Lessons from the Past: How other disruptive technologies became mainstream

In the increasingly wired world of healthcare, there are hundreds of technologies designed to improve patient care and ease the workload of healthcare providers. The proliferation of information and communications technologies over the past five years has been overwhelming. Yet the rate of adoption of some of these technologies has been slow.

The introduction of new technologies has always represented an uneasy shift. Welcomed by some, it has been rejected by others who see it as disrupting the accustomed way of doing things and creating new demands. I am a firm believer that the past can offer many insights to those who are trying to introduce new ideas or concepts. Therefore, to better understand the factors influencing the uptake of new technologies it is helpful to look back in time. Looking at the printing press, the telegraph, the radio, the automobile, the telephone, the fax machine, the cell phone, the Internet, and the World Wide Web, we asked some key questions. What were the conditions that permitted the adoption of technology? What was the pace at which technologies were dispersed, and why? What role did the government play?

What is a disruptive technology?
Most new technology is self-sustaining and improves performance along dimensions that the mainstream customers in major markets have historically valued. By contrast, disruptive technologies typically have worse performance, at least in the near term. But:
* They have features that a few fringe and generally new customers (mavens) value and which represent a key source of competitive value in the future;
* Products based on them are typically cheaper, simpler, smaller and frequently more convenient to use -often representing a new product architecture.
* They often bring a new and different value proposition.
(Adapted from The Innovator's Dilemma: When New Technologies Cause Great Firms to Fail by Clayton Christensen)

Applying an analytical framework to the adoption of nine significant technologies from our past allows us to observe key elements and uncover lessons from history that may hold true for the adoption of healthcare technology today.

"Several variables seem essential to the successful uptake of technology: providing an infrastructure, finding a function, establishing the right price point, and becoming a necessity."

There's no question that these "disruptive" technologies have changed the way we work. But from the printing press to the telephone, the telegraph to the World Wide Web, this analysis identifies the common attributes and conditions which determine how fast a technology is adopted, how quickly it is diffused, and how well it is received.

In Diffusion of Innovation (1995), Everett Rogers defines the five following attributes as being important variables in determining how fast a technology is adopted:

Relative Advantage: the degree to which an innovation is perceived as better than the idea it supersedes

Compatibility: the degree to which an innovation is perceived as consistent with existing values, past experiences, and needs of potential users

Complexity: the degree to which an innovation is perceived as relatively difficult to use and understand

Trialability: the degree to which an innovation may be experimented with on a limited basis

Observability: the degree to which the results of an innovation are visible to others

To begin, is the technology perceived as being better than the idea that preceded it, thereby having a relative advantage? Is it compatible with existing values, needs, and past experiences? What about complexity -- how difficult is it to learn, understand and use? Can the idea be piloted, on a limited basis, to demonstrate its trialability? And finally, can the results be observed by those who may use it or be affected? These are the attributes that determine how successful an innovation will be. But what about the conditions which can nudge a technology along and get the ball rolling? Several variables seem essential to the successful uptake of technology: providing an infrastructure, finding a function, establishing the right price point, and becoming a necessity.

Change takes time
In a world where we have become impatient with delays and accustomed to rapid change, the slow embrace of new technologies can be frustrating, but we shouldn't be surprised, or discouraged. It has always been that way, despite the pervasive belief that change is instantaneous.

Take the telephone. We are so dependent on this technology it is difficult to imagine that when it was first introduced in 1877, people had to be convinced that it was useful. Despite its simple design and seemingly obvious value, it took 75 years for the telephone to reach 50 million users, and it wasn't until the 1960s that users saw a residential phone as a necessity.

Even the printing press, with its obvious advantage over laborious copying by hand, was not an instant success. Although the technology was seized on quickly by the Protestant Church, which encouraged literacy, it took centuries for the technology to be used for a mass publication newspaper -- the New York Sun took to the streets on September 3, 1833, more than 300 years after Gutenberg invented the first printing press.

The printing press has important parallels to today's revolution in information technologies. Like the Internet, it suddenly made information available to many more people, and the increase in the spread of information led to confusion and mis-information. Different scientific and religious theories appeared simultaneously -- which one was right? There was no peer review necessary to publish, no infrastructure in place to regulate the publishing industry.

The healthcare community and patients themselves face similar issues as medical information proliferates on the Net. Whose research is correct? Which is credible? How can people sort out the truth from the quackery? Many patients believe it would help if they received medical information online from their own doctors, someone they could trust.

Comparison: Rates of Diffusion
Although it's difficult to define exactly when a technology is fully "diffused", it is interesting to compare how quickly technologies were adopted.

The printing press: 400 years following its invention it was finally used to reach a wide public audience with the publication of the first mass newspaper in 1833.

The automobile: 75 years from the introduction of the first internal combustion engine in 1885 to the point of market saturation in 1960

The telephone: 85 years from 1876 when Bell applied for his patent to full saturation in the 1960s

The fax machine: 144 years from its invention in 1843 to 1987, when enough people were using fax machines for it to make sense for everyone to get one

The Internet: 30 years, from 1968 to mid-2000 when an estimated 130 million Americans had access to the Internet

The diffusion of the telegraph was somewhat faster than the printing press. Samuel Morse presented his prototype of the electric telegraph to the US Congress in 1838, and by 1873 Western Union had carried more than twelve million messages. One of the reasons for the telegraph's rapid success was the creation of the infrastructure which supported it -- reliable connections, cheap and predictable rates, and a shared language. Common standards and a high degree of inter-operability made the telegraph a relatively easy sell.

"...any new technology must eventually be seen as a necessity. It must become part of the everyday way of doing things,...It's hard to remember life before 'What's your e-mail address?' "

But what about more recent technologies? It took five decades for the telephone to reach 10 per cent of U. S. households, but it took only five years for the Web to do the same. In fact, the Internet has reached 330 million users in only 30 years, arguably the fastest diffusion rate in history.

This is partly because the Internet builds on an existing communications infrastructure, and its speed and efficiency are easily observed. In the case of the Internet and the Web, users can develop their own functions, and generate their own content. These decentralized conditions allowed technology to spread quickly.

So what can we learn from these experiences, and how can we apply this knowledge to the health sector?

FROM STRUCTURE AND FUNCTION TO NECESSITY
One of the most important lessons is the importance of providing the critical underpinnings that will support a technology as it attempts to break new ground. This infrastructure varies, from the entire political and social structure, as with the printing press, to the regulatory environment in the case of the telegraph, the telephone and the radio.

For technologies to succeed, they must also find their function, sometimes creating a need where none existed before. With technologies that basically did the same thing, only faster, like the printing press or the fax machine, function wasn't really an issue. But the social function of the residential telephone was largely ignored by industry for the first half of its history.

What we can deduce from this is that frequently the consumer determines the use of a technology, not the inventor, the vendor, or the marketer. This is especially true of technologies like the Internet and the Web. Finding the right price is another important variable, although it would seem an obvious one. And finally, while it may take decades to get there, any new technology must eventually be seen as a necessity. It must become part of the everyday way of doing things, as "invisible" and as vital. It's hard to remember life before "What's your e-mail address? '

Cheaper, faster . . . better?
For many sectors, such as manufacturing and retail, the main contribution of information technologies has been to provide cheaper, faster handling of information. In other words, nothing particularly new, just a better way of doing it. A good example is the banking industry. For the cost of opening a branch to serve a single neighbourhood, a bank can set up a web site accessible to more than 15 million households. Cheaper, faster, an obvious function, and a ready-made infrastructure.

But most sectors share similar problems. Introducing a new technology can be a complex process, and it takes both time and effort to change the way people work. There are also issues of security and privacy -- a key issue in the transmission of sensitive information. Ironically, many sectors have found out that word -of -mouth is one of the most effective ways of persuading people to try out a new technology. Opinion leaders who act as champions play a key role in getting it adopted and creating a demand.

Applying the old to the new
By applying the analytical framework and deriving the lessons of history and the experiences of other sectors, we can shed light on how we expect the medical community to adopt information technologies, and on the role the government can play in making it work.

The government has frequently regulated a new technology, or created the rules that allow commerce to take place fairly. But the government has also played a larger role by developing appropriate policies for technology's use and distribution, by providing strategic funding, and by showcasing their own use of technology.

The government can also act as a catalyst. Apparently even the most skeptical critics of the telegraph were convinced of its advantages when the successful nominees at a United States' Whig National Convention, transmitted by telegraph, were announced to the crowd 64 minutes before the list arrived by train. It was the U. S. Congress that paid for the first of Morse's telegraph lines.

