Ontario’s LHINs growing up – some faster than otherst

By Andy Shaw

TORONTO – Ontario’s 14 regional health authorities are now in their third year of existence and much like toddlers, they are maturing in different ways and at different rates. Their grasp of technology, for example, differs widely.

That came clear at a two-day “Information Technology Within LHINs” conference organized by Insight Information earlier this year in Toronto. Presenters from various LHINs gave conference attendees a 2008 snapshot of their varying IT deployments – just before Ontario’s Ministry of Health and Long-Term Care was scheduled to hand all LHINs the results of an “Effectiveness Review” of their efforts to date.

From the review, the LHINs were to learn how ready the Ministry thinks they are for future growth and what new strategy Ministry has divined to guide them.

By time of writing in September, however, a Ministry spokesperson could only say that the review, which was due in June, wouldn’t be out until “sometime this winter.”

The LHINs are also waiting for the province’s formal eHealth strategy, which was rumoured to be ready last spring but has yet to rear its head. Its major components are said to include Chronic Disease Management, an electronic health record viewer for healthcare providers across the province, and e-prescribing capabilities.

So the LHINs have been left pretty much free to toddle on independently as they have since their inception.

Born by provincial decree only in 2005 as the lumpily-named Local Health Integration Networks, Ontario’s LHINs have grown up so far without much parental guidance at all. From the outset, the LHINs were allowed by the Ministry to set their own strategy and wend their own way toward region-wide integration. Within broad guidelines, each LHIN could pick its own priorities, design its own eHealth pilots and projects, select its own partners and vendors, as well as appoint its own chief executive officer. As a result, some have grown up faster than others.

A few precocious ones such as LHINs 1 and 2 in south-west Ontario now stand noticeably taller than their siblings when measured by their deployment of technology. Their growth spurt started early with a healthy grant from Canada Health Infoway in late 2003 to help the two authorities establish a common diagnostic imaging (DI) network and repositories they could both dip into. Today, as DI project director Babette McRae told attendees at the Insight conference, the two LHINs have most of that shared PACS network in place, stretching from Windsor north up to Tobermory and east over to Cambridge. That span stands out against the accomplishments of other slower developing LHINs, a few of which have yet to even select a CEO.

To be fair to Ontario’s late-comer LHINs, it was not until April of last year (2007) that the Ministry of Health gave the LHINs full authority to get on with integrating services and technologies across their respective regions. Yet even then the province did not fully articulate how they should go about it. It’s almost as if the Ministry decided: Let’s see how the kids make out on their own at first, and then we’ll decide how to raise them after that.

Nonetheless, many of the LHIN kids are doing OK, albeit in various ways. Most have developed some sort of eHealth strategy as a foundation for their efforts at regional integration. Others are already on to creating regional data warehouses that will make an electronic health record (EHR) work. But only a few LHINs have built meaningful connections beyond their hospitals walls and integrated their acute care facilities with community care organizations or with family physicians in their region.

One that has, however, is the North Simcoe Muskoka LHIN, anchored in Barrie, a burgeoning city on the edge of cottage country north of Toronto.

“We started out by doing a survey of our needs and purposely went beyond organizations that get LHIN funding. So we included community caregivers and our doctors in the survey too,” says the LHIN’s e-Health Lead, Rod Burns. “Consequently, we got a clear snapshot of the whole healthcare community’s IT capabilities and their readiness for an EHR.”

The survey revealed that only about 40 percent of the LHIN’s community care institutions were taking advantage of the IT services such as the secure email offered by the Ontario government’s Smart Services for Health Agency (SSHA). Indeed, adds Burns, many in community care do not even know what the SSHA is or does. Doctors in his LHIN on the other hand pretty much know and are chomping at the bit to go all electronic.

“In Barrie, we have a family health team of 72 physicians, or about 85 percent of all our doctors in town, and none of them want any more paper,” says Burns. “They don’t want to be sent faxes. What they told us they want very clearly is an electronic interface with whatever institution or provider they send their patients to.”

