Ontario�s community-care providers revitalize IT systems

By Jerry Zeidenberg

TORONTO � Ontario�s Community Care Access Centres (CCAC) have launched a group of new IT systems that are expected to enhance the way case managers and staff serve their clients.

Among the solutions being deployed is a new case management system called CHRIS (Client Health Related Information System). CHRIS is designed to give case managers and administrators a common system to enter and track patient information and service plans across the province.

Through what is referred to the Health Partner Gateway, or HPG, which was also developed for the CCACs, CHRIS is able to link electronically with the many healthcare service providers across the province who deliver nursing and personal support services.

This goes a long way in eliminating earlier solutions using automated fax machines and other less attractive communication methods, which in today�s technology landscape are clearly outdated.

The Community Care Access Centres (CCACs) in Ontario are operating in over 200 offices/locations throughout the province and employ more than 8,000 people. They serve more than 500,000 clients, and provide more than $1.6 billion worth of health services annually to the citizens of Ontario.

The CCAC�s case managers co-ordinate the delivery of nursing and personal support services to patients at home and provide assistance to clients when they need to enter a long-term care facility. They also assist the public by directing them to the right health-related support services available to them in their community.

CHRIS is a replacement system for a number of the existing legacy systems, which lacked many of the more advanced capabilities � including support for Ontario�s healthcare transformation and eHealth strategy.�There were some systems in use that were 20 years old,� commented Kevin Arbour, vice president and CIO of the Ontario Association of CCACs.

By modernizing, automating, and better supporting case management processes through CHRIS, the case managers will be better able to coordinate client care, and spend more quality time with their clients.

Getting CHRIS up and running in each of the CCACs is a substantial task, as historical patient data must be migrated to the new solution at each location. As well, training and change management coaching must be conducted as staff become familiar with many of the new capabilities.

Interestingly, CHRIS was developed in-house at the OACCAC. Arbour says it was an unusual move, taken after a review of available market solutions found that none readily fit the needs of the CCACs.

More functionality is expected to be added to CHRIS, for which off-the-shelf solutions will probably be needed. But for the core case management system, �we couldn�t find anyone who had what we needed, so we decided to build it ourselves.�

For his part, Arbour is an experienced IT executive who worked at Bell Canada, Nortel Networks and several entrepreneurial startup companies, in Canada and the United States before joining the OACCAC and the healthcare sector.

Remarkably, and in the short span of a few years, Arbour has created within the OACCAC an eHealth Services team focused on supporting the business and operational needs of the CCAC�s across Ontario. In close partnership with the CCACs, the team completed the initial development of CHRIS and began the provincial roll out in March of 2008. �It�s the unique partnership and level of collaboration we have with all the CCACs across the province that make this a success,� says Arbour. �It is truly a privilege to be part of the CCAC transformation in the delivery of healthcare services to the people of Ontario.

Other IT systems introduced to CCACs of late include automated client assessment tools based on international assessment standards, that help determine the right care plan for clients on CCAC service; an enterprise-wide data mart, which helps CCACs analyze care plans and client outcomes, and continually refine and improve services delivered to their clients; an enterprise wide solution that ties together a variety of different databases of community services, in order to more easily direct clients to any community service available within Ontario; and a modernized Voice over IP telecom system that eases internal CCAC operations, enhances communications with partner organizations, and supports Client access to case managers whether they are in the office, or mobile.

To modernize and secure the flow of information among the CCACs, the organization revved up an effort to install new computers and laptops across the province. Additionally, the OACCAC modernized the CCAC computing environment using Dell�s virtualization technology. All new CCAC systems are being located in Class 5 data centers and take advantage of the SSHA provided network backbone.

New computers are going into CCAC offices, pre-configured with the software and enterprise class services such as email, messaging, and desktop video conferencing, together with access to all CCAC IT systems needed by staff.

The modernized systems are helping case managers to be mobile and productive while working in different care settings � such as nursing homes, primary care settings (namely, Family Health Teams), hospitals and community.

Said Arbour: �Dell, Microsoft and Allstream continue to be among our more strategic private sector partners. They�re playing a key role in fulfilling the CCAC provincial eHealth Strategy and supporting our IT infrastructure, access services and unified communications and mobility strategies.�

The deployment of a new, province wide, voice-over-IP network is just one such example of the infrastructure solutions devised in conjunction with these technology partners. According to Arbour, it�s a key enabler in supporting the CCAC front line as case managers work in various community care settings.

