Inside the November/December 2010 print
edition of Canadian Healthcare Technology:
Feature Report: Hospitals of the Future
Alberta to expand its Netcare EHR portal
Alberta, which claims leadership amongst the provinces in its
development of a single, province-wide Electronic Health Record,
announced this past summer it was devoting another $224-million to
expand its capabilities in this critical area.
Saving infants in the NICU
Project Artemis, a new system that has been deployed at the Hospital
for Sick Children in Toronto, is showing that it can spot
deteriorating health in babies in the NICU at an early stage. That
will allow treatment to begin sooner.
READ THE STORY
Connecting EMRs with EHRs
Getting hospital reports to doctors has been a slow process in the
past – sometimes physicians don’t even know their patients were in
hospital. An alliance in southern Ontario has now created an
electronic solution that speeds up the delivery of reports to
READ THE STORY
By outsourcing its dictation and transcription to a Canadian company
with D/T expertise, North York General Hospital reduced its costs by
40 percent in the first year. Further significant gains are expected
READ THE STORY
Future of nuclear imaging?
The Chalk River reactor is back online and producing isotopes, but
Canada still hasn’t produced a strategy for the future. What does
this mean for nuclear medicine in the next few years?
PLUS news stories, analysis, and features and more.
Alberta to expand its Netcare EHR portal
By Paul Brent
Alberta, which claims leadership amongst the
provinces in its development of a single, province-wide Electronic
Health Record, announced this past summer it was devoting another
$224-million to expand its capabilities in this critical area.
“We will be the lead province in having a provincial, integrated
electronic network,” said Mark Brisson, acting assistant deputy minister
for health system performance and information management. “We have built
up a lot of infrastructure across this province, the real challenge over
the next three, five to seven years is the integration of all that
infrastructure. One patient, one record is where we want to be. Not
leading just for the sake of leading but for the sake of better patient
Nearly half the capital spending over the next three years
($107.8-million), will go towards the further build-out of the
province’s already impressive EHR system, which it publicly calls the
Netcare EHR Portal.
That effort includes expanding Alberta Health’s shared health record
initiative, essentially capturing and distributing the bits and pieces
of patient data that are currently not gathered, said Brisson. “It is
the rest of the data – lab, drugs and diagnostic imaging are the main
pieces that are pretty well part of every hospital event. The other ones
include a whole bunch of encounter information, such as immunization
data, and we are also looking at adding text reports and test reports.”
Determining the amount of data and just which data should be made
available to healthcare providers through Alberta’s EHR system has been
left up to a clinical working group comprised of healthcare
professionals. “It is not about techies telling providers what they
want, it is by providers for providers,” said Brisson.
Over the next few years, Alberta Health Services will also start a
program with physicians to pull certain health information from
physicians’ office systems. Key doctor’s office information that AHS
would like to be able to share includes information regarding test
results, immunization and a list of medical professionals a patient has
“There is no intent to pull all the records out of physicians’ offices,
it is only some key information that would help with diagnosis,” said
Brisson. “If you are an emergency room doc, you would like to know who
the patient’s regular doctors are, and the reasons the patient has been
The EHR build-out will also include a pharmaceutical information
exchange component that will collect the information concerning
dispensed drugs from pharmacies. It will be stored in a central location
and ultimately displayed in a medication viewer within the province’s
That work will also include an electronic prescribing application for
doctors’ offices that will be tied in with pharmacy management systems
across the province.
Alberta Health Services is also in the requirements, design and initial
build phase to create a personal health portal that will leverage the
existing EHR infrastructure which is geared to physicians. The personal
health portal is aimed at chronic disease management patients and those
who want to have more health information at hand in a secure portal.
They could use that tool on a first visit with a physician or when
visiting a specialist or alternate care provider, such as a
chiropractor, said Brisson.
AHS will soon put out a request for proposal for a provider to create
the personal health record software – something similar to Microsoft’s
Health Vault platform. It will allow Albertans to aggregate some of
their health information.
