Hospitals produce order sets quickly, using web

By Jerry Zeidenberg

TORONTO – Open Source Order Sets (OSOS), a web-based resource for quickly producing and sharing high-quality order sets, is catching on with Canadian hospitals from coast-to-coast.

The brainchild of an innovative physician and nurse practitioner at Trillium Health Centre, it appears that OSOS is in take-off mode – largely because it enables hospitals to create order sets rapidly and at lower cost than on their own.

“We’re providing an ecosystem for the development of order sets,” said Dr. Christopher O’Connor, a critical care physician at Trillium Health who has been working on order sets for nine years. Dr. O’Connor, who is also the director of medical informatics at the hospital, launched the collaborative web site in 2006 with nurse practitioner Kathy De Caire.

Since then, over 80 hospitals in four provinces have joined the network.

“Everyone on the network can see everyone else’s order sets,” noted Dr. O’Connor. Member hospitals can use the order sets developed by OSOS, along with those produced by other organizations as they develop their own order sets – effectively reducing their costs and speeding up development. “It prevents them from re-inventing the wheel,” he commented.

Dr. O’Connor estimates the cost of producing an order set from scratch, without the help of other organizations, at $15,000 to $60,000, as the exercise requires the time and effort of physicians and other professionals. By utilizing order sets developed by others, a great deal of time, effort, and resources are saved.

Kathy De Caire estimates it can take a hospital, working on its own, nine months to a year to develop a single order set. But there’s an extraordinary change when they work with OSOS.

“We have members who’ve gone to our master repository order sets and after making small changes, they’ve been able to approve and start using them within a week.”

It’s a quick way for a hospital or health region to enter the world of order sets. “We’ve had situations where members have started with no order sets,” said De Caire. Through OSOS, they obtained what they needed and were up-and-running in a few weeks.

Usually, the only delays are matters of fine-tuning, she said, such as customizing the medications to adhere to the local formularies.

OSOS has attracted member hospitals from across the country, mostly by word of mouth. The province of Prince Edward Island and its eight hospitals signed on earlier this year. Another Maritime member is the Atlantic Health Sciences Corporation, the largest group of hospitals and medical centres in New Brunswick.

Meanwhile, on the West Coast, Vancouver Island Health Authority has been using the service for over a year.

Numerous hospitals in Ontario have become members since the inception of OSOS in 2006 – including the Central East Local Health Integration Network (LHIN), of which the 800-bed Scarborough Hospital is a part. Trillium Health Centre, a two-hospital organization with facilities in Toronto and Mississauga, Ont., is also on board – after all, it’s the place where Dr. O’Connor and De Caire first began the concept of online order sets. What’s more, in December 2008 OSOS gained its first U.S. member, the Wayne Memorial Hospital, in Honesdale, Pennsylvania.

Order sets have become hot commodities in hospitals across North America. In the wake of studies showing a high incidence of deaths and injuries due to preventable medical error, hospitals are scrambling to improve outcomes and order sets have been shown to dramatically enhance the quality of patient care.

In a nutshell, order sets consolidate the best practices and procedures for treating medical problems – from pneumonia to pre- and post-op treatments for hip fractures, and hundreds of others. They act as decision-support tools, guiding doctors as they treat patients with myriad problems each day, ensuring the right steps are taken and that important procedures are not forgotten.

The challenge for physicians, of course, is that there are countless medical problems and knowledge about them is skyrocketing. “If you try to keep all of this inside your head, you’ll never remember,” commented Dr. O’Connor.

That’s why a printed order document, using the best current practices – based on evidence in literature and clinical experience – can be of immense aid to the working physician.

Dr. O’Connor stressed, however, that order sets do not force the physician to follow set procedures. “It’s not cook-book medicine,” he said, “where the physician is simply following the recipe.” An order set will typically provide 80 percent or more of the treatments that a patient will require. It is expected that the physician, for the other 20 percent, will need to adapt to the individual needs of the patient and his or her disease and modify the treatment accordingly. He will then need to draw on his own background and experience, along with the expertise of colleagues.

It has been found that most physicians are happy to have a ‘check-list’ before them, ensuring that nothing important has been forgotten.

“That’s why we’ve got a 100 percent retention rate from the organizations who have joined OSOS” he said.

So far, OSOS has created over 350 different order sets, with 10 to 20 new ones produced each month. Dr. O’Connor estimates that OSOS will eventually offer a library of some 1,000 different order sets.

There are nearly 1,200 order sets in use across the network, but many are different versions for the same problem, created by different hospitals and health regions. Interestingly, noted De Caire, a user can click on a link for one type of order set, such as pneumonia admission, and all the order sets for that problem across the OSOS network will pop up. “You can compare practices across the country, and adopt the parts that you find most useful.” That’s a quick way of boosting the quality of an order set.

Dr. O’Connor asserted that studies of hospitals using order sets have shown impressive increases in quality and patient safety.

