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Inside the October 2003 print edition of Canadian
Healthcare Technology:
Feature Report: Developments in telehealth
 Hospital council
announces new slate of e-health projects
The Ontario Hospital eHealth Council has announced
support for three new projects that will help create a province-wide
network of electronic health records.
Online education
Web-based CME is growing in popularity among
doctors, due in part to the movement away from industry sponsored
educational conferences for physicians. mdBriefCase has been
a beneficiary of the trend.
Shortage of imaging technologists threatens healthcare, experts
say
The situation has become a political issue
in Ontario, where the opening of private MRI and CT clinics has
led, according to some observers, to the “poaching”
of technologists from public hospitals.
Mobile IT at Ottawa Hospital
The Ottawa Hospital has had excellent results
from two pilot projects using wireless technology — a system
for providing physicians with point-of-care information when
treating ovarian cancer patients, and a dictation system that
generates reports in hours rather than the traditional days or
weeks.
Benchmarking IT projects
At a time when accountability is becoming
a high-profile issue, columnist Richard Irving provides some
guidelines for assessing the performance of information technology
investments.
Easy-to-use monitoring
Adcom Videoconferencing plans to market the
Health Buddy in Canada, a device that connects home-care patients
with monitoring centres and provides communication through just
four keys.
PLUS news stories, analysis, and features and more.
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Hospital council announces new slate of e-health projects
By Jerry Zeidenberg
TORONTO – The Ontario Hospital eHealth
Council has announced support for three new projects that will
help create a province-wide network of electronic health records.
The systems are aimed at giving physicians and other authorized
care-providers access to a greater range of data about patients,
resulting in faster and more accurate diagnoses and treatments.
The initiatives include:
• An expansion of the current e-pharma strategy to include
medication information about all residents of Ontario. The existing
initiative, announced last year, focuses on giving doctors access
to medication data about senior citizens that’s stored in
the Ontario Drug Benefit Program database. The new plan is to
broaden the scope of the project, by tapping into additional
sources of information such as pharmacies, to provide authorized
care-givers with drug usage information about all individuals.
• A standard method of transmitting laboratory data, so
there is one specification for sharing information. There are
currently several projects in the works to make computerized
lab information available to healthcare professionals, including
a pathology system from Cancer Care Ontario, the Ontario Lab
Information System and an initiative from the e-Physician Program.
As well, there are plans afoot to provide physician practices
with access to hospital lab results. “Rather than have four
different specs, we’d like to develop one, consistent specification
for all labs,” said Kurt Rose, Director of eHealth Strategies
at the Ontario Hospital Association. “We want to make sure
that everyone is on the same page.”
• The creation of a province-wide secure e-mail system for
all Ontario healthcare providers, including the provinces 20,000
physicians, to enhance communication within the health system.
The Ontario Hospital eHealth Council was launched by the Ontario
Hospital Association in 2001. The following year, the Council
announced two projects as its priorities, the e-pharma system
drawing on information from the ODB program database, and an
electronic waiting list system for cancer patients. The e-pharma
project recently won funding from the Canada Health Infoway,
and Cancer Care Ontario has begun putting together pilot projects
for its waiting list system, which will enable patients to better
determine which provincial facilities have openings for treatment.
Sam Marafioti, Vice-Chair of the Hospital eHealth Council and
Vice President, eHealth and Chief Technology Officer at Sunnybrook
and Women’s Health Sciences Centre, said a request for funding
the three new projects will be submitted shortly to the Ontario
Ministry of Health and Long-Term Care, to obtain financing for
the 2004-2005 fiscal year.
Mr. Marafioti stressed the Hospital eHealth Council, a part of
the umbrella Ontario eHealth Council, favours a strategy based
on the creation of regional electronic health record networks.
“That’s because 80 percent to 90 percent of healthcare
is delivered on a local basis,” he said, with patients moving
from primary care physicians and clinics to hospitals and labs,
and in some cases to nursing homes or home-care settings –
all in the same community.
