New technologies have made videoconferencing easier

By Andy Shaw

Ever since Alberta psychiatrists in Edmonton began pioneering on-camera consultations with their remote patients a decade or so ago, videoconferencing has been moving, albeit haltingly at times, into the mainstream of primary and acute care. Today, the confluence of staff shortages, growing consumer embrace of video technology, the need for caregiver collaboration and most recently, new high-definition capabilities are all helping the videoconference do a gradual dissolve from a costly nice-to-have to an affordable must-have.

Indeed, some believe we may be entering a whole new era of what you might call “videocare”. Dr. Ed Brown, head of the Ontario Telemedicine Network, (OTN) is one.

“It is indeed time for this technology. The prices are dropping for it. People are all wired up these days, and they’re used to the video aspects of the internet like FaceBook and YouTube. So it just seems more natural now. The timing is very good.”

So is Dr. Brown’s.

Under his leadership as CEO and with substantial help from Canada Health Infoway, the OTN has grown to be envy of the telemedicine world. Some 2,000 physicians and other healthcare providers are now using OTN. And in 2008, they provided over 48,000 videocare consultations. The OTN, stretching 1,500 kilometres north-south from Hudson Bay to Windsor, covers the province like a spider’s web linking 750 videoconference sites. It is the planet’s biggest, most used telemedicine network.

That ubiquity is something double-lung transplant patient Lauren Childerhose is grateful for. Indeed, she will likely owe her prolonged life and good health to it.

The 21-year-old had her 18-month post-op check-up done recently in hometown Kingston – though it was conducted by her doctors and respirologists gathered in Toronto. Lauren’s was telehealth appointment #1,000 for the Toronto General Hospital’s (TGH) lung transplant program. Consequently, it was an occasion Lauren agreed could be celebrated and also witnessed by the media.

“We did our first consultation in 2002 via videoconferencing and we realized it was a very good method. So we’ve been doing all our pre-transplant patients from out of town this way until they are ready to come to Toronto for a full assessment or the transplant,” said respirologist Dr. Lianne G. Singer, the medical director of the Toronto Lung Transplant Program run by the TGH’s Respirology Division. “And we’re also using this occasion to announce that we are extending the program to follow patients after their transplant. And Lauren will be the first.”

The examination begins in TGH’s multi-disciplinary telehealth room in downtown Toronto featuring two large Tandberg videoconference screens and two cameras. We see Lauren on the left-hand sitting demurely in the telemedicine room at Kingston General Hospital some 240 kilometres away. While the right-hand screen shows the cast of physicians, several telemedicine assistants, TGH’s videoconference technician, and this CHT contributor all assembled for the occasion.

Lauren sees two similar screens in Kingston with the same pictures. Technician Adam Smith controls the cameras at both ends, zooming in for a close-up when anyone speaks. On a separate monitor in each location, Smith can display close-ups of Lauren’s chart and other medical records.

On the desk beside Smith and his box of controls is a digital stethoscope that Dr. Cecilia Chaparro Mutis will use later to listen in Toronto with utter clarity to her patient Lauren’s breathing in Kingston.

But then something even more extraordinary happens. As Lauren and her doctors begin to talk, the technology between us in effect disappears. We are witness to this pleasant chat with Lauren who seems to have moved into the room. And we can see and hear she’s feeling pretty good these days about her life – one that promises to be significantly longer for a cystic fibrosis sufferer.

Before her lungs plugged up with CF’s infection and mucus, reducing their capacity to a wheeze, her life expectancy was measured in weeks. But the double lung transplant means she will likely live at least eight more years, and with luck much longer.

“After five years, the survival rate falls below 60 percent,” said Dr. Singer. “But some of our patients have now lasted 20 years since their transplant.”

The hope is that the new post-op videocare Lauren and others like her will receive, may raise survival rates.

Admittedly during the consult, the images of Lauren are grainier than you’d like. But even though much sharper high definition (HD) videoconferencing has arrived, it is not the technology that has been driving the videocare boom so far. Rather in Ontario’s case, says OTN’s Dr. Brown, it is the robustness of eHealth Ontario’s “ONE Network” backbone the OTN rides on. And for technician Smith at TGH, it is the simplified switching that comes with it.

“It’s about as easy now as placing a phone call,” says Smith as he scrolls through hundreds of OTN’s sites on his laptop. “Providing someone is at the other end, I can just click their link on this list, and bingo, we’re seeing and talking to each other. I can also switch the link into the desktops and videocams in the individual offices of our lung transplant physicians.”