Another $90 million has been budgeted for the next three years to
maintain some of Alberta Health’s IT systems, to develop administrative
systems for flowing data from clinics to the ministry, for health
workforce forecasting and to fund business intelligence for public
policy support and health system management.
AHS has also earmarked more than $26 million over the next two or three
years to install ‘thin’ diagnostic imaging viewers in doctors’ offices
and clinics across the province. Alberta has already created the
repository of DI records and this next step will be the final phase in
making that information available to referring physicians.
“It is very valuable to have those images available across the province
and the intent by the end of next year is to have them available in the
thin viewer that is connected to our Netcare portal,” Brisson said. “We
have already captured 100 percent of the images across the province in
these repositories. But to make them available to referring providers
across the province has a lot of value. It will reduce the number of
images, the amount of (radiation) exposure to patients, and also the
hassle of having to go again and have an image taken.”
While much of the infrastructure spending over the next three years is
going towards hard-to-see elements, such as heightened security and
improved access, the most visible change will likely be the personal
health portal. “In three years we will be able, hopefully, to provide
clinical data back to patients who want it and start to change the
relationship between patients and providers – so that if they want to
book appointments online or have a different dialogue with a provider,
we will be able to have that happen,” said Brisson.
The payoff for clinicians should come in the form of more available
resources with the introduction of time-savers such as online
prescription renewals, which would mean patients would no longer visit a
doctor’s office just because they were running low on a certain
Ultimately, the “one patient, one record” system will shrink the
province for all Albertans, and will offer leading-edge care to all
citizens, not just the two-thirds who happen to live near the major
cities of Calgary and Edmonton.
If you break your leg in Banff and you live in Vegreville, you will be
able to access your diagnosis and test results, including the diagnostic
scans, when you go back to your general practitioner in Vegreville,
explained Brisson. “That is the real value statement for what we are
trying to do,” he said.
Artemis brings artificial intelligence to NICUs in
Canada and abroad
By Jerry Zeidenberg
TORONTO – An innovative project that aims to apply the principles of
real-time, business intelligence (BI) to babies in Neonatal Intensive
Care Units has demonstrated that it can spot when infants are getting
sick at an earlier stage than before – meaning that doctors and nurses
can take action much more quickly to save the lives of ailing newborns.
Launched first at Toronto’s Hospital for Sick Children, the
Canadian-developed technology – which is still in the research phase –
has now been implemented at Women & Infants Hospital in Providence,
Rhode Island, as well, and may soon be installed at an additional site
in Canada. What’s more, authorities in China are now interested in the
system, which is called the Artemis Project, and have asked for a
demonstration of the technology.
“Clinical units in NICUs are still documenting by paper, usually at 60
minute intervals,” said Dr. Andrew James, associate clinical director of
the NICU at the Hospital for Sick Children in Toronto. “A lot of the
data is lost.”
Dr. James gave an update on the Artemis Project at IBM’s research and
innovation summit, held at the Toronto lab in late September. He was
joined in the presentation by his chief collaborator, Dr. Carolyn
McGregor, Canada Research Chair in Health Informatics at the University
of Ontario Institute of Technology, in Oshawa. IBM Corp. is also a
partner in the research.
Even traditional electronic patient record systems aren’t delivering the
goods, observed Dr. James. It’s difficult to find systems that can
consolidate the data feeds of medical devices in real-time, and harder
still to find any that can analyze the information flows in a meaningful
“It’s not the electronic patient record that I needed,” said Dr. James,
“it’s intelligent analysis.”
He pointed out that NICUs are dynamic, stressful environments that are
full of interruptions. “They’re chaotic,” said Dr. James, “but we as
physicians thrive on chaos.”
Nevertheless, in this kind of environment it wouldn’t hurt to have some
help in the form of computerized early warning systems. Better still if
the systems are equipped with a form of artificial intelligence that
gives them predictive abilities.
Hence the development of Artemis. “We want to predict the onset of
particular medical conditions that have a bearing on mortality,” said
To that end, Drs. James and McGregor are devising electronic systems
that collect multiple feeds of data in real-time, and which analyze the
information to alert doctors and nurses about problems far sooner than
Project Artemis began with a focus on nosocomial infections in infants –
hospital borne infections that can lead to complications and even death.
