Oracle readies advanced system for e-patient records

By Jerry Zeidenberg

TORONTO – Oracle Corp. is about to expand its healthcare software business with the creation of a suite of clinical applications, including a sophisticated, electronic patient-record system capable of connecting care-givers and patients across wide geographical areas.

The software is said to be different than other systems currently on the market in that it will use a variety of communications technologies to link patients with various types of healthcare providers – including physicians in hospitals and private practice, and pharmacists. It will also take advantage of Oracle’s strengths in databases, customer-relationship management and transaction processing.

“Not only will a physician be able to send prescriptions on behalf of patients to pharmacists, but the system will also send messages from the pharmacy back to the doctor, informing him or her about whether the patient actually picked up the medication,” said Dr. Thomas Jones, senior director, healthcare applications, for Oracle Corp.

Dr. Jones spoke to a gathering at the COACH/CIHI e-Health 2001 conference in Toronto last May.

“Over and above that, the system will then connect to the patient’s cell phone, reminding him to take his medication. It can even be programmed to ask the patient to call back, confirming that he or she has done so.”

As a result, the patient record system not only captures information, but also plays a role in health promotion and compliance.

Ian Fish, Oracle Canada’s national industry leader for healthcare, said Oracle refined the design of the system earlier this year and that coding began this summer. The company has already arranged pilot projects in the United States – with HealthSouth Corp.- and in the United Kingdom with the National Health Service. Oracle has also been speaking with authorities in Canada to establish a pilot project here, said Fish.

For its part, the U.S. trial could lead to an extensive implementation. “HealthSouth has medical facilities in all 50 states,” said Dr. Jones. “The goal for us is to become their information highway.”

While other companies, such as HBOC and Cerner, have dedicated their resources to the creation and implementation of electronic patient records, market research shows that many hospitals and nearly all privately practicing physicians have yet to install a system.

Moreover, even among hospitals and clinics that have implemented an electronic patient record system, there is no clear market leader when it comes to vendors. Instead, the marketplace is extremely fragmented.

Dr. Jones acknowledged the move into electronic patient records systems is a significant step for Oracle, which has traditionally been a provider of back-end systems such as powerful databases and enterprise resource planning systems. “It’s a sea-change for us,” he noted. “But our success in ERP applications persuaded us to enter another sector, and to produce healthcare applications.”

Earlier this year, Oracle announced that it would partner with HealthSouth to build a “digital hospital” in Birmingham, Ala. The partners say it will be the most highly computerized facility in the United States.

“This will be the hospital model for the world,” said Richard Scrushy, CEO of HealthSouth, in a corporate release. “By creating the first automated hospital, HealthSouth and Oracle are taking an idea that many have talked about and making it a reality. We will demonstrate how technology can lower healthcare costs, greatly reduce human errors and provide patients with the best medical care available.”

The hospital’s technological features will include patient beds with display screens connected to the Internet, electronic medical records storage, digital imaging instead of traditional X-ray film, and a wireless communications network that will permit healthcare professionals to securely access electronic patient records while using handheld computers.

For its part, HealthSouth intends to invest US$100 million to US$125 million in construction of the 219-bed hospital. Work should begin in the first quarter of 2002 and end by mid to late 2003.

Oracle said the hospital will make use of the company’s systems for administrative and business processes, along with its new healthcare software, including core clinical applications.

Other companies involved in the project include:

• Carl Zeiss, a leader in the fields of optics, precision engineering and electronic visualization.

• Dade Behring, a provider of laboratory diagnostic products and services;

• Datascope, a medical device company that manufactures and markets products for interventional cardiology and radiology, cardiovascular and vascular surgery anesthesiology, emergency medicine and critical care;

• General Electric Medical Systems, a world leader in diagnostic imaging technology;

• Hill-Rom, an international provider of healthcare products including beds, therapy surfaces, room furniture, modular wall systems, medical gas management systems, perinatal/neonatal products, staff/patient communication systems, stretchers, surgical columns and lighting;

• Pyxis, a provider of medication and supply dispensing systems;

• Smith and Nephew, a leading provider of medical devices principally in orthopedics, endoscopy and wound management;

• STERIS, a supplier of infection prevention and contamination prevention, microbial reduction, and therapy support systems, products, services, and technologies; and,

• Visualization Technology, a world leader in electromagnetic image guidance systems, specializing in ENT, cranial, spine and fluoro applications.