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Pilot brings Safer Healthcare Now! campaign to the home-care sector

By Jerry Zeidenberg

Several Canadian organizations have joined forces to bring the benefits of the Safer Healthcare Now! campaign into the home-care arena.

In September, a patient-safety pilot project for home care, with sites across Canada, was launched by the Victorian Order of Nurses (VON), in conjunction with the Edmonton-based Canadian Patient Safety Institute and the Institute for Safe Medication Practices Canada of Toronto.

In particular, the project will seek to explore and enhance medication reconciliation in the home-care sector. The plan is to launch with 20 teams located at sites in all provinces.

To date, the nation-wide Safer Healthcare Now! project � which aims to improve outcomes and reduce medical error � has focused on hospitals and nursing homes.

With buy-in from large-scale medical centres across Canada, Safer Healthcare Now! (www.saferhealthcarenow.ca) has had considerable success in 10 different interventions, including the prevention of ventilator-associated pneumonia, disseminating best practices for myocardial infarction and boosting the use of medication reconciliation to reduce drug-related medical errors.

But medication reconciliation is an important issue in the home care sector, too. Prescription-drug troubles often start at home, where patients are away from the supervision of professional care-givers for days or weeks at a time.

�Medication error in the home setting is a huge problem, commented Philip Hassen, president of the Canadian Patient Safety Institute, a key supporter of the Safer Healthcare Now movement. �In hospitals, the management of medications is all controlled. At home, you�re on your own.�

Hassen noted that many problems occur with prescription drugs once patients leave hospital � problems often leading to sickness and re-admission. A major challenge occurs right upon discharge from hospitals, as many patients don�t understand when or how to take their medications.

�We know that after six months, less than 40 percent of patients are taking their medications,� commented Hassen.

Other patients tend to take too many medications. They visit a variety of physicians and care-givers and will obtain multiple prescriptions � which can lead to medication conflicts or over-doses. �The classic case is the cardiac patient who is discharged from hospital with a prescription for warfarin. But the doctors didn�t know the patient was already taking coumadin at home,� said Hassen, in reference to a commonly used heart drug that is known by several names.

He also cited a study by Dr. Alan J. Forster, co-director of the Ottawa Hospital Center for Patient Safety, who found that 23 percent of patients discharged from hospital suffer an adverse event, and of those, 72 percent were drug related.

�This is why we�ve got to look at home care,� Hassen said. ��We need a better understanding of how home-care patients are taking their meds � what they�re taking and how they�re taking it.�

According to Safer Healthcare Now!, medication reconciliation is a formal process of:

� Obtaining a complete and accurate list of each patient�s current home medications � including name, dosage, frequency and route;

� Using that list when writing admission, transfer and/or discharge medication orders, and;

� Comparing the list against the patient�s admission, transfer, and discharge orders, identifying and bringing any discrepancies to the attention of the prescriber and, if appropriate, making changes to the orders.

As part of the project, home care nurses will work to clarify which medications their patients are taking, creating a complete and accurate list � called the Best Possible Medication History, or BPMH. They will then identify discrepancies, especially at the transitions of care, when patients are handed-off from one provider of care to another.

The discrepancies will be reported to the patient�s physician, so that changes will be made to the orders, when appropriate. Moreover, the medication list, and any problems encountered, will be communicated to the patients themselves, along with their families and allied care-givers.

The homecare pilot will design and test strategies for implementation of medication reconciliation in client settings across the country. As well, the teams will measure actual patient results, and develop a structured and sustainable framework for use in the long-term.

The project will build on a �mini-pilot� conducted by Safer Healthcare Now!�s western Canadian node over a one-year period that ended in April of this year. The project, known as the medication reconciliation collaborative, involved acute-care hospitals, long-term care centres and home care providers.

�We�re using their learnings to advance this pilot,� commented Anne MacLaurin, project manager for the Canadian Patient Safety Institute. In particular, expertise developed in Saskatoon and Vancouver will be relied upon to help jump-start the project. �They were our star performers,� said MacLaurin.

