Medical Grade Telecom Networks - University of Albertajed3/Theses/Kulshreshtha-MEng... · 2006. 6. 13. · 2. Picture Archiving and Communication System 2.1. Introduction Many healthcare

Medical Grade Telecom Networks by

Prabhat Kulshreshtha, B.Sc.

Report

Presented to the Faculty of Graduate Studies

of the University of Alberta

in Partial Fulfilment

of the Requirements

for the Degrees of

Master of Engineering

Master of Business Administration

The University of Alberta

August 2006

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Prabhat Kulshreshtha, B.Sc.

APPROVED BY

SUPERVISING COMMITTEE:

_________________________

_________________________

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Prabhat Kulshreshtha, MEng, MBA

The University of Alberta, 2006

SUPERVISORS: John Doucette, Roy Suddaby

ABSTRACT

A number of very compelling factors are expediting the integration of technology

into the healthcare sector. This integration is of significant importance to any healthcare

stakeholder since such technology can: help reduce loss of life, facilitate global

collaboration, reduce annual operating expenditures, and of course greatly increase

productivity. This work presents a full economic and technical study concerning the state

of e-healthcare today (2006) with a focus on Canada and Alberta in particular with

specific case studies from around the world. In particular, the dominant healthcare

applications place unique constraints on the underlying telecom networks. Our industry

analysis not only reveals the technical requirements of state-of-the-art networks, but it

also reveals strategic opportunities. Most notably we present current trends in

availability design as well as the organizations that are responsible for e-healthcare

deployments. We also outline the growing issue around protocol standardization since

many current deployments are unable to communicate seamlessly with other sites. A

significant opportunity exists for a protocol translator to allow communication between

disparate systems. The data and material we present can also be of great value for e-

healthcare related market research.

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VITA Prabhat Kulshreshtha was born in Winnipeg, Manitoba on December 10, 1978, the son of

Nand and Chhaya Kulshreshtha. After graduating from Harry Ainlay High School,

Prabhat matriculated to the University of Alberta. There he completed the academic and

work experience requirements of the Bachelor of Science in Electrical Engineering

Cooperative Program. The majority of his work experience during this degree was at

Nortel Networks in various design roles. Upon graduation in 2001, Prabhat accepted

employment at a telecom start-up, Innovance Networks, as a network designer. Later in

2004, he returned to the University of Alberta to complete the MBA /MEng Program.

This report was typed by the author.

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Table of Contents 1. INTRODUCTION............................................................................................................................... 1

1.1. MEDICAL APPLICATIONS.............................................................................................................. 2 1.2. DOMINANT APPLICATIONS ........................................................................................................... 3

2. PICTURE ARCHIVING AND COMMUNICATION SYSTEM .................................................. 5 2.1. INTRODUCTION............................................................................................................................. 5 2.2. PACS COMPONENTS .................................................................................................................... 6

2.2.1. Modalities ............................................................................................................................... 7 2.2.2. Campus Network..................................................................................................................... 8 2.2.3. Storage Area Network ............................................................................................................ 9 2.2.4. Local Monitors ..................................................................................................................... 10 2.2.5. DICOM................................................................................................................................. 11 2.2.6. Application Layer ................................................................................................................. 11

3. ELECTRONIC HEALTH RECORDS ........................................................................................... 13 3.1. INTRODUCTION........................................................................................................................... 13 3.2. SCANDINAVIA ............................................................................................................................ 15

3.2.1. Kingdom of Denmark............................................................................................................ 15 3.2.2. Kingdom of Sweden .............................................................................................................. 18 3.2.3. The Baltic e-Health Project .................................................................................................. 20

3.3. INTERNATIONAL EHR DEPLOYMENT PROGRAMS ...................................................................... 22 3.4. ELECTRONIC HEALTH RECORD STANDARDS .............................................................................. 23

4. COMPETITIVE STRUCTURE ..................................................................................................... 24 4.1. PICTURE ARCHIVING AND COMMUNICATION SYSTEM VENDORS ............................................... 24 4.2. ELECTRONIC HEALTH RECORD VENDORS.................................................................................. 25

4.2.1. HIMSS EHRVA..................................................................................................................... 25 4.2.2. OpenEHR.............................................................................................................................. 26 4.2.3. IBM....................................................................................................................................... 26

4.3. OPTICAL NETWORK VENDORS ................................................................................................... 27 5. CANADA ........................................................................................................................................... 28

5.1. CANADA HEALTH INFOWAY....................................................................................................... 28 5.1.1. Background........................................................................................................................... 28

5.2. ALBERTA SUPERNET.................................................................................................................. 29 5.2.1. Background........................................................................................................................... 29 5.2.2. Implementation Strategy....................................................................................................... 31 5.2.3. SuperNet Users ..................................................................................................................... 32

