Community health in Ontario installs EMR software

By Andy Shaw

Ontario’s 56 multi-discipline health centres serving inner city, small town, and other “under-served” communities are out of the electronic starting blocks early. In an unprecedented $2 million purchase of electronic medical record (EMR) technology, the Ontario Association of Health Centres (OAHC) is readying its members to run in Ontario’s slow-to-get-rolling race towards an information technology based healthcare system.

“We’ll have the hardware and a really good software product in place so that whenever and whatever changes come along in the restructured system, we’ll be ready plug into them,” says Linda Stewart, the OAHC’s manager of information systems.

The “really good software product” is actually a $1.2 million customized blend of two products. One is the Microsoft-based Dossier of Clinical Information (DIC) from Purkinje Inc. in San Antonio, Tex., a unit of Purkinje Partners in Montreal. The other is “Medical Desktop” from York-Med Systems Inc., Purkinje’s Ontario sales and support firm in Markham, Ont.

Together they will run on the standard PC networks that are now common to the province’s health centres. Purkinje’s DIC uses a pen-based technology to document patient encounters. It’s said to be used in over 1,000 sites. Medical Desktop is York-Med’s medical administration application – featuring patient profiles, appointment management, and electronic data transfer.

“We picked Purkinje because out of the 22 vendors we contacted, it was the one product that was going to meet almost all of our needs. It also scored very well on the independent technical review we made on the seven companies we short-listed,” says Stewart. “ I’ve done a lot of software purchasing and it’s something I have a healthy skepticism about. But in every single reference check we made on both Purkinje and York-Med, everyone talked about the excellence of their service. It’s something both companies have won awards for.”

York-Med’s service this time will include deploying the software combo to all 56 centres and their 400 caregivers, and then provide on-going technical support.

“We’ve got six beta sites running now but we are aiming to have them all operational by Christmas this year,” says Stewart.

In terms of service to the community, Stewart says the new set-up will go far beyond the normal doctor’s office systems that simply keep track of clients and provincial health insurance billings.

“It’s really going to be a decision support tool among other things,” says Stewart. “If someone comes in a health centre door with a cough, a screen will come up to guide the user through the diagnosis. But it is also going to be almost like a project management tool that will eventually start helping us make community health care more effective and measurable, really for the very first time.”

Traditionally, the wide range of clinical, social work, and housing services performed at community health centres have been too complex to get a single handle on. But their new Purkinje/York-Med software will help them to systematically identify healthcare challenges and react.

“This kind of data may take years to build up,” says Stewart. “But let’s say the system shows an unusually high number of respiratory problems are coming in the doors from a suspected local polluter. The health centre would then be able to organize the community and work with the company involved.

“And that experience can be shared. So the important thing the system will do for us is to be able to transfer abilities to the community, so that in providing health care each one becomes more and more self-sufficient.”

Stewart says initially the individual health centres will not be linked into a network, but that’s the long-term goal. Still, right from the start, through their new Medical Desktop data transfer facility, all 56 will feed non-nominal, aggregate information to a central repository in the Ministry of Health regularly. There will be no unique individual identifiers but the data will facilitate research and analysis of health trends in local communities – much in the way that the Canadian Institute for Health Information (CIHI) analyzes data flowing in from individual hospitals.

Using the data to measure community health centre effectiveness is the next stage.

“That’s what we’re working on right now,” says Stewart. “We’ve got a steering and research committee whose first task is to come up with some effectiveness indicators. They’re leaning heavily right now to many of those used in a United States model for a managed healthcare organization.”

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Surgeons at London Health Sciences Centre leaders in robot-assisted heart operations

By Jerry Zeidenberg

LONDON, ONT. – Surgeons at the London Health Sciences Centre have emerged as world leaders in robot-assisted cardiac operations. Since last year, when they began using ‘keyhole’ surgery for cardiac bypass operations, specialists at the LHSC have performed more than 200 of the robot assisted procedures.

They expect these numbers to rapidly escalate, as patients seek the dramatically shorter hospital stays, and reduced incidence of stroke and infection that are associated with keyhole cardiac surgery.

The hospital has already broken ground for a new cardiac operating theatre that will be outfitted with state-of-the-art robotics.

The LHSC has become perhaps the most advanced site in Canada for minimally invasive heart surgery, largely because of the drive and pioneering work of Dr. Douglas Boyd, director of the minimally invasive and robotic surgical program, and his colleague Dr. Alan Menkis.

The physicians are working with companies like Computer Motion Corp., of Santa Barbara, Calif., to devise new robotic equipment and medical procedures.