The Victorian Order of Nurses is spearheading the new project, but MacLaurin noted that several other home nursing agencies are also participating. They include Paramed, Cancare, VHA Home Healthcare and St. Elizabeth in Ontario, and the Centre de Sante et Services Sociaux Jeanne Mance, in Quebec.

The announcement of the home care pilot project came during Patient Safety Week, in September. It�s an annual event, and this year the theme was better communication as a way of improving patient safety.

�The week will encourage patients to become involved by speaking up and asking more questions, communicating with healthcare providers, and understanding the important role they play in providing accurate information about their current medications,� said Hassen.

The Canadian Patient Safety Institute is urging all Canadians to keep an updated list of their medications � both prescription and non-prescription drugs � and to always take this list with them when they visit a healthcare provider.

Moreover, Hassen said that if the patient is unable to do so, it�s important to have a family member be aware of the medications they are taking and to accompany them when visiting the healthcare provider.

He lauded the efforts of various provinces to create electronic drug information systems, which will log the drug profiles of patients and provide secure access to physicians and other care-givers, as needed. �The goal is to develop a secure e-record,� said Hassen. �It should include �all patients, all drugs�.�

Hassen noted that one of the biggest trouble spots for adverse drug events concerns the communication of medication information to patients. This often occurs at discharge from hospital, when a patient feels stressed or disoriented, or is inundated with information and can�t process it all at once. As one strategy for dealing with this, Hassen said doctors at some hospitals are now asking patients to repeat back to them the instructions they have given for taking meds. This helps ensure the patient has understood what was said.

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Analytic system for DI aims to improve performance and patient care

By Dianne Daniel

In Ontario, there are four times as many CT scanners and 12 times as many MRI machines in use today than 15 years ago. Yet, patient wait times for these types of medical imaging tests still range anywhere from five to 14 weeks.

Thomas Hough, founder and president of Mississauga, Ont.-based True North Consulting & Associates Inc., is aiming to improve those statistics with the release of Clearica3 (pronounced Clearica cubed), a web-based decision support tool his company has developed.

The system is designed specifically to increase operational efficiencies within Diagnostic Imaging (DI) departments.

�We�ve now got an environment that is ripe, where we�ve got all transactions occurring electronically,� says Hough, referring to widespread use of picture archiving and communication systems (PACS) and radiology information systems (RIS) within Canada hospitals. �Now, business intelligence can collect information on the fly as it occurs, and show it on a digital dashboard with dynamically changing gauges.�

Clearica3 is to be officially unveiled this month at the OHA HealthAchieve conference in Toronto. It represents 18 months of development work with Halton Healthcare Services Corp., a multi-site healthcare organization in Ontario serving Oakville, Milton and Georgetown. It is designed to give users a real-time view of everything from utilization rates for imaging tests (modalities), to patient wait times, to number of exams completed, to number of exams ready for reporting, and also provides drill-down capabilities for further analysis.

For example, a gauge may indicate an MRI is running at 21 percent efficiency. By double-clicking on the screen image, a user is presented with more detailed information, such as the number of exams performed on that machine so far that day, accompanied by a list that may include the patient name and hospital ID, session number, clinical area, time of completion, who ordered the test, who the radiologist was and who the technologist was.

Another gauge may indicate the number of outstanding cases waiting to be reported by the radiologist. And yet another gauge may show estimated patient wait times.

�In the past, radiologists would have an exam done on a Monday but not report until Tuesday or Wednesday,� notes Hough. �The objective is to get to �just-in-time radiology�, so they are doing the exams, reporting them and getting them signed off on the same day as the image acquisition occurs.�

Karen Worlidge, DI informatics system administrator at Halton Healthcare, says Clearica3 not only enables users to react to day-to-day operations, but also allows them to harvest information for reporting purposes. �A lot of the work we do in digital imaging is analysis after the fact, looking at what you did last month as opposed to being proactive and being able to determine what will be good for tomorrow,� she says. �The information provided by this tool is key to being able to redistribute resources, staffing and caseload in a real-time situation.�

From Worlidge�s viewpoint as an alpha user, Clearica3 has the potential to achieve better turnaround times for patient care by identifying and improving bottlenecks in imaging. �Patient �days of stay� is really important to try to minimize,� she says. �If there�s any way you can reduce those patient days because they�re waiting for imaging � they can�t get an imaging test so they�re being held over � it will help to reduce overall expenses for the hospital.�

Clearica3 improves workflow by giving users a �live look� at cases waiting to be done, cases completed, and cases waiting to be reported. It enables administrators to see where usage is down and to shift staff accordingly in order to avoid the peaks and valleys in activity that cause inefficiencies, she says. It also enables hospitals with multiple sites to move patients to where they can get their exams done faster.

