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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.


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 doctors.


Outsourcing D/T
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 to follow.


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 care.”

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 been with.

“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 seeing them.”

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 health portal.

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 medication.

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 way.

“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 Dr. James.

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 ever before.

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 draw conclusions.

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 later retrieval.

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 province.

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 Northumberland.

The initiative grew out of discussions in the LHIN with the Primary Care Working Group, championed by Dr. Christopher Jyu of the Scarborough Hospital.

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 with it.”

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 transcription services.

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 operation.

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 overseas.”

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 Powerchart.’”

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.”