“Nosocomial infection is far too common an occurrence,” said Dr. James,
“and the diagnosis is difficult.”
Indeed, by the time doctors and nurses notice that a baby is sick with
an infection, the illness has often reached an advanced stage. But by
monitoring and analyzing various data streams, Project Artemis is
showing that infections can be spotted even before the baby is visibly
ill. That can be done by monitoring subtle changes in heart rate, blood
pressure, temperature and other variables, and by using algorithms to
While the project started with nosocomial infections, the goal is to
expand into other problems as well. NICUs are typically monitoring
infants with various respiratory, cardiac, neurological and
gastrointestinal problems; by catching complications at an early stage,
clinicians have a greater ability to restore the children to health.
This kind of decision support could have monumental repercussions on
neonatal care around the world. Earlier diagnosis and treatment can also
lead to dramatic cost reductions for neonatal units, which can be
enormously expensive to run.
For her part, Dr. Carolyn McGregor is an Australian PhD who moved to
Canada in 2008 after winning grants that enabled her to establish a
laboratory at the University of Ontario Institute of Technology.
In Australia, she specialized in business intelligence and performance
management for the corporate sector. But after meeting Dr. James and
others from Canada, she realized that her expertise could be turned to
the healthcare world.
“I’m passionate about taking what I know in computing, to translate it
and save lives,” said Dr. McGregor. In particular, she noted that the
creation of expert systems for neonatal care would have a tremendous
impact on rural areas and the developing world.
“Babies in rural areas of Canada have twice the mortality rate as in
urban centres,” she said. “And in China, they have nine times the
mortality rate as in cities.” When fully developed, systems such as the
Artemis Project could be used not only in hectic urban NICUs but also by
hospitals in resource-challenged rural areas.
By August 2009, Dr. McGregor and her team had deployed the system at the
Hospital for Sick Children. It’s taking 1,000 readings a second and
analyzing the information in real-time, as well as storing the data for
Success with the initial system led to the second implementation at
Women & Infants Hospital in Rhode Island; as word spreads, additional
hospitals are seeking to joint the project.
“In future, our goal is to upscale and to expand to ICUs beyond
neonatal,” said Dr. McGregor.
TDIS lets hospital systems and physician EMRs talk
to each other
By Rosie Lombardi
Hospital EHRs and physician office EHRs – which normally don’t talk to
each other – are edging closer towards interoperability in Ontario. The
Timely Discharge Information System (TDIS) project that’s under way in
Ontario’s Central East LHIN is one of several initiatives in the
Funded in part by eHealth Ontario, the system automatically generates
information to family doctors within 72 hours of the patient’s discharge
from participating hospitals in the LHIN, which covers eastern Toronto
and bordering regions such as Durham, Kawartha, Haliburton and
The initiative grew out of discussions in the LHIN with the Primary Care
Working Group, championed by Dr. Christopher Jyu of the Scarborough
Discharge summaries can take weeks to be passed on from hospitals to
family doctors. And the format is typically paper-based – via Canada
Post and faxes – even for doctors who have EMRs.
“Doctors said they needed more timely access to the summaries, and they
wanted a way to get the information electronically into their EMRs,”
says Lewis Hooper, regional CIO of the LHIN and project sponsor.
Patients will inevitably show up at their family doctors’ offices for
post-hospital care – but their doctors are often not even aware they’d
been admitted to hospital. This has far-ranging consequences, beyond
embarrassment, due to the slow pace of information transfer. The real
issue is continuity of care, says Hooper.
“Patients are often discharged with a list of meds in the discharge
summary, but if doctors don’t have it, they can’t reauthorize the
medications. They sometimes need to send the patients back to the
hospital physician to get things straightened out. There’s research that
shows timely discharge information can prevent re-admissions to
hospitals, so there’s a big cost to this.”
That was the genesis of the TDIS project – to create a level of
interoperability that would enable the automatic transmission of the
information, says Hooper. Six hospitals in the LHIN and 292 family
doctors were involved in the first phase of the project, with Lakeridge
Health, in Oshawa, Ont., acting as the central hub for all processing.
