100% Paperless Healthcare and the EHR

Whether your hospital is in Toronto or 100 Mile House, Cape Breton or Restigouche—one thing’s for sure. No matter how “wired” your healthcare facility is, you’ll still find lots of paper forms and processes. Paper is endemic in Canadian hospitals and clinics, even in those with fairly robust enterprise information systems. Paper is still used for staff scheduling, HR processes, reporting, transfers, discharges, and all kinds of other workflow-related tasks. There are a number of valid reason why this is.

Many Healthcare Informatics (CIS/HIS) vendors could extend an existing (standards-based) platform to support a fully-automated, (fully paperless) digitized-workflow---but often the perceived aggravation, delays, and high costs associated with modification (and integration) simply doesn’t justify the effort, or more importantly, the required ROI.

Specialized software can solve some of the smaller problems, but adding additional applications in an already crowded and complex arena of applications (that don’t talk to one another) can further compound issues. The biggest problem with any paper-based workflow is that it is static, and therefore cannot be shared beyond the physical limitations of the department.

This directly impacts our goal of a Canada-wide electronic health record (EHR), as existing patient information cannot readily be made available when and where it is needed. Clinicians and administrators need access to this patient data to enable the most informed decisions around patient care (regardless of geographic location) and to optimize operational performance. Most would agree that significant improvements are required in the area of clinical information acquisition, storage, retrieval, sharing, and especially presentation. An important first step is simply to get all existing data into the hands of clinicians and other health care professionals, as informed decisions can help save money and—more importantly, help save patient lives. Ultimately any (and all) patient health records, whether in an Acute Care, clinic, laboratory or General Practitioner (GP) setting, will need to be available digitally in a standardized and regulated format.

What the @#$% is an Azyxxi?

There’s been a lot of scuttlebut around Microsoft's acquisition of a technology (and company) known as Azyxxi from MedStar Health in Washington, D.C. To clarify, Azyxxi (according to their website) is "a unified health enterprise platform that helps improve cross-organizational access and insight to clinical, administrative, and financial data."

What Pain Points Azyxxi will address in Healthcare IT?
o Improvements are needed in clinical information acquisition, storage, retrieval, sharing, and presentation—an important goal in any health care strategy.
o As we move toward the future, an important first step is simply to get all existing data into the hands of clinicians and other health care professionals.
o In today's hospital enterprise, already-existing information may not readily be available when and where it is needed.
o Best-of-breed systems lack integration, creating an environment in which information is hard to access and harder to aggregate for optimal value.
o Clinicians and administrators need access to data that enables the most informed decisions around patient care and operational performance.

The Microsoft Azyxxi solution
Health care professionals could benefit from the ability to quickly pull this data into a consolidated and customized view, to help enable informed decisions and peak performance. Azyxxi focuses on improving clinical information acquisition, storage, retrieval, sharing, and presentation. Azyxxi sits across most current best-of-breed systems in the hospital. It aggregates patient data so that clinicians can get an instant picture of the data in the hospital's systems. There's no waiting for archived information. Azyxxi aggregates relevant data for one, nearly instantaneous, view. Healthcare workers can maximize the value of information to help make the most informed decisions. Informed decisions can help save your business money and—most importantly—help save patient lives.

Architecture
A hospital or health system typically has a configuration of best-of-breed IT systems that operate independently of each other. One system controls imaging, another manages emergency room systems, yet another addresses operating room management and the list goes on. Azyxxi sits across most current best-of-breed systems in the hospital and aggregates patient data so that clinicians can get an instant picture of the data in the hospital's systems at any time. The information is viewed and analyzed according to the individual needs of the user. Azyxxi customizes the results to help enable the most informed decisions and best patient care.

Existing IT State
You have hard-working, disparate information systems that cannot coordinate to feed you an integrated view of results. This results in frustrated clinicians and administrators who may not have access to all the data they need. Traditional enterprise-wide health IT systems have evolved from transactional systems. In these systems data is organized and locked in strings that have been created to resolve a specific transaction request. System requests are slowed down by the inability to search on individual data components, as the search request must move through all the transaction codes in the system to identify the relevant data pieces—an inefficient process in a business that may depend on timely decisions to help save patient lives.

Why Microsoft Azyxxi is different?
It's seemingly built on a federated-database model similar to MEDSEEK. Your clinicians and administrators need integrated and customized views and analysis of clinical, financial and administrative data. Azyxxi was developed as a solution to data storage and search issues, integrating across multiple best-of-breed health IT systems. It does not replace them.

Results for your health organization
Data is divided into multiple components, clearly identifiable within each transaction. This means the data can be re-organized into multiple buckets to answer a wide variety of queries. Search is fast because it does not require scrolling through thousands of transactions to source the data. Detailed queries and analysis become easier the more you use Azyxxi, as you increase your potential to leverage existing criteria sets and views.

Azyxxi's flexible federated architecture means that it can be customized any number of ways, depending on the user's needs. Much like competitor Medseek's "eConnect" platform, views and workflows can be optimized over time as workflows evolve, making it increasingly valuable the more that it is used. For more information on Microsofts Azyxxi solution, please visit:http://www.azyxxi.com

Age and culture as impediments to the adoption of healthcare IT

by Bill Crounse, MD | Worldwide Health Director, Microsoft

A friend sent me a link to an article written for SearchCIO.com by senior editor, Kate Evans-Corriea. Ms. Evans-Corriea's article entitled "Age Does Matter" reflects on what she says was a common theme at Gartner's recent Symposium ITxpo. That theme is perhaps best captured in a quote from Gartner analyst, Tom Bittman, who says, "It's not the technology; It's not the process that's holding us back. It's the culture".

As I read the article, I couldn't help but think about a conversation I had just had with a colleague who currently serves as a hospital CIO. He expressed to me his total frustration with hospital culture and healthcare providers. In fact, he is so frustrated that after ten years on the job he is looking for another position; this time likely in another industry.

His hospital had recently purchased a very advanced surgical management system that included anesthesia scheduling and work-flow automation. The anesthesiologists at first welcomed these new tools, although one of the docs had initially pushed back because he had designed his own solution that he thought was a lot better than the vendor solution selected by the hospital. Even so, after a few weeks using the new system, several of the older and most influential members of the anesthesia group simply proclaimed that they didn’t like what the hospital had purchased and would be going back to using their old paper processes. And, as my colleague noted, "that was that".

A similar scenario had recently played out in the radiology department. The mammography unit was asked to start using the hospital's digital PACS system. They prepared the docs for the fact that their productivity could initially fall by as much as 30 percent until they got used to the new tools and work-flow. The docs agreed to give it a try, but as soon as their productivity actually did take a nose-dive, they rebelled and refused to use the new system. I know what you may be thinking. Screw the doctors! Tell them they have no choice but to use the new systems. As a doctor and a former hospital VP/CIO and CMIO, I know it's not that easy. Those doctors are the life blood of the hospital. It took years to recruit the physicians who run the mammography unit. And the anesthesiologists? They along with their powerful surgeon allies are responsible for most of the hospital’s profit margin.