For example:

• order sets have led to an over 300 percent increase in the ordering of DVT prophylaxis

• they have reduced the mortality of patients with sepsis by over 35 percent

• Order sets were one of only two strategies found to improve the care of children with asthma in Ontario emergency departments, significantly reducing return visits. (The other was referral to a pediatrician.)

As used now, order sets are typically downloaded from a hospital’s section on the OSOS web site (www.ordersets.net) and printed as needed. They’re made up of various parts, including check-lists that can be filled-in by the physician and then handed off to nurses and other allied healthcare professionals – such as colleagues in the lab and DI departments. They also include areas for free-text input and educational notes.

While most medical centres are currently using order sets in paper format, the creation of such documents sets the stage for computerized order entry and routing – commonly known as CPOE, or computerized practitioner order entry.

Dr. O’Connor stressed that paper-based order sets are “critical enablers for CPOE.”

“You need them for computerized solutions,” he said. “They’re the foundation.”

Very few hospitals in Canada or the United States currently have CPOE, but as Dr. O’Connor said, most have put it on their road maps, as it’s widely believed that computerized ordering systems will further reduce the incidence of medical errors and provide numerous decision support tools.

For its part, OSOS is designed to work with all electronic health record systems, the company said, and its order sets can form the content for a CPOE implementation.

Hospitals and health regions that join OSOS pay a monthly subscription fee. They are set up with their own section on the web site, and they receive access to the work produced by OSOS and that of other hospitals. They also receive order set development and project methodology, and unlimited remote project support from the OSOS team.

Costs hinge on a variety of factors, including the size of the organization and the number of order-set projects under way that will be supported by OSOS.

One of the first users of OSOS was the Grey Bruce Health Network, an alliance in rural Ontario that includes one regional hospital and 10 small hospitals. Before joining OSOS in 2007, the group had struggled for five years to produce 10 clinical pathways, documentation packages which included physician order sets. But in the next two years, by using Open Source Order Sets, it produced and implemented 88 more order sets.

“It has really helped us,” commented Jessica Meleskie, evidence-based care program coordinator for the Grey Bruce Health Network. “We might have just one specialist in a given area, but they (OSOS) have developed order sets that incorporate the expertise of hundreds of specialists. It has been an effective way to get access to the best practices in healthcare.”

Meleskie noted that the service becomes even more useful as it adds members, as it helps to be able to see the order sets developed by a variety of hospitals. “You can pick and choose what you find best from, say, five order sets dealing with the same problem.”

Six months after joining OSOS, Grey Bruce conducted an audit to see how much use doctors were making of the new order sets. There was variation in usage, but some sites had up to 80 percent usage of the order sets. Some departments were heavy users of the documents – for example, there was close to 100 percent usage in the OB/GYN department, and 90 percent usage by surgeons, while only about 30 percent of internists were using the sets.

“The patients and procedures on the medical floor can be much more complex,” said Meleskie. On the other hand, she said, “OB patients tend to be more routine and lend themselves to the use of order sets.”

Grey Bruce is about to conduct another audit to see how usage may have changed 18 months after the previous survey.

As it is committed to bringing best practices and evidence-based medicine into standard use at its hospitals, Grey Bruce has fine-tuned its own methods of developing and implementing order sets. In the past, each of the 11 member hospitals would review the work through their own committees; now, there is a centralized committee for order sets, which greatly speeds up the whole process.

Meleskie noted that using a centralized web site for downloading order sets also helps ensure that all of the organization’s hospitals are using the latest documents. As a practical measure, the 11 centres are urged to download order set documents on an as-needed basis, to ensure they’re using the latest versions.

Paper order sets are also setting the stage at Grey Bruce for CPOE, as the organization is in the process of rolling out an electronic health record system from Cerner. Meleskie said that virtually everything is computerized now, including nursing documentation, but the physicians have yet to use the system in a comprehensive way. That will change, as the doctors’ ordering system will be ramped-up in the next few years.

“It may start even sooner,” said Meleskie, “because some of the doctors are eager to get started.”

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Ultrasound at the bedside benefits patient care and the bottom line

By Cathy Fix, RDMS; RDCS

In many acute care units, patients needing diagnostic ultrasound exams must be transported to the ultrasound department for imaging. Unfortunately, moving any critically ill patient places the patient at great risk. And at St. Paul’s Hospital (Vancouver, British Columbia), this practice also left the intensive care/cardiac care units (ICU/CCU) frequently short of skilled staff while disrupting the normal workflow and revenue generation of the ultrasound department (USD).

St. Paul’s Hospital is a 520-bed acute care, teaching and research hospital that is home to many world-class medical and surgical programs, including cardiac services, HIV/AIDS, and kidney care. St. Paul’s is part of Providence Health Care, a large Canadian faith-based healthcare organization operating 14 sites in Vancouver, BC.