There's no question that the computerization of health data and the emergence of information technologies has created unprecedented opportunities for providing better health care services. But, like any other sector, and as with any new technology, the medical community has to be convinced the new way is better than the old. Remember relative advantage?

The Brookings Task Force on the Internet concluded that the US healthcare system could significantly reduce their costs by using the Internet to handle information faster and cheaper. Nothing new, but better. Other studies of information technologies applied to healthcare have shown that the benefits could include improved management of patient-care delivery, improved access to information, reduced medical and medication errors, more timely care, and a better quality of life for chronically-ill patients.

Information technologies applied to healthcare also stand a better chance at succeeding if they are compatible with the medical culture. For example, more than 50 per cent of US physicians use wireless or handheld devices -- a technology that fits comfortably into the working environment of hospitals. Government-funded sector councils can be pro-active in this area, making sure that the design, development and marketing of healthcare technologies takes the healthcare provider's needs into account.

"The medical community is not averse to new technology, but they need to see and understand how it fits into the way they work, without disrupting the care of patients."

For many in the health care system, the time crunch is a genuine barrier to the adoption of new technologies. So, the less complex the technology, the more likely it is to succeed. For health workers already struggling with the demands of paperwork, one more thing to learn can seem like too much. Of course sometimes a technology is perceived to be complex, when it really isn't, and here is where extensive trials and demonstrations can be useful. Tips and lessons on how to use a technology can be spread throughout a healthcare organization by an on-site "e-vangelist", someone within the organization who can also offer useful feedback to government.

The communication of the lessons learned from trial runs is a vital step in getting technology accepted. The government can use e-services directly to communicate with the health care sector, using technologies such as online conferencing. Outsourcing can also provide an excellent trial run for healthcare technologies -- for example, one online platform service where patients log on and pay by credit card for prescription renewals, non-urgent medical advice, sick notes etc, has already been picked up by hundreds of physicians. It's one thing to try a technology out, another to have it observed. Successful examples of information technologies being used in health care need to be promoted at all conferences, symposia and workshops, as well as models of the government's own success in using them. Marketing strategies can also make use of the mainstream and specialized press to get the message out, increasing public profile. Healthcare opinion leaders and champions must also speak up, widening the net of influence and acceptance.

Creating the right conditions
So far, the lessons on how certain attributes contribute to the adoption of technology apply as much to telemedicine as they did to the telephone or the automobile. But what about the essential conditions: providing the infrastructure, finding a function, finding the right price and becoming a necessity?

A significant legal and policy issue for the healthcare sector is privacy, and this is one of the most critical areas for government policy. Medical data is a sensitive area. Canadians will need to be reassured that the information technology used here is secure and reliable, before a corresponding infrastructure can be provided.

In addition, as with the telegraph, there also needs to be a common language, and standard definitions for data. The significance of this kind of infrastructure was borne out by the experience of the big three automakers in the US, who created the Automotive Industry Action Group to standardize processes. This group also started the Manufacturing Assembly Pilot Program, which ensured that everyone involved spoke the same language.

With earlier technologies, function was king. But with healthcare technologies today, who determines the function? The patient. According to the Toronto Star, most Canadians want online communications with their care providers, while most providers do not. For physicians and other health workers, it's probably a question of time. For patients, it's a matter of convenience. But it's this interaction that will likely determine the ultimate function of e-mail in the healthcare setting.

The right price point is also a key condition for technology's success, and this applies as much today as it did a hundred years ago. Faced with tight budgets and a wide variety of competing innovations, the healthcare sector will certainly take price into consideration when considering the adoption of technology.

And finally, new technology must become a necessity. In the case of the Internet, the patient is determining what healthcare services will become essential. Some 84 per cent of Canadians who reported using the Internet in 2001 said they would like online access to their doctor to ask general health or education questions. In another survey, 62 per cent said they would also like to go online to make appointments or renew prescriptions.

The medical community is not averse to new technology, but they need to see and understand how it fits into the way they work, without disrupting the care of patients. Take the automobile, a technology that was quickly embraced by doctors who saw it as a better, faster way to reach the patients who needed them.

But if a laptop takes four minutes to boot up, and a doctor has only seven minutes with his first patient, the old hand-scribbled medical chart is going to seem like a more efficient way to enter patient information. Perhaps the key lies in integrating new technologies with established practices? For example, wired personal digital assistants can help doctors retrieve medical records quickly while they're consulting with their patients, and avoid mistakes in filling prescriptions that may be hard to read.

There are hundreds of examples, and the healthcare community needs to be selective in deciding which technologies work, and which don't. Their value must be clear, and where the function is patient care, there is a natural low tolerance for risk.

To sum up, if there is one vital lesson we have learned from the experiences of the past, it is this: change takes time. Solutions need to incubate, but we have discovered that as technologies are introduced, there are ways to influence the rate at which they are adopted. Governments, health care workers, patients themselves all have an active role to play in this process, especially in our increasingly inter-connected world. The rewards of this involvement will be an improved healthcare system, and better health for Canadians.

William Pascal, Director General
Office of Health and the Information Highway, Health Canada.
In Healthcare Information Management & Communications Canada, Vol. XVI, No. 2, 2nd Quarter, June 2002 http://www.hc-sc.gc.ca/hcs-sss/pubs/ehealth-esante/2002-lesson-lecon-pass/index_e.html

“e”Health: More than just “electronic”

Everybody talks about e-health these days, but few people have come up with a clear definition of this comparatively new term. Barely in use before 1999, this term now seems to serve as a general "buzzword" used to characterize not only "Internet medicine", but also virtually everything related to computers and medicine. The term was apparently first used by industry leaders and marketing people rather than academics. They created and used this term in line with other "e-words" such as e-commerce, e-business, e-solutions, and so on, in an attempt to convey the promises, principles, excitement (and hype) around e-commerce (electronic commerce) to the health arena, and to give an account of the new possibilities the Internet is opening up to the area of health care. Intel, for example, referred to e-health as "a concerted effort undertaken by leaders in health care and hi-tech industries to fully harness the benefits available through convergence of the Internet and health care."

Because the Internet created new opportunities and challenges to the traditional health care information technology industry, the use of a new term to address these issues seemed appropriate. These "new" challenges for the health care information technology industry were mainly:
a.) the capability of consumers to interact with their systems online ("business to consumer",)
b.) improved possibilities for institution-to-institution transmissions of data ("business to business",) and
c.) new possibilities for peer-to-peer communication of consumers ("consumer to consumer".)

e-health is an emerging field in the intersection of medical informatics, public health and business, referring to health services and information delivered or enhanced through the Internet and related technologies. In a broader sense, the term characterizes not only a technical development, but also a state-of-mind, a way of thinking, an attitude, and a commitment for networked, global thinking, to improve health care locally, regionally, and worldwide by using information and communication technology. This definition hopefully is broad enough to apply to a dynamic environment such as the Internet and at the same time acknowledges that e-health encompasses more than just "Internet and Medicine". As such, the "e" in e-health does not only stand for "electronic," but implies a number of other "e's," which together perhaps best characterize what e-health is all about (or what it should be).

The “e” in “eHealth”

1. Efficient - one of the promises of e-health is to increase efficiency in health care, thereby decreasing costs. One possible way of decreasing costs would be by avoiding duplicative or unnecessary diagnostic or therapeutic interventions, through enhanced communication possibilities between health care establishments, and through patient involvement.

2. Enhancing - quality of care - increasing efficiency involves not only reducing costs, but at the same time improving quality. E-health may enhance the quality of health care for example by allowing comparisons between different providers, involving consumers as additional power for quality assurance, and directing patient streams to the best quality providers.

3. Evidence based - e-health interventions should be evidence-based in a sense that their effectiveness and efficiency should not be assumed but proven by rigorous scientific evaluation. Much work still has to be done in this area.

4. Empowering - consumers and patients - by making the knowledge bases of medicine and personal electronic records accessible to consumers over the Internet, e-health opens new avenues for patient-centered medicine, and enables evidence-based patient choice.

5. Encouraging - of a new relationship between the patient and health professional, towards a true partnership, where decisions are made in a shared manner.

6. Educating - of physicians through online sources (continuing medical education) and consumers (health education, tailored preventive information for consumers.)

7. Enabling - information exchange and communication in a standardized way between health care establishments.

8. Extending - the scope of health care beyond its conventional boundaries. This is meant in both a geographical sense as well as in a conceptual sense. e-health enables consumers to easily obtain health services online from global providers. These services can range from simple advice to more complex interventions or products such a pharmaceuticals.

9. Ethical - e-health involves new forms of patient-physician interaction and poses new challenges and threats to ethical issues such as online professional practice, informed consent, privacy and equity issues.

