south of France accent. “They may go by different names, but a lot of procedures are virtually the same. So you find one that is the most representative and then build in links to the others.”

Now, when a cardiac nurse, for instance, goes online and finds an unfamiliar procedure, Ivorra’s template springs to the screen with 17 headings – Anatomy/Physiology, Room Set Up, Equipment for Anesthesia, Equipment for Surgery, Trays, Instruments & Drapes, Hold Items, Small Items, Drugs & Irrigation, Surgeon Preference, Count, Position, Prep, Draping, Drains & Dressing, Nursing/ Point of Care Considerations, Care of Equipment, and Procedure Description.

Under each heading, nurses can review the selected procedure’s every aspect, including the anatomy involved and a blow-by-blow description (written by a surgeon) from skin opening to skin closing. There are even assembly instructions and photos (taken by Ivorra with a digital camera and scanned in) for the surgical equipment needed. An uncertain nurse can find out the preferences of each surgeon who operates in that discipline – from the sutures and patient position they use to their correct glove size and preferred colour of gown.

“Now surgeons don’t have to waste time explaining over and over again what they want,” says Watt. “And neither the scrub nor the circulating nurses have to scurry around at the last minute getting things right.”

To see how popular the Reference Book would be with surgeons, Ivorra, Fleming and Watt staged a demonstration last June at an annual Toronto heart disease conference.
“Surgeons usually aren’t very interested in what nurses do, but we had about 95 percent of the attendees come see us,” reports Watt. “One Japanese surgeon was so impressed he wanted to take our demo computer home with him.”

He’d be even more impressed now. Fleming says six of Toronto’s 10 operating room services now have functioning templates and the remainder are in the works. When complete, more than 7600 surgical procedures will be available in the Reference Book.

“The toughest parts of this,” says Ivorra, “was to get the nurses thinking abstractly about their service so they could categorize their procedures.”

To aid their thinking, a nurse heads up each service’s development team and every nurse in each discipline writes up a portion of that discipline’s contribution.

“That breeds both camaraderie and healthy competition. And everybody takes ownership of it,” says Ivorra who alone controls the content of the site.

To measure just how much they value it, the Reference Book’s home page tallies up the daily hits with a counter. But even without statistical proof, others are impressed.

Says Bob McArthur, the hospital’s director of technology transfer and research business development, “These nurses have set a terrific example for us. They’ve applied the tools at their disposal to solve real world problems.”

And the real commercial world has noticed too.

“The number one operating room scheduler and documentation firm, as well as Johnson & Johnson, have talked to us about it,” reports Fleming.

But the three developers are determined not to let their software get out of their hands at least until the Toronto Hospital project is complete. “Once we’ve finished with our site, we want to extend it to the Princess Margaret and Toronto Western sites of the hospital. ”

Taken beyond the boundaries of the Toronto Hospital campuses, the Reference Book could be adapted to every other hospital and become a teaching tool for nurses world wide. But Ivorra, Fleming and Watt remain modest about their accomplishment.

“What we’ve developed is really nothing new,” says Ivorra. “Everyone knows what a web site is. It’s just what we are doing with it that’s different.”



TeleMedisys remote monitoring targets chronic disease management

By Dianne Craig

Following its recent launch of a remote cardiac-patient monitoring program, Telemedisys Inc. of Montreal is exploring ways that distance monitoring can improve management of chronic diseases. The company recently announced plans to launch a trial with cystic fibrosis patients in the Montreal area early in 1999.

“We’re moving into disease management,” says Stephen Maislin, president of TeleMedisys. “Chronic illness is the one area the healthcare system has difficulty in managing. People who have ongoing problems like that tend to drop through the loop.”

Much of this, he adds, is due to budget constraints that make it hard for physicians to do what they really want to do. Another important consideration for effective long-term disease management is patient compliance.

“One reason many disease management programs fail to deliver maximum utilization of healthcare systems and a better quality of life is because of low compliance with treatment protocols on the patient’s part,” says Maislin. “We aim to change this.”

TeleMedisys was established in 1995 with one clear objective: to find more “cost effective and higher access” methods of delivering healthcare.

For example, says Maislin, until recently, when physicians used TVs for conferencing purposes, it was always a link with other physicians. TeleMedisys focuses on improving the link between physicians and patients.

“We wanted to build a link between patients and healthcare professionals irrespective of where they (both) are,” says Maislin.

The goal of the company’s disease management and compliance programs is to optimize clinical outcomes, reduce costs and stress on the healthcare system, and to enhance patients’ quality of life.

Distance monitoring of chronic diseases offers several benefits, says Maislin, including greater mobility – since scientific data can be communicated from anywhere in the world.