And then he casually adds, as he reaches into his shirt pocket, “I can set up a videoconference even when I am not here – using this BlackBerry.”

But the best is yet to come for switching, says Brantz Meyers, the director of healthcare business development in Canada for communications giant Cisco Systems, now partnering with Dr. Brown and the OTN.

“We’re the fabric underneath Ed Brown’s network. We supply the high quality, secure network for all OTN’s telemedicine sessions,” says Meyers. “Now we’ve moved into all aspects of such telemed networks, right down to supplying the cameras and microphones. We’ve also developed what we’re calling a ‘health pod’ which we have in various world trials aimed at satisfying health regulators who will have to certify it.”

The Cisco health pod, explains Meyers, provides point-to-point, or point-to-multi-point, high-definition experience for people who can in effect have face-to-face meetings with a doctor, a dietician, or a psychiatrist, for example, in private.

“It’s the non-verbal communication that the health pod brings out best and that’s a very important part of any consultation,” says Meyers. “That was missed in the past. The video quality and technology wasn’t very good in many ways – jittery, echoey, blurry – and even difficult to make the connection.

“So many times, I’ve been in video conferences and people would get the phone connection up first then start trying to get the video going. They’d be fumbling with ISDN addresses or IP addresses. And if they tried to move the equipment from one room to another, that room might not have the wires they needed,” says Meyers. “So we’ve taken all those problems and eliminated them – by creating a high-quality system that really is as easy to use as the phone.”

Indeed, it is a telephone call that first links users of the pilot Cisco health pod system and begins the video transmission between them.

“But what we’ve added is secure, encrypted, biomedical telemetry,” explains Meyers. “So, if at one end you house a patient in the pod, which looks something like a photo booth, he or she can have a face-to-face, locked-door discussion with the doctor. And that could include the doctor saying, ‘OK put the collar beside you on your arm and we’ll take your blood pressure’.

Or even ask the patient to strip down to underwear and step on a scale the doctor can read from afar. High resolution cameras in the pods can also be handled by patients so that the physician can examine healing wounds or skin lesions up close and professional.

“That’s just about the full range of things that ever happen in a normal primary care physician’s office,” says Meyers. “But now we can extend these capabilities to people pretty well anywhere in the world.”

Even eventually right into their living rooms. “We’re working on video conferencing technology that will allow home monitoring, particularly of chronic diseases via your regular television set,” says Meyers. “One day you may get a call from your doctor’s office saying we don’t like what we’re seeing on your blood pressure readings, so tonight at 8 o’clock turn on your TV to channel 80 and we’ll have a nurse practitioner and a dietician have a chat with you to get you back on track. Further on, using Bluetooth, we could even do home monitoring over the channel of blood pressure or glucose readings.”

That’s the videocare Meyers says Cisco is ultimately pursuing. Of course, as Meyers is quick to admit, there’s re-engineering of cable or satellite TV networks to be done beforehand. But obviously Cisco is serious about its intent.

“We now own Scientific Atlanta, which makes TV set-top boxes for many cable distributors (including Rogers), so we are now in a position to use that set-top box as a bi-directional, video end point,” explains Meyers. “And that could mean Channel 80 would be your own personal telemedicine network.

In the meantime, videocare is advancing over the well-established OTN. Its Telestroke Program, for example, has treated over 1,000 patients since it began in 2002. In caring for a stroke patient, speed and neurological expertise are of the essence. But not even emergency helicopters are always fast enough to put a big city neurologist and a remote town patient together in time.

“Telestroke makes it possible for a neurologist to be at the patient’s bedside – even when that patient is hundreds of miles away – and assist the local physician with determining the most effective therapy possible,” says Dr. Frank Silver, who is the Telestroke Program’s medical director.

With a clear view of the patient, for instance, Telestroke neurologists can recommend the attending physician administer the clot-busting drug tPA. It is a highly effective treatment that can dramatically reduce a stroke’s debilitating effects – if used within the first three to four hours of a stroke’s onset.

Also over OTN, videocare is setting foot in the intensive care unit (ICU).