Dr. Boyd explained that he and Dr. Menkis are able to perform minimally invasive bypass operations with the assistance of these sophisticated robots and special instruments.

Traditionally, to conduct a coronary artery bypass operation on a patient, cardiac surgeons cut a long incision into the chest and crack open the breastbone to gain access to the heart.

That way, they can fix a clogged artery by sewing a healthy blood vessel into the artery just above and below the blockage. It allows blood to flow past the blocked portion – hence the term ‘bypass surgery’. The new artery is ‘harvested’ from another place in the body, either the leg or the chest.

To do this delicate stitching, surgeons also temporarily stop the heart and put the patient on a heart-lung machine to oxygenate the blood. That’s because it’s difficult to sew the arteries together when the heart and vessels are moving.

In all, the standard, open-heart surgery is a grisly procedure, and one that usually requires a recovery period of three months for the patient.

By contrast, to perform the keyhole version of a coronary artery bypass operation, surgeons first make three, five-millimeter incisions between the ribs. They insert a robotic camera through one, a harmonic scalpel through another (it cuts by vibrating at 55,000 Hz), and a grasper through the third opening.

In this way, they can harvest a mammory artery to be used for the bypass procedure. All the while, they make use of the voice-activated, robotic camera to watch where they’re going and what they’re doing inside the chest of the patient. “I wear a little headset, like they do at McDonald’s,” said Dr. Boyd. “I talk to the robot, and the robot responds to the verbal commands, like move up, move down, move right, move left.”

Next, instead of cracking open the sternum to obtain access to the heart, Dr. Boyd uses the harmonic scalpel to cut another 5-millimetre opening from the inside. “Through that little incision, we insert a little retractor to open up the ribs a bit, and then put in place a little stabilizer plate which straddles the artery and stabilizes it,” he said.

Through this tiny opening, he can use traditional instruments to sew the graft onto the coronary artery.

The patient recovers much more quickly, because there’s less trauma involved. Since there’s no major incision and no heart/lung machine used, blood transfusions are rarely needed, there’s less chance of infection, and there’s a much lower incidence of stroke.

Dr. Boyd noted that in traditional open-heart surgery, the possibility of stroke always looms in the background, largely because of the heart/lung machine. “You have to remember, when you go into a heart/lung machine, you’ve got a little tube that’s about a centimetre in diameter sticking into a blood vessel. It’s blowing at five litres per minute, so any debris that might be hanging inside the artery gets sandblasted up into the brain.”

Even though the results of robot-assisted surgery are excellent, Dr. Boyd said they could be even better. He intends to perform totally closed-chest, bypass operations on patients this year.

Instead of cutting a small opening over the heart and using standard instruments to stitch the arteries in place, Dr. Boyd plans to use a new generation of robots to sew the graft from inside the chest.

Using this technology, he’ll be able to do double, triple and quadruple artery bypass procedures – grafting new vessels onto several blocked coronary arteries in the same session.

And to ensure the stitching is accurate, even though the heart is beating, the robotic instruments will themselves move in concert with the motions of the heart and blood vessels. “This is what we call intelligent robotics,” said Dr. Boyd,”

The camera and the robotic arms are moving in sync with the heart. In fact, the robot will make decisions on its own about where to move or track.”

The surgeon, however, will be orchestrating all of this – sitting at a console away from the patient, wearing goggles that give him a three-dimensional view of the patient’s interior through the endoscopic camera.

While commanding the camera by voice, the surgeon guides the remote-controlled robotic arms and instruments that are working inside the chest of the patient by manipulating a parallel set of instruments with his hands.

All of this takes enormous skill and training on the part of the surgeon. Indeed, Dr. Boyd sees robot-assisted surgery as a revolution in medicine, and one that may upset some practitioners.

“A lot of doctors are comfortable doing surgery the way it’s always been done, and it’s unstabling to know that there’s a new and better way,” said Dr. Boyd. “Some of them just don’t welcome it. It’s going to change their lifestyle – it requires learning new surgical skills and a change of philosophy.”

However, Dr. Boyd said this form of surgery will become standard practice – not because certain doctors champion it, but rather because the public will demand it.

“It’s patient driven,” he said. “Patients want to have less invasive procedures. They don’t want to be in hospital for 10 days, and they don’t want to be off work for three months.”

The promise of reduced pain and complications, along with a speedier recovery, led Tom Hunt to become Dr. Boyd’s first recruit for robot-assisted cardiac surgery in the fall of 1998.

When Mr. Hunt was told that he could receive a coronary-artery bypass through four small incisions in his chest, without anyone sawing his breastbone in half, he was all for it.