Testing for the first phase pilot was completed this spring; further
implementation is now under way. The second phase, which will begin this
fall and is slated for completion in May 2011, will add three more
hospitals and hundreds more family doctors.
There are clear benefits to hospitals, says Hooper. “It helps them get
out of the process of printing paper and faxes. It’s a lot less work to
do it electronically.”
TDIS is a big step towards interoperability. It is being achieved by
creating a central data repository in a hub that connects hospitals and
doctors. The data repository holds the data temporarily until it is
processed, packaged, and sent to the secure file transfer protocol
server. “All the hospitals that are on different systems talk to the hub
at Lakeridge, which is jointly owned by them all, and it then streams
the information to doctors. TDIS uses a secure file transfer system,
with the HL7 standard and interfaces at the hospital end, and then the
doctor’s system automatically retrieves the discharge summary through an
SFTP server,” Hooper explains.
Doctors without an EMR can also receive the information via automated
fax, he adds. “We created our own physician database with contact
details for the doctors we dealt with, but longer term, eHealth Ontario
is building a provider registry for the province.”
For doctors with EMRs, interfaces had to be built for each vendor’s
system to enable them to feed the information automatically into EMR
data fields, says Marlene Ross, senior project manager at the CE LHIN.
“We worked in conjunction with Jonoke, Nightingale, Healthscreen and
Practice Solutions to build interfaces, and we will be working with more
in the second phase. Although the data on the hub is ‘universal’, each
EMR has its own nuances, so the system needs specific logic to pull the
data in and parse it into a format it can accept.”
The data is processed in a way that goes straight into the EMR without
human intervention, adds Ross. “It’s like a PDF file but wrapped in
meta-data so fields can be matched.”
The technology for TDIS is fairly straightforward, and there were few
issues in the first phase of the project, says Hooper. “We came in
on-time and on-budget for that component.”
Not so for the governance component. The biggest difficulty wasn’t the
technology, he says. It was all the privacy, security and service level
agreements needed to set this up with all parties. “That took more time
and dollars than we anticipated.”
Interoperating with external entities is new territory for most
healthcare organizations, so agreements around information exchange had
to be developed from scratch between hospitals and doctors so that
everyone would be comfortable with the arrangements. In addition,
threat-risk and privacy impact assessments were conducted. Ironically,
going paperless involves a great deal of contractual paper.
At the hospital end, Lakeridge needed an agreement with each hospital
and also a master hosting agreement for itself, says Hooper. “Because
Lakeridge is hosting information, they needed an agreement with each
saying ‘You allow us to hold the data on your behalf.’
At the doctors’ end, service level agreements (SLAs) were put in place
with the 292 doctors. “We felt these were needed so they would know what
to expect and who to turn to if there was a problem. We worked with the
Canadian Medical Protection Association and eHealth Ontario to ensure
this was acceptable to the doctors.”
Dr. Jyu’s efforts in championing the system were instrumental in
reassuring family doctors, says Roberta MacDonald, Toronto-based senior
manager at healthcare consultancy Beacon Partners, who was the project
manager and liaison in developing agreements.
“Dr. Jyu put together a letter and information package explaining the
SLA had been reviewed by the CMPA, and its purpose was to protect them
as information custodians. Once they got the package, they were all good
There are other similar initiatives afoot. OntarioMD, for example, is
also working on a patient discharge project at the Royal Victoria
Hospital in Barrie, says Hooper. “Our project is slightly different
although both have similar objectives. We’re both funded by eHealth
Ontario and we all sit on the same steering committee, so we’re working
together. It’s not prudent to have only one way of doing things.”
Ultimately, these and other pilots under way in Ontario aim to achieve
healthcare computer system interoperability throughout the province. The
key lesson learned in the TDIS project is that more standardization will
be necessary to allow healthcare systems to talk to one another. “We
need standardization in many areas that goes beyond nomenclature – we
need consistent workflow and business processes too,” says Ross.