Aware that emerging technology, including miniaturization, has allowed for faster, smaller portable ultrasound systems with excellent image quality, St. Paul’s Hospital decided to investigate changing current practice by bringing the ultrasound exam to the ICU/CCU patient’s bedside. Wireless connectivity, also now available on these smaller systems, could remotely connect the sonographer at the bedside to the radiologist in the ultrasound department, further improving patient care by generating timely diagnostic reports.

But would the obvious advantages of scanning at the bedside also translate into cost benefits and greater efficiency for St. Paul’s Hospital? That was the crucial question.

A high stress environment: In 2008, current practice at St. Paul’s Hospital was to transport critically ill patients from the ICU/CCU to the USD for ultrasound exams. A fatal event during transport was a grave concern, as was spread or cross-contamination of infectious diseases. In 2007 (the most recent statistics available), at least 25 percent of St. Paul’s ICU/CCU patients were infected with methicillin-resistant Staphylococcus aureus (MRSA) and/or vancomycin-resistant enterococci (VRE).

If a patient could be moved, ICU/CCU teams (comprising nursing staff, a respiratory technician and porter) needed to accompany the patient during transport, leaving the units critically short-staffed during their absence. Preparation and transport back and forth took at least 60 minutes, and all monitoring equipment (including respirators) had to be portable and connected to the patient during the move.

The USD prepared by leaving a room ready for the patient for at least an hour. If the patient became unstable at the last minute, the exam would be cancelled, leaving nursing staff, porters, technicians, and the USD with unproductive time. Further, the USD, with a workload of approximately 25 percent inpatient and 75 percent outpatient, was struggling with increasing wait times for booked outpatients, and the waiting list was growing. The wasted hour of a cancelled ICU/CCU exam meant two outpatients did not get scanned and the USD lost billable revenue.

If the ICU/CCU were unable to transport the patient, the USD would send a radiology resident to the bedside with a large, unwieldy, old technology ultrasound unit that had poor image quality. As a result, a repeat ultrasound or additional diagnostic imaging was sometimes required, causing delay and increasing costs.

These factors were creating a high stress environment with little or no control of patient workflow and poor management of staff resources.

Stakeholders and concerns: Stakeholders in this process at St. Paul’s included ICU/CCU teams, an information technology (IT) team, sonographers, radiologists, and the ultrasound vendor. Patients were also considered stakeholders, their interests represented by nurses who work closely with them.

Among the concerns were exams being done in a timely matter with little or no disruption to patient workflow, possible lack of nursing support for USD while scanning in the critical care units, proper triaging of exams, and increases in the number of ultrasound exam requests upon arrival on the ICU/CCU wards. Other concerns included image quality, stable networking, and difficult or complicated cases requiring radiologist support. All stakeholders, of course, were intent on reducing risk to patients and improving patient care.

The plan takes shape: St. Paul’s Hospital chose a small, battery-powered ultrasound unit (z.one ultra Convertible Ultrasound System, ZONARE Medical Systems) with excellent image quality that was capable of wireless networking. The vendor lent the USD an ultrasound unit worth approximately $80,000 for the six-month pilot study.

The ultrasound vendor worked with IT to establish stable networking. The cost of upgrading the ICU/CCU departments to support wireless networking was $24,000.

Protocols and guidelines were established by the stakeholders and distributed to all concerned. Participants kept in daily contact, whether in meetings or by phone calls and emails, everyone working to support positive outcomes, especially for the patient.

Senior sonographers (with five years’ experience or more) who would be performing the bedside exams familiarized themselves for a month with the new ultrasound unit.

The pilot program would evaluate:

• Efficiency and cost of not transporting patients to and from the USD
• Effect of bedside exams on USD outpatient wait lists
• Image quality of portable ultrasound unit (any repeats scans required?)
• Reliability of remote wireless networking to ensure timely reports

Up and running: The ultrasound system arrived on July 14, 2008. On August 18, 2008, the first portable ultrasound was performed in the ICU. The USD went live with wireless networking on September 23, 2008, delivering diagnostic reports directly to the bedside. Since then, St. Paul’s Hospital has been regularly and successfully scanning ICU/CCU patients in the units with the new portable ultrasound machine.

Feedback has been positive among all stakeholders, and the hospital already has plans to expand the program to the emergency department and eventually the medical and surgical wards.

The bottom line: Scanning ICU/CCU patients at the bedside clearly alleviates the considerable risks involved in moving critically ill patients. But is it also cost effective? What is the approximate cost of moving a critically ill patient? Or the cost of leaving an ultrasound room open for ICU/CCU patients while revenue-generating outpatients are waiting in line? Would the costs outweigh the cost of a portable ultrasound unit? Could these costs even be estimated? These are some of the questions the stakeholders had to consider.

