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Inside the September 2006 print
edition of Canadian Healthcare Technology:
Feature Report: Hospitals of the future
Regional DI projects aim to achieve major benefits
The plans for three giant diagnostic imaging
projects are moving forward – in Quebec, Ontario and Saskatchewan –
all with expected financial contributions from Canada Health Infoway.
Eastern Ontario hospitals share data using EMPI
Four hospitals in Eastern Ontario have started
linking electronic records, with the goal of enabling care-givers at
any of the sites to review patient histories and provide fast,
accurate diagnoses and enhanced treatments.
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ONLINE
Potential of RFID
Radio Frequency Identification (RFID) systems are
coming of age, allowing hospitals and other healthcare organizations
to track equipment and patients more accurately than before.
Medication management
A new standard for messaging in pharmaceutical
networking has been devised, with the assistance of Canada Health
Infoway. The standard is a key part of networks under development in
PEI, Newfoundland and other provinces.
READ THE STORY
ONLINE
Long distance nuclear medicine
Northern Ontario’s two radiologists specializing
in nuclear medicine have been assisted by the emergence of an
imaging system that runs on the provincial Smart Systems for Health
Agency network. It allows the busy physicians to review images and
reports anywhere, anytime.
Patient education
A web service launched by the Annapolis Valley
District Health Authority, designed to educate patients about
medications and treatments, has become one of the most popular sites
in Nova Scotia.
PLUS news stories, analysis, and features and more.
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Regional DI projects aim to achieve major benefits
By Jerry Zeidenberg
The plans for three giant diagnostic imaging projects are moving forward
– in Quebec, Ontario and Saskatchewan – all with expected financial
contributions from Canada Health Infoway.
The much-heralded projects – first announced late last year – involve a
mixture of Picture Archiving and Communications Systems (PACS),
Radiology Information Systems (RIS), imaging modalities, and the central
repositories needed to house and share millions of DI exams each year.
For its part, Quebec is taking steps to create new DI networks in the
Quebec City-Laval area, and also in Sherbrooke.
The Laval diagnostic imaging project, focused on the region known as
Reseau Universitaire Integre de Sante (RUIS) Laval, is one of Canada’s
biggest. Its 51 sites cover approximately 50 percent of the surface area
of Quebec, and its population of 1.8 million currently generates 2.6
million DI exams annually.
With the addition of new modalities and growing demand for DI exams, it
is expected to generate over 3 million studies annually within 30 months
– the timeframe for the current project.
The huge region is unusual in that most of its facilities – about 80
percent – do not yet have a PACS. To provide PACS to most of the
hospitals, along with RIS and a central repository (with active
redundancy), RUIS Laval selected Agfa as its prime vendor; details for
the contract are currently being worked out.
The DI budget for RUIS Laval is huge – about $60 million will be
invested in PACS/RIS, with another $18 million allotted for CR/DR
systems, along with DICOM transfer units.
Moreover, RUIS Laval plans to spend an additional $40 million on
modality upgrades over the next three years.
Tremendous benefits are expected from the region-wide systems, asserted
Dr. Jacques Levesque, clinical director of the project and former chief
of radiology at the university hospitals in Quebec City.
Dr. Levesque noted that RUIS Laval is suffering from a severe shortage
of radiologists – it has 150, but needs 50 more. But shortages of
radiologists are plaguing many regions of Canada, and realistically,
RUIS Laval is not going to find such numbers any time soon.
Dr. Levesque says the upcoming PACS will dramatically alleviate the
shortfall. By quickly converting to digital imaging, and transmitting
files over Quebec’s RTSS network, hospitals without radiologists
available to interpret exams will be able to send studies to other
centers.
“With PACS, we’ll be able to read most exams within 24 hours,” said Dr.
Levesque.
This capability will prove to be a godsend for centers like Rimouski;
for its part, Rimouski generates 250,000 diagnostic imaging exams
annually, but currently has only two radiologists.
Other centers are similarly hard-pressed; the problems become even more
acute when radiologists go on holidays, leaving an even bigger workload
for their associates.