These regional networks, however, could be connected to form
a provincial network, and with further links a national system
could be produced. The larger networks would enable health records
to be easily transferred when patients need special care in a
distant treatment centre or require attention when traveling
outside their communities.
While noting that a good deal of progress is being made in the
construction of electronic networks by many communities, Mr.
Marafioti acknowledged that most physicians still aren’t
participating in these systems. “Primary care physicians
are one of the most important parts of the healthcare system,
and without them, a network is like a three-legged stool that’s
missing a leg,” commented Mr. Marafioti.
He said that’s why the Council is backing the creation of
a province-wide e-mail network that would reach doctors, running
on the Systems for Smart Health network and offering physicians
connectivity to each other and to various providers in the healthcare
system.
“Given the SARS crisis and the recent blackout in Ontario,
we see how important it is to have a quick and secure means of
communication for the doctors,” said Mr. Marafioti. “Doctors
need instant information.”
He noted that a province-wide email network for healthcare professionals
would provide fast transmission of alerts and treatment protocols
in emergency situations. “We don’t have three years
to get this up and running,” he commented. “We feel
it has to be done within a year.”
Mr. Marafioti also observed that once Ontario’s 20,000 physicians
are connected with an e-mail network, many other applications
may become popular. “The network, with a complete physician
directory, is likely to drive a lot of other applications,”
he noted. “We experienced this at Sunnybrook, where we gave
people the network and they started using it in many unexpected
ways that improved the delivery of healthcare.”
Mr. Rose added that the proposed e-mail system would also include
hospitals and other facilities. “We learned from the SARS
crisis that communication is critical, for the doctors, hospitals,
CCACs and for public health,” he said. “We want to
fast-track the creation of a provincial healthcare email system
to support our provider community.”
New wave of online educational ventures provides anywhere,
anytime access
By Andy Shaw
Seems everybody these days is rushing to get
involved with online medical and healthcare education. “People
are all of sudden taking it very seriously,” says Greg Cook,
president of mdBriefCase Inc. The company provides accredited
continuing health education programs written by physicians and
available online through its website.
In July, mdBriefCase entered into an exclusive partnership agreement
with GlobalMedic, a Canadian Medical Association (CMA) business
subsidiary that focuses on information technology and runs the
CMA’s website. Canadian member doctors can access mdBriefCase
courses via the CMA site.
“People are now calling us, whereas a year ago it was pretty
difficult to get potential sponsors for online education,”
says Cook, a 10-year veteran of the pharmaceutical business and
related consulting before taking over the medical education forerunner
of mdBriefCase.
Eager sponsors in numbers, ever the sign of a something that’s
truly caught on, are a crucial part of the mdBriefCase-GlobalMedic
deal. Companies including Pfizer, Johnson & Johnson, AstraZeneca,
Boehringer Ingelheim, Aventis, Bristol Myers Squibb and Solvay
Pharma, among others, have been more than generous in their
grants that enable the physicians to take the mdBriefCase courses
without charge.
So far, over 6,500 Canadian physicians had gone on the mdBriefCase
website and completed at least one of its courses. Indeed, most
of them have done more than one.
Among the 30 courses mdBriefCase offers, no one course seems
to be more popular than others. That may have something to do
with the fact that every course earns physicians a credit towards
the CME they are all obliged to undertake every year they practice.
Family physicians receive a MainPro M1 credit – a superior
accreditation to M2 credits in most eyes, since those are self-reported
credits.
“All our courses are M1 accredited and the criteria for
that accreditation is set by the College of Family Physicians,”
says Cook. “Our courses are also accredited for specialists.”
For the most part, there are no tests or examinations to prove
that the knowledge gleaned by physicians has been absorbed.
“What we do have are multiple choice questions and answers.
So the doctors can see how they are doing compared to other physicians,
but they can do it anonymously,” says Cook.
Although there are no formal exams to gain the credit, there
are a couple of online hoops that physicians must jump through
which are monitored by mdBriefCase.
“One of the things required of them is that they have to
have participate in an online discussion forum and we can easily
check if they have,” explains Cook. “We certainly don’t
monitor them constantly, but we can check to see that they have
completed the various sections of their courses.”