The CIO also told me about his hospital's struggle to implement an electronic charting system in nursing. He said the VP of Nursing gives the initiative good lip service, but her first in command is a 50 year old nurse who has never worked anywhere else, and there’s a lot of passive-aggressive behavior going on in the rank and file. Since the nurses are all employees, you might think administrators could just lay down the law and mandate the use of the nursing documentation system. But you would be naïve to think that. The average age of nurses working at the hospital, especially as managers and unit leads, is 50-plus. There’s a huge nursing shortage with lots of vacancies in posted positions. They have a powerful union. It’s hard to tell them what to do.

I share this because it is so typical of the culture in healthcare, and not only here in America. It speaks volumes on the issue that Gartner is drawing to our attention; it isn’t so much about the technology as it is about the culture, and the need for more carefully orchestrated change management. Of course some of these hassles will resolve as the “dinosaurs” retire. But based on what Gartner is saying the age and culture issue won't go away. Instead of “why must I use this computer instead of my paper” the argument will become “why must I use this (fill in the blank) instead of my computer"?

Posted by Bill Crounse, MD | Worldwide Health Director, Microsoft
http://on10.net/Blogs/bcrounse/age-and-culture-as-impediments-to-the-adoption-of-healthcare-it/

Carrots or sticks | Making a case for heightened government involvement in EHR

As confirmed in Frost & Sullivan's 2005 Analysis of the Canadian Healthcare IT Markets, Canada has a national health service which provides hospital care and other medical services to the entire population and is publicly financed. The health service is highly decentralised, with the management and delivery of health services being the responsibility of the provincial and territorial governments, which have jurisdiction over 97% of the nation’s hospitals.

The provinces and territories operate health insurance plans which are obliged to conform to the principles of the Canada Health Act and are collectively known as Medicare. The government responsibilities for healthcare delivery include:

Federal
• Setting national standards for health
• Oversee the implementation of the ‘Canada Health Act’
• Provide funding to Provinces
• Promote health protection, disease prevention & health promotion

Provincial/ Territorial
• Managing and delivering health services
• Planning, financing and evaluating the provision of hospital care,
physician and healthcare services

In order to promote healthcare IT, some provinces have set in motion various plans to reform the healthcare IT infrastructure at the primary care level. Ontario’s Primary Care IT Strategy is being implemented to assist primary care physicians with the adoption and implementation of IT in their practices. This involves a dual approach to the procurement of Clinical Management Systems (CMS)—Application Service Provider (ASP) Solutions and Local Solutions.

Over 95% of Canadian Hospitals are Public, Non-profit Entities. The provincial and federal government hospitals account for over 95% of all beds. Private hospitals account for only 4% of all beds, the vast majority of which are in Quebec. Public hospitals operate as not-for-profit organisations with their own governing boards, which have control over day-to-day decisions and allocations of resources. However, boards must stay within annual operating budgets negotiated with their local healthcare commission on an annual basis. All hospitals in Yukon are federally managed.

There has been an increase in Outpatient Care in Acute Hospitals and Hospital Day Surgery Programmes also. Increasingly, fewer patients are hospitalised overnight and those that are admitted to in-patient facilities are generally admitted for shorter periods of time. There is also increasing pressure to reform from an institutional to a community-based model.

The problem is the number of Canadian Hospitals still acting alone (as IT-fifetoms) in their continued procurement of CIS/HIS/IT platforms that are not scalable or standards-based. This is most relevant related to our quest for a national EHR.

To compound issues, significant differences exist across Canadian Provinces on the local, regional and national level in terms of per capita spending on (and inputs to) healthcare systems. However, quality, accessibility, and sustainability of care are also limited because best practices are not freely shared. What results are small, politically charged, competing fifetoms. Action at a national/ federal level would be indispensable, as the lack of accountability ensures higher integration costs. To wit, Canadian Healthcare delivery organizations require much stronger, mandated guidelines on eHealth interoperability. It is difficult and highly inefficient to continue with Hospital Networks (and their numerous stakeholders) working in isolation to improve their healthcare systems---AS eventually all entities will need to be integrated to achieve a national EHR.

The current state of most Clinical Information Systems' (CIS) across Canada, as an example, is draconian in comparison to what is available using today's technologies. Especially from an operational efficiencies standpoint. In fairness, a.>the primary/ acute care HIS/CIS platform across the country is 10-15 years old on average, and b.> Canada Health Infoway's Funding Timeline has replacement funding for primary CIS (tentatively) forthcoming Q3-2009 (and procurement of new systems will likely be delayed until this time, if only to capitalize on this Government compensation.)

Canada Health Infoway, has successfully promoted eHealth standards and guidelines, however, using incentives to progress interjurisdictional cooperation between neighbouring healthcare providers---is akin to herding cats. Simply moderating the procurement process hasn't had the effect it might have.

The difference between the "carrot" (subsidizing standardized IT procurement,)and the "stick" (mandating connectivity standards) would hopefully ensure Vendors either adhered to a standardized level of connectivity, or they would not be allowed to sell in Canada. This act alone could eliminate 50% of the total cost (and at least 40% of the time)to our achieving a national EHR.

The importance of interjurisdictional cooperation in Canadian healthcare cannot be understated in terms of cost to the taxpayer. In order to cut the red tape related to the use of shared health services, it is imperative that an electronic systems standard be established of patient identification. Secondarily, there must be heightened support to introduce mandatory eHealth and telemedicine services (telemedicine, teleconsultation, laboratory services, shared medical imagery (teleradiology),eBilling, ePharmacy, federated eHealth Portals, and sharing of standardized protocols.)

To a growing extent, standardized eHealth contributes to fairer health services across geographical and social boundaries, as well as helping to reduce (or at least limit) the growing costs of the healthcare. Services would not create extra financial burden, as it would depend on voluntary basis of services provider and would present another alternative to the existing system. eHealth by definition requires the sharing of patient identifiable data when and where necessary. When the processing of such personal data relates to a person's health, processing is particularly sensitive and therefore requires special protection. In the eHealth context, the processing of personal data in health systems across multiple jurisdictions varies significantly due to their specifics and the diverse legacy platforms currently in place. It is therefore important to consider whether the Canadian government (Health Canada) should mandate national guidelines (rather than only incentivizing decisions through Canada Health Infoway.) Manadated cooperation between regional and Provincial stakeholders provides, as an example, a framework for greater legal certainty and accoutability of eHealth products and vendors (and services liability within the context of existing product liability legislation. )

Although interoperability is not a goal in itself, since Canadian healthcare delivery organizations (at all levels) are now directing their health policies to subscribe to a new paradigm of common visions, and common values, a definitive focus are now required for eHealth interoperability. In the context of Canada’s (taxpayer-funded) public healthcare system, Canada Health Infoway’s ‘incentivized’ funding methodology has only managed to add a layer of broad standardization, which clearly doesn’t go far enough. The wasteful management and misaligned allocation of funds, while intended to evolve Canada to a national EHR, unfortunately will require strong Federal guidelines and enforcement to protect taxpayer interests. The only thing more blatent than the misappropriation of healthcare dollars in Canada, is the lack of any ROI accountability.