5.3. NORTH NETWORK ...................................................................................................................... 33 5.4. MBTELEHEALTH........................................................................................................................ 34

6. CANADIAN IT SURVEY ................................................................................................................ 35 6.1. METHODOLOGY ......................................................................................................................... 35 6.2. IT BUDGETS ............................................................................................................................... 35 6.3. SATISFACTION LEVELS............................................................................................................... 36 6.4. BARRIERS TO IT IMPLEMENTATION............................................................................................ 37 6.5. STRATEGIC PRIORITY OF CLINICAL SYSTEMS ............................................................................ 38

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7. HEALTHCARE IN ALBERTA ...................................................................................................... 39 7.1. PAPER RECORDS ......................................................................................................................... 40 7.2. ELECTRONIC HEALTH RECORDS ADOPTION............................................................................... 41 7.3. PHARMACIES.............................................................................................................................. 42 7.4. INTEROPERABILITY .................................................................................................................... 43 7.5. INFRASTRUCTURE ...................................................................................................................... 44

8. FUTURE TRENDS........................................................................................................................... 45 8.1. PACS......................................................................................................................................... 45 8.2. EHR........................................................................................................................................... 46 8.3. PRIVACY ISSUES......................................................................................................................... 47 8.4. IMPLICATIONS FOR PRACTITIONERS ........................................................................................... 48 8.5. INTEROPERABILITY .................................................................................................................... 49 8.6. NETWORK AVAILABILITY .......................................................................................................... 50 8.7. LEGACY DATA ........................................................................................................................... 52

9. CONCLUSION ................................................................................................................................. 53 10. REFERENCES............................................................................................................................. 54

Prabhat Kulshreshtha – Medical Grade Telecom Networks Page 1

1. Introduction

While health care professionals spend more than 80% of their time manipulating

information, they often do not perceive themselves as doing so [1]. This makes the

health profession ideally suited for technology integration to help manage information.

While technology provides many productivity gains, over time technological complexity

has also substantially increased. Most healthcare facilities now maintain a technology

group staffed with engineers who maintain and update their systems.

There are some unique macroscopic trends in healthcare visible today. Due in

part to increased global trade and travel, the spread of disease quickly crosses regional

divisions. Clearly, tracking the spread of disease and healthcare information sharing

between countries is becoming increasingly important. A single global effort is

logistically impossible so this effort must be decentralized into regions. Scandinavia has

demonstrated the greatest progress in this regard and they are often viewed as e-

healthcare pioneers. Scandinavian countries first built respective national IT

infrastructures and are now attempting to integrate themselves together. We will discuss

Scandinavia in great depth in section 3.2.

This report will outline the current trends in healthcare technology in detail along

two dimensions. The first dimension is regional. Regional technologies offer

productivity gains within a facility with some external benefits as well. The second

dimension is macroscopic inter-facility technologies. These technologies help to

integrate multiple regions together with the obvious ultimate goal of world-wide


integration. Key market stakeholders and conditions will be examined along with

specific case studies outlining recent deployments and trends.

This report will begin by providing a comprehensive analysis of current medical

applications to illustrate the nature of medical technology as it pertains to

telecommunications. Since the industry is marked by significant interest from both

public and private firms, we will then examine both the competitive environment as well

as publicly funded initiatives around the world with particular focus within Canada. We

will conclude with forward looking ideas and provide inspiration for future

developments.

1.1. Medical Applications Very simply, medical grade networks are those networks that support medical

telecom applications. Symbiotically, these applications specify network design and

performance criterion necessary to facilitate them.

The following is a comprehensive list of applications in common use today at

healthcare facilities:

1. Patient Care Systems (PCS): PCS is similar to a point of sales system often

used by retailers. Customer visits, interaction details and billing information are

all stored and generated here.

2. Pharmaceutical Systems: These systems are responsible for drug procurement,

distribution, and delivery.

3. Core Patient Information Systems: Some facilities have centralized databases

that contain patient information.

4. Laboratory Information Systems: These systems facilitate remote

appointments and lab result inquiries between administrators and labs.

5. Decision Support Systems (DSS): These consist largely of databases with a user

interface for the purpose of aiding practitioners in making decisions.

6. Radiology Information Systems (RIS): RIS helps radiology clinics manage

patient flow.

7. Picture Archiving and Communications Systems (PACS): PACS enables

digital archiving of medical images.


8. Community Health Systems: CHS is typically a web-based solution for health

facilities to engage the public. Halifax has such a web-portal at www.hfch.org

9. Tele-health: Tele-health systems allow physicians to remotely diagnose and in

some case operate on patients.