10. Equitable - to make health care more equitable is one of the promises of e-health, but at the same time there is a considerable threat that e-health may deepen the gap between the "haves" and "have-nots". People, who do not have the money, skills, and access to computers and networks, cannot use computers effectively. As a result, these patient populations (which would actually benefit the most from health information) are those who are the least likely to benefit from advances in information technology, unless political measures ensure equitable access for all. The digital divide currently runs between rural vs. urban populations, rich vs. poor, young vs. old, male vs. female people, and between neglected/rare vs. common diseases.

11. In addition, e-health should also be easy-to-use, entertaining, engaging, and exciting.

Excerpts from http://www.jmir.org/2001/2/e20/

What is eHealth?

eHealth (also written e-health) is a relatively recent term for healthcare practice which is supported by electronic processes and communication. The term is inconsistently used: some would argue it is interchangeable with health care informatics, while others use it in the narrower sense of healthcare practice using the Internet.

The term can encompass a range of services that are at the edge of medicine/healthcare and information technology:

o Electronic Medical Records: enable easy communication of patient data between different healthcare professionals (GPs, specialists, care team, pharmacy)

o Telemedicine: includes all types of physical and psychological measurements that do not require a patient to travel to a specialist. When this service works, patients need to travel less to a specialist or conversely the specialist has a larger catchment area.

o Evidence Based Medicine: entails a system that provides information on appropriate treatment under certain patient conditions. A healthcare professional can look up whether his/her diagnosis is in line with scientific research. The advantage is that the data can be kept up-to-date.[citation needed]

o Consumer Health Informatics (or citizen-oriented information provision): both healthy individuals and patients want to be informed on medical topics.

o Health knowledge management (or specialist-oriented information provision): e.g. in an overview of latest medical journals, best practice guidelines or epidemiological tracking.

o Virtual healthcare teams: consist of healthcare professionals who collaborate and share information on patients through digital equipment (for transmural care.)

from http://en.wikipedia.org/wiki/EHealth

Patients and Healthcare Providers to Experience Significant Benefits from the Use of the Internet

Thursday, 05 July 2007 | Frost & Sullivan
The growth of Internet applications in healthcare has been rapid. A growing number of patients are becoming increasingly involved in the healthcare service they receive. These 'power patients' possess characteristics that distinguish them from traditional patients and are an important factor in driving the use of the Internet in healthcare.

"Power patients are a growing share of the population and healthcare organisations will need to meet their needs," notes Frost & Sullivan Industry Analyst Konstantinos Nikolopoulos. "Free choice of doctors, control over treatments received, access to quality information about their care and extremely high levels of customer service are some of the expectations of power patients."

Besides, over the years, healthcare organisations have had to adapt to numerous changes, from advances in diagnostic and therapeutic procedures to the emergence of concepts such as managed care and telemedicine. The e-Health model represents another such change with far-reaching implications for healthcare organisations. In such a scenario, the Internet's capability to empower patients, support information exchange and thus result in new operational strategies, business and service delivery models can be very appealing although quite challenging.

Moreover, public health policies and regulations greatly influence the way in which healthcare organisations can use the Internet. For instance, uncertainty over privacy and security regulations regarding the use of electronic health information can deter organisations from sharing health records or administrative and financial information across the Internet.

"The transition to electronic healthcare and the use of the Internet to exchange health information raises serious security concerns," explains Nikolopoulos. "While the perception of the lack of security is inhibiting the use of the Internet for sharing clinical information, various technologies and procedures are being developed to deal with these security problems."

The European Union is already enforcing strict medical data security standards and the North American market is also demanding improved security and confidentiality in healthcare transactions with the Health Insurance Portability and Accountability Act (HIPAA).

In this scenario, all stakeholders will need to realise that in matters concerning security, privacy and confidentiality, ensuring 100 per cent absolute security and confidentiality is impossible. Instead, maintaining a good balance between actual or realistic needs, risks, costs and potential losses (including the impact on reputation), is essential. Until there is widespread consensus on such issues, security concerns will continue to inhibit the use of the Internet in healthcare.

The Role of the Internet in Healthcare is part of the Healthcare & Life Sciences IT Growth Partnership Service, which also includes research on patient data safety in the European healthcare IT markets, the computerised physician order entry systems market, the electronic medical records market and the hospital information systems market in Europe. All research included in subscriptions provide detailed market opportunities and industry trends that have been evaluated following extensive interviews with market participants. Interviews with the press are available.

If you are interested in a virtual brochure, which provides manufacturers, end users and other industry participants with an overview of the latest analysis of the Role of the Internet in Healthcare, send an e-mail to Radhika Menon Theodore, Corporate Communications, at rmtheodore@frost.comThis email address is being protected from spam bots, you need Javascript enabled to view it with your full name, company name, title, telephone number, e-mail address, city, state and country.

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Canada’s e-Health efforts increase

From Health Imaging News | July 5, 2007 | Top Stories
The not-for-profit organization Canada Health Infoway recently reported a 39 percent increase in electronic health initiatives that modernize the way clinicians deliver healthcare. From 2006-2007, Infoway approved investments of $518.9 million in EHR initiatives across Canada. Infoway’s complete plan for electronic health progress can be found in the report “2015: Advancing Canada's Next Generation of Health Care,” which outlines a road map for modernizing Canada's healthcare system and forms the strategic framework to guide future investments and priorities.

The report is available at: http://www.infoway-inforoute.ca/en/pdf/Vision_2015_Advancing_Canadas_next_generation_of_healthcare.pdf

All eHealth Portals Are Not Created Equal

All levels of government across Canada are experiencing similar pressures today to cut healthcare delivery costs while increasing patient safety and care. With this growth in managed care and capitation, eHealth Portals are quickly evolving to meet new and more complex requirements, with significant benefits to medicine and healthcare in general.

As the practice of medicine is inherently dependent upon healthcare technology, the sustainability of our healthcare system depends, to an extent, on its ability to find ways to gain efficiencies and effectiveness in every aspect of our daily activity. Canadian Healthcare providers need to find ways to work smarter, not harder.

Building the future is really about building the present.
Marshall McLuhan once observed that too often people steer their way into the future while staring into the rear-view mirror---because the past is so much more comforting than the present. The problem with history however, is that our love of certainty and continuity often causes us to draw the wrong conclusions. To this end, in the past, the acquisition of technology had been viewed as an end in and of itself. Decisions about technology and usage were typically driven by the question of how to improve the effectiveness of what hospitals were already doing. Today’s information systems should be viewed as a vehicle to transform what Hospitals actually do. Moreover, there is a demonstrated understanding of the need to evolve healthcare informatics toward a more open, standards-based, patient-centric model that brings together all imperatives: clinical, administrative, financial, managerial, and human resources---in a meaningful way that concentrates on patient outcomes as the primary goal of the organization (and the method by which other parameters, such as financial efficiency, are to be judged.)

Lessons from False Starts
Whether an early-adopting visionary or a more cautious pragmatist, with the myriad of messaging from analysts, researchers, and pundits—concerns about implementing seemingly new or nascent eHealth Portal technologies is understandable. The sheer volume of new technologies coming to market only adds to the confusion and it’s a real challenge for most healthcare organizations to create a tactical plan to ensure that their IT capabilities support current and future objectives. To overcome these barriers and eliminate false starts, part of doing it right the first time requires an understanding of a.) the clear differences in the eHealth Portal solutions available in our Canadian market and b.) the new (transinstitutional model) horizontal architectures.

"Federated" and "Centralized" database models REDUX
When a healthcare organization sets out to extend a longitudinal ‘cradle-to-the-grave’ patient record (readily accessible via the Internet) linked to clinical protocols and guidelines—most people picture only one scenario. In this scenario, a user enters a query about a patient. That query goes to one source where all the patient information has been stored in a single “centralized” database (or vertical architecture.) The system searches that one database and returns the answer to the user. But information does not have to be accessed in this manner, as the patient data already resides somewhere in existing systems. Instead of duplicating that data in a new centralized system, the healthcare organization could leave the existing data in place. Then, when the user asks a question, the system gathers the appropriate patient data from wherever it is stored. This approach — leaving the data in place and retrieving it on demand — is called a “federated” database model (or horizontal architecture.) By definition, a federated database is a collection of data stored on multiple autonomous computing systems connected by a network that is intuitively presented to users as one integrated database.