The regional PACS, however, will allow hospitals to share the services
of 150 radiologists by making use of the electronic network. That also
means centers without specialized radiologists, such as pediatric
experts, will now be able to send images to other centers for second
opinions.
And as in other PACS implementations, productivity gains are expected
within hospitals, as support staff are no longer required to pull films,
deliver or re-file them. For the radiologists themselves, all images
will be available within seconds – no more lost films, or waiting for
others to finish with studies.
Dr. Levesque observed that one challenge on the agenda is the bandwidth
of the RTSS network – it’s not nearly as fast as he and his colleagues
would like. However, the Quebec government is working to upgrade it.
He commented that the selection of Agfa as the preferred vendor resulted
from an intensive competition among three short-listed suppliers. While
all performed well, Dr. Levesque said Agfa was judged by the region’s
radiologists and administrators to have the best combination of features
and price.
He said the PACS will comprise a wide variety of tools, giving RUIS
Laval radiologists a comprehensive set of viewers – over time, every
radiologist will have access on his or her console to viewers for MR,
CT, nuclear med, orthopedics, virtual colonoscopy, and others.
That means radiologists will not have to move to other stations to
obtain specialized viewers; in the past, in some hospitals, this has
meant lost productivity as radiologists moved from one area to another,
and often had to wait for other physicians to finish.
“You won’t need to fight for a workstation,” said Dr. Levesque. “All
tools will be available on all consoles.”
And because of the single preferred vendor, the tools and interfaces
will all work in the same way. That’s a huge benefit to radiologists
moving from one hospital to another – in other regions, where the
solutions have been supplied by a variety of vendors, radiologists have
had to learn to use several types of software, often with great
difficulty.
Dr. Levesque is also clinical director for the DI project in RUIS
Sherbrooke, which has 15 hospitals reading some 1.1 million diagnostic
imaging exams annually.
The Sherbrooke project is much different than Laval, since most of its
hospitals already have PACS (in most, they’re using the Fuji PACS). As a
result, the focus of the Sherbrooke project is on the creation of a
central repository and connectivity among the hospitals.
RUIS Sherbrooke will use Agfa’s IMPAX repository to integrate the
existing PACS, enabling every hospital to access any image, regardless
of where the image was originally taken. The budget for the RUIS
Sherbrooke project is approximately $20 million.
Meanwhile, in Ontario, the Toronto East Network, containing many of
Ontario’s fastest growing healthcare centres, has just completed the
planning process to implement a Picture Archiving and Communication
System (PACS)and a regional central repository that will connect 16
different hospital corporations and their 26 clinical sites. The
regional system will allow the sharing of diagnostic images and reports
between the sites. With the planning phase completed, the project is
currently reviewing funding options.
The hospitals are located across three of Ontario’s new Local Health
Integration Networks (LHINs), and include high-density urban and
suburban areas in the GTA, as well as rural zones in Northeastern
Ontario.
The centres currently generate approximately 2 million diagnostic
imaging exams annually. Another 2 million exams are produced each year
by independent imaging centres. In the future, regional CIO Lewis Hooper
would like to see the private imaging facilities connected to the
central data repository, although the initial plan focuses on getting
the hospitals connected first.
Seven sites in the TEN hospital group do not yet have PACS installed,
but as part of the next phase of the project they will implement picture
archiving and communication systems. After an evaluation of PACS
solutions that began with 12 suppliers, the TEN project decided on Agfa
as its preferred vendor.
In addition to PACS, Agfa will supply a central repository with backup
and redundancy, as well as integration and networking services.
Hospitals that will install a new PACS include:
• Southlake Regional Health Centre
• Toronto East General Hospital
• Stevenson Memorial Hospital
• Campbellford Memorial Hospital
• Rouge Valley Health System
• Peterborough Regional Health System
• Haliburton Highlands Health Services
Hooper asserted that several important benefits are expected from the
regional system, with a significant return on the investment.
In particular, it’s expected to improve both the speed and quality of
healthcare delivery. Radiologists at any site will be able to retrieve
and access new and historical exams of patients within seconds -–
instead of waiting for film to be delivered, or ordering new images to
be taken because the files for a patient reside at a different site.
