Calgary wins U.S. award for its e-record implementation

By Neil Versel

OJAI, CALIF. – The Calgary Health Region is gaining accolades outside the province for its use of IT. In July, the region became the first non-U.S. winner of an award meant to honour excellence in applied medical informatics.

The Association of Medical Directors of Information Systems (AMDIS) presented the Calgary Health Region with a 2007 AMDIS award in recognition of the regional health authority’s in-patient electronic health record, known as the Patient Care Information System or e_record. The award also recognized the region’s computerized physician order entry system, which links three urban, adult, acute care hospitals.

“Calgary Health Region has redefined industry norms, delivering a thriving e_record solution that has made quantifiable safety, quality and access improvements realizable,” states the AMDIS award citation.

Several leaders of the project were on hand to accept the prize, in Ojai, Calif., at the 16th annual Physician-Computer Connection Symposium, the annual meeting of the fast-growing group of medical informatics specialists. “It’s always nice to see the work that you’ve done recognized by an international organization,” said executive director of clinical transformation, Belinda Boleantu, who made the trip to the California resort.

AMDIS chairman Dr. William Bria said the awards committee was impressed by the level of multidisciplinary collaboration the Calgary project achieved. “The idea of starting to launch these [types of projects] needs to be celebrated,” commented Bria. “We’re looking for real incorporation of information technology into the process of patient care.”

Dr. Tom Rosenal, past medical director of clinical informatics for Calgary Health Region, believes that the e_record has done just that, transforming the entire way of practice in the three hospitals. With computerized physician order entry, the goal had been to achieve as much usage as possible within 18 months.

“The order entry rate is very high,” said Dr. Rosenal, noting that it now tops 90 percent for medication orders and 80 percent overall, with a 90 percent usage rate among physicians. Currently, the Eclipsys Knowledge-Based CPOE system handles 20,000 orders a day.

“It’s been that way since roughly two days after implementation [at each site]. It was virtually instantaneous,” Rosenal reports.

Another way the technology has become part of the care process is in allergy reporting.

Boleantu believes the computerized entry of allergies at the point-of-care represents a major workflow shift. “The impact from a patient-safety perspective has been enormous,” she said.

“Previously, allergy information could be found in 42 different places in the chart,” Dr. Rosenal explained. Now, it’s all in one spot. “And, it’s much more detailed information.” Boleantu also said on-the-spot documentation using the electronic medication system has resulted in a tremendous improvement over the previous practice of retrospective data entry. “One of our mottos for the project was ‘moving to real time,’” she notes.

The scope of the inpatient e_record implementation is impressive. The $80 million acute e_record project has linked a total of 2,000 beds, starting with Rockyview General Hospital in September 2006, expanding to Peter Lougheed Centre in November 2006 and then to the largest facility, 927-bed Foothills Medical Centre, in January 2007. The entire rollout, to more than 12,000 employees and 1,200 physicians, took all of 21 weeks.

“It was a ‘big bang’ at each site in terms of CPOE and nursing documentation,” Boleantu said. Every unit of each hospital had “super-users,” necessitating the training of 100 physicians and 700 other staff members to help their peers learn the system. “They were the arms and legs of the whole implementation,” she said.

Indeed, Boleantu is convinced the region could not have been successful without full participation from clinical staff – a point the AMDIS award panel agreed on. “We really believe clinicians lead, and this was a system by clinicians and for clinicians,” Boleantu commented. “The uniqueness of what we’ve done has been the engagement of clinicians.”

Take the CPOE build-out, for example. The region follows the recommendations of the Institute for Healthcare Improvement for post-heart attack, anti-coagulation and diabetes care, for example, and the technology has helped assure clinicians follow organizational protocols. Said Dr. Rosenal: “We’ve been able to standardize care delivery with our information system.”

But getting there required the development of 1,300 order sets and the clinical decision support that must accompany CPOE. A team of 10 clinical leaders solicited the input of 700 physicians within the region to develop best practices, around which the order sets were built.

Complicating matters was the fact that some parts of Calgary Health Region have had inpatient CPOE for 17 years, and very little was standardized. “We had a huge number of personal order sets,” Rosenal explains. “All of that had to be re-done, but it was done by people with a lot of experience.”

Calgary Health Region leaders now are planning another monumental undertaking, extension of the e_record to some 500 facilities, including Alberta Children’s Hospital, eight outlying hospitals, plus ambulatory clinics, urgent care centres, home health bureaus and long-term care.

