FEATURE REPORT: ELECTRONIC HEALTH RECORDS — SEE PAGE 22 · 2019-04-26 · For his part, Lemonde...

BY JERRY ZEIDENBERG

TORONTO – Demand for informationfrom users inside hospitals – and frompartners and patients logging into por-

tals outside the facilities – is “becoming insa-tiable”, as one healthcare executive at Mi-crosoft’s recent “Future Now” conference put it.

So how will hospitals manage the rocket-ing growth of servers and apps, as new sys-tems are added to deliver the data, alongwith the privacy and security issues that arebound to crop up?

And it’s not just computers that have tobe tracked.

“What do you do when you’re keepingtrack of 5,000 desktop computers, and youmove to monitoring 100,000 sensors,” askedLydia Lee, Healthcare Lead at KPMG, andthe former CIO of the University HealthNetwork. She was the session’s keynotespeaker, and noted that every computerizeddevice in hospitals is now being tied into anetwork – or soon will be.

“It’s a quantum shift,” said Lee. “You haveto respond in a different way.”

Dr. Sarah Muttitt, VP and CIO at theHospital for Sick Children, commented onthe fast expansion of systems at the medicalcentre, which will only grow further withconstruction of a new tower for patient care.As well, the hospital has a leading-edge re-search centre, and has also embarked on a

new initiative in artificial intelligence. “Datais pivotal, and reliability is critical,” she said.

One of the solutions is to outsource somefunctions to industry experts. As one exam-ple, she noted, the hospital has outsourced itsnetwork management and security to Telus.

Now, it’s also looking to the cloud as away of managing the many servers and ap-plications the hospital has spawned.

“We’re looking to see what we can shift tothe cloud,” she said. “We don’t want to be inthe data centre business.”

She said Sick Kids is now looking at everyserver, every blade, to see what could poten-tially be transferred to the cloud. “We’respending the next year figuring it out.”

She noted that Sick Kids recently went livewith the Epic electronic information systemin all of its departments, which has had a bigimpact on the hospital. Now every user, inevery department, can access informationacross the organization, in the same way.

“We were a siloed organization fordecades,” she said. “The new system has beentransformational.”

She said that access to information isnow vastly improved. “What we’re going todo with that information will also be trans-formational.”

In particular, there’s a big emphasis onimproving performance through the use ofanalytics – something she credited the hospi-

Hospitals are outsourcing and moving IT to the cloud

CONTINUED ON PAGE 2

CAMH, in Toronto, held an innovation day, complete with panels to assess the technologies produced by hospital teams. The ‘Dragons’, Dr. Cather-ine Zahn, president and CEO of CAMH, tech author and guru Don Tapscott, and Cisco Systems Canada president Rola Dagher, evaluated the pro-posals of six finalists chosen from 41 applicants. The top solution, a suicide safety plan app, was funded with $35,000. SEE STORY ON PAGE 7.

CAMH promotes innovation with ‘Dragon’s Den’

“We’re looking to see what we canshift to the cloud,” said Dr. SarahMuttitt, CIO at SickKids.

INSIDE:

INFRAM reaches CanadaMarkham Stouffville Hospital,north of Toronto, has become thefirst centre in the country to usethe Infrastructure AdoptionModel (INFRAM). The model hasbeen adopted by HIMSS.Page 4

Rush to the cloudRush Health, in Chicago, ismaking the cloud its number onepriority when it comes toinformation technology. Otherlarge U.S. healthcare providersare also transferring applicationsto hosted systems, like Azure,Google Cloud and AWS.Page 8

Virtual house callsPhysicians in Hamilton, Ont., havelaunched their own platform toprovide telehealth services topatients who have trouble gettingout of their homes to see adoctor.0

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FEATURE REPORT: ELECTRONIC HEALTH RECORDS — SEE PAGE 22

CANADA’S MAGAZINE FOR MANAGERS AND USERS OF INFORMATION SYSTEMS IN HEALTHCARE VOL. 24, NO. 4 MAY 2019

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tal’s previous CEO, Mike Apkon, with fos-tering. Dr. Apkon served as CEO at Sick-Kids for five years before leaving to becomeCEO at Tufts Medical Center in Boston.

“We’ve been putting in dashboards forevery part of the business,” said Muttitt.“We’re looking at clinical, administrative,equipment, everything to optimize the or-ganization.” Everyone needs this informa-tion, she said, and use of the Azure cloudhas been speeding up the process.

It’s all in a bid to improve clinical out-comes, workflows and patient satisfaction.“We don’t want patients to come down-town and not find a parking spot,” shesaid. “Or to wait four hours for an ap-pointment, or eight hours in the ED.”

For its part, the Ottawa Hospital, whichhas also implemented Epic, just com-pleted a big cloud project using MicrosoftAzure. The organization, which is alsohosting systems for several surroundinghospitals, has shifted its disaster recovery(DR) to the cloud.

By moving DR to the cloud, “We’re sav-ing $400,000 a year just for the Epic work-

load,” said Jean-Claude Lemonde, IT Leadat the hospital

What’s more, the Azure cloud offers re-covery services; and if there is a disrup-tion, service can be switched over within30 minutes.

Lemonde said the organization lookedat shifting its day-to-day Epic systems tothe cloud, but there wasn’t the cost savingsavailable that occurred with DR.

“When we looked at the numbers, itwould only have worked if we removed thewhole IT team,” said Lemonde. “But westill needed the team to manage the othersystems we’re using.”

However, he said like technology ingeneral, costs for the cloud may continueto drop over time, making it more viable toput the mainline systems into hosted sys-tems like Azure, Google Cloud or AmazonWeb Services.

He mentioned that in addition to theOttawa Hospital and its partners that areall on the Epic system, the group will ex-tend Epic to 250 primary care clinics onJune 1st. It’s going to be the first large-scaleimplementation in Canada of an Epic sys-tem that includes both acute and primary

care providers, all in one integrated solution.For his part, Lemonde doesn’t think all

of the hospital’s systems will migrate to thecloud, even if prices make it enticing. “Idon’t think an organization should go fullyinto the cloud, because with outsourcing,you lose your own expertise.” You’ll alwaysneed some feet on the ground, he said, forproblems that come up on the site.

As well, he doesn’t believe in putting allof one’s eggs in a single basket. “You mightwant to go with AWS and Microsoft,” hesaid. “This is also an option.” On the otherhand, he acknowledges that using two ormore cloud vendors complicates things.“Then you’re using two massively differenttechnologies.”

Mark Rajack, Director of Innovation atNiagara Health Systems, discussed how hisorganization has been building links tocommunity health providers, like Emer-gency Health Services. He also noted theinterest among the public for access totheir health records.

For these reasons, Niagara Health justrolled out a solution that helps with identitymanagement. The Identos system helps de-termine the outside user is authorized to ac-cess the information that he or she wants.

“How do we know you are who you sayyou are,” asked Rajack. “For example, whensomeone is calling us from their home?”

The new solution also works with mobiledevices, which is increasingly the way peopleare accessing information of all kinds.

Overall, when it comes to innovation,Rajack said Niagara Health first looks atthe problems its providers and patients aretrying to solve. It then seeks out the besttechnology.

“What is the pain point that, for exam-ple, the imaging team needs help with?,” heasked. The IT and innovation teams at theorganization will then work with the clini-cians to source the right technology.

On the topic of surprises, Sick Kids’sSarah Muttitt mentioned that her organi-zation recently implemented a speechrecognition solution for clinical documen-tation, along with Epic mobility tools forclinicians. “They both took off, with verylittle training from us,” she said, observingthat users took to these technologies natu-rally and largely on their own. “Sometimes,you don’t know what you don’t know.”

Art DirectorWalter [email protected]

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Address all correspondence to Canadian Healthcare Technology, 1118 Centre Street, Suite 207, Thornhill ON L4J 7R9 Canada. Telephone: (905) 709-2330.Fax: (905) 709-2258. Internet: www.canhealth.com. E-mail: [email protected]. Canadian Healthcare Technology will publish eight issues in 2019. Featureschedule and advertising kits available upon request. Canadian Healthcare Technology is sent free of charge to physicians and managers in hospitals, clinicsand nursing homes. All others: $67.80 per year ($60 + $7.80 HST). Registration number 899059430 RT. ©2019 by Canadian Healthcare Technology. Thecontent of Canadian Healthcare Technology is subject to copyright. Reproduction in whole or in part without prior written permission is strictly prohibited.

Send all requests for permission to Jerry Zeidenberg, Publisher. Publications Mail Agreement No. 40018238. Returnundeliverable Canadian addresses to Canadian Healthcare Technology, 1118 Centre Street, Suite 207, Thornhill ON L4J 7R9.E-mail: [email protected]. ISSN 1486-7133.

CANADA’S MAGAZINE FOR MANAGERS AND USERS OF INFORMATION TECHNOLOGY IN HEALTHCARE

Volume 24, Number 4 May 2019

Contributing EditorsDr. Sunny MalhotraTwitter: @drsunnymalhotra

Dianne [email protected]

Dianne [email protected]

Dave [email protected]

CONTINUED FROM PAGE 1

Pictured at the Future Now conference: (l to r) Microsoft VP Jason Hermitage; The Ottawa Hospital’s Jean-Claude Lemonde, Dr. Sarah Muttitt of The Hospital for Sick Children, and Mark Rajack of Niagara Health.

To improve performance, hospitals outsource and move IT to the cloud

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BY JENNIFER RIDEOUT

s part of a plan to upgrade andmodernize its IT infrastructure,Markham Stouffville Hospital,located north-east of Toronto,

has become the first medicalcentre in Canada to make use of the IN-FRastructure Adoption Model (INFRAM).

Initially developed by the Cisco health-care team in Australia and New Zealand,INFRAM has been officially adopted bythe Healthcare Information and Manage-ment Systems Society (HIMSS) Analyticsas the global model all health care organi-zations should adopt and follow when cre-ating architectural infrastructure to sup-port their Electronic Medical Records(EMR) and other technology rollouts.

Markham Stouffville Hospital beganlaying the groundwork for a major digitaltransformation more than two years ago,with a focus on two major priorities: pa-tient care and future-proofing the hospi-tal’s IT systems.

“Much of the technology we had sup-porting our network was in need of a re-fresh,” says Michael Cole, who came on-board in 2017 as the hospital’s Chief Tech-nology Officer. “For example, our wiredand wireless infrastructure was end of lifein many areas and end of support in others.

“A refresh was necessary not only to en-sure stability and the improvement of our se-curity posture, but also to enable ourselves,our providers and our patients with thefoundation for the technology requirementsneeded now and for the foreseeable future.”

In February 2017, the hospital an-nounced one of its first digitization projects– a shared health information project withNewmarket’s Southlake Regional Health

Centre and Alliston’s Stevenson MemorialHospital. This new project will supportseamless patient care across the three orga-nizations by centralizing patient recordsand streamlining access for healthcare pro-fessionals, patients and their families.

Markham Stouffville has already movedits Meditech deployment into a new manageddata centre in preparation for the alliance.

However, working with the hospital’sIMIT (Information Management Informa-tion Technology) leadership team to con-tinue making digitization a top priority,

Cole quickly concluded that the new datacentre implementation was not enough.The hospital needed a stronger, underlyinginfrastructure for its entire digital network.

Markham Stouffville engaged CiscoCanada to undertake a complete networkassessment, with the ultimate intention ofdesigning a full refresh of the hospital’swired and wireless network. Key to this as-sessment was the INFRastructure Adop-tion Model. For the assessment, Vertite-chIT, an IT consultant with a holistic viewof IT strategies, worked closely with Cisco

and the hospital, helping to lead the reviewand engagement model.

The INFRAM review takes organiza-tions through a detailed process and assess-ment from an infrastructure perspective,focusing on five technology pillars: trans-port layer, data centre, unified communica-tions and collaboration, mobility and secu-rity. It provides an infrastructure architec-ture roadmap that can be used to detail theorganization’s specific technology require-ments based on what they already have inplace, and where they want to go.

INFRAM is complementary to theHIMSS Analytics Electronic Medical RecordAdoption Model (EMRAM) and its corre-sponding levels. Using it, healthcare organi-zations can improve care delivery, reduce cy-ber and infrastructure risk, and create apathway for infrastructure development tiedto business and clinical outcomes.

INFRAM can also help them achievecost-savings throughout the upgradingprocess, while adopting EMR or when look-ing to drive efficiencies throughout their in-frastructure. By increasing transparency inthe assessment, evaluation and planningstages, it provides a more accurate pictureof where resources should be allocated, re-ducing the risk of wasted investment.

“Cisco took an agnostic approach, re-gardless of technology involved, that basi-cally says ‘here’s where you are’ in order togive Markham Stouffville Hospital a base-line from an infrastructure perspective,”says Rob Campagna, Regional VP of On-tario Public Sector, Cisco. “The power ofINFRAM is that it can be mapped in sucha way that organizations can create astrategic architectural roadmap from thetechnology perspective, focusing on how

N E W S A N D T R E N D S

BY NEIL ZEIDENBERG

Women’s College Hospital(WCH) in Toronto is afully ambulatory hospitalfocusing on short term

patient stays, and day surgeries. By usingdata analytics and evidence-based medi-cine, they dramatically lowered patientdischarge times for knee and hip re-placement surgery.

“Now patients can go home on thesame day they have surgery,” said JackWoodman, Chief Strategy & Quality Offi-cer at Women’s College Hospital. “That’sa big improvement over the four to sevendays patients used to spend in hospital.”

In a February webinar by Health Qual-ity Ontario titled, How Big Data ChangedSports and Will Revolutionize YourHealth Care, Dr. Sacha Bhatia – cardiolo-gist and director of the Institute forHealth System Solutions and Virtual Care(WIHV) at Women’s College Hospital –(and basketball mega fan) talked abouthow Big Data has already played a majorrole in sports performance, and how itsuse can make a difference in healthcare.

“Data analytics has been used in pro-

fessional sports for a number of years tohelp improve individual and team per-formance,” said Bhatia. “But it can alsobe used to help improve physician per-formance,” and the healthcare team.

Since the early 2000s analytics has beenused in sports to track the tendencies ofits players, ball movement, shot selection,successes and failures. “By 2011, everyteam in the NBA was using it to help ex-plain performance,” said Dr. Bhatia.

As an example, “Analytics determinedthat the three-point shot (from beyondthe arc) is the most efficient shot, and theworst shots are taken from under the bas-ket.” It was even used to highlight whereon the court pro ballers LeBron James andStephen Curry were most effective in theirshot-making to help improve their game.

“A great sports franchise will alwaysbe great because it has great leadership.And in a hospital, great leadership leadsto the best patient care. We need moredata, not less. And we need to think ofmore ways to collect data so we can useit. However, you don’t want to create dataoverload. Collect the data; analyze it andthen think about how you’re going to useit to improve patient care,” said Bhatia.

In 2015, Atul Gawande – a surgeonand professor at Harvard Medical School,wrote an article for the New Yorker maga-zine about healthcare needing Pit Crews,not cowboys. Doctors are efficient inde-pendent caregivers, but can be even betterif they performed more like pit crews –who operate as a team. Everybody on apit crew has a specific job and they all

have to work together or it can seriouslyaffect the outcome of a race.

A study by Health Quality Ontariodetermined as much as 30-percent of alldiagnostic tests ordered in Ontario areunnecessary. It means many patientshave tests with little or no benefit, andpatients who really need these tests aredelayed in getting them.

In the Choosing Wisely campaign,they sought to measure the overuse ofcare – e.g. the ordering of low-value tests

which have little benefit for many pa-tients. The study measured the orderingpractices of nearly 2,400 high-volumephysicians and found that about 20 per-cent of the physicians were responsiblefor ordering 40 percent of the tests.

Echo WISELY was a program thatstudied the impact of providing doctorswith feedback on their echo orderinghabits, and whether it could reduce un-necessary heart tests. It determined thateducational tools and feedback can in-deed improve the use of imaging andprotect patients from potentially harm-ful testing.

Dr. Bhatia says that clinicians are al-ready data driven – meaning they’ll re-spond to the evidence. If you show themwhere they can improve and how, they’llchange their approach. “You need toknow what the problem is in order to fixit. Use the data to create a strategy, andthen solve the problem,” said Bhatia.

A data-driven approach to problemsolving uses real-time stats to developnew models of care. The potential bene-fits are huge. It can lead to better out-comes, better doctors and lower health-care costs.

“In a hospital, greatleadership leads to the bestpatient care,” says Women’sCollege’s Dr. Sacha Bhatia.

Whether it’s sports or healthcare, analytics can improve performance

Markham Stouffville Hospital first in Canada to use INFRAM model

Leading the INFRAM initiative at MSH: Maged Ghebrial, Sr. Consulting Systems Engineer, TELUS; CynthiaEsnard, Account Executive, Healthcare, TELUS; Michael Cole, Chief Technology and Privacy Officer, MarkhamStouffville Hospital; Shanti Gidwani, National Director, Healthcare, Cisco Canada; Mark Leyser, Senior SalesSpecialist, Security; Rob Capagna, Regional VP Sales, Ontario Public Sector, Cisco Canada.

A

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h t t p : / / w w w . c a n h e a l t h . c o m4 C A N A D I A N H E A L T H C A R E T E C H N O L O G Y M A Y 2 0 1 9

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BY DAVE WEBB

Don Tapscott is in. At a recentpitch session for innovationprojects at Toronto’s Centre forAddiction and Mental Health

(CAMH) – modeled after popular CBCTV series Dragon’s Den, where entrepre-neurs compete for investment cash fromfinanciers – Tapscott the Dragon offeredup his own cash for one proposal.

“Don’t the Dragons get to buy in (onthe TV show)? I’ll give you $10,000,” Tap-scott told a group of presenters during theafternoon session of CAMH’s InnovationExpo in February.

Tapscott, author of 16 books on tech-nology and new economic models, joinedCisco Systems Canada president RolaDagher, Muhammad Mamdani, director ofSt. Michael’s Hospital’s Li Ka Shing Centrefor Healthcare Analytics Research andTraining, and CAMH president and CEODr. Catherine Zahn on a Dragons-stylepanel. They evaluated the proposals of sixfinalists, chosen from among 41 applicantsfrom across CAMH.

The panel chose HOPE, an individual-ized suicide safety plan app, to receive afunding request of $35,000.

The app would incorporate outpatients’written safety plans (a recognized suicideprevention best practice) with smartphoneaccess to Canada-wide resources, Cana-dian content like crisis numbers andCAMH links, and journaling in an always-at-hand format.

The app was proposed by CAMH direc-tor of quality innovation for patient safetyand experience Nicole Thomson, opera-tions manager Tim Rankin, and IT special-ist Gurpal Bubbra.

Future phases of the app would incor-porate mood and medication trackers, ma-chine learning technologies, and deeper

integration with CAMH’s operational sys-tems. The team envisions a resource thatcan be shared among patients, families andtherapists.

“I think you guys are going to make ahuge difference. You’ve also got a lot ofwork to do,” Dagher said. “You should haveasked for more money.”

CAMH Innovation Expo attendeesvoted Data That Heals, a project thatwould leverage existing technology with$100,000 in hardware to bring personal-ized analytics to the inpatient bedside, asthe People’s Choice award winner. Theproposal’s slick and humorous presenta-tion came from behaviour therapists LouisBusch and Mahfuz Hassan and seniorbusiness analyst John Fernandes.

Senior management at CAMH willpitch in to help develop the business casesfor the implementation of HOPE and DataThat Heals.

Take My Photo – the proposal that Tap-scott offered to fund – may have won on adifferent level. The project would bring pro-fessional photography standards to a once-

a-year shoot to replace patient admissionphotos, often taken when people are dis-tressed and dishevelled, with poor lightingand image quality.

That image can influence a clinician whoviews it as a chart picture, and the public ifa photo must be released of a missing pa-tient, said team spokesperson Zeynab Has-san, a clinical informatics nurse. Project an-alysts Matthew Jabile and Kevin Leung werealso on the team.

The photos would integrate with thepatient’s “This Is Me” page which providesmore detailed personal information in I-CARE – CAMH’s electronic health record.

Other proposals included Ask MeKiosks to complement the centre’s wel-come staff (Maxine Rukundo, projectmanager; Alan Tang, web applicationslead); CAMH Coach, a multi-lingual videoprogram for anxiety management andclinician skills development (James Wat-son-Gaze, psychologist); and Spot CAMH,a wayfinding application incorporatingaugmented reality technology (EmilyGrant, senior project analyst; Gurpal Bub-

bra, IT specialist; and Caitlyn D’Souza, co-op student).

The “Dragons’ Den” portion of theCAMH Innovation Expo was a follow-upof sorts to a similar event last year that in-volved only information managementstaff, said Damian Jankowicz, vice-presi-dent of information management forCAMH and its chief information and pri-vacy officer.

The “This Is Me” page that Take MyPhoto was to integrate with was a productof last year’s event.

But innovation doesn’t work best in asilo, so CAMH opened the competition toideas from management, clinicians andoperations management as well.

Jankowicz, who hosted a morning panelon the challenges of innovation in health-care, said while ideas may be plentiful, theyoften aren’t brought to the fore. Instead,we “stew in our own juices.”

“We don’t always progress and imple-ment our ideas,” he said. “Today, I’m hop-ing we can close some of those gaps.”

In fact, “pilot purgatory” is a frequent is-sue for innovation, said panellist LiamKaufman, founder and CEO of WinterlightLabs, whose AI-based technology can de-tect cognitive impairment from a few linesof speech.

People are too comfortable with incum-bent processes and technologies for incre-mental improvements and efficiencies toget user buy-in, he said.

Zayna Khayat, future strategist withhome-care provider SE Health Care, for-merly St. Elizabeth Health Care, defines in-novation as a “next practice” with at least afivefold improvement.

“We have to think way bigger in termsof what we can do,” concurred ShivaniGoyal, lead of strategy and research ateHealth Innovation at Toronto’s UniversityHealth Network.


Healthtech partnered withthe Government ofNunavut for the Terri-tory-wide implementa-tion of a comprehensive

MEDITECH 6.x application suite, alongwith PACS and digital radiography. Thisextensive project included nearly 2,200healthcare providers in hospitals andhealth centres in 25 communities, overan area of more than two million squarekilometers.

As a direct result, Nunavut has en-abled more timely, closer-to-home inter-disciplinary clinical care for all of its37,000 citizens. The project has loweredthe barriers to accessing care and re-duced patient transportation costs – twoissues widely identified as major chal-lenges by all Northern regions.

Nunavut has accomplished its goal ofachieving a Territory-wide electronichealth record, and Toronto-basedHealthtech has been a partner through-out this journey.

A project of this size requires a com-

prehensive, collaborative team.Healthtech was engaged to provide bothimplementation project management andMEDITECH subject matter expertise.

External partners included ChangeHealthcare for PACS, CalicoMedical/Nuon Imaging for Digital Radi-ography, and Dynacare for lab interfaces.Partners in the Government of Nunavutincluded eHealth for application supportand Community and Government Ser-vices to provide both hardware and in-frastructure.

Initially, the project scope only in-cluded MEDITECH foundational mod-ules. However, these modules were sosuccessful that Nursing and PhysicianClinical Documentation were includedas well. These additional modules weresuccessfully piloted in one community,and quickly became part of the roll-outplan to all communities.

The project deployed MEDITECHmodules for iEHR and Teleradiology in astaged approach using the CanadaHealth Infoway Change Management

Framework. The first implementation ofthis comprehensive, integrated systemwas at Iqaluit’s Qikiqtani General Hospi-tal and other clinical sites in Iqaluit. Thenext rollouts were in Cambridge Bay andRankin Inlet, followed by deploymentactivities in 22 other communities. Digi-tal Radiography was also deployed ineach community. MEDITECH’s ARM

module was implemented in Nunavut’sSouthern referral sites to manage med-ical travel outside of the territory.

The project required extensivechange management because it was anentirely new system for the Nunavuthealthcare providers. The team ensuredtheir concerns were addressed prior toimplementation, and staff were fully

supported during implementation. Since the communities are extremely

remote, the team did not have the luxuryof being on-site before implementation.To address this, workflow calls weredone for six weeks prior to implementa-tion, a remote parallel run was donewith an on-site resource, followed by “at-the-elbow” training on-site. This train-ing provided practical approaches andbest practices to healthcare delivery inNorthern communities.

The team of local Nunavut resourcesand vendor partners were exceptionallydedicated to the project, showing the de-termination and flexibility required tocoordinate with team members, and awillingness to express their unique needsand requirements. This was especiallyimportant in what can sometimes be achallenging Northern environment. Fol-lowing each community health centreimplementation, the entire team en-gaged in a debrief to discover new bestpractices and discuss lessons learned,

Nunavut has accomplished itsgoal of achieving a Territory-wide electronic health record,with the help of Healthtech.

Nunavut implements successful iEHR and teleradiology project

Innovation teams at Toronto’s CAMH make their cases to ‘Dragons’

Panelists Rob Meikle, CIO, City of Toronto; SE Health’s Zayna Khayat; Liam Kaufman, CEO of Winterlight Labs.


h t t p : / / w w w . c a n h e a l t h . c o m M A Y 2 0 1 9 C A N A D I A N H E A L T H C A R E T E C H N O L O G Y 7


BY JERRY ZEIDENBERG

ORLANDO, FLA. – An employeeof Sisters of Mercy Health,one of the top five hospitalorganizations in the UnitedStates, used to spend 30

hours a week manually collecting informa-tion for reports. When the I.T. staff atMercy created dashboards and reportingtools that could perform the same tasks inseconds, the employee refused to use them.

“It was a massive cultural change,” com-mented Curtis Dudley, VP of PerformanceSolutions at Mercy, speaking at the recentHIMSS conference in Orlando. “She feltthere had been value in the way she worked,and she needed to understand the new wayof doing things.” It took a while for her tomake the mental shift, Dudley said.

Still, with the right coaching and coax-ing, reluctant staff have made the transi-tion to analytics and dashboards.

Dudley and executives from a numberof large hospital organizations talked abouthow they’re using cloud technologies at theconference, which brought 45,000 atten-dees to Orlando. The presenters all showedhow they were applying analytics to theirreservoirs of cloud-based data.

“We are sharing data using Microsoftand Google [clouds],” commented Dudley.He noted that Mercy, based in St. Louis,employs 44,000 people, has 40 acute careand specialty hospitals, and generates $6billion in revenues annually.

For years, Mercy has been an Epic client,and it produces an enormous amount of

data. Now, it’s all being brought togetherusing an “Explorer” style tool that providesstaff and clinicians with dashboards and re-ports. “The tool has been a game-changer,”said Dudley.

To make things even easier, Mercy hasdeployed natural language processing(NLP) to make sense of the various waysthat employees and clinicians chart or logtheir data. One dilemma the organizationfaced was the differing ways in whichphysicians were charting ejection fractionresults – cardiology data that was capturedin unstructured notes.

“It’s a measure captured in the clinical

note, and it determines whether you’repart of the heart failure group,” observedDudley. “So, did we need to retrain 400doctors to chart in a certain way?”

Instead, the organization created anNLP app that searches the doctors’ notesand extracts the ejection fraction results.“It can even tell if the result is calculatedor estimated.”

The NLP application and medical on-tology was purchased from an outside sup-plier – Linguamatics. “They’ve developed amedical language library, and we’ve foundit to be incredibly helpful,” said Dudley.

NLP is also able to determine the con-

text. For example, shortness of breath issometimes abbreviated as SOB. However,quipped Dudley, “SOB doesn’t alwaysmean shortness of breath,” and the systemhas to be able to tell the difference!

Dudley observed that analytics are be-ing used to solve many problems at Mercy.The shortage of nurses is a constant chal-lenge, he observed, with some 1,400 posi-tions open at any one time. The questionwas, how to attract and retain nurses?

“We did some work to create a predic-tive model,” said Dudley. “We wanted tofind out, who is most likely to turn over intheir first year?”

By analyzing the data, they found outthat overtime is actually an incentive tonurses. “But only to a point. So knowingthat, we’ve been able to work on ourturnover.”

Meanwhile, Rush Health, in Chicago,has put a big push on cloud. “Before 2017,we were doing cloud as a side project,” saidJawad Khan, Director of Data Science andKnowledge Management. “Now, it’s themain project.”

In 2017, Dr. Bala Hota joined Rush asVP and Associate CIO. An infectious dis-eases physician by training, he ushered in acultural transformation at Rush, in whichit is putting a premium on technologicalsolutions to improve patient care. “Wewant to innovate and bring new technolo-gies into the practice of medicine. But ofcourse, we can’t lose focus on the patients.”

The four-hospital Rush Health systemhas already put its data centre into the

Managers from Rush Health told HIMSS19 attendees, in Orlando, that the cloud is now their top IT project.

Cloud processing facilitates the use of analytics at U.S. hospitals

BY IAN MAYNARD

Cloud is key to achieving theefficiency gains needed to re-spond to growing demandson our healthcare system. It

can also help organizations break freeof vendor-induced information silos,and improve collaboration for betterpatient outcomes while reducing overallsystem costs.

Anthos, Google’s multi-cloud solu-tion, now allows customers to build theirown applications and transfer them toany public cloud provider, all withoutchanging a single line of code.

So, what about security? Banks, hospitals and companies from

almost all industries have realized thatthere are no privacy or security issuesthat can’t be addressed. In many cases,cloud solution do it better, because ofthe scale of available resources. Therearen’t too many organizations that canafford 1,000 engineers dedicated to se-curing their infrastructure.

Relative to data encryption, you havethe key to your own security. With en-cryption keys held at your site, or in thecloud, data is encrypted both in transitand at rest.

Now customers control whether any-one in the cloud provider organization

can access their data, even for support ortrouble shooting. If access is granted,you now have full transparency aboutwho within the provider organizationaccessed what data.

For its part, Google announced that itis the first to offer full data access con-trol and transparency. To quote ThomasKurian, CEO of Google Cloud, “Yourdata, is your data and no one else’s.” Sowhy is this important for healthcare? Fortoo long organizations have beentrapped in vendor-induced informationsilos, with information inaccessible tofront-line staff, physicians, patients orcollaborating colleagues.

How can we expect to increase systemefficiencies while remaining constrainedby what systems exist within one organi-zation’s network?

Can we realistically expect to stream-line processes, balance workload and re-duce system-wide costs that way?

Historically, what you could do inpeer review, for example, depended onwhat system you had internally.

Well, no more. Now you can connectwith colleagues across sites, systems andacross the country, to benefit from acritical mass of peer experience in yoursub-specialty, leverage cloud based AIand Big Query to identify patterns, learnof the latest findings, all while helping

you avoid medical errors you may beprone to so as to reduce patient mortal-ity and morbidity.

Now, patients with authenticated ac-cess to their own information, can col-laborate in their own care.

To quote, Alpna Doshi, PhilipsGroup CIO: “AI also means that as apatient you are well informed … so selfmanagement becomes possible.”

Still, what barriers remain? Now that customers have the choice

of full cloud; cloud plus partial onpremise architec-tures (hybridcloud); encryptionkey held on-site, orin the cloud; fulldata access controland transparency;coupled with zerovendor lock; Iwould suggest thatthere are no mate-rial barriers to cus-tomers charting

their own course to the cloud.In fact, I would submit, that

“Achievement of certain system-wideefficiency, capacity increase and costreduction objectives, simply won’t bepossible, or will remain prohibitivelyexpensive and hence unrealized, save

for cloud enabled solutions.” As we all know, either we become

more efficient, especially at scale, or thesystem and its associated costs becomeunsustainable.

What about the nay-sayers? Ah yes, the nay-sayers. They’ve been on

the wrong side of every technical transfor-mation since the invention of the wheel.

You know, when there’s a tidal wavecoming, it really doesn’t matter howmany people decide to stand on theshore shouting at the sea, eventually, re-ality hits.”

Has there ever been a seismic shiftthat could be pushed back into place?Okay, Superman did it once in a movie,but even then, it was too late. Fortu-nately, he could turn back time. Whoknew circling the earth fast enough toreverse its rotation could turn back time.For the rest of us however, turning backtime, just isn’t an option.

Where will this wave find you? Strat-egy mapped out ready to ride, or stand-ing on the shore shouting at the sea?

Ian Maynard is CEO and Co-founder,Real Time Medical. To learn about GoogleCloud + and Real Time Medical’s easilyinterfaced solutions, AICloudWorks™ and AICloudQA™, please see: www.RealTimeMedical.com

Full cloud, hybrid cloud, multi-cloud solutions are now available

Ian Maynard

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What if you could improve diagnostic efficiency and throughput by 25% – 60%?

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All as a compliment to your current systems (EMR/RIS/PACS)

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BY DR . DENNIS DIVALENTINO

HAMILTON, ONT. – The Vir-tual House Call Project wasstarted in 2017 to address asignificant gap in access tocare for patients who are

considered marginalized. For clarity, amarginalized patient is one who cannot re-ceive primary healthcare in a manner thatis appropriate for their disease burden orneeds in general, and consequently ac-cesses ER and hospital services in lieu ofprimary care access.

This is a costly problem for the healthcaresystem and one that produces unnecessarysuffering for patients and their families.

Usually, serious illness can be preventedwith timely access to basic primary careservices. These services are simply not ac-cessible for marginalized patients who ex-perience, in some cases, insurmountablebarriers to healthcare access.

Limited mobility and serious mentalhealth disorders are examples of commonbarriers to healthcare access. These barriersare usually compounded by poverty. Theconsequences range from the delivery ofcare that is unnecessarily excessive in termsof cost, to significant patient and family suf-fering, to premature and unnecessary death.

Our solution: The solution to this con-cern, like many current health concerns,lies in the application of technology. Toreach the group of patients described asmarginalized, my colleague, Dr. RichardTytus and I developed a new tool calledVirtual House Calls.

We were assisted by a $25,000 innovationgrant from Joule, part of the Canadian Med-ical Association; the funding was used to ac-

quire equipment. We’ve shouldered the ad-ditional costs of staff time and training, andthe cost of delivering the service, as Ontariodoes not yet compensate physicians for am-bulatory telemedical services. However, webelieve it is the compassionate thing to do;and as telemedicine proves its worth, wehope the funding situation will change.

The Virtual House Call solution usesvideoconferencing and also employs newperipheral devices that allow providers toconduct more high-level patient encounters,in a virtual fashion, than we ever could be-fore. The provider remains in the office andis available to provide care to other patients.The patient remains in his or her home.

The technology: The goal of a virtualencounter is to best approximate the qual-ity of an in-person encounter, primarilywith respect to the collection of objectiveinformation.

Collecting subjective information re-motely can be done in many ways, includ-ing by telephone. The first version of ourplatform included a Microsoft Surface Protablet, a USB enabled stethoscope and aUSB enabled otoscope/dermoscope.

Several peripheral devices were tried, inorder to determine the best possible devicesfor quality, reliability and interoperability.

The limitations of the devices trialled arediscussed below. The platform is powered bya mobile Wi-Fi stick, such that there are notechnical requirements on the patient end.

In terms of software, several softwareplatforms were tested. The platform thatwe ended up using is called REACTS, aCanadian platform developed by a Mon-treal-based physician named YanickBeaulieu. The REACTS platform is ideal forthis type of service due to its ease-of-use

for both providers, and nurses or aides op-erating on the patient interface.

It has a high level of interoperability, mak-ing it peripheral device agnostic, thus allow-ing greater flexibility with respect to upgrad-ing peripheral devices and improving thequality of objective information attained.

All of the hardware is stored in a mes-senger bag to create the “Virtual House CallBag”. This bag is completely mobile and candeliver care to essentially anywhere.

The service: We first delivered this ser-vice to patients who were identified by casemanagers at our local home care organiza-tion as being marginalized, and thus notreceiving any type of primary care services.

We wanted to target patients who wereknown to be using hospitals for primary

care services. We cared for 20 patients inthe initial pilot.

The “Virtual Bag” was brought to thepatient home by a nurse or healthcare aideat the request of the patient or anotherhealthcare provider or service.

The first pilot conducted was a proof-of-concept and technology. We wanted todemonstrate that the technology could beused to conduct a visit with patients intheir homes, while connected to a remoteprovider, and that this visit would approxi-mate the quality of an in-person encounter.

With some technical limitations, we feltthis was achieved. We also noted an ex-tremely high level of satisfaction from pa-tients and family members or caregivers.

Some patient stories: Some of the pa-tients, and circumstances that we encoun-tered, were quite upsetting, even for us asurban core primary-care providers. Whenwe see patients in our office, we often donot get a full appreciation of the difficultsocial circumstances they face.

We get it intuitively, but often the reality iseye-opening. This project was eye-opening.

We provided care for one patient, Anne,who we met after she was diagnosed withstage 4 cervical cancer. Anne had severeagoraphobia, for which she was not med-icated. She also had bony metastases as a re-sult of her cancer. This is generally regardedas one of the most painful conditionstreated in medicine. Anne was in significantpain, but she could not leave her house.

In her case, the fear of leaving her housewas more significant than the pain that sheexperienced due to her cancer.

Anne was thrilled at the availability of aVirtual House Call. Over many weeks wesaw her several times. We provided herwith pain medication and we managed heranxiety, and she never left her home.

As things progressed, Anne worsenedand she requested to be transferred to hos-pice care, which she noted was somethingshe had wanted all along but was afraid toconsider due to her anxiety.

With proper treatment she became a dif-ferent person. A few weeks later she notedthat her wish was to have a peaceful death inhospice, but her anxiety had precluded herfrom doing that. She no longer felt this way.

Two weeks later, she was transferred to


Patients who have difficulty going to the doctor’s office have been pleased with the Virtual House Call.

Virtual house calls bring care to marginalized patients in Hamilton

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expertise can support your digital healthcare strategy!

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BY GILLIAN WANSBROUGH

Being able to connect with a specialistby video made a world of differencefor Abbi Wright Pereira. It meant no

more driving across the city with a new-born and four-year-old in tow to get care,

and all while potentially feeling dizzy,faint, and as if her “head would explode”.

The 43-year-old Mississauga womansuffered from postpartum hypertensionafter the birth of her second child, whichbrought her to the ER. Following an initialoffice visit, internist and clinical pharma-

cologist Dr. Jeff Alfonsi recommendedweekly video visits, or eVisits, and an appto track her blood pressure.

“It’s great,” says Wright. “It’s virtuallyface-to-face. And I am more comfortable(dealing with this) now – I’m really beingmonitored. I also use my phone to track

my BP and send Dr. Alfonsi the report.And I email him when I have a question.”

Dr. Alfonsi is equally enthusiastic.“Video consultations have made a hugedifference for some patients. Relationshipsare built because you can respond to pa-tients more quickly than would be the caseif you were only scheduling in-office visits.Couple that with the fact that they don’thave to drive to appointments or pay forparking and you have receptive patients.”

Specialist eVisits through the OntarioTelemedicine Network (OTN) are simple:providers simply log into the platform (theOTNhub) and send a secure OTNinvitelink to patients. Patients use the device oftheir choice – smartphone, PC or tablet.

It’s ideal when an in-person physicalexam isn’t needed. Dr. Alfonsi, who hasbeen doing eVisits to the home for about ayear, says other benefits of the modality forhealthcare providers and the healthcaresystem are greater practice flexibility andsaving “inpatient space” for people who re-ally need it. A recent pilot included close to600 physicians providing specialized care.They conducted some 11,000 clinicalevents for which they were able to bill.

A survey showed that more than three-quarters of physicians were satisfied withtheir eVisit experience and that the qualityof care they were able to provide was thesame or somewhat better than an in-officeappointment. Another plus was the avoid-ance of missed/cancelled appointments.

“Patients find it convenient, allowingthem to avoid both travel and having tomake arrangements for their dependents,”said OTN CEO Dr. Ed Brown. “Providersalso see the value of integrating video, es-pecially with respect to follow-up care, pre-operative consults, and periodic check-ins.”

A second OTN-led pilot called eVisitPrimary Care is leveraging virtual care tosupport primary care. It enables patientsto connect with their own family doctorsusing secure messaging, video, or audiothrough one of two platforms co-designedand developed by OTN, participating re-gional partners, and vendors NovariHealth and Think Research.

“We live in an age where everyone ex-pects to be able to manage their livesthrough their smartphone. Healthcare isno exception, though it certainly hasunique considerations given the personalinformation involved,” says Dr. Brown.“It’s exciting to be partnering with careproviders and arming them with the toolsto enhance their practices and, for pa-tients, to improve the healthcare experi-ence and make it easier.”

Through eVisit Primary Care, patientsare conveniently able to initiate contactwith their doctors at a distance for simple,non-emergency, health requests like colds,flu, rash, pink eye, allergies and chronic dis-ease management. Resolution is timely andthe need to come to the office can beavoided. It’s delivered at no cost to the pa-tient and with all eVisit details recorded inthe medical record. “The platform has beenable to help my patients who have difficultygetting to the office, and for some of mypatients who recognize recurring symp-toms that I can address immediately,” saysDr. Nihal El Khouly, a family physician inBolton, Ontario. “I love it!”


Tests of virtual visits show positive results for patients and physicians


BY NEIL ZEIDENBERG

The Centre for Aging + BrainHealth Innovation (CABHI), inpartnership with Mary Furlong& Associates, held its first-ever

What’s Next Canada Conference in March,bringing together experts and thought-leaders in aging and brain health to net-work and discuss current innovations inthe care of seniors.

By 2050, it’s expected that one in fivepeople will be 65 or older. But aging bringswith it chronic conditions, and providingtreatment to such expansive numbers maybe unaffordable without new advances.

“Most people over 65 are living withtwo or more chronic conditions. Andwhile treatment for these patients can becomplex, it also creates a great opportunityfor innovation,” said Mary Furlong, Presi-dent and CEO of Mary Furlong and Asso-ciates, a strategy and business develop-ment company specializing in the boomerand seniors sectors.

Regarding the next big wave in agingcare, experts point to emerging technolo-gies such as smart medication manage-ment, EMR connected technology, robot-ics and virtual reality. They’re also look-ing to AI to help relieve the burden oncaregivers and help them navigate thehealth system.

The conference featured a Pitch Com-petition that included nine innovativecompanies – all with a goal of improvingtreatment and quality of life for seniorsthrough technology. Participants had justfive minutes to highlight their solutionsand impress a panel of six investors – withthe goal of being selected winner of the2019 CABHI Innovation Award or thePeople’s Choice Award.

The panelists were looking for scalableprojects that were relatively low-cost, im-proved quality of care for seniors, and couldbe readily adapted for commercialization.

All participants in the pitch competi-tion are current CABHI-funded projectsand are receiving acceleration services withthe goal of getting their innovations com-mercialized. Acceleration services includeaccess to an advisory panel of experts withlived-in experience in aging and caregiv-ing; business development services, andknowledge mobilization.

The 2019 CABHI Innovation Award was

presented to Darmiyan, an online platformfor the early detection of Alzheimer’s andrelated dementias. Darmiyan is a virtualmicroscope of the human brain, meant toquantify values and provide earlier andmore accurate diagnosis. By using a routinebrain MRI, Darmiyan can predict whetherindividuals with cognitive impairment willdevelop Alzheimer’s. The system is beingtested at Baycrest, UHN, Hamilton Health

Sciences, Sunnybrook and Southlake Re-gional Health Centre.

The People’s Choice Award went to Cat-alyst Healthcare, of Kelowna, BC, for amedication adherence solution. The com-pany aims to reduce the number of inci-dents of patients taking their medicationincorrectly, thereby ensuring medicationadherence. Catalyst Healthcare’s app, calledMyMedTimes alerts patients to take their

meds, and it also connects pharmacists andpatients, providing a real-time communi-cation platform.

Other innovators included:• Linked Senior: A cloud-based resident

engagement solution that offers real-timereports and analytics; it shows care-giverswhat is working for each client, and what isnot. By understanding a resident’s life ex-perience, staff can see beyond a person’smedical needs and develop a more person-centric care plan, including music therapy,brain fitness and sensory activities.

• Motitech: Through the use of video,music and physical activity, Motitech aimsto improve quality of life for seniors bypromoting an active mind and body. Aftersix-months of beta testing, there was a dra-matic reduction in falls, and some clientsin wheel chairs gained back their mobility.Whether combined with or without an ex-ercise bike, seniors can take a trip throughtheir old neighbourhood and reminisce.

• Careteam Technologies: A digital col-laboration platform that helps care teamsfollow up with patients and their families,tracking their progress and keepingeveryone on the same page. The result isbetter communication and improved careprovider experience.

• Memotext: Utilizing an Amazon Echo-type device to provide medication re-minders, Memotext bridges the gap be-tween patient and caregiver. Like a virtualnurse providing patient support, Memo-text checks on medication adherence, andthe patient’s well-being. The result is betterpatient outcomes.

• Intuition Robotics: A friendly AI de-vice, called ElliQ, can connect seniors tofamily; play music, give the weather, mon-itor their well-being with reminders todrink water, exercise and even providecompanionship. Beta tested with 100 el-derly adults, it can integrate with tele-health. ElliQ is meant to supplement, notreplace human interaction.

• InteraXon: An application that uses neu-rofeedback technology, via a headband, todetect and measure an individual’s brainsignals during meditation. InteraXon aimsto explore what’s happening in a person’shead to help improve well-being.

• RetiSpec: Transforming Alzheimer’sscreening in the blink of AI. The applicationaims to provide intervention of brain dis-ease before symptoms begin to appear.RetiSpec is a simple eye test that doesn’t useeye drops, and has been clinically tested on31 patients in the early stages of Alzheimer’s.It works by detecting Alzheimer’s biomark-ers prior to patient diagnosis.

Graeme Moffat, Chief Scientist at Inter-aXon, believes one of the challenges ofbringing a device to market is taking it fromconsumer to clinical usability. In an idealecosystem, there is a rapid adoption of solu-tions so it’s important to bring the right so-lution to market. “We need to get the tech-nology prototype in front of the user, andget real world response and evidence beforereleasing it to the mainstream.”

Ane Solesvik Oppedal, CEO of AblyMedical Inc., agreed, and added “As muchas people would like us to get it to marketquickly, it’s even more important we doour due diligence, and test it properly be-fore bringing it to market.”


Top photo, L to R, Dr. Allison Sekuler, Managing Director, CABHI; Mary Furlong, CEO, Mary Furlong &Associates; Teresa Pitre, GM, Pack4U Ontario representing Catalyst Healthcare; Mel Barsky, Director, BusinessDevelopment, CABHI. Bottom photo, L to R, Dr. Allison Sekuler; Mary Furlong; Dr. Kaveh Vejdani, ChiefMedical & Technology Officer, Darmiyan; Mel Barsky.

What’s Next Canada conference highlights innovations for seniors

Microsoft Azure cloud. To do this, it re-trained its entire I.T. team in cloud tech-nologies. “Instead of hiring, we trainedour existing people,” said Khan.

As with Mercy, the use of analytics inthe cloud is a major focus at Rush. It,too, is working to make sense of un-structured data in the records to im-prove performance and outcomes. Inone use case scenario, Khan highlightedan effort to ensure that patient historieshad been completed before surgeries.“It’s a requirement that a patient has

this done 30 days prior to surgery. Ifnot, the surgery is cancelled.”

Cancellation is very disruptive forboth patients and staff, so a drive wasmade to build a Deep Learning modelthat reads the patient notes and deter-mines whether all of the needed data ispresent.

“We’ve got it to a 95 percent accuracyrate,” said Khan. “With this tool, we cancall patients beforehand and address theissue.” And the application only tookfour months to build, he said.

Finally, Dr. Ashish Sharma, an Assis-tant Professor at the Department of

Biomedical Informatics at Emory Uni-versity, discussed how he and his col-leagues have devised a system to predictthe onset of sepsis in patients four toeight hours in advance of its onset. “Thesystem is a second set of eyes for thephysician,” said Dr. Sharma.

Called Deep AISepsis Expert, orDeep-AISE, the system is Google Cloud-based. The developers have been earlyusers of the Google Healthcare API andHL7 FHIR. He explained that sepsis af-fects 30 million patients worldwide an-nually, with 1 million in the UnitedStates stricken each year.



Cloud storage and processing ease the use of analytics

cerner.ca @CernerCanada

Working together to improve health and careCerner is proud to work with the Centre for Addiction and Mental Health (CAMH), Canada's leading mental health hospital. In 2018, CAMH received the HIMSS Davies Enterprise Award for using health information and technology to substantially improve patient care using Cerner Millennium® infrastructure.

Among other improvements, Millennium – branded locally as I-CARE – also enabled CAMH to improve medication safety for patients with schizophrenia, to improve medication reconciliation for all patients upon discharge from hospital, and to streamline the provision of opioid withdrawal therapy.

Cerner is proud of the ongoing value we are providing to CAMH patients and clinicians.


BY JERRY ZEIDENBERG

lberta physicians have been able touse the province-wide, electronic

health records network – calledNetcare – as an effective tool for

combatting the opioids crisis for severalyears now.

Dr. Allen Ausford, an Edmonton familyphysician and clinical professor of medi-cine, discussed ways in which he has usedthe Netcare system for this purpose, andfor making better diagnoses of patientproblems, in general.

In one instance, Dr. Ausford was cover-ing for a colleague when a patient asked foran opioids prescription renewal. The pa-tient was normally seen by Dr. Ausford’sclinic partner, who was away on vacation.

By checking into the provincial EHR,Dr. Ausford was able to see the patienthad been seeking and obtaining opioidsfrom several different physicians andpharmacies.

He then asked the patient to come in fora chat, and upon further discussions, dis-covered the woman was actually beingstrong-armed by her boyfriend to obtainopioids, as he was selling them on the street.

“She wasn’t an abuser, she was beingabused,” said Dr. Ausford.

He was then able to obtain the appropri-ate help for the woman – rescuing her froman abusive relationship, and eliminating anillicit source of opioids from the streets.

Dr. Ausford was recently at the HIMSSInternational conference in Orlando, Fla.,where he gave presentations about Netcareand its usefulness for Alberta’s physicians.

He noted that the Health InformationExchange software in Netcare aggregatesrecords from many different sources andpresents them to clinicians in a user-friendly way. Currently, users of the systemcan see the records of 96 percent of all dis-pensed medications in the province; 92percent of all lab tests; and 92 percent of allradiological images and reports.

A new project, expected to beginshortly, will add parts of the EMR recordsof family physician offices to Netcare, in-cluding a new Community Encounter Di-gest (CED). The CED report includes pa-tient visit information including birthdate,gender, clinical assessment, and observa-tions (allergies, blood pressure, height,weight, etc.), immunizations and referrals.

Alberta is in the midst of a conversion ofits hospital electronic records to the Epicclinical information system. Some generalpractitioners, including Dr. Ausford, alsouse Epic ambulatory in their offices,though many community doctors use sys-tems from Telus, QHR and Microquest.

Netcare is already an enormous help inthe care of Dr. Ausford’s patients.

He observed that on one typical day inFebruary, he saw 24 patients at his clinic.For six of them, he used Netcare to makedecisions that were actually different thanif he had used his EMR alone.

He also gave the example of an Edmon-ton patient who had sudden onset ofshortness of breath while skiing in Can-more, Alberta. The patient was taken forcare to Foothills Hospital in Calgary,where he was given a CT scan. A blood clotwas found on the lung, and the patient was

soon able to be transferred back to an Ed-monton hospital.

“The CT in Calgary showed a bloodclot, but the radiologist later added an ad-dendum in the report, stating there was atumour, as well,” said Dr. Ausford. That ad-dendum was sent to the Calgary physiciansbut not to the Edmonton physicians. “Wewere able to discover this by checking thereport on Netcare”.

“Because of that, we were able to starttreating him for the tumour,” he said.

Dr. Chris Hobson, medical advisor withOrion Health, the supplier of the softwaresolution, noted that more than 120 differentsystems have been integrated into Netcare.

Because the system is used in healthcaresettings around the world – including theCleveland Clinic, in the U.S. – the companyhas devised methods of quickly patching indifferent applications.

“We can do them in three weeks, threedays or sometimes, three hours,” said GaryFolker, executive director of Orion Health.

In Alberta, the system is now being usedfor e-referrals from GPs to specialists, med-ication reconciliation during transitions ofcare, and tracking of allergies. It includesfeeds from pharmacies, labs and hospitals,as well as long-term care and home care.

Dr. Ausford said the system has been es-pecially useful with new patients, includingthe elderly, who often can’t remember thenames of the medications they’re taking.

“They often come in and say they’re ona green one or a blue one,” quipped Dr.Ausford. But by using Netcare, he can seeexactly what they have been prescribed.

“With a new patient, the first thing I dois a Netcare review,” said Dr. Ausford. “Onepatient told me he was on a few medica-tions. When I looked in Netcare, I saw hewas on a lot more than that, and had justhad a few hospital visits, too. He hadn’tmentioned that.”

He can also see if they are properly tak-ing medicines. For example, he may see apatient’s last prescription for a regularmedication was a three-month supply thatwas dispensed five months ago. In this way,it’s helpful with tracking compliance.

SIOUX LOOKOUT, ONT. – As theLab Manager for Sioux LookoutMeno Ya Win Health Centre(SLMHC), Brenda Voth under-stands the pressure to deliver

timely and decisive lab results, just oneof the many demands of an acute carehospital lab.

So, when leading life science companyBio-Rad Laboratories Limited approachedthe Kenora Rainy River Regional Lab Pro-gram with an opportunity to pilot the firstversion of their risk management software– designed specifically to meet these needs– Voth and the five other regional labmanagers jumped at the chance.

“At that time in 2015, no other NorthAmerica labs had ever used theMission:Control software, so it was quitean opportunity for our area labs,” saidVoth, who anticipated immediate benefits.“Deciding what quality control rules touse is a time-consuming and sometimesambiguous process, often left to the labmanager or senior technologist. I felt that,if it worked as promised, Mission:Controlcould relieve that added workload.”

As it turned out, the software exceededher expectations. Its ability to eliminatefalse rejections saved the equivalent ofaround two weeks of full-time work peryear, according to Voth’s estimates.

The time saved from troubleshootingwas a boon for her department. Moreimportantly, the decrease in trou-bleshooting allowed patient results to bereleased consistently quicker.

Voth explained that if the quality con-trol passes and no troubleshooting isneeded, then the result can be releasedimmediately, in some cases 10 to 20minutes earlier because of theMission:Control software.

Voth pointed out what she sees asMission:Control’s greatest benefit. “Theway it constantly pulls the data and doesbehind-the-scenes calculations decreasesthe likelihood of sending out an incor-rect patient result. That’s the most im-portant part of the software-total riskmanagement for patient care.”

Recognizing her aptitude for the soft-ware, Bio-Rad later decided to beta testthe next version of Mission:Controlsolely with Voth and her SLMHC labteam starting in early 2018.

“It was a natural next step to inviteBrenda and her team to participate in theMission:Control 2 Early Adopter pro-gram,” said Kevin Koole, Business Man-ager for Bio-Rad. “Brenda is herself achampion and ‘super-user’ ofMission:Control, regularly evaluating riskperformance as part of on-going lab op-

erations, but also providing Bio-Rad withfeedback and suggestions for improve-ment. She and the SLMHC team haveuncovered efficiencies that will allow staffto better understand complex qualitycontrol rules as well as run the appropri-ate amount of daily quality control.”

Last October, Bio-Rad sent Voth tothe Quality Control Summit in Beijing,China to share SLMHC’s experiencewith its leading-edge software.

Voth estimated there were around 200lab managers and directors in atten-dance, which was much larger than what

she had initially anticipated. Regardless,she went into her very first summit pre-sentation undaunted. While toting thesoftware’s benefits, Voth also acknowl-edged that the SLMHC lab was the firstlab in North America to pass accredita-tion with this software in place.

“The accreditors had never seen theprogram before, but I reviewed it withthem and they agreed that it completely

complies. The fact that assessors are nowfamiliar with Mission:Control can giveother labs confidence to implement thesoftware themselves... It’s nice knowingwe are pioneers in that.”

Koole acknowledged how Voth’s in-formative presentation helped stimulateinterest in the software and inspired theaudience. “Brenda spoke of her successin using Mission:Control to turn statis-tics into actions that improved lab effi-ciency, quality, and speed-all of whichimproved patient care. It’s a real Cana-dian success story.”

SLMHC President & CEO HeatherLee further extolled the lab manager’s ef-forts. “Brenda is a leader in her field. Be-ing asked to present her findings to fel-low healthcare professionals halfwayaround the world is testament to that.She committed herself to improve thequality of services we offer at SLMHC,and she did so by teaming with fellowleaders in the field-milestones in bothinnovation and collaboration.”

“I am fortunate to work for an orga-nization that values innovation andpartnership,” said Voth. “Together, wework with our partners to offer the bestand newest technologies available. Beingremote doesn’t mean we should go with-out. All our patients deserve the best.”

Meno Ya Win Health Centre implements new risk management software

Netcare province-wide EHR helps Alberta docs fighting opioids crisis

The lab software helped withquality control, and saved theequivalent of two weeks offull-time work per year.

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they want to achieve clinical excellence intheir hospitals. A model like this has neverreally existed before.”

Cole is extremely pleased with the result.“INFRAM gave us a great opportunity tohave a third party come in and give an ob-jective point of view of where Markham’sinfrastructure was to date,” he says. “Itprovided a strong starting point, showcas-

ing where we were at the time and what weneeded to do to craft tangible steps todrive forward.

“In addition, it gave us a succinct snap-shot not only of our HIMSS (EMRAM)score, but also of where we stood aroundsecurity and stability. Using it, we wereable to easily communicate with our lead-ership team.”

Cisco continued to work with Cole andthe IMIT team on the infrastructure design,at which point they brought in TELUS as atechnology partner to provide the equip-

ment needed to build the new foundation. Cisco worked with TELUS on a com-

plete redesign of the hospital’s networklayer, wireless infrastructure, data centreand security. TELUS was responsible forthe network access control, firewalls, LANand wireless LAN, cabling, racking, stack-ing and mounting of equipment, as well asall networking configuration.

“TELUS’ role was to hone Cisco’s designand make it more specific to MarkhamStouffville’s needs,” says Cynthia Esnard,Healthcare Account Executive with TELUS

Business Solutions. “It’s our job to imple-ment that design and establish a partner-ship going forward to continue to assistthe hospital in reaching that higher IN-FRAM level. Ultimately, we are the enablerof the foundation for the recommenda-tions resulting from INFRAM.”

Markham Stouffville now has aroadmap to become one of Ontario’s lead-ing digital hospitals. Some of the areas thatwill be focused on in the near future in-clude cybersecurity and an upgrade in col-laboration tools.

“This has been a crucial step in elevat-ing Markham Stouffville’s digital transfor-mation journey to the next level,” saysCole. “Over the next few years, we can startmapping out projects to improve the pa-tient experience and enable our providersto deliver even better care.”

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Markham StouffvilleCONTINUED FROM PAGE 4

which added to the success of subse-quent implementations.

Project management was key toproject success. With challenges suchas multiple partners, weather andequipment delays, and transient staff,the project required a significantcommitment, strong attention to de-tail, and perseverance. Weekendtravel was often necessary, and signif-icant weather delays were sometimesunavoidable.

Another major project success fac-tor was ensuring knowledge transferafter each community health centreimplementation. At the larger healthcentres, a Nunavut eHealth memberprovided a day of crossover trainingfollowed by in-person support dur-ing the entire second week.

For the smaller healthcare centres,knowledge transfer was done byphone, followed by daily check-ins toensure staff were comfortable sup-porting the site. The project managerand subject matter experts playedmentorship roles and were alwaysavailable to eHealth staff.

The project has met or exceededadoption targets in all categories.Each of Nunavut’s nearly 2,200healthcare providers is using thetechnology in their community caresetting and across the vast and re-mote geography of Nunavut. Digitalradiography report turnaround timeshave been reduced from eight days tojust two days or less. And the integra-tion with Dynacare (a southern part-ner) has allowed faster laboratory re-porting.

The new, comprehensive Elec-tronic Health Record has enabledNunavut to support patient-centeredcare for all Nunavummiut. Clinicalcoordination and communicationbetween all healthcare providers hasbeen greatly enhanced.

The Territory-wide electronichealth record has been Nunavut’slargest healthcare project. Without thededication of the team and all part-ners, it would not have achieved sucha successful outcome or provided suchsignificant, measurable results.


Nunavut implementssuccessful iEHR


P R E C I S I O N M E D I C I N E

BY MORGAN DONALDSON

On the 15th floor of 150 Yorkplace in downtown Torontosits a patient awaiting her an-nual health assessment at Med-

can. This year, she will get something newas part of her assessment – information onhow her DNA may affect her response tomedications.

A fixture in the community for over 25years, Medcan provides a range of innova-tive health services for individuals, em-ployer groups, executives and their fami-lies. Among the many services available toclients at Medcan is pharmacogenomic(PGx) testing: the profiling of one’s DNAto more accurately predict their responseto a medication and to reduce the risk ofan adverse drug reaction (ADR).

Since 2016, Medcan has partnered withMinneapolis-based startup OneOme, toprovide clinically actionable PGx testing totheir patients. OneOme’s RightMed com-prehensive test, co-developed with MayoClinic, analyzes a patient’s DNA and pre-dicts how they may respond to more than300 frequently prescribed medications:from common analgesics to anti-depres-sants, statins and anticoagulants.

There are an estimated 200,000 adversedrug reactions and 22,000 fatalities as a re-sult of ADRs in Canada each year, accord-ing to Adverse Drug Reaction Canada(adrcanada.org). Adverse drug reactionscan manifest as uncomfortable side effectsin cases where a patient is not clearing amedication fast enough, or, they can man-ifest as a lack of therapeutic response, inpatients who report that their medicationjust doesn’t seem to be working.

Many factors can contribute to the de-

velopment of an adverse drug reaction, in-cluding: age, number of concurrent med-ications, liver function, gender and regi-men adherence.

However, none are as significant as anindividual’s pharmacogenomic profile,which studies suggest can account for up to90 percent of an individual’s response to amedication. In other words, the RightMedtest allows physicians to greatly increasemedication safety for their patients.

At Medcan, clients routinely opt intoPGx testing in order to optimize theirmedication management and to reduce therisk of unwanted side effects.

As of March 2019, several hundred pa-tients had received PGx testing throughMedcan’s various health management pro-grams. When looking at medications thatthese patients were already on, it wasfound that approximately 40 percent had a

gene-drug interaction identified by theirRightMed test results – meaning the DNAof these individuals may adversely affecthow they metabolize a medication theywere already prescribed.

“The addition of pharmacogenomictesting to our health management pro-grams has armed our physicians with anadditional tool to help make more in-formed prescription choices for ourclients,” says Dr. Jason Abrams, AssociateMedical Director at Medcan.

The RightMed comprehensive test isn’treserved for the lucky few. In fact, thecompany’s mission is to provide cost-ef-fective pharmacogenomic testing andmedication optimization tools for health-care providers and patients worldwide.OneOme most recently partnered with anAlberta-based medication therapy man-agement startup, GenomeRx, to make the

test available to Canadians through theircommunity pharmacies.

“We chose the RightMed PGx test be-cause it is backed by the most rigorous clin-ical evidence and because the RightMedAdvisor platform is so intuitive to use,” saidStephen Williams, founder of GenomeRxand owner of Apollo Clinical Pharmacywhere the test is sold. “Using the RightMedtest, we have been able to optimize medica-tion management for many patients, espe-cially those with psychiatric conditions,pain, or gastrointestinal conditions.”

Through the GenomeRx network of af-filiate pharmacies, Albertans can now or-der the test from their local pharmacy,where trained clinicians can provide pa-tients with a consultative review of theirtest results and explain the impact to theircurrent medication regimen.

OneOme, named by Fast Company asone of the 50 most innovative companiesin the world in 2018, is determined tomake pharmacogenomic testing the stan-dard of care in hospitals and health sys-tems around the world. With several toptier clinics and hospitals like Mayo Clinic(USA), St-Catherine Specialty Hospital(Croatia), Tucker Medical (Singapore),and GenoMedik (Mexico) already usingthe RightMed test, the company is rapidlyexpanding its global footprint.

In 2019, OneOme plans to continuegrowing its medication optimization plat-form with seamless EHR integration solu-tions and risk stratification tools in orderto help enhance the adoption of pharma-cogenomics globally.

Morgan Donaldson is Director of Interna-tional Business Development for OneOme.She is based in Ottawa.

Personalized prescriptions help Canadians get more from their meds

BY JOEL DIAMOND, MD

Today’s healthcare profession-als are witnessing a rareevent: The rapid and dimen-sional change in how health-care is practiced.

The force driving this change? Atsunamic shift from trial-and-errormedicine to precision medicine poweredby discoveries in genomic science.

Few advances have captured the at-tention of the healthcare community(and, even more significantly, the health-care consumer) than the opportunity toleverage genetic and genomic insights toguide better diagnosis and treatment.

More than a year ago, the PersonalGenome Project Canada publishedresults of a study in which 100 percentof participants recognized the impactof pharmacogene variants, carrierstatus for recessive alleles and/or copynumber variants on their health andwellbeing – an astounding level ofawareness.

Researchers also reported they identi-fied genomic variants with potential im-plications for health management in a

full 25 percent of the participants – im-plications not only for the individualsstudied, but also for their families andfuture generations.

It’s clear that, when extrapolatedacross the patient population of thetypical health system, the impact ofgenomics on disease prevention andtreatment optimization could bemomentous.

Precision medicine is gainingtraction. In the months since the studywas published, my colleagues and Ihave seen a marked uptick in interestin precision medicine – specificallyrelated to pharmacogenomics and,somewhat surprisingly, among mid-sized organizations in addition to largeacademic centres. Contributing factorsappear to be:

• Commercially available genetic tests,which have fanned consumer interest.Increasingly, patients are approachingprimary and specialty care providers toask about how genomics might improvetheir care.

• Availability of new clinical ap-proaches that empower individualproviders. In this era of burnout and

disillusionment, physicians feel ener-gized by genomic insights they canleverage with patients in real time. Onephysician told me genomics was “mak-ing medicine fun again.”

• Research advances – and consequentregulatory approvals – driving adoptionof targeted molecular therapies for treat-ment of diseases like cancer.

Still, barriers toadoption remain.Our challengenow is to harnessthe potential rep-resented by recentfindings (andgrowing clinicalinterest) andleverage them indaily medicalpractice. One ofthe most signifi-

cant barriers, according to providersacross the industry, is making this criti-cal information actionable at the pointof care.

To date, results of genomic testinghave been difficult for clinicians to ac-cess in a meaningful way. Often, results

generated by molecular labs are deliv-ered on paper or in pdf, which preventsthem from being integrated with clinicalinformation or stored as discrete datafor optimal utility.

Nor are genomic data and analysisreadily available within the EHR work-flow, impeding providers’ ability to con-veniently factor crucial information intotheir clinical decision making.

To overcome these barriers, forward-thinking healthcare leaders are adoptinginformatics and data managementstrategies to ensure their organizationscan maximize the value offered throughgenomic advances.

Rather than looking at specialty-spe-cific software (e.g., oncology genomicsor pharmacology-only tools), they seekplatforms that offer the potential foradoption across their entire enterpriseand deliver functionality that can adaptto future scientific discoveries and clini-cal applications.

Plus, they require solutions capable ofingesting data from multiple lab sources,integrating these insights with clinicalinformation, and delivering the resulting

How care providers can maximize the benefits of genomic knowledge

Joel Diamond


h t t p : / / w w w . c a n h e a l t h . c o m M A Y 2 0 1 9 C A N A D I A N H E A L T H C A R E T E C H N O L O G Y 1 9

BY DR . SUNNY MALHOTRA

rtificial intelligence is a field of computerscience whose goal is to mirror humanthought processes and our learningtechniques.

AI has many forms, many of whichare being applied to healthcare soft-

ware, including systems for psychiatry, schedulingand radiology, to name but a few. The use of artificialintelligence will never replace healthcare profession-als, but the various forms of technology can changehow we manage our services by improving waittimes and health outcomes.

Time is an important performance indicator inclinical care. Universal healthcare is part of funda-mental care in Canada, but there are issues with ac-cess to care, which have contributed to increasedemergency room hospitalizations.

Same day or next day appointments are difficultto obtain, leaving patients with few options. Variouscompanies have tried using statistical methods to es-timate delays that can occur in appointments, butthese methods have not been able to lower the aver-age waiting time below 45 minutes in a busy clinic.

Research has found that more than 60 percent ofpatients find that the wait in the lobby is the mosttaxing part of going to the doctor!

Adopting artificial learning techniques has provento be beneficial in reducing clinical wait times. Deeplearning techniques, which are a subset of machinelearning, can be designed to improve efficiency.

These techniques use a pool of data to train an al-gorithm, which is then able to determine which is theoptimal output. Depending on the patient, data fromblood pressure readings, lab results and doctors’notes can be available.

In deep learning, different forms of data can berun through models, which are able to detect specificpatterns. For example, a deep learning system can be

designed to detect factors that influence wait timesand optimize for them.

Software programs are currently being designedand improved for scheduling appointments to re-duce wait times. One such example is seen in StrongMemorial’s emergency department in Rochester,New York. A program called On-Cue works to adjust

schedules for many procedures in the emergency de-partment, inpatient and outpatient clinics, with itsmain goal to decrease wait times for patients.

On-Cue has the ability to include many factors intoits algorithm when scheduling procedures, includingthe need for contrast fluids before getting a test done.

This allows for schedules to be adjusted as thetimeline shifts and as new requests come in.Strong Memorial Hospital has six scannersin operation that are divided into threerooms, each spaced a considerable distancefrom each other.

Before the hospital adopted On-Cue,communication between staff memberswould be through rushed phone calls and

non-streamlined communication. With the use ofthis program, communication has improved drasti-cally, as staff members are able to view each scannerthat is in use on their screens and are even alertedwhen a scanner is free, should a request come in.

Technicians are also able to chat with each other be-tween rooms with a messaging system while also writingout notes about the patient. This allows for a much moreefficient system throughout the hospital, improving waittimes for scheduled patients as well as emergent cases.

A technology company located in Quebec has de-signed a program that can cut wait times in doctors’clinics to less than 20 minutes.

Bonjour Sante is a company that overlooks book-ings for more than 300 clinics throughout Quebec.Bonjour Sante has paired up with Montreal’s flagshipartificial intelligence lab to create a sophisticated al-gorithm that can predict delays. The program looksat prior appointments and at factors such as the cur-rent weather or prior patterns of the doctor beingdelayed.

The software can send out a personalized SMStext message two hours before the scheduled ap-

pointment time, informing the patient whenthe doctor will be able to see them. This cuts down waiting times and makesclinic visits more efficient. The ability ofthese programs to detect specific patternsand to decipher through a large collectionof data can improve diagnosis speed while

also reducing wait times, improving healthoutcomes and decreasing cost.

To be sure, artificial intelligence is con-tinuing to evolve and is being imple-

mented universally. By creatingnew associations betweendata, it’s helping to solvehealthcare problems andimprove the quality of careprovided.

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AI solutions are already in use, improving care delivery in hospitals and physician practices.

Cutting down on wait times by using artificial intelligence

Dr. Sunny Malhotra is a US trained sportscardiologist working in New York. He is anentrepreneur and health technologyinvestor. He is the winner of thenational Governor General’sCaring Canadian Award 2015,NY Superdoctors Rising Stars2018 and 2019. Twitter: @drsunnymalhotra

By creating new associations betweenvarious types of data, AI is helping tosolve healthcare problems and improvethe quality of patient care.

More ambition is needed in healthcare procurementBY DENIS CHAMBERLAND

In an earlier column I mentionedthat the Council of AcademicHospitals of Ontario (CAHO) is-

sued a publication intended to de-bunk what it calls ‘myths’ in procure-ment. In The Art of the Possible: AQuick Reference Guide to OntarioBPS Procurement Myths, CAHO clar-ifies and explains 16 points relating toOntario’s BPS Procurement Directive,with the stated goal of removing “ma-jor barriers to innovation adoption”.

In other words, according toCAHO, the procurement rules inOntario are shrouded in so manymyths that hold back innovation inhealthcare.

CAHO formed the view that bar-riers to innovation abound in pro-curement based on a survey it con-

ducted in 2016, where apparently76% of hospital respondents identi-fied policies, directives and procure-ment rules as barriers to innovation.

To address such barriers, CAHObrought together a group of myth-busting experts to write a referenceguide designed to help unleash newlevels of innovation in healthcareprocurement. The task was not aneasy one: the myth busters wouldalso offer strategies to overcome bar-riers while complying with the vastregulatory framework that informshealthcare procurement in Ontario,including the BPS Procurement Di-rective, all applicable legislation, aswell as the domestic and interna-tional trade agreements.

Though not mentioned explicitlybut obviously included in the com-pliance exercise was the mountain of

court decisions that inform health-care procurement in Ontario.

Point no. 12 is representative ofthe guide’s 16 points, as it tackles thelong-standing belief in Canada that

the public sec-tor is not al-lowed to nego-tiate with ven-dors. Theguide goes onto point outthat a healthsystem is per-fectly entitledto negotiate“with a suc-cessful propo-

nent” provided the intent to negoti-ate is expressly noted in the bid calldocument (i.e., RFP). This is abouttransparency (as in ‘open, fair and

transparent’). The rules of the com-petition must be accessible upfrontto those who want to know.

There is no legal basis, however,to the statement that negotiationsare only allowed with a single party,the “successful proponent’, as theguide suggests.

The Directive does not bar con-temporaneous negotiations with twoor more bidders, which consistentlygenerates much more value from theprocurement process than singlingout the top-ranked proponent(which only becomes the “successfulproponent” after contract execution).

Contemporaneous negotiationsobviously tax a health system’s re-sources but the added measurablevalue that the ongoing competitivetension between the proponents


Denis Chamberland

A


V I E W P O I N T

BY JERRY ZEIDENBERG

ORLANDO, FLA. – It drives PeterBak nuts when hospitals touttheir HIMSS Analytics EM-RAM scores and make reach-

ing Stage 6 or 7 the object of their I.T.strategies.

Not that he’s against the EMRAM pro-gram. It’s just that he believes there’s more tohealthcare I.T. than dreamt of in the HIMSSAnalytics philosophy. “EMRAM doesn’tcover what’s going on, above and beyond thepatient charts,” he said. “It’s limited.”

Bak, CIO with Humber River Hospitalin Toronto, gave an interview to CanadianHealthcare Technology while at the annualHIMSS conference, in Orlando.

For its part, Humber River Hospital –which calls itself North America’s first ‘Dig-

ital Hospital’ – re-cently invested in apredictive analyticsCommand Centre.It presents real-timedata on screens atthe front of theroom, called tiles,and alerts the staff iftoo many patientsare waiting for carein the ED, if thereare delays in diag-

nostic tests for patients on the floors, and ifpatients are waiting to be discharged.

Once they are apprised of these delays,staff in the Command Centre can providesolutions. That’s made the hospital muchmore efficient. Since its opening at the endof 2017, the Command Centre has led tothe creation of 23 “virtual beds”, whichmeans extra capacity for the hospital with-out the cost of extra nurses or staff.

Yet, this kind of project isn’t part of theEMRAM ladder.

“Where’s the Command Centre in theEMRAM score?”, asks Bak. “It’s nowhere.”

Another example: outside of each pa-tient room at Humber River is a large-sizedcomputer monitor and a supply cabinet.

The computer screen is connected tothe patient electronic chart, and it displaysicons of note to the nursing staff. So, if thepatient has special needs or conditions,like an infection or risk of falls, the nursesees a warning right away.

Moreover, if there is a particular pre-caution that requires gloves or gowns, asindicated on the monitor, the nurse does-n’t have to trek to a supply station – thesupplies are right there, in the cabinet.

“This saves time for the nurse, andsaves steps,” commented Bak. “And it’s notin EMRAM.”

Neither are the integrated bedside ter-minals that are used throughout the hospi-tal. They enable the patient chart to be dis-played, and also connect the patient with anurse, when needed. They allow the pa-tient to control the lighting in the room,temperature and window shades, and alsooffer entertainment services.

They contribute to both better patientcare and patient satisfaction. “But they’renowhere in EMRAM,” reiterated Bak.

He observed that lab orders, which usedto take two to four hours of turnaroundtime in the old hospital, are now com-

pleted in one hour, with zero labelling er-rors. “This is what digitalization is allabout, and it’s not in EMRAM.”

Bak said that planning for I.T. shouldstart with the healthcare and administra-tive improvements an organizationwishes to make; it should then acquire the

right technology to achieve these goals.In the case of Humber River Hospital, the

planning started with a strategic vision thatincluded the elimination of “never events”.These are medical errors or adverse eventsthat experts say should never happen.

The Canadian Patient Safety Institute says

they include surgery performed on the wrongpatient or body part; the wrong tissue ofblood type given to a patient; an unintendedforeign object left in a patient after a proce-dure; patient death or serious harm as a resultof pharmaceutical errors; and several others.

Humber River goes beyond EMRAM to achieve better patient outcomes

Peter Bak



BY DIANNE DANIEL

When a zero-day virus hitHealth Sciences North in Sud-bury, Ontario, earlier this year,HSN and 21 hospitals puttheir main electronic medicalrecords on downtime to avoid

further contamination. No data was corrupted andthere was no privacy breach, but it did lead to a slow-down in a number of departments until the issue wasresolved four days later.

In May 2017, the National Health Service in Eng-land was hit by WannaCry, a virus that encrypts dataon infected computers and demands a ransom pay-ment to allow users access. It was the largest cyberattack to affect the NHS, resulting in the cancella-tion of thousands of patient appointments and sur-gical procedures.

And on Boxing Day, 2018, Seattle’s University ofWashington Medicine in Washington became awareof a vulnerability on a website server that made pro-tected files available and visible by Internet search.Though there was no evidence of misuse or at-tempted use of the information, letters were distrib-uted to approximately 974,000 patients to alert themthat files containing their names and medical recordnumbers had been compromised.

The list of events like these will go on, say se-curity experts. From ransomware attacks toserver misconfigurations and unpatched pro-grams, the threat of new vulnerabilities is ever-present in healthcare.

“Security is never 100 percent solved,” says JoshWood, solution lead, Security, at Compugen Inc., anIT solution provider based in Richmond Hill, On-tario. “It’s a treadmill where you’re always moving,trying to work to a better position.”

According to PricewaterhouseCoopers (PwC),healthcare is a greater target than other industry sec-tors because personal health and research informa-tion is deemed such a high-value commodity. Healthsystems are also increasingly interconnected, mean-ing more people have access to networks from allover, which in turn poses greater risk.

In 2017, PwC assessed the cybersecurity readinessof a sampling of Ontario healthcare organizations bysimulating techniques used by attackers. Not surpris-ingly, they were able to access sensitive informationwithout being detected. Based on their analysis, theyrecommended that organizations take five steps to-wards cybersecurity resilience: develop a risk-in-formed cyber strategy; actively monitor systems; im-prove security awareness among staff; discover andact on vulnerabilities; and, engage leadership.

In short, healthcare organizations need to developa culture of security which must be accepted andadopted at all levels, says Wood. “You can’t just havesilos of security,” he says. “Security has to be man-aged right across your organization, from the personat the front door all the way to the person at the backof the building and everyone in between, includingthe doctors, the surgeons, the admin staff and IT de-partments. They all have to be aware of security andthe potential breaches.”

Compugen security solutions focus on eliminat-ing both internal and external risk. Not long ago, saysWood, it was normal for new iterations of securityproducts to arrive on the market every two to three

years. Today, major revisions are coming out everythree to six months.

“The core problem is customers need more secu-rity than they think they can afford and they need toimplement it more quickly,” he says, noting that theshortened timeline is in direct response to the in-creased velocity and complexity of attacks.

“At the moment, the skills of attackers are gettingbetter faster than many companies can adapt to theattacks,” adds Wood. “There’s always going to besomeone out there looking for your vulnerabilities. Ifyou’re not locking your doors, watch out becausethey’re always going to be knocking on them to seewhat they can get.”

Many healthcare organizations face the need tosecure both older on-premise infrastructure as wellas newer cloud services. One important concept that

is emerging as a security best practice for the cloudis micro-segmentation, a method that creates securezones in data centres and cloud deployments by iso-lating workloads. Wood says it’s analogous to givingevery user on a network their own office withsoundproofing.

When micro-segmentation is properly archi-tected, it is transparent to users, doesn’t impact per-formance and dramatically improves security. Yet,just like any other security implementation, it needsto be routinely reviewed and improved over time inorder to maintain effectiveness.

Compugen is currently working with MackenzieVaughan Hospital, a new build in Ontario expectedto be complete by 2020, to ensure security challengesare addressed in its design. A smart hospitalequipped with state-of-the-art technology, the site isintroducing cutting-edge innovations that rely heav-ily on a secure, highly available wireless network andthat means security needs to be forward-thinking.

One of the objectives is to implement a smarttracking system for hospital beds. As a patient iswheeled in a bed from one floor to another, or froman inpatient ward to a CT scan suite for example, the

elevator will be able to track the bed’s location andensure an elevator is ready and waiting when it ar-rives with a goal of expediting patient care, particu-larly in critical situations. On the security front, thechallenge is to enable uninterrupted wireless connec-tion while protecting sensitive data.

“Our team is working to make sure that as much aspossible, we future-proof ... We have to think ahead tothe standard two to three years from now,” says Wood.

First Nations Health Authority (FNHA) in B.C. isanother healthcare organization partnering withCompugen to provide best-in-breed security forhealth records. Established in 2013 to reform the wayhealthcare is delivered to First Nations communitieswithin the province, the health authority manages pri-mary, mental, dental and environmental health ser-vices, and health benefits for roughly 142,000 citizens.

In response to a provincial mandate that all healthauthorities install a secondary data centre tosafeguard patient data and maintain operationsin the event of an attack or other catastrophe,FNHA implemented hyperconverged technol-ogy from Nutanix that integrates compute, stor-age and virtualization resources in a single sys-

tem. Data from its primary data centre isreplicated to the new environment every

24 hours; in the event of a compro-mise, health records seamlessly failoverto the backup data centre.

As a young organization, FNHA hadthe benefit of putting privacy and security

departments in place from the start, and sys-tems are “growing in parallel” with privacyand security policies, says FNHA IT manager,Core Technology, Valeriu Surdu. “Everythingis monitored 24/7; we’re trying to be proac-tive rather than reactive,” says Surdu.In addition to its 12-person IT team, whichis responsible for applying patches and con-

figuring firewalls, the health authority has adedicated IT security team of two people whomanage governance, policy and ongoing sys-tem monitoring. According to Surdu, the hy-perconverged architecture is inherently se-cure and simpler to manage.

“It gives us the ability to easily segregate data sowe can protect client data much better and more ef-ficiently,” he says. ‘With hyperconvergence you alsohave the ability to encrypt data at rest, which is a fu-ture we’re looking at.”

Michael Lonsway, president of Toronto-based Da-pasoft Inc., says the more interconnected the health-care ecosystem gets, the easier it is for threats to popup and propagate. Hence the need for an approachthat embraces “secure by design.”

“All developers need to be thoroughly trained insecure development principles, and that needs to bepart of any solution deployed in healthcare today,recognizing the new and ever-changing threats re-lated to cybersecurity,” says Lonsway.

In March, Dapasoft merged with iSecurity Inc. ofToronto to collaborate on evolving Dapasoft’s Coro-lar Cloud product. The move is intended to benefitcustomers “looking for a highly secure cloud inte-gration platform” and to “offer cybersecurity alongwith DevSecOps advisory and managed services tocustomers across multiple industry verticals,” in-cluding healthcare.

Raheel Qureshi, a partner at iSecurity, says the

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As healthcare organizations computerize,security threats may impact more users

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two companies are working hand in handto identify the real security challenges fac-ing healthcare and correct them at the rootcause. He points to several areas of securitythat need to be top of mind for any health-care organization, in addition to microseg-mentation and disaster recovery.

First, it’s important that organizationsmaintain the right level of applying soft-ware updates. “Patch management contin-ues to be a challenge and we need to un-derstand why,” says Qureshi, noting thatsome organizations delay applying secu-rity updates because it may require down-time and they are reluctant to negativelyimpact system availability.

Compugen’s Wood agrees that effectiveapplication of security updates is an areawith which every customer struggles, re-gardless of industry. There are differentapproaches to mitigate the risk, includingusing an external or automated patchmanagement service, but nothing on itsown offers the perfect scenario, he says.

“Some patches you can automate butsometimes it requires a human eye,” he ex-plains, noting that an update in one areamay cause an unwanted cascade effect in an-other. The benefit of using an external man-aged service, he says, is that a serviceprovider can keep on top of the process and“clean it up as quickly as possible” if or whena patch goes awry without adding a largeamount of work to the existing IT staff.

A second recommendation from Qureshiis that healthcare organizations focus onproviding the right level of protection toprivileged users, who often hold the prover-bial keys to the kingdom. “When hackers getin, the first thing they want to do is get ac-cess to the privileged IDs,” he says.

Protection means designing a securityarchitecture so that identity and ac-cess management is properly han-

dled, using tools like Microsoft Azure ActiveDirectory, a cloud service that can also beintegrated with on-premise directory tools.Manual practices for tracking and sharingprivileged account passwords should be re-placed with automated privileged accountmanagement (PAM) software that will pro-vide visibility into who’s doing what, when,helping to identify potential threats.

As pointed out by PwC, active monitor-ing is another step healthcare organiza-tions should be undertaking to safeguardsystems and data. It’s not enough to imple-ment a security information and eventmanagement (SIEM) product to providereal-time analysis of security alerts and callit a day. Qureshi recommends organiza-tions start with an effective threat model-ling exercise to truly understand their in-frastructure and all of the various avenuesof inbound and outbound traffic that areunique to it.

Even when effective strategies are ap-plied to guard against cybersecurity threats,no organization is immune from an inci-dent. Sometimes the best defence meansgoing on the offense, applying a red team,blue team approach. Borrowed from themilitary, the terms are used to signify teamsthat simulate real-word attacks using thesame techniques of a would-be hacker.

Red teams focus on penetration testing,exposing back door or exploitable vulner-abilities that pose a threat. Blue teams fo-cus on strengthening incidence responseefforts and making the entire security in-

frastructure more responsive to unusual orsuspicious activity.

Often the challenge is finding the secu-rity professionals to do the testing. Foryears, industry analysts have predicted ashortfall of cybersecurity talent with re-cent estimates suggesting there will be asmany as 3.5 million unfilled cybersecuritypositions by 2021.

Qureshi says that’s why hospitals need to

rely on security partners, like the way carmanufacturers rely on suppliers. A largeautomobile manufacturer sources multipleparts from multiple vendors in order to as-semble a car, for example, but at the end ofthe day they still maintain responsibilityover the end-product and its certification.

“It requires a team of individuals whobring all of this together to build a robustsecurity strategy for an organization,” says

Qureshi, pointing to skills such as securityarchitect, forensic security officer, threatspecialist and those with deep knowledgeof security monitoring techniques. “No onehospital has all of those skill sets and noone person does either ... Own the gover-nance, own the oversight, have the right se-curity program but when it comes down tovalidating and securing all of those compo-nents, leverage your partners,” he says.

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BY BAILEE DENICOLA

Imagine being in charge of the healthand wellness of 300,000 people scat-tered over a wild and remote area thesize of France, where there’s one bearfor every two people, ten-hour drives

between communities are the norm, andwinter brings temperatures of -20 or below.

This is the challenge faced by NorthernHealth, the organization responsible forproviding healthcare in northern BritishColumbia.

However, thanks to a shared electronicmedical record (EMR), healthcareproviders in parts of northern BC can noweasily access the most up-to-date informa-tion about their patients at any time of theday or night, enabling them to providebetter care.

The EMR in question is MOIS® (Med-ical Office Information System), first de-veloped in 1990 by Dr. Bill Clifford ofPrince George, BC.

More than 11 years ago, Dr. Cliffordselflessly donated the software to a not-for-profit, and now MOIS® is owned, collabo-ratively developed, administered, and li-censed by the Applied Informatics forHealth Society (AIHS). AIHS has beenworking with Northern Health ever since.

“We partner with Northern Health toimprove efficiency and outcomes,” saysAIHS CEO Bill Gordon.

“We’ve had a great partnership withAIHS for over a decade,” says DarrenDitto, Regional Manager, Clinical Applica-tions & Specialty Care Solutions, atNorthern Health. “Things have changedand grown over the years, but what re-mains constant is that by working in part-nership with our providers and AIHS, wecollectively make MOIS better able toserve our patients. Another huge benefitof AIHS is that they’re not-for-profit, so

we can work on a system and not have toworry about the bottom line in decidingwhat features are included – it truly is forthe good of the patient.”

Northern Health currently has severalseparate instances of the MOIS EMR.

“We’re working with Northern Healthto consolidate the instances and to reduceany barriers between health teams, in aneffort to provide the right information tothe right people at the right time,” saysLarry Chrobot, Senior Director at AIHS.

MOIS functionality includes docu-menting and in many cases, electronicallydownloading, key elements of the patientmedical record, including:

• Encounter notes and measures• Prescriptions, long-term medications

and labels• Health issues and rankings• Allergies and medication

administration records

• Past procedures• Diagnostic imaging reports• Consultation and referral reports• Patient preferences and care plans• Team-based communication, including

EMR-to-EMR communication• Service documentation

Sharing this information between dif-ferent members of the healthcare team iskey in providing comprehensive, coordi-nated care.

Dr. Suzanne Campbell is a GP whoworks at the Omineca Clinic in the smallnorthern BC farming community of Van-derhoof (pop. 4,439).

Northern Health is implementingchanges to strengthen basic healthcare:they’re putting a model in place where aninterprofessional team will support eachphysician’s or nurse practitioner’s office.

Depending on the size of the commu-nity, the interprofessional team can include

nurses, physiotherapists, occupational ther-apists, social workers, and more. Dr. Camp-bell is an important part of the Vanderhoofinterprofessional team: “While the patienthas the most vested in their health outcome,the physician is the quarterback of teamhealthcare,” says Chrobot.

When the team began using the sameMOIS EMR, all team members, includingDr. Campbell, could view patient noteswhenever needed, helping them providecontinuous, coordinated care.

“The Omineca Clinic in Vanderhoofwas one of the very first clinics to put theirhand up and ask for that integration inMOIS,” says Chrobot. “They took that leapof faith in the pursuit of better patient out-comes. They were visionary, and one of thefirst in northern BC to do that. For a clinicto take that on, that was tremendous.”

As one example, Dr. Campbell’s patientAshley (all patient names and identifyingdetails have been changed) gave birth viac-section, returning afterwards to her re-mote rural home, where she struggles withfinancial and transportation issues.

Dr. Campbell worried how Ashleywould cope with a newborn, in addition torecovering from surgery plus her otherchallenges. She feared that with Ashley’stransportation difficulties, it would behard to check in on the young mom.

However, when Dr. Campbell saw onAshley’s MOIS chart that a nurse hadbeen in regular contact, assessing Ashleyat home and documenting the visits, herconcerns were assuaged. The MOIS chartclearly showed that Ashley was recover-ing from her c-section, was coping withher other challenges, and that the babywas thriving.

Bailee Denicola is a Communications Advi-sor, Primary & Community Care and Clin-ical Programs, Northern Health.

Pictured: Dr. Bill Clifford, CMIO, Northern Health; Alyssa Halliwell, Director, Support and Services, AIHS.

In November 2018, Baycrestadopted the long-term care (LTC)sector’s leading electronic medicalrecord (EMR) software,PointClickCare, for the Apotex

Centre, Jewish Home for the Aged. It rep-resents another technological step for-ward, as Baycrest PointClickCare providesinnovative tools for both clinical andnon-clinical staff and enables enhancedcommunication among the care team.

“This was more than just a technol-ogy upgrade, it was a clinical project andtechnology was merely the enabler,” saysAndrew Pigou, Program DirectoreHealth and project co-lead. “With theright people at the table, strong executivesponsorship from the beginning, and arobust EMR implementation plan, wewere able to focus on where practice andtechnology intersect, improving systemsand workflows to make PointClickCarework for Baycrest.”

Baycrest’s goals for this project in-cluded more efficient allocation of clini-cal resources relative to resident health-

care needs, the ability to track clinicaldocumentation, capturing informationat the point-of-care, resident assess-ments, tasks and care assignments, med-ication management including ordering,tracking and administration of medica-tions and treatments.

“Baycrest’s innovative approach to-ward addressing clinical and operationalchallenges through innovative technologyis evidence of its dedication to care andforward thinking,” said Stuart Feldman,General Manager, Canadian Operations,PointClickCare. “As the healthcare sectormoves toward a patient-centered caremodel, technology will serve as a forcemultiplier and key enabler for providers.”

“At their fingertips, our clinical leader-ship now benefits from innovative dash-boards, reports and analytic tools, whichallow them to monitor resident care,”added Maria Muia, Executive Director ofInformation & Technology. “The teamcan instantly pinpoint short-term oppor-tunities to improve quality of care, whilealso leveraging the data to inform longer

term strategic initiatives for enhancingoutcomes and resident experience”.

Advanced technologies are now inplace, which maximize the availability ofe-health records, optimizing uptake andadoption. These include fully mobilecomputerized medication administra-tion carts, treatment carts and iPads,

which operate across a sophisticatedwireless infrastructure.

Baycrest is not only meeting the in-dustry standard, but it is surpassing itwith the development of the physiciandocumentation tools led by Dr. AndreaMoser, Apotex Associate Medical Direc-tor and Chief Medical Information Offi-cer. Dr. Moser points out that “Baycrestis the first LTC home in Canada using

the platform to implement computer-ized physician order entry (CPOE).”

Computerized physician order entryimproves the ability to enter and processorders in a timely manner, decreasing re-liance on verbal orders and reducing po-tential medication errors.

One example is how it allows clinicalstaff to document patient progress andcondition in real time for staff in the nextshift, making the care delivery and com-munications process more intuitive. “Thishas been very valuable,” says Dr. Moser.“Being able to tell a resident’s story to thenext shift of staff is vital, and making thatstory more detailed with the help ofPointClickCare is truly beneficial.”

“Uptake and adoption is very strongamong our clinical teams who arethrilled to have a system that fully meetstheir clinical documentation and work-flow requirements,” said Simon Akin-sulie, Executive Director of Long TermCare. Akinsulie noted “the rapid rate atwhich staff are adjusting to an extensiverange of new technologies.”

EHR at Baycrest offers CPOE, improved communication and analytics

Baycrest is the first LTC homein Canada using the platformto implement computerizedphysician order entry (CPOE).

Shared EMR leads to better outcomes for patients in northern BC


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MARKHAM, ONT. – Markham Stouf-fville Hospital (MSH) has part-nered with VitalHub to create a

streamlined, digital onboarding and orien-tation process for the hospital’s new profes-sional staff. A mobile application namedVH Engage, referred to at MSH as MSH Ig-nite, is being used.

MSH is a community hospital locatedin Markham, Ontario. After an expansionin 2014, MSH doubled in physical size,adding over 100 new inpatient beds andeight new operating rooms. It also tripledthe size of the emergency department andwelcomed almost 100 new highly skilledprofessional staff.

Due to this significant growth, therewas a need to address the process of on-boarding professional staff. Prior to Ignite,onboarding professional staff involved aflurry of activity, which intensifies in the48 hours before they officially started.

With all the demands of a busy hospitalenvironment a new professional staffmember is expected to hit the ground run-ning. Before they can do so, there are vari-ous agreements to sign, hospital policies tounderstand, and questions to answer, suchas “where do I park?”, or “how do I contactanother doctor?” and “how do I log in toaccess lab results?”

MSH found that their paper-basedprocess to onboard new residents and pro-fessional staff was very cumbersome andtime-consuming. And because MSH tendsto hire a large proportion of locums, it canget especially complicated for professionalstaff who need to quickly adapt to systemsthat are often completely different fromhospital to hospital.

MSH brought this challenge to the firstcohort of a MaRS led initiative called ‘Inno-vation Partnership: Procurement by Co-De-sign’. VitalHub responded to the co-designinnovation partnership opportunity andwas selected through a competitive evalua-tion process to develop a smartphone appli-cation, leveraging its mobile application de-velopment framework and experience.

MSH sought a solution that would al-low professional staff to be onboarded, ac-cess vital hospital information, completerequired documentation, review leader-ship structure and other important tasksall remotely via their mobile devices. Theapp efficiently addresses these areas as wellas increases knowledge transfer and helpsfoster the relationship between profes-sional staff and administration.

“This isn’t just about orientation … thisis about building an enhanced culture of re-spect between the hospital and our profes-sional staff,” says Dr. George Arnold, Chief,Department of Obstetrics and Gynaecology,Clinical Innovation & Strategic Ventures.

The app was launched in the summer of2017 on IOS devices and made availableon Android devices in the fall of 2018.MSH Ignite has been very successful withall professional staff using the app to com-plete onboarding and orientation. “Thisapp helped me access important informa-tion when I needed it and helped me keepup to date with events at the hospital,” saysone new physician.

Ensuring professional staff have readyaccess to updated policies, QBPs, and med-ical directives though MSH Ignite is a prior-

ity for the hospital. This app has made thisknowledge transfer faster and easier, reduc-ing potential risks in patient care delivery.

This enhanced communication flowmeans that professional staff have the infor-mation they need, when and where theyneed it. “We’re providing our newly ap-

pointed professional staff with the neces-sary tools, so that they can provide our pa-tients with the best care possible,” says Dr.Caroline Geenen, Chief of Staff at MSH.

Using the app makes 80 percent of pro-fessional staff feel more engaged and 60percent continue to access information and

resources after onboarding. One of thegoals of this project was to reduce theprocess time for Medical Administration.To date, there has been a 50 percent in-crease in time savings for both MedicalAdministration and professional staff withthe digital process.

Innovative partnership creates process for digitally onboarding hospital staff

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BY TAYLAN PINCE

new digital platform has launchedto help busy doctors, patients, and

clinic staff communicate better. Avocare, an AI-powered chat-

bot, is vastly improving communication inOntario clinics, with over 8,500 patientsusing the digital platform to book appoint-ments, request doctor’s notes, message re-ception staff, order refills, and contact theirphysicians directly. Since implementing thechatbot last year, calls to the front desk atToronto’s Village Family Health Team clinichave dropped from 12,000 to 9,500 permonth – a 20 per cent decrease.

Previously, patients could only emailtheir doctors through an outdated, provin-cially-approved communications platform(with no limit on the number of messagesthey could send), and front desk staff hadno way of directing the flow of emails be-tween patients and doctors. This meantthe extra administrative burden was fallingsquarely on the doctors’ shoulders.

“Before using the Avocare chatbot, Iwould spend long days working at theclinic – then often spend an additional two

to three hours at home responding to pa-tients’ emails,” says Dr. Manisha Verma ofthe Village Family Health Team.

But the frustration wasn’t limited to doc-tors and administrative staff. Patients werefrustrated too, as many of their requests toreschedule appointments were met with aresponse directing them to contact the frontdesk. Upon calling the front desk, patientswere being placed on hold for long periodsof time. It was a poor solution to a simplerequest, and it meant that nobody was get-ting what they needed.

The power of AI: This is where artificialintelligence (AI) comes in. If a chatbot wereto improve the clinic’s congested user flow,it would need to understand and respondto the requests submitted by patients.

In order to train the AI-powered chat-bot to engage in conversation with pa-tients, around 10,000 pieces of text andemail correspondence were collected.From this data, the chatbot learned how toidentify different types of requests and re-spond accordingly. Eventually, some of thebasic requests could be handled automati-cally, while the more complex querieswould get forwarded to the front desk.

As with all machine learning, the AI-powered chatbot only gets smarter withtime. The more patient requests that Avo-care fields, the better it’s able to respond;and the better it’s able to respond, thesmoother the clinics run.

The biggest hurdle: The biggest hurdlein implementing Avocare has been working

within the bureau-cratic, technological,and privacy con-straints of Canada’soutdated ElectronicMedical Record Soft-ware (EMRS). About75 percent of EMRSplatforms don’t al-low for integrationwith software likeAvocare, either be-cause the technology

is too archaic or the owners of the softwarewant to guard against competition.

The remaining 25 percent of EMR plat-forms do allow for some level of integra-tion, and Avocare is currently running inthree such clinics. However, all OntarioEMRs will eventually be required to play

nice with outside software, and Avocare willbe in a first-mover position to offer their so-lution when that change comes into effect.

When it comes to patient privacy, Avo-care adheres to strict security protocolsand data encryption requirements. Everythree months, privacy standards set out bythe government are reviewed, in additionto the software undergoing regular stresstests from a third party.

Small steps forward, no big steps back:‘Small steps forward, no big steps back’ isadvice commonly given by nurses to theirpatients. It’s not about overnight recovery,it’s about gradual improvement. It’s also afitting mantra for a new software like Avo-care looking to integrate into Canada’sslow-to-change healthcare system.

Once the barriers to integration are re-moved, Avocare will reach more clinics,with the goal of saving administrative stafftime, allowing doctors to focus on beingdoctors, and ensuring patients get whatthey need quickly.

It’s clinic communication that works.

Taylan Pince is CTO and Co-Founder ofAvocare.

BY KARIM KESHAVJEE,

DAVID GORANSON

AND FAHREEN WALIMOHAMED

Over the last several years,we have been researchingoptions for how to managethe upcoming complexityin healthcare – such as ag-

ing populations, rising costs and techno-logical revolutions. We have spoken withleaders in health information technologyfrom around the world and looked at casestudies in other industries, such as retail,the airline industry, transportation andthe financial industry to identify methodsthat have worked to manage high levels ofcomplexity and rapid change.

Our interviews with health informa-tion technology leaders have identifiedrecurring features of success:

• good governance of information technologies;

• physician leadership of technology programs; and

• alignment of incentives for key players in the system. We have noted that the complexity in

the health system spans so many differ-ent domains (consumerism, cost, infor-mation flow, diagnostics, treatments,system complexity, artificial intelli-gence), that existing methods of dealingwith the needs of patients and providersare no longer working.

Previous arrangements which haveworked for decades are breaking down.Ministries of Health can’t seem to findcommon ground with physicians any-more. Information technology costs aremushrooming, yet don’t increase safetyor quality of care. What is the pathwayout of this maze?

New principles are required that in-volve more stakeholders at all levels ofthe health system than has previouslybeen the case, especially patients.

We need to work together more as acommunity of participants and stake-holders, including vendors, researchers,guideline developer-implementers andhealth informatics professionals.

A multi-stakeholder governancemodel provides us with a self-organizingand self-correcting mechanism foradapting in real-time to an ever chang-ing environment.

In addition to a broadened and moreinclusive definition of good governance,we need new principles of patient em-powerment that enable patients to play amuch more active role in the healthcaresystem at multiple levels.

Patient empowerment cannot be lim-ited to health education and access tomedical records. Empowerment needs toencompass power at the individual,community and societal levels. Patientsneed to be able to bargain collectively,just as other stakeholders are able to bar-gain collectively.

Patients and health seekers shouldalso have their alternative ways of learn-ing respected. They should have owner-ship, control, access and possession(OCAP™) of their data.

Patients should also be able to partici-pate in the monetization of their data,an increasingly common feature of thehealth system landscape. The recent Pa-tient Declaration of Values in Ontario isan excellent start.

We need better ways of encouragingvendors and investors to bring new in-novations to market. Canada is famousfor doing health information technology

pilot projects that go nowhere. Thisneeds to end.

The reason for stalled pilot projects isclearer than ever. The lean startup move-ment has shown that there is no suchthing as a perfect product meeting pent-up demand in one fell swoop.

A minimally viable product has to beevolved over time by working closely withkey customers. This type of market shap-ing requires time and robust markets.

Without markets for new products andpatience for evolving products, we will al-ways be stuck in pilot mode. Given thelow rates of return on product invest-ments in the Canadian healthcare system

compared to the rates of return in the US,government intervention is required. Gov-ernments need to help create markets forhealth information technology products.

Given the large gap between existingand desirable patient care, there is an op-portunity for governments to encouragemade-in-Canada solutions for mobiletechnologies that serves the needs of pa-tients. This is likely to be popular withpatients, will encourage external invest-ments and growth of Canada’s softwareand services marketplace and create newjobs for mobile app developers, healthcoaches, data analysts and user interfacedesigners. A quadruple win for the Cana-dian healthcare system and our economy.

Canada also needs to support moredirected research in interoperability. Cur-

rent approaches to interoperability havenot worked. Canada has spent billionsover the last two decades pursuing an in-teroperability approach that doesn’t addvalue to any of the players involved.

All the blaming and shaming of ven-dors for data lock out is a red herring.Interoperability is hard. We need to con-duct more research to understand whatmakes it hard and come up with solu-tions that make it easier.

Finally, we need better integration ofour healthcare system. Our healthcareorganizations all work in silos. Thisproblem was recognized long ago, butthe problem is difficult to solve.

However, increasingly, patient caresuffers because hospitals, home care andprimary care are not able to coordinatecare sufficiently for patients. We need tothink about how we can use our healthinformatics resources in this country tohelp us better integrate our health careorganizations.

Over the next several months, we willbe creating a virtual Meeting Place orPublic Sphere where all interested stake-holders can join and propose policiesthat will help us identify and prioritizeproblems together, create solutions to-gether and collectively work together toshape the information technology futureof Canada’s healthcare system. After all,Canada’s healthcare system is our collec-tive pride and joy.

Dr. David Goranson is a rural family physi-cian in BC; Dr. Karim Keshavjee is a healthinformatics consultant and an Adjunct Pro-fessor at the University of Toronto. FahreenWalimohamed is a student in the Master’sof Health Informatics program at the Uni-versity of Toronto.

Patients should help design systems, along with vendors and investors

AI and bots are reinventing how patients connect with health clinics

The upcoming virtual meetingplace will allow stakeholdersto propose policies to improvethe healthcare system.


Taylan Pince

A

hospice care at her request, where shedied peacefully. There are many otheranecdotal stories like this one, includingone Virtual House Call that we per-formed to a patient who had neither heatnor electricity. We conducted this visit byflashlight!

I imagine as other front-line providersread this article, patients will come tomind who would clearly benefit from thistechnology and service.

In time, it is my hope that we can findmore resources and opportunities for col-laboration to make this service morewidely available.

Limitations: When the first version ofthis service was offered, in 2017, the discus-

sion around integrating digital health intothe Canadian system was in its infancy.

There was limited ability to integratethis care with other services, and while wehad good success with conducting en-counters with patients, we struggled to in-tegrate this service into their healthcareand often lost track of patients as they tra-versed the healthcare system.

Admission to hospital in some in-stances was unavoidable, and subsequentdischarge did not return the patient to ourcare. Moving forward, and with greaterawareness of the benefits of digital health,improved integration of these types of ser-vices should prove beneficial.

More resources will be required todemonstrate the magnitude of the benefitwith respect to reduced hospital admis-sions and ER visits, among other things.

Technical limitations: Early technical

limitations related primarily to the qualityof objective information obtained in thecourse of conducting an assessment andmaking a diagnosis and treatment plan.

Videoconferencing capabilities havesupported the collection of subjective in-formation, i.e., history, for a long time.

Many software platforms provide the

required security for this encounter. Thechallenge, however, lies in the physicalexam. Early stethoscopes proved techni-cally limited in several ways.

Higher level Bluetooth stethoscopes thatare very similar to traditional stethoscopespromised connectivity, but in practice, theywere not overly reliable, especially for re-mote use in real-time (asynchronous re-mote care is another topic entirely!)

The quality of the acoustic informationwas good, but unreliable.

Basic USB enabled stethoscopes, such asthe one that we ultimately used, offeredeasy connectivity (to REACTS, not all plat-forms) but limited quality of information.

These stethoscopes do not offer the abil-

ity to adjust the frequency settings. This iscritically important for digital auscultationas background noise is a much more signif-icant factor than in person auscultation.

High-frequency sounds, such as lungsounds, require different settings in digitalauscultation than low-frequency soundssuch as heart sounds. The device that weused performed well at low-frequencies(heart sounds), but poorly for higher-fre-quency sounds (lung sounds).

Accordingly, auscultation of the lungswas of low-quality, and in some instancesrendered the visit technically suboptimal.After each visit a telemedicine providershould assess whether or not the visit ap-proximated an in-person encounter; if itdid not, then the patient should be notifiedof this concern and the assessment andplan may be modified.

Summary: Virtual House Calls are tech-nically feasible and result in high levels ofpatient and caregiver satisfaction. Techno-logical advancements since the inceptionof this program have made this serviceeven more beneficial, such that it is rarethat a trained provider would be unable toapproximate an in-person visit.

More study is required to produce infor-mation on the scalability of this service andthe cost savings that will be realized. Con-sideration will have to be given to the factthat acquiring data requires an investment.

On another note, Humber River is usingtechnology to improve overall efficiency,quality and to reduce resource utilization.

“It’s a logical progression,” said Bak.“Everything we do is driven by thesethemes.”

He asserted the direction was originallyset by former CEO Dr. Rueben Devlin andcurrent CEO Barb Collins.

One of the ways in which communica-tion has been improved in the hospital hasbeen through the use of Ascom smart-phones, which are assigned to staff whenthey start their shifts. Of course, one might

think a personal phone would do the job,but Bak asserted that these devices aremore than just phones, they are “tools ofthe trade” and thereby need to be wellmanaged: devices must always be availableand working.

Once nurses are on a shift, patients canreach them through the smartphones.There’s intelligence built into the system,too. For instance, the system knows if a pa-tient’s primary nurse is occupied with an-other patient and cannot respond; it willautomatically re-direct the call to the sec-ondary nurse.

Moreover, the nurse must respond tothe call. “You can’t just ignore it,” saidBak. “We’ve created service level agree-ments with the nursing staff, and theycan’t let the patients sit there. There’s alsoa central dispatch centre that can see ifyou’ve responded.”

This is all part of a quality drive.“Whether the patient is in serious pain, orsimply wants a blanket, we want to re-spond,” said Bak. “For this, the communi-cation system is very valuable.”

While much has been accomplished inthe past few years, Bak said, “We still havea lot to do.” In particular, more work is be-ing done on the Command Centre. A set of“generation two” tiles are being con-structed to provide alerts in new areas.

One of the focuses is on perinatal alerts,and Humber River is creating an early

warning system for babies in distress dur-ing perinatal care. Bak stressed that Hum-ber River’s strategic direction isn’t the onlysolution for improving care and efficiencyin the hospital sector. “We’re not saying it’sthe only way to go. But it’s how we’ve cho-sen to invest our money.”

“It is my hope that we can findmore resources andopportunities to make thisservice more widely available.”


Humber River goes beyond EMRAM

comprehensive record directly into theclinician’s workflow regardless of EHR.

The advantages of this approach aremany and include critical IT considera-tions such as:

• Data liquidity. This enterprise approachmeans genomic insights can be appliedacross the organization for better patientcare and population management.

Assembled into a comprehensive and dis-crete informatics layer, data can follow apatient into various clinical settings. The

entire care team can access valuable in-sights; information is available and notisolated in a single care encounter or spe-cialty area.

• Data governance. There is no doubt thatprecision medicine introduces new chal-lenges related to lab ordering practices, pre-scribing decisions and data management.An enterprise-spanning informatics ap-proach means organizations can enact con-sistent practices according to their own poli-cies and priorities – as well as apply gover-nance to this new layer of complex data toensure organizational and legal compliance.

Recognized as a thought leader in the fieldof precision medicine, Dr. Joel Diamond isan Adjunct Associate Professor of Biomed-ical Informatics at the University of Pitts-burgh. He is a diplomat of the AmericanBoard of Family Practice and a fellow inthe American Academy of Family Physi-cians. He cares for patients at Handels-man Family Practice in Pittsburgh, Penn-sylvania.

Learn more about Allscripts innova-tions at the e-Health 2019 Conference,Toronto, May 26-29. Allscripts is a SilverSponsor.


Care providers can maximize benefits of genomic knowledge

produces is often startling and makes theexercise well worth the extra effort.

So effective is this approach that thehealth system’s procurement counselshould be asked to structure a robustdual-track negotiation process and beprepared to put his (her) fees at risk inthe event of a disappointing result.

There is also reason to doubt the ac-curacy of the guide’s assertion that ne-gotiations are legitimate provided theydo not “result in a material change tothe scope of the RFP and the terms ofthe legal agreement.”

What if the RFP explicitly reserves aright to materially change direction asthe health systems learns of the solutionsbeing offered during the procurementprocess? Particularly where the healthsystem is tapping the market for a highlyinnovative solution and may even bedefining a new path never seen before inthe industry, there is nothing sinisterabout an important change in direction.There is no process unfairness. As al-

ways, provided the language of the bidcall document properly anticipates thepossibility of an important change, therule on transparency is honored.

It is noteworthy that the misconceptionaround the bar on negotiations with ven-dors precedes the arrival of the BPS Pro-curement Directive by precisely 30 years!Clearly the Directive did not trigger thismisconception, and the guide – while use-fully clarifying that negotiations are not

prohibited by the Directive and despitethe best intentions of the myth busters –may well contribute to new misconcep-tions, as can be seen by point no. 12.

To have called the guide The Art ofthe Possible is apt, as it connotes thegoal of trying to achieve something thatis good enough rather than being driveninto complete paralysis by a desire toachieve perfection. To be sure, the pro-

curement regulatory framework is com-plex and will continue to provide end-less learning opportunities for all of usworking in the field. But waiting to havemastered everything before innovatingis unrealistic, will not produce the re-sults hoped for, and will unnecessarilyslow the pace of innovation.

As a procurement specialist who hasworked in public procurement in manyindustry sectors over many years inCanada and abroad, I believe what isneeded now is a higher level of ambi-tion to try new approaches in healthcareprocurement. The guide purports to be“for hospital executives”. If significantnew innovative outcomes are to beachieved through healthcare procure-ment, it will fall on such executives tosee their way through the barriers to in-novation, real and imagined, and ambi-tiously lead the way.

Denis Chamberland is CEO of MESGroup and a lawyer with extensive pro-curement, technology and trade law expe-rience in the healthcare sector in Canadaand Europe. He can be reached [email protected]

Denis ChamberlandCONTINUED FROM PAGE 20

“I believe that what is needednow is a higher level ofambition to try newapproaches in procurement.”

“Whether the patient is inserious pain, or simply wants ablanket, we want to respond,”says Bak.


Virtual house callsCONTINUED FROM PAGE 10

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