10. Administrative Systems

11. Human Resource Systems

12. Education and Training Systems

1.2. Dominant Applications Over the next 10 years, our research suggests that network designers will find two

applications to be of most relevance due to their integrative nature. They will be

introduced here and subsequently analyzed in detail. The first application, which is very

rapidly emerging is Electronic Health Records (EHR). EHR involves digitizing paper

records and deploying networks to connect those who require access to this information.

The second application is the Picture Archiving and Communications Systems (PACS).

PACS involves storing and accessing digital images produced by medical equipment

directly rather than converting them to physical form and storing them in paper files.

Technically, the main benefit of both EHR and PACS comes from the digital

nature of the new format, allowing

electronic manipulation and

instantaneous diagnostics. In

addition to the significant cost

savings, these applications tend to

consolidate the slew of

applications in use today. Among

other benefits is the reduction in

complexity and administration.

The final application worth mentioning is tele-health. There are multiple

definitions of tele-health ranging from any healthcare application using

Picture Archiving and

Communication System

Electronic Health Records

Patient Care

Pharmaceutical

Core Patient Information

Community Health

Laboratory

RIS

Picture Archiving and

Communication System

Electronic Health Records

Patient Care

Pharmaceutical

Core Patient Information

Community Health

Laboratory

RIS


telecommunications to remote diagnosis and even remote surgery. The definition used in

this report refers to video conferencing applications for medical professionals. As an

example, in some cases, a physician must gain the approval of a specialist before

administering treatment. This is particularly a concern in rural locations where

specialists often do not reside. To bridge this distance, video conferencing has been

implemented in a number of regions. As a result, these specialists can visually assess the

situation and in many cases, approval can be granted immediately. However, medical

professionals are also turning towards web-cam technology since the technology has

substantially improved and it offers many other conveniences. Video conferencing, for

example, typically has a dedicated room where patients must be transported. However, it

is more convenient to hold the conference in which ever room the patient currently

resides. Furthermore, current collaboration tools allow electronic document sharing.

This gives the specialist access to the original document rather than trying to view it

through a television monitor. Obviously this reduces errors as well.


2. Picture Archiving and Communication System

2.1. Introduction Many healthcare facilities still use physical film and transparencies for medical

imaging applications. However, digital imaging technology is quickly replacing old

paper-based methods. The Picture Archiving and Communication System (PACS) is an

integrated system used to manage medical images and related data. The visionary

concept for PACS was first presented at a conference of the Society for Optical

Engineering (SPIE) in 1982 [2]. Optical networks dominate deployments due to the high

bandwidth demands that this application places. After years of evolution, PACS

technology finally matured in the late 1990s and is now considered commercially robust.

In fact recent customer approval ratings are among the highest. Currently, PACS

suppliers and analysts alike estimate annual global growth of approximately 20% over the

next five years. [3]

Given the widespread integration of digital technologies in our society, benefits of

PACS-type systems are now largely axiomatic. However, in addition to instant file

access and electronic diagnosis, there are other benefits perhaps unique to healthcare

facilities. Some of these are listed below.

• Facilities are required to keep images for up to 20 years and in some cases, for life

[4]. The probability of misplacing, damaging, or theft of a physical image is quite

high with equally high legal ramifications. While no system is capable of

eliminating all risks, PACS can significantly curb them.

• Particularly in large facilities, a library must be maintained and staffed to

catalogue the records of thousands of patients. Storage and maintenance costs can

be dramatically reduced with the use of PACS.


• PACS can virtually eliminate operating costs related to physical film and image

handling. For example, Concord Hospital, NH [5] a 300-bed facility spent only

$73,000 on film after the first year of implementation. Their annual costs had

typically been $504,000. The corresponding reduction in chemical consumption

is also better for the environment.

• Overall patient care efficiency reduces patient wait times and increases patient

flow.

Originally PACS was used in Radiology clinics because at the time such clinics

produced the highest volume of images. Later with the emergence of other imaging

equipment such as MRIs, uses of PACS were progressively broadened.

While the healthcare industry has taken leadership in the area of digital image

libraries, many other sectors can also benefit from this technology. For example, the

United States Navy maintains over 237 million drawings and over 15 million technical

manuals [6]. The corresponding annual maintenance cost is approximately $4 billion.

Clearly there are obvious crossover benefits.

2.2. PACS Components PACS can largely be described by its constituent elements.

1. Imaging Modalities

2. Campus Network

3. Storage Area Network (SAN)

4. Local Monitors

5. Digital Imaging and Communications in Medicine (DICOM)

6. Application Layer


The following diagram outlines a typical PACS implementation.

CAMPUS NETWORK

MODALITIES

SAN NETWORK

MONITORS

Internet

REMOTE ACCESS

2.2.1. Modalities For health professionals, the term ‘modality’ is defined as a therapeutic method or

agent that involves the physical treatment of a disorder. Specifically, these agents

include MRI, X-Ray and CT scanners. The images produced from patient studies

originate from these instruments. Listed below are some common file sources and sizes

[7].