Many of the sites are private practices, but the regional directorate will provide I.T. support.

“You want to be sure there’s consistency across those settings,” said Dr. Rosenal. “Medical errors happen at points of transition,” he noted, particularly when in-patients are discharged to ambulatory or home care.

By 2010, regional officials hope to have a comprehensive EHR called My e_record for each of the 1.2 million people in the Calgary service area. They plan to make it interoperable with a picture archiving and communication system (PACS) repository for all of Alberta, funded by Canada Health Infoway.

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With years of success at home, Canadian telehealth experts reach out globally

By Andy Shaw

Canada’s already wide reach in telehealth is now extending overseas. After more than a decade of piloting and implementing telehealth networks that bring better healthcare to Canada’s furthest flung outposts, our expertise in practicing medicine remotely is beginning to help others do the same.

There are new Canadian-driven telehealth projects sprouting up in locations from North Africa and the Middle East to the Far East and stretching down to South America in between.

In Libya, for example, the Digital Group of Telehealth Companies, based in Halifax, expects to help that oil-rich country do nothing less than create its whole national eHealth and telehealth infrastructure. On the other side of the globe, in the remote islands of the Philippines, telehealth experts from Alberta are helping villagers not far removed from the Stone Age improve their health via the cell phone. And in Brazil, the Brazil-Canada Indigenous Telehealth (BCIT) project is sharing the telehealth experience and know-how of our native peoples with their counterparts living in the wilds of the Amazon.

The key to these so-far successful international telehealth outreaches seems to be a typically Canadian keep-it-simple, low-key approach.

“In our case, we simply call it the toolbox approach,” says Digital Group CEO Wayne Bell. “All you do is look at what needs to be done, then you look in your toolbox of technologies and you pick the tool that’s right for the job.” Once Digital’s deal with the keen-to-computerize Libyan health ministry is signed, Bell should have plenty of tools to choose from. “They asked me what I guessed it was going to cost to bring eHealth and telehealth to Libya, and I said about one billion US dollars. They just nodded their heads and said, ‘Fine’.”

In the poorer but better connected Philippines, the tool of choice has become the low-cost cell phone and a ubiquitous network that feeds it.

“Much of what we have developed for telehealth over the years in Canada is built on web-based conferencing, but for that you need bandwidth and more importantly, you need computers and an electrical power supply. But in remote areas of the world, like on some of the Philippine islands, there isn’t any local power, never mind computers,” says Dr. Marilynne Hebert, a Calgary medical professor and one of the Philippines project leaders at the Alberta Centre for Innovation in Health Technology. “However, when we first visited there, we found there are cellular repeater towers everywhere. So I think that’s what makes this project so exciting: we’ve learned what can be done with a telehealth tool that’s as simple as a cell phone.”

In Brazil, as we have here in Canada, the BCIT project is likely to use satellites as tools for practising medicine remotely over huge distances. “Brazil is only just a little smaller than Canada and even though it has 180 million people, or six times our population, it still has vast expanses in the northern Amazon region where travel to any healthcare centre is long and difficult. There it might be by boat, but it’s not unlike Nunavut, where you had to travel a very long way by snowmobile or airplane,” says telehealth consultant Dr. Jocelyne Picot. “The Brazilian government is expanding its satellite network and appears very determined to use it to improve the health of its aboriginal people.”

There is similar determination from the top evident in Libya, says Bell, who has a good feel for government intent stemming from his role as telehealth advisor to the World Bank. “Libya wants to turn its healthcare around with health information systems and telehealth, and it is well prepared to do so. Not only does Libya have about $100 million a day coming in from its oil industry, it has human resources as well. They have a main teaching hospital in Tripoli, for instance, that has 2,500 medical students. But outside of it and Bengazi, the second largest city, there are few specialists available to patients in the rest of the country’s smaller and widely spread communities. So telehealth can bridge that gap.”

Bridging the gaps between the developed and the under-developed is never easy. But one part of the quiet Canadian telehealth style seems to be working well abroad: work with a university or other partner there, shun any bravado about our expertise, be sensitive to local interests, and ask questions first.

“We are working with a university in the Philippines and together we have taken a community approach to the project,” says Dr. Hebert. “There are so many dialects in the country, but we found young people who could speak them as well as speak English, and we’ve made them part of our team as a sort of health brigade attached to each community. Then we asked those brigades, in turn, to ask the villagers what they think is their most important healthcare need.”