Another advantage is the ability to monitor work in progress. If a physician office phones to inquire about a specific patient, employees in the DI department can find out whether the test has been completed, or provide an approximate wait time if the patient is still in the waiting area.

On the reporting side, the software helps hospitals to measure their productivity in terms of workload units specified by the Canadian Institute for Health Information (CIHI).

As Hough explains, every exam, test or function is assigned a certain number of workload units. By comparing actual times to target times, a hospital can get a better picture of its performance and can start to make improvements or changes to bring those numbers more in line. Through a regional reporting facility, they can also compare themselves to other hospitals, he adds.

Any hospital with a PACS and electronic informatics system or RIS can use the decision support tool, which is designed to interface with DICOM and HL7 standards respectively. True North Consulting is using a software-as-a-service model to offer the product, which includes hardware, software, customer support, application training and ever-greening services for one monthly fee.

�We install it and allow them to run for six months; then we will send in a consultant to do a two-day review of workflows and look at how they can improve their productivity,� explains Hough.

The company�s intent, he adds, is to roll Clearica3 out nationwide before investigating decision support opportunities in other �ologies� of medicine such as pathology or pharmacology. Meanwhile, Halton Healthcare is still in the �alpha� stage but intends to move forward with a full implementation in the future.

�This tool is really what is needed in Diagnostic Imaging in order to improve services,� says Worlidge. �We�re really a hub to the hospital; so the fact that we have something that�s DI-centric that can help patients get better care is key.�

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New technologies lead to unexpected breaches of privacy and security

By E. Michael Power

Last year, a CBC reporter was tipped off to an unusual privacy breach outside a Sudbury health clinic. Any nearby vehicle with a rear-view backup camera, an increasingly common wireless device, was able to intercept images from the clinic�s unsecured Wi-Fi video surveillance system of methadone patients giving urine samples.

The incident embarrassed the clinic publicly, forcing it to switch to a secure wired system, and prompted Ontario�s privacy watchdog to urge healthcare providers to immediately review any wireless surveillance systems.

Just months before that 2007 incident, a laptop computer with personal health information on 2,900 patients at Toronto�s Hospital for Sick Children (SickKids) was stolen. An investigation revealed the laptop�s highly sensitive information was unencrypted and not even relevant to the researcher�s work.

More recently, a consultant working from home for Newfoundland and Labrador�s Provincial Public Health Laboratory was shocked to get a message from a stranger that sensitive health data on his laptop was connected to a file-sharing program and exposed to the Internet through an open computer port.

The common thread? Unintended privacy and security consequences in leveraging technology. Telecommuting, high-capacity USB drives, GPS-enabled cell phones, cell phone cameras, Wi-Fi hot spots, Radio Frequency ID (RFID) and other technologies in the healthcare sector are raising new and complex issues for care providers, administrators and patients concerning the safety of personal health information.

A major challenge ahead for healthcare providers is balancing the benefits of new technologies with potential privacy risks. Thankfully, some �best practices� are beginning to emerge to help healthcare providers, organizations and industry vendors bring a new level of due diligence to ensuring privacy is maintained when healthcare technology intersects with personal information.

Think �Privacy�� Everywhere: Not long ago, most technologies storing personal information (PI) were safely behind a healthcare facility�s administrative, IT or finance doors. That fact has driven the existing privacy and data security measures or policies in many organizations.

Today, however, PI-enabled technologies play an increasing role in the direct care of patients. As such, administrators may be blindsided by �old school� thinking that privacy is only a concern for the file storage room, data centre or back-office computers. From handheld devices with access to medical histories to Wi-Fi networks, the new reality is technology and privacy concerns are everywhere. For example:

Telecommuting and Mobile Data: Among the biggest privacy risks in healthcare organizations is allowing data to move or flow outside the confines of the organization. Laptops can easily be stolen or accessed by others inappropriately. Employees may have out-of-control curiosity, causing them to access personal information on family, ex-spouses, friends, community leaders or celebrities treated in their facilities. Does your organization protect, encrypt or block access to PI wherever it flows?