After reviewing the available data, St. Paul’s Hospital found that in 2007, before USD began scanning in the critical care units, the total costs for moving these patients was $35,809.18, and the total loss of USD revenue was $49,804.32. The elimination of these costs due to bedside scanning could easily offset the cost of the new handheld machine.

In addition, if emergency, medical, and surgical patients were also scanned on the wards (as is planned), cost recovery could easily cover the equipment and wireless networking setup costs within a year, and would certainly cover the salary of one full-time healthcare worker. Moreover, the additional bedside scanning could create the availability of at least 400 outpatient appointments that could help with current USD wait lists.

The additional time saved in room clean-up could also be significant. The 2007 statistics revealed that 25 percent of ICU/CCU patients had MRSA or VRE. This number is likely underestimated but is significant enough to cause concern regarding the time required for proper cleaning and the risk of spread.

A lean, green imaging machine: Several sonographers noted that the ultrasound system has no heat output. It turns out the unit uses less power than standard units, which are larger, and can be considered a green machine. This alone has meant a great deal to the staff – the fact that the hospital is creating a better environment.

In addition, sonographers who scan at the bedside do not have to be concerned about finding a plug or unplugging the unit and pulling it away from a patient during a critical event in the ICU/CCU.

A beneficial mode of service delivery: There has been nothing but positive feedback from the ICU/CCU teams (including nurses and physicians); the ultrasound department has generated respect for providing timely exams; and everyone is relieved that patients are not placed at risk and the ICU/CCU departments are not left short of staff. Due to the success of this pilot project, St. Paul’s Hospital USD will start scanning at the bedside of patients in the ED in April 2009, eventually followed by the medical and surgical wards.

The future applications of this technology could include house calls, i.e., going to patients within the community. With wireless connectivity, images could be sent to the hospital’s radiologist and interpreted in minutes, just as is now done in the hospital. Further investigation of the costs of inpatient care versus using the new technology in the community setting needs to be done.

In the final analysis, St. Paul’s Hospital has found scanning at the patient’s bedside to be a beneficial mode of service delivery with a favourable cost impact.

Cathy Fix, RDMS; RDCS, is a Clinical Instructor, Department of Radiology, Faculty of Medicine, University of British Columbia. She is also Ultrasound Section Head, Providence Health Care, Vancouver.

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Assisted by real-time imaging systems, surgeons can improve the quality of results

By Andy Shaw

Dr. Ivar Mendez, surgeon and chairman of the Brain Repair Centre in Halifax, can see better than any other neurosurgeon in the country. But that has little to do with his own eyes. Enhancing Dr. Mendez’s sight and consequent surgical decision-making are two real-time imaging marvels – the PoleStar iMRI Navigation Suite and the O-arm Imaging System, both from Medtronic. Equally enhancing his view are the human newcomers Dr. Mendez brings into the OR with him.

“On the equipment side, the PoleStar is a low-field (0.15T) intra-operative MRI which can guide us in real-time as we proceed with cranial operations,” explains Dr. Mendez who also heads up neurosurgery at Dalhousie University. The O-arm, he noted, is a three-dimensional imaging system for the spine that provides surgeons with real-time images in the operating suite, allowing to perform complex work – such as putting in screws and bars to stabilize the spine – with great accuracy.

Dr. Mendez believes that the PoleStar and the O-arm, and especially the technical people who now venture into the OR with them in Halifax, are harbingers of a new surgical era.

“Having real-time intra-operative imaging means we can do much more complex operations and much safer operations in future,” says Dr. Mendez. “Also, as we’re doing here now in the Brain Repair Centre, part of the surgical team will be computer experts, imaging technologists, and biomedical engineers. People who know the equipment and what it can do intimately. So in future operating rooms, there will be not just clinicians, but a whole multidisciplinary team.”

These new OR team members, according to Dr. Mendez, provide two great benefits.

“First, they help you get the best out of the equipment. They know how to generate the clearest images – so you can do the best possible work on the patient,” says Dr. Mendez. “But also, as we all gain experience with the real-time imaging, we are tending to develop other instruments and other applications that enhance what PoleStar and the O-arm do. It happens naturally. You have the technical and engineering experts right there in the OR with you, and you work with them every day. So new ideas just emerge. One of them, for example, is the ‘Halifax Injector’.”

Key to all of this is the ‘intra-operative’ nature of the PoleStar and the O-arm real-time images – you can see things ‘live’, as they happen.

“With the (PoleStar) intra-operative MRI, we can take a picture just before we close up the head after brain surgery – to make sure we don’t have a haemorrhage going on in there,” says Dr. Mendez. “In the past we would do the surgery based on pictures we took perhaps four or five hours before the surgery – and then we look at them again right near the end of the operation to help us judge how well we think we’ve done. But those pictures are not real time. After they were taken there could have been some shifts or other changes in the brain. And there could have been a haemorrhage.