Modality Image Dimensions Images /study File size per study

Ultrasound 256 × 256 × 8 25 1.5-MB

MRI 512 × 512 × 8 50 13-MB

Computed

Tomography (CT)

1024 × 1024 × 8 50 50-MB

Mammographic Image 4096 × 5120 × 12 4 160MB

4D CT 2-GB


These image sizes are by no means static. Equipment manufacturers continuously

increase the resolution of the images produced. As an example, early CT scanners

produced 512 × 512 pixel images. Current improvements represent a 4 times increase in

file size. Furthermore, cost indifference and ease of use creates incentives for physicians

to increase the study size. Due to these factors, the total size per study is expected to

increase over time.

2.2.2. Campus Network Network bandwidth is of particular importance for PACS implementation. File

sizes produced by equipment are not uniform and data traffic cannot be easily estimated.

In health facilities, there may be load spikes of a few gigabytes. Hence networks should

not be designed based on average load nor can they be designed based on current peak

loads. Due to increasing file sizes, a facility must estimate future file sizes or ensure

scalability on demand.

Some academics have attempted to study traffic trends in PACS implementations

but statistical distribution predictions have so far been weak. As a result, network design

is currently based on worst-case scenarios. There is also anecdotal evidence that facilities

are guided by successful designs used elsewhere and simply copy the same setup. The

following table outlines some healthcare facilities and the core network speed they chose

to implement. It appears as though Gigabit Ethernet is the most common

implementation. At this speed, given 50% bandwidth utilization, a practitioner can

expect to wait about 13 seconds to download a 100MB file.

Facility Beds Core speed Availability Requirement

Vendor

Central DuPage 394 10-Gbps 99.999% Cisco

Clarian Health 1340 10-Gbps 99.999% Cisco

Austin Radiological Association 1.25-Gbps 99.999% LightPointe

Aurora Health Care 129 1-Gbps N/A Enterasys

Orlando Regional Healthcare 1,640 1-Gbps N/A Nortel


Facility Beds Core speed Availability Requirement

Vendor

Peninsulas Health Care Corp 305 1-Gbps 99.999% 3Com

Queens Medical Center 526 1-Gbps N/A N/A

San Antonio Community Hospital 330 1-Gbps N/A N/A

North Kansas City Hospital 351 622-Mbps N/A N/A

Scalability is another advantage of optical networks. In fact Nortel’s networks

can be upgraded in 1Mbps increments on-demand to a maximum of 10-Gbps [8]. Since

most current commercial transponders operate up to 10Gbps, this feature is a

consequence of the design. Obviously beyond this speed additional equipment must be

installed.

2.2.3. Storage Area Network Statistically, image data obtained within the last year is accessed 80% of the time.

The remaining 20% of data queries are for older files [9]. Legally, data must be retained

from 5 to 7 years, depending on local policies. For some infants, data may need to be

held until maturity. As a result, to reduce administrative complexity, some facilities

simply retain records for life.

Clearly much of the data resident on a system is hardly accessed. As a result, a

healthcare facility typically divides its data strategy into three categories: online, near-

online, and offline [10]. Online data is stored on magnetic hard drives and can be

accessed very quickly. A DVD jukebox with a robot arm controller is an example of

near-online access because this technique introduces access delay. Tape drives are an

example of an offline strategy because to access a single file requires the full tape to be

read.

For online data, Storage Area Network (SAN) architecture seems to be most

favoured due to high reliability and scalability. However, even SAN was not originally

designed to support the large file sizes in PACS. To increase reliability, data is typically

stored in 2 independent servers and possibly in a backup tape. A SAN would typically be

designed to hold data for one year.


For older data, a DVD jukebox is often advocated, with some caveats. This

choice is driven entirely by cost. The cost per megabyte is lower for optical memory than

for magnetic memory. However, since the price of commercial magnetic memory falls

every year, a facility is encouraged to make purchases in yearly increments. Furthermore

many decision-makers are concerned with obsolescence of removable media. [11] They

feel that, much like floppies, one day computers may no longer be sold with DVD

readers, in favour of a new technology, and all their backup data will become

inaccessible. Information lifecycle management is therefore very important to

practitioners. In the event of disaster recovery, manually feeding tapes into the system

and saving the data to the proper database can potentially take months. In contrast, an

automated system can significantly reduce complexity and time.

2.2.4. Local Monitors Medical imaging devices produce images with greater than 256 shades of grey.

This level of contrast is required to make the required diagnosis. As a result a PACS

library must be equipped with the appropriate monitors. These monitors must have at

least 8-12 bits of grey information per pixel.

Such facilities have traditionally been equipped with black and white monitors;

however, a strong business case for purchasing colour monitors now exists. The latest

ultrasound equipment, for example, can produce images in colour. This adds an

additional requirement for the monitors.

