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Inside the May 2003 print edition of Canadian
Healthcare
Technology:
Feature Report: Developments in surgical systems
 Lack of attention
to human factors imperils IT projects, survey says
Computerized solutions may not be used to
best advantage – or used at all – unless the hardware
and software are supported by people who can assist with training,
troubleshooting and process change.
Ontario’s first private-sector PET imaging clinic open
for business
A pair of enterprising experts in Positron
Emission Tomography (PET), in partnership with two other businessmen,
have invested nearly $5 million to open Ontario’s first
private-sector molecular imaging center.
Ottawa beefs up health IT
The federal government’s latest budget,
announced in February, contains several measures that will have
a dramatic impact on healthcare IT in Canada. One example: new
spending on radiology equipment includes PACS purchases.
New emphasis on security
As patient records become increasingly computerized,
hospitals and other medical centres have been widening the scope
of security measures for IT, such as conducting random sweeps
for problems.
Physician IT group
Growing interest in computerized solutions
on the part of physicians has led to the creation of a user’s
group for doctors in Richmond, B.C. It has already attracted
48 participants – 20 percent of the local physicians.
Leading-edge fluoroscopy
The London Health Sciences Centre has installed
a new fluoroscopy system that offers greater image detail than
previous machines. It will be used for diagnostics and interventional
radiology, enabling radiologists to guide catheters and instruments
with greater precision.
PLUS news stories, analysis, and features and more.
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Lack of attention to human factors imperils IT projects
By Jerry Zeidenberg
It’s important to have up-to-date equipment
when implementing hospital IT projects. But the computerized
solutions may not be used to best advantage – or used at
all – unless the hardware and software are supported by
people who can assist with training, troubleshooting and process
change.
Alarmingly, nearly a third of Canadian hospital IT directors
doubt whether their facilities have the necessary human resources
– namely training, support and change management –
to successfully implement new Electronic Patient Records projects,
according to a new survey.
Hospital IT directors are even more skeptical of their chances
for success when installing other electronic systems, such as
Computerized Physician Order Entry (CPOE), OR scheduling, OR
charting and new ADT applications. Again, they cite a dearth
of skilled support staff.
The study, organized by Canadian Healthcare Technology magazine,
found that hospitals are planning extensive investments in a
wide variety of computerized solutions over the next 12 months.
But as IT directors indicated they don’t have the training,
maintenance or change management resources needed for a successful
implementation, the report concludes that many of the projects
are likely to fail.
Significantly, it’s the human factors involved in technological
change that are the sore spots, not the computer hardware or
software itself.
In this light, it’s important to note that while many healthcare
organizations have been calling for greater funding of hospital
IT, with a focus on the technology, CIOs actually directing the
work say they require greater investments in people and management
processes to improve the chances of success and to obtain the
much-heralded benefits of electronic solutions.
For example, 30 percent or more of the CIOs said they didn’t
have enough IT maintenance and support for a successful implementation
of new projects for electronic patient records, OR scheduling,
emergency room, ADT, OR charting or computerized physician order
entry (CPOE) systems.
Similarly, 30 percent or more said they didn’t have adequate
IT training resources for successful installations of electronic
patient records, OR scheduling, staff scheduling, ADT, CPOE and
OR charting systems.
Nevertheless, hospitals are planning significant investments
in computerized systems. In each of 14 different application
areas examined by the study, 40 percent or more of the hospitals
are planning to upgrade their systems in the next 12 months.
The findings of the study, titled The 2003 Report on Canadian
Hospital IT: Top Issues, Applications and Vendors, has important
implications for hospitals wishing to modernize their operations
with a new generation of computerized solutions.
Moreover, there are repercussions for organizations like the
Canada Health Infoway, which was established to spur the creation
of electronic health records in hospitals and other healthcare
facilities across the country.
As indicated by the cross-Canada poll of hospital CIOs, all organizations
investing in IT to improve medical outcomes and raise productivity
would be well served by recognizing the key importance of issues
such as training, support and change management to information
technology projects.
The survey portion of The 2003 Report on Canadian Hospital IT
was conducted over a six-week period from the end of November
2002 to the first week of January 2003. Canadian Healthcare Technology
and Arrowsmith Research Co. polled 339 hospital CIOs across Canada
using e-mail and a secure web site, and received confidential
responses from 109 – a 32 percent response rate. The questions
were developed through a series of pre-survey discussions with
hospital IT directors about the major issues confronting them
as they implemented electronic solutions in their organizations.