“All of the participants have agreed to work together to ensure full integration of equipment,” Scrushy said. “That is a revolutionary development, and is a major step toward overcoming the biggest obstacles in healthcare – communications gaps created by incompatible computer systems, the over-dependency on paper systems for documentation and inefficiencies in daily communications.”

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OHA launches e-Health council, calls on governments for funding

By Jerry Zeidenberg

TORONTO – If the federal government is serious about creating a modern, computerized health system, it must quickly establish an e-Health fund that will pump an extra $2 billion into the technological infrastructure of hospitals and other providers of medical services nationwide over the next four years.

That’s the prescription from the Ontario Hospital Association, which recently announced the formation of its own e-Health Council. The council is headed by Tom Closson, CEO and president of the University Health Network in Toronto.

The OHA also called for the Ontario government to separately infuse $750 million into provincial initiatives to build the e-Health capabilities of healthcare organizations during the next three years.

The OHA stresses that it should be new money – over and above programs previously announced.

The OHA’s e-Health Council has produced a report, Building the Foundation for e-Health in Ontario, that studied the potential gains of increased investment in computer technologies. (The report is available at www.oha.com)

At a press conference, Closson said the new council is urging the federal and provincial governments to increase spending on computerized solutions to help speed up delivery of service, improve medical outcomes and reduce costs in the public health system. He pointed to the chronic under-investment on information technology in the healthcare system as a major problem.

“The hospital sector spends 2 to 3 percent of its total costs on I.T., compared with the banking sector, which spends about 12 percent on I.T.,” said Closson. “It’s not surprising that we’re having troubles in our industry.”

The OHA report cites a myriad of benefits that can be obtained through computerized healthcare systems, including:

• A dramatic reduction in medication errors through physician order-entry systems that are linked to pharmaceutical databases capable of detecting prescribing errors;

• Improved patient care at the point of delivery through better access to patient and clinical information, such as electronic patient records containing medication histories and other details;

• Greater access to specialists, especially in remote and rural regions through telehealth;

• Evidence-based care through best practices, made possible by integrated decision-support tools;

The OHA study probed the barriers to implementing computerized solutions in hospitals, and found that to date, the number one hurdle has been a lack of funding. This was followed by a shortage of skilled computer and communications professionals.

Disagreement about I.T. strategy is also a problem for many hospitals. When it comes to creating a system-wide network, most hospitals cite a lack of common standards as the main stumbling block. They also cited the absence of a shared vision and leadership as significant barriers.

To address these and other issues, the OHA asserts:

• The federal and Ontario governments must provide additional money for computer infrastructure and solutions.

• Centralized bodies – such as Ontario’s nascent Smart Systems for Health and the Ministry of Health itself – should take a leadership position in establishing I.T. directions for the health system. According to the report, this would “help hospitals to better understand provincial priorities for the future and to coordinate their own planning decisions accordingly.”

• The Ontario government should fund 100 percent of ICT system-wide infrastructure and 85 percent of hospital ICT investments related to Smart Systems for Health.

The council says it will soon appoint a Chief e-Health Strategist. What’s more, it says it will produce an action plan this month. The plan will refine priorities that the council established:

• The immediate establishment of a task force to develop common identifiers for all patients in Ontario;

• The OHA and the Ontario government must quickly implement the Smart Systems for Health (a secure network), to provide secure, real-time transmission of confidential data. “We recommend that it be set up at arms-length from government, so we can make some quick movement,” said Closson.

• The OHA and member hospitals should work with the Ontario government, other providers and stakeholders to quickly implement personal health privacy legislation that protects patients against unauthorized and inappropriate disclosure of confidential information;

• The OHA and member hospitals should work with government, Smart Systems for Health and other providers, to ensure common data and technology standards for sharing of key information.

• The Ontario Ministry of Health should provide $15 million in start-up funding for the development of an Emergency Department Information System, as a pilot project, and that the results of this project should be made available to hospitals across Ontario as soon as possible.