Years ago, the centralized approach represented the more attainable of two limited choices — even though a massive initial investment of time and money was required (to build, load, and integrate a centralized database coupled with the painful patchwork of disparate legacy systems, brokers, and related integration and maintenance problems.) A good example of this is Trillium Health Centre’s $100 million dollar, seven year initiative to integrate all patient information into a single record. However, advances in technology and new product capabilities have made the federated approach a far more practical and significantly more cost-efficient option. Compared to a centralized eHealth Portal built on a single “centralized” database (or vertical architecture,) a “federated” database (or horizontal architecture) can achieve equivalent or better results at a fraction of the cost and time. Given our Canadian healthcare funding reality — this is an option that more and more healthcare organizations are likely to choose.

The real value: A fraction of the cost and time.
Anyone who uses the Internet takes the delivery of content from multiple systems for granted. Almost every Web page on a major commercial site is assembled automatically from multiple sources. Click a button and data is retrieved from other databases and servers. Users may not be aware of this, but it goes on constantly. Federated databases operate by means of a similar principle, except that each data resource is defined by means of a database schema or view, and the user has much more power to access and manipulate the data. With the federated Portal approach, the economics are significantly different and can be extremely advantageous. You don't buy the massive database server (or related brokers) and you leave all your data where it is. You don't need to build systems to update the database, as the integrated database is virtual. It exists only in the form of the views presented to the users. When a user submits a request for data, the federated database system performs extraction, cleansing and transformation, and the equivalent of loading for only that data needed to satisfy the user's request.

One of the greatest advantages of a distributed (federated) architecture is that it naturally lends itself to supporting a large variety of connected systems and guarantees the scalability of the portal system at the enterprise level. Moreover, a federated portal approach allows bandwidth, hardware, administration, and other infrastructure costs to be distributed over time, keeping pace with the development and deployment of the facility. This can significantly reduce networking and system-interfacing costs and opens up a number of added functional possibilities by extending data to the organization’s value chain delivering clear, tangible benefits for your short and long term needs.

Follow the leaders
The use of eHealth Portals has gained significant traction as a cost-effective way to transform healthcare delivery. Whether physician, nurse, technician, or administrator, eHealth Portals offer a proven, quick and efficient way of accessing, sharing and organizing hospital information and patient records. Portals also extend process-integrated decision support and a clear stepping stone to a national electronic health record. However, what has become clear, is that all portals are not created equal. As a result, identifying the right portal approach and architectural model, is critical for healthcare delivery organizations to maximize tax dollars and return on investment.

Examples of Canadian Hospitals who have successfully implemented an eHealth Portal initiative (whether Physician, Patient, or other) using a “federated” database model (or horizontal architecture) are Hamilton Health Sciences “ClinicConnect” initiative and Mississauga Halton's (LHIN 6) "REACH" initiative. An overview of the “ClinicConnect”solution is available at: http://www.hamiltonhealthsciences.ca/quicktour.htm

The changing face of Healthcare in Canada.

It’s all about the patient
Information technology has made a significant impact on the healthcare industry. Over the past decade, many hospitals have adopted technology to increase the efficiency and accuracy of their healthcare systems. However, with the growth of managed care and capitation, information systems are quickly evolving to meet new and more complex requirements. One does not have to look very far to see the fundamental changes that are occurring in the health care industry. Economic, social and many other drivers are forcing changes to the focus of health care. First and foremost, health care is becoming a more patient-driven industry. Over years to come, the healthcare system in most Canadian jurisdictions will not be able to sustain the increase in demand for service that it will face. The sustainability of the healthcare system depends, to an extent, on its ability to find ways to gain efficiencies and effectiveness in every aspect of its daily activity.

Challenges, market drivers and restraints
There is a demonstrated understanding of the need to shift the focus of health care efforts from the management of illness to the maintenance or promotion of wellness. As a result, there is increased emphasis on the management of diseases for example, across the continuum of care and along the lifecycle of the disease. To support this, the industry is experiencing a significant shift in how clinical decision making occurs. Specifically, the “lone ranger” decision-making practices of the past are being replaced with truly collaborative, interdisciplinary, and evidence-based approaches. Decentralized and generalized care is becoming more centralized and specialized.

Today’s hospitals are evolving toward a model that brings together all imperatives: clinical, administrative, financial, managerial, and human resources, in a way that concentrates on patient outcomes as the primary goal of the organization and the method by which other parameters, such as financial efficiency, are judged. In short, today’s savvy healthcare providers are evolving their information delivery platforms toward a more open, vendor-neutral, patient-centric environment that extends a single/unified patient view (EHR) across different jurisdictions and domain boundaries.

The market factors driving this evolution include the need to:
o Reduce errors, cut and control costs, and improve the delivery (efficiency) of patient services. Note: Patient safety and effective healthcare can only be achieved with a robust, integrated information system.
o Replace stand alone systems (best of breed.) Although they might work well in small hospitals and restricted departments, however, are incapable of scaling up. This puts a serious limitation on these systems as they become redundant in large set ups and thus have to be either replaced or abandoned.
o Leverage latest technological advancements that allow a monolithic (enterprise-wide) platform to be completely integrated and provide customization at every level. Some of the earlier integrated hospital information systems were such that they did not offer the extent of customization that departments wanted. There were problems in scaling up and closing the gaps in integration. However, all of these issues have been overcome and the modern information delivery platform provides seamless enterprise integration.

Note: On average, employing a single vendor, integrated, enterprise-wide informatics solution (versus a disparate, fragmented, silo’d model) has been benchmarked (based on analysis) to increase efficiencies by 30% minimally.

The Vision
The promise of today’s Healthcare Informatics technology is to capitalize on the opportunity to offer on-demand access to any and all relevant data from any disparate database across the continuum of care through one intuitive, unified web-based view (EHR)---whether physician, nurse, technician, administrator, referring physician, or even patient. Furthermore this unified view (Longitudinal Record) must be standards-based such that information is transferable across different health care entities (e.g. RSHIP, LHIN, RHIO.)

As an aside, the elimination of redundant processes alone using today’s eHealth technologies, combined with the convenience of single sign-on, single patient search, secure eMessaging, and full access via wireless and mobile devices (within a PIPEDA/HIPPA-compliant privacy framework)---has proven, without exception, to dramatically improve outcomes and provide higher satisfaction to both patients and providers. Note: Never underestimate the importance of cost-efficiency as providing high-quality care at a lower cost yields savings that can be reinvested in other parts of the health care system.

Ideally, any next steps related to informatics investment should adhere to providing/extending a:
o Vendor-neutral, Patient-centric environment
o Intuitive, meaningful views (customized by user) of all clinical patient data
o Clear, measurable Value add (ROI) to the provider
o Timely and accurate access to information where and when required
o Interoperability and Integration
o Standards-based solution (HL7, DICOM, XDS, HIPPA, PIPEDA, et al.)
o Replicable solution — patterns, components to all stakeholders
o Phased controlled rollout built on a scalable architecture to support future
growth, and competition
o MPI and eMessaging
o Secure, private, and auditable platform
o Comprehensive offering that addresses both Clinical and Administrative

In this proposed “best-practice” patient-centric environment, all information follows the patient as they move through the system. Complete information is therefore available to all as needed along the continuum of care.

Canadian eHealth Trends

New technology will improve the delivery of healthcare. When asked to conjure an image of the typical physician, most people will describe a person wearing a white lab coat, with a stethoscope around their neck and a chart in their hands. This simple image neatly captures three key activities performed by the doctor, namely, the collection of data (using instruments such as the stethoscope), the recording of information (usually onto a paper chart) and the analysis of the information (using the doctor’s training and experience) to make a diagnosis. Unfortunately, as healthcare grows ever more complex, the information needed to diagnose a patient’s condition is increasingly scattered across a myriad of different systems, some of which are electronic, many of which are still paper-based.

eHealth, the application of information and communications technology to improve healthcare services delivery, offers the promise of simplifying this complex situation so that a healthcare provider can quickly and easily retrieve all information about a specific patient, perhaps even on a device that mimics the traditional paper chart.

Tipping Point
eHealth has reached a "tipping point "beyond which implementation will accelerate rapidly. Although there are certainly many challenges to overcome and risks to be addressed, there is a growing consensus that eHealth can facilitate the transformation of healthcare services delivery in ways not previously possible. eHealth is no longer a question of "Why?" but of "How?"

Why is eHealth important?
A 1999 Institute of Medicine report, “To Err is Human: Building a Safer Health System,” concluded that preventable hospital-based medical errors are the eighth-leading cause of death in the United Stated. An estimated 44,000 to 98,000 Americans die each year from medical errors such as incorrect medication administration, the equivalent to one passenger jet crashing and killing all occupants each and every day of the year. A similar situation exists in Canada. In addition to an alarming incidence of preventable deaths, the cost of providing healthcare in Canada has been increasing, on average, six per cent per year. Assuming no significant change to the underlying factors driving healthcare costs, the Conference Board of Canada predicts that by 2020 some provinces might be spending more than half of their annual operating budgets on healthcare services delivery.

