Regionally Accessible Secure Cardiac Health Records - University of Ottawa Heart Institute

Health and the Information Highway Division, Health Canada
June, 2003

Table of Contents

• Executive Summary
• 1. Project Description
  • 1.1 General Description
  • 1.2 Functionality
  • 1.3 Administrative Benefits
  • 1.4 Minimum Cardiac Dataset
  • 1.5 Interface to Legacy Databases
  • 1.6 Security and Privacy
  • 1.7 Technical Description.
  • 1.8 Awards
  • 1.9 Partners
• 2. Achievements
  • 2.1 Goals Reached
  • 2.2 Major Tasks Accomplished
  • 2.3 Obstacles or Challenges
  • 2.4 Additional Successes
  • 2.5 Goals Not Reached
  • 2.6 Documents or Products Generated
• 3. Main Impact
  • 3.1 Human Resources Impact
• 4. Privacy and Protection of Information
  • 4.1 Changes in Behavior
  • 4.2 Policies and Procedures
  • 4.3 Privacy Assessment
  • 4.4 CHIPP Privacy Survey
  • 4.5 Patient Views
  • 4.6 Help or Hindrance
  • 4.7 Patient Privacy
  • 4.8 Patient Consent
  • 4.9 Privacy Impact Assessment
  • 4.10 Smart Systems for Health
  • 4.11 Influence
• 5. Policy and Research Implications
• 6. The Future
  • 6.1 Existing Situation
  • 6.2 Desirable Option
  • 6.3 Long Term View
  • 6.4 Need for Additional Pilot Projects
• 7. Communications
• 8. Other

Executive Summary

The Regionally Accessible Secure Cardiac Health Record (RASCHR) System was developed by the University of Ottawa Heart Institute (UOHI) and its partners with a contribution of $1.5 million from the Canada Health Infostructure Partnerships Program (CHIPP) of Health Canada. RASCHR assists in providing improved patient care by making the patient record more readily available when and where it is required . The original workplan called for RASCHR to be connected to 9 regional hospitals. To date 16 hospitals or clinics have been connected and this number is continuing to expand. . Therefore many more patients are potentially being provided better care because RASCHR is in place in a greater number of locations. The project started in August 2001 and is finishing in June 2003.

RASCHR provides authorized healthcare workers in hospitals and clinics in Eastern Ontario immediate access to cardiac health records of patients who have catheterization, percutaneous coronary intervention (PCI), or cardiac surgery at UOHI. Using RASCHR, hospitals refer patients to the Heart Institute electronically, follow up to obtain booking dates for treatment and obtain results. For patients who consent, their patient record can be available to any of the participating hospitals in Eastern Ontario. Then, if a patient needs to visit any hospital, after treatment at the Heart Institute, their record is immediately available to the treating physician.

RASCHR is consistent with the view that patients and their healthcare providers should have timely, appropriate and secure access to their healthcare records when and where they are required. Respect for privacy and confidentiality are fundamental to this vision.

Rapid access to a patient's record is made possible by secure Internet connections or secure private networks such as the SSH network in Ontario to a database located at the Heart Institute. The security of the patient record is ensured through a Public Key Infrastructure (PKI) system. Authorized healthcare workers need special security keys, names and passwords to access RASCHR. Great care is taken in issuing security keys making security paramount. Also, every access to the database is recorded so that accesses or changes to a patient record are documented. All information sent across the Internet connection is coded with specialized encryption techniques to optimize security of both the information and the system.

Objective of Project

The principal objectives of the project were:

• To improve the health care providers' accessibility to cardiac patient health information in the region of Eastern Ontario.
• To allow the referring physicians to monitor/follow-up on their patients remotely without requesting data from the UOHI and having to wait until the request can be addressed.
• To improve the overall quality of cardiac health services in the region.
• To establish this project as a Pan-Canadian Electronic Health Records model that demonstrates a secure electronic health record system over Internet, portable to other regions in the Country.
• To provide a basis and framework for a clinical cardiac records data warehouse. By storing the electronic cardiac patient records in a database, the medical meta data could be used for future analysis purposes.

All of these objectives were achieved. The healthcare provider's access to cardiac health information has been improved in Eastern Ontario by making the records available 24 hours a day, 7 days a week in 16 hospitals or clinics. This is 7 more sites than in the original plan. The system will be expanded for use in all 34 hospitals that refer patients to UOHI as time and funding permits. The referring physicians in the 16 hospitals and clinics can monitor and follow-up to obtain information on their patients without the need to telephone UOHI.

The RASCHR system has been in operation since December 2002 and there are now more than 3000 patients in the system. This number will increase as time goes by.

There is improvement in the quality of healthcare provided by making the cardiac records available when and when they are required.

The RASCHR system is a model that could be replicated in other jurisdictions and, in fact, UOHI is prepared to make it available to any other cardiac health care facility in Canada at no cost.

The basic framework for a clinical cardiac records data warehouse has been achieved. This would require considerably more effort and funding to make it complete. However, RASCHR could be expanded to a full data warehouse for cardiac patient records.

Major Tasks

The major tasks in the RASCHR project were:

• To create an Enhanced Patient Registry System (EPRS) that will be accessible over the Internet using Web technology.
• To establish a template process for automating the data transfer of patient legacy data to the cardiac care database.

Both these major tasks were completed successfully and the system is very well accepted by the users.

Partners

The partners for the project were:

xwave was the system developer and also contributed to the development cost.

Bell Canada contributed the PKI Internet security system.

The following hospitals and clinics assisted in the development of the RASCHR system.

• Almonte General Hospital
• Arnprior and District Memorial Hospital
• Carleton Place and District Memorial Hospital
• Cornwall General Hospital
• Deep River and District Hospital
• Hôtel Dieu Hospital Cornwall
• Kemptville District Hospital
• Ottawa Cardiovascular Centre
• Pembroke General Hospital
• Queensway-Carleton Hospital
• Renfrew Victoria Hospital
• St Francis Memorial Hospital

1. Project Description

1.1 General Description

RASCHR was put in place by UOHI to provide authorized healthcare workers in hospitals and clinics in Eastern Ontario immediate access to cardiac health records of patients who have catheterization, percutaneous coronary intervention (PCI), or cardiac surgery at UOHI.

Using RASCHR, hospitals refer patients to the Heart Institute electronically, follow up to obtain booking dates for treatment and obtain results. For patients who consent, their patient record can be available to any of the participating hospitals in Eastern Ontario. Then, if a patient needs to visit any hospital, after treatment at the Heart Institute, their record is immediately available to the treating physician.