USB Flash Drives: A 2007 U.S. study polled 370 IT professionals and found 38 percent believe USB drives and portable storage devices are their top security concern � above even malware or viruses. And, 80 percent of respondents said their organizations had no measures in place to combat unauthorized use of portable storage devices. Does your organization control portable storage?

Cell Phones: Hardware and software applications in cell phones make them as powerful as desktop computers. Many organizations have policies on the use of cameras in phones, but few have policies on the use of �find/seek� GPS features in the latest phones that allow people to be tracked.

On the issue of tracking, a technology being touted as the next big thing in healthcare is the use of RFID to monitor medical supplies, devices and even people. A Singapore hospital, for example, is using RFID in its emergency ward. Fueled by a SARS scare, the hospital�s system issues all patients, visitors, and staff a card embedded with an RFID chip, which records when and where a person enters and leaves the facility. The information is stored in a computer for 24 hours and can track who has had direct contact with whom.

Recently, Ontario�s information privacy commissioner, Dr. Ann Cavoukian, issued a detailed analysis of the potential privacy risks and benefits in using RFID in healthcare. While endorsing its use and potential to save lives, the commissioner also noted privacy concerns heighten as RFID is used to tag people or �things linked to people,� such as patient dossiers.

Examples of potential concerns are RFID tags used to monitor hand-washing compliance or track the use of �smart cabinets� � storage cabinets with RFID �interrogators� that detect specific ID numbers before allowing access. While the hospital�s intention may be to track compliance with its rules, RFID could also be used to create a surveillance record of every individual.

The commissioner also expressed concern over RFID tags that are re-writable or vulnerable to identity theft, recommending organizations take steps to ensure RFID data cannot be copied in an unauthorized manner.

Quoting a recent European study on RFID technology, the commissioner notes technologies that involve privacy issues �exacerbate a power imbalance between the individual and the collecting organization.�

Among fears commonly cited are: surreptitious identification of staff members without prior knowledge or consent; systemic tracking and surveillance; compilations of histories of individuals and interactions; and incorrect inferences about individuals arising from the data.

Out of the commissioner�s analysis of RFID usage, however, emerge some useful ideas and best practices for implementing new technologies of any kind.

Best practices for privacy and security: First, it is important to note the International Organization for Standardization (ISO) offers two valuable standards for security controls and operational processes � ISO 27001:2005 and ISO 27002:2005. They typically target security in three operational areas:

� Physical safeguards (locked cabinets, restricted office access, alarms, etc.)

� Technical safeguards (passwords, encryption, firewalls, etc.)

� Administrative safeguards (policy statements, clear responsibilities, access restrictions, staff training, confidentiality agreements, etc.)

Beyond these or other standards, the next �best practice� is to understand your own privacy and security risks. As the Commissioner suggests, compile an �information life-cycle� for your organization, which follows PI as it flows through your systems. Learn what and how data is collected, for what purposes, how it is stored and used, and with whom it is shared.

Next, ask some tough questions about how your technology affects PI. When reviewing portable storage or communications technologies, for example, one might ask:

� Is there an authorization procedure in place for PI to be taken from the facility?

� If PI is removed, is it encrypted or otherwise made anonymous?

� If a device or data is lost or stolen, could you identify what PI is stored on it?

After asking enough tough questions, other best practices will become apparent, such as:

� Ensuring staff and outside contractors have training on and access to written privacy and security policies, as well as signing confidentiality agreements

� Ensuring staff and outside contractors understand they may not copy or transmit PI of third parties from computers unless authorized (including e-mails or instant messages)

� Providing facilities (e.g., shredding machines for CD-ROMs) to securely destroy or dispose of PI no longer required

� Removing or changing access to physical facilities and IT assets as soon as staff leave or change responsibilities

� Creating operational and systematic controls that can be measured and verified

� Regularly monitoring the effectiveness of these controls

Another effective best practice is launching an internal awareness campaign to foster a culture of privacy. At eHealth Ontario (formerly Smart Systems for Health Agency), for example, employees were extensively trained on privacy policies and then exposed on a regular basis to a poster campaign reinforcing our privacy and security messages.

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