But therein lies the challenging complexity all LHINs face when trying to interface. The North Simcoe Muskoka LHIN, for instance, has seven family health teams, in all, who use electronic medical records (EMRs) from four different vendors. To get what the physicians are asking for, those EMRs must be made to interface with hospital information systems (HIS) from two different vendors at North Simcoe Muskoka’s six hospitals. A daunting task.

And so North Simcoe Muskoka officials decided to simplify things.

“We’ve laid out a simple roadmap to get all of our hospitals on the same Meditech system that four of the six are on now,” says Burns. “We also have a regional health information council that looks at how our legacy systems in each institution can be extended and shared. That’s precisely what we are doing now with PACS (picture archiving and communications system), too. To have one HIS and one PACS for the entire LHIN is our goal.”

A shareable PACS for the entire province is the goal of a provincial government effort that will eventually bind all 14 LHINS and their 148 hospitals together. The Ministry’s DI/PACS Initiative will use repositories to make diagnostic imaging information shareable. By 2010, the goal is that 100 percent of the images taken by Ontario hospitals from Cornwall in the south-east to Thunder Bay in the north-west will be digitally stored and retrievable by all authorized care providers.

For an example of system-wide connectivity, however, Canadians might want to take a close look at the Australian experience. According to Mark Groper, it’s perhaps the best example on earth of how a parent health ministry should treat its children.

Groper is an executive vice-president at Emergis (now a Telus company) and is very familiar with what South Australia – a state equivalent to a Canadian province – has already accomplished in the direction that Ontario seems to be heading, however haltingly. He tells of a case study of South Australia’s 10-year-long commitment to computerizing its caregivers, including 82 public hospitals, which can now all share their electronic records through data repositories. And more specifically he talks about the state’s use of the Oacis clinical information system, configured and implemented by the consulting firm Accenture to provide a single point of access to 4.5 million online patient records from anywhere and by any authorized caregiver in South Australia.

“Their program has been wildly successful,” says Groper, a person not given to over-statement. “And one of the main reasons is that they put data warehousing early into their implementation cycle.”

Data mining of those data warehouses has enabled South Australia’s ministry of health to measure and trumpet the benefits of computerization and consequent integration right from the start.

“That’s brought physician, patient, and political buy-in, and so it’s generated huge momentum as a result,” says Groper. “So much so that the ministry of health has recently authorized another $400 million of technology expenditures, a remarkable figure for one of Australia’s smaller states of only about 1.5 million people.”

As Groper points out, the changes brought about by South Australia’s investment in and integration of its clinical information system, data warehousing, and data mining technologies are significant and highly evident: automated discharge summaries, for example, now appear on average within 2 days of a patient leaving hospital instead of the previous paper-based norm of 48 days; any death following surgery is automatically noted and analyzed, often resulting in changes of standard procedure and saved lives of similar patients; chest pain protocols are tracked state wide to measure the degree of compliance and consequent outcomes; the impact of vaccines is also being monitored with the result that one brand has been ordered off the market; and scorecard technologies are plucking data from the depositories and measuring the performance of individual specialists.

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Carestream offers ‘low-cost’ DR solution with wireless detector panel

By Jerry Zeidenberg

ROCHESTER, N.Y. – Carestream Health has announced a cost-effective innovation for the Digital Radiography marketplace – a wireless DR detector panel that can be used with existing X-ray machines to replace the film that’s still widely used in hospitals and clinics.

Carestream’s new wireless X-ray panel slides into the ‘bucky’ that’s used to hold a film cassette.

There’s a startling difference in workflow between traditional film-based radiology and the digital version. Using X-ray machines and film, technologists must carry the film cassette to a machine for developing, and then ship the images to a radiologist for reading – a process that can take anywhere from minutes to hours.

By contrast, the wireless DR panel transmits the image to a workstation or PACS, where they’re ready for a radiologist to work with in a matter of seconds.