That’s expected to cut down considerably on repeat testing and
treatment-decision turnaround time. Moreover, it will be much easier to
obtain second opinions from radiologists at other sites, simply by
sending studies electronically over the network. Hooper said this will
be especially valuable in neurological and orthopedic cases, as well as
in pediatric radiology, when the insights of these scarce specialists
will be vitally important. The regional repository will also allow
family physicians to access a comprehensive view of the DI record as a
component of the Electronic Health Record.
The implementation of a PACS network also means that hospitals can send
images, instead of patients, to other hospitals, when second opinions
are needed. Hooper, who is based at Scarborough General Hospital, in
Toronto, observed that patients are often sent to Sunnybrook Health
Sciences Centre or to downtown Toronto hospitals for referrals. Once the
regional central data repository is in place, doctors will be able to
view diagnostic exams from other medical centres, saving patients
unnecessary travel and radiation exposure.
The central repository for the Toronto East Network PACS will have
backup and redundancy, ensuring that service interruptions will be
minimal. This means that if a component of the system did go down,
another unit would kick in. “It’ll have the five nines,” commented
Hooper, “with 99.999 percent uptime.”
And by banding together and acting as a group, the TEN hospitals are
obtaining a significant price reduction on the cost of the PACS and
related equipment — Hooper estimates they’ll achieve an overall discount
of about 30 percent.
The regional system will initially operate over existing high-speed
lines connecting various hospitals; eventually, Hooper expects it will
run on the high-bandwidth network being established by Ontario’s Smart
Systems for Health Agency (SSHA).
“Importantly, the infrastructure being established for the PACS will be
re-usable for a host of upcoming applications,” commented Diane Salois-Swallow,
CIO for two hospital organizations that are part of the Toronto East
Network -– York Central Hospital in Richmond Hill, and Southlake
Regional Health Centre, in Newmarket.
“We’re building capacity for the electronic health record in general,”
said Salois-Swallow. “We’ll be able to run applications for labs, drugs,
and others, across the network. You don’t want to build separate
networks for all of your needs.”
In addition, she noted the dramatic savings in staffing and training
that will arise through shared services. Ultimately, fewer personnel
will be required to operate and maintain the centralized servers and
storage systems than if every hospital were trying to run its own data
centre and systems.
Moreover, smaller hospitals are hard-pressed to keep their IT systems
running in peak form when technical staff get sick, go on holiday or
move on to other jobs. By being part of a larger group, they’ll be able
to rely on the expertise of TEN staff members for problem-solving and
training.
“We’re setting up tremendous resources and infrastructure for the
future,” said Salois-Swallow.
Eastern Ontario hospitals share data using EMPI
Different hospitals, different patient records,
different patient ID numbers. It is all too common for patients, but in
the Ottawa area, the duplication is finally coming to an end.
An innovative project – the Enterprise Master Patient Index (EMPI) – has
quietly taken a first step to linking patient records. Sharing clinical
information between the four pilot hospitals that have developed links
between their patient records is now set to begin. And better patient
information will help those who care for them to make better clinical
decisions.
The hospitals – The Ottawa Hospital, Queensway Carleton Hospital,
Hawkesbury District General Hospital and the Renfrew Victoria Hospital –
have linked their patient records from their admission, discharge, and
transfer systems and will soon be able to share full clinical data,
including patient histories and test results, regardless of the hospital
where a patient was treated.
Says J.P. Soublière, chair of the Champlain Region IT steering
committee: “Providing hospitals with better access to patient
information will lead to a transformation which will result in less
duplication of resources, less frustration for patients, and faster,
more informed care.”
The OACIS (open architecture clinical information system) regional EMPI,
developed by DINMAR, an Ottawa-based supplier, runs over Smart Systems
for Health Agency’s ONE Network, which connects all Ontario hospitals.
SSHA hosts the EMPI in its state-of-the-art data centres, ensuring the
application is always available.
The project provides region-wide tracking by creating a single record
for each patient. Data covers 10 years of patient history from each
hospital. The system connects patient demographic data by creating links
based on a patient’s first name, last name, date of birth, Health Card
number, gender, father’s first name and mother’s maiden name. Patient
records are matched based on these data elements. To date, 93 percent of
the medical records were linked automatically. The others are processed
manually and reviewed by health record professionals.