The study was led by Richard Irving, PhD, an associate professor
at the Schulich School of Business, York University, in Toronto;
Gordon Atherley, MD; and the editors of Canadian Healthcare Technology
magazine.
Perhaps for the first time in Canada, the survey identified the
leading I.T. vendors in 14 of the top electronic applications
used in hospitals. Hospital CIOs were asked which vendor is
their main supplier for the following applications:
• Electronic Patient Records;
• Admission, Discharge and Transfer (ADT);
• Staff scheduling;
• Picture Archiving and Communication Systems (PACS);
• Radiological Information Systems;
• Finance/Accounting;
• Materials management;
• Pharmacy
• Laboratory
• Emergency Department;
• Operating Room scheduling;
• Operating Room charting;
• Computerized Physician Order Entry;
• Integration Engines.
The study found that not only have Canadian hospitals begun to
implement electronic patient records, but they also appear to
be on the cusp of a major effort to significantly increase their
investments in this area.
Of the 109 hospital CIOs who responded to the survey, 28 percent
said their hospitals have implemented an electronic patient record
in some form.
Despite complaints of chronic under-funding of IT in the hospital
sector, hospital CIOs are planning a significant amount of activity
in this area. Organizations that already possess electronic systems
are, in many cases, intending to upgrade their modules using
the same vendor.
A relatively high proportion of the hospitals with electronic
systems are planning to switch to different vendors. In particular,
those with pharmacy, RIS, asset management, ADT, materials management
and OR scheduling show the greatest incidence of migrating the
application to a different supplier.
The 2003 Report on Canadian Hospital IT: Top Issues, Applications
and Vendors, is marketed by Canadian Healthcare Technology magazine.
Single, printed copies of the report are available in June at
a cost of $495, while an electronic version that can be shared
within an organization is available at a cost of $1,995. Details
are available
here.
Ontario’s first private-sector PET imaging clinic open
for business
By Jerry Zeidenberg
MISSISSAUGA, ONT. – A pair of enterprising
experts in Positron Emission Tomography (PET), in partnership
with two other businessmen, have invested nearly $5 million to
open Ontario’s first private-sector molecular imaging center.
The facility is part of a clinical trial backed by Health Canada.
And while they’re charging members of the public $2,500
for each study, the new CareImaging clinic in Mississauga is
designed to run on a break-even model and not at a profit. Indeed,
to qualify as a Health Canada trial, it must operate on a non-profit
basis. By comparison, if Ontario citizens were to seek PET scans
in the United States, they would pay US$3,000 to US$4,000 for
the tests.
The goal, explained Dr. Nek Manji, vice president of technology
and research at CareImaging, is to collect the clinical data
that’s needed by governments in Ontario and other provinces
before they endorse the technology and start reimbursing hospitals
and clinics for PET scanning services.
“They want more evidence of the effectiveness of PET,”
said Dr. Manji, who has a PhD in medical physics. “Our goal
is to collect the data that will allow them to make a decision.
“We also believe in this technology, and we think that we
can make an impact on the lives of people in Ontario.”
According to Dr. Manji, there are an estimated 25,000 people
in Ontario that could benefit from a PET scan. The technology,
which was invented in the United States about 15 years ago, has
shown impressive results in the early detection of cancer and
Alzheimer’s disease, along with many other medical conditions.
Nevertheless, Canada’s publicly funded healthcare providers
have been slow to adopt the technology. While there are some
400 PET scanners now operating in the United States, there are
only about a dozen in Canada and most of those are purely for
research purposes, not for diagnosing diseases in ailing patients.
Unlike MRI and CT scans, which show details of the structure
of bones, organs and other tissues in the body, PET scanners
identify changes in metabolism in the various parts of the body.
By showing abnormal biochemistry in this way, the technology
can effectively spot cancers, heart disease, and other conditions.
Often, PET scanners can do this much earlier than MRI and CT
scans.
A PET study is performed by injecting the patient with a tracer
that’s composed of a radioactive isotope attached to glucose.
Once in the body, the glucose is absorbed at different rates
by various types of tissue. For example, a malignancy will absorb
the tracer at up to three times the rate of normal tissue.
This concentration of radioactivity is picked up by the PET scanner,
and shows up on the computerized image as a ‘hot spot’.
Dr. Manji explained that the CareImaging clinic will start using
PET for the treatment of breast cancer, lymphoma, melanoma, colorectal,
lung, prostate cancer, and will eventually add other cancers,
along with Alzheimer’s disease and cardiac viability, as
PET can also detect defects in the heart muscle.