What they need first in many cases, it turns out, is a healthcare fundamental – clean water.

“We’re working on taking water purification units out to remote communities, but how do you make sure that people know how to use them properly?” queries Hebert. “But then the light went on when saw how people in the Philippines were using text messaging on their cell phones. They don’t phone long distance and they don’t use email, but they use text messaging to communicate because it’s cheap. So we thought: Why not equip our young health brigades with cell phones if they didn’t already have them? And now we send out messages to them every day that they, in turn, can pass on to the villagers. So we don’t have to worry about getting paper notices about how things work out to the communities, or make sure they are posted where everyone is likely to see them.”

In communities that do have a local power supply to run laptops and projectors, a remote specialist can communicate with patients or educate and mentor local healthcare providers without a land line connection needed between them.

“We’re planning 10 weekly conference sessions to start with, where caregivers in outlying areas can take a digital picture of a patient’s condition and send it up from a laptop to the cellular network for discussion with peers or a specialist. The images go from the cellular network and then on to the Internet,” explains Hebert. “And with the e-learning software we have from Elluminate, anyone in the conference can draw a circle or arrow with their mouse on the image to help focus the discussion. Similarly, we can put up PowerPoint slides for more formal remote education sessions.”

All this data exchange will be run from a server at the University of Calgary, but Hebert sees that soon shifting to a Philippines based server.

This fall, in the next phase of the BCIT project, Brazilian healthcare providers are shifting north for a visit to our National Aboriginal Health Organization (NAHO) centre in Ottawa.

“The aim of the project is to help indigenous people accomplish their own means of accessing healthcare,” says Picot. “And one of the first steps, as we learned here, is to identify the principle diseases and their causes afflicting their particular population group. The Centre has (software) tools that help them collect such statistics.

“They also have tools and guidelines that enable native people to control their own data and specify how the information will be used and distributed. That’s something that’s been abused badly by others in the past. So the Brazilians will see first hand how to use these tools and will be able to plan the next practical steps of their own project.”

The hope is the Canadian International Development Agency (CIDA) and the Brazilian government will help fund these next BCIT steps – and chances are good that they will. The First Nations and Inuit Health branch of Health Canada helped launch the project, spurred on by a new federal policy fostering the transfer of our First Nations and Inuit healthcare know-how around the world. That policy complements a United Nations effort to do the same.

In the meantime, Picot, who was a founding member of the Canadian Society of Telehealth , has formed a non-profit organization (www.e-kss.org) presided over by her Canadian-born Brazilian counterpart, Luiz Esteves, to keep the BCIT project rolling.

Picot, who holds a PhD in communications, is herself president of Infotelmed Communications Inc., a telehealth consulting organization that was spun out of seminal work Picot did for the federal government when she led a team of researchers and consultants to complete several major studies of the Canadian telehealth industry.

“We are beginning to work more internationally now,” says Picot. “One of our Infotelmed consultants, for example, has just come back from doing some telemedicine work for Mali in Africa.”

Infotelmed itself is also a strand in an international web of health informatics consultants who offer telehealth as a specialty. It is a member of The Keston Group, which has offices in seven countries, but is headquartered in Canada – naturally.  

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Telemental health program expands to all ERs at River Valley Health

By Valerie Hagerman and Janice McIntyre

In June 2007, the telemental health service of River Valley Health, in New Brunswick, expanded to all six emergency departments in the region. All ER physicians and nurses in the region have 24/7 access to the expertise of ER psychiatric nurses and psychiatrists located at the regional hospital in Fredericton.

Situated west-centrally in the province, River Valley Health (RVH) delivers health services in the largest geographic region (Health Region 3) in New Brunswick. Through a network of healthcare facilities and community-based sites, staff and physicians provide programs and services ranging from primary care to specialized tertiary services.

To improve access to services and to reduce the costs associated with travel within the region, a variety of services are delivered through telehealth technology. In 2006-07, telehealth utilization increased by approximately 100 percent.

River Valley Health began delivering telemental health services in 2005-06. Since that time, over 200 patients have accessed specialized psychiatric, nursing, social work and psychology services through this technology.

The decision to expand the ER Telemental health region-wide was based on the results of a third-party evaluation of a pilot project completed in 2006 and a more recent survey distributed in the spring of 2007.

During the pilot project, mental disorders (e.g., depression, panic disorders, and phobias) were identified as one of the top three preventable admissions to hospital in River Valley Health.