“The software assigns a patient identifier to link records from
participating hospitals,” says Suzanne Law, interim manager for the
eastern Ontario Regional Link Team. “This solution will enable systems
to link clinical data to the appropriate patient and allow care
providers to view each patient’s data from the different participating
hospitals. If a patient visits one hospital and gets referred to
another, the new care provider will be able to see the original
diagnosis, description of symptoms, list of medications, drugs
prescribed, any lab results and so on. At the moment, our focus is on
matching patient data and eliminating duplicates in our systems, so when
we start sharing clinical data, there will be minimal confusion and risk
of data being attached to the wrong patient.”
Duplicate records are a big challenge for hospitals. Different
hospitals, and even different sites of the same hospital may enter data
differently. This means a patient may have multiple records. The risk is
that a provider may not be looking at the whole picture.
“This project provided the opportunity to develop standards for patient
registration,” says Debbie Read, director of health records, The Ottawa
Hospital. “This has been something our region has been talking about for
many years, but now we have an immediate common goal – building a
shareable electronic record for our patients. With standardization comes
improved quality of data within our systems.
“When patients come to a hospital,” she says, “a lot of history is
taken. Patients are required to repeat clinical information at different
points throughout their stay, and then all over again if they go to
another hospital. With the EMPI and the ultimate goal of sharing
clinical information between hospitals, this duplication will be
eliminated.” The EMPI will eventually link all 18 hospitals in the
region by 2007.
New RFID technology offers clinical and administrative benefits
By Jerry Zeidenberg
There are astonishing benefits in the offing from a
relatively new technology known as RFID – short for Radio Frequency
Identification – a technology that easily allows you to track people or
objects.
That may not sound so compelling – until you consider how difficult it
can be to find patients or products in a hospital.
Speaking at a recent seminar on RFID, Philip Bradley, healthcare sales
manager for systems integrator Unis Lumin, noted the following problems
in hospitals – all of which can be resolved or improved by RFID location
systems:
• 40 percent of a caregiver’s time is spent looking for something – a
patient, document, or medical device.
• 30 percent of the time, nurses don’t know where their patients are.
(They could be away for tests, walking around the floor, or simply in
the washroom.)
• A good deal of equipment is lost or stolen. “Some hospitals buy 50
percent more wheelchairs than they need, simply because they go out the
door and don’t come back,” commented Bradley.
• Overall, hospitals misplace or lose 10 percent to 20 percent of their
valuable medical equipment annually.
• Hospitals over-procure by a margin of 20 percent to 33 percent to
ensure ready access.
• Because nurses want to know where equipment is when they need it, they
often tuck it away in a closet or room for safekeeping. However, it then
becomes unavailable to others who might need it.
• When equipment can’t be found in an emergency, patient care suffers.
The challenge was expanded upon by Mark Dyer, channel sales manager with
RFID developer PanGo Networks, of Framingham, Mass. At the Unis Lumin
seminar, Dyer recalled the case of one U.S. hospital whose clinical
engineering department was overspending by $1.5 million a year, simply
because it couldn’t find medical equipment when it was needed.
“They’d spend three days looking for a pump,” said Dyer. “If they
couldn’t find it, they’d buy a new one. They ended up losing $4,000 a
day.”
It’s a tale that’s repeated in hospitals across the United States and
Canada.
All too often, medical equipment goes missing in hospitals and nursing
homes. In some cases, it’s simply borrowed – one department will lend a
specialized bed, IV pump or wheelchair to another. But in the din and
fray of a hectic week in a hospital, where the equipment went or who
actually borrowed it is quickly forgotten.
RFID systems have emerged as an important solution to this dilemma. They
make use of small tags that can be attached to equipment or people.
Using wireless technology, they can easily spot the location of whatever
they’ve been attached to – whether it’s a person or product.
The telltale wireless signals show up on a computer screen, displayed on
drawings of a building or even a multi-site campus. You can spot exactly
where something is – even if it’s tucked away in a closet or washroom.
