St. Michael’s to roll out advanced systems, aims to optimize workflow

By Jerry Zeidenberg

TORONTO – St. Michael’s Hospital is preparing to install an advanced ‘Workflow Engine’ as part of their clinical information system – essentially smart, computerized programs that will inform caregivers of the best practices to follow when patients present to the hospital with various medical problems.

This intelligent software also has the ability to provide alerts to healthcare professionals and support staff, resulting in faster and more appropriate care throughout the hospital.

“The system can automatically trigger calls to physicians, nurses, infection control, admitting, dietary, and housekeeping,” said Dr. Dan Cass, medical lead for I.T. and chief of emergency medicine. “It will push these processes along, instead of leaving things to chance.”

As Dr. Cass explained, “At times in the past, some processes have broken down; because the appropriate medical staff and team members haven’t been notified in a timely way.” St. Michael’s expects care delivery to become faster and smoother through use of Soarian’s workflow engine.

The workflow project is one of several components of the hospital-wide Soarian clinical information system implementation at St. Michaels.

St. Michael’s Hospital is a high-profile academic health science centre offering care for the sick and poor in Toronto’s inner city. Affiliated with the University of Toronto, the hospital is a clinical leader in the many areas, including heart disease, trauma and critical care, neurosurgery, arthritis and osteoporosis, keyhole surgery, diabetes and cancer care.

The hospital has 4,800 staff and 600 physicians. Each year St. Michael’s teaches 1,800 students, performs 25,000 day surgeries, treats 600,000 patients in clinics, sees 57,000 patients in the emergency room and provides round-the-clock care to 24,000 in-patients.

According to hospital executives, its all-encompassing Soarian Clinical Information System is the most comprehensive installation of the Siemens product in Canada.

Soarian has many components, but the workflow engine is especially important to St. Michael’s. “This was the real distinguishing factor when we looked at acquiring new information systems,” said John King, executive vice president and chief administrative officer at the hospital.

The hospital examined a variety of systems, but determined that Soarian and its advanced workflow solution had the most value for St. Michael’s.

Anne Trafford, chief information officer, noted that the hospital intends to implement their first workflow, enabled by Soarian’s workflow engine by the end of 2007. A second technology-enabled workflow is expected by March 31, 2008.

Other workflow processes being considered include infection control notification and management, and primary physician notification.

Andy Hind, vice president of the medical solutions division at Siemens Canada, noted that currently 66 different technology-enabled workflows have been implemented at Soarian customer sites worldwide. In time, more workflows will be developed – many by the users themselves, such as St. Michael’s.

Organizations using Soarian can trade applications, customize the solutions, and lend expertise to one another. “It almost becomes shareware for Siemens clients,” commented Dr. Cass.

Hind added that the workflow engine offers ‘role-based’ security, providing care-givers a different view or set of patient information, depending on whether he or she is a physician, nurse or other healthcare professional.

St. Michael’s launched Soarian in 2004, sunsetting their legacy solution in March of this year. A wide variety of departments now operate using Soarian – including nursing units, clinics, lab, pharmacy, cardiology, radiology, and dietary services. By using Soarian Clinical Access, physicians now have a single view and can obtain all lab, pharmacy, radiology reports and images, as well as ECGs. “It provides us with a single view of all the available electronic patient information,” said Dr. Cass.

In 2005, in concert with clinical transformation, Soarian Scheduling was also implemented and now supports all 245 clinics throughout the hospital. This has allowed St. Michael’s to address wait times, and patient and staff satisfaction in the ambulatory care setting

Implementing the wide-ranging system, however, required buy-in from the board of directors – which King says has given full support. It also needed the confidence of physicians and clinical staff.

To that end, a great deal of education and change management work has been done. “We spent a whole year building the trust of clinicians,” said Trafford. Part of the conversion program included a mock shut-down of the older system, to demonstrate the effectiveness of the new, integrated Soarian solution.

As part of the multi-year project to implement new information systems at the hospital, known as Project Gemini, St. Michael’s budgeted $7 million for education and training, e-learning and change management. “It’s a major investment,” said Trafford.

The new systems are working well, and they have hospital-wide acceptance, said King, who emphasized that a large measure of the credit goes to Trafford and Dr. Cass. “We’ve got people with clinical expertise and understanding leading the work,” he said, referring to Dr. Cass, the head of the emergency department, Sally Remus, the hospital’s director of clinical informatics, and Trafford, who at one time was employed as a nurse at St. Michael’s.