Also documented was a high demand for mental health and addiction services in rural/small urban communities and a need for more health system and community-based resources in these communities.

The healthcare professionals interviewed during the pilot project evaluation reported relatively poor access to psychiatric services for patients in rural communities in the region.

Situations involving patients in crisis (e.g., suicidal patients) and patients who arrived anytime of the day or night at the regional hospital in Fredericton, often via sheriff’s transports, were described as a logistical nightmare for professionals and patients.

In March 2007, the RVH ER Telemental Health Work Group distributed a survey to emergency room nurses and physicians. Most (50 percent) respondents indicated that the greatest challenge in either diagnosing or managing patients with a psychiatric disorder was lack of qualified personnel at the local level.

In the same survey, the priority areas of focus for a region-wide emergency telemental health service were identified as improved access to:

• ‘Just in time advice’ on how to manage patients locally

• Suicide risk assessment

• Appropriate referrals to the regional hospital and/or community mental health centre

• Educational opportunities for ER staff and physicians on the management of psychiatric emergencies

• Patient transfer protocols

• Guidelines on the appropriate use of psychotropic medications in the ER.

Results: Overall, the results of the third-party evaluation of the initial ER Telemental health pilot project demonstrated that:

• Patients requiring emergency psychiatric services strongly supported a telehealth mode of delivery

• Rural emergency room nurses and physicians found telemental health increased their confidence in handling psychiatric emergencies at the local level

• Clinical decision-making was improved relative to patient transfer, treatment, and follow-up.

Patient feedback: As one patient reported during the pilot project, “Sometimes asking for help is difficult when you are sick. With telehealth it is so quick you don’t have time to hurt yourself, you get the feeling that yeah, there is help.”

Overall, the formal evaluation of the pilot project reported that all patients interviewed were very positive about their telehealth experience.

Most patients described their experience as uncomfortable at first, but soon after the consultation began, they started to feel comfortable and felt as if they were sitting in a room with the specialist.

Nearly all patients interviewed were either satisfied or very satisfied with the services they received through telehealth.

The large majority (89 percent or more) of respondents on the patient satisfaction with telehealth feedback form reported that they were able to communicate easily, were satisfied with privacy and audiovisual quality, would use the system again, and felt that telehealth was of value to them and their community.

Overall, 96 percent were satisfied with the telehealth session. A high proportion (82 percent) preferred telehealth to traveling to the regional hospital in Fredericton.

Health Professional Feedback: “The region-wide expansion of emergency psychiatric and mental health services means patients do not have to travel to Fredericton to access specialized care,” said Dr. David Addleman, clinical chief of mental health, River Valley Health. “Psychiatrists in this region fully support the expansion because it allows us to provide a more rapid response to health professionals in rural ERs.”

Overall, health professional feedback from the pilot project saw telemental health as most useful for screening purposes, especially for those requiring urgent care. It was seen as being used to improve access and to avoid travel by clients or healthcare professionals.

Telemental health was found to be effective in dealing with most emergency psychiatric situations. It was also seen to reduce isolation of healthcare professionals and improve communication among them.

River Valley Health has concluded that telemental health is a viable and acceptable model of service delivery for adult patients requiring emergency psychiatric services.

Service quality will be monitored on a regular basis through the administration of patient and professional surveys and the collection of specific utilization data. More work is being done to implement a standardized suicide-risk assessment program for all ERs. There is also a need to provide regular continuing educational offerings for rural emergency physicians and nurses.

We would like to acknowledge the funding support received for the original pilot project from Health Canada, First Nations and Inuit Health Branch and the Department of Health, Province of New Brunswick.

We would also like to acknowledge ER Nurse Managers and other members of the RVH Emergency Room Telemental Health Work Group who have collectively planned for this region-wide expansion.

More detailed information on the results of the original pilot project can be found on the River Valley Health web site (Telehealth section) at www.rivervalleyhealth.nb.ca.

Valerie Hagerman BN MED, is Regional Director, Telehealth, River Valley Health; Janice McIntyre BN, is Nurse Manager, Mental Health, River Valley Health.

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Quebec to launch pilot project in January for province-wide EHR

By Andy Shaw

Quebec’s Health and Social Services Minister, Dr. Philippe Couillard, a physician, keynote speaker, and host this spring of eHealth 2007 in Quebec City, discussed plans at the annual conference for the nearly $560 million that will be invested in the province’s eHealth infrastructure by 2011. The centrepiece is nothing less than an electronic “Dossier de santé du Québec” (EHR) for all Quebec residents. The clinical information carried in the Dossier will be shared by caregivers, with the patient’s consent of course, province-wide. At a minimum, Quebec’s EHR will contain a patient’s lab and diagnostic imaging results, emergency data, a pharmacy profile, and his or her vaccination records. It will give Quebec, said the Minister with some pride, one of the most advanced health information networks in the country.