Cook counts himself and his company lucky to be in the position
they are in.
“We are Canada’s number one CME website by a wide margin
– both in terms of our content and the number of participants
we have. We were in the print end of healthcare education to
begin with, but we happened to be in the right place at the right
time when we shifted to online education.”
That timing was also helped by new restrictions and guidelines
that have grown around the activities of pharmaceutical companies.
Their traditional practice of sponsoring weekend-long educational
sessions and inviting doctors to them is now largely looked on
as a no-no by regulating bodies on both the medical and pharmaceutical
sides. The online courses make it easier to put the stamp of
being ethical and above board on them. So growth of online courses
and the numbers who take them seem inevitable.
“I think the most attractive thing about them is the time
they save,” says Cook. “That’s of primary importance
to physicians these days, and particularly saving time at the
office where they have patients waiting. They can do online courses
at home. The courses usually take an hour or less to do, so they
can do that while dinner is being prepared.”
Others across the land also working hard at making online learning
more user friendly, both for course takers and course developers
alike.
The Pan-Canadian Health Informatics Collaboratory (HIC), involving
a number of Canadian universities and institutes of technology
under the co-ordination of the University of Victoria, is “re-tooling”
online learning in healthcare thanks to a two-year $1.6 million
grant from the federally-backed CANARIE high-speed initiative
(see story in Canadian Healthcare Technology, October 2002).
The grant runs out at the end of this year and developers are
putting the finishing touches on instruments that should eventually
enhance the online learning experience enormously.
Dr. Michael Shepherd, Director of Health Informatics at Dalhousie
University, for instance, leads an HIC effort that at once will
make learning online more accessible, more interactive, and less
expensive to set up.
“We are really working on two projects in that vein here,”
says Dr. Shepherd. “The Open Text software we are using
as the basis of our courseware does not have Voice-over-IP capability.
So we are working on a tool or module that would allow the moderator
of a course to open up the module and have everybody in groups
of say, 6 to 10 people, in an educational session see each other
on-screen and converse – all over the Internet.
“The other thing we are doing is building what we call a
packaging piece of software. So that rather than content developers
having to create a whole lesson as one big conglomerate, they
can develop lessons in a modular fashion. Each module then goes
into a database and is tagged. Once their sequence in the delivery
of the lesson is known, then the whole lesson can very quickly
be pulled together and packaged.”
As at other HIC participating schools, such work at Dalhousie
involves more than just medical and healthcare specialists.
Dr. David Zitner is Dalhousie’s director of medical informatics
in the faculty of medicine and is co-ordinating the efforts for
the HIC of Dr. Shepherd, a library scientist by training as well
as that of Greta Rasmussen from the medical faculty’s CME
division who is concerning herself with online content, and Wes
Robertson, an informatician with a degree in English who is working
on developing better communications infrastructures for online
learning.
“I learned sometime ago when I was a medical quality consultant
at the Halifax Infirmary that you need access to developmental
tools that are normally only available to academics,” says
Dr. Zitner. “So if you’re going to solve healthcare
problems with new tools you need the collaboration of people
who understand both healthcare and technology.
“You need to have the faculty of medicine collaborate with
the Math department and with the Computer Science department
and then get contributions from the faculties of management and
graduate studies. That’s exactly what we did to develop
our new graduate program in healthcare informatics that we now
have under way here.”
Similarly, the University of Waterloo, also an HIC collaborator,
has taken the collaborative approach to its post-grad health
informatics that can be taken from off campus.
The Education Program for Health Informatics Professionals (EPHIP)
provides the successful student with a university-level diploma
earned usually over two years and completing seven courses.
The courses are taught using audio-conferencing and Internet
document conferencing. Communication with professors and collaboration
with fellow students is carried out mostly by e-mail.
As the program’s director, Dominic Covvey, a full professor
in Waterloo’s science faculty, wrote in our October edition,
“I have tens of students who have interacted with me for
as many as 60 hours and have never seen me.”
Forays into online healthcare education have gone so far that
early adopters are now at that inevitable second stage of admitting
to and correcting their start-up mistakes.