The grey-scale requirement places restrictions on where images can be diagnosed.

In one respect this limitation is innocuous since most external networks are ill-equipped

to service the required bandwidth demands anyway. For example, a 100-MB file could

take over an hour to download using a DSL connection. However, for those physicians

that need to access these images, low resolution jpegs are often made available through a

web-server. Clearly these images should not be used to make detailed diagnostics but

they do provide decision makers with some information.


2.2.5. Digital Imaging and Communications in Medicine (DICOM) DICOM is the underlying protocol that imaging modalities use for

communication. Different levels of the DICOM protocol include information

management services, image quality, reporting mechanisms, and security. [12]

The information management component regulates the basic image transfer and

storage process. For example, DICOM ensures that a local image cannot be deleted until

the file has both been copied to another location and the responsibility for that file has

been transferred to the new location. This reduces the likelihood of accidental erasure.

Image reproducibility between sites has also been a source of consternation. The

DICOM standard ensures that an image viewed on different monitors or printed on

different printers is produced identically. This includes specific monitor settings such as

contrast and brightness. Also, annotations that physicians make to the image are

preserved by the DICOM standard. Previously, there was no common platform with

which to do this.

DICOM also allows a user to attach a structured report. This report is digitally

linked to the image. File management and orphaned pictures are also of particular

concern and this feature helps to reduce both these problems.

Lastly DICOM has a built-in user logging mechanism so that images can not be

manipulated without the receiver noticing. DICOM also incorporates standard

encryption methods when transmission is across a public network.

A major concern with DICOM is that while it is a protocol with growing adoption

rates, many vendors are tweaking the standard with custom enhancements [13]. These

enhancements reduce interoperability between systems.

2.2.6. Application Layer The various components of PACS integrate together at the applications layer.

This places PACS application vendors at a unique advantage. Not only do these vendors

claim to understand the full integration process, but their brand is also the most visible

since users log into the system using their software.


Bandwidth management is a key issue with PACS. Phillips, a PACS vendor, has

devised an innovative technique to avoid downloading the entire file at once. Using the

mathematical concept of wavelets, the image is essentially stored in parts. A portion of

the image is downloaded at the lowest resolution and as the user desires greater

resolution, higher components of the image are downloaded. This technique is

particularly beneficial when the underlying network is of lower speed. In fact, Phillips is

so confident in this method that it

guarantees 99.99% availability regardless of

the network bandwidth. Phillips claims that

theirs is the highest availability guarantee in

the industry [14].

Certainly the cost of any PACS

implementation depends on a number of

factors but a rough estimate can be made

based on the number of beds. A 300-bed

facility can face implementation costs between $5 million to $7 million plus annual

maintenance charges which are estimated at 8% of the implementation cost [15]. To

entice purchasers, many vendors have moved to a “pay-per-study” business model. A

customer would pay continuous fees to view, distribute and store images rather than pay

upfront capital costs. For those facilities without the budget to make large purchases, this

model allows easy cost amortization of such equipment over time.

Cost-per-view also alleviates another significant burden facilities face. Namely,

medical facilities rarely have the technical expertise to source and deploy a functional

system. As a result larger facilities have had to hire the requisite expertise. In contrast,

cost-per-view vendors typically agree to provide and service all the underlying

equipment. Medical facilities benefit from the resulting reduction in complexity.

Source: Phillips Global PACS


3. Electronic Health Records

3.1. Introduction Electronic Health Records (EHR) is an enabling technology that is redefining how

medical practitioners store and communicate patient information. Globally, medical

information is largely transacted using paper documents and the sector is eager to

capitalize on the benefits offered by electronic formats.

An EHR is an electronic version of patient health information stored in a

predetermined template. Each patient-practitioner encounter results in an EHR entry.

This information can include but is not limited to:

• Demographics

• Progress notes

• Medical history (personal and family)

• Laboratory data

• Radiology data

• Medication conflicts

The global push towards electronic records has largely come from the concrete

benefits that they offer. Specifically, the success of Danish and Swedish implementations

has motivated other governments to follow their lead. Indeed, the Scandinavians have

proved that electronic records not only improve the patient delivery process but that they

also reduce the total cost of delivery as well. The following advantages are among the

most quoted.

• The accuracy and completeness of the data reduces the likelihood of medical

errors. In 2000, the Institute of Medicine (U.S.) submitted a report to Congress

indicating that between 44,000 and 98,000 people die in Hospitals each year due

to medical errors. Among the strategies presented to cope with the situation was

to form a national reporting system [16].


