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

“e”Health: More than just “electronic”

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

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

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

The “e” in “eHealth”

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

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

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

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

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

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

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

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

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

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

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

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

What is eHealth?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

About Frost & Sullivan
Frost & Sullivan, a global growth consulting company, has been partnering with clients to support the development of innovative strategies for more than 40 years. The company's industry expertise integrates growth consulting, growth partnership services, and corporate management training to identify and develop opportunities. Frost & Sullivan serves an extensive clientele that includes Global 1000 companies, emerging companies, and the investment community by providing comprehensive industry coverage that reflects a unique global perspective and combines ongoing analysis of markets, technologies, econometrics, and demographics. For more information, visit http://www.frost.com.

Canada’s e-Health efforts increase

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

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

All eHealth Portals Are Not Created Equal

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

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

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

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

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

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

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

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

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

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

The changing face of Healthcare in Canada.

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

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

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

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

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

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

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

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

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

Canadian eHealth Trends

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

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

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

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

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

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

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

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

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

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

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

All eHealth PORTALS are not created equal

INTRODUCTION

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

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

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

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

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

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WEB PORTALS: DEFINITION AND DESCRIPTION

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

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

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

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eHealth EVOLUTION: BABY STEPS INTO THE FUTURE

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

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

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

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

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

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

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

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THE PORTAL COMMUNICATION SOLUTION

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

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

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

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FOUR AREAS REMAIN UNDERSERVED DESPITE THEIR GREAT PROMISE:

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

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THE PORTAL PROMISE

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

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

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

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TECHNOLOGY THAT OVERCOMES ADOPTION ISSUES

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

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

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

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

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

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

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

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


FOLLOW THE LEADERS

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

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

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