Dyer noted the surging interest in RFID in the United States. One
customer, the Beth Israel Deaconess Medical Center, a Boston-based
organization that’s affiliated with Harvard University, started out with
an application for tracking equipment and people in its Emergency
Department. It’s now rolling out the RFID application across the entire
enterprise.
“Alerts will sound if equipment moves out of its proper zone,” said
Dyer, noting that Beth Israel Deaconess is in this way keeping tight
rein on the location of medical devices and gear.
Currently, Beth Israel Deaconess is tracking bio-medical equipment such
as IV pumps, bedside monitors, wheelchairs, glucometers, and telemetry
units. In the future, it intends to extend the system to monitor
patients, as well. “If a patient has left the room for more than 20
minutes,” said Dyer, “it can sound an alert.” The system can also tell
you where that patient has gone – an important function, if you’re got
him or her lined up for a diagnostic test or operation and you’ve only
got a short timeframe.
John Riley, director of advanced business solutions for Unis Lumin,
explained that RFID technology comes in two forms, active and passive.
The passive tags are tiny and cost about 15 cents. They operate within a
building that’s outfitted with RFID antennas.
Active tags contain their own transmitters and batteries. They operate
at longer range – for instance, they can still tell you the location of
a device (or patient) that has moved beyond the walls of a hospital.
These devices cost between $50 and $100 apiece.
While the more expensive active tags use open systems, to date, the
lower-cost passive tags have all involved proprietary systems. Many
hospitals have balked at investing in them, as they didn’t want to
invest in yet another wireless network.
Riley commented that developers have recently worked to develop a common
standard for the passive tags; it should be ready next year.
In the meantime, however, the active tags are being used to track
patients and expensive equipment, such as infusion pumps, and customized
beds and chairs. Riley estimates a system capable of tracking 1,000
assets can be implemented for under $300,000 – that includes tags,
software and integration services.
What’s the payback for a system like this?
Unis Lumin estimates that a 500-bed hospital (tracking 3,200 assets)
will save $400,000 a year in reduced equipment purchases alone. Bradley
points out there are other savings – such as the time of clinical
engineers who can quickly find equipment for maintenance, and nurses and
doctors who can find equipment for patients when they need it. That also
translates into savings, and boosts the return on investment to $2
million annually. And of course, the effect on patient care – having
equipment ready to go in an emergency situation – is incalculable.
Infoway standard for pharma systems propels creation of networks
By Dianne Daniel
Canadian provinces are one step closer to developing
province-wide pharmacy networks that will track “all drugs for all
people”, now that Canada Health Infoway has deemed its new CeRx clinical
messaging standard stable for use. First out of the starting gate are
Prince Edward Island, Newfoundland, Saskatchewan, Alberta and B.C., but
as Infoway’s Bob Serviss points out, it’s only a matter of time before
all jurisdictions are on board.
“What we’ve done is speed up the process,” notes Serviss, who serves as
group director of Canada Health Infoway’s Drug, Lab and Innovation
programs. “We’ve been working hard to encourage the provinces to share
as much of their information between them as they can, so that they
don’t have to reinvent the wheel all of the time.”
Key to their efforts is unanimous support of CeRx, which is based on HL7
version 3 and essentially outlines communications standards such as
messaging and naming, so that different systems from different vendors
can share information. According to Serviss, projects to advance
provincial pharmacy networks were put on hold while the standard was
developed, and now that it’s available, early adopters are pushing
forward.
Alberta, B.C. and Saskatchewan, for example, are in the process of
upgrading their existing drug information systems (DISs) to comply with
the standard, while Newfoundland and PEI are proceeding with final
deployment of province-wide systems based on CeRx.
Quebec is currently in the process of evaluating and selecting a vendor,
and Ontario, Manitoba, New Brunswick and Nova Scotia are about to enter
the planning stages. In each case, the goal is to create a system that
will manage complete medication information for all residents, enabling
physicians and pharmacists to check for medication history, allergies
and drug interactions, and to perform electronic prescribing –
regardless of whether a patient has insurance, is a welfare recipient or
a senior, or none of the above.