• Once implemented the cost savings are enormous. A recent 2005 American

federal study by Project Hope has estimated a cost saving of US $77.8 billion per

year [17]. In Canada, the federally funded Infoway has estimated savings of CAD

$3.4 billion [18]. Denmark, a country of 5 million people currently saves €60

million each year [19]. In all cases, the cost savings are many orders of

magnitude greater than the cost of implementation.

• The electronic format lends itself to instant computerized diagnostics and

complex search criteria. The EHR system can also be used to track the

macroscopic progress of disease within a country. This is particularly useful

when tracking pandemics.

• Patients appear to be comfortable with their data being stored electronically.

Security concerns are not particularly high either. PriceWaterhouseCoopers

(2001) found that that 92% of Canadians are at least “somewhat willing” to carry

EHR smart cards [20]. Accenture (2005) found that U.S. citizens would even be

willing to pay $60/yr for this electronic service [21].

• EHR systems can automatically create progress notes per patient visit. This

reduces physician’s paperwork and expedites patient delivery.

Electronic records are often referred to as Electronic Health Records (EHR) as

well as Electronic Medical Records (EMR). This difference is not simply a matter of

semantics; there is specific meaning behind each. EMR are those records that medical

practitioners work on. A user has full read/write access to these records and they contain

notes specific to the physician. When the EMR is released by the practitioner, it turns

into an EHR. The EHR is then shared between facilities as a read-only document. The

EHR contains the final information and all work-in-progress notes are stripped away.


3.2. Scandinavia Any discussion of Electronic Health Records would be incomplete without

mentioning Scandinavia. Namely Denmark and Sweden provide the strongest success

stories about how EHR can be implemented.

3.2.1. Kingdom of Denmark

Denmark is the smallest of the

Scandinavian countries with a population of 5

million inhabitants. Much like U.K., Denmark

is a constitutional Monarchy with both a Queen

and Prime Minister. Denmark typically

follows socialist leanings and is considered to

be a welfare state with one of the highest taxation systems in the world. As such,

Denmark has a public healthcare system and its 14 Counties are responsible for providing

universal, free, and equal access services. Despite being a decentralized system, the

Danish Counties have cooperated with one another for the national e-health program.

MedCom, the Danish e-health program was founded in 1994 [22]. Perhaps the

greatest accomplishment has been the successful cooperation between authorities,

organizations, and private firms with stakes in the Danish healthcare system. MedCom

has passed through five iterations starting with MedCom I to MedCom V.

MedCom I can be attributed to the efforts of the County of Funen, which

proposed a vision to develop a national system to electronically communicate messages

between healthcare stakeholders. The first system transferred electronic lab results from

hospitals to the office of a General Practitioner. Over the following two years, features

were increased. The objective of MedCom I was to develop and test a working

Electronic Data Interchange (EDI) system using the public internet with secure VPN

tunnels.

Source: en.wikipedia.org


MedCom II followed the success of the localized MedCom I implementation.

The program was expanded nationally and involved thousands of healthcare

professionals. The pure “EDI” standard was narrowed to cater to specific healthcare

needs and the EDIFACT standard was adopted as the communication protocol. Dentists,

home care, and other telemedicine pilot projects were introduced. By 1999 electronic

communication had been significantly adopted in primary care facilities.

MedCom III was responsible for consolidating all the systems and streamlining

the delivery process. The focus shifted from technology development to patient quality

assurance. The structure of the electronic reports were formed and agreed to by large

healthcare focus groups.

MedCom IV introduced an internet strategy. The Danish Health Portal was

introduced and provided a direct access point for citizens to the healthcare network. This

system allows patients to book appointments, conduct email consultations with GPs, and

renew prescriptions.

MedCom V is currently underway with a number of new enhancements to the

MedCom systems. These include a number of structural reforms that are meant to

include more regions and increase supply chain robustness.

As a result

today in Denmark, all

paper messages have

been converted to

electronic formats. To

illustrate, when a

General Physician (GP)

prescribes a laboratory

test, the appointment is

automatically booked

for the patient. This

obviously speeds up the

Source: Presentation by Henrik Jensen (europa.eu.int) - 2003 ehealth

conference.


patient queuing process and once the results are obtained, they are instantly transmitted to

the GP. Simultaneously, the various agents are reimbursed by the public insurance

agency.

There have been a number of reasons for the success of MedCom [23]. Firstly,

the Counties have provided great support to the practitioners. A Data Consultant visits

all practices regularly to train staff on the system. This also provides two-way

communications for staff to offer new ideas. A user can call a national help desk to ask

for advice or instructions. For new GPs, the County helps to set up the infrastructure to

connect to the network. Secondly, MedCom set strong standards. The program obligated

the Counties to participate so there was little room for debate. Furthermore, technology

vendors participated throughout MedCom’s evolution so they could provide

implementation insights. Finally, cultural acceptance has helped to promote adoption.

Those GPs not connected to MedCom are considered to have archaic practices while

connected practices are viewed more favourably and tend to attract more patients.