In his eHealth 2007 news conference formally kicking off Quebec’s EHR rollout and in his fully bilingual keynote speech, Dr. Couillard in effect answered questions about his plans, further illuminating Quebec’s eHealth aspirations.

CHT: You are one of the longest serving health ministers in recent Quebec history, but you admit it has taken a while to get your EHR under way. How come?

Couillard: E-Health was one of my priorities when I was first sworn in, back in 2003. But there were two reasons why it has taken us nearly four years to announce these first concrete plans. And the first one had to do with privacy.

Respect for people’s privacy is a commitment and responsibility at all times for government. So first we had to adopt the right legal framework – one that would ensure the safety of any data being exchanged between hospitals and their partners beyond hospital walls, such as clinics and community groups.

Then we took all the precautions possible when we designed the architecture in order to abide by the law and to ensure a very high level of security for the system and for the exchange of information. Keeping the data of patients confidential is built right into the foundation of the system. And just to make sure it is, we put aside $71.3 million for the privacy aspect of the project alone.

CHT: What was the second step that took time?

Couillard: The second step was for us to join the CIHI (Canadian Institute for Health Information) and also align ourselves with Canada Health Infoway. As you are no doubt aware, the previous (separatist) government didn’t give these ‘Canada’ organizations a high priority. Without Infoway, however, there would be no EHR project in Quebec and we are deeply grateful for their funds. (Editor’s note: Infoway is footing over half the bill for the Quebec project.)

CHT: What are you hoping will be the benefits of the Dossier de santé?

Couillard: With this shared EHR, clinical teams at the local, regional, and inter-regional levels will be able to share, in complete security, information that is pertinent to the health of their patients. So what we’re speaking of here is better co-ordinated interventions, improved use of diagnostic resources, better managed care, and also more autonomy for our regions. With the computerization of our health and social services network, we will have in hand a formidable tool. When placed at the disposal of the medical community, it will save everyone time and provide better care for the entire Quebec population.

CHT: Where and when does the EHR roll out actually start?

Couillard: It begins with a trial in the national capital area of Quebec City, for which I am also the responsible Minister. Healthcare professionals in the national capital will be the first to go live with the Dossier. Beginning this coming January, 50 clinicians from the area’s hospitals, other healthcare institutions and organizations, 12 in all, will collaborate in the pilot scheme. The main goals of the pilot are to see how well the technologies supporting the EHR are integrated and how well we safeguard patient privacy.

CHT: What role are vendors playing in the development of Quebec’s EHR?

Couillard: One of the objectives of the project is to use the expertise of Quebec firms and develop jobs here as a result. So they are heavily involved. By working this way with industry in other sectors, we’ve been able to transform the local economy here from a government-based one to an innovation based economy with great success. It is almost full employment here as a result. Unemployment is now less than 5 percent and that is something we are very proud of.

CHT: Beyond the EHR, how else are you investing in eHealth?

Couillard: We are building a diagnostic imaging network beginning in eastern Quebec that will provide a central diagnostic imaging repository for 43 institutions by the end of 2009. It will cross-connect six health regions that are anchored by one of Quebec’s ‘RUIS’or university -based health information networks, at Laval University. The images will all be stored by code numbers and will be available to healthcare professionals for joint consultation. They will be able to easily call them up from any of those institutions and transmit them to colleagues elsewhere. This will mean a significant reduction in the number of people who have to be uprooted, or who have to suffer the delay of waiting to get advice from medical experts.

CHT: Getting back to the EHR and what you know of other EHR implementations, how do you hope the Quebec public will react to their EHR?

Couillard: I visited Israel last year and I was very impressed with what I saw there. People in Israel have health cards which carry their records. So their record is very real and clear to them. And here I think we need to give people similar access to their health information and confidence in the health system that carries it. Otherwise, the system becomes opaque to them and they won’t trust it.

CHT: Anything else you think the rest of Canada should know?

Couillard: Well, we hope to see as many people from across Canada here next year in 2008, because we will be celebrating the 400th anniversary of Quebec City, which of course is the birthplace of our country. 

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