Outsourced dictation and transcription lead to cost
savings at NYGH
In an era of budget cuts, bed reductions, and increased demand for
patient care, hospitals are doing more with less. North York General, a
600-bed hospital in the Toronto area, is doing just that by outsourcing
non-core hospital functions such as dictation technology and
The decision to implement a fully outsourced solution from Accentus has
resulted in first-year cost reductions of 40 percent and is expected to
save North York General Hospital $3.5 million in the first five years of
Just a few years ago, North York General Hospital had a dictation and
transcription dilemma. It was using an aging dictation system and had
outsourced transcription services to about 20 independent contractors
who worked from their homes.
It was a difficult situation, said Maria Muia, director of health
information, decision support and privacy for the hospital. At times,
this scenario created a backlog of transcriptions, and the hospital was
typically about a week behind for non-urgent cases, she said.
To catch up or handle spikes in volume, North York General sometimes had
to hire additional transcription agencies.
This had an impact on patient care. “Hospital physicians’ notes weren’t
there when clinicians needed to make decisions about treatment,” said
Muia, “and discharge summaries for family doctors could take up to two
weeks or longer to process.”
By moving to an outsourced solution and shifting the onus of
turn-around-time, quality and production management to Accentus, North
York General was able to accelerate the completion of reports. Today,
reports are finished and available to physicians within 24 hours.
Managers at the hospital realized they needed a new dictation system and
a better way of handling transcription. The trouble was, however, many
of the available solutions were expensive, and the hospital wasn’t keen
on making a major capital investment that instantly became dated with
ever changing technology. Transitioning to a-software-as-a-service (SaaS)
based business model made a lot of sense; it would eliminate the need
for a large capital investment while providing access to the latest
dictation, transcription and voice recognition technologies on a pay-
and scale- as-you-go basis.
After an RFP process and review of various vendors three years ago,
North York General selected Ottawa-based Accentus. “They provided the
latest technology, a 24-hour turnaround transcription service, strict
adherence to quality metrics and they were wholly Canada-based,” said
Muia. “We weren’t prepared to send our confidential information
Importantly, the company provides a data quality program, added Muia.
“Their transcriptionists must pass certain tests before they can be
assigned to hospital accounts. We run independent data quality reports
on a regular basis, as well as ad hoc checks. Our transcribed reports
are typically 99 percent correct.”
Implementing Accentus’ solution took about four months, she said. A nice
feature of the system is that dictated reports become part of the
electronic health record. “We wanted the transcribed reports to upload
directly into our Cerner Powerchart EMR, so our IT staff worked with
Accentus to build the interfaces.”
When hospitals opt for our fully outsourced solution, there is no longer
a physician dictation system on-site, explains Nick Noreau, director of
sales at Accentus.
“We install a voice capture box on-site. Doctors continue to dictate the
same way via the phone system, and the box captures the audio and
transmits it via a secure, Virtual Private Network connection to our
data centre in Ottawa.” It is completely seamless for physicians.
Hospitals are only charged for services they use, based on minutes of
audio dictation, and the company is able to anticipate and handle spikes
in demand. Accentus monitors volumes, trends and seasonal dictation
patterns to ensure that the 24-hour turn around time is met.
“Anytime we expect a surge in volume, we let Accentus know so they can
ensure they have adequate resources available for our work. In addition,
Accentus offered continuity of employment to all of our previous
contract transcriptionists so they didn’t lose their jobs, which was
important to us. It turned into a win-win for everybody,” said Muia.
NYGH’s physicians are also pleased with the new arrangement, she said.
“In the past, physicians complained, ‘Why are you asking me to complete
my charts when they don’t get transcribed for weeks, anyways?’ Now
they’re saying, ‘No sooner do I dictate my notes do I see them in
Noreau said NYGH’s 40 percent savings are typical for users of the
Accentus eDoc Enabled Transcription Solutions, adding that the company
has implemented full and partial outsourcing solutions at several other
major Canadian hospitals. “Outsourcing the transcription piece saves
about 30 percent on the labour side. Combined with our technology
solution, savings can reach up to 70 percent.”