It can increase the ‘comfort level’ – since it keeps remotely-based patients or healthcare professionals in touch with each other, reduces the costs travelling to and from hospitals, cost of frequent appointments, length of hospital stays, etc.

“We are going to be signing our first hospital for remote cardiac monitoring soon,” says Maislin. “It will drop the number of days a patient spends in hospital after an MI (myocardial infarction) by over four days.”

When asked why TeleMedisys has chosen cystic fibrosis for the pilot project, Maislin said there is a need for more attention to this serious disease. “If kids don’t live in the immediate area (close to the hospital) they don’t get the same quality of care. If they develop an infection, they have to make a trip to the hospital, incurring tremendous costs, such as overnight stays.

“For patients with chronic illnesses living farther from the hospital, the need for remote monitoring of their condition becomes even more apparent. “As the distance gets greater, so does the value of what we are trying to do,” says Maislin.

A CD player-sized spirometer, manufactured by Cardguard of Tel Aviv, Israel, that patients use to measure lung function is so small it can be carried anywhere.

When the patient blows into it, the spirometer calculates several values, and then compares those with both standard values and the patient’s own baseline values recorded at norm. “It deviates and indicates the patient’s condition according to the algorithms the physicians have developed. We relay information back to Ste-Justine (the Montreal children’s hospital).

It takes about two minutes of a doctor’s time, as opposed to the time a visit would take. It takes just 45 seconds for the patient to transmit values to us. And then about two or three minutes of conversation with a doctor or other health professional.”

Calls from patients participating in remote monitoring programs are received at the TeleMedisys call centre in Montreal. The centre is staffed by cardiac nurses, pulmonary therapists, nurses who specialize in endocrinology, and other medical staff with specialized backgrounds.

There are three to four nurses in the centre at one time and incoming calls are routed to the call-centre nurse best equipped to respond to that patient. Currently, the call centre’s computer equipment is being upgraded.

Maislin is overseeing a shift to large, industrial 16-slot PCs from the 8-slot systems they had before. “We’re doing this so they will be able to receive almost everything – every form of data that could come in,” says Maislin.

In some cases, the spirometer alone is sufficient for remote patient monitoring. Doctors have also expressed an interest, says Maislin, in having call-centre nurses be able to see some of those patients face-to-face for effective assessment of their condition.

For these patients, a camera the size of a box of Kleenex will be used for assessment in conjunction with the spirometer. The camera, made by Eight-by-Eight of Santa Clara, Calif., simply plugs into a patient’s phone and TV and provides two-way teleconferencing, so both physicians or other health professionals and patients can see and converse with each other in real time.

“We wanted to find a product that allows full lung function testing in the home. We also wanted to find a camera that would run over regular phone lines, so there would be no extra common costs (such as the need for extra bandwidth in ISDN lines).

Asked whether there are any ways to measure the effectiveness of the cystic fibrosis pilot project, Maislin said there are a number of outcomes analyses built into the project.

Participants in the pilot project will include children who spend more than 40 days a year in hospital and live more than 20 kilometres away from it. Fifty patients will participate. “We’ve asked for the most severe patients,” says Maislin.

The project, which is scheduled to begin early this year, will begin as soon as funding has been secured.

“We have a partnership with Ste-Justine children’s hospital in Montreal,” says Maislin. When the pilot project is completed it will be rolled into a regular program almost immediately.

“We are trying to be of assistance to the physician but also a benefit to the general public,” says Maislin. “It helps diminish complications and provides a convenient way for patients and health care professionals to check in with each other regularly.”

TeleMedisys also intends to develop programs for diabetes and kidney disease in the near future, says Maislin.

“It’s a simple concept. You don’t have to build something that does everything. We want it to enable you to go as mobile as possible, so you’re not tied to your home or your bed,” says Maislin.

Telemedisys will continue to develop new remote monitoring programs, with new capabilities, he adds. “We have many more technologies to incorporate into our system.



Integrated health networks will require patient record systems that mesh

By Andy Shaw

“..Canadians want better and faster care – improved quality, speed, affordability and appropriateness.”
— from a Maclean’s magazine Dec. 7, 1998 essay by Michael Decter on healthcare in the 2000 Millennium

Canadians began this twilight decade of the current millennium with some 900 independent hospitals at the cornerstones of their healthcare delivery system. But as the 1990s progressed, a mounting body of evidence showed that a good deal of care could be provided outside of the traditional hospital, and that it could be delivered there more efficiently and cost-effectively. As a result, predicts Toronto health consultant and writer Michael Decter, when the new millennium dawns next year we will see those 900-odd hospitals reduced and synthesized into 150 to 200 regional healthcare delivery systems.