And captured digitally in this way, the images can be manipulated with electronic tools by physicians, resulting in higher-quality readings and potentially better outcomes for patients.

The impact on workflow – and patient throughput – in hospitals and clinics could be enormous, according to Carestream. With increasing demand for X-rays in populations around the world on the one hand, and a simultaneous shortage of skilled technologists to operate machines on the other, a solution that speeds up the flow of patients through an X-ray department is much desired.

While DR has offered faster throughput for many years, it has been financially out of reach for most organizations. Indeed, according to stats from Carestream, there are 200,000 general X-ray rooms around the world, but only 6 percent of them have DR.

“DR has been too expensive,” commented Todd Minnigh, worldwide director of marketing for digital radiography at Carestream. He estimates that it costs up to $650,000 to outfit an X-ray room with standard Digital Radiography equipment. In comparison, the DRX-1 system that’s being released by Carestream will sell for approximately $125,000.

“At this price, you could convert four rooms to wireless DR for the price of a one-room, dual detector DR suite,” said Minnigh.

He noted that another technology, Computed Radiology (CR), is less expensive than traditional DR, but “you don’t get the benefits of DR workflow with it.”

That’s because CR uses a cassette that must be moved from the exam table or wall stand to a machine for processing – essentially the same, awkward manouver as with film, although the processing is somewhat faster and CR converts the images into electronic format for viewing in a PACS.

With the wireless DR panel, by contrast, the detector can stay where it is, and it will transmit high-quality preview images in less than five seconds. In 15 seconds, the panel is ready to send another image.

The detector panel contains a battery, and each battery can power up to 90 exposures. The batteries snap in and out of the panel, so that a technologist can replace a spent battery with a fresh one, without disrupting the flow of patients through the suite.

According to Carestream, a battery replacement can be done in less than a minute. Recharging a battery takes three hours, and a re-charger can hold up to three batteries.

Carestream has had the DRX-1 under development for about two years. It expects to start selling the system – currently a work in progress – in the first quarter of 2009.

The system will be demonstrated at the upcoming Radiological Society of North America conference in Chicago. While other companies have been working on wireless DR panels, Minnigh said this is the first one that fits the dimensions of standard X-ray buckys.

That means it’s easy to upgrade rooms to DR – you simply replace the X-ray cassette with the wireless panel. And in the off chance that the wireless system is out of commission, you can substitute a film cassette or a CR panel until the DR system is back online.

“No modifications to existing X-ray systems are needed and facilities can continue to use the bucky with CR or film-based cassettes, if desired,” said Diana Nole, president, digital medical solutions at Carestream health. “In addition, the wireless functionality of the DRX-1 can improve efficiency by allowing a much more flexible workflow to meet the specialized needs of each individual facility.”

According to the company, the DRX-1 can be used in general radiology, trauma, orthopaedics and virtually all other X-ray exams.

The system is being sold with one panel, which can be inserted into a table bucky or upright stand, as needed. But Minnigh noted that each DRX-1 console can support up to three wireless panels. Additional panels will cost approximately $100,000 each.

Image quality is at 139 um pixel pitch, the company said. The panels are durable, and have been designed to sustain a drop from three feet. They’re expected to handle about 56,000 exposures a year, with a lifespan of seven to eight years.

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Privacy of electronic records enhanced using masking techniques

By Pat Jeselon and Ruth Yeo

Some say there is no need to be concerned about personal privacy, as we have none anyway. Others express great concern that our personal privacy is being constantly and consistently eroded. The latter concern is frequently cited amongst those individuals who worry that the electronic health record (EHR) will wipe-out whatever remaining privacy we have in today’s world of Facebook.

In a recent survey conducted for Infoway and the Office of the Privacy Commissioner of Canada, 88 percent of Canadians support the EHR. The poll showed nearly two-thirds of Canadians believe there are few types of personal information that are more important for privacy laws to protect than personal health information. Of those Canadians surveyed who support the EHR, the following was also reported:

• Canadians want to ensure that privacy and security safeguards are in place to protect their health information.