The surgeons wouldn’t need to stop his heart and put him on a heart/lung machine. The whole procedure could be done with his heart pumping away.

Mr. Hunt, 45, who is national service manager for C.W. Wood Ltd., a Guelph, Ont. manufacturer of freezers, was diagnosed last year with close to a 100 percent blockage in a coronary artery. Last September, he became the first patient in Canada to have minimally invasive bypass surgery performed on his heart.

“It was all done through keyholes,” said Dr. Boyd.

Mr. Hunt was able to go home three days later, and returned to work 19 days after surgery. That compares with a recovery period of five-to-seven days in hospital, and about 90 days at home for patients who undergo traditional cardiac bypass surgery.

Encouraged by the excellent medical outcomes of Mr. Hunt and other patient, Dr. Boyd and his colleagues are now seeking to establish a national centre for robot-assisted cardiac surgery.
While it will require an investment of millions of dollars, the facility will quickly pay for itself.
“We know that if you can avoid one stroke, the cost of rehabilitation, the loss of work, and the cost to insurance payers is hundreds of thousands of dollars,” said Dr. Boyd.

“If you can avoid even a couple of strokes, that alone will pay for the centre.”

And to patients themselves, the improved medical results are priceless. “This is a technology,” said Dr. Boyd, “absolutely worth investing in.”

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High-flying ERP software companies run into market turbulence

By Issie Rabinovitch, PhD

ERP stands for enterprise resource planning, a type of software with the lofty goal of making enterprises more efficient and more profitable. This is an ugly sounding acronym, but what can you expect from a category whose leader is known by the name SAP?

ERP software consists of multiple modules that allow an organization to improve productivity by linking business operations like sales, finance, marketing, and human resources. On the one hand, AMR Research predicts that the $15-billion-a-year ERP market will grow to $52 billion by 2002. On the other hand, all of the big players in this market are currently mired in disappointing results.

The largest supplier of ERP software, by far, is SAP of Germany. The others, in what is generally considered the first tier, are PeopleSoft, Oracle, J. D. Edwards, and Baan. Growing faster than any of these is Geac, a Canadian company with headquarters in Markham, Ont., but with offices around the world. According to a recent survey, Geac is at number 26 among all software companies, and number 1 in Canada.

As mentioned above, ERP vendors have recently had less than stellar results. This phenomenon appears to be more a result of greater competition in the ERP market, a continued downturn in the global economy, and decreased software purchases as companies shift resources from ERP implementations to year 2000 projects, than of major faults of the vendors.

SAP’s dip in earnings in Q4 led to a reorganization of their Canadian operations. Baan has gone through a more serious restructuring, reducing its total headcount by 20 percent worldwide. PeopleSoft let 6 percent of its workforce go earlier in the year, while J. D. Edwards has been struggling with flat results.

Geac, in particular, has been on a roller coaster this year. Its shares dropped 30 percent in a single day in February, and in July it took a $270 million writedown, $200 million of which was linked to its purchase of SmartStream, the ERP component of its purchase of the enterprise software unit of Dun & Bradstreet in 1996. Also in July it acquired, for about $250 million, an English company called JBA that produces ERP software for mid-sized businesses. Geac may have had disappointing results recently, but its revenues and profits continue to grow.

Let’s leave financial matters, and focus on Geac’s technology. Geac targets healthcare industry solutions, and its software has been adopted by some high profile institutions in the U.S. and Canada.

Geac’s SmartEnterprise Solutions division has a SmartStream suite of enterprise applications, which is heavily based on Microsoft technology. Geac’s implementation of SmartStream Financials and Procurement at St. Michael’s Hospital in Toronto was selected last fall as a finalist for Microsoft’s Industry Solutions Award in Healthcare.

SmartStream’s architecture allows additional applications of the suite to be added without major effort, but the applications currently in use, General Ledger, Accounts Payable, and Purchasing, have already led to noticeable improvements.

“SmartStream has improved the hospital’s productivity by virtually eliminating manual processing and associated errors and providing an automated electronic workflow process for purchase orders, funds transfer and advance shipping notices,” said Brian Edmonds, director of finance and patient information at St. Michael’s Hospital.

With more management information available than before, he finds it easier to evaluate the hospital’s supply chain and vendor performance, which leads to reduced costs, improved efficiency, and increased profitability.

Geac has tight ties with Microsoft, as advertised by the “Best experienced with Microsoft Internet Explorer” and “Powered by Microsoft BackOffice” logos on its Web site. Microsoft Office is the preferred front end for users, but all SmartStream applications run on UNIX and Sybase SQL databases, as well as Microsoft Windows NT and SQL Server.

Some of the vendors offer much greater choice in technology. J.D. Edwards’ OneWorld has an architecture-neutral foundation that allows it to accommodate a large number of databases (including DB2, SQL Server, and Oracle) as well as hardware technologies. In addition to Intel hardware, you can mix and match the AS/400, RS/6000, HP 9000, and others.

Oracle has many of the same advantages, but Oracle has no turnkey applications of interest to healthcare. Oracle has industry-based solution suites, but it lumps healthcare together with pharmaceuticals, and places greater emphasis on the latter. Oracle provides tools for producing powerful state-of-the-art solutions, based on its database technology, but the cost of doing a custom programming job is prohibitive.

SAP and PeopleSoft have well-articulated healthcare strategies and products, and numerous customers, although in this context “numerous” means more than a hundred. PeopleSoft supports 220 customers in a variety of healthcare businesses.

A good way to learn about PeopleSoft’s offerings is to order their free Healthcare Supply Chain Management CD. PeopleSoft claims that their suite of applications reduces the administrative burden on healthcare employees and reduces operating expenses by up to 6 percent. Employees are given tools to do Enterprise Planning (determine where and when to distribute materials across your enterprise based on resource and capacity levels), Project Analysis (drill down to specific purchase orders and invoices, forecast project costs using historical data, and manage labor costs), and Order Management. On the Materials Management side, tools to do Purchasing (automatic procurement and contracting, EDI), Inventory, Accounts Payable, Asset Management, and Reporting. Even if you’re not interested in a PeopleSoft solution, this CD is a valuable learning tool.

There are several developments of a more general nature that are worth noting. One is the growing interest in outsourcing. Several vendors are jumping into the ERP outsourcing market, including SAP. Outsourcing may make ERP applications more appealing to small and midsize businesses, who often have neither the money nor the IT skills to implement ERP applications internally. In addition to speeding up implementation times and reducing costs, outsourcing may also increase success rates. Recent surveys have shown that close to two-thirds of all [in-house] ERP implementations fail to live up to expectations.

Accounting firms seem to be interested in this approach. Since many of their clients are running non-Y2K-compliant products, they can move them to an updated package more easily in a hosted environment. Oracle and Baan also have offerings in this area.

IBM may have triggered a trend earlier this year with an announcement of a performance-warranty program for customers who install its hardware and Baan’s ERP software.

This gives IBM an advantage over Hewlett-Packard and Sun Microsystems, who compete in the same space. There’s a lot involved in making such a guarantee, and it will be interesting to monitor how the market, as well as HP and Sun, respond to this IBM initiative. Not as interesting, however, as monitoring the ERP market once concern for the Y2K problem has dissipated. Will we then see a return to the explosive growth of recent years?

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System charts patient data at ICU bedsides across Calgary

CALGARY – The Calgary Regional Health Authority has announced that a critical care information system is now operating in the adult intensive care units at three hospitals in the city. It’s believed to be the first system of its kind in Canada and one of the first in North America.

The bedside computer-charting system links the Intensive Care and Cardiovascular Intensive Care Units at the Foothills Medical Centre, the Peter Lougheed Centre and the Rockyview General Hospital.

The system provides doctors and nurses with instant access to a variety of patient data as it monitors vital functions and organs, with abnormal results showing up in red on the screen. The system also displays recent lab results, x-rays, drug history and other information.

“The care of the patients requires the collation and analysis of data from a vast array of monitoring devices, laboratory services, and other sources,” said Dr. Dean Sandham, division chief, critical care, for the Calgary Regional Health Authority. “This system instantaneously provides doctors, nurses and others managing the ICU patient with all the data at the bedside, as it is generated.”

The project will also support on-going quality assurance projects, clinical education of staff and medical and nursing trainees, and research to improve the understanding and management of critical illnesses.

Calgary’s ‘networked’ critical care system was first envisioned in 1995. Over the next year, members of the division of critical care evaluated products from several vendors and selected Quantitative Sentinel from GE Marquette Medical Systems of Milwaukee, Wis.

In 1996, following a detailed pilot evaluation in the intensive care unit at the Foothills Medical Centre, a strategic partnership with Marquette was developed. In 1997, complete installations were performed in the two Intensive Care Units at Foothills Medical Centre, followed by implementations in 1998 at the Peter Lougheed Centre and this year at Rockyview General Hospital. The system is now active at over 50 bedsides at ICUs across Calgary.

Now, when patients require transport between units within the region, all data can be transferred electronically in the same format.

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