If Decter is right, this new foundation will give us far fewer, more specialized hospitals better integrated via technology with community-care facilities, home-treatment services and disease-prevention programs. The hoped-for result is a streamlined healthcare system that not only costs the taxpayer substantially less but also sustains a healthier populace. In other words, the bet is regional integrated delivery systems will deliver a lot more bang for the healthcare buck.

But that’s not going to happen overnight. The developers of integrated healthcare systems have to clear several big hurdles first.

To appreciate these challenges, it’s worth looking at an integrated system’s two great advantages. First, it enables all its providers – acute care hospitals, community clinics, physicians in private practice, home-visiting nurses and pharmacies alike – to concentrate on what they do best. And it also enables patients to move seamlessly from one provider to another as their condition deteriorates or improves and thus receive the most cost-effective care.

But this efficient continuum requires providers to share information about patients securely, swiftly and cheaply. So the first challenge is to develop uniform medical records that can be electronically stored, retrieved and moved across the region readily. That, in turn, means healthcare institutions must make their individual computer systems all “talk” to each other. These are no small tasks.

Finally, and this is the really tough part judging from the early going, care providers in a region must agree on how their system will function and see clearly what the benefits to them and their patients will be – if the system is even to get off the ground.

That’s why Ken Lawless was surprised. Lawless is executive director of the Ottawa Life Sciences Council (OLSC). It is the facilitator for one of the country’s most vigorous and sophisticated efforts at developing a regional healthcare system.

“Right from the outset of our project just over 18 months ago, I was surprised by how all our partners pretty well had a common vision of what it would look like and what the benefits would be,” said Lawless in a recent interview.

The OLSC is the co-ordinating body for the Ottawa Community Health Information Partnership, OCHIP for short. OCHIP is a consortium of 20 healthcare providers and organizations including the Ottawa Hospital, the University of Ottawa Heart Institute and several private sector suppliers. Currently funded by the Ottawa regional government, OCHIP is charged with revamping the Ottawa-Carleton Region’s healthcare delivery system. By next year, Lawless expects OCHIP to become a self-sustaining not-for profit corporation.

But OCHIP began as a regional project in April of 1997 on the heels of an Ontario government healthcare restructuring report. The report noted that Ottawa hospitals had made a significant investment in technology, but that it was not well integrated across the region. Formally, OCHIP’s consequent aim is to provide the Ottawa area with “a secure integrated regional electronic patient information system that links providers, educators and researchers throughout the Region’s system.”

Informally, OCHIP states its common vision much more eloquently and memorably on an OLSC web site ( page entitled “Imagine”. It is an ideal every regional health system might well strive for and reads:

Mr. Jones is 45 years old, a successful businessman in the prime of his life. He has just eaten lunch and is walking along in a local shopping mall and develops heaviness in his chest and thinks he has indigestion. He stops at the drug store for some antacid.

He speaks to the pharmacist who hears his complaints. Mr. Jones is starting to feel disoriented. The pharmacist, with Mr. Jones’ permission, retrieves his electronic record to discover that he is a known heart patient.

The pharmacist directs him to go to the urgent care clinic, which is in the mall and alerts the clinic electronically that Mr. Jones is coming. Jones allows the clinic nurse to access his regional electronic chart and his primary care physician’s charted notes. The nurse discovers that Mr. Jones is a known high-risk patient with a past history of coronary disease and refers him immediately to the clinic physician who orders an electronic ECG to discover evolving changes of a heart attack.

Through the facility of video teleconferencing, the physician reaches the cardiologist on call who reviews the findings and the new ECG, which is available to him over the network. He agrees with the diagnosis, orders the transfer and arranges for the angiographic suite to be prepared to receive Mr. Jones directly. Mr. Jones is transported directly to the Heart Institute angiographic suite where he is assessed and is shown to have an acute occlusion of his left anterior descending coronary artery which is successfully opened with a newly developed thrombolytic agent undergoing clinical trial.

Mr Jones’ symptoms are relieved, he undergoes angioplasty and stenting the next day and he is discharged from hospital after 2 days. Prior to discharge, Mr. Jones and his family participated in a comprehensive coronary education program. His family physician and home care providers are notified electronically of the admission and follow-up arrangements.

The time from the onset of Mr Jones’s symptoms to the diagnosis in the community clinic was 30 minutes. The time from onset of symptoms to definitive therapy was 90 minutes.

A few days later, Mr. Jones’s primary care physician reviews Mr. Jones’s lab, ECG, and cardiology notes in the patient’s electronic record. Mr. Jones recounts the benefits of his experiences:

• prevention of life threatening heart damage
• reduced length of stay in hospital
• faster recovery
• faster scheduling
• avoidance of costly duplication of tests and traumatic surgery
• efficient use of community based health care resources across the continuum from the pharmacist to the home care provider
• elimination of delay due to multiple assessments at different facilities which could have delayed his ultimate treatment at the Heart Institute if his history had not been retrievable

The Institute’s Utilization Management Committee reviewed the costs associated with this episode of care as part of an ongoing study to increase efficiency and reduce costs. The data was also made available to the clinical epidemiologists for their study of cardiac care clinical outcomes.