RASCHR is consistent with the view that patients and their healthcare providers should have timely, appropriate and secure access to their healthcare records when and where they are required. Respect for privacy is fundamental to this vision.

Rapid access to a patient's record is made possible by secure Internet connections to a database located at the Heart Institute. The security of the patient record is ensured through a Public Key Infrastructure (PKI) system. Authorized healthcare workers need special security keys, names and passwords to access RASCHR. Great care is taken in issuing security keys making security paramount. Also, every access to the database is recorded so that accesses or changes to a patient record are documented. All information sent across the Internet connection is coded with specialized encryption techniques to optimize security of both the information and the system.

1.2 Functionality

RASCHR partially replaces a system based on faxing patient referral forms from the regional hospitals to UOHI and then following up with telephone calls.

Using RASCHR, a healthcare provider at a regional hospital completes an electronic form online and transmits that information to UOHI. The information transmitted includes information on the patient's cardiac condition, the procedure for which the patient is being referred, the name of the referring physician and other information that uniquely identifies the patient. The triage department at UOHI then processes this form. Triage assigns an urgency rating, which is dependant on the patient's condition, assigns booking dates for procedures and assigns the treating physician. This information is then instantly available to the referring hospital so that follow-up telephone calls are reduced considerably. As the patient is treated at UOHI, some of the treatment results are automatically input into the RASCHR system. For example the results of Angiograms and PCI are automatically entered into RASCHR immediately after the patient is treated. Some other results are manually entered and some are not entered into RASCHR at the present time. However, RASCHR will be expanded to collect the other results later. Overall, the RASCHR system improves the collection and flow of cardiac care information among hospitals in Eastern Ontario resulting in minimal delays and improved service, with costs remaining at current levels.

1.3 Administrative Benefits

Using RASCHR reduces paper work and telephone calls and messages are replaced with information available at any time on any day. Frequent telephone calls by referring physicians and other regional hospital staff to obtain booking dates for patients that have been referred for treatment are replaced with access to a patient record via the Internet. This allows better management of patients being held at regional hospitals awaiting treatment at UOHI. In addition, the processing of patients with a well designed system allows more checks and balances to be put in place which ensures that nobody slips through the cracks because of administrative errors. Overall, the RASCHR system improves the collection and flow of cardiac care information among hospitals in Eastern Ontario resulting in minimal delays and improved service, with costs remaining at current levels.

1.4 Minimum Cardiac Dataset

The development of RASCHR provided the opportunity to develop a minimum dataset for cardiac care. The dataset used with RASCHR is consistent with the dataset that is used by the Cardiac Care Network (CCN) of Ontario but is broader and in some cases allows for more detailed information on the patients condition. This dataset would be expanded as extra information is added to RASCHR.

1.5 Interface to Legacy Databases

The RASCHR system provides an interface to legacy databases at UOHI. In particular, the results of angiograms and PCI's (percutaneous coronary intervention) are transmitted to RASCHR immediately after the patient is treated and, therefore, are also instantly available to a regional hospital. This enables follow up by the regional hospital to determine the treatment given to patients. This is particularly valuable if the patient should enter a hospital with a cardiac condition after treatment at UOHI. Access to the record of treatment given to the patient previously ensures that the patient will be provided the most appropriate treatment for their condition.

The RASCHR system is also being interfaced to the Ottawa Hospital's admission, discharge and transfer (ADT) system in order to automate input of basic demographic information. It is also being interfaced to the local database of the Cardiac Care Network (CCN) of Ontario in order that data can be automatically transferred to the provincial system and avoids some double entry.

1.6 Security and Privacy

An independent security assessment including a penetration test was carried out on RASCHR to ensure that the security system was well designed and could not easily be penetrated. The assessment found no problems with the RASCHR system. In addition, a privacy assessment was carried out to ensure that the privacy of the patient records was being protected.

1.7 Technical Description

Referring to Figure 1 below, RASCHR consists of a web enabled three tier application with a Web server facing the Internet, an application server to handle the business logic and database containing the data. As shown in Figure 2, these elements are all duplicated to provide the highest availability possible and to prevent loss of vital data. Figure 2 also shows the system is well protected with a firewall between each layer.

When a user at a regional hospital or at UOHI connects to the web server at UOHI a valid security certificate is requested. The user's security certificate is then verified at the Bell certificate server and passed to the web server. If the user's certificate is valid and they have privileges to access the RASCHR system they are permitted to access the system.

The components of the RASCHR system have been chosen to provide the best performance today and allow for future expansion. The software represents the best in class for the various elements. The front end is the I-Planet web server. The middle layer is the BEA application server and the database is Oracle. There is fail over protection on the Web servers so that if either of these servers fail, the system will continue operating without delay. If an application server or a database server fails then a manual process is used to activate the back-up server. In the future, it would desirable to implement clustering on the database servers to ensure fail over protection without any delay and implement fail over protection on the application servers.

A picture of the actual RASCHR system in the server room at UOHI is shown in Figure 3 left.

The screens presented to the users of the RASCHR system have been ergonomically designed to provide the users with a pleasant and efficient experience in using the system. Use of frames to divide the web page presented into meaningful sections has been used extensively. As can be seen from the patient record page shown in Figure 4 below, there is an index of the information available on the patient in the left hand frame and the right hand from provides specific information. In the example shown this is only the patient's demographics but it could also be the patient's referral information or the treatment results.

1.8 Awards

RASCHR has already been recognized as a leading application in the healthcare field. At its annual award ceremony held in 2002 in Ottawa, the Society of Canadian Office Automation Professionals (SCOAP) awarded top honours for community advancement to the project partners. At the Annual Showcase Ontario awards ceremony held in Toronto in September 2002 RASCHR was awarded an award of merit for the project's potential positive impact on the community .

1.9 Partners

RASCHR was developed with a contribution of $1.5 million from Health Canada.

xwave was the system developer and provided a 30% discount on the development cost.

Bell Canada contributed the Internet security system.

The following hospitals and clinics assisted in the development of the RASCHR system and are now users of the RASCHR system.