For example, the Ontario Hospital Association launched an online
service called Healplex last year (see Canadian Healthcare Technology,
March 2002) in the hope that hospital administrators and other
staff would take courses in great numbers. But they didn’t.
So the OHA pulled the plug this year and is at least temporarily
shifting its remote education emphasis to videoconferencing.
“What happened with Healplex is that we essentially took
it off because our market place surveys showed us that it was
too expensive,” says Robert Houlden, director of educational
services for the OHA. “It was very much subscription based
and you couldn’t pick off separate courses.”
Holden says Healplex also had an image problem.
“It was set up as a separate company and people didn’t
really associate it with the OHA. So it didn’t resonate
with our members very well. We’ll no doubt return to some
kind of online education but this time we’ll likely keep
it under the OHA brand.”
Shortage of imaging technologists threatens healthcare, experts
say
By Andy Shaw
There’s been much hue and cry in Ontario
lately, in case you missed it, about the “poaching”
of MRI and CT technologists by the province’s newly minted
private imaging clinics. This summer, the Toronto Star newspaper
in a number of articles drew attention to examples of robbing
Peter to pay Paul – including how the University Health
Network, the country’s largest conglomeration of publicly
supported acute care, had to scale back its hours for MRI because
of the loss of several technologists to a private clinic, one
sanctioned by the Ontario Government.
Those stories in turn stirred up the Loyal Opposition and other
government critics to call for the Premier’s resignation,
the Minister of Health’s head and the padlocking of the
clinics.
The fury, of course, stemmed from the original notion that the
entrepreneurial clinics would increase the province’s dreadful
lack of imaging capacity, not diminish it. The carrot that the
Government hung out to attract entrepreneurs into the field and
help fill the void included the admonishment not to “steal”
technologists from the public system. However, it was a stipulation
that not only proved unenforceable, but flew in the face of the
very supply and-demand economics Conservative governments champion.
It was also offensive to the technologists themselves, who indirectly
were being told they shouldn’t go looking for better pay,
more convenient hours, or perhaps more interesting jobs that
the private clinics might offer.
So this summer in Ontario, aside from SARS, the West Nile virus,
and the Great Power Blackout, the poaching of radiological talent
was seen as a big healthcare problem.
But poaching is not the problem, says Normand Laberge, the chief
executive officer of the Canadian Association of Radiologists
(CAR). The root problem is the process – the privatization
process Ontario evidently blindly chose.
“Nova Scotia went through the same poaching problem the
year before. We told Ernie Eves (the Ontario Premier) and Tony
Clement (the Health Minister) that Nova Scotia was the example,
that the same thing would happen in Ontario and that it would
not be to the advantage of anybody. Of course, they’re thinking
the health system is not sustainable, so they have to go private.
But in this case, it is sustainable if the approach is properly
organized and administered.”
There is, luckily says Laberge, another example province where
things diagnostic are properly organized and administered, but
which Ontario unfortunately also chose to ignore.
“Alberta does not have a poaching problem, and yet in a
way it is far more privatized than the systems in Nova Scotia
or Ontario,” says Laberge. “In Alberta, the radiologists
and the technicians are not employees of the hospitals or the
clinics. They are a separate corporate entity that is hired by
the hospitals and clinics to manage their diagnostic imaging
departments.”
In effect, the Alberta healthcare system has “outsourced”
diagnostic imaging to an entrepreneurial group that supplies
services to both public and private users. That group allocates
which radiologists and technologists go where, and consequently
there is no stealing of one from the other.
A sustainable integrated model, in short, compared to what Laberge
terms a disastrous one in Ontario that is bound to crash. “What
Ontario has done by creating private clinics that are not part
of the system is equivalent to putting on a car a front wheel
that can’t be steered.”
He sees the competition for scarce diagnostic imaging staff created
by the private clinics not only driving up salaries, but healthcare
costs generally, without reducing the imaging backlog. To retain
their staff, Laberge reasons, hospitals will have to increase
wages or bow to inevitable demands of their best people to match
the weekdays-only, daytime-only and other job perks the private
clinics offer – creating a need to hire more staff to fill
the other hours a hospital must work that a clinic doesn’t.