On a related front, St. Michael’s is also getting ready to implement the online documentation project, in which nurses will record patient histories, vital signs and physical assessments in Soarian. The pilot project will go live by the end of the fiscal year.

And as the next major step, with initial planning already under way, the hospital intends to implement computerized physician order entry (CPOE) for medications. “CPOE has the potential to have the greatest impact on physicians, but it could have negative implications if it’s not done correctly,” asserted Dr. Cass. “We’re taking great pains to do it right.”

As part of that process, the team is looking at hospitals where CPOE has been implemented effectively and others where implementation was not as successful. It’s all part of the effort to learn what works, and what doesn’t.

Organizations that have deployed CPOE with great success, said Dr. Cass, include the Cincinnati Children’s Hospital Medical Center, the University of Pittsburgh Medical Center, and the Calgary Health Region.

If done correctly, he added, CPOE can have tremendous benefits for patient care. “It’s not about saving time, because it won’t do that,” said Dr. Cass, explaining that it may take longer for physicians to enter medications and data into the computerized system than to scribble an order and send it off to the pharmacy.

“But it will save time downstream,” he said. Medication errors often have tragic consequences for patients. Well-designed and executed CPOE systems have been shown to be effective in reducing the rate of serious medication errors. Prevention of errors can be attributed to CPOE systems with structured orders and medication checks that help to prevent errors during the ordering, checking, dispensing and administration process.

What’s more, through the decision support capabilities of a CPOE system, such as evidence-based medicine and suggested therapies, “you’ll have better results,” he said. Patients will get better, sooner – resulting in greater patient satisfaction, reduced complications and lower costs to the health system.

Results like those should appeal to all caregivers. And it’s this approach that St. Michael’s is taking to raise physician support for the new systems – it’s all about improving the level of care. “This is really a clinical project that’s supported by IT,” said Dr. Cass. “It’s not an IT project, in and of itself, and that makes a big difference when you’re working with physicians, nurses and other health disciplines.”

BACK TO CONTENTS LISTING

Abbotsford to invest $84 million in new technologies

By Walter Hiller

ABBOTSFORD, B.C. – Technology systems to be installed at the new Abbotsford Regional Hospital and Cancer Centre include some of the most innovative and advanced in the country, and will enable healthcare professionals to provide focused, patient-centred care in a world-class facility.

When the hospital and cancer centre opens in summer 2008, it will transform the delivery of healthcare services in the Fraser Valley.

The Abbotsford Regional Hospital and Cancer Centre is planned as a 300-bed replacement for the aging MSA Hospital in Abbotsford. This $355-million project will be an important regional referral hospital for the Fraser Valley and the fifth regional centre in the BC Cancer Agency’s provincial cancer control network. About $84 million in new equipment and technology will be installed in the new hospital and cancer centre.

In June 2007, the Province of British Columbia announced a $30 million agreement with GE Healthcare to provide state-of-the-art medical imaging equipment, patient monitoring systems and digital picture archiving communications system (PACS) for the hospital and cancer centre. This technology package also includes transitional, educational and consulting services that will help streamline hospital operations and allow staff to save time and bring an even greater focus to frontline patient care.

A variety of technology solutions will give healthcare professionals critical decision-making information right at the patient’s bedside.

One innovative example is the anesthesia patient delivery and physiological monitoring system. The GE Healthcare anesthesia delivery system unites patient demographics and diagnostic information right at the point of care. The anesthesia station is essentially comprised of three different components that work together as an integrated unit.

The first is the anesthesia delivery unit, which provides sophisticated ventilation options and a “fuel injection” delivery of anesthesia medication using an electronic control. Patients will benefit from the synchronized “gentle” ventilation parameters. As well, the anesthesiologist can deliver full pressure control ventilation if needed. This system also has the potential to significantly reduce the use of expensive anesthetic agents.

The second component is a robust patient monitoring system that will allow physicians to view vital signs and electrocardiogram rhythms of their patients in the recovery room directly on monitors in the operating room – similar to a picture on a television set.

In addition, patient laboratory data is going to be directly available to physicians at the anesthesia workstation.

The third and perhaps most beneficial component is the electronic anesthesia record. All of the data from the anesthesia delivery unit and patient monitor is continuously recorded and made available to the electronic record. “The anesthesiologist currently spends a lot of time away from focused patient care, recording this data manually,” explained Dr. Derek Campbell, head, department of anesthesiology at MSA Hospital. “The electronic capture and reporting of this data will be critically important in emergency cases, when there is little time available for record-keeping. There is no doubt that a more complete and accurate representation of the procedure will result.”