The final analysis [24] proves that MedCom has resulted in substantial savings for

the Danes. Estimates indicate that the system has freed up 50 minutes per day in a

normal GP’s practice. Since

virtually all stakeholders now

communicate electronically, the

number of phone calls placed to

hospitals has been reduced by 66%.

Compared with the old paper based

method, each new electronic

message costs €2.3 less. In 2003,

the annual cost savings were €60

million per year. These are certainly

extraordinary results and have

inspired governments around the

world to follow the Danish example.

Source: Danish Center for Health Telematics

(MedCom IV: status, plans and projects).


3.2.2. Kingdom of Sweden

There are many similarities between

Sweden and Denmark. Sweden is also a

constitutional monarchy, symbolically ruled by

King Gustaf. He governs a population of about

9 million (almost twice that of Denmark)

spread over 450,000 sq. km (ten times bigger

than Denmark).

The nation is marked by generous social benefits for its citizens. The government

covers all medical costs such as childcare, healthcare and dental care through a publicly

funded system. Financing for these services has typically come from high taxation.

However, the Swedish tax system is currently facing reformatory pressure. Membership

with the E.U. has resulted in abuse of its programs and the country is also attempting to

attract business to improve its economic standing. As a result, the country has lowered

corporate tax rates and other taxes may fall as well.

Sweden is divided into 21 Counties. Much like in Denmark, Swedish Counties

have a high degree of regional autonomy. These Counties are largely self-governed by a

counsel of elected and appointed members. Healthcare services are among the main

responsibilities for the Counties.

A 2005 study conducted by Robert Huggins Associates, (a think tank in Wales)

found that Stockholm, Sweden is the leading location for IT Knowledge outside the US

[25]. High tech firms such as Song Networks, Saab Dynamics, and Optillion are among

many sources of national telecommunication expertise. This centre of competency is

particularly beneficial for a country implementing a national IT health network.

The Swedish Electronic Health initiatives can be traced to the efforts of the seven

Counties that led its development in 1998. The network is called Sjunet. ‘Sju’ is the

Swedish word for seven and was chosen to honour the founding Counties. The pilot

project was funded by the Counties and the federal ITHS R&D fund. In 2001 Carelink,

an independent body responsible for national healthcare ICT was established.

Source: en.wikipedia.org


The first iteration of Sjunet used the internet with VPN tunnels [26]. Connection

was provided by Telia, the Swedish telecommunications carrier. Five years since

inception, Sjunet purchased its own dedicated IP optical network from Song Networks.

This dedicated network provides greater availability

and has built-in redundancy. Each County accesses

Sjunet with a 10-100Mbps connection. The higher

bandwidth of Sjunet has enabled some interesting

applications. Firstly, videoconferencing has become

more ubiquitous fostering greater communication

among physicians. Secondly, Sjunet has also

incorporated a national population database and

various other e-Government services related to

healthcare monitoring and administration.

Sjunet connects over 80 hospitals, 800 primary

care centres, 900 pharmacies and a large number of

GPs. The solution is highly scalable and can easily be connected to new institutions.

Currently, the core bandwidth is 1 Gbps but this can presumably be upgraded as well.

This bandwidth seems to adequately service the current national needs.

Since the administrative and development costs are distributed among the

Counties, each County pays €12,000 per year for a 10Mbps connection [27]. The costs

are incrementally higher if the County desires greater bandwidth. In any case, this is an

insignificant sum when compared to other alternatives. In fact, Uppsala County

conducted an in depth cost-benefit analysis and found that Sjunet saves them €600,000

per year [28]. The savings are largely attributed to improved collaboration, lower staff

costs and reduced physical transportation of paper documentation.

Source: carelink.se


3.2.3. The Baltic e-Health Project

Denmark, Sweden and Norway have all established impressive national IT health

networks. The differences are rather minor. Given the success of these national

networks, in 2005 the European Union initiated a transnational project by allocating

European Regional Development Funds to this cause. The initial vision was to provide

rural locations with the same healthcare benefits as their urban counterparts. It was

hoped that such projects would not only foster multinational cooperation but also stave

rural migration [29].

The pilot project, the Baltic

Health Network (BHN), consists of five

hospitals in five separate countries [30]:

1. Funen Hospital (Denmark)

2. Västerbotten County Counsil

(Sweden)

3. St. Olav's Hospital (Norway)

4. East-Tallinn Central Hospital

(Estonia)

5. University Hospital (Lithuania)

Interestingly Denmark, and in

particular, the County of Funen has

again taken the lead role in

implementing BHN.

Initial clinical trials are in the areas of e-Radiology and e-Ultrasound. The intent

of these trials is to verify the reproducibility of the data once it has traversed the network.