As reported by Canadian Healthcare Technology earlier this year, Sudbury Regional Hospital in northeastern Ontario is the hub for a pilot “virtual critical care service”. It offers the staff of ICUs in the region’s smaller hospitals on-demand intensive care support around the clock. At their beck and call are electronic medical record and PACS image sharing, as well as real-time audio and video links in telemedicine carts at the patient’s bedside. A similar virtual critical care pilot is also now under way in the Bowmanville area, just east of Toronto.

Those pilot services are managed by CritiCall Ontario. The agency co-ordinates the care of emergent, critically ill patients around the province, saving lives and money. “For the past few months we’ve been using OTN, for example, to share CT scans in southwestern Ontario. So now anytime a patient comes into any Emergency there, our CritiCall neurologists can quickly determine their exact state and whether they need to be moved,” says Kris Bailey, CritiCall’s modernizing CEO. “And the immediate result has been that the percentage of patients needing to be transferred has dropped from 60 percent to 40 percent.”

That experience has opened other doors in Bailey’s mind about what might be done to effect far greater savings with a more costly patient group – if more videocare is added to CritiCall’s technology mix.

“I’ve been talking to Dr. Brown at OTN about how we might bring this idea of specialist consultations at distance, using all of OTN’s tools, including video to the chronically ill, as well.” says Bailey.

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Quebec’s electronic health record system is running late

By Paul Brent

The $563 million Dossier de santé du Québec (DSQ) electronic health record network rollout is behind schedule and could face cost overruns, the province’s Auditor General warned in a little-noticed report issued in May.

The ambitious program intended to allow as many as 95,000 doctors, nurses and other healthcare professionals to access patient information from a single system got off to a late start, has had a second project added to it in midstream and has had its final completion date pushed back a year to June 2011.

Quebec’s Auditor General, who has been following the DSQ for two years, warned of unsatisfactory implementation in seven of 12 recommendations it had made in the spring of 2008. Besides falling behind schedule, the provincial watchdog is concerned that users and service providers will not adhere to the DSQ and opt instead to utilize an Electronic Patient Record (EPR) system that is being developed in parallel to the DSQ.

The report notes that some groups have made the EPR, which contains a patient’s local computerized record, a priority because it is seen as offering more short-term benefits than the DSQ.

Total costs of the DSQ “are still not known,” the Auditor General noted. The original cost estimate has not been revised to account for a slower introduction of the system and also does not account for recurrent costs which could reach $85 million annually, the Auditor General asserts, quoting experts.

“In summary, neither the timetable nor the scope initially defined will be respected,” the Auditor General concludes. “Moreover, an efficient harmonization between the DSQ and the EPR is essential. As for the costs, they could be subject to overruns. It should also be pointed out that there is a major risk that physicians, nurses and pharmacists will not adhere to the DSQ and consequently, will not participate in this undertaking.”

The Auditor General came up with a list of recommendations. Among them: that the Health Ministry create a short and medium term strategy to merge the DSQ with the electronic patient record; produce a pilot project evaluation report, and; re-run its cost estimates to account for changes to the scope and timeframe of various projects

The initial, and as yet still official $563 million cost of the DSQ will be funded by $260 million from the province of Quebec and $303 million provided by Canada Health Infoway. The original timetable was planned for completion from 2006 to 2010.

Quebec’s Health Minister Yves Bolduc acknowledged in April that implementation of the DSQ was falling behind and would take three to five years before it was put in place in all clinics and hospitals. The Minister also told reporters at that time that it will take time for medical professionals to adopt the new system. “Any culture change takes five to 10 years,” he said. “It is probably the second or third year of this system. We must allow time to do things. It runs at the same speed as other provinces.”

A DSQ spokeswoman recently echoed that sentiment: “It is not a delay that we are speaking (of) exactly, it is more the complexity of the thing,” says Loraine Desjardins, director of promotion at the office of the DSQ. “This is the first time that the province of Quebec is in this kind of project, so we don’t have lots of experience in that.” She said the fits and starts the DSQ introduction is experiencing are similar to those experienced in other provinces that are creating EHR systems.

That is an opinion shared by Nadeem Ahmed, managing director of healthcare with xwave, which is working on EHR projects in Quebec and a number of other provinces. “As projects go, where you are doing something for the first time, hiccups are pretty well the norm. The big question is, how do you step up to those challenges,” he said. “Overall on the iEHR projects across Canada, given the challenges in terms of complexity of the health system, stakeholders, and the transformation we are expecting, they are doing all right.”