“It will be an exciting time for patients and physicians as we begin to use this new technology. In the end, the goal is to maximize the amount of time we spend on patient care and minimize the time spent focused on machines and manually recording data. The ability to view X-rays, laboratory data and electrocardiograms directly at the anesthesia workstation will be a significant time saver,” said Campbell.

There are other examples of how technology is saving time and allowing healthcare professionals to focus on patient care. The hospital and cancer centre is being designed and constructed to accommodate structured cabling and a complete wireless network infrastructure that will enable the use of all forms of wired and wireless communication devices.

Emergin will provide an integrated alarm management solution that will route critical patient alarms from bedside monitors and ventilators to the wireless phones being deployed to nursing staff, physicians and technicians throughout the new facility.

This unique software platform uses dashboards, reporting tools and services to help healthcare professionals manage critical alarms and events. In addition, nurse call will be integrated with the alarm management system to provide seamless communication between patients, staff and equipment.

Another innovation is the installation of operating room message boards. There will be five sets of 32-inch liquid crystal display monitors mounted throughout the operating room areas that will contain information about each of the nine ORs in the hospital. A quick glance to any one of these screens will provide staff with critical information about the status of activity in each OR, resulting in better time and equipment management. This information will be displayed in both text and real-time video through closed circuit television.

At the Abbotsford Regional Hospital and Cancer Centre, technology will also be used as a tool to improve patient care and safety. Physicians caring for cardiac patients in the hospital will benefit from the wireless transmission of diagnostic cardiology exams directly from the patient’s bedside, with the ability to review these exams electronically from multiple locations throughout the hospital or from the physician’s office.

In addition, the GE Healthcare perinatal information system will provide the labour and delivery area with central surveillance of labouring mothers, resulting in significant improvements to nursing staff workflow and patient safety. Moreover, the system is designed to capture and store electronically, information from fetal monitors and other physiological equipment to create a comprehensive clinical record about mother and infant. Information can then be transferred from the mother’s chart to the baby’s record without re-entering data. The result will be less time spent on redundant, multiple data entries and more time spent on direct patient care.

With the integration of a cancer centre and a hospital – a first in Western Canada – residents of the eastern Fraser Valley will benefit from the spectrum of world-class cancer care services closer to home. In addition, the cancer centre will be the first radiation therapy department in the province to solely use computed tomography (CT) simulators for the planning of radiation therapy treatments. Treatment planning is an important part of cancer care and outcomes and this allows better visualization of anatomical structures within the areas of treatment.

Walter Hiller is the President and Chief Project Officer of Abbotsford Regional Hospital and Cancer Centre Inc.   

BACK TO CONTENTS LISTING

GIS techniques, when applied to healthcare, can solve many problems

By Jerry Zeidenberg

It’s remarkable what you can do with geographical information systems (GIS) – if you’ve got enough data to work with and the smarts to figure out what the information means.

Recently in Sault Ste. Marie, Ontario, a team of GIS experts provided mapped data showing that about 65 percent of the city’s low birth-weight babies were coming from low-income neighbourhoods. Using another set of a data, it was also determined that these areas had a high number of expectant mothers who admitted to smoking during pregnancy. This was the kind of evidence that experts were looking for to show that smoking mothers may be having smaller babies.

As low birth-weight often leads to health troubles later in life, public healthcare officials took action by providing women in these neighborhoods with anti-smoking literature and programs.

This sharp-shooting strategy was more effective, and cheaper, than a shotgun approach which might blanket the whole city. “You don’t need to send brochures to neighbourhoods that haven’t had a birth in five years,” quipped Paul Beach, manager of the Community Geomatics Centre (CGC) in Sault Ste. Marie.

Beach and Tom Vair, executive director of the Sault Ste. Marie Innovation Centre, gave a fast-paced and fact-filled presentation at a May conference on GIS in Healthcare, held in Toronto. The conference, sponsored by GIS software developer ESRI Canada, involved a number of speakers from government and healthcare organizations who are deploying geographical information systems.

They showed how the rapidly growing field of GIS can provide new and effective tools for health promotion. In a variety of ways, geographical systems can be used to nip trouble spots in the bud – meaning that you can prevent the outbreak of illnesses and thereby keep people out of doctors’ offices and acute-care hospitals.