“But when you can take real-time images of the patient’s brain right there in the OR, you are much more likely to fix that haemorrhage on the spot and prevent the patient from returning to the operating room in a few hours or to the hospital days later.” In other words, said Dr. Mendez, systems like the PoleStar and the O-arm provide better quality outcomes for patients – and they are going to save the healthcare system money.”

Dr. Mendez said the O-arm cost about a half-million dollars to acquire, while the PoleStar MRI came in at over $2 million. “But we also recognize that PoleStar and O-Arm are pioneering systems. So we know they will eventually go down in price as demand for them goes up.”

One feature of both systems that seems sure to drive that demand up is their convenience.

“The PoleStar is a portable system that can be put in a closet in the operating room, and then it can be wheeled out when you need it and put back when you don’t. Similarly, the O-arm can also be wheeled in and out of the OR,” says Dr. Mendez. “So that means the operating room doesn’t have to be dedicated to spinal or brain work. The OR can be used for other types of surgeries as and when needed.”

Dr. Mendez reports that since the O-arm became operational at the Brain Repair Centre over a year ago, “hundreds” of spinal patients have had their surgeries done with it. The PoleStar, just installed last fall, is put to use once or twice a week in its current work-up phase.

“Eventually, though, the PoleStar will be used for all the brain tumour operations done in Halifax,” predicts Dr. Mendez.

That will certainly make the folks at Medtronic happy. And they think hospitals will be happy with them too.

“The two systems certainly enhance the surgeon’s ability to get things done,” says Bruce Leggett, senior product manager for Medtronic Navigation. “But from the hospital’s point of view, it’s their mobility and the low-field of the MRI that make the devices especially appealing in these difficult economic times.”

As Leggett points out, the immense size and power of traditional high-field MRIs usually demand that a hospital make extensive, costly renovations or even build whole new wings to accommodate them.

“But with the PoleStar and the O-arm there are no construction costs. They can normally be accommodated by existing structures,” says Leggett.

They are also less dangerous to users.

“We are starting to see reports now of surgeon’s getting cancer, which can be traced to radiation exposure over their career,” says Leggett. “And surgeons know when they are approaching their maximum allowable radiation dosages. However, with the O-arm and the PoleStar they can continue to work comfortably without exposing themselves high levels of radiation.”

It’s a pragmatic approach to image-guided surgery that Medtronic is proud of and which Leggett says has already won wide acceptance.

“We have 27 PoleStar installations in the U.S. and 50 around the world, as well as over 100 O-arms installed mostly in the U.S. And we have both O-arm and PoleStar together in about a dozen sites. So as the Brain Centre in Halifax is demonstrating, they are complementary systems,” says Leggett. “But I think what makes Dr. Mendez and the Brain Centre unique is that they are not driven by the profit-motive. So they are free to brainstorm and develop new procedures and prototypes. That’s really what we like to help our users do.”

Though he is a 13-year veteran at Medtronic Navigation headquarters in Louisville, Colorado, Leggett is familiar with non-profit approaches to healthcare. He is a Canadian who began his career with ISG, the Toronto airport-area company that took their aircraft navigation systems and flew them into the human body. What ISG and radar did for pilots and passengers, Leggett sees Medtronic and real-time imaging doing for surgeons and patients – saving lives.

But Medtronic and the Brain Centre are not alone in that mission.

At the University Health Network (UHN) in Toronto, the Guided Therapeutics (GTx) Program is aiming to do nothing less than “revolutionize the way that cancer is treated.” Based at the UHN’s Princess Margaret Hospital and at the nearby MaRS Centre, the country’s top oncology surgeons, biomedical engineers, and medical physicists are researching, collaborating on, and applying real-time imaging to real patients. That’s leading to greater precision in the surgical removal or radiated ablation of tumours. And like the Brain Repair Centre in Halifax, they are making room for teams of techies in the OR.

“This is not over the horizon research. GTx is a concerted attempt to develop the next generation of image-guided procedures and supporting technologies,” says principal investigator Dr. David Jaffray, the head of radiation physics at Princess Margaret and who pioneered the patented Cone Beam CT.

He strongly supports the GTx credo that the convergence of imaging, computers, and minimally invasive or, better yet, non-invasive techniques can “..turn surgeons into sharp shooters who are able to view, track and treat disease with precise, patient-specific therapies guided by intra-operative 3D imaging.”

None more spectacular in their clarity and variety than those images from the Cone Beam CT. During an interview, Dr. Jaffray demonstrates with a “dashboard” of images drawn from one CT scan of a patient’s head. The range from left to right, through traditional shadow and light images to high-definition colour views of the head and neck muscles, (with a tumour evident in red) to a bones-only skull shot. Rotate them, flip them, any way you like to plan and track your approach.

In another interview, surgeon Dr. Jonathan Irish, the head of surgical oncology at UHN and also a GTx principal investigator, takes a 3D image of cancerous lower-jaw bone and “prints” it on a so-called 3D printer, that’s more like a Star Trek replicator. Out comes an exact black-coloured mould of the jaw-bone that he hands over for examination.