“Our partners in OCHIP are all anxious to see this happen here,” says Lawless who adds that the partners are equally realistic about how to make it happen. They’re doing it one step at a time.

“One of the first things we did was to bring in a consultant group that had experience establishing similar systems elsewhere,” explains Lawless. “It was an American firm, the First Consulting Group. It had helped set up 17 systems in the United States. And they recommended we not try to do it all at once but take a modular approach.”

OCHIP’s first operational module was the Integrated Clinical Information System (ICIS) announced last fall and currently being used and evaluated by the Women’s Breast Health Centre on the Civic Campus of the Ottawa Hospital. ICIS allows large volumes of patient records and diagnostic information to be stored, accessed and viewed securely by healthcare providers across multiple sites. Partners in ICIS include JetForm Corp., Newbridge Networks, and Oracle Corp.

But at the heart of ICIS is Canadian-designed software from another partner, Mainsource (formerly PARJplus) Software Corp. of Ottawa. Its Multimedia Clinical Document Management System (MCDMS) provides a single point of access to patient information regardless of whether it is stored as paper, electronic data, sound or video.

MCDMS is an electronic repository that can store an unlimited number of medical records and deliver them within hospitals and beyond to outside clinics, doctors’ offices and even eventually to homes. The repository and system at work in the Women’s Breast Health Centre handles patients’ scanned bar-coded charts, lab results, transcriptions and discharge summaries.

Integrated with the Ottawa Hospital Civic Campus diagnostic and hospital information systems, the MCDMS-driven ICIS will also soon be able to store, retrieve and convey voice notes, graphics, x-ray, MRI and other images as well as short video clips connected with a patient’s record. (A similar system is also operational across town at the National Defence Medical Centre, although the two are not yet linked.)

To make this work, the MCDMS sits on a hardware configuration of a Digital Alpha server 4100, a StorageWorks Raid array and a Digital optical jukebox. A Mainsource desktop program integrates the software combination of JetForm’s electronic forms and an Oracle database.

“The JetForm software generates the form. It is then filled in, printed, bar-coded and scanned back into the system,” explains Paul Duff, vice president of sales and marketing for Mainsource. “Then we use Oracle as a tool to figure out where that form and all other data we enter should be stored in the repository.”

When clinicians retrieve data from the Health Centre’s repository, the records travel along the hospital’s Newbridge ATM local and wide area networks to 15 workstations at the Civic Campus. “Eventually users will be able to access the repository from some 300 workstations spread across all three Civic, General and Riverside campuses of the Ottawa Hospital,” says Ray Berringer, district manager for Newbridge.

“When they are at that stage, they’ll be ready to use InTempo, our workflow tool,” says Pam Ferenbach, an account executive with JetForm. “That means users will not only be able to store and retrieve them, but actually be able to move patient forms around for approval or digital signature.”

Elsewhere, other regions are taking different approaches. In Winnipeg, for example, Jim Kerr, divisional director for Communications and Information Services with the Health Sciences Centre, reports that the regional Winnipeg Health Authority is joining up a dozen or more of its providers into a regional system.

But even though its eventual goal too is rapid and secure distribution of patient information, Winnipeg’s initial focus will be on the other end of the integrated healthcare spectrum – analysis of outcomes.

“We’re developing a universal database or repository and giving users an Oracle tool-set to tap into it,” explains Kerr. “They can learn how to use the tool-sets within an hour and can start designing their own datamart right after that. The datamarts allow users to query the repository for information that’s specific to their interests. So if someone at the Health Ministry, for example, wants to find out or keep tabs on, say, how many women between the ages of 25 and 40 were treated for the flu this winter, they can.

“Such custom reports were possible to create in the past, but to generate them, that might take our Health Sciences information system up to three months. With our new set-up, users themselves can generate the reports in three minutes. So we’re starting out by first solving that old conundrum about technology leaving you information rich and knowledge poor.”

In another variant on regional system development, Ontario’s HealthLink is taking a different tack. Originally a provincial government-funded project to link seven Toronto area hospitals, it was forced early on to solve another challenge to developing regional healthcare delivery systems. What to do when start-up government dollars dry up? Unlike its counterparts in Ottawa and Winnipeg,

HealthLink receives no funding from a regional authority. So it has turned its own expertise into a self-sustaining moneymaker. Unlike OCHIP, for example, HealthLink sells consulting and implementation services to hospitals wanting to set up their own internal information systems as a prelude to interfacing externally with a wider network.