Members of the Council stressed that steps should be taken immediately. “We’ve got a year-long window of opportunity to start creating synchronized systems across the country,” said Sam Marafioti, chief technology officer at Sunnybrook and Women’s College Health Sciences Centre and a member of the e-Health Council. “If there’s foot-dragging for longer than that, there will be a loss of credibility [at the federal and provincial levels], and organizations will go back to creating their own solutions in an unsystematic way.”

To demonstrate a successful e-Health solution, Dr. Ed Brown, an emergency physician at Sunnybrook and program director of the NORTH telehealth network, participated in a videoconference with a patient at the Kirkland & District Hospital, in Kirkland Lake, Ont.

The NORTH network was established four years ago to address the shortage of specialists in remote and rural areas of Ontario. It uses videoconferencing and remote medical instruments to connect specialists at Sunnybrook and other tertiary care centers with hospitals in remote and underserved parts of the province.

Using the systems, physicians working in over a dozen areas of medicine – including orthopedics, dermatology and psychiatry – have been able to examine patients at a distance.

“We’ve conducted 1800 consultations, 200 educational events and have had 300 physicians involved,” said Dr. Brown. “Our patient satisfaction level is 94 percent, about as high as you can get in surveys of this kind,” he said.

On a related front, Andrew Szende, CEO of the electronic Children’s Health Network (e-CHN), described the system and noted that it has been expanded to include a total of seven organizations. (Credit Valley Hospital and the Bloorview-McMillan Centre were most recently added.) He asserted that e-CHN could become the foundation for a province-wide electronic-patient record network.

“You could expand the system to include, for example, cardiac, cancer or geriatric patients,” he explained. “You could set it up any way you choose.”

eCHN was spawned under the leadership of the Hospital for Sick Children, with the assistance of the Ontario government.

At the time of Szende’s presentation in July, the system consisted of a secure network that connected five locations, with a total of 25 different clinical systems. “eCHN brings data from different locations into a single view,” said Szende. “The record goes with the child,” whether that youngster is treated at three or four different hospital sites.

“By sending the records electronically, you reduce the duplication of tests that goes on,” said Szende. “You also eliminate the need to search for records at different locations,” as the computerized information is quickly available to doctors and other healthcare professionals across the network.

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Wireless computer access to Internet offered to patients in Toronto

By Winton Cape

A pilot project at Toronto’s smallest downtown hospital is giving one patient round-the-clock wireless access to the Internet. Until now, patients at Toronto Grace Hospital who wanted to access the Internet had to use the Resource Centre – a mini-library with one computer. Access was limited due to staff usage and volunteer availability. But thanks to wireless access cards, all patients will soon have independent, hassle-free access.

Chronic-care patient Vanda Rocha is the test subject. “I didn’t want to go through my life without a computer just because I was living in a hospital,” she said.

With roaming Internet access from anywhere in the hospital, she has access to the outside world via her laptop.

The sense of independence and convenience she feels is tremendous. “I really appreciate the Resource Centre, but I wanted to answer my e-mails when I felt like it.” Rocha’s Compaq 100S notebook is equipped with an SMC wireless network card. She can connect to the Internet from almost anywhere in the hospital – her room, the patient lounge, even the cafeteria.

“For chronic care patients, keeping in touch with friends and family is very important and we want to ensure patients have the best and most reliable experience possible,” says Anne Lawrence, Canadian Health & Education Manager, Compaq Canada Corp. “By supplying Compaq notebook technology and wireless access cards, the Toronto Grace Hospital allows patients to connect with the Internet anywhere, anytime.”

Recently, the technology infrastructure of the hospital was being upgraded to include wireless. When one of our patients asked for Internet access in her room, this created a win/win opportunity. We could improve the quality of life for patients at our hospital while also positioning our technology infrastructure for the future changes in the healthcare system.

The hospital already uses wireless technology in its administration area, and moving the technology into the nursing areas was a natural transition. A wireless access unit was added to the existing nursing hub and the patients’ wireless access cards are configured to communicate with this unit. It was not difficult to create this new service for our patients – almost plug and play!

By taking advantage of our T-shaped building and placing the access units at the intersections of two main corridors, a 1500-foot spherical field or cell was created allowing for maximum access to the signal. Our patients are not the only ones to benefit from this system – the staff also has easy access to the Internet, e-mail and the Intranet from anywhere on the unit.

