MB and ON give clinicians easier access to patient records

CTRL +E is Dr. Tunji Fatoye’s favourite computer shortcut these days. As unit director at Winnipeg’s Kildonan Medical Centre, he uses it when he’s seeing a patient for the first time and wants to know what drugs were prescribed previously. He uses it to check lab results, including diagnostic imaging services, urine and blood cultures, and smear tests. As of July 2016, he even uses it to learn about his patients’ recent hospital visits.

It’s a simple sequence of keys that delivers big results, thanks to ongoing efforts within the province of Manitoba to deliver eChart, a secure electronic system that allows authorized healthcare providers to access integrated patient health information.

“If I’m on my electronic medical record (EMR) system and I’m looking at Jane Doe, all I have to do is hit CTRL +E and I open Jane Doe’s eChart, right within my EMR,” says Dr. Fatoye, one of more than 5,800 active users who are regularly accessing eChart each month.

It wasn’t always so straightforward. When Manitoba eHealth first launched eChart in 2011, early users like Dr. Fatoye had to minimize their EMR screens, log in separately and search for a patient. “We said, ‘This is great but we need it to work better. How can we integrate it?’” he recalls.

Each healthcare provider accessing eChart is assigned a unique user name and password. If they are using a Manitoba certified EMR, Manitoba eHealth will work with the EMR vendor to embed a link to eChart, establishing what’s referred to as an in-context pass-through. The link – in Dr. Fatoye’s case, CTRL +E – automatically connects to the correct patient, removing the need to re-enter information and decreasing the likelihood of error. Although integration happens behind the scenes, users still need to refresh their passwords every 90 days and remain subject to the same auditing procedures as users who don’t have a certified EMR and log into eChart separately.

Integration is a primary focus as Manitoba eHealth works towards its vision of “one system, one network,” says Liz Loewen, Director, Coordination of Care, at Manitoba eHealth. “We’re very happy with the inroads we’ve made.”

The province is using Allscripts dbMotion to collect and store data from disparate clinical information systems. As Loewen explains, data is held in a clinical data repository hosted and managed by Manitoba eHealth, and presented to healthcare providers through eChart.

Data sources connected to date include the provincial client registry/registration system which holds unique personal health identification numbers (PHINs) for each Manitoban; immunization records; prescriptions filled through the province’s Drug Programs Information Network (DPIN); laboratory test results; diagnostic image reports; and, most recently, administrative information related to hospital visits at Winnipeg and Interlake-Eastern hospitals. Two modalities not yet connected are cardiology and pathology test results.

“The originating information is always very clearly living with those source systems,” says Loewen. “If there’s ever a concern about the result being posted correctly, or that it has come with an error, we work back with that source to get it updated and sent through, if need be.”

Five years after its launch, eChart is in 61 percent of primary care settings, 77 percent of hospitals and 96 percent of nursing stations. Work is continuing to make eChart available to authorized healthcare providers. “I would say the work in operating a system like this is as heavy on the business side as it is on the technical side,” says Loewen.

Manitoba eHealth follows a very structured process to qualify and authenticate users, establishing formal relationships with employer organizations to ensure users only have access to the information they are supposed to. “A nurse in one setting may have a very different role from a nurse in another, so we didn’t feel it was appropriate to assume all nurses needed the same level of access,” she says.

All user access to eChart is recorded and audited to comply with Manitoba’s regulatory and legislative standards related to protecting personal health information. At any time, patients can request a copy of their personal information presented in eChart, ask to see who has viewed their information, or use a disclosure directive to hide their personal information. “It’s hidden but it can be retrieved by a subset of users who must indicate the reason for doing so,” says Loewen. As of June 2016, there were 136 disclosure directives in place and 537 patients had made requests for records of user access.

One unexpected benefit of eChart is that the province is collaborating around what Loewen calls “small s” standards. For example, work is under way to ensure lab results have a similar look and feel, eliminating the differences created because laboratories use disparate analyzers. If a client goes to multiple labs for their bloodwork and other tests, those results can be difficult to navigate because results for the same test are displayed differently.

Manitoba’s approach to delivering integrated health information was province-wide from the start and is advancing each year. Dr. Fatoye says every change is a welcome one.

For example, results were only accessible from one lab in the beginning. Now, several private laboratories are also onboard, meaning he no longer has to steer patients towards hospital labs when handing out requisitions. “It’s more patient-friendly in that regard. They can go where it’s more convenient for them and the data is still available in the provincial repository,” he says.

For its part, Ontario is also working toward province-wide access to patient healthcare data. However, given the large population of the province, eHealth Ontario decided upfront to take a regional approach, dividing the province into three major partners: the Greater Toronto Area, Northern and Eastern Region, and Southwest Ontario.