For its part, the CGC in Sault Ste. Marie has become a leader in the application of GIS to healthcare. The centre has been mapping the city and outlying regions since 2000, using advanced computer techniques. Indeed, all 70,000 buildings have been photographed and mapped. So has every stop sign and fire hydrant. As a result, Beach believes the northern Ontario city now has the “most comprehensive municipal GIS in North America, and perhaps in the world.”

Using several data sources, analysts at the CGC can determine where people work, play and live, and who is young or old. Some of the data is updated daily, and all is refreshed at least on a yearly basis.

Of course, it’s not how much data you’ve collected, but how you use it. In the case of Sault Ste. Marie, they’re actively putting the information to work.

Beach and Vair noted a host of healthcare problems the city has faced, and outlined how GIS was able to crack various mysteries, leading to solutions and the elimination of problems.

• Using geographical databases, it was determined that about 90 percent of the kids presenting at the local hospitals with injuries were coming from low income neighbourhoods, particularly from the social housing complexes. The reasons for this are currently under investigation. Possible explanations include a lack of parental supervision, and a lack of accessible recreation facilities and programs. Now, city and YMCA officials are preparing to bring sports and recreation programs closer to where these children live. Also being suggested is a community bus for children that would provide direct transportation from less advantaged neighbourhoods to sites of organized activities like soccer and swimming, or to libraries.

• Sault Ste. Marie has the second-highest rate of elderly people among municipalities in Canada, noted Beach. But by collating records and mapping the data, the city has identified the areas with the greatest concentrations of seniors. Knowing this, they’ve been able to prioritize these areas for quick salting and sanding after sidewalks are plowed. That’s intended to prevent falls and hospitalizations. Similarly, the city has embarked on a campaign to ensure that street corners are cut and sloped in neighborhoods with seniors, to provide easier access for the handicapped and people with walkers.

• By mapping the dwellings where people are wheelchair-bound, blind, or have other mental and physical handicaps, alerts can be programmed to pop-up at emergency services in the event of fires, floods or when medical help is needed. This ‘special needs’ capability is currently being developed in Sault Ste. Marie. As a result, “emergency services will be better prepared,” said Beach, who observed that the city will be “the first municipality in Canada to have a comprehensive system of this sort.”

• In the battle against West Nile Virus, which is transferred to humans by mosquito bites, city officials sought to eradicate sources of standing water – sites where mosquitoes are known to breed. While out walking, Beach discovered, that mosquitoes were emerging from the grates over electrical transformers, which had been built below sidewalks. “It was a bad idea (to locate the transformers under sidewalks),” said Beach. “They’re tripping hazards and water pools into them, where it’s heated by the transformers.” He explained that the standing water becomes a prime breeding ground for mosquitoes. With a database of the location of all such transformers in the city, officials were able to target them for larviciding.

• Large buildings, too, can be mapped and analyzed to resolve problems. In 2003, the Sault Area Hospitals (SAH) had an outbreak of c. difficile. The CGC was brought in to determine how the disease made its way around the hospital. Vair noted that experts collected a wide variety of information, including patient admission and discharge dates, the onset of disease in afflicted patients, patient room movement, the availability of washrooms, which patients were in private rooms and which were in wards, the flow of clothing and food, among other factors. The information will be used for future planning, to help prevent or isolate diseases upon outbreaks.

Beach asserted that GIS databases require an extraordinary amount of information. “The amount of data is tremendous, and you have to put in role-based security,” he said. “A lot of our investment went into that.”

So far, he said, some 1 million documents are contained in the database. And while the geomatics centre has only six employees, Beach observed that a great deal can be accomplished with clever programming. “When we change one address, it will affect 23 other variables in the database,” he said. “We’ve built-in that kind of intelligence. It makes us much more efficient.”

Asked about data quality contributed by partner organizations, Beach replied that “it can be quite poor, with a 20 percent to 50 percent reject rate.”

But he said that data quality problems can be overcome by using the right collection techniques. “We go in and train the organizations,” said Beach, “and soon enough, their data is clear and more valuable.”

BACK TO CONTENTS LISTING

‘Smart’ pumps reduce the incidence of IV medication mistakes

By Neil Zeidenberg

The Scarborough Hospital, a bustling two-site organization in Toronto, has found an effective solution to the problem of IV medication errors by implementing ‘intelligent’ pumps and software.