Faced with a need to protect patient safety as well as to increase productivity as a partial means of addressing rising costs, healthcare, like other industries, is turning to Information and Communications Technology (ICT). Although ICT has been used for decades in hospitals, it has largely been employed in “back-office” applications, with front-line healthcare providers relying on pen and paper. By integrating ICT into front-line healthcare service delivery processes, eHealth can help reduce medical errors by making health information more readily accessible. Further, eHealth can reduce costs by saving time, reducing duplication and improving efficiency, savings that can reduce healthcare costs by as much as 10%.

Canadian eHealth trends
While every Canadian citizen has access to publicly funded healthcare, the manner in which the healthcare system is structured, funded, and governed varies from province to province. This situation can best be described as “variations on a theme” and it extends to eHealth, with every province setting its own priorities and timetable for eHealth adoption. Notwithstanding the provincial variations, several major healthcare trends are emerging that have a direct impact on eHealth adoption:
o The consolidation of healthcare services delivery, through either hospital amalgamation or regionalization.
o The vertical integration of healthcare services delivery across the continuum of care primarily through regionalization.
o Third-party provisioning of eHealth service through various mechanisms including outsourcing, shared service organizations and partnering between several healthcare organizations.
o Strong senior-level support for eHealth within healthcare organizations, regional health authorities, and provincial ministries of health.
o Alignment of provincial eHealth agendas with priorities set by Canada Health Infoway, a federal organization created to foster and accelerate the development of pan-Canadian electronic health information systems.

Modern Processes
Effective healthcare service delivery is heavily dependent upon timely access to relevant patient information. Existing manual, paper-based processes simply cannot keep pace with the explosion of information and ever more complex diagnostic and treatment options. eHealth will provide patients and healthcare providers alike with the tools needed to easily and quickly access the information needed to make timely and effective decisions, thereby increasing patient safety, and improving overall healthcare system efficiency.

Variations on Common Themes
Political debate in Canada often focuses on what makes one province or region different from the others. While it is possible to extend this same focus on provincial differences to an examination of eHealth, most differences were largely variations on a number of common themes, including:
• Regionalization
• Electronic Health Records
• Digitizing healthcare processes
• Provincial eHealth strategy
• Patient at the centre of care
• Provincial connectivity

Differences in how the provinces address the various common themes are driven by a myriad of factors including geography, demographics, and economics. The result is distinct provincial
eHealth agendas and strategies that reflect local realities while, at the same time, sharing many common elements and approaches. Viewing the differences between provincial eHealth agendas and strategies as variations on common themes provides vendors and policy makers with a framework with which to develop Canadian eHealth strategies and tactics.

Electronic Health Records
Driven by concerns about patient safety, the Electronic Health Record (EHR) has emerged as an important means of reducing preventable medical errors by providing quick and ready access to relevant patient information. Although it is not the only eHealth application that will offer significant benefits, every province has or is developing an EHR strategy. This intense focus on the EHR, encouraged by investments from Canada Health Infoway Inc., is driving a variety of activities that will support other eHealth initiatives in addition to the EHR. Although the term "electronic health record" implies the existence of a single record for each person and a database in which such records are stored, an electronic health record is actually derived from data stored in multiple systems. Taking this perspective into consideration, an electronic health record initiative is really an enterprise integration project, with the patient and all data associated with that patient as the common integration point and the enterprise consisting of multiple healthcare facilities across the continuum of care.

Future Vision
By combining various predictions, a composite picture emerges in which:
• The existing "silos" of information and expertise no longer exist.
• "Patients" have become "consumers" of healthcare services and are taking a more active role in their care.
• eHealth technologies are in use across the continuum of care and are an integral, largely "invisible" component in the delivery of nearly all healthcare services.
• Healthcare providers make extensive use of mobile devices to access the information they need, when they need it, wherever they might be located.
• Clinicians are shifting from a mindset of having to remember everything to routinely consulting handheld devices and on-line applications to order tests, review test results, refine a diagnosis, select the most appropriate care plan, schedule therapy, and prescribe medication.
• Healthcare providers no longer need to be in the same room as the person they are treating in order to make a diagnosis or even deliver many aspects of care.
• Genetics, combined with eHealth technologies, is emerging as a means of creating personalized care plans and shifting the focus of care from cure to prevention.

All eHealth PORTALS are not created equal

INTRODUCTION

Canada's health system is a tangled, highly fragmented network that often wastes a great number of resources by duplicating efforts, leaving unaccountable gaps, and failing to build on the strengths of our health professionals and clinical expertise. Even though Canada’s health care delivery carries a significantly higher price tag than more than most other industrialized nations, Canadian’s only receive only about half of the recommended care for that investment. With an aging population, extended wait times, and chronic conditions reaching epidemic proportions, our healthcare system will not survive without radical change.

According to Frost & Sullivan , increasing integration is creating the need for a single point of contact to healthcare IT (HIT) systems, which in turn, is driving the eHealth market. eHealth, the application of web-based information technology to healthcare, can profoundly change the way the business of healthcare is conducted—making it safer, more affordable, and significantly more efficient. However, transforming traditional modes of delivering care will require Health Care Organizations (HCO) to take advantage of the enormous potential offered by information technology in far more complex ways. Previously, eHealth was stalled by interoperability issues and a lack of workflow-driven, secure information exchange. Today however, progressive technology and innovative solutions are enabling unprecedented advancements.

The relatively brief history of Health Information Technology (HIT) has taught organizations the high costs of failure, which has caused Health Care Organizations (HCO’s) to prudently proceed with guarded optimism. Although there is recognition of the benefits of eHealth, when combined with a market already crowded with HIT vendors attempting to help HCO’s realize a return on investment (ROI,) it becomes increasingly difficult to identify a vendor with a meaningful track record. As such, the majority of Health Care Organizations have been watching the progress of vanguard organizations before they commit their time and money.

Waiting to join the eHealth movement has its own disadvantages. Besides prolonging current inefficiencies, laggard organizations may miss an important window of opportunity, and the benefits of adopting eHealth strategies are too great to ignore. For HCO’s determined to take advantage of the current Infoway-driven EHR environment, the next imperative action is to outline an appropriate technical platform for their eHealth strategy.

Fundamentally, organizations are seeking a platform that allows the seamless delivery of information across the continuum of healthcare. Fortunately, this objective can be met without cost-prohibitive, universal replacement of existing HIT. Moving forwards with a portal communications strategy can bind the information technology of disparate facilities and stakeholders into an interactive user community using advanced, but proven, web portal technologies.

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WEB PORTALS: DEFINITION AND DESCRIPTION

From the user perspective, a web portal is any technology that allows an individual or user community to gain convenient access to a broad range of information and services through their web browser. Most HCO’s serve a variety of stakeholder communities, including providers, payers, patients, employees, and consumers. Each of these stakeholder communities benefits from a portal that is targeted specifically to their needs, aggregating information of value for them and allowing them to communicate freely with the host organization and each other.

For the hosting HCO, a portal is an integration tool that incorporates service and data management applications with workflows and business processes to present a unified, personalized, and streamlined gateway to their enterprise for its stakeholders. The HCO establishes a portal strategy to offer timely access to real-time information resulting in better customer service that is accessible from a single point of entry, regardless of which system generates the information or where the information resides. While a provider portal, patient portal, employee portal, and a consumer portal each appear independent of the other, they are clearly interrelated. Since healthcare consumers may be patients, employees, or even providers, their needs will overlap. Therefore, each stakeholder may require access to the others’ data as well as additional common data sources.

A portal solution can serve to aggregate information stored in disparate, incompatible systems using a Service-oriented architecture (SOA). SOA describes a product architecture that allows tight integration with underlying applications, without requiring system interoperability. This also allows users to access software functions independent of the underlying platform and/or programming language. It permits services to be rolled into larger applications that can be incorporated into portals, without locking the enterprise into a specific vendor. While the SOA concept has been around for quite some time, emerging standards-based integration technologies like Web services and XML have just recently made it practical. The benefit for your healthcare organization is clear ---a SOA enables eHealth while protecting the enterprise’s investment in legacy software. As organizations search for viable tactical path to leverage a service-oriented architecture, many can use portal products as a first step.