Patients must be referred to the centre by a physician.
On a tour of the facility, Dr. Manji explained that the 7,000
square-foot building was built specifically for the needs of
radioactive PET imaging, and the walls of the clinical portion
of the structure contain a 1-1/2-inch lead lining.
There are special precautions taken to ensure against radiation
poisoning, including negative pressure ventilation systems and
regular sweeps for radioactivity. As well, technologists and
physicians working with radioactive tracers use a variety of
lead shields to protect themselves.
Dr. Manji noted that the FDG tracer used for the scanning has
a half-life of two hours, which means the process of conducting
a study is on a tight schedule. “Timing is crucial,”
he said. “From the time we receive the (tracer) package,
to the time the patient is on the table, we’ve got the logistics
down to five minutes (for each step).”
Once injected, the patient waits approximately one hour for the
tracer to fully make its way through the body. He or she is then
placed in the full-body scanner; a complete study takes about
half an hour.
CareImaging obtained the PET scanner from CPS Innovations of
Knoxville, Tenn. According to Dr. Manji, it is the most advanced
PET machine in Canada, as it uses a new LSO detector technology
that produces a much improved image quality. It also scans 50
percent faster than previous PET machines.
Dr. Manji and his colleague, Dr. Robert Stodilka, chief scientist,
lead the CareImaging team as they conduct the studies and acquire
the images. Interpretation of the PET images is performed by
medical doctors who are trained in reading PET studies.
The centre has an empty room, which in the future will house
a combined PET/CT machine. Dr. Manji noted that this ‘fusion’
technology is especially good for imaging the head and neck,
which have a complex anatomy. The combination of structural and
metabolic information that’s collected in this way is extremely
useful for surgical planning, among other things. “If you
can fuse the two, you have the best information possible,”
said Dr. Manji.
2003 Federal Budget beefs up spending on healthcare technologies
By Andy Shaw
The federal
government is getting an “A” for effort, so far, for
the healthy healthcare technology commitments it made in its
2003 Budget. Finance Minister John Manley unveiled significant
funding for five major healthcare technology-related initiatives.
Together, they signal a new understanding at the highest government
levels of the importance and urgency of using information technology
and data gathering to speed the reform of Canadian healthcare.
Among the funds Manley allocated were:
• $1.5 billion of new funding for diagnostic imaging equipment
(as part of a larger budget for all forms of new medical equipment);
• $600 million more for the pan-Canadian electronic health
record now under development by Canada Health Infoway;
• $45 million spread over five years for the Canadian Coordinating
Office for Health Technology Assessment (CCOHTA);
• $50 million over five years for the creation and administration
of a new Patient Safety Institute;
• and money for a new national Health Council to monitor
outcomes of medical procedures. While in and of itself not a
technology initiative, the Health Council will need to avail
itself of sophisticated information and communication technologies
to collect, monitor and analyze the performance of Canada’s
healthcare providers.
Since the new funds were announced, the affected agencies have
been beavering away developing processes, if not yet detailed
plans, for spending the money. By June, Health Canada, CCOHTA,
and Infoway will all have tabled various action steps for themselves
and their stakeholders. All this effort is imbued with a new
sense of purpose stemming from the historic federal-provincial-territorial
(FPT) healthcare reform agreement (officially the 2003 First
Ministers’ Accord On Health Care Renewal) reached in Toronto
on February 5.
“The Accord is founded on three pillars that all have implications
for technology,” says Meena Ballantyne, Health Canada’s
director general for the Health Care Strategies and Policy Directorate.
“One is timely access, the second is improved quality of
care, the third is long-term sustainability. And it’s hard
to see how you can achieve any of those three without using technology.
Technology is key to healthcare reform.”
There is in effect, adds Ballantyne, a fourth pillar with information
technology implications. “There’s much more accountability
built into this accord than previous ones. Specifically, there’s
going to be much more reporting to the public, so that people
can see their money is buying change; that it’s not going
to be an infusion of billions of dollars that when spent, leaves
people with the same problems.”
While encouraged by this new emphasis on accountability, Normand
Laberge warns, “I’m not turning in my private investigator’s
badge yet.”
Laberge is the CEO of the Canadian Association of Radiologists
(CAR), whose intensive investigations into what was the decrepit
state of digital imaging equipment in Canada and consequent lobbying
of the federal government has had more than a little to do with
both the size and nature of the funds allotted by Manley to imaging
upgrades.