• 77 percent would like audit trails that document access to their health information, and 74 per cent want strong penalties for unauthorized access.

• 66 percent of Canadians want clear privacy policies to protect their health information.

• A majority of Canadians (55 percent) would like to be able to hide or mask sensitive information contained in their record.

The basic benefit of the EHR is to provide healthcare providers with up-to-date relevant personal health information on the patients for whom they are providing care. The basic risk of the EHR is that an individual’s personal information could be accessed by authorized users who do not have a professional relationship with the individual.

The challenge faced by privacy specialists is to find a pragmatic balance between enabling access to personal information for healthcare providers, on the one hand, while providing patients with a degree of control over who can access the information in their EHR, on the other hand.

The “need to know” principle is the basic tenet of the majority of access control programs. Notwithstanding the issue of establishing what is “need to know” rather than “nice to know” or “helpful to know”, roles-based access control (RBAC) is a worthy approach to ensuring that only those who need to have access to a patient’s information in the EHR are permitted to do so. Most hospitals are good examples of RBAC at work.

The patient-provider relationship is based on trust and healthcare professionals are well aware of their responsibilities to hold in confidence any personal information their patients may disclose to them.

However, there are frequent instances where personal information is disclosed; not through the original healthcare provider, but because another provider accesses the person’s information outside the patient-provider relationship. Privacy breaches of celebrities (remember George Clooney?) by staff are not uncommon, but neither are those of everyday citizens by healthcare providers who are ex-spouses, next-door-neighbours, or a relative of the patient (such as the September 2005 privacy breach at the Ottawa Hospital).

Consent directives give the individual the ability to place a “mask” on all or some of their personal information in the EHR.

Authorized users are thus precluded from accessing that person’s EHR unless the person gives their consent. Often, consent takes the form of a keyword that when entered into the EHR system temporarily lifts the mask, enabling the healthcare provider to access the information.

Canadian jurisdictions are entering into legislative or policy consideration of consent directives in response to this public concern. Ontario’s health information privacy legislation (PHIPA) supports this concept, as does BC’s “E-Health Act”. New Brunswick and Nova Scotia are also contemplating the use of consent directives, and a recent ruling by the Alberta Privacy Commissioner requires the implementation of consent directives in that province. PEI has already introduced masking functionality into its EHR.

All this is good, but some myths still persist.

For example, some believe that masking personal information in a record will put the patient at risk by preventing a healthcare provider from having full access to all available personal information about the patient. In reality, masking functionality is always counter-balanced with un-masking functionality.

Similarly, there are those who think that electronic health records will destroy the patient-provider relationship because of the inherent privacy risks. Privacy risks do exist with an EHR, as the distributed environment upon which the EHR is premised increases the risk of privacy violation. But it also provides protections that the paper-based record system cannot: access control based on “need to know”; audit logs and alerts; consistent implementation of security technologies; and consent directives that enable masking.

Privacy gone? We think not.

Pat Jeselon, MBA, CMC, is an eHealth Privacy Consultant working in BC, Ontario, Nunavut and Atlantic Canada. She is President of Pat Jeselon & Associates Consulting. Ruth Yeo, BSc Health Information Sciences, is an eHealth Privacy Consultant working in BC. She is President of Hourglass Consulting.

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STARTEL takes heart failure management into patients’ homes

Capital Health is pilot testing Nova Scotia’s first home telehealth venture through STARTEL, a multi-year research project that aims to transform heart failure management across Canada – from crisis response to proactive intervention.

STARTEL is putting sophisticated monitoring and communications equipment into 100 heart failure patient’s homes across Nova Scotia and New Brunswick, in partnership with the Atlantic Health Sciences Corporation. Patients check in daily, using the equipment to record their weight, heart rate and blood pressure measurements and send them to a central station, where experienced heart failure nurses interpret the data. The nurses monitor the patients’ input and contact them immediately if the results indicate a problem is brewing.