Summary
Without a mandated, standardized (versus incentivized) interoperability framework, our Canadian healthcare system is so rife with misappropriation of healthcare funds (by people of relatively high social or economic status) to make money for themselves or to further the aims of their organization---taxpayers will pay twice (2:1) as much to achieve our objectives of a National EHR. If history has proven anything, it’s that without a formal audit process or investigative arm regulating Canadian taxpayer dollars invested in Healthcare---only the illusion of objectivity is provided. Behind the scenes, the spoils are being pilfered so flagrantly it would make Imelda Marcos blush. No Federal watch-dog, no accountability.

The Healthcare Enterprise | Making a case for eHealth Investment

Many healthcare executives look at technology as a cost of doing business. However, investment in strategically chosen technology can enhance revenue while lowering operational costs. Labour, as an example, is the most expensive and valuable resource in a hospital. Therefore, any measurable improvement in the use and efficiency of labour can improve a hospital’s bottom line considerably.

Whether business office staff processing claims information, nurses performing patient assessments, or physicians diagnosing and treating patients, with the current disarray of disparate information databases (and wireless and remote technologies;) users are constantly striving to gather the information required in order to perform and optimize their job function. Strategic implementation of new Technology can significantly improve efficiency in:
• Clinical Operations (ex: Nursing, Physicians and ER)
• Financial Operations (ex: Contract Management, Administration and Registration and Accounts Payables and Material Management)
• IT Operations (ex: Training, Help desk, Network, etc.)

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CLINICAL OPERATIONS
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1. Nursing:
This is the primary area for patient care improvement and enhanced patient revenue. All aspects of technology must perform smoothly – and be transparent to the end user – or nursing will not use it for patient care. When this area is not supported by IT effectively, nurses and other clinicians will revert to paper as the only reliable way to record information regarding patient interventions and notes on the patient’s status. When this happens it significantly lengthens the process, potentially up to two hours per patient per shift. Furthermore it results in duplicate processes and redundant data capture – so much so the caregiver spends too much time managing the clerical tasks, and the patient care process is inhibited. Accurate and timely charging for patient procedures, tests and supplies do not always occur resulting in lost revenue for the hospital. The key technology elements that must all be operating effectively are:
• Robust Clinical Application System including Case Management and Scheduling
• System reliability (99.9% availability)
• System performance (instant response time)
• Easy to use and accessible system devices (e.g., wireless, PDA’s, tablets, printers, etc.)

2. Physicians:
Physicians’ have two main concerns
• time to see patients and
• the timely availability of accurate patient information.

Therefore, creating a way for physicians – no matter where they may be – to continuously receive updated information on their patients addresses both of their primary concerns. Providing this technology is a key contributor to recruiting and retaining satisfied physicians, as well as providing high-quality patient care. The key technology elements that must all be operating effectively are:
• Physician-oriented presentation of patient results information
• Easy-to-Use computerized physician order entry system
• Online access to patient’s diagnostic x-ray and ultrasound information (PACS)
• System reliability
• System performance
• Support for multiple input and output devices (e.g., wireless, PDA’s, tablets, printers, etc.) from in-hospital as well as remote locations
• Integration to their office practice management and EMR systems

3. EMR:
The ultimate goal of most healthcare organizations is a paperless electronic medical record to improve the efficiency and effectiveness of the enterprise workflow process and enhance the revenue generation process. Healthcare management understands, at a conceptual level, that having an automated digital hospital would improve the entire patient care workflow process, and thus, patient satisfaction and staff productivity. The successful automation of previously paper-based processes requires a robust IT infrastructure, and careful planning among all the affected stakeholders.

4. PACS:
A PACS system not only has proven to produce positive bottom-line results, but also is often considered a necessary precursor to the EMR. A wise investment that often pays for itself within 3-5 years, it allows the “reading” of images from all modalities from a workstation that is either in the hospital, or in a remote office. The biggest benefit however is the ability to transmit and view the image to wherever it is needed, and removes all of the barriers to access that exist with traditional film. To achieve all the available benefits, the network bandwidth must be in place to support very large image files, and again, careful planning among all the affected stakeholders is critical to a successful implementation.

5. ER:
Increasingly hospitals are realizing that their ER is a major entry point for patients and should not be overlooked as a revenue source. Providing comprehensive computerized systems that are optimized for the ER’s workflow are mandatory if the hospital desires to realize the potential benefits available. The key technology elements that must all be operating effectively are:
• Emergency Room Patient Tracking System
• System reliability
• System performance
• Easy to access and use input and output devices (e.g., wireless, PDA’s, tablets, printers, etc.)
• Seamless Integration to a hospital’s Master Patient Index to retrieve patient information and provide billing data
• Integration with the EMR to maintain a comprehensive clinical record.

6. Laboratory:
Laboratory orders are processed promptly because of the need of the patient. However, in a paper-based environment, charges can be overlooked because of the multiple steps required to process a patient chart and the extra work involved in capturing charges. A comprehensive Laboratory Information System (LIS) that is fully integrated with the HIS will alleviate this problem, as well as improve the overall efficiency and effectiveness of the Laboratory staff. The key technology elements that must all be operating effectively are:
• Robust Laboratory Information System including integration with all laboratory instruments
• Integration with hospital’s EMR and/or order entry system
• Integration with any external reference laboratory used to enable a complete view of patient’s lab results
• System reliability
• System performance

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FINANCIAL OPERATIONS:
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The key to strategic gains in the Financial/Administrative area is to invest in the newest technology that enables business processes to function more efficiently, and ensures the most accurate billing practices for the organization. Even small procedural changes can create more effective billing and substantially improve the bottom line. Likewise, the implementation of comprehensive scheduling systems can improve turnaround times and help ensure the optimal use of expensive fixed assets throughout the hospital. Other areas suitable for increased investment are described below.

1. Contract Management:
Many hospital billing operations submit claims based upon the personal knowledge of staff billers. Billers often overlook minute and incremental charge optimization opportunities simply because of the volume of bills and claims that must be generated and submitted. The computerization of code optimization and the underpayment analysis of payer reimbursement will have an ongoing and profound impact on a hospital’s bottom line. Whereas these billers are very knowledgeable, their true value is in the management and adjudication of claims denials. The loss of revenue per claim may be small, yet the total volume of claims equates to a substantial loss. Computerization of the claims submission and denial process quickly pays for itself and can immediately increase the hospital’s cash. The key technology elements that must all be operating seamlessly:
• Contract Management Application System
• System reliability (minimal downtime)
• System performance (immediate response time)
• Adequate storage (retrieve discharged patient’s complete information)
• Electronic interface to primary payors
• Integration with hospital’s patient accounting system

Hospitals will vary on the impact of automating these areas of operation. The cumulative effect can be quite surprising. As PriceWaterhouseCoopers and HIMSS analytics reported in their study of cardiac care in 36 hospitals in March 2005, there was an “85% reduction in medical errors and a 65% reduction in inappropriate denials from payors…” in the hospitals studied.