“Using our technical people in the OR to call up computer databases and algorithms, we can now image the exact contours and even make patient-specific models of what we are targeting. And by combining different real time imaging modalities we can be even more precise. We can see for sure where to cut and where not to cut, so that only the cancer is removed and nothing else,” says Dr. Jaffray. “Or in non-surgical radiation therapy, say for a thyroid or a prostate cancer, if the patient moves on the table, we can see how to re-target the shifted position of the tumour. Our physicists in the OR can now even shape the radiation beam so that it attacks the more virulent part of the tumour more than the rest.”

Less radiation going astray, lower levels of radiation, and fewer side effects are among the patient benefits. Such innovations are what GTx investigators and supporters hope will soon emerge as regular practices. Likely they will first in the spacious ORs of another UHN institution, the Toronto General Hospital (TGH).

“We started out in 1997 to replace all our ORs,” says TGH chief surgeon, Dr. Bryce Taylor. “Of course we didn’t know then what technologies would appear in the next 10 years. But we knew imaging had to play a role in the OR of the future, so we built them big enough to accommodate lots of new equipment. We planned and built 19 new such ORs but as a hedge against the future we simply walled off the space for three or four more, about 4,000 square feet in all and just left it.”

Now the walls are coming down, and under Dr. Taylor’s supervision and support, GTx is creating the first of three state-of-the-art, image-guided to the hilt ORs in the vacant space. Called Translational Image-Guided Operating Rooms or TRIGORs for short, they will be dedicated to clinical development and trials.

Not to be outdone by all those smart Torontonians, Dr. Mendez and his practical Haligonians are proceeding with the Halifax Injector project.

“It will eventually work with our intra-operative imaging systems to deliver cells or drug compounds into the brain and treat diseases there without any cranial surgery,” says Dr. Mendez.

Providing, of course, Dr. Mendez keeps his biomedical engineers and other technical wizards happy with their work in the OR.

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Southwest Ontario leads way on DI connectivity and interoperability

By Andy Shaw

W hen it comes to obtaining the big benefits from eHealth solutions, interoperability of the systems used in a region are prerequisites for success. On this score, regions across the country should take a look at the Southwestern Ontario Digital Imaging Network (SWODIN).

Begun as an eight-hospital pilot project just four years ago with Canada Health Infoway help, SWODIN in its current phase will soon enable radiologists, referring physicians, and specialists from nearly 30 hospitals to access, exchange, and store patient RIS reports and PACS images – regardless of which maker’s machines generated them.

“We’re the second regional network in the world, after one in Norway, to prove out interoperability among multiple PACS vendors, and we are the first in North America,” said Babette MacRae, SWODIN’s project manager. “So, I believe we are leading the way.”

When MacRae and other project leaders finish SWODIN’s final phase, hospitals on the network will climb to 60 or more and cover a vast geographic area stretching from Windsor in the west, to Hamilton in the east, to Owen Sound on Lake Huron in the north – ignoring the boundaries between four regional health authorities and leaping the technical gaps between multiple RIS/PACS systems.

That reach and agility is enabled by GE Healthcare’s Centricity Enterprise Archive, which is housed in two separate and anonymous London locations, for redundancy, and its Centricity OneView software.

“In simple terms, the project has been about creating a central repository for the records of radiological encounters with patients that can be shared across a variety of connected sites,” explains John Letterio, project manager for GE Healthcare. “There are three layers to the architecture. The top layer is a patient normalizing solution that matches up patient information.”

That’s so the patient record emanating from, say, Windsor for “Bobby Jones”, is recognized as the same patient as the “Robert Jones” on record in Owen Sound. The first layer can do this by finding the same birth dates and other identical data on both records.

“That first layer then feeds the confirmed information on the patient to the OneView application,” continues Letterio. “And that’s where the user begins to interact with the system and pull up what we call a “longitudinal” view of the patient’s records from all the sites the patient may have visited in Southwestern Ontario.”

And that view is not clouded by whether his or her innards were captured, described, and their images held by a RIS/PACS system from GE, Philips, Cerner, Siemens or Carestream.

“We share them all in one deep archive and we’ve done that since we began the project back in 2004, first with the Thames Valley Planning Partnership that included two London hospitals and six community hospitals,” explains Dianne Beattie, VP and CIO for the London Health Sciences Centre, as well as the “executive sponsor” for the SWODIN project.

“We picked up another six hospitals when we began expanding to the Grey Bruce Health Services region in our second phase. In this third phase, we’re adding another 13 hospitals from Windsor-Essex. Those are all in LHINs 1 and 2. But we are not stopping there. We’re just now in the infancy of connecting up with LHIN’s 3 and 4, taking us into the Waterloo-Wellington and Hamilton-Niagara Regions. Now, we won’t all be sharing the same PACS, but all the records will go into that one deep archive.”