“In the last Budget, there was half a billion dollars given
to the provinces for new diagnostic imaging equipment, but what
we found out subsequently was that much of it went for anything
but diagnostic imaging, because there were no controls on the
money. The provinces were spending it as they saw fit, including
on things like lawn mowers.”
For the 2003 budget, Health Canada consulted CAR and Laberge,
but still could not manage to achieve the direct accountability
both would have liked.
“In order to satisfy the provinces, Parliament passed a
special bill so that all the money for diagnostic imaging could
be placed in a trust fund,” explains Laberge. “That
means the provinces can draw down on the fund whenever they want
it and do not have to wait for the federal government to dole
it out over a number of years. So the provinces are happy. It
still means, however, that they do not have to submit any bills.
Instead, they’ve agreed to a process of benchmarking that
we at CAR will help carry out. We’ll see if there is an
improvement in the nature and amount of diagnostic equipment
available after they have spent the funds.”
Laberge says that’s a better arrangement than before, but
it is after-the-fact-accountability that does not necessarily
preclude the provinces from buying something unintended with
the money. “When you give provinces money with only after-the-fact
accountability, you still have to worry like when you give kids
lunch money that they don’t go out and buy a pack of cigarettes
with it.”
Laberge says he was so concerned about the misuse of diagnostic
imaging funds, he got himself accredited as a journalist for
the February 5 announcement of the Accord – just so he could
ask a pointed question.
“I asked them the lawn mower question, “ admits Laberge.
Among the more satisfying answers Laberge got at the conference
was the good news that purchases of picture archiving and communications
systems (PACS) are permissible. They were excluded before.
Another bright spot, says Laberge, stemmed from the joint FPT
commitment to making diagnostic services available to at least
50 percent of all Canadians around the clock.
“Of course, we don’t have the resources to do that
in every community in Canada,” says Laberge. “So they’ve
figured out that means we also need to be spending money on teleradiology.
And you need PACS to make teleradiology work. Also, more money
for a comprehensive electronic health record (EHR) has been made
available. And you need PACS to help make up a complete EHR.
So it all fits.”
Laberge concludes that with the 2003 Budget, at least the “the
table is set” for improving the diagnostic imaging regime
in Canada. It remains to be seen, of course, how well the provinces
know how to eat. So CAR and Laberge are not taking any chances.
“We’re going out pro-actively this time and working
with provincial associations like we are now in Newfoundland,
for example,” says Laberge. “We’re making sure,
that in the upcoming meetings we have with the Newfoundland provincial
minister of health, that the minister understands the implications
of the measurements we will be taking. We’re letting provinces
know now that we have photo radars up and working across the
country checking on their progress. So we think the provinces
will be less inclined to buy more lawn mowers.”
For it’s part, CCOHTA will be using its new funds to buy
a lot more high technology assessment (HTA) and to develop more
extensive relationships with its members.
CCOHTA, established in 1989 as a private, not-for-profit research
organization, gathers unbiased evidence on the cost-effectiveness
of new technologies and encourages their appropriate use by healthcare
providers. It reaches those providers through the 14 deputy ministers
of health representing all Canadian provinces and territories
who constitute its board of directors and who are CCOHTA’s
“members”. CCOHTA also maintains links with similar
international associations to watch for best practices elsewhere.
“The new funds came along just when we were re-examining
our five-year business plan,” says Dr. Jill Sanders, CCOHTA’s
president, who previously managed missions and technology for
the Canadian Space Agency. “So we metamorphosed the new
money with the old and we will present a new plan to our members
near the end of May.”
Those members will be considering how CCOHTA will spend $9.3
million this fiscal year on HTA, bumped up from its original
budget of $4.3 million by the new federal funds. Similarly next
year, CCOHTA’s budget for HTA has shot up to $14.3 million.
One topic CCOHTA is likely to be asked about is telehealth. It’s
already a new priority with Infoway.
“What the federal budget recognizes, in effect, is that
the electronic health record is a fundamental part of our healthcare
reform and that you can’t make effective use of an EHR in
widespread country like ours unless you have telehealth,”
says
Philip van Leeuwen, vice president of communications for Infoway.
“So we will be giving telehealth new emphasis in what we
are already doing with the EHR.
“We will be pragmatic about it and do an assessment of the
state of telehealth in Canada. Also, by June, we will have developed
a business plan for telehealth and have it integrated into our
consultative process.”
Like Laberge and Sanders, van Leeuwen has praise for the federal
funding initiatives. “They are recognition that if we’re
going to improve our primary care, we need to modernize the flow
of healthcare information,” he says.