• Almonte General Hospital
• Arnprior and District Memorial Hospital
• Carleton Place and District Memorial Hospital
• Cornwall General Hospital
• Deep River and District Hospital
• Hôtel Dieu Hospital Cornwall
• Kemptville District Hospital
• Ottawa Cardiovascular Centre
• Pembroke General Hospital
• Queensway-Carleton Hospital
• Renfrew Victoria Hospital
• St. Francis Memorial Hospital

2. Achievements

2.1 Goals Reached

From Appendix A for the original project plan the principal goals of the RASCHR project were:

• To improve the health care providers' accessibility to cardiac patient health information in the region of Eastern Ontario. This allows referring physicians at remote locations to securely enter patient referral data directly into the cardiac care database, thereby reducing the administrative effort required to process a patient arriving at the UOHI. In addition, making critical patient data available for study by the UOHI cardiologists in advance will improve the quality of care a patient receives when he or she arrives at the UOHI.
• To allow the referring physicians to monitor/follow-up on their patients remotely without requesting data from the UOHI and having to wait until the request can be addressed.
• To improve the overall quality of cardiac health services in the region.
• To establish this project as a Pan-Canadian Electronic Health Records model that demonstrates a secure electronic health record system over Internet, portable to other regions in the Country.
• To provide a basis and framework for a clinical cardiac records data warehouse. By storing the electronic cardiac patient records in a database, the medical data could be used for future analysis purposes.

All the Goals were reached: healthcare providers at UOHI and at 16 regional hospitals or clinics now have access to cardiac health records at UOHI 24 hours a day 7 days a week. They can refer a patient electronically and obtain the results of treatment given at UOHI. This is potentially very beneficial to patients since their record can be available at a regional hospital whether or not they have visited that hospital before. Referring physicians or their assistants can monitor/follow-up on their patients remotely without requesting data from UOHI. This is not only useful at the referring hospitals but also within UOHI. With paper-based records, it is difficult for everybody to have access to the same record at the same time. With RASCHR this is no longer a consideration. Administrative effort has been reduced at certain points in the process. For example, many calls to triage for information on a patient are eliminated because the information is available on line. However, it may have increased the workload at UOHI in the triage office because they find they are entering more patient data. This should decrease as the regional hospitals and clinics increase the amount of data that they enter and as more regional hospitals are connected. It will also decrease when work on connecting the admitting discharge and transfer system is linked to RASCHR and when RASCHR can automatically transfer date to the Cardiac Care Network of Ontario. Both these links would reduce duplicate entry of data that occurs at the moment.

Making the cardiac patient's record more readily available when and where it is required has improved the overall quality of health care in the region. However, during the very short evaluation period the extent of this benefit has not been ascertained. It is planned to do a follow-on evaluation, which will include determining changes to the Quality of Care provided to patients in about a year's time.

A model for a Pan Canadian Cardiac health record has been established. RASCHR could be easily replicated in any other cardiac care centre in the country. In fact, UOHI will make RASCHR available free to any other cardiac centre in the country that would like to implement it.

A framework for a clinical cardiac records data warehouse has been established. This would require considerably more effort and funding to make it complete. However, RASCHR could be expanded to a full data warehouse of for cardiac patients.

2.2 Major Tasks Accomplished

The major tasks as stated in the original project plan were:

• The first phase will create an Enhanced Patient Registry System (EPRS) that will be accessible over the Internet using Web technology. The existing Patient Registry System used at the UOHI will form the basis for the underlying functionality to be provided in the EPRS. In order to provide this functionality in a secure fashion, a highly secure network infrastructure will also be installed to link all participating hospitals.
• The second phase will establish a template process for automating the data transfer of patient legacy data to the cardiac care database. This work will also create the link between the raw patient data and the EPRS such that in the future, raw treatment data could be accessible to physicians via the EPRS.

Both of these tasks were completed successfully and the RASCHR system is in use in 16 hospitals or clinics. This is seven more hospitals than in the original plan. It is planned to expand RASCHR to all 34 hospitals that regularly refer patients to the UOHI in the future. The first phase was the basic RASCHR system that allowed access to the cardiac health records at UOHI. The second phase actually linked the catheterization and PCI results from the cathcor machine directly to RASCHR. The second phase has also provided a template that can be used to interface other legacy databases to RASCHR in the future.

There are now more than 3,000 patient records in RASCHR and this number increases daily. The graph below shows access to the system since it was switched on in November. As can be seen the general trend is for increased usage of the system although it is thought that dealing with the SARS epidemic has interrupted usage in some of the regional hospitals.

The key contributing factors to completing these major tasks were the expertise of the principal contractor, xwave, the generosity of Bell Canada in proving the PKI infrastructure and security advice and assistance and the dedication of the staff at UOHI and in the regional hospitals to ensuring that the system met the needs and deployed properly. The availability of the SSH network was also useful in giving regional hospitals without good Internet connections high speed access to RASCHR.

Below in Table 1 is the list of major tasks as originally submitted in the project plan with a note against each that indicates that it has been achieved. As can be seen from this list, all the major tasks in the original project plan have been achieved. The only down side is that most of them were achieved later than originally expected.