In Prince Edward Island, which will likely be the first province to have
a fully integrated DIS, says Serviss, work on a drug claims processing
system began in 1997. In 2001, the province attempted to build on that
system (which was limited to the 35 percent of the province’s population
who were seniors or were involved with special health programs through
Social Services) in order to create a repository that could track all
sales of all drugs to all people. It was forced to hold back when
pharmacy information system vendors began to push for standards, says
Sherry McCourt, DIS project manager for the PEI Department of Health .
Now that CeRx has been certified for use, PEI is proceeding and intends
to go live with the Medigent DIS from DeltaWare Systems Inc. next June.
Initially, the system will be open to all pharmacists and physicians,
with a link to the province’s hospital clinical information systems
expected to be complete by March 2008. The goal is to seamlessly
integrate pharmacy point-of-sale systems, physician electronic medical
records and hospital information systems, using the messaging standard
as glue.
As McCourt explains, most of the support will come from pharmacy vendors
who must ensure their systems comply to the standard in order to
interface to the Medigent DIS. PEI released its implementation guide at
the end of June and the DIS will be available for vendor testing by
February 2007.
“Canada Health Infoway reined everybody in and started working on a
standard, primarily at the request of the vendor community,” notes
DeltaWare project manager, DIS development, Peter Lawlor. “No standard
can make everything exactly the same, but it does make life easier for
the vendors.”
Lawlor estimates it took 18 months to develop CeRx and another nine to
build up the expertise to work with it. The advantage of working with a
small jurisdiction like PEI, he says, is that the process of testing and
validating the standard moves along quicker.
According to McCourt, Canada Health Infoway has expressed an interest in
sharing some of the “knowledge objects” developed in PEI – such as the
implementation guidelines and testing simulator – with other
jurisdictions. In fact, the non-profit organization is encouraging as
much collaboration between provinces and vendors as possible, even if
they choose to use competing products.
The Newfoundland and Labrador Centre for Health Information (NLCHI), for
example, has selected Emergis as the lead vendor for its pharmacy
network and, unlike PEI, is starting from scratch.
“Right now in Newfoundland there’s no central repository for
prescription information,” says Margot Priddle, project manager and
pharmacy consultant for NLCHI. “… What happens is when you get a
prescription filled at a particular pharmacy, that’s where the
information stays.”
The proposed Newfoundland and Labrador Pharmacy Network will be
implemented in three phases. Under phase one, the province’s 190
community pharmacies will be connected so that information can be
collected and populate the DIS on a go forward basis. As well, a
provider care portal will be placed into hospital emergency rooms so
that clinicians without links to a pharmacy system or computer will have
a means to access the information.
Phase two entails building an interface to the clinical systems within
the province’s hospitals, which have all standardized on Meditech.
“There are pockets of information as you travel in and out of acute care
systems and your medication profile doesn’t go with you, just the bag of
drugs that you’re taking – if you remember to bring them along,” notes
Priddle. The Meditech interface will change that, allowing clinicians to
both access and update key medication data.
The final phase will be the electronic prescribing component, which is
currently being reviewed by the project’s clinical advisory group.
“We’ve been through a fair bit of due diligence in this process,” says
Priddle, noting that the business case was written in 2002. After
issuing a Request for Proposals in 2005, NLCHI selected Emergis, along
with Systems Xcellence Inc., Courtyard Group Ltd. and zedIT Solutions
Inc.
The cost of Newfoundland’s network is estimated at $25 million over four
years, of which Canada Health Infoway has committed $17 million. The
remainder is being provided by the Department of Health and Community
services.
While there are administrative benefits to establishing provincial drug
information systems, the primary advantages will be clinical in nature.
“A lot of people don’t know the medications they take,” says NLCHI’s
Priddle. “’One for the heart, a little white one and a little blue one’
isn’t really helpful when you’re trying to figure out what the profile
is and what the exact chemical structure of that medication is.”
“I think drug information is one of the most important components of the
electronic health record because it says a lot about the condition of a
patient,” says Serviss. Getting complete and accurate information about
the medications taken by patients should go far in helping physicians
deliver the best care possible.
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