Growing number of initiatives aim to create computerized network of patient information.

KEVIN MARRON
Special to The Globe and Mail

Friday, July 30, 1999 — A 78-year-old man recently hobbled into an Edmonton emergency ward suffering from acute stomach pains.

He told a doctor he'd been constipated for 10 days, but a physical examination revealed no cause. Nor could the patient remember taking any drugs that would have caused the problem. Normally, the doctor's next step would have been to subject the man to a painful and invasive probe to look for colon obstructions. Instead, this doctor found what he was looking for on his computer.

With only a few keystrokes, the doctor was able to view the drug record of his elderly patient under a pilot program run by the provincial agency alberta wellnet, which gives two Edmonton hospitals electronic access to the records of all prescription drugs purchased by seniors under the Alberta Blue Cross benefit plan. With that information, the doctor was able to see that the man had taken a painkiller with side effects that were causing the problem -- a painkiller he had forgotten to mention to the doctor.

The alberta wellnet project is one of a growing number of initiatives aimed at creating a shared network of electronic patient records -- allowing any medical practitioner anywhere to gain access to lab tests, medical histories, hospital charts, diagnostic procedures, drug records and any other medical information from pharmacies, labs, doctors' offices, clinics, hospitals and other medical facilities.

By going electronic, this information will be available instantly by computer networks and secure Internet connections at the desktop or mobile computer of any medical practitioner who needs to see them. The federal government and an advisory team of medical experts expect these electronic records will eventually be available for every patient and at every medical facility in the country. The federal Health Ministry has committed $328-million toward various initiatives to help realize that goal. Many provincial health ministries, regional health authorities and hospital networks have already built their own networks for exchanging electronic records. These include alberta wellnet, which links the province's 17 newly created regional health authorities; several initiatives in British Columbia, including a network that lets all pharmacies in the province share prescription records; and a plan in Quebec that will make it possible to access any information on an individual patient through a chip embedded on a smart health card.

For Tom Noseworthy, electronic medical records are a major medical breakthrough that will transform Canada's healthcare system.

"It's potentially life-saving," says Dr. Noseworthy, a professor and chairman of public health science at the University of Alberta and co-chair of the federal advisory council on health infostructure.

Creating such a network is an enormous task for a complex and fragmented health system strapped for cash and facing enormous problems of confidentiality and security of patient information. In many hospitals and doctors' offices, patient records are still kept on paper. But this creates a problem in an era of restructured healthcare services, where patients may go to one hospital for emergencies, to another for heart surgery and to a third for follow-up. Provincial governments, regional health authorities and amalgamated hospital corporations therefore have been scrambling in recent years to create computerized patient records that can be sent electronically from one department to the next and from one institution to another. But each of these small networks has grown in isolation, many using proprietary technologies that do not talk to one another. Now, service providers such as Markham, Ont.-based IBM Canada Ltd. are creating middleware applications that bridge the gap and link disparate systems.

For example, the newly created electronic Child Health Network (eCHN) connects Toronto's Hospital for Sick Children with four other facilities, each with its own proprietary system. With doctors able to use the electronic network to share information, more children can be treated closer to home instead of going to Sick Kids for consultation, says pediatrician Alan Goldbloom, the hospital's vice-president of academic and clinical development. "They only come to us for the most acute and most complex things."

Database technology from Oracle Corp. of Redwood Shores, Calif., is helping a network of public health authorities in British Columbia provide electronic access to children's immunization records and to keep track of communicable diseases to give early warnings of potential outbreaks. Layton Engwer, director of information management at the B.C. Centre for Disease Control, says the electronic records are replacing vaccination cards that were kept by children and their parents. These would often get lost, with the result that some kids got immunized more than once and others did not get immunized at all.