Despite what many see as Ontario’s privatization boondoggle,
others see at least a silver lining in it, including Dr. Renate
Krakauer, president and CEO of The Michener Institute for Applied
Health Sciences in Toronto. It trains and supplies the province
with its radiology technologists, both diagnostic and therapeutic.
“I think the newspapers have made too much of so-called
poaching. It’s not really the human resources issue it’s
made out to be,” says Dr. Krakauer, who adds that with additional
funding supplied by the province earlier in the year, she expects
the Institute will be able to train many more diagnostic imaging
technologists, at least on the MRI side of things.
Indeed, Michener Institute staff see the private clinics as breathing
fresh air and more career chances into what was becoming a moribund
profession.
“After Ontario re-structured its hospital system, there
were really no opportunities for advancement or growth or promotion
within organizations for our people,” says Nicole Harnett,
the dean of diagnostic imaging and therapy at Michener. “So
they got tired of their jobs. They saw them as dead ends and
they were leaving the imaging profession.”
But the growing demand for MRI technologists, in particular,
now accelerated by private clinic demands for them, has been
re-invigorating. MRI training is a post-diploma program, meaning
those that take it already have certification as some sort of
radiological technologist and are generally leaving behind a
vacant job.
“We do need to fill those lower level jobs, but MRI training
is at least keeping people in the imaging department. We are
no longer losing them like we used to,” says Harnett.
To fill the extra demand for MRI’s, Michener trained an
extra cohort of technologists this year.
“We usually run two MRI programs every year, producing about
40 graduates, but our labour market analysis told us we would
need about 60 to meet the needs of the province, so we ran an
additional program,” says Lorraine Ramsay, Michener’s
chair of advanced imaging. “We received about $350,000 from
the government to help out with that extra group, but that doesn’t
really cover all the costs.”
Michener officials wish there was similar hope and support for
other disciplines.
“Imaging technology has been receiving all the publicity
but there are shortages in the other modalities that we also
train here,” says Krakauer. “Nuclear medicine and radiation
therapy are particularly in need. But we have not been funded
to increase the class size in either and that is a concern for
us.”
A Michener study released late last year, for example, predicts
that by 2007 the province will be short nearly 300 nuclear medicine
technologists.
Such a shortfall of technologists echoes a larger, country-wide
dearth of the higher radiological skills. According to a human
resources study conducted by CAR, Canada has a ratio of one physician
radiologist for every 18,000 of its citizens while our own federal
government recommends there should be a radiologist for every
13,000 people. By next year, the study predicted, Canada would
be short some 500 radiologists. What’s worse is that while
the number of diagnostic images that need to be interpreted by
radiologists is rising by as much as 5 percent a year (despite
technologist shortages and thanks largely to an aging population),
the average age of the radiologists is also rising. Already some
10 percent are continuing their practices past the age of 65,
and retirements are expected to accelerate in the next few years.
Ottawa Hospital tests wireless charting and dictation applications
By Dianne Daniel
For physicians working in the Ottawa Hospital’s
gynecologic oncology program, instant access to accurate and
up-to-date patient information in a clinical setting has moved
from wish list to reality following the launch of a wireless
pilot project this summer.
Using Microsoft Windows Server 2003 and .NET connection software,
along with database management software from SysteMagic Software
Solutions Inc., the hospital has created a patient data collection
and analysis system intended to assist doctors and researchers
as they work to find a cure and to improve treatment for ovarian
cancer in Canadian women.
According to Dr. Tien Le, associate professor of gynecologic
oncology at the University of Ottawa, the program currently sees
between 30 and 40 women at its weekly cancer clinic, including
both new and follow-up patients. The goal of the newly designed
system, called GOSOCS for Gynecology-Oncology Services Ovarian
Cancer System, is to put the most complete patient information
into the hands of physicians, pharmacists, nurses, social workers
and other healthcare professionals involved in the ongoing care
of cancer patients.