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eHealth EVOLUTION: BABY STEPS INTO THE FUTURE

The Gartner Group has identified five levels of eHealth development using Portals, the elements that comprise them, and what it takes to move from one level to the next (see illustration Figure 1 below). Health Care Organizations continue to significantly use portal products to build and deploy a variety of customer, citizen, partner and employee-facing enterprise portals. Portals have evolved through four generations of technology and are embarking on their fifth generation. In the beginning, eHealth bore relatively simple websites that provided new levels of information accessibility to healthcare consumers. As the technology evolved to Level 2, searchable directories and more interactive features were added, providing dynamic new options for HCO marketing and administration departments. It was possible to promote classes and services, help people find reliable current health information and appropriate specialists, make human resources information readily available to employees, and collect and manage data using the Internet.

Since Generation 2, portals have leveraged service-oriented (SOA) capabilities. Generation 2 portals provided a rudimentary method of composite application assembly known as interportlet communication. Organizations can use interportlet communication to build composite applications by linking portlets related to a specific business process. This type of composite application is referred to as "on the glass" because the integration is at the presentation layer rather than deep in the business logic. This integration approach is effective for user-driven processes, and advanced enterprise portals use interportlet communication extensively.

Level 3 applications required a broader revolution within healthcare from paper to electronic medical records, which was reliant on emerging data standards and the willingness of HCOs to empower their users with more control and access. Generation 3 portals enabled systems to handle basic Web services. These portal products could consume Web services. The addition of workflow, which is a feature of most portal products, introduced a new way to orchestrate composite applications.

Over time, the experiences of the early adopters and results of pilot projects generated sufficient results to compel cautious HCOs to pursue the promise of eHealth. With Level 3 adoption no longer stalled by technological limitations and the pervasive wait-and-see mentality, the next wave in eHealth is cresting. Transformational web portals will offer business process management with workflow automation, alerts, and reminders, integration with patient records, medical device uploads and a host of other equally exciting advances. Together, the unified data resources and user interaction will radically alter best-practices for patient care and healthcare efficiency.

In February 2006, a survey of healthcare CIO’s ranked the area for which they would be most likely to offer increased functionality via their web presence. Offering patients the ability to schedule appointments through their website was most frequently identified, followed by utilizing a physician portal link and providing consumer health information. However, only a handful of the CIOs report that their website is used to offer patients secure and authenticated access to medical records.

Finding themselves repeatedly on the cutting edge of eHealth, vanguard organizations are evaluating the appropriate technical platform for Level 4 applications. With Generation 4, portals started to leverage advanced Web services. This included the ability to provide Web services, as well as consume them. It also supported the first Web services standard for portlets, Web Services for Remote Portlets (WSRP), which enables one portal to consume a portlet from a different portal, using Web services protocols. Thus, portal pages could include local and remote portlets, all supporting a single set of processes.

Generation 5 is emerging (see Figure 1.) Advanced features include support for business process management (BPM), service-oriented applications (SOBAs) and orchestration, critical features to support advanced composite applications. Business Process Execution Language will become the standard orchestration language for portal products and will extend beyond the capabilities of their current workflow features.

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THE PORTAL COMMUNICATION SOLUTION

Although eHealth applications serve the needs of many different stakeholders, there are four major stakeholder groups, which illustrate the value of this solution: patients, physicians, consumers, and employees. In spite of the differences in type and format of information and services each group requires, there is significant overlap and common desire for:
o A more positive Physician/Patient experience between clinicians and patients
o A more satisfying and effective clinical experience for patients and caregivers
o A more transparent technology experience for all of the stakeholders, but particularly the caregivers and IT staff, easy to use and easy to maintain
o Better IT cost control to make the CIO and CFO’s job of keeping costs down easier
o More referrals and admits because of streamlining and efficiency improvements that expand a facility’s capacity
o Brand advancement, fulfilling the goals of the marketing department and CEO of improving community awareness and market position
o Better recruiting retention because of more effective use of staff time and skills, and easier access to human resources and other employee information
o Improved operations for administrators and clinicians, building on existing skills and significantly reducing unnecessary mundane tasks.

Each of these improvements provides additional benefits to each of the stakeholders. By empowering patients, providing rapid, real-time data access, greater efficiency, and increasing patient/ physician collaboration—everyone benefits.

However, while many vendors offer partial solutions, few offer a comprehensive portal communication solution. Legacy HIS/CIS vendors offer applications targeting information access and management, and while they improve the physician/patient experience and provide operational efficiencies, the needs of the other stakeholders are not addressed. Traditional web vendors, on the other hand, tend to focus on content management systems that excel at promoting an organization’s brand but leave the needs clinical and operations stakeholders underserved. Somewhat more comprehensive, electronic medical record (EMR) vendors offer vital elements of the big picture solution, but cannot accomplish the complete transformation that browser-based systems promise.

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FOUR AREAS REMAIN UNDERSERVED DESPITE THEIR GREAT PROMISE:

1. Consumerism - Rather than being passive participants in their own healthcare, today’s patients are looking for return on investment and driven by the spiraling cost of health insurance and growing out-of-pocket expenses.
2. Clinical - Advances in service delivery and clinical outcomes through better adherence to clinical protocols and more informed decision-making, reductions in medical errors, decreased morbidity and mortality, and expedited recovery times.
3. Financial - Cost reductions and revenue enhancements from quicker charge capture and shorter billing cycles, productivity gains from all types and levels of staff.
4. Organizational - Improvements in stakeholder satisfaction through shorter wait times, better access to reliable healthcare information, and better relationships with clinicians; higher productivity from increased procedure volume, reductions in the average length of stay, quicker transaction processing turnover, lower administrative staff and resource requirements; more effective risk mitigation, and increased adherence to federal, state, and accreditation organization standards.

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THE PORTAL PROMISE

Current, partial solutions can be made whole with interoperable portals through which all healthcare stakeholders will exchange information and engage the enterprise. Enterprise information portals are intended to consolidate a vast array of information from a multitude of sources onto a single screen. Portal technology enables different IT systems and software applications to communicate, to exchange data accurately, effectively, securely and consistently, and to use the information that has been exchanged.

A comprehensive portal communications solution should include broad-based applications through:
o Flexible, easy-to-use web content management tools for rapid application development by both non-technical staff and programmers
o Interoperability between incompatible legacy HIS systems, and real-time data access
o Secure communication allowing patients and providers to communicate conveniently
o Integrated third party applications for additional functionality

Moreover, a portal strategy should be built on a stable, secure framework, offer single sign-on, single-patient/ single-view access to all information using a coherent system of portals— simultaneously serving the needs of the wide variety of stakeholders.

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TECHNOLOGY THAT OVERCOMES ADOPTION ISSUES

Elusive Return on Investment
With billions being invested in the migration from paper to electronic records, rapid ROI is a determining factor on the minds of executives and administrators concerned about their bottom line. Speedy, enterprise-wide adoption is critical for any eHealth initiative to realize the full benefits of their investment. Delays and patchwork systems negatively impact the organizations’ ROI. Still, adoption continues to be spotty, despite incentives. In part, the gradual adoption curve can be ascribed to common complaints of HIT; accompanying workflow and systems integrations require process changes that can be intimidating. Reengineering the way work is done presents challenges that extend far beyond use of the technology. Changing the enterprise culture and convincing busy professionals to adopt and learn new systems are essential but challenging components.

A study conducted in 2001 found 121 administrators and physicians working for HCOs agreed that in order to remain competitive, providers must move toward interactive consumer web self-service capabilities (e.g. scheduling services, pre-registering for services and bill payment) and online physician patient communication. However, the reluctance to proceed was tied predominantly to a lack of funding followed by a lack of commitment, fear, politics and other intangibles that must be overcome if an organization is to be able to achieve the advanced website functionality. These findings were reiterated in the 2006 HIMSS CIO Leadership survey, which found that for the sixth consecutive year, respondents identified a lack of adequate financial support for IT as the most significant barrier to a successful implementation of IT at their organization.

Certainly, ROI is an important factor in any healthcare IT acquisition. A prudent capital investment is measured by its contribution to the sustained financial strength of the organization. However, the use of capital assets for eHealth objectives cannot be measured solely on the balance sheet. When capital investment improves clinical outcomes, reduces preventable medical errors, and eliminates common sources of waste, the return is evident in healthier patients.

Clinical System Interoperability
The fragmentation of legacy HIT systems causes interoperability issues that can undermine an organization’s confidence in their ability to successfully implement a comprehensively integrated web solution. The data systems needed for an outpatient setting require a different level of sophistication than those that regulate admissions, discharges, and transfers within in a large hospital. Each system is defined by unique vendor standards, some of them decades old. These hurdles make a seamless, rapid data sharing format seem out of reach. Integration can be tackled with the latest web technology. Using a “virtual electronic health record (EHR)” model, any HCO can connect underlying systems rapidly and cost effectively to deliver views of clinical information through secure, single sign-on, web-browser technology. The virtual EHR is dependent on a decentralized, federated data model. Using this architecture allows HCOs to leverage legacy HIS/CIS investments, avoiding the maintenance of an expensive Central Data Repository (CDR).

The federated data model eliminates system integration hassles and overcomes patient identification challenges with master patient indexing logarithms. It seamlessly integrates disparate clinical and census data, transforming fragmented data into a clean and concise dashboard of clinical information. For example, a virtual EHR presents admitting, attending, and referring physicians with ready access to all of their patients’ clinical information and, when combined with systems such as computerized physician order entry (CPOE), provides the ability to input patient order entry and review via a web browser. Additionally, online continuing medical education (CME), calendars, scheduling, clinical trial information, grand rounds, physician newsletters, and relevant clinical content may all be presented in a customizable view for each user.

Physician Acceptance
The biggest concern for busy physicians is the time and energy required to transfer data and learn a new system. They are understandably reluctant to spend time away from patient-facing activities to address administrative business. To reduce training time, leading eHealth solution providers devote considerable resources to researching and designing intuitive applications that build on existing user experiences best practices. Additionally, the federated data model eliminates the need for physicians to learn underlying applications for checking labs or reviewing films, as the view they see does not require them to interact with the software, only to view it.

Patient Identification, Privacy, and Compliance
Understandably, HCOs and physicians are sensitive to their responsibility to protect confidential patient information and may see rapid, real-time online access to vital information as a threat to privacy. Adequate security measures and an architectural design must be engineered to allow an organization to implement eHealth applications with demonstrable compliance with regulations and respect for the patients’ rights. Authentication protocols and CAPTCHA , encryption of secure messages, automatic audit trails of information access, controlled workflow and secure servers guard patient information from unauthorized access.

Cost and Training Issues
In the 2006 HIMSS CIO Survey, lack of staffing resources was identified as the second most common barrier to IT adoption. Time and resource efficiencies enabled by eHealth have been demonstrated to pay for themselves in as little as a year. Fewer chart pulls and phone calls, speedier access to accurate information, lower record maintenance, and staffing costs, and revenue enhancements together create a synergy of efficiency—more than compensating for the up-front investments. For example, reducing the need for just one administrator/trainer can save significant financial resources. One estimate based on a 40 hour work week over 50 weeks, and an average annual salary of $50,000, suggests that reducing one full time trainer can yield a savings of $61,000 USD a year. The architecture and design of eHealth products are focused on allowing non-technical users the maximum flexibility to manage their websites and portals. Additionally, intuitive design reduces the need for training and results in an immediate cost saving.


FOLLOW THE LEADERS

eHealth is no longer in its infancy, yet sustained concerns about implementing new technology is understandable. It’s a real challenge for most organizations to create a tactical plan to ensure that their web capabilities support current corporate objectives. It is far more difficult for HCOs to devise a long term plan that serves the evolving needs of the organization, adapts to technological advances, and meets new societal demands. The pressure to deliver on high-priced projects adds gravity to the matter. The initial expenses are just a small piece of the overall financial commitment an HCO makes in the transition to eHealth, and the failure rate for EHR implementations is estimated at 30 to 50 percent. False starts and implementation timeline overruns are too costly for most HCOs to risk.

To overcome these barriers, part of doing it right the first time requires research to learn from organizations that have been successful in their own eHealth initiatives. Over the past decade, a wide variety of HCOs have achieved eHealth success, from early-adopting visionaries constantly striving for better ways to engage their stakeholders, to more cautious pragmatists waiting for proven solutions to their online needs.

Some proven Canadian eHealth leaders are Hamilton Health Sciences (Case Study below,) William Osler Health Centre, and Halton Healthcare Services, Credit Valley Hospital, Scarborough General, and Scarborough Grace Hospitals. They recognize that the best way to predict the future is to create it. They did their homework and performed a thorough analysis of what is available in the market, assessed the vendors, risk, and ROI—and chose a federated horizontal portal solution to achieve enterprise-wide system interoperability while facilitating better decision making and improved communications (not to mention a virtual EHR.)

Patient Destiny: Consumers must have access to their health records

By Kevin J. Leonard and David Wiljer

Just as customers accessing their information have reduced banking industry costs, it is a general assumption that the same will hold true in healthcare. As more patients bypass the “hands-on” personal method and obtain information for themselves, it is estimated that great savings will be gained, and consequently, a tremendous amount of strain will be removed from the system.

However, very seldom is patient information (e.g., the specific results of diagnostic tests) ever shared with the patient. As a result, it is very difficult for patients to enter a dialogue with their doctors about treatment, because the healthcare provider is the only one with the information. One truism seems to be constantly ignored: It is impossible for patients to manage their health without the requisite information! This is not just a passing fad or part of a catchy slogan, but rather a conclusion that is based on a number of logical premises, outlined as follows:

Times have changed: This may not appear to be all that insightful, at first glance, but this premise contains very important building blocks. We are no longer in an era where businesses and governments tell people what to do and when. The rise in consumerism has created the demand from the public for better information and better service. The public wants information in the way they want it, when they want it. We have rapidly progressed through the Information Age into a “Knowledge Era”. Information that is meaningless to consumers has no value. In the next 20 years, the industries that will be successful will be the ones that can take advantage of technology and deliver pertinent information, which is “targeted knowledge” channeled down to the individual consumer.

Patients are at the centre of healthcare: We have seen many Hospital Mission statements echoing this same message – changing to patient-centered care. However, this ‘mantra’ has not been firmly understood or appreciated. Without the patient, there is no need for healthcare professionals. The patient is the one constant throughout all of the healthcare system.

What patients do want, and will demand, is better information about the system, about who does what services, and about how well they perform these services. Answers to these questions will allow consumers to make informed decisions surrounding their care.

Patients want access to their own patient information – and they want to be able to understand what it is that they are reading. In particular, they want to know more about their illness or disease, and they want information on treatment options and success rates. Often, they would like to get in touch with other patients to exchange experiences and to get advice. After all, it is only when they interact with other patients that they get real information about what they are going, or will go, through.

Ultimately, patients are the decision makers: When patients are faced with difficult healthcare questions, they seek advice – from their doctors, other health professionals, and their own personal network. Even though the physician will provide the best medical support, ultimately, it is the patient who has to decide whether they want this drug treatment or that surgery.

It is understood that not all patients may have the maturity or cognitive ability to comprehend the decisions that they have to make. Many caregivers have used this argument to withhold information; but, in actuality, this rebuttal only applies to a small percentage – perhaps, to 20 percent of our population. The remaining 80 percent have the ability and the right to make their own decisions. What they lack is the medical background in order to facilitate all the information and to process it in order to make an informed choice.

It is our belief that in the healthcare system of the future, we will see physicians (and other professionals) act as advisors to patients, rather than the old model, where patients are told what to do. Gone will be the day where patients will feel that they are not free to question facts or to seek options.

Decision-makers need information: It is well understood in information theory, and in the decision analysis literature, that decision-makers need information to assist in making any decision. It then becomes clear that we must get the critical information to the patient in order for them to make informed decisions. This means that the focal point of the healthcare system of the future must be on the patient record, since that is the only point where all the data reside. In order to move the data and information around efficiently, it is obvious as well that this record will have to be in an electronic form.

Conclusion: Patients must be able to access their health records and other patient information if they are to make informed and effective decisions about their health management. Consequently, it is impossible for patients to manage their health without this requisite information!
Access to records improves satisfaction for lung transplant patients
Over 40 percent of patients have at least one chronic illness, accounting for nearly two thirds of all medical expenditures. Because of their long timeframe and high attendant costs over time, chronic illnesses lend themselves to electronically mediated self-management tools. Prototypes of web-based, patient-centered Information and Decision Support Tools have been demonstrated to improve self-management of illness and enhance understanding of the complications of poorly controlled disease. Patients living with chronic illness are also more likely to use health information than their healthier counterparts, although each chronic illness has specific, recognizable challenges for affected patients in symptom comprehension, information management, task fulfillment and social interaction.

It is our hypothesis that leadership will come from these chronically ill patients (either individually or within a group) by demanding better access to health system and service information. In recent research, we interviewed patients on a number of “access to information” issues. Unfortunately, asking patients (or computer end-users or stakeholders) what information they would like to receive is not efficacious due to the fact that end-users are normally not well versed in “system options”.

What stakeholders are very good at, however, is identifying functionality they would “like to have” at the moment that they experience it. As a result, we have engaged different groups of patients suffering from a chronic condition. In this instance, we present results on post-lung transplant patients in both passive (survey interview) and active (simulation) environments to elicit their needs and wants. (This group was analyzed due to accessibility, however, it is believed that many of the findings are applicable across a number of illnesses or chronic conditions.)

Almost two-thirds of these lung transplant patients (63 percent) had seen some portion of their medical record (most commonly blood work or X-ray results) and a similar percentage believed a personal medical record would help them manage their personal healthcare. The most common reason respondents wanted access to their medical chart was to enhance their understanding of their medical condition. This desire to have further access to personal medical information was expressed despite a comprehensive patient education program provided by the transplant program, and despite the fact a high degree of patients felt they were provided with an adequate degree of information upon discharge from hospital. As a whole, this group appears to have a high level of interest in their medical information and can be described as active participants in their care.

The patients were then asked what they believe would be the most valuable aspect of having access to their medical information. Respondents were encouraged to check all that apply:

• 57 percent of patients believe that access to their medical information would help enhance their understanding of their medical condition.

• 13 percent of patients indicated that access to their medical information would help ensure the information was available to their family doctor.

• 13 percent of patients felt access to this information was important in case of an emergency.

Further, over 60 percent of patients believe that having access to information about the medical care that they receive would help in managing their healthcare while at home. The difference in the phrasing of each question may illustrate the importance patients’ place on information necessary for self-management over information about their hospital stay. Sixty percent of patients believe that if they were provided with their medical record, they themselves and their family physician would use it the most. Related to the use of the patient’s medical record, 73 percent of respondents did not have any concerns about a family physician, family members or other medical specialists having access to their record.

Patients were also given the chance to choose what type of information from the hospital they would find useful to help manage their care at home The most popular choice was the lab test and results (67 percent) followed by a summary of their medical history, medication information (history and current), contact information (specialists and emergency contacts) and blood pressure/ temperature charts. Family and personal history and height/weight charts were not strongly endorsed. Only 17 percent of all respondents felt the inclusion of an allergy history was necessary in their personal health record. Given a choice, 63 percent of patients would want this information as a paper copy. Other preferences included CD (13 percent), secure Internet (13 percent), and other storage device (10 percent). Forty-seven percent of respondents indicated that they would find it useful to have the entire lung transplant manual in an electronic format.

The survey indicates that lung transplant patients are interested in accessing their personal health information to support their health management. At the time of the survey, well over half of the sample group was connected to the Internet and according to the literature, it can be expected they are accessing health information through that medium. This desire stems from increased self-reliance in the management of personal health and the desire to take a more active role in the medical decision-making process. While the effect that this information may have on patient health outcomes is not clear, access to personal health information is associated with improved patient satisfaction. As patients move to a more self-reliant role in the management of their health, the demand for personalized information will only increase.

Conclusions: We must begin to put pressure on the system to support patients in gaining access to their own health information. As presented herein, this is needed and soon will be demanded. Ultimately, this inevitability has been framed by the term Patient Destiny, where patients are actively involved in all healthcare decision-making. This is an infeasible proposition in a paper-based system, which means we must move to more Electronic Health Records or EHRs. Since patient access to individual healthcare provider organizations’ health record systems appears to be almost as unviable, due to limitations in data format, unique patient identifiers and system constraints, one appealing approach is to follow the path whereby patients interface with their health-related information across the many providers in a Web 2.0 environment.

A web-based patient interface between consumers and the health system could help patients search for quality information and link them to resources that address their needs. In detail, the benefits for the consumers could be as follows:

• Obtain quality health information, quickly and efficiently, based on personal and contextual needs;

• Access an up-to-date consumer health directory with listings and satisfaction ratings of trusted healthcare providers in Canada and elsewhere;

• Connect with like-minded users to share health experiences, knowledge and resources;

• Allow consumers to use monitoring tools to manage active lifestyles and primary healthcare conditions such as blood pressure, weight and high sugars;

• Provide a pathway to their own health information and expectations; and

• Design a reward system for their investment in health, well-being and where health-conscience behaviour is rewarded within a ‘point collection’ system.

In essence, a health sector-wide strategy of patient awareness and education is now required. All consumers of healthcare – the healthy and the ill – need to be presented with a forum for a comprehensive discussion on healthcare, one that deals with the trends of rising consumerism and greater expectations relating to information access and delivery. We must promote an “effective and coordinated consumerism” perspective within healthcare. Hopefully, this will provide an incentive to all consumers to become more involved in their own care and health management and to demand more from health providers.

Kevin J. Leonard is Associate Professor in the Dept of Health Policy, Management & Evaluation, University of Toronto.

David Wiljer is Director, Knowledge Management and Innovation, at Princess Margaret Hospital, University Health Network, Toronto.

Hamilton Health connecting around the world

by Cathy McKnight on Mon 02 Apr 2007 05:00 AM EDT

Hamilton Health Sciences' orthopedic surgeon Dr. Justin deBeer was halfway around the world in Taipei, Taiwan but wanted to be able to keep tabs on his patients back in Canada. What in the past would have been a next to impossible proposition was actually done quickly and easily thanks to ClinicalConnect – a web-based portal for physicians that brings together data from three of the hospital’s most commonly used clinical software systems in an electronic health record format.

Hamilton Health Sciences worked with Medseek to design and implement the ClinicalConnect portal, but also engaged physicians from a variety of disciplines to offer input and drive the creation of the final product. Since Meditech is the most widely used information system at Hamilton Health Sciences, it was the first to be merged into the ClinicalConnect environment. ClinicalConnect offers a user-friendly view of the Meditech information, which ranges from admission information to lab results, and allows physicians to view the information simply by signing on to ClinicalConnect.

The next step involved adding views of patient records, stored in a system called Sovera. Currently the charts are scanned and merely displayed through ClinicalConnect, however, the portal does allow physicians to view the information and also indicates the number of chart deficiencies that need to be resolved. By the end of this year, physicians will be able to access Sovera directly through ClinicalConnect, which will enable them to interact with patient information in real time and directly resolve any chart deficiencies.
In the future, physicians will have the option to e-edit and e-sign Meditech-based charts in the portal, and the updates will be passed back to the Meditech system. When this feature is available in the portal, it will also be available via PDAs.

Adding PACS to the system proved to be a tremendous enhancement, since it enables physicians to view X-rays from the same system that houses other clinical information about their patients. And by signing on to one system, physicians can access and interact with all of this information. They can also customize their views and pick and choose which information they want to see and when.

“Our ClinicalConnect portal gives physicians and other clinicians secure, real-time access to electronic patient records. Whether they are at the hospital or elsewhere, our physicians can quickly access all clinical reports, lab results, PACS images, pharmacy medication lists and much more,” said Dale Anderson, information and communications technology manager of projects and e-Health solutions at Hamilton Health Sciences.

As Hamilton Health Sciences expands the wireless network within its four sites, ClinicalConnect will become even more valuable. Already, some physicians have been piloting wireless applications of the system on PDAs in certain areas of the hospital. They’ve got access to all available patient information when they are seeing the patient. Patients are also able to ask questions about particular tests and procedures when they are with their doctor and do not have to wait for results to be retrieved from another computer or system.

The remote access to patient information through ClinicalConnect enables healthcare providers him to use remote Internet access to call up the patient’s information, including X-ray images and blood work, to check up on patients.

"Canadian Implementation of e-Health projects increases by 39 per cent"

Initiatives benefiting patients in every province and territory.

Toronto, ON 06/25/2007: -- Canadian patients are benefiting from a 39 per cent increase in electronic health initiatives that are modernizing the way clinicians deliver health care, announced Richard Alvarez, President and CEO, Canada Health Infoway (Infoway).

"In the past year, we've seen tremendous growth in the number of electronic health record initiatives that are delivering enhanced patient care, shorter wait times and a more productive health care system for Canadians," said Alvarez, who recently released Infoway's annual report. "While this growth is encouraging, momentum must be maintained so we can capitalize on the efficiencies generated through electronic health initiatives as our population continues to age and grow."

In 2006-07, Infoway approved investments of $518.9 million in EHR initiatives across Canada, surpassing its target of $335 million. The digitization of diagnostic imaging, Drug and Laboratory Information Systems projects and the interoperable electronic health record made significant progress. With 227 projects complete or underway across Canada, Infoway and its partners are investing in modern health information systems that are uncovering efficiencies in healthcare settings across Canada. The result is better patient care and outcomes, reduced wait times and cost savings. Infoway's plan for further electronic health progress is outlined in 2015 -- Advancing Canada's next generation of health care, its long-term strategic vision document. The document is available at www.infoway-inforoute.ca.