Table 1 Major Tasks and Outcomes

Task #	(*) Major Task	(**) Milestones	Target Date	Planned Outcomes	Actual Outcome	Date Completed
	Quarterly Reports
40		Quarterly Report1 Issued	18-Oct-01		Issued	26-Oct-01
42		Quarterly Report2 Issued	18-Jan-02		Issued	4-Feb-02
44		Quarterly Report3 Issued	19-Apr-02		Issued	14-May-02
46		Quarterly Report4 Issued	16-Jul-02		Issued	19-Aug-02
48		Quarterly Report5 Issued	16-Oct-02		Issued	29-Oct-02
		Quarterly Report6 Issued	31-Jan-03		Issued	19-Feb-03
		Quarterly Report7 Issued	30-Apr-03		Issued	25-Apr-03
	Security Policy
69		Security Policy Development	29-Oct-01	Security policy available	Many outcomes from technical and operation viewpoint see text. RASCHR operation policy document produced	10-Jun-02
	Evaluation
86		Issue RFP	24-Jul-01		Statement of work prepared and vetted by Steering Committee	1-Sep-01
89		Issue Contract	20-Aug-01		Contract Issued to Sisters of Charity	24-Sep-01
92		Baseline Data Collected	26-Dec-01		Baseline data collected	15-Jul-02
94		Baseline Data Report	10-Apr-02	Report issued	Baseline Report Issued	14-Aug-02
96		Post Implemen- tation data collected	13-Aug-02		Post Implemen- tation data collected	27-May-03
99		Evaluation Report Complete	4-Nov-02	Report issued
	Ongoing risk assessment
103		Ongoing risk assessment 1	20-Jun-01	Initial risk assessment report	Submitted to Health Canada with Project Plans
104		Ongoing risk assessment 2	20-Sep-01	Updated risk assessment report	Risk assessment updated	26-Oct-01
105		Ongoing risk assessment 3	20-Dec-01	Updated risk assessment report	Risk assessment updated	4-Feb-02
106		Ongoing risk assessment 4	20-Mar-02	Updated risk assessment report	Risk assessment updated	14-May-02
107		Ongoing risk assessment 5	20-Jun-02	Updated risk assessment report	Risk assessment updated	19-Aug-02
108		Ongoing risk assessment 6	20-Sep-02	Updated risk assessment report	Risk assessment updated	29-Oct-02
109		Ongoing risk assessment 7	20-Dec-02	Updated risk assessment report	Risk assessment updated	19-Feb-03
		Ongoing risk assessment 7	30-Apr-03	Updated risk assessment report	Risk assessment updated	25-Apr-03
	Evaluation Contract
113		Collection Data Methodology Available	20-Aug-01		Collection Data Methodology Available	29-Nov-01
115		Collection Data Methodology Available	5-Feb-02		Collection Data Methodology Available	14-Aug-02
118		Post Implemen- tation Data Processed	23-Aug-02		Post Implemen- tation Data Processed	22-Jun-03
	Cash Flow Projections
122		Cash flow projection for 2001/02	31-Aug-01	Cash flow projections to H.C	Cash flow projections to H.C	31-Aug-01
123		Cash flow projection 2002	30-Aug-02	Cash flow projections to H.C	Cash flow projections to H.C	30-Aug-02
	Final Report
132		Final Report Delivered	17-Dec-02	Final Report Delivered	Final Report Delivered	22-Jun-03
	Xwave Development
	Risk Management Reports
138		Risk Management Reports 1	25-Jun-01	Risk Management report to S.C. &H.C.	Project not started	30-Jun-01
139		Risk Management Reports 2	25-Jul-01	Risk Management report to S.C. &H.C.	Project not started	30-Jul-01
140		Risk Management Reports 3	27-Aug-01	Risk Management report to S.C. &H.C.	Report delivered	30-Aug-01
141		Risk Management Reports 4	25-Sep-01	Risk Management report to S.C. &H.C.	Risk factors incorporated in main report to Health Canada	30-Sep-01
142		Risk Management Reports 5	25-Oct-01	Risk Management report to S.C. &H.C.	Risk factors incorporated in main report to Health Canada	30-Oct-01
143		Risk Management Reports 6	26-Nov-01	Risk Management report to S.C. &H.C.	Report delivered	30-Nov-01
144		Risk Management Reports 7	25-Dec-01	Risk Management report to S.C. &H.C.	Report delivered	30-Dec-01
145		Risk Management Reports 8	25-Jan-02	Risk Management report to S.C. &H.C.	Report delivered	30-Jan-02
146		Risk Management Reports 9	25-Feb-02	Risk Management report to S.C. &H.C.	Report delivered	28-Feb-02
147		Risk Management Reports 10	25-Mar-02	Risk Management report to S.C. &H.C.	Report delivered	30-Mar-02
148		Risk Management Reports 11	25-Apr-02	Risk Management report to S.C. &H.C.	Risk factors incorporated in main report to Health Canada	30-Apr-02
149		Risk Management Reports 12	27-May-02	Risk Management report to S.C. &H.C.	Risk factors incorporated in main report to Health Canada	30-May-02
150		Risk Management Reports 13	25-Jun-02	Risk Management report to S.C. &H.C.	Risk factors incorporated in main report to Health Canada	30-Jun-02
151		Risk Management Reports 14	25-Jul-02	Risk Management report to S.C. &H.C.	Risk factors incorporated in main report to Health Canada	30-Jul-02
152		Risk Management Reports 15	26-Aug-02	Risk Management report to S.C. &H.C.	Risk factors incorporated in main report to Health Canada	30-Aug-02
153		Risk Management Reports 16	25-Sep-02	Risk Management report to S.C. &H.C.	Risk factors incorporated in main report to Health Canada	30-Sep-02
	xwave Phase 1
159		Requirements Analysis Phase	14-Aug-01
165		Phase 1 Requirements Completed	14-Aug-01	Requirements analysis document available	Fourth version of Document available	28-Feb-02
	Detailed Design Phase
167		Prepare Design Document	5-Oct-01		Document available	28-Feb-02
177		Phase 1 Design Completed	5-Oct-01	Phase 1 design available	Initial System Testing	31-Aug-02
	Implemen- tation Phase
202		Phase 1 Implemen- tation Completed	22-Feb-02	Phase 1 development complet	System Installed at UOHI	15-Nov-02
	Testing
220		Phase 1 FAT Completed	1-May-02		System accepted with minor mods	4-Mar-03
	Deployment Phase
227		Phase 1 Deployment Completed	29-May-02	System installed at hospitals	Started December 2002 and still ongoing	15/12/2002
231		Phase 1 Beta Trial completed	28-Jun-02			4-Mar-03
235		Phase 1 User Trials Completed	2-Aug-02	Phase 1 system installed and complete	User trials started in December but final testing not undertaken till March	11-Mar-03
	Documentation
249		Phase 1 Documentation Completed	26-Jun-02	Phase 1 documentation available	Most documents available	20-Mar-02
	Training
263		Phase 1 Training Completed	14-Jun-02		Training started in Sept 02.	11-Mar-03
265		Phase 1 Completed	20-Aug-02	All staff trained	Training is an ongoing requirement since users are continuously added.	11-Mar-03
	xwave Phase 2		25-Jul-02
	Requirements Analysis Phase
273		Completion of Requirements Phase 2	6-Mar-02	Requirements analysis document available	Requirements documents available	10-Sep-02
	Detailed Design Phase
276		Completion of Design Phase 2	30-Apr-02	Phase 2 design available	Design documents available	10-Sep-02
	Implementation
284		Implemen- tation Completed Phase 2	31-May-02	Phase 2 development complete	System available at UOHI	15-Dec-02
	Testing
300		Phase 2 FAT Completed	4-Jul-02	Phase 2 factory testing complete	FAT completed at UOHI	4-Mar-03
	Deployment Phase
307		Phase 2 Deployment Completed	15-Jul-02	Phase 2 installed at all hospitals	Started December 2002 and still ongoing	15/12/2002
309		Phase 2 completed	25-Jul-02	Phase 2 fully functional at all hospitals	Potentially this was possible at mid-January 2003 However, some hospitals are slow in fully implementing the system	11-Mar-03

2.3 Obstacles or Challenges

The most important challenge was developing a system that would meet the users needs, would be easy to use and be ergonomically acceptable. This required a lot of interaction with the future users of the system both at UOHI and at the regional hospitals. Some of the suggestions made by the future users were incorporated into the system. Quite a few requests could not be accommodated because of the limited budget and development time available. Many of these requests will be incorporated in an enhanced RASCHR system, which will be developed as funding becomes available. The challenge also involved making sure that the appropriate documentation was developed to accurately describe the system and ensure that the principal contractor delivered the system as specified.