Beattie says that she and her colleagues on the SWODIN project wanted to go big like that right from the start. But she credits the leadership of Infoway for restraint at the outset.

“Infoway thought it was better if we began with a pilot first,” said Beattie. And she’s glad they did.

Starting smaller allowed them to test and refine the systems before ramping up. Favourable results gave Infoway and Ontario Ministry of Health backers the confidence to put $50 million into SWODIN, and Beattie expects their total contribution to be about $100 million.

Indeed investment could climb higher if private radiology clinics are encouraged to come into the SWODIN fold – providing a connectivity cost issue can be resolved.

“Connectivity to remote users from their offices or homes, we can do. But in the interest of security and privacy, we have to build Virtual Private Network tunnels, and VPNs are expensive and difficult to maintain,” said Beattie. “So right now, we are evaluating two different approaches that are much less costly but equally secure.”

As SWODIN grows, the challenges, Beattie expects, will not be so much technical as human.

“Much of what we do depends on having good relationships. Before it was easy, if you needed to see someone, you could just jump into your car and go visit them within a few minutes. But now, we are getting further from our home base, so people you might need to see are two hours down the road. As a result, we have to think a little differently. We’re putting more emphasis on interoperability planning and thinking ahead of time about workflow.”

Ironically, it’s saving time on the road and better workflow that’s providing SWODIN’s patients and physicians with much-welcomed benefits.

“Because we’re able to share the records, we’re saving patients many unnecessary road trips, but also we’re seeing benefits not just to radiologists but also to specialists,” said project director MacRae. “The specialists are getting access to more information and that’s resulting in better decisions.”

The network has been proving its worth in the real world, judging from clinician reaction to SWODIN’s offerings.

“Remember that we are still in the implementation phases, but we’ve been surprised by the number of clinicians who want to sign up and get access to the network. There’s been quite a bit of excitement in the clinical community,” said MacRae.

Mike Clarke knows why.

“Think about a patient in a remote area who has had a traumatic accident with head injuries,” said Clarke, who is general manager of GE Healthcare’s IT business. “Now, a neurosurgeon in a large centre can take a look at the digital images coming off the network, advise if the patient should be airlifted, and if so, have the operation planned before the helicopter even touches down. That’s opposed to a patient arriving unannounced with a bag of film stuck to the chest.”

Clarke mentioned other benefits of the retrieval enabled by SWODIN: elimination of duplicate exams and comparison of say, mammography exams taken here versus another six months ago taken there, and maybe on some other system.

“I think that is the challenge we have met in the SWODIN project – being able to straddle a heterogeneous environment of different RIS and PACS providers,” said Clarke. “And its complexity is far greater than what GE is doing in Newfoundland, for example. There, in effect, because they’ve settled on one vendor, there’s one super-PACS in place. But in Ontario, we’re striving to preserve the investments in legacy systems. We’re doing just that in a northern Ontario project right now, as well.”

Making disparate systems talk to each other has been made possible by SWODIN’s adherence to HL7, DICOM, and IHE standards for interoperability, which together greatly facilitate third-party integration, points out GE’s Letterio.

MacRae values GE’s Application Provider Interface (API), which enables users to see what SWODIN terms the whole “longitudinal patient jacket”, regardless of the system their desktop is on.

“The beauty is that they can continue to do their own workflow, on their own PACS, but also have access to our network at the same time.”

Project leader MacRae points to a long-standing relationship with GE that formed the initial basis of trust. And it continues to this day, in Mike Clarke’s view, because of the focus GE keeps not just on its Centricity archive and the OneView access to it, but on the workflow improvements they enable.

“Anybody can put images in a bucket. That is easy to do,” said Clarke. “And most of the vendors bring the same palette of technologies to solving all the inherent complexities of a multi-vendor environment. But the secret lies in careful consultation with the radiologists, the technologists, and the specialists as to how they work best, and then, for their benefit, masking all the complexities behind the scenes.”

For Beattie, a key to SWODIN’s success to date has been the leadership shown by Infoway, as well as the Ontario Ministry of Health and Long-Term Care. She points out that SWODIN was initially helped by the province’s Network Refreshment Program. That program led to the backbone-providing Smart Systems for Health Agency (SSHA) and its secure Virtual Routing and Forwarding (VFR) technology, which SWODIN now rides on.

“The Ministry is also making sure we are leveraging what we have learned,” said Beattie. “And already there have been some interesting spin-offs. For instance, we’ve just set up a mini-PACS for neurosurgery and everyone concerned with trauma cases. If someone needs a CT scan done immediately, the request goes to the province’s central trauma case agency, which immediately finds the resources needed to do the scan, and the mini-PACS delivers the images to where they’re urgently needed.”