2. Admissions and registration:
This area requires system speed and a reduction in the complexity of screen layouts. There is typically a lot of turnover in this area. Yet Admissions is the first location for revenue enhancement and the primary source of errors and inaccurate data for billers to deal with claims denials. The key technology elements that must all be operating effectively are:
• Comprehensive admission-discharge-transfer system
• Integration with payors to confirm patient coverage
• Integration with patient scheduling system
• System reliability (no downtime)
• System performance (immediate response time)
• Easy to access and use input and output devices

3. Accounts Payable/Materials Management:
The goal of automating the replenishment of the hospital supplies (using just-in-time processes), while taking maximum advantage of the hospital’s contracts, in an effective and efficient process, has a significant impact on the hospital’s profitability. Accurate, ongoing, and continuous inventory, minimal loss of stock, and maximum chargeability are the key components. Taking advantage of discounts by being able to pay vendor’s invoices within the discount can benefit the hospital’s bottom line. The key technology elements that must all be operating
effectively are:
• Comprehensive Accounts Payable System
• Comprehensive Materials Management System
• Integration between Accounts Payable and Materials Management
• System performance (immediate response time)
• Easy to access and use
• Adequate storage

4. Barcoding:
It has been shown that barcoding data at the bedside, from the pharmacy, and through materials management reduces medical errors tremendously, as well as, improves the automation of input of data into the patient chart. It holds the ability to speed and integrate the purchasing, distribution, administration, charting, and billing for pharmaceutical and other supplies. An effective barcoding strategy not only provides more accurate and timely information, but also saves time and improves the work lives of clinicians, managers, and staffers by making things run more smoothly and simply. To realize the full benefits of a barcoding implementation, attention must be paid to the workflow changes necessary to get maximum returns. When combined with supply chain automation, the entire process of acquiring the correct supplies, packaged and correctly prepared for patient delivery, are made available to the care-giver when needed – and the documentation for billing, inventory reordering, and the patient chart, is captured as a by-product of the patient care process.

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IT OPERATIONS:
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The common thread in improving IT Operations in healthcare is to achieve maximum leverage of the staff resources to implement and support an ever-increasing array of emerging hardware and applications. Through continual centralization of the environment, more ROI is squeezed out of fixed assets and the staff becomes more efficient by giving them the tools to do their job more effectively. Whether it’s server administration, network management, application support, or user provisioning, the innovative investment in the IT infrastructure can improve service levels and ensure optimum utilization of expensive staff resources. Practical examples include:

1. Training:
As the general workflow process is automated, the need for personnel to understand how to use the tools at hand becomes paramount. Training is needed in two distinct areas; the IT staff and the users:
• The IT staff must be trained to understand how to use the servers, switches, software and network to maximize the users’ capabilities. Each IT staff member has a “multiplier effect” upon the user community’s effectiveness. Most should therefore be certified in their area of expertise.
• The automation process is for the benefit of the user and the organization. Therefore, the user must be trained in the optimal usage of the system and the tasks they perform. This means that an ongoing training program should be implemented to ensure employees are accomplished on the system(s) they use and fully understand the implication of their actions when using automated systems to perform their jobs.

2. Help Desk/ Service Level Management:
IT departments may have a phone number for users to call in case of need, however most facilities do not have an automated structured process to monitor
technology, diagnose problems, administer support, and measure performance by automated reporting. It is imperative to be able to understand the source of help desk calls in order to properly plan for the improvements needed to improve customer service.

3. Network:
The network is the nervous system of an organization’s information flow. There are a number of components of a network that must be able to transport data at a guaranteed minimum volume.

4. Switches, bridges, and routers:
The switches, bridges and routers are the devices that route data from one part of the network to another. Considering that a fully automated healthcare workflow process will have a minimum of 25 major applications that will route data for 30 departments, the switches need to be configured to handle the volume of traffic anticipated.

5. Backplane:
A backplane acts as a “traffic cop” for the data that comes from all of the different switches within the network. Therefore, it must handle the accumulated burstable volume of the network. For a fully integrated and automated workflow process, a backplane may need to burst to 4 Gigabytes/sec. of volume.

6. Network Management Software:
Many of the major network vendors have the ability to continuously “ping” the network through a technology called SNMP. This allows IT to proactively monitor the “health” status of switches, PCs and servers. The same software now also keeps an inventory of hardware and software, as well as version control, so that the network can now distribute patches, updates, and fixes to the users quickly. Finally, most of these network vendors now have integrated help desk and service level management automation into their support process. Therefore, IT can now receive a request for assistance, log it, prioritize it, and escalate it automatically. They can then diagnose and fix (either remotely or by the system dispatching a person) user’s hardware and software. Finally, the IT tools can then print out a report that shows the amount of time systems were up for the month, how many service calls were responded to by prioritized need, who was serviced and when, as well as the outcome of that service call.

7. Wireless and Remote Capabilities:
Wireless PDAs, tablet PCs, smartphones and laptops are transforming the way information is gathered and processed. Systems can now be structured so that physicians may plug their device into the hospital system and be uploaded with what happened to their patients overnight. Additionally, caregivers and hospital staff can now work from home.

8. VoIP:
Currently the dual networks and dual support staffs to run a network and a PBX system are costly. Time and again, the return on investment (ROI) to move the phone system onto the network, department by department over a period of time, has shown to be a good investment. There is no charge for moves, adds and changes (MACs) now, the administration of two systems can be handled internally by one group, and future cabling costs are minimized.

9. Cabling:
Cabling is an infrastructure issue and often its importance is overlooked. But, it is foundation of the information highway for a hospital. In addition, as hospitals are adding increasing computerization, cabling installed two years ago may soon be outdated. Cabling should be an integral part of a hospital’s computer plan.

10. Standardization:
Standardization means that the technical components of servers, switches, and PCs should have the same memory, cache, and storage. The reason for this is that servicing a few standards reduces the complexity of support, which has shown time and again to be the best way to reduce the cost of operations.

11. Servers:
Most servers are currently purchased as individual standalone machines. This creates two problems: first, it means that each server is a single point of failure for its own data and there is no failover capability from one server to another; and second, the storage usage of each machine is usually less than 50% of capability. Therefore, the architecture of servers should be configured into a storage array network (SAN) of blade servers configured to backup each other.

Conclusion:
The implementation and continued automation of the healthcare workflow process is analogous to building a house. All departments run their own operation, but are interconnected and dependent upon each other to provide a complete workflow environment. The foundation of said “digital house” however, is the technological infrastructure. Any weak points in the infrastructure will create bottlenecks in the workflow process. The demand for quick and accurate patient information in hospitals is continuously on the increase. Hospitals have to improve their technological infrastructure in order to meet the needs of caregivers and to enhance their revenue. Healthcare workflow process improvement will take time to accomplish in a coordinated, synergistic manner that will improve patient care and hospital revenue.

Forging ahead: The electronic Child Health Network (eCHN)

The electronic Child Health Network (eCHN) provides services to enable Health Information Custodians, such as hospitals, to use electronic means to share personal health information with other [Canadian] Health Information Custodians.