“What we’d like to be able to do is retrieve information
quickly in the clinical setting when we encounter a patient,
so that appropriate decision making can be made regarding patient
management,” says Dr. Le.
As part of the pilot, physicians are using handheld and tablet
PCs to access the hospital’s computer network, and ultimately,
the GOSOCS database. Not only are they able to retrieve the most
current patient data available, but they can also input their
own notes while seeing a patient, which are then automatically
updated in the database. The value, says Dr. Le, is that physicians
are better equipped to deal with patient needs as they arise.
“If a patient has a concern from a psychological perspective,
I can address it from the clinic,” he explains, “rather
than waiting to go back to my office and placing a call to the
social worker to determine what the concerns are.”
At press time, the Ottawa Hospital was ready to complete the
last phase of GOSOCS, involving the installation of an 802.11
wireless network with wireless access points throughout the hospital,
so physicians can access the database “live” as opposed
to using PC docking stations to synchronize data. According to
Dr. Le, the pilot is mainly taking place at the Ottawa General
campus, but the plan is to extend it to include all hospitals
in Ontario involved in the treatment of ovarian cancer.
What makes GOSOCS portable between environments is its use of
XML Web services on the client side, so that data collection
remains device independent while the Internet can be leveraged
on the backend. “Hospitals have so many different types
of computing services, from a myriad of vendors. Putting in place
a Web services interface was not only a great solution for this
specific project, but it also gave us a framework for healthcare
from a proof-of-concept standpoint,” says Ben Watson, senior
project manager, Web services at Mississauga, Ont.-based Microsoft
Canada Co. “... If we can prove that we can deliver multiple
customized patient reports at the hospital level while standardizing
the data on the backend, then I think we’ll have a huge
win in terms of what people can leverage for future healthcare
projects.”
It appears Ottawa Hospital is one place where wireless technology
will continue to play a significant role in the future. In the
Department of Medicine, for example, a group of physicians are
currently using mobile dictation services provided by Accentus
Inc. of Ottawa, following the successful completion of a pilot
project in March.
As Dr. Doug Smith, the department’s deputy chairman explains,
physicians dictate into handheld PCs or personal digital assistants
(PDA) and then send the voice files to Accentus via PC docking
stations. Within four hours, the completed medical transcription
is returned in a format that is compatible with any word processor
as well as the hospital’s electronic health record system,
OACIS. In addition to the rapid turnaround time, the main benefit
is that doctors can use one device for multiple purposes, says
Dr. Smith.
“The only thing that makes this different from the Dictaphone
is that it combines the dictating capability with my agenda,
e-mail and contact list,” he says. “Ultimately what
we are looking for is one device that will allow you to do all
of that, plus be your cell phone and pager, but we’re not
quite there yet.”
Dr. Bill Cameron, professor of medicine and infectious diseases
at the University of Ottawa, was one of the first physicians
at Ottawa Hospital to use the Accentus mobile dictation service.
Unlike other doctors who were already using a handheld computer,
Dr. Cameron was introduced to the technology for the first time
through Accentus. While it did take a few weeks to become accustomed
to the device, he says he has no desire to return to his previous
method of using a recorder for dictation.
“I think it’s neophobia; we don’t like something
that’s different because we don’t understand its workings,”
says Dr. Cameron. “Now I just see it (the mobile device)
as a black box – I speak into it and back comes a letter.”
Both Dr. Cameron and Dr. Smith envision a time in the future
when the mobile dictation service will be able to leverage the
hospital’s investment in a wireless network, allowing physicians
to dictate on the fly as opposed to using docking stations. Notes
Dr. Smith. “I know we’re heading in that direction.”
Since the pilot in March, 15 Department of Medicine physicians
have signed up for the service and more are expected to follow.
The main reason for increased interest in the mobile dictation
service is that it facilitates the concept of the electronic
patient record, which remains a major thrust for the department,
says Dr. Smith.
“If a patient came into the emergency and was seen by a
resident, rather than writing a handwritten note, they could
dictate into this technology and it would actually appear on
the chart within hours rather than days or weeks,” he says.
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