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Healthcare centres use less paper with document scanning systems

By Dianne Daniel

To scan or not to scan? That’s the question facing healthcare institutions as they implement document management strategies. And while the answer seems to be a clear ‘yes’ when referring to paper created today, it’s not so cut and dried when determining the best way to handle storage rooms filled to capacity with legacy paper charts.

“What do you scan, why do you scan it and how do you make it accessible in the best possible way to your clinical community?” asks Jean Huot, chief information officer (CIO) at Centre Hospitalier de l’Université de Montréal (CHUM) and McGill University Health Centre (MUHC) in Montreal. “Every clinician has a different view... ranging from scanning everything in the paper record from the start of the hospital to scanning nothing.”

In October, 2009, CHUM and MUHC are going live with an integrated document management and workflow solution from Telus Health (formerly Emergis) and Streamline Health Solutions Inc. At that point, anything created on paper – including discharge summaries, clinical notes, referral notes and follow-up notes – will be indexed, scanned and made available for on-line viewing through the healthcare facility’s existing clinical information system, Telus’s Oacis.

The project is being undertaken for two reasons. First, the health centres must deal with the challenge of how to provide centralized access to patient information across a multi-site facility. Right now, they move a lot of paper around at a cost and it seems the “paper file is never at the right place,” says Huot. Second, they need to prepare for a future move to a new location at which point the goal is to progressively implement a digital hospital strategy that won’t necessarily be paperless, but will use less paper.

For the past year, CHUM and MUHC have been working diligently with Telus and Streamline Health to design a multilingual version of Streamline’s accessANYware software. They’ve also spent a great deal of time formulating a document indexing strategy that will rely on barcoded forms to ensure information such as medical record number, visit number and form type are scanned and entered correctly.

User empowerment is key throughout the process, says Huot, noting that the information technology (IT) department relies on the collaboration of chief clinical officers – doctors who are leaders in their fields, respected by their peers and whose role is to ensure clinical needs are being met.

When it comes to decisions about back-scanning, however, those needs aren’t so apparent. Together, the CHUM and MUHC health centres serve more than two million patients per year from eight different hospital locations. “So essentially, when we’re talking about indexing and back-scanning and trying to create a uniform approach, it gets very tricky,” says Guy Mathieu, director, information systems. “We realized soon enough that you couldn’t just build a new standard record from old records that were standing in different hospitals.”

As they prep for a final decision on what to scan from the past, CHUM and MUHC are continuing to seek participation from clinicians and are also conducting extensive studies to determine the best approach to take. For example, the centres have looked at patient flow to determine the likelihood of a repeat visit from an old patient, as well as the number of charts per patient and number of pages per chart to determine the feasibility of scanning. “The merits of back-scanning are not yet publicized sufficiently to know if there’s a definite avenue we should follow,” says Mathieu.

At Kingston General Hospital (KGH) and Hotel Dieu Hospital (HDH) in Kingston, Ont., the question of back-scanning has once again been put on hold after a review by a patient records committee earlier this year. In July, 2007, the hospitals launched a forward-scanning document management strategy using Synergize, an imaging and indexing system from Richmond, Hill, Ont.-based Microdea Inc.

All paper notes are now indexed, scanned and integrated into the Quadramed health information management system for viewing, and are destroyed by confidential shredding after a period of 60 to 90 days has elapsed.

That means no new paper is being added to the medical records storage area, currently housed in a basement facility at Hotel Dieu, but the question of what to do with the legacy paper charts remains. “If we have to move from there, then we would have to look at what we would do,” says Barbara Nayler, director, patient records, registration and privacy. “For now, the committee doesn’t see any real clinical value in scanning the information that’s down there.”

Part of the reason for the decision not to back-scan is that KGH and HDH have been using Quadramed since 1995 and 1997 respectively, and all transcribed notes, lab results, X-ray results and PACS images occurring since then are already available on-line for viewing. Most of the older, typed notes in storage are accessed for research purposes only and in the case of Hotel Dieu Hospital, are available on microfilm readers and printers maintained by the Medical Records department.

Meanwhile, the forward-scanning effort has more than paid off, says Nayler. It used to be that anywhere from 700 to 800 paper charts would be pulled from the Hotel Dieu storage area on a daily basis and now that number is down to 80 or so. Rather than hiring couriers to deliver paper charts pulled for Emergency physicians during off-hours – on weekends, statutory holidays and midnight shifts – the midnight security supervisor now handles the job, and it only happens once or twice every two to three days.

“We used to have five to six shifts of four-hour clinical people a night, pulling records for the next day’s clinics, and now we’re down to two,” adds Nayler, noting that physicians themselves stopped requesting paper charts earlier than predicted.

Both the Kingston and Montreal health centres have approached scanning as a necessary interim solution on the road to a completely electronic health record. Right now they rely on barcoded forms to ensure the right information gets attached to the right patient chart, but the hope is to implement an e-doc strategy so that some day paper may disappear altogether.

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