For patients, the information systems department charges a small monthly fee for this network access, not unlike the fee for cable television service.

“Through innovative technology solutions, Toronto Grace has provided a vital service to its patients – a connection to the world from their room,” says Lawrence. “In addition, Toronto Grace provides a service that generates additional revenue for the hospital.”

Toronto Grace Hospital is home to a number of chronic care patients and the Internet is an excellent way for them to keep up to date by using e-mail, and to keep in touch with electronic greeting cards and net-based discussion groups.

Winton Cape is the IS manager at the Toronto Grace Hospital.

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Canadian healthcare dot-coms are undergoing a chilly reality check

By Dr. Alan Brookstone

The chill that has affected U.S.-based Internet healthcare services for physicians and consumers has drifted north of the border to Canada. In June 2001, New Jersey-based WebMD Corp. quietly pink-slipped its Canadian editorial staff.

WebMD, in conjunction with Scotia Bank, the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada had launched the Canadian Doctors’ Network (CDN) less than one year earlier as a portal service to Canadian physicians. According to Dr. Claude Renaud, director of professional affairs for the College of Family Physicians of Canada, “The Canadian Doctors’ Network will continue to exist.” Instead of being hosted in Canada, the new portal service will be provided as customized version of the WebMD (USA) physician site.

Most Canadian content from the original CDN service will appear under a ‘Canada’ tab located on the new web portal navigation bar. The service will continue to be provided at no cost to members of the CFPC and RCPSC.

Consumer health information services in Canada have been affected just as significantly as their professional counterparts. Vancouver-based Medbroadcast.com, a provider of Canadian consumer health information is desperately trying to survive. A recent cash injection of $5 million by CanWest Global Communications Corp (18 percent owner of Medbroadcast Corp.) has allowed the struggling company to carry on while a new CEO is sought.

Meanwhile, Dr. Michael Pezim, a general surgeon and son of the late stock promoter Murray Pezim, resigned as president of MedBroadCast to return to medical practice.

While all of the rationalization has been taking place in the Canadian Internet health space, the Canadian Medical Association has been developing its own strategy. Larry Mohr, assistant vice-president of marketing for the Canadian Medical Association, described the CMA strategy as being, “A long term approach to integration of the Internet into the organization in a manner that is sustainable.”

As Canada’s largest physician representative association, the CMA sees its role as establishing a virtual national medical community built around the CMA brand. In order to achieve this objective, the CMA acquired Montreal-based GlobalMedic through CMA Holdings, the business arm of the CMA, in April 2001. GlobalMedic will provide the technical expertise to the CMA as the organization moves towards implementing its Internet strategy.

Currently, physicians continue to run primarily paper-based medical offices, utilize the Internet very little in day-to-day practice and are just beginning to adopt smidgens of technology in terms of handheld devices and electronic patient records.

What the past two years has provided is a health dose of reality. The healthcare industry does not change quickly. It is like a giant pendulum that is continually swinging from side-to-side with each arc taking about 10 years to complete.

Changes are often made in a knee-jerk fashion, affected by the long cycles of change and generally out of synch with the reality of time. The Internet is a fantastic tool and no one doubts that it will significantly change the way in which healthcare is delivered in the future on both the physician and consumer side.

Unfortunately, in the early days of the Internet, the expectations were too high, the changes too quick and the business strategies unsustainable.

Dr. Alan Brookstone is a physician based in Richmond, B.C.

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Canadian hospitals seek better security as computer systems multiply

By Dianne Daniel

As Canadian hospitals begin to move towards electronic patient records and centralized information databases, it’s somewhat ironic that the recommended starting point when securing such systems is a return to the very thing they are aiming to replace – paper.

“A lot of hospitals know of a security policy or say they have one, but it’s not documented, not written and this is really the first step,” says Kevin Krempulec, enterprise sales manager, Canada, for Symantec Corp. of Toronto. “You need to have a written policy of the actual steps you’re going to take (to secure your data) and what actions you’ve taken to fulfil those.”

It sounds elementary, but according to Krempulec if it ever comes down to proving duty of care in the event of a security breach – showing that a healthcare institution did in fact take steps to ensure data remains confidential – a written security policy will prove invaluable. Even if such a document already exists, it should be re-examined before any technology decisions are made, he adds.