For the past year, the busy Scarborough sites have been using over 400 of Hospira’s new Smart IV pumps and their attendant MedNet software.

The result?

A resounding success, notes director of pharmacy Patricia Macgregor, as the Smart pumps are catching and preventing potential errors. They’re flashing alerts to nurses when the medication being dispensed goes beyond or below the parameters set as ‘best practices’ for a particular drug.

Although not widely publicized, IV-related adverse drug events (ADEs) are quite common. In fact, approximately 35 percent of all medication errors are IV related.

“IV errors can often be fatal because the medication goes directly into the blood stream, and many patients are receiving high-risk drugs, such as oncology medications, narcotics, high potency electrolytes, anticoagulants, and insulin,” said Macgregor.

According to a 1995 study on ADEs, administering drugs represents one of the most high-risk activities for nurses in healthcare facilities.

Many errors occur because nurses are working long shifts, see many patients and become tired and stressed. Often due to staff shortages, nurses are required to complete shifts in different patient-care units with patient types that are less familiar to them.

Various patient types may require different dosages of the same medication. For instance the dose of morphine tolerated by a surgical patient will generally be far lower than that of a palliative patient.

Addressing this challenge, MedNet software is completely customizable by patient-care area, such as pediatrics, ICU, and step-down. It permits specific drug lists and dosing limits according to the needs and tolerances of the patients in these units – thereby providing additional patient-safety protection.

“A nurse can easily go into a ward, accidentally give the wrong drug to the wrong patient, or the wrong dose,” said Pascal Couture, product manager for medication management systems, at Hospira Healthcare Corporation (Canada), in Montreal. “Sometimes it’s fatal and sometimes not. Even when it’s not, it may mean the patient stays in hospital longer,” resulting in a poorer outcome and lower-quality experience for the patient, higher costs to the healthcare system, and longer waits for other patients.

Before being deployed, the Smart IV pumps receive a Drug Library “push”. The Drug Library is programmed centrally at the hospital pharmacy through the MedNet software, then pushed out electronically to all the pumps. The software allows the hospital to pre-configure appropriate upper and lower dosing limits for intravenous drugs –- thereby setting organizational protocols for such high-alert drugs as heparin, insulin or morphine.

Pharmacists, nurses and physicians work together to develop ‘best practices’ for various medications, using published evidence-based medicine and their own population needs.

This process, along with the ease of programming through MedNet, enables a consistent, evidence-based approach to patient care, with the ability to respond quickly to changes in drug therapy reported in the literature, Macgregor said.

The technology is relatively simple to use, and requires as little as 1-½ hours of training.

If the data entered by the nurse at the point-of-care doesn’t match what’s been pre-programmed by the pharmacy, the IV pump will ask for verification. In some cases, this can be overridden by the nurse, but it always makes him or her re-think whether the patient is getting the right medication, in the right dose at the right time.

Nurses and staff have benefited from this safety mechanism, but patients, naturally, have been the biggest beneficiaries.

Macgregor said approximately 2,000 full-time and part-time staff at TSH use the technology. Despite a few extra steps and additional time that’s needed to operate the pumps (compared to a “rate + set + go” program from a non-MedNet pump), the gains have been huge – making the extra steps of data-entry well worth the effort. The patient is safer and nurses provide care with more confidence.

MedNet – the software application for the pumps – is able to compile daily, weekly or monthly status reports tracking the number of patients infused, drugs dispensed, time and date, and problems that occurred, such as keying errors or alerts and the response of staff to those alerts.

In the near future, the procedure will be simplified further by the use of bar code scanners, which will eliminate some of the key entry. Next year, Hospira expects to introduce MedNet N5. In addition to verifying the 5-Rights (Right medication, Right dose, Right time, Right patient and Right route), this software upgrade can also identify the nurse who infused the patient and the particular patient being infused.

Staff will be required to scan not only the barcode of the drug being infused, but the barcode on the patient armband and his or her ID badge.

All these data can help identify when and where errors happen – ICU, emerg, pediatrics, oncology, or other departments. They can also help determine if particular staff members need further training or re-education on best practices, or if the patient-type or clinical treatment regimens have changed on the patient-care unit. They may also indicate that a review of the literature is required, along with a potential revision of the drug monographs to meet the changing needs of the population. 

BACK TO CONTENTS LISTING

HOME - CURRENT ISSUE - ABOUT US - SUBSCRIBE - ADVERTISE - ARCHIVES - CONTACT US - EVENTS - LINKS