The second challenge was to accommodate the late delivery of the system and still remain within the allowable project budget and keep the future users from losing interest and faith that the system would eventually be delivered. The system was late for several reasons. The initial time frame for the project was in-fact realistic. However, the project time frame was compressed to meet the original needs of Health Canada. In the end, this proved unrealistic and the project ran over even the original schedule. Fortunately, Health Canada was very understanding and provided two extensions to the project. Even with these extensions it was difficult to get sufficient use of the system to undertake a full evaluation. It is expected that another evaluation will be undertaken after the system has been in place for about 1 year.

The security and privacy concerns of electronic health records available over the Internet to many different institutions posed more of a challenge than most people realized at the start of the project. There were many discussions on what each user would be able to view and how patient consent would be obtained. In the end, it was decided that a user in a regional hospital could only view patients on an individual basis and could not view any lists of patients even for their own hospital. This was reflected in the operational policy for RASCHR. The ethics board of UOHI reviewed this operational policy and legal opinion was obtained on the patient consent issue.

In addition to the policy concerns for security and privacy, there were also technical and operational issues. Security design was very thorough and this was confirmed by an independent security assessment. In addition, a post implementation security assessment was undertaken including ethical penetration tests. The system was found to be very secure from a technical perspective.

The regional hospitals and the clinical staff in UOHI contributed significantly to the project. However, hospital staff always face competing demands for their time and clinical priorities always come before a new system implementation. This was true throughout the project however, it was clearly demonstrated in the usage statistics, which were climbing quite nicely until SARS came along and at that point took a large dip.

2.4 Additional Successes

There were a few successes beyond those specified in the original work plan.

The original work plan called for only 9 regional hospitals to be connected. To date 16 hospitals or clinics have been connected and this number is continuing to expand. This has greatly increased the number of patients that will benefit from the use of RASCHR particularly because some of the regional hospitals added refer a lot of cardiac patient to UOHI.

The functionality described in the original plan was not well defined. This was expanded to ensure that the system designed provided the best performance and functionality possible within the funding and schedule available.

An independent security assessment was carried out. This was not in the original plan but was considered desirable to increase confidence in the security of the system and to ensure that patient records were in fact secure.

2.5 Goals Not Reached

The most noticeable goal not reached was the schedule. Because software development ran behind schedule it delayed the implementation of the system. This increased costs for some of the partners and delayed the implementation of the system at UOHI and at the regional hospitals. Just as systems were starting to be installed and used in the regional hospitals the SARS outbreak hit and delayed things again, particularly in the regional hospitals. This means that many of the hospitals have not used the system adequately to provide an effective evaluation.

Improved administration efficiency has not been achieved to date. In fact, some administrative work has increased. This is not unusual when a new system is introduced. It is expected to improve as more interfaces are completed for the RASCHR system and as RASCHR is expanded to include more functionality.

Apart from the impact of the schedule and the improved administrative efficiency the other goals for the project were reached and although the system was late being delivered it did function very well and the users generally found the system very good.

2.6 Documents or Products Generated

Document /Product Name	Available in Paper and /or Electronic Form	License Fee Required for use (Yes/No)	Previously Provided to Health Canada (Yes/No)	Appendix Name /Number
Cardiac Health Information Portal Project Proposal Synopsis sent to Canada Health Infoway	Electronic	Not Applicable (N/A)	Yes	A - Proposal Synopsis, v12.pdf
RASCHR - Software Requirements Specification	Electronic	N/A	Yes	B-File 010-04.doc
RASCHR - Software Requirements Traceability Matrix	Electronic	N/A	Yes	C-file 011-03.doc
RASCHR - System Design Description	Electronic	N/A	Yes	D-file 015-02.doc
RASCHR - Database Schema	Electronic	N/A	No	E-file RASCHR Database Schemamod 10 September.doc
RASCHR - Security Design	Restricted for security reasons	N/A	No
RASCHR - Acceptance Test Plan	Electronic	N/A	No	F-file 020-02.doc
RASCHR - Acceptance Test Procedures	Electronic	N/A	No	G-file 021-02.doc
RASCHR - Factory Acceptance Test Report	Paper	N/A	No	H
RASCHR - SAT Report	Paper	N/A	No	I
RASCHR - Training Plan	Electronic	N/A	No	J-file 030-001.doc
RASCHR - System Maintenance Guide	Electronic	N/A	No	K-file 032-01.doc
Online Patient Registry: Triage User Training (PPT)	Electronic	N/A	No	L-file Online Patient Registry - Triage User Training.ppt
Online Patient Registry: Clinician User Training (PPT)	Electronic	N/A	No	M-file Online Patient Registry - Clinician User Training.ppt
RASCHR Installation Guide	Electronic	N/A	No	N -file RASCHRInstallationguide.doc
Abbreviated Guide for the Operation of the RASCHR System	Electronic	N/A	No	O -file RASCHR OPERATION GUIDE1.doc
Draft Operational Policy	Electronic	N/A	Yes -previous version	P- File - operational policy1 updated June 20th 2003.doc
Security Assessment post-implementation	Restricted for security reasons	N/A	No
Security Assessment pre-implementation	Restricted for security reasons	N/A	No
Interface Specifications SMS Corporate ADT to RASCHR	Electronic	N/A	No	Q -file - RASCHR SMS Interface.doc
Evaluation Pre-implementation	Electronic	N/A	Yes	R -Baseline Report.doc
Evaluation Final Report - Post - Implementation	Electronic	N/A	No	S -files: Evaluation Final Report.doc, Final Evaluation Appendix B.doc, Final Evaluation Appendix A.doc
Evaluation Design Methodology	Electronic	N/A	No	T-file: Design Methodology mod.doc
Privacy Assessment Report by PRIVA-C	Paper	N/A	Yes	A3

3. Main Impact

As is well known, healthcare facilities in Canada are behind other industries in the implementation of IT in support of business processes. Therefore, RASCHR was at the leading edge of applications that make health records sharable between institutions. The impact of RASCHR was, therefore, considerable from several points of view.

Patients are being better served because their cardiac health record is available when and where it is required.