“In essence, we’re taking the heart function clinic into people’s homes, with added benefits,” says Michelle Currie, Capital Health’s STARTEL project coordinator. As she notes, there is only a handful of heart function clinics in the province. “It’s difficult for many patients to travel to these clinics – they may be a long distance from home, and some patients may be too ill or lack the resources to get to the clinic easily or often.”

Unlike ‘bricks and mortar’ heart function clinics, STARTEL provides patients with daily professional monitoring of their key disease indicators. It also provides them with ongoing education, through scheduled bi-weekly telephone or videoconference ‘clinical visits’ with the nurses.

The nurses work closely with cardiologists, as well as the patients’ family doctors, to adjust the patients’ care plan as needed. They also stay in close contact with patients to ensure patients understand and follow their treatment – so they may potentially avoid crisis situations.

“One of STARTEL’s unique elements is the inclusion of the primary care physician,” says Dr. Jonathan Howlett, the Capital Health cardiologist who developed the project. “We send patients’ bi-weekly reports to their physicians, to keep them in the loop and give them a say in their patients’ cardiac care. We also notify them of any non-cardiac problems the patient may be having, so they can follow up. We’re creating specialist-primary care teams, as opposed to parallel and possibly conflicting care from two isolated groups.”

After an initial assessment at the QEII Health Sciences Centre for patients in Nova Scotia or the Saint John Regional Hospital for those patients in New Brunswick, patients enrolled in STARTEL are assigned to a control group or the home telehealth group for a one-year period.

Half of this group receives a video-equipped device and half receives a device with audio only. The researchers want to learn which device is most effective, and how patients in the telehealth group fare compared to those who receive the ‘usual’ care from their family doctor and heart function clinic.

“We are using blood work to determine changes in kidney function, fluid retention, hemoglobin, clotting factors and other heart failure indicators,” notes Ms. Currie. “At the same time, we’re reviewing health records to see how many visits patients made to their family doctor or local emergency department, and whether or not they were hospitalized for their heart failure symptoms. This will give us a clear picture of the benefits and cost-effectiveness of the home telehealth system.”

Canada Health Infoway and AstraZeneca Canada are the major funders of this research project; with contributions from NB Heart and Stroke, as well. Dr. Howlett envisions STARTEL will roll into a clinical program – and not just in Nova Scotia and New Brunswick.

With shortages of nurses, family doctors and specialists across the nation, the STARTEL approach offers a way to extend the reach of limited resources, while providing proactive health care. The ultimate aim: healthier heart failure patients, at home, not in hospital.

How does STARTEL work? Let’s look at the experience of a patient enrolled in the program. Each morning, Vere Brydon’s STARTEL heart-health monitoring device chimes a greeting and asks him how he’s feeling. That’s his cue to go to the unit and touch the screen to enter his answer – the same, better, or worse than yesterday.

The voice then asks him to take his blood pressure with the attached cuff, providing step-by-step instructions, and displaying the score on the screen. After weighing himself on the attached scale and entering some more information, he presses the spot on the screen that sends his report to the hospital, where STARTEL project coordinator Michelle Currie and/or heart failure nurse Kim Bentley reviews it.

At 85, Mr. Brydon has seen his share of heart troubles. The WWII veteran had his first of more than a dozen heart attacks at the age of 44. He’s since had a quadruple bypass, several stents, and now a re-synchronization defibrillator (pacemaker). He lives independently in spite of his heart failure, and credits STARTEL with a newfound peace of mind.

“Being in this project gives you confidence,” says Mr. Brydon, the first Nova Scotian patient to receive a STARTEL device. “It’s like having a nurse in the house who can take your blood pressure anytime. It makes you feel a lot more comfortable.” Yet his main motivation for joining the study was to help others in the future. “This is the kind of research that will help keep people independent, and out of hospital or nursing homes, longer. It’s a wonderful program.”

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