Better flow of better information is also what the new Patient
Safety Institute and Health Council are all about, according
to Health Canada’s Ballantyne. She says both are manifestations
of the Accord agreement to let the public know whether it’s
getting better healthcare or just more hospital lawn mowers.
Both buttress the Accord’s pillar of improved quality of
care.
The Health Council will grow from the working group and be the
monitor of the healthcare reform initiatives launched by the
Accord. Its exact structure and governance is to be determined.
However, the Patient Safety Institute, already has the ground
paved for it.
Leading up to the Accord, a FPT-backed Steering Committee on
Patient Safety developed an exhaustive report on indicators of
medical error and the barriers to better patient safety in Canada.
In its work, the committee drew on the experience of 26 domestic
healthcare organizations, as well as already established patient
safety institutes in Australia, the United Kingdom, and the United
States.
“It will take a little time to work out the structure of
the Patient Safety Institute. But we know now that it should
operate at arms length and should involve all the stakeholders,”
says Ballantyne. “We’re looking at the models in other
countries, but you can be sure it will be very much based on
the 19 recommendations of our own Steering Committee.”
Creating a community of practice: the Richmond Physicians’
IT User Group
By Alan Brookstone, MD
Despite the low level of current usage of
technology in their clinical practices, physicians tend to be
very receptive to tools that help them provide better care or
demonstrate true improvements in efficiency.
This is reflected in the number of physicians now carrying PDAs
as decision support tools, loaded with clinical software such
as ePocrates or the 5-Minute Clinical Consult.
For many other tools, there is still an extremely large Value-Gap
that has to be overcome. In other words, it is still very difficult
for the end-user to clearly see the benefits of a significant
investment of time and money in advanced technologies such as
Electronic Health Records.
This is complicated by the fact that many of the products are
only partial solutions to very complex problems, and do not interface
with enough sources of information to make the value-proposition
clearly evident.
In September 2002, in conjunction with a group of physicians
in Richmond, B.C., we formed the Richmond Physicians’ IT
User Group. The objective was to create a meeting environment
where physicians in our community could meet on an intermittent
basis to share information and learn about the use of technology.
The group is not restricted to computer-savvy physicians, but
is open to all doctors. The aim is to utilize local expertise
as a resource for other physicians who wish to become greater
users of technology in the future.
The first meeting was held at my office in November 2002 and
was attended by 14 physicians. It was a first opportunity to
meet as a group and discuss our needs as community-based physicians
in terms of the use of IT specific to our hospital and location
of practice.
Currently the IT User Group numbers 48 physicians – approximately
20 percent of the physicians in our community. It’s exciting
to see that the numbers are growing steadily as more physicians
become aware of the group.
An important component of the Canada Health Infoway strategy
(www.canadahealthinfoway.ca) is to encourage and support the development
of ‘Communities of Practice’ amongst end-users of technology
in order to create a more receptive environment for the adoption
of electronic health record systems across Canada. The objective
of the Canada Health Infoway is to facilitate the creation of
IT-focused communities, such as the Richmond Physician’s
IT User Group, and then provide electronic support tools via
an Internet portal to support Communities of Practice.
In March 2003, Canada Health Infoway attended and facilitated
a meeting of the Richmond Physicians’ IT User Group in Vancouver.
The objective of the meeting was to assist the IT User Group
in defining a structure that would be sustainable in the future,
and to clearly define objectives and action items for 2003.
The meeting was facilitated by Monique Lafreniere, VP Change
Management; Mariana Catz, VP, Knowledge Management and Jennifer
Bayne, Director of Content Management for Canada Health Infoway.
Jennifer will be heading up the Communities of Practice Initiative
on behalf of Canada Health Infoway.
Together, we were able to define objectives for the coming year.
Our two immediate priorities are to increase the use of voice
recognition software within our community and to investigate
ways to cost-effectively increase high-speed Internet access.
These two areas were chosen because they are regarded as extremely
useful to working physicians, and they’re projects that
could demonstrate quick results. We already have specialists
using voice recognition in our community, and these physicians
are able to transfer their knowledge to the rest of the group.
Moreover, there is interest in creating high-speed connections
among physicians, along with wireless networks. Once these systems
are in place, the value of exchanging various types of medical
data could be quickly demonstrated.
We realize that this is just the start of a long process, one
that will be a continuous process of change. However, we have
started and it feels good to be actually doing something as a
community of physicians.
Alan Brookstone, MD, is a practicing physician
based in Richmond, B.C. He is also a consultant and conference
speaker on the use of clinical information systems in the delivery
of healthcare.
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