To this end, an image is transmitted to two hospitals simultaneously and physicians

diagnose the images independently. Preliminary analysis reveals that the discrepancy in

diagnosis is less than 10% between hospitals. Hospitals in Denmark, Estonia and

Source: www.baltic-ehealth.org


Lithuania are responsible for e-Radiology while Norway and Sweden are focused on e-

Ultrasound.

Blurring of national boundaries in Europe has resulted in highly mobile

populations [31]. In many cases people work in one country and live in another. Ideally,

Swedish citizens would have access to their medical information in Denmark. A

significant technical challenge is that while all nations have implemented the EDIFACT

standard, each country has adapted the standard in slightly different ways [32]. Hence a

Danish GP can not simply send an EDIFACT prescription directly to a Swedish

pharmacy. Multinational implementation requires that either standardization be achieved

or protocol translators be installed at interface points. There are a number of other issues

that arise as well:

1. Legal jurisdiction and responsibilities.

2. Cultural differences.

3. Language barriers.

4. Billing jurisdictions.

The goal of the designers of the Baltic Health Network is to increase use and

expand its size and scope. Other facilities or regions are welcome to participate provided

that they prove that their own regional network is secure and that they have reason to join

the BHN. Clearly there is much technical as well as political work to be done before the

Baltic e-Health initiative is complete but these first steps are vital to demonstrate

feasibility.


3.3. International EHR Deployment Programs Perhaps inspired by the success of Scandinavia, many governments have set up e-

Health Programs to implement electronic health records. In many cases, substantial

funds have been devoted to this cause with non-partisan steering committees.

From a macroscopic perspective, once a large number of countries implement and

interconnect their EHRs, a number of benefits emerge. Modern diseases such as SARS

and the more recent Bird Flu cross international boundaries freely. A global EHR system

could provide extensive statistics regarding the spread of illness that may yield

illuminating correlations. Additionally, such a network would facilitate greater informal

collaboration between countries in addition to formal publications. This could expedite

medical progress and promote best practices.

Country Program Target Deployment date Australia Integrated Health Record and

Information System - part of the HealthConnect programme

Canada National program for a pan-Canadian electronic health record - a major part of Canada Health Infoway

50% of the population by 2010

Denmark Implementation of electronic health records in hospitals, community health care and general practice

2003 -

England A major part of Connecting for Health (NHS, England)

2010 (for all patients in England)

Finland Implementation of national interoperable electronic patient records

2007

France Dossier médical personnel (DMP) - personal health record

By July 2007 (for all French citizens over the age of 16)

New Zealand Health Information Strategy for New Zealand, 2005 (HIS-NZ)

USA A major part of the Health Information Technology Plan

"Most Americans" by 2014. ("Participation by patients will be voluntary.")

Hong Kong Introduction of a patient-held medical record system in all General Out-patient Clinics (Hong Kong Hospital Authority initiative).

2007

Singapore EMR Exchange (EMRX) - Initiative by the Singapore Ministry of Health and the two public healthcare clusters to share information held on EMRs across all public hospitals and polyclinics.

From April 2004


3.4. Electronic Health Record Standards As noted earlier, standard harmonization is a critical issue. Not only are there a

number of organizations developing standards but regional implementations of the same

standards also differ.

Currently, HL7 (CDA) appears to be the most popular in North America and a

majority of the vendors produce HL7 compliant products.

Standards Description ISO 18308 Clinical and technical requirements for an Electronic Health

Record Reference Architecture "that supports using, sharing, and exchanging electronic health records across different health sectors, different countries, and different models of healthcare delivery". (2004)

ASTM Committee E31.19 Standards on Electronic Health Record Content and Structure

CEN 13606 The European electronic healthcare record interoperability standard (2004). Includes: EHR reference model, archetype interchange specification, reference archetypes and term lists, security functions, exchange models to support communication.

Health Level 7 (HL7) v3 Messaging standard to support communications "between hospital and physician record systems and between EMR systems and practice management systems" (2003).

Health Level 7 (HL7) Clinical Document Architecture (CDA)

An XML-based generic model for the representation and transfer of clinical documents. "CDA is being used also in electronic health records projects to provide a standard format for entry, retrieval and storage of health information." The CDA release 2.0 was approved as an ANSI standard in May 2005.

ASTM Continuity of Care Record (CCR)

A projected XML document standard for a summary of personal health information (data set) to help achieve interoperability between medical records and to ensure "a minimum standard of health information transportability when a patient is referred or transferred to, or is otherwise seen by, another provider."

e-MS (Electronic Medical Summary)

A projected standard for the Canadian province of British Columbia for an e-MS minimum dataset, messaging standards and technical architecture to support integrated health information management.

Health Level 7 (HL7) RIM Reference information model: "a single, all-encompassing model of the data structures that healthcare applications can exