Project: Bridges to Better Health

2004
Canada Health Infostructure Partnerships Program

Project Description

Originally, the Children's and Women's Health Centre of British Columbia (C&W) project was to develop a system to allow the pediatric oncology clinics at Victoria General (VGH) and C&W to share patient data and build a common patient chart that could be viewed, and updated, electronically. With the change of the B.C. Health Regions in early 2002, the underlying technology for the project was changed to the B.C. Cancer Agency CAIS environment. The scope of the work and the intent of the project remained the same: to establish a sustainable electronic health record in the support of paediatric oncology in B.C.

Outcomes

Pre-Project "Bridges" Status:

The paper-based charting system had had problems ensuring that patient data was consistent at both sites. In addition, survey results indicated that both clinicians and parents of oncology patients felt that information had not been consistently transferred between sites.

Post-Project "Bridges" Status:

Due to delays in implementation, and subsequently delays taken for learning the system, the post-implementation evaluation phase had to be shortened from 5 months to 2 months. As a result, the small sample size did not note conclusive results. The project has recommended that further time be given for more data collection.

Additional successes were noted:

• There was a significant improvement in interpersonal communications between the clinical teams, a success factor which greatly assisted the project team during the project lifecycle;
• Both clinical teams at C&W and VGH collaborated to develop a consistent, standard form containing all relevant discharge information. This "Discharge Summary Form" is now used universally with the Pediatric Oncology Form in B.C. The Discharge Summary was also established as an eForm and fully integrated into the CAISystem
• Not all systems, including the CAIS, at C&W are HL7 compliant, therefore, the Bridges team had two primary integration issues to resolve: how to interface the ADT (Admitting Discharge Transfer) system at C&W (which was HL7 compliant) with CAIS; and how to transfer laboratory results from the C&W Lab system (not HL7 compliant) with CAIS.

The ADT interface to CAIS was constructed using Microsoft BizTalk which could accept an HL7 message from the ADT system, parsed by a NeoTool translator, that called a SQL server stored procedure on the CAIS system. This allowed an almost real-time update of C&W patient demographics into CAIS.

Once the demographics were in CAIS, and a patient record existed, the C&W and VGH lab systems could produce a lab report which was directed to print to a remote printer at BCCA - in fact the "printer" was a parsing program that read the lab report and associated it with the patient record in CAIS. These two solutions allow a clinician to recover a lab report for a patient from the CAIS system more easily and usually faster than using the LIS (Laboratory Information System) directly. Secondly, the experience gained while integrating the BizTalk system with the ADT system has provided C&W with the tools and knowledge necessary to convert the old HL7 interface engine to a more modern and more versatile system based on BizTalk in a much faster time than would have been possible previously.

Policy Implications

Throughout the project there has been an implicit recognition of the role of the parent as part of the care team. At Children's and Women's Health Centre, parents have the right to request a copy of any information in the child's chart, to be provided by Health Records. While parents of sick children have this access to information in paper copy, there exists some confusion regarding their right to access such information electronically.

As a matter of public policy, some thought must be given to the basic issues of "ownership" vs "custodianship" of an individual's information. In the case of the EHR, the organization storing the data may have policies in place which restrict or inhibit access to that information by third parties, e.g. parents, while the organizations which individually provide pieces of data freely permit such access. The "Partners in Care" Committee is a BC Provincial group of parents who are actively seeking a resolution to this issue. The contact for this group is Mr. Dan Mornar at the Department of Oncology and Haematology, at C&W.

Research Implications

None noted

Lessons Learned

• The primary issue that has surfaced during construction is the question of how to uniquely identify a patient record that may exist under many guises in a wide range of clinical systems;
• An EHR must accept a wide range of information in many formats, and if it is to be effective, the EHR must then present this information in an organized way to the clinical user; and
• Prioritization of clinical information in a chart is often a matter of individual preference by the medical staff. Given the range of documents available and the various medical disciplines, it is very difficult to develop one electronic chart that satisfies everyone's needs.

The Future

Technology: Looking to the future, in the healthcare sector there is a very definite trend towards data centric clinical systems and away from document centric systems.

Standards: Data standards within the healthcare sector are well published, although adopted and applied only in a very limited way. HL7 in all its variations has been a mainstay of clinical data integration for some time, but the evolution of this standard and the slow pace of vendor compliance has limited its use, in Canada more than in the US.

Within the health regions in BC, there is no "standard" adoption of HL7 for Lab, ADT or other clinical data. While CAIS itself does not inherently support an HL7 dataset, the potential for further electronic integration in BC is very limited. The solution developed by the Bridges team was to "translate" an inbound HL7 message to a format directly useful to the CAIS SQL database. This might be feasible as an integration solution for other systems, however the underlying CAIS architecture is not specifically designed to operate on discrete data elements with the complex data relationships found in commercial clinical systems.

Technology "standards" may also prove to be a limiting factor to any further expansion of this EHR solution. The C&W environment is built on modern, current Microsoft products such as Windows XP and Office XP. Other organizations may neither use Microsoft products, nor be as up to date as C&W. The consequence of this is the technology lag effect, experienced acutely by the Bridges project when integrating Office XP documents with CAIS.

Communication standards and infrastructure in BC are very well defined and managed. A provincial healthcare network called Healthnet, links all major clinical centers with a secure high speed ip network. While individual organizations may use alternative networking technologies, the overall infrastructure is consistent and very suitable as the backbone for a provincial EHR.

In BC the client registry is notorious for being out of "synch" with hospitals and their view of the patient's demographics. As such, the Provincial Health Number is not universally used as the definitive patient identifier in BC. Hospitals rely on their health records systems and their own MRN/MRUN or Medical Record Number to uniquely identify their patients. Unfortunately the MRN is not a standardized number and it is facility specific. The fact that the PHN is not universally used, combined with the confusion surrounding the MRN and identifying healthcare facilities, means that until a functional eMPI (electronic master patient index) is available in BC, real electronic systems integration will be difficult and expensive to implement safely.

Human Resources: Any well designed EHR will have the potential to positively impact human resource demands on an organization, by shifting the manual and clerical aspects of health records management to a more automated and self-validating model. Conversely, a poorly articulated EHR will add a significant burden to those who would potentially use it.

Systems Integration: The future potential for the Bridges - CAIS system is very limited due to the complexity and expense associated with systems integration.

At the core of the systems integration issues are data standards which may be "defined" within the technology industry, but which have not been widely deployed in BC. Those organizations that have implemented modern clinical information systems, for example Vancouver Island Health Authority and their Cerner systems, already have a standard, multi-facility EPR and EHR. Clearly integration with a standards based system will be much simpler than attempting to integrate with a proprietary non-standard environment.

Those organizations without a data-centric, standards based system will remain at a significant strategic and cost disadvantage when the EHR opportunity is presented.

Appendix A: Document or Products Generated

None were documented within the project final report as required although products such as the Discharge Summary Form were developed.

For additional information, please contact Don Gibson at 604-875-3858 or at dgibson@cw.bc.ca