Sharon Baker, chief executive officer of Toronto-based HealthLink Clinical Data Network Corp., predicts that improvements in handheld computing and the increasing capacity of wireless networks are about to precipitate a boom in the use of electronic health information, because it will mean that clinicians will be able to consult electronic records at the bedside and in hospital wards without having to find a desktop computer. For example, wireless technology developed by Toronto-based Autros Hospital Systems Inc. has automated the dispensing of drugs at Toronto's West Park Hospital, where nurses carry handheld devices that scan identification codes on patients' bracelets, exchange information with a central database in the hospital pharmacy and send signals to a mobile trolley to release the correct dose for each patient.

Web-based technologies are making it easier to extend health-information networks to doctors' offices and community agencies. For example, doctors in the area of Markham-Stouffville Hospital are using Calgary-based Clinicare Corp.'s recently released WebCPR software to share records over the Internet and view lab results and images such as X-rays on an ordinary desktop computer.

Physicians in British Columbia are doing something similar, with the help of database technology from Ottawa-based Mainsource Software Corp. Chris Skinner, vice-president of healthcare business development at Mainsource and a neurologist at Ottawa Hospital, says the database creates an index of all the records about each of these doctors' patients, which may be located in computer systems in various institutions. All the information remains in its original location, but the software can find, retrieve and send copies of any relevant data whenever an authorized clinician makes a request.

The Canadian Forces are using Mainsource technology to create an electronic database of the health records of more than 60,000 personnel. This project will be particularly complicated because it will mean gaining access to the records of civilian hospitals in every province, says Lieutenant-Colonel Jim Kirkland, the officer in charge of health-information management and communications. But he sees enormous benefits. When a Canadian soldier in Bosnia has heart palpitations, for example, military-base medical staff able to check his electronic records on-line will know whether the soldier has a minor condition or one requiring immediate removal to hospital.

As electronic communications make it possible to study old X-rays or view recent test results almost instantaneously, the technology is changing the nature of patient records, says Deborah Del Duca, executive director of the Canadian Health Record Association. Instead of being just a historical chart, it becomes "a living, breathing database of what is happening now."

PRIVACY PROTECTION

As life-saving as electronic health records can be, many patients may be reluctant to have an insurance company, an employer or even close relatives have access to such information. That is why security and confidentiality are the most sensitive issues -- and potentially the greatest barriers -- in creating a nationwide electronic health-data network.

"If we cannot make systems secure and ensure confidentiality, we cannot proceed," says Tom Noseworthy, co-chair of the federal advisory council on health infostructure.

This is not just a matter of making sure that personal information is kept secure by means of encryption technologies. It also means agreeing on policies about who should have access to what information when, and making sure patients have control over how their personal information is used, he says.Jim Norton, chairman of the Canadian Managed Care Council and senior vice-president of health strategies at Toronto-based Aon Consulting Inc., says many doctors are worried about the way health information is used in the United States, where the practices and results of individual physicians are often compared on the basis of information gleaned from electronic records.

"They see the U.S. situation, where various groups publish report cards on doctors with regard to how they treat patients and what drugs they prescribe, and they fear that type of thing," Mr. Norton says.

But technology can actually make it easier to control who uses the information and in what circumstances by setting up rules for access to data so that each person within the healthcare system receives only the amount of information that he or she requires for the job at hand, says Sharon Baker, chief executive officer of Toronto-based HealthLink Clinical Data Network Corp., which connects more than 40 healthcare organizations in Ontario. Legislation and policies governing privacy and confidentiality are being evolved at a provincial level. Because each province has differing priorities and needs, the challenge of getting everyone on the same page is enormous, says Shelagh Maloney, director of information management at the Canadian Institute of Health Information, the body entrusted with co-ordinating these efforts.

"The technical side is the easy piece compared to making sure that there are policies in place to guide the application of technology," Ms. Maloney says. "Each province and region has different requirements, but there needs to be a base standard to which we all adhere."

Besides getting confidential information into the hands of physicians and keeping it confidential, a national health-information network should be able to strip personal details away from health data to present it in an anonymous format that can be used for research, Ms. Maloney says.

"We are making decisions on the management and restructuring of the health system. It is important to be able to make these decisions on the basis of good information."