Healthcare workers can find a patient record a little easier than in the past because at least part of it is on line.

RASCHR clearly demonstrated that it is possible to build secure patient record systems that can be accessed over the Internet by a number of institutions in a region. Cardiac Health Records are now available to institutions that refer patients to UOHI. This facilitates the follow-up of a patient's treatment at UOHI by a regional hospital. It also makes the patient record available at many more locations should the patient have a reoccurrence of his/her problems and present at a hospital at a later date.

The processing of the patient by UOHI is improved because the process is more automated than it was previously which tends to reduce the possibility that a patient will slip through the cracks.

RASCHR has built a solid foundation that can be expanded to collect more cardiac patient data electronically. As time and funding permit, it is planned to produce and enhanced RASCHR that will collect data on more procedures administered to patients at UOHI. Eventually RASCHR will be evolved to a full cardiac portal providing a range of cardiac information and services to both healthcare providers and patients.

RASCHR clearly demonstrated that web based technology can be used to enable several institutions to have access to health records at the same time. This will encourage others to implement similar applications, which can achieve a similar purpose.

Although this has not been done yet, the collection of the patient data electronically facilitates research of the patient data to assess better treatments or processes. It is now possible to search the patient data and look for trends in the patients that are being referred to UOHI. This was not possible before without a lot of labourious manual searching of patient records.

The success of RASCHR could potentially impact on the development of responsive health delivery policy and applied research agenda by demonstrating what is a possible and indicating direction for the future. We believe that RASCHR is an excellent example of a disease specific patient record system that could easily be replicated in other regions. This could lead to much more efficient sharing of information across regions and could eventually lead to a patient record that could, with the patients consent, be available across the province or across Canada. In addition, RASCHR can be expanded to include the complete cardiac patient record and also allow access by not only hospitals by also family physicians and other institutions

3.1 Human Resources Impact

There is obviously human resources impact any time that a new way of doing something is introduced. This is true in the case of RASCHR but in the overall scheme the impact is not large. Most people using RASCHR were previously familiar with the use of computers and the Internet. Therefore, there was not a huge leap in the skills required.

The biggest impact was probably in the triage department at UOHI. Although RASCHR improves the processing of a patient as they receive treatment at UOHI, triage has been entering most of the patient referral data into the system. This should not be a permanent situation but was particularly true at first when they processed all patients that were referred to UOHI for treatment. As more regional hospitals and clinics have been connected to RASCHR and more users in UOHI have also been added, it has reduced the extra workload at triage. This situation will continue to improve as more people use RASCHR for referring patients to UOHI. The workload in triage will also decrease as the admitting, discharge and transfer system is interfaced to RASCHR as this will reduce the need to re-enter demographic and other information.

No new positions have been developed but there are some responsibilities have changed to accommodate RASCHR. In triage at UOHI, more time is spent managing patients in RASCHR rather than managing patients using forms that were faxed to UOHI. This has reduced time spent at photocopiers etc. but has increased time spent at the computer. It has also reduced the amount of time spent on the telephone to the regional hospitals since the regional hospitals can look up data they require on the patient on-line. In addition, the IT section has a new system to look after which has changed some responsibilities.

The user has not increased demand on service providers.

Job satisfaction probably hasn't changed a great deal since the people using RASCHR are still doing the same fundamental function of serving patients. They are just using a different tool for part of the task.

Productivity in the administrative area may have changed slightly. To change productivity to a larger extent will require that RASCHR be expanded to include other treatments administered at UOHI so that the electronic health record is used more widely.

There was resistance to change. This was generally not because people were reluctant to start using computers but more from the fact that they must stop using one process and switch to a new process. It is always easier at the moment to carry on doing things the same old way. There were also delays in getting the machines set up at some hospitals because of local technical problems. It is also a fact that clinical staff will often put off doing something new because of real or perceived clinical emergencies at the time.

4. Privacy and Protection Of Information

Privacy and security were given a high priority in the RASCHR project and in fact consumed a lot of time. Research was conducted on the legislation governing the privacy of patient records, the existing policies of UOHI and the regional hospitals were examined, an operational policy was developed for RASCHR and independent security assessments were carried out on the RASCHR system.

4.1 Changes in Behavior

There have not been any significant changes in the behavior of health professionals/staff with respect to the protection of personal health information. The protection of personal health information has always been considered important and this has not changed. With the RASCHR system a good deal of caution was used by the professionals in deciding what should and should not be allowed to be viewed. The end result is a system that is useful but fully respects the privacy of the individual.

4.2 Policies and Procedures

We did not make changes to the existing policies and procedures. However a new procedure was added for the operation of RASCHR. This new document referenced existing patient record procedures at UOHI.

4.3 Privacy Assessment

We did complete an in-house privacy impact assessment. An assessment of the existing legislation was carried out, the existing policies of UOHI and other hospitals were examined. Senior staffs at UOHI were interviewed to determine how the existing policies were implemented. In addition the privacy assessment tool provided by the privacy commissioner of Ontario was used to assess the situation. The results of this assessment were good. However, it was found that the privacy assessment tool of the privacy commissioner was aimed more at commercial companies rather than public or healthcare institutions. Therefore, some of the questions were not relevant in a healthcare setting. RASCHR makes it possible for patient records to be more widely available than previously possible. This can be an enormous benefit to the patient should they require treatment at a regional hospital they have not visited before. However, this increased availability has to be balanced against the need to keep the health record private. In RASCHR, it is believed that we have struck a good balance.

4.4 CHIPP Privacy Survey

We did participate in the CHIPP Privacy and Security Survey. This survey did find a number of strengths in the privacy and security for the RASCHR system. The following provides comments on the report including comments on the reports recommendations.

On page 3. under Access. - The scenario outlined in the report was not correct. It should have stated that a clinician user can input information into the system until such time that they refer the patient to triage at UOHI. It is only then that the patient record is locked against further updates by the clinician user. This is an operational necessity for the correct management of the patient. In addition in this section the administrative user does not modify patient information per se but is allowed to enter new users or hospitals into the system and can modify users privileges.

In Gaps on page 4. it mentioned that there is a GAP in the grievance process and recommends that the project formalize guidelines for handling complaints. It is true that we have not implemented anything specific for the RASCHR project per se but it is important to remember that RASCHR is only part of the patient record and there are procedures in place in UOHI and probably all the hospitals that participate in RASCHR to allow patients to challenge the management of their patient record. Things such as contact individuals and an escalation procedure do exist.