“We thought that was the most efficient and cost effective way to go ahead,” says Patricia Trott, eHealth Ontario Director of Communications. “Right now we have all of the foundational elements of the connected electronic health record in place … and we’ve made great strides in connecting clinicians in each of the regions.”

Trott reports the program currently has about 80,000 users across the province, gaining 40,000 or so within one year after launching the ConnectingOntario viewer in central Ontario last summer. Due to the ongoing success of its regional integration strategy, the program recently announced a shift in branding. Originally the three regional hubs were referred to as connectingGreaterTorontoArea, connectingSouthWestOntario and connectingNorthern and Eastern Ontario (cGTA, cSWO and cNEO respectively); they will now share the ConnectingOntario brand, accompanied by their regional name.

A top priority for all three service delivery hubs is to ensure rigorous standards are in place, starting with the collection of priority clinical data from various regional systems, including drug information, lab information and hospital discharge summaries.

“Leveraging provincial assets is a very efficient way of getting at data,” says Mel Casalino, Senior Director, ConnectingOntario North Eastern Region, and Acting Director, ConnectingOntario Greater Toronto Area. “We’re also building interfaces into the hospitals for all hospital reports and information that’s being collected and managed there.”

Moving forward, the program is looking at ways to connect with the primary care community, as well as public health units. Community Care Access Centres (CCACs) are already contributing data, he says.

Similar to the way Manitoba’s eChart operates, users can either log onto the ConnectingOntario viewer using their secure user name and password, or they can use a single sign on approach, accessing it from within existing applications such as a hospital information system, electronic medical record system, or the Client Health and Related Information System (CHRIS), a web-based patient management system used by Ontario CCACs.

“Say they’re looking at a patient and they want to access information about that patient from ConnectingOntario,” explains Casalino. “They click on a button and that patient information is automatically uploaded, there’s no additional searching because the system already knows you’re looking at that patient.” Most importantly, accessing the information doesn’t cause a disruption in workflow, he adds.

The complexity of integrating a variety of data sources is hidden in the background and is supported by rigorous standards. In both Manitoba and Ontario, the eHealth organizations need to ensure multiple patient identifiers are linked. “Because every hospital could have a different identifier … we have very sophisticated client registries in the background, making sure the information on the patient is accurate and timely,” says Casalino.

Trott reports that users of the ConnectingOntario viewer are calling it transformational and are starting to use the data available to them in ways they never anticipated.

Doctors can quickly call up diagnostic imaging test results and lab results, a real time-saver and something that will reduce the need to repeat tests. As well, they can access drug information for millions of Ontarians, including seniors, a particularly vulnerable population, to see what the patient has been taking and to guard against adverse reactions.

Patients no longer have to remember their medical histories, including the last time they visited a hospital.

“You build in pockets, you build the foundational elements, and then once you get to that point where you’ve really done your work behind the scenes and standards are done, you start to see it spread more quickly and you start to see other people wanting to come onboard because the system is so useful,” she says. “It takes time. It’s a big task, but we’re really making progress.”

Key priorities for the ConnectingOntario program include rolling the viewer out to more sites and looking at different data types that could be added. Trott says eHealth Ontario is also working to ensure the systems are as fast and reliable as they need to be. “We’re looking at technology to make sure clinicians have responsive systems that are faster and continue to be available close to 100 percent of the time,” she says.

In Manitoba, Loewen is also hearing positive feedback about eChart. At first, clinicians considered it an extra place to visit and did not work it into their daily workflow immediately, she says. But that all changes after one “aha moment.” “When they actually find something in eChart that they didn’t realize was available to them, they kind of have that moment of realizing this is a very powerful tool,” she says.

Both eChart and ConnectingOntario initiatives provide a certain degree of customization, allowing users to filter information provided so they can more quickly access what’s most relevant to them.

At the Kildonan Medical Centre, Dr. Fatoye says he has come to rely on eChart. He finds it particularly useful for treating elderly patients who aren’t always familiar with their medications, sometimes referring to pills by colour. “You ask them … and they’ll tell you it’s the pink pill,” he says. “If I look at the same patient in eChart, I could go back five years and say, ‘You took this medication four years ago. Why was it stopped?’” Prior to eChart, it was only possible to access prescription information within the last six months, he adds.

Access to integrated information is also useful in helping to manage pain medications. If a patient arrives at the centre seeking a renewal for a narcotic, Dr. Fatoye can check eChart to ensure pills weren’t already prescribed at an earlier emergency room visit, for example. He also finds it useful to view results from tests ordered by another practitioner in cases where he isn’t formally copied. “Those results won’t be in my electronic medical record, but they will be in eChart,” he says.