When developing a security policy, Krempulec suggests looking at three broad areas: a perimeter assessment, using software tools to scan your network for vulnerabilities and implementing a firewall; an anti-virus program to protect against known threats; and finally, intrusion detection software to guard the servers where the patient data resides.

Steve Chapman, program marketing and sales manager at the Canadian Imperial Bank of Commerce (CIBC) in Toronto agrees a documented security assessment is a good place for hospitals to start. As the Canadian national affiliate of VeriSign Inc., a provider of outsourced public key infrastructure (PKI) services, the CIBC operates a business unit dedicated to helping organizations secure their data using digital certificates. For a yearly fee (usually between $100,000 and $200,000), users receive a completely managed solution, leveraging the CIBC’s existing secure facility and trained technicians to protect their data.

While there are many PKI products on the market, most designed to assist an organization in building its own in-house PKI infrastructure, CIBC/VeriSign differentiates itself by offering PKI services based on an outsourced model. All that’s required of a hospital, explains Chapman, is to ensure users who need access to the secure data have a PC and an Internet connection. They then enroll for a digital certificate, a small footprint that is integrated into the user’s desktop via the Web browser and must be presented in order to gain access.

Typically, CIBC/VeriSign begins by analyzing an organization’s entire IT infrastructure in order to determine any security vulnerabilities that may exist. In Chapman’s experience, most healthcare organizations lack a written security policy so a PKI discovery – or assessment – is first. Then, once it is determined who needs access to what information, digital certificates, most often based on two-factor authentication are issued, one to each desktop. As part of its service, CIBC/VeriSign manages the certificates, ensuring they are renewed every year and that users change their `factors’ frequently.

“Based on what we see in the marketplace, healthcare providers are really looking to have access to the necessary patient information where and when they need it, but in a secure manner,” says Chapman.

For the past year, Miyo Yamashita has been on a mission to do just that; ensuring people have access to the information they require to do their jobs at Mount Sinai Hospital in Toronto. In her newly created role of data security officer, Yamashita manages access privileges across the hospital and takes steps to secure data from area to area. It’s also her role to serve as an internal resource on privacy, legislative and data security issues, and to help various areas secure patient data and understand the issues of patient confidentiality.

“What gets complicated at large teaching hospitals is you have people who play multiple roles and have different access privileges as a result,” she says. “In healthcare, denying access could be a matter of life or death in a worst case scenario, so you want to make sure individuals do have access to the information they require to do their jobs.

“On the other hand, you want to make sure that’s balanced with patient confidentiality concerns.”

When Yamashita arrived in June 2000, Mount Sinai Hospital already had a corporate confidentiality policy in place. All new staff are required to sign a waiver outlining the policy and penalties for breaches. Interest in security has heightened, she says, because of the great move towards integrating separate health information systems, both within a hospital and among different care providers.

Another reason for the growing concern is the recent trend towards health privacy legislation, which has already been passed in some provinces and is looming on the horizon in Ontario. At the federal level, Bill C-6, the Personal Information Protection and Electronic Document Act, will cover healthcare information by January 1, 2004, and will apply to any province that does not already have similar legislation in place, explains Yamashita.

Regardless of the content of such legislation, Mount Sinai is taking steps to ensure patient privacy using the standard multiple security layers such as firewall, virus protection and intrusion detection, as well as by running regular random audits on users.

“With Bill C-6, it’s going to be required that hospitals show they’ve improved security for compliance,” notes CIBC VeriSign’s Chapman. “Probably the biggest hurdle we have to face is educating people that security is an ongoing procedure; it’s not something that’s a static event where you buy something and you’re secure.”

That may be one reason why there has been growing interest in managed security services, he adds, where a vendor like CIBC VeriSign will provide firewall, virus protection and intrusion detection services for a monthly fee. Such outsourced services can be a cost-effective alternative for hospitals that lack the internal resources to deal with security issues and are faced with tight budgets.

“The frustration is that even if they had an infinite amount of budget, they’d never be 100 per cent secure,” notes Chapman. “So you have to find that sweet spot where you balance off your costs – how much you’re comfortable spending – versus how secure you’re going to be.”

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