Under Gaps again - privacy recourses, it recommends an individual with the project be designated as the contact point for privacy issues. During the development of the RASCHR the project manager was the contact point for privacy issues. However, on an ongoing basis this is not appropriate since the RASCHR project manager is not a permanent position. Privacy issues on RASCHR will be handled in the same way as privacy of patient records in general where the appropriate mechanisms and individuals already exist. E.g. an ethics committee exists at UOHI.

Under gaps again - Policies and procedures, the report recommends that RASCHR should review its operational policy and current UOHI policies to ensure policies are in place to deal with patient privacy requests. As mentioned above, there are mechanisms in UOHI and in other hospitals to deal with privacy requests from patients.

Under Gaps again - Privacy breaches or incidents. Dealing with privacy incidents is already a readily known process to medical staff at UOHI.

Under Gaps again - Privacy Impact Assessment, the report recommends that RASCHR or UOHI conduct a Privacy Impact Assessment. As explained above an in-house privacy impact assessment was carried out and the executive of UOHI is mandated to review its privacy practices on a regular basis. It is possible that a full privacy impact assessment for RASCHR would be useful. However, the funding to do this is not available at this time.

Under Gaps again - it recommends that RASCHR should investigate the ability to monitor network traffic. It is agreed that this may be desirable. However, this would not be done just for RASCHR this would be done for the whole of UOHI's network. The access to RASCHR is limited because it is behind several firewalls. It is much more likely that UOHI's main network would notice problems before malicious network traffic would affect RASCHR. If funds were available continuous network monitoring on UOHI's LAN would be implemented.

Under Gaps again it recommends that RASCHR should formalize a process to assess their information handling practices. We are not sure what is meant by this statement. We already have a quality assurance and audit function on RASCHR. Quality assurance users have special limited time privileges to correct errors that may have occurred on data entry into RASCHR. From another point of view we have an ethics committee that must approve the use of data from RASCHR for anything other that it's original clinical purpose and this committee would ensure that data used does not in anyway affect patient privacy unless specific consent has been obtained from the patients.

Overall we found the Security Assessment Report from Priva-C useful and it will help guide future directions on privacy policies and procedures.

4.5 Patient Views

We have not received any patient views/concerns/compliments on the handling of their personal information.

4.6 Help or Hindrance

Privacy/confidentiality rules have not been an issue with respect to helping or hindering healthcare providers. There is a possibility that if a patient does not provide consent to allow their record to viewed by other hospitals that treatment could be delayed because of lack of access to their record. However, this has not become an issue yet. The PKI security system has required a considerable amount of management particularly during the start-up phase. However, the management requirements should decrease over time and the number of new users to be added to the system is minimal.

4.7 Patient Privacy

Patient privacy was a major concern during the trial. This was the first time that most of the hospitals had experienced a system that would allow the sharing of electronic patient records between institutions. There was, therefore, a lot of discussion about who would be allowed to see what patients on the system. This took a considerable amount of discussion to arrive at a consensus on how the system should operate to meet the healthcare providers and the patients needs.

4.8 Patient Consent

Patient consent is managed using a paper form that is placed on the patient record. While it has only been in use for a short while we have not experienced any patients refusing consent.

4.9 Privacy Impact Assessment

As mentioned earlier the executive committee of UOHI is charged with regularly reviewing privacy policies of UOHI. They would decide when privacy impact assessments should be conducted.

4.10 Smart Systems for Health

The RASCHR project has had discussions with the provincial health infrastructure networks on the issuance of security certificates for PKI systems which involves the protection of personal health information. These were on the availability and the use of these certificates and how the use would be managed. In addition, RASCHR does make use of the Smart Systems for Health network where Internet access at regional sites is limited to dial-up connections.

4.11 Influence

This project has probably influenced privacy policy and process development in the region since it was the first project to share patient records on a permanent basis with a sizable number of institutions. Future project will probably examine what was done on this project to determine how to proceed. This was certainly done in the design of RASCHR where other projects such as the Children's Health Network in Toronto were examined to determine their best practices.

5. Policy and Research Implications

Major finding #1:

RASCHR has clearly demonstrated that it is possible to share cardiac health records between healthcare institutions in a secure and efficient manner. While RASCHR needs to be expanded to cover the complete cardiac care record it is a very good start.

Policy Implication: This is very positive for implementing policies that would seek to make patient records available on regional provincial or even on a national basis. RASCHR is available to any other Cardiac Care Institution in Canada that would like to implement it. Therefore, there is the possibility that it could form the basis of sharing cardiac records on a much wider basis than just Eastern Ontario.

Applied Research Implication: RASCHR is a model that can be implemented in other cardiac care institutions at a fraction of the cost that it took to develop it in the first place. This should be attractive to other institutions and may lead to shared development of an enhanced RASCHR system.

Recommendation for next steps: Next steps should involve partnering with other cardiac care institutions to obtain funding for an expanded RASCHR system to evolve the RASCHR system to a full Cardiac portal providing a range of cardiac services to healthcare providers and patients.

Major finding #2:

Implementing PKI security infrastructure can be very labour intensive particularly where the user base is distributed across a region. The method of implementing PKI security should be refined to make it less labour intensive. Extra tools in the hands of UOHI would have made it easier to implement the PKI infrastructure. In addition, serious consideration should be given to eliminating the need for security certificates within UOHI itself and possible when RASCHR is used over the Smart Systems for Health secure network.

Policy Implications: Be careful how the PKI infrastructure is implemented in the future and try to make sure that it will be easy to manage.

Applied Research Implications: develop or make sure good tools are available for the management of the PKI infrastructure. In addition, make sure that the PKI system to be used will function with all the operating systems likely to be used by the users.

Recommended Next Steps: seriously consider modifying RASCHR to allow name and password log-on from within the UOHI LAN but maintain the requirement for security certificates for users in the regional hospitals.

Major finding #3:

It takes time for some hospitals to get organized to use a new system. Some have a very formal process of making sure everybody is trained before they start to use the system. There is also some resistance to moving from the present method of doing things to using a new system. This means that much longer than expected is required to get healthcare workers to use a new system and get sufficient data to carry out a good evaluation of the impact of the new system.

Policy Implications: Try and arrange schedules to allow plenty of time for system use before carrying out an evaluation. Although an initial evaluation is valuable soon after the system is implemented it would be good to have an evaluation 9 to 12 months after the system is implemented and have this available as part of the project record.

Applied Research Implications: Design programs to allow sufficient time for usage of new systems before carrying out a final evaluation.

Recommended Next Steps: Consider this in any future phases of the RASCHR project.

Major finding #4:

Managing a project with the participation of a large number of regional hospitals in the development stages is not necessarily the best approach. In a similar circumstance to the development of RASCHR, consideration should be given to reducing the number of hospitals involved in the project to a few potentially large users of the system and then expanding the group during the roll out phase.

Policy Implications: Development projects should involve a core group with the potential for involvement or comments on the plans from a larger group rather than trying to involve everybody in everything.

Applied Research Implications: none

Recommended Next Steps: Consider this when designing the next phase of the project or similar projects

Major finding #5:

Managing in-kind contributions from the regional hospitals is a major headache. It is very difficult to obtain the in-kind forms from them in a timely fashion to enable the quarterly reports to be filled in time for submission to Health Canada. In addition, the level of in-kind from the regional hospitals did not reach the levels expected in many cases.

Policy Implications: do not design programs that involve large numbers of regional hospitals contributing in-kind resources.

Applied Research Implications: none.

Recommended next steps: Consider this when designing the next phase of RASCHR or similar projects.

6. The Future

6.1 Existing Situation

RASCHR as it exists at the moment can be maintained at minimal cost. The software licenses are for ever, the warrantee for the servers is good for about another year and the system functions in a satisfactory manner. There is the occasional maintenance and minor changes that are required that can be carried out by the IT department at UOHI. There are a small number of ongoing charges such as the renewal of the server security certificates. In addition, there is a need to complete the interfaces to the SMS and other systems, which are presently being worked on by the IT department at UOHI. The major obstacles to the continuation of RASCHR are the security certificates that are required by each user to the system, the ongoing maintenance for the issue and renewal of the certificates and maintenance of user lists in the RASCHR database. If a major device should fail such as a firewall or a load balancer, it would need to be replaced but this is all manageable within budgets at UOHI.

6.2 Desirable Option

Leaving the RASCHR system in its present state is not the desirable option. There is already a considerable list of minor enhancements that should be carried out on the system. These enhancements could eventually be carried out by the IT department at UOHI. However, the time required for the IT to fully learn the RASCHR system, develop the code, test and implement the changes would be considerable. It would be far better to contract out the required modifications and this will be done when funding is available at UOHI. The funding required would be about $100,000. In the meantime the IT department will continue to make minor changes until increased funding is available.

6.3 Long Term View

UOHI's longer-term view is an enhanced RASCHR system evolving to a cardiac portal providing a range of services to both healthcare providers and patients. Access to the cardiac health record would be expanded to include not only the clinics and hospitals that refer patients to UOHI but also family physicians, community care access centres and the e-Emergency system being put into place by SSH. In addition, services directly to patients would be added. This would include those recently discharged from UOHI and those needing continuing monitoring such as heart failure patients. This is described in a project proposal synopsis that has already been provided to Canada Health Infoway and is attached as Appendix A. As can be seen from this plan things such as:

• Ongoing vision and mission
• Governance and leadership
• Human resources needs
• Communications
• Needs of healthcare professionals
• Technical development plans
• Funding requirements
• Interoperability with other projects and systems

have all been considered to a greater of lesser extent.

It is hoped that Infoway will request a full proposal and the plans for the future of RASCHR would then be further developed.

6.4 Need for Additional Pilot Project

The expansion of RASCHR includes services directly to patients over the Internet. These services will include such things as support for patients recently discharged from hospital, monitoring of heart failure patients, rehabilitation services to patients who for mobility or distance reasons cannot attend a rehabilitation session at a hospital. This is a new area where pilot projects would be very useful in defining the services and determining the overall impact.

7. Communications

Clearly, communications is important in generating support for projects -- support in the community and among other interested groups. What methods or tools did you use to communicate with your stakeholders? Please provide a copy of the documents you will list below as appendices.

Methods or Tools	Date	Targeted Audience	Documents or Presentations Produced	Appendix Name /Number
Canadian Society of Telehealth Conference	23-Oct-01	Healthcare Professionals	Regionally Accessible Secure Cardiac Health Records (RASCHR)	U - File: CST_RASCHR[2] .ppt
SCOAP - award to the project for its potential positive social impact	17-Jun-02	High-tech and general press	Award given for RASCHR Press Release	V - File: SCOAP award_02.doc
Presentation of paper at Showcase Ontario	9-Oct 02	High tech, government and healthcare providers	Regionally Accessible Secure Cardiac Health Records (RASCHR)	W - File: RASCHR Presentation3.ppt
Article in Canadian Health Technology		Health Care Professionals		X - File: Canadian Healthcare technolgy July 2002.doc
Formal Launch of RASCHR	Jan 27 02	Health Canada, Regional Hospitals and Press	Press articles, TV coverage.	Y - File: RASCHR Release 4.do
Presentation at UN peaceful uses of Outer space conference in Vienna	Feb 17 02	International Hi-tech and healthcare.	Presentation	A2 - File: Unisppace-slidesmin.ppt
Presentation at Faculty of Medicine, University of Southampton, England	Feb 20 03	International Healthcare	Presentation	N/A
Brochure	15-Oct-02	Patients	Brochure on RASCHR	Z - Files: RASCHR eng.pdf and RASCHR fr.pdf
Website (please provide the Website address)	17-Sep-02	Patients and their families	Web pages explaining RASCHR	www.ottawaheart.ca /hcraschr.htm
BEA press Release	19-Jun-03	Hi-tech trade and healthcare	Press release	A1 File: BEA Press .doc

8. Other

UOHI very much appreciates the funding and support that Health Canada has provided for the development of RASCHR system. It has made it possible for UOHI and its partners to make a very good start on the implementation of a full cardiac health record that could be shared, as appropriate, with all healthcare workers in Eastern Ontario down to the family physician level. With RASCHR as a base, it has enabled UOHI to plan more ambitious projects for the future

Hospitals in Ontario are definitely under stress mostly because of a lack of funding to implement more modern and automated processes for providing patient care. The implementation of RASCHR with Health Canada support has clearly demonstrated that benefits are possible from the implementation of advanced information and communication technology. However, the gains do not come immediately and they do not come without a cost to existing operations. It is difficult or impossible for healthcare workers under stress to put in the extra effort and time to use new systems even when it is clear there will be benefits down the road. This is why adoption of new technology by healthcare workers in Ontario will remain limited until there is a concerted effort to re-engineer some of the methods used for the provision of patient care and appropriate resources provided to make sure the solutions can be implemented. RASCHR is a start in one small area of cardiac care in one region. Much much more investment in information and communications technology is required to bring healthcare to the same level of efficiency and effectiveness as found in other information intensive industries.