Stated Mission
To be the preferred enabler of electronic health data and information for providers of maternal, newborn and child health care in Ontario and Canada.

Stated Vision
eCHN's vision is that electronic health information in Ontario and Canada should be a universal system that is inter-operable, comprehensive, accessible, flexible and available in a secure and controlled environment.

There are two primary eCHN offerings: PROFOR and HiNET.

PROFOR
PROFOR is a password protected professional development website for health care providers. Through PROFOR, health care professionals have access to the following types of information:
o Professional presentations and discussions including rounds for medical, nursing and other professional services.
o Educational material that can be printed from PROFOR and given to parents and children for their reference after their office or hospital visit.
o Pharmacy information, including the Sick Kids Pharmacy Formulary of Drugs.

Benefits of PROFOR
o Provides the latest information on many paediatric topics as provided by leading experts.
o Provides educational material that may be used as resource material for parents or patients.
o Provides the current Sick Kids formulary as a reference.
o Assists health care professionals in obtaining credits for continuing education.
o Permits health care professionals to benefit from educational presentations even when they are unable to be present at then time.

Read more about PROFOR at http://www.echn.ca/professionals.html#profor

Access to PROFOR: Health care professionals interested in accessing PROFOR can send their name, professional affiliation and email address to profor.requests@sickkids.ca.
Note: A password and user ID will be issued. There is no charge for accessing PROFOR.
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HiNET
HiNet is a secure system in which a child's medical records are available electronically to health care providers when and where they are required. This information includes laboratory results, doctor's notes, xrays, visit information and personal information such as age, address and phone number. HiNet uses the latest security technology and all information remains private within eCHN. HiNet is available only to pre-authorized health care providers. Patient participation is voluntary and written parental consent may be required. Although the decision not to participate will not affect the care delivered to any child, there are substantial benefits to having a child's health data on the network. These include faster access to patient records, more complete information available to health care providers and a reduction in duplicate X- rays and diagnostic tests.

Benefits of HiNET
o Health care professionals have instant access to the most current patient information.
o Information is available when and where it is required.
o HiNet reduces the opportunities for lost or unavailable records.
o The need to repeat tests completed recently may be reduced.
o The requirement for the patient to travel may be reduced.
o Facilitates delivering better, safer and more timely health care.
o Helps clinicians use their time more effectively by spending less time on paperwork and more time on providing care.
o Sharing health information improves continuity of care.

Read more about HiNET at http://www.echn.ca/professionals.html#hinetben

Download a HiNET brochure (English/French available) at http://www.echn.ca/eCHN%20brochure.pdf
Health care organizations and professionals interested in obtaining access to HiNet should contact eCHN by telephone at 416-813-8807 or via e-mail at echnmail@echn.ca

To view current eCHN Members please visit http://www.echn.ca/memberorgs.html
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All content as per eCHN website http://www.echn.ca

Health Canada | eHealth Thesaurus

To access Health Canada's eHealth Thesaurus, please visit:
http://www.hc-sc.gc.ca/hcs-sss/ehealth-esante/res/thesaurus/thesaurus_hier_e.html#list

Doctor Google and Doctor Microsoft; if not them, who?

via HealthBlog on Aug 14, 2007

Bill Crounse, MD Worldwide Health Director Microsoft

The Internet is abuzz today following a New York Times article by Steve Lohr about Microsoft's and Google's designs to change the game in healthcare. Readers who follow this Blog will understand very well where I come down on all of this. As a country, maintaining the status quo in our broken healthcare system (which really isn't a system at all) just isn't a viable option. We spend about twice as much money per capita on health than any other nation on earth, yet the US ranks far behind other countries in many of the ways we measure the overall health status of a population.

Do I think that some kind of universal, government-run healthcare fix is the answer to all of our problems? Absolutely not! One of the things I have learned as I have traveled around the world these past few years is that providing timely, cost-effective, equitable healthcare for an entire population of people is challenging no matter what payment system is in place. Healthcare is expensive and it doesn't matter whether the payor is government (we pay), employers (we pay) or private citizens (again, we pay); many of the miracles of modern healthcare have become so expensive and so out of the reach for people of ordinary means, there's just not enough money in any system to apply them universally and equally to every citizen. Therefore, healthcare always has been and always will be rationed in some way.

So, if how we pay for healthcare has flaws no matter what system is in place, we must find better ways and better systems to deliver more affordable and accessible care. I've taken a few hits for my positive stance on retail clinics, home health, patient self-service, physician-patient e-mail, personal tele-health services, and other modalities to provide health information and medical services in ways besides those that our current "system" provides. Many of my physician colleagues are on a war path against retail clinics. They are calling every state legislator and pulling out every tool in their regulatory armamentarium in an attempt squash the movement, but they will ultimately fail.

Prohibition doesn't work. Retail clinics will thrive or falter based on the quality of services they provide and the value that their customers perceive. The whole reason this movement has gained a foothold is because medical professionals haven't been listening to their patients. Patients want healthcare to behave like other industries. It really doesn't matter who's paying the bill. We are all paying the bill, and we expect more than we have been getting considering how BIG that bill has become.

Doing something about this will take more than coming up with new ways to pay for healthcare as it is presently delivered. We need new care delivery models, staffing models, business models, and a bevy of contemporary information and communication technologies to truly revolutionize American medicine. Neither Google, nor Microsoft nor any of the other companies mentioned in Lohr's article can be your doctor, nor should they be. But these companies can and should help us with the technologies that will be needed to change the game. If not Microsoft or Google, then who?

Google preparing ehealth portal initiative

Google is planning a product that it hopes will overhaul the way patients, doctors, vendors and pharmaceutical companies manage their medical information online. Dubbed the Google Health Scrapbook, the product is in developmental stages now and there is no certainty that it will be launched. Google executives met last week with their counterparts at WebMD in New York to pull them in as a partner for the new online service. They plan to pitch the product to other potential partners in the coming weeks.

The plan, as it stands now, calls for there to be four different directories for each different type of user. The prospect of listing a separate directory for medical devices seems to have been scrapped. Users will be able to log in with their own account information and do things such as add a new medical provider, check their medical records or pay their bills.

The product would also provide information about hospitals such as the frequency that a hospital performs a specific type of procedure or which hospitals perform which procedures most often.

Aside from WebMD, Google is hoping to partner with Intuit on the product. Intuit currently offers consumers a software program that helps them keep track of their medical expenses. The company has already met with the CEO of AllScripts LLC, Glen Tullman, and representatives of Epic Systems Corp., which has signed a non-disclosure agreement.

Involved in the project is Missy Krasner, a project manager who joined Google earlier this year. She was previously a top official in the Office of the National Coordinator for Health Information Technology. Adam Bosworth is rumored to be the one directing the company's overall health initiatives.

Google observers who have been expecting a major Google Health initiative to be announced in May were surprised that the company’s health-related release was Google Co-op. Google Co-op is a social search product focused around vertical areas such as health, autos and travel. Its health directory allows users to bookmark interesting pages and add them into the directory, which can then be viewed by others. It also allows users to subscribe to feeds from a variety of sources such as WebMD and the Mayo Clinic.

A Google press official declined to comment specifically on their plans. The press official released this statement: "Health has been an area of interest at Google for some time. We have been doing a variety of research in the health area, including how to improve the quality of health-related search results. Google Co-op is one reflection of that. We continue to look for more ways to benefit our users in the area of health, but we do not have any products to announce at this time. As part of our efforts, we work with many companies in formal and informal ways.”

If the company’s Google Health Scrapbook launches, its health information offering will immediately go far beyond what is currently available to its users via Google Co-op.
http://vcratings.thedealblogs.com/2006/07/google_preparing_health_portal.php

Google's Personal Health Record Initiative

The social-networking revolution is coming to health care, at the same time that new Internet technologies and software programs are making it easier than ever for consumers to find timely, personalized health information online. Patients who once connected mainly through email discussion groups and chat rooms are building more sophisticated virtual communities that enable them to share information about treatment and coping and build a personal network of friends. At the same time, traditional Web sites that once offered cumbersome pages of static data are developing blogs, podcasts, and customized search engines to deliver the most relevant and timely information on health topics.

Google Health, codename “Weaver”, is Google’s planned personal health information storage program. Google’s Vice President of Engineering Adam Bosworth lobbies for the program for quite a while now. Adam said the current US health care system is challenged when it comes to “supporting caregivers and communicating between different medical organizations.” Adam went on to say that people “need the medical information that is out there and available to be organized and made accessible to all ... Health information should be easier to access and organize, especially in ways that make it as simple as possible to find the information that is most relevant to a specific patient’s needs.” Adam adds that this – making information accessible – happens to be along Google’s mission.

The New York Times today writes that “about 20 percent of the [US] patient population have computerized records – rather than paper ones – and the Bush administration has pushed the health care industry to speed up the switch to electronic formats. But these records still tend to be controlled by doctors, hospitals or insurers. A patient moves to another state, for example, but the record usually stays.” But, the NYT continues, initiatives like the one by Google “would give much more control to individuals, a trend many health experts see as inevitable.” A prototype of Google Health has now been shown “to health professionals and advisers,” the NYT reports.

To find out just what you might be able to see in a future Google Health service, take a look at these screenshots from Google’s prototype which have been sent in here. As prototypes go, certain approaches of the program may change, and the specific interface may or may not be kept like this in a final release. “We’ll make mistakes and it will be a long-range march,” the NYT quotes Adam Bosworth.

To see more Screenshots of Google's new Personal Health record initiative, please visit http://blogoscoped.com/archive/2007-08-14-n43.html

For more information, please visit http://blogs.zdnet.com/Google/?p=135

Pan-Canadian Health Information Privacy and Confidentiality Framework

Canadians expect and have confidence that the privacy and confidentiality of their personal information will be protected when governments use it in the course of providing programs and services. In no field is the maintenance of this trust more critical than in the health sector.

Recognizing the importance of privacy, the Federal/ Provincial/Territorial Conference of Deputy Ministers of Health tasked its Advisory Committee on Information and Emerging Technologies to develop a Pan-Canadian Health Information Privacy and Confidentiality Framework. The objective of the Framework is to respond to Canadians' privacy and confidentiality expectations and to suggest a harmonized set of core provisions for the collection, use and disclosure of personal health information in both the publicly and privately funded sectors. Consistent, or at least more consistent, privacy regimes among jurisdictions would facilitate health care renewal, including the development of electronic health record systems and primary health care reform.

The Framework is a valuable tool to inform and influence any privacy legislative process within jurisdictions affecting personal health information. Since the Personal Information Protection and Electronic Documents Act (PIPEDA) applies in jurisdictions which, unlike Quebec and British Columbia, have not adopted "substantially similar" legislation, the Framework can also serve as a guide to achieving that objective. However, it is also understood that it is only a guide, not a prescription. The actual intent and wording of jurisdictional legislation will ultimately determine whether the legislation can result in an exemption from PIPEDA. Quebec did not participate in the development of the Framework, while Saskatchewan withdrew near the end of the process.

For more information on Pan-Canadian Health Information Privacy and Confidentiality Framework please visit - http://www.hc-sc.gc.ca/hcs-sss/pubs/ehealth-esante/2005-pancanad-priv/index_e.html
Health and the Information Highway Division, Health Canada January 27, 2005

The Electronic Health Record (EHR) Solution Blueprint

A roadmap for planning and implementation in Canada
The Blueprint is focused on interoperability - the capability of computer systems to seamlessly communicate with one another. It provides guidance for integrating the approximately 40,000 existing health information systems in use across the country, while remaining flexible to allow for incorporating new and better information systems and capabilities. The Blueprint, based on extensive consultations and collaboration, is a useful tool for information technology professionals in governments, health regions and hospitals who plan to implement Electronic Health Record solutions. It is also valuable for technology vendors who want to align their products and services with the vision for the interoperable Electronic Health Record.

To access a (Flash-based) overview of Canada Health Infoway's initiatives please visit:
http://knowledge.infoway-inforoute.ca/EHRSRA/flash/index_big.html

The EHRS Blueprint is a technology framework for sharing health information securely and appropriately across Canada. Based on extensive collaboration, it's a valuable tool for governments, health regions, hospitals and technology vendors who are involved in implementing Electronic Health Record solutions. The revised version of the Blueprint is now available. Incorporated into the EHRS Blueprint, the Electronic Health Record (EHR) Privacy and Security conceptual Architecture (PSA) helps ensure that future interoperable EHR systems will comply with federal / provincial / territorial, as well as cross-jurisdictional Privacy and Security (P&S) requirements.

To view Canada Health Infoway’s latest EHR Blueprint please visit:
http://knowledge.infoway-inforoute.ca/en/knowledge-centre/ehrs-blueprintv2.aspx

Canada Health Infoway Passport

The Infoway Passport is your key to the various tools and services offered by Canada Health Infoway.
With an Infoway Passport, you may subscribe to newsletters on Electronic Health Records, access Infoway's e-Health Knowledge Way - the gateway to bilingual resources for all topics related to the implementation of the Electronic Health Record - as well as access to, with proper authorization, discussion forums, toolkits, and private website sections. With an Infoway Passport, you have only one password to remember, and voilà! you're in!

To register for your Infoway Passport visit: http://www.infoway-inforoute.ca/en/InfowayPassport/InfowayPassport.aspx?ReturnUrl=http%3a%2f%2fknowledge.infoway-inforoute.ca%2fen%2fDefault.aspx

The Province of Nova Scotia (Department of Health) eHealth Initiatives

For all information regarding the Province of Nova Scotia (Department of Health’s) Electronic Health Record (EHR), Wait Time (WT) and Panorama Projects— please visit: http://www.gov.ns.ca/health/EHR/iEHR.htm

For a summary of Wait Time (WT) projects — please visit:
http://www.gov.ns.ca/health/EHR/Wait%20Time%20Guarantees/Summary_all_3_projects.pdf

For a summary of Panorama projects — please visit:
http://www.gov.ns.ca/health/EHR/panorama.htm

E-health is key to re-engineering Canada's healthcare system.

Borderless. Seamless. Accessible in all reaches of our diverse country. A patient-centric healthcare system that delivers fast, accurate and assisted diagnosis and treatment. A system where health care providers are equipped to focus on prevention and evidence-based treatment. Where all points of care (homes, schools, family practitioners, community clinics and hospitals) are linked. Free from red tape and wasteful duplication. Offering individuals the tools to take control over their own health. A system where the privacy, security and confidentiality of personal health information is respected.

That is indeed the vision for Canada's health care system. It's based on e-health or the application of information and communications technologies (ICT) to improve the quality, accessibility and effectiveness of health care. It features a pan-Canadian electronic health record (EHR), a range of telehealth services, and trusted health information for all Canadians. It is focused on the needs of patients, practitioners, administrators, policy makers, researchers and the general public. It leverages the Internet and all supporting technologies.

E-health is not about replacing in-person care or simply cutting health care costs. Rather, e-health is about enhancing the overall quality of care, providing treatment choices and supporting self-care. Moreover, It's also about increasing the overall effectiveness of the system so that we get more for our tax dollars. E-health is key to re-engineering Canada's health care system.

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William J. Pascal, Director General, Office of Health and the Information Highway, Health Canada. http://www.hc-sc.gc.ca/hcs-sss/pubs/ehealth-esante/2001-vision-action-article/index_e.html

Sharing the Wealth for Better Health

The case for broader exchange of information about the use of information and communications technologies (ICTs) in healthcare.

As explorers, inventors and iconoclasts have always known, the innovative spirit can be isolating. The same holds true for people pioneering promising new applications for information and communications technologies (ICTs) in health care, which by their very nature are uncommon, cutting-edge, even unique.

And yet, nowhere is the need to link up, to share information with others, to create a common body of knowledge, more pressing than in this field. Because each initiative has the potential to enhance the well-being of Canadians or to contribute to the sustainability of the health care system, it is essential that the experiences be widely and swiftly shared.

It is as complex a challenge as it is urgent. Success will demand the support of all quarters - researchers, health professionals, administrators, non-governmental organizations and governments alike.

At OHIH, Health Canada's Office of Health and the Information Highway, we have no vested interest in any particular structure or mechanism. We can, however, serve as a catalyst for action, encouraging all parties to participate in a shared solution. To underscore our concern, we have recently launched an important new Web-based resource. Known as the ICTs in Health Initiatives Database, it is a searchable online tool that enables health providers, researchers, administrators, policy-makers, analysts and other interested people to post and find information about initiatives involving ICTs in the health services field. (See sidebar on page 2). This database is one of many resources being shared through OHIH's ICTs in Health Infoway web site (www.hc-sc.gc.ca/hcs-sss/ehealth-esante/index_e.html).

The web site is not a signal that the Government of Canada intends to lead a comprehensive information-sharing exercise among developers and users of ICTs in health. It is merely a spark for the process, highlighting one way of connecting people for the benefit of all Canadians.


A Meeting of Minds
OHIH and its partners have launched a searchable online tool to allow researchers, health professionals, administrators, policy makers and others to post or find information about projects using Information and Communications Technologies (ICTs) in health care.

The new ICTs in Health Initiatives Database is designed to provide reliable, quality-controlled, timely and relevant information profiles on Canadian initiatives involving the use of ICTs in health - especially projects involving electronic health records and telehealth technologies.

The database is set up to enable contributors to describe their initiatives, including objectives, the organizations involved, target populations, the technologies used, funding, points of service, links to related Web sites, and contact information. A unique feature of this database is that contributors may post background documents relevant to their projects, such as evaluation reports and multimedia clips. These can be downloaded by visitors to the site. The database is, first and foremost, a tool for sharing information and experiences about ICT applications in the delivery of health services. It serves as a vital data source for researchers, and helps organizations and individuals find suitable health partners for collaborative activities. It also allows administrators and policy-makers to monitor trends and investments in ICTs in health, as a support to solid, evidence-based decision making.

While some portions of the database are accessible only to registered users, others are open to all visitors, including consumers. The initial contributors to the database included the Government of Canada; provincial, territorial, regional and municipal governments; primary health care delivery organizations; acute and long-term care facilities; universities and non-governmental organizations.

Understanding the challenge
Without question, the challenge is vast. First, with so many people trying to apply ICTs in so many novel ways, we need a comprehensive and reliable mechanism for others to find out about the work. The objective should be to harness every potential resource in the search for new uses of ICTs in health and health care. The health care system has neither the time nor the money to waste on duplicated effort or demonstrated failures.

Second, we need to be able to convert all our sources of experimental learning into knowledge. We need to be able to promote collaborations that can take ideas beyond the pilot stage to where they can have a positive and lasting real-world impact.

And finally, we need to be able to share our acquired knowledge. It is a fundamental principle of Canada's health care system that people are entitled to benefit equitably from initiatives that promise improved care, no matter where they happen to live.

Thanks to the spadework already performed by other sectors, we can use their experience to illuminate our thinking on translating information into knowledge and then aggressively sharing this knowledge.

Start with first principles:
We can surely agree that it makes sense to find better ways to share information about ICTs that improve either the functioning or the outcomes of the health care system.

Suppose, for instance, that a community health service agency in Quebec City has developed a simple, yet effective, technological application that gives travelling home care workers timely information about the next patient, as well as some guidance on the best course of care. Over time, the agency accumulates extensive experience related to developing or acquiring the technology, implementing it and training staff, managing information and privacy issues, and evaluating the impact of the initiative on patient health, provider satisfaction and agency budgets.

Clearly, all this information would be of tremendous benefit to home care services right across Canada - all of them questing for better, more cost-effective ways to handle growing caseloads.

This scenario is one of many occurring in Canada right now. But for all the excellent ways we are finding to improve both the health outcomes of Canadians and the efficiency of the health care sector, we have yet to develop a systematic way of sharing the know-how gleaned through our laudable, though disconnected, efforts.

The rationale of sharing
Several questions follow. Why share knowledge? If it makes sense to share, what exactly should be shared, how do we do it, and who is going to make it happen?

First the why.
We share knowledge for several compelling reasons that, in sum, could be said to benefit patients, health care providers, institutions, government and non-governmental funding sources, and society at large.

Simply put, a lot of information related to the use of ICTs in health is a public good that is best converted to knowledge within the public domain. This truth holds from its collection clear through to its use. For instance, in our publicly funded system, virtually all exploration of potential application of ICTs in health is sponsored by publicly funded institutions such as hospitals and universities, or with government.

Because the information typically concerns the public as patients or taxpayers, the resulting knowledge should be seen as being developed in the public interest, and therefore shared in the public domain. Moreover, if the knowledge acquired through such projects is applied for the good of one segment of the public - home care clients in Quebec City, for instance - then it is only right that the knowledge be made as widely available as possible for the benefit of home care clients everywhere. Knowledge in the health care system becomes ever more powerful as it is shared.

Sharing the risk
Apart from the "public good" argument, there's also a business case to be made. Sharing knowledge means distributing risk and earning a better return on the investment dollar.

Let's say an institution wants to apply a new technology to its internal health care processes. The innovation can be costly to develop, demonstrate, refine, implement and sustain over time. Its introduction may be complicated given the conservative culture that exists in the healthcare system which leads to slow adoption rates and, in some cases, outright resistance to change.

By sharing information about experiences and results, however, several groups with similar objectives can tackle the challenge together. This affords them a greater chance of coming up with solutions that are appropriate to the needs and the marketplace, while avoiding the duplication of costly and demoralizing errors. The collaborative process could also be expected to proceed faster than any organization could manage alone, and at less cost to each partner. Moreover, different minds united in purpose can often come up with creative solutions that neither would have envisioned alone.

If the "why" of knowledge management is relatively straightforward, the "what","how" and "who" are considerably tougher. What information do we really need? How do we assess quality and ensure its consistency? How do we know where the gaps are, and what should fill them? How do you persuade people to discuss the glitches and failures they have experienced, as well as the things that worked?

What format should information be in to make it most useful for others? What technological functions would make it most accessible? Indeed, in a field as human and personal as health care, what are the roles and limitations of technology?Although we have little history to draw upon when contemplating these questions, Health Canada's experience with HISP, the Health Infostructure Support Program, offered some useful pointers. A report, soon to be available on the OHIH website, evaluated this program and has taught us what worked and what did not, and helped us start to understand the steps necessary to translate information into knowledge that can be shared. As we reflect on what information and knowledge we need to generate, manage and share, the question of how we ought to go about it necessarily arises.

Connecting minds
Information and communications technologies of all sorts are available to connect people these days. But in the health sector, are they being used as they should? While many people have vigorously embraced new networking technologies, others are only reluctant converts. Strapped for time or distrustful of technology, some health professionals are simply overwhelmed by the new digital world.

But since the clocks cannot be turned back, it makes sense to build trust and ease the transition, especially for the skeptics. Typically, there is comfort to be drawn from interactions with peers. The proliferation of informal networks over the Internet and at professional conferences and workshops attests to a hearty appetite for interpersonal communication - a prerequisite for sharing and developing knowledge.


OHIH's Information Exchange Initiatives
Through OHIH, Health Canada facilitates the exchange of information about the use of ICTs in health through its ICTs in Health Infoway website (www.hc-sc.gc.ca/hcs-sss/ehealth-esante/index_e.html) which includes:
* maintaining lists of organizations and initiatives related to ICTs in health
* maintaining databases of relevant international conferences and online literature
* facilitating online access to full-text periodicals and a range of Health Canada publications
* collecting information on provincial and territorial government-sponsored initiatives, plans and priorities related to ICTs in health, and making this information
* providing information about professional development resources, including education and training
* organizing and supporting workshops, stakeholder conferences and electronic discussions.

Initiatives like Health Canada's Canada Heath Infostructure Partnerships Program (CHIPP) also foster partnerships that begin as short-term arrangements, but often evolve into lasting professional relationships. More formal structures, such as the Networks of Centres of Excellence and the Canadian Institutes for Health Research build more permanent ties. Even so, there's precious little yet in the way of organized communications mechanisms linking groups and individuals who would not normally be engaged in collaborative ventures.

There should be, though, and they should be so comprehensive as to cut across disciplines and sub-sectors of the health care field. But how do you make that kind of communication work? What's in it for the different players?

Carrots and sticks
The truth is that the time crunch in the health care sector is real, severe and not about to improve. Even if they were inclined to share their knowledge, health professionals, researchers and administrators have enough to preoccupy them without worrying what others are doing.

There are few levers, although money is invariably one. Support grants are virtually always tied to a requirement to publish results. But is that enough? Is the information available quickly enough - even if it is posted on the Internet? Is it accessed and used by enough people? The right people? How do we know?

Where funding cannot compel communication, only incentives and a shared concern about the health of Canadians will work.

Suppose, for example, that you know of an initiative elsewhere that could benefit your own work. Clearly, it is worth your while to contact the group to inquire about their project.

But what if you do not know about their work, because they have yet to publish in the traditional literature? Could there be a mechanism to let you know, in a timely way, what is out there on the cutting edge, to connect your problem to a potential solution?

Conversely, let's say you possess the cutting-edge knowledge: you have developed a technological initiative that is serving you and your patient population well. What would motivate you to reach out and share the information with others?

It could be professional courtesy, pride in your accomplishments, or all-round generosity of spirit and good will. You might be the kind of person happy to show off an exciting innovation, or flattered to be solicited for your expertise. It may be possible, on an intellectual level, to see the pooling of minds as inherently right. Rationally, it may also be perceived as contributing to system-wide efficiencies and economies of scale. But does that translate into individual altruistic action?

Leadership potential
As the issues around the "how" of sharing information about the use of ICTs in health care begin to crystallize, we must also concern ourselves with the "who."

Who will build the information-management capability we need? Who will pull information together, massage it into knowledge of a useable form, and actively bring that to the attention of those who might use it? Who can build a culture of sharing, with all the trimmings such as trust, leadership and accountability?

As the federal government in a federated health care system, we try to be helpful in this regard. After all, helping Canadians gain access to better health care and quality information are key priorities. In our funding projects, we apply the same principles that exist in any public research institution: Information and knowledge must be shared through publication and accessible so that others can review, substantiate, refute, use or apply it.

Admittedly, though, this is a small piece of a huge health-care pie, with most of the work we support typically at the research, pilot or demonstration stage. Moreover, while the emphasis is on innovation and the development of new applications for ICTs in health, it is not necessarily on the mechanics of information and knowledge sharing.

Some of that is occurring on an institutional level, or within stakeholder groups such as Canada's Health Informatics Association, the Canadian Society for Telehealth and the major professional associations. For the most part, however, the issues are not being addressed on a system-wide basis. While governments regulate many things in health care, they cannot (nor should they) compel information sharing. The federal government could, however, play the role of catalyst to spark progress in this endeavour. Our new ICTs in Health Initiatives Database is one step in that direction.

But, as the process gets underway, who would guide it along? Should there be a central co-coordinating agency? Does it need to be within the purview of the public sector, or could private enterprise perform the function? If so, how are issues like privacy and the public interest safeguarded?

To be sure, we do not know the answers; we may not even have identified all the questions yet. We do know, however, that it is time to engage, and everybody has to get involved. The challenge is vast and one model won't meet all the needs. Just as car designers test their prototypes on drivers of all shapes, sizes and preferences, different groups bring different perspectives and competencies to the table.

And, no matter which solutions we choose, the outcome will surely touch all Canadians. All of us who care about better health and a more efficient health care system have a powerful vested interest in getting it right.

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by William Pascal, Director General
Office of Health and the Information Highway, Health Canada. In Healthcare Information Management & Communications Canada, Vol. XVI, No. 1, 1st Quarter, March 2002 , pp. 39-42. http://www.hc-sc.gc.ca/hcs-sss/pubs/ehealth-esante/2002-sharing-partager/index_e.html

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