For its part, the Quebec Medical Association says it is supportive of the DSQ project and looks forward to the benefits it will bring to healthcare in the province. “For us it is a helpful way to increase the number of patients that a doctor can meet, whatever the system,” said QMA director of public affairs Gilles des Roberts. He noted that studies show a 20 percent efficiency gain with the use of electronic health records.

The association is also preaching patience. “We are focusing on the result, not the means,” said des Roberts. “It’s a huge project involving many companies and many hospitals and some of the components of the DSQ are already up and running so we are very optimistic about the end result.”

QMA members were given a demonstration of the DSQ’s capabilities at a meeting in April where the Health Minister also acknowledged the system’s slow implementation. “People were really, really impressed by it,” the QMA spokesman said. “In terms of implementation…we are focusing on the end result.”

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Single, integrated EMR system in the works for the Montreal region

By Andy Shaw

MONTREAL – The Montreal Regional Health Authority (MRHA) is accelerating the region-wide deployment of its OACIS Health Records system, an electronic charting solution, by means of a $31.5 million investment with Telus Health Solutions.

First signed three years ago, the twice-revised contract now calls on Telus to accelerate the extension of the Oacis health record “as quickly as possible” to all 138 of the MRHA’s hospitals, clinics, community service, long-term care facilities and family health practices.

Those facilities are providing care for the region’s nearly 2 million people on the island of Montreal – be they French or English speaking.

For that, Montrealers can thank the bilingual foresight of the MRHA’s two biggest healthcare organizations, the McGill University Health Centre (MUHC) and the Centre hospitalier de l’université de Montréal (CHUM).

“Back in 2003, McGill and the CHUM – even though one served an English community and the other a French community – the two of them decided to form a partnership and find a common electronic health record system,” says Mr. Louis Coté, the MRHA’s multi-hatted director of human resources, information, planning and legal affairs.

“The MRHA was also part of that partnership since our information technology centre operates out of McGill. So we had an option in our agreement – if the system the MUHC and the CHUM chose functioned well, we could extend it to our other MRHA outlets on the island of Montreal. And we knew that if it did work well, we could replicate and implement the system at a great cost-saving since the two founding partners were going to make it work in both languages from the outset.”

Having seen how well Oacis soon did work for both MUHC and CHUM, Coté and the MRHA exercised their option and negotiated a contract with Telus in 2006 for Oacis’s wider distribution beginning in 2007, upgrading it again in May this year.

As Coté further explains, the additional $31.5 million added this year brings MRHA’s total deal with Telus to about $70 million and will pay for a quicker turnkey implementation of its three major elements: an unlimited Oacis license extendible to all MRHA providers, the building of any Oacis interfaces they will need, and the digitizing of all their paper records.

The Oacis solution they will receive includes a clinical information application that is fed by a document imaging system which digitizes documents and integrates the electronic results into a “Unified Patient Record”.

So far, eight hospitals including MUHC and CHUM already have the document imaging system up and digitizing away.

According to Telus Health, “This solution enables the complete unification of health records within departments or whole facilities, without the risks or high costs generally associated with the replacement of existing IT infrastructure. The solution will be overlaid on top of technology currently deployed, in order to preserve existing data and investments already made within the healthcare delivery organizations.”

Coté says Telus Health’s quickened extension of Oacis to all 138 sites, including 89 hospitals, should be complete within four years, making it one of the first health regions in North America to have a full continuum-of-care EHR.

And he expects the effort will be well received.

Telus Health officials report that the Oacis unified patient record has proven particularly popular with its first users at MUHC and CHUM because it gives clinicians “ a 360-degree view of their patients’ health status and history” – making for better informed decisions and improved patient outcomes.

Though no Canada Health Infoway money is involved in the massive MRHA project so far, no doubt that federal organization mandated to implement a Canada-wide EHR is watching with interest – particularly to see how it may help bridge the yawning electronic gap that still exists in most regions of the country between hospital networks and individual doctor’s offices.

According to a spokesperson from Telus Health, when physician offices are ready to join the MRHA network, they will need an Oacis-friendly electronic medical record system (EMR). Consequently, Telus Health is working with Kinlogix Médical Inc. in Quebec City to develop such an EMR.

Whatever EMR for physicians comes out of that development, it will have to be certified by Quebec’s provincial health ministry. But Coté says he then expects help from Infoway, which is facilitating the certifying of EMRs.

Among the major benefits Telus Health sees for both care givers and patients will be “…faster and more reliable access to full patient records and medical history, faster processing and improved service.”

Coté adds that what the MRHA can expect from a fully deployed Oacis-based network is a lower incidence of medical error and a higher level of productivity. “We all face a shortage of doctors, nurses, and technicians, so we need to give them the best technical tools if we are going to get the most out of the people we do have.”

And there are other tools in the works for them, adds Coté. “We expect everyone will have the Oacis viewer by 2013. After that will come an automated nursing plan system, and in conjunction with the Douglas Mental Health University Institute we are developing various modules, including one for patient evaluation. It will be a 10-year trip before we’re fully done, but in those first four years we will have all the main functionality of an EHR installed in all the institutions on the island of Montreal.”

Coté says the provincial EHR system being developed by the Quebec government – better known by its French initials, DSQ, for dossier de santé du Québec – will be a separate but compatible system with the MRHA’s.

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Best Route increases capacity and reduces costs for home care sector

By Jerry Zeidenberg

Home care agencies typically have hundreds – even thousands – of nurses and workers on the road visiting clients. Driving back and forth on these visits is costly and time-consuming, but it must be done – after all, clients rely on home-care personnel for help.

Now, Victoria-based Procura, a home-care solutions developer, has produced an innovative system which may dramatically reduce the amount of time that visiting nurses and other home-care workers spend on the road. It does so by optimizing routes and schedules through the use of innovative geographical software.

Company vice president and product architect Scott Overhill notes the new system, called Best Route, is expected to slash the cost of mileage paid out to visiting nurses and other home care workers by up to 25 percent. The company has worked with historical data from its customers to develop the software and to arrive at the estimated savings.

Cost reductions of 25 percent can work out to be a considerable savings, since some agencies are paying out hundreds of thousands, and in some cases, millions of dollars in travel fees each year.

Overhill said that one agency the company works with spends some $12 million annually on mileage and time costs for its home care workers. By achieving a 25 percent reduction, it could conceivably save the organization $3 million annually.

“That saving of $3 million is the equivalent of 50 more nurses,” commented Overhill.

Visiting nurses and allied workers are usually compensated for travelling to the homes of clients, either with a mileage or time fee, or a combination of both. According to Procura, agencies pay between $1,500 and $3,000 annually per employee in mileage and travel time fees. Rural home care workers, in particular, can spend a good deal of time on the road, due to the long distances they must travel to reach clients.

Procura president Warren Brown observed that while cost control is always a challenge for home care agencies, they are also grappling with serious personnel shortages. By reducing the time that employees are on the roads, they can increase their time with clients. Put another way, by optimizing their routes, home care personnel can see more clients each day.

“The system is addressing the capacity issue,” said Brown. “It can give home care workers 10 percent of their time back.”

He added that, “If you can recover 10 percent of your time each day, there are significant benefits.”

Brown gave the example of a large agency with 3,500 workers using Best Route. “That’s like having 350 more workers available each day.”

There are similar gains for agencies of all sizes, he said.

Overhill said that Procura has created the new application by customizing the popular MapQuest system, which can be found on the web. In a partnership agreement with MapQuest, Procura has adapted and integrated the solution into its own home care management system.

“It’s a snap-in module, and with our customization, it looks and feels just like Procura,” said Overhill.

Procura has utilized the MapQuest Platform: Enterprise Edition (http://platform.mapquest.com/specs-enterprise.html) to optimize routes for dozens or hundreds of workers in an organization. These workers, moreover, have multiple destinations each day. “A nurse could have eight or 10 visits each day,” Overhill said.

Used as a front office application for planning and management, Best Route can be used to schedule the best routes to take for a whole week’s worth of appointments.

To the best of his knowledge, no other North American home care company has integrated such a system – capable of optimizing routes for an entire enterprise – into its software, said Overhill.

The system reduces mileage and time on the road by optimizing routes, and automating the paperwork that’s traditionally been required when planning schedules and claiming expenses.

It can:

• Determine the best routes to client sites, reducing time and mileage on a daily and weekly basis, and quickly make this information available to employees.

• Avoid misreporting of mileage and travel time.

• Automate the process of entering mileage and travel time, and reduce the time needed for audits.

• Eliminate unintentional rounding-up and misreporting by employees.

At the time of writing, Procura was about to begin pilot tests of the Best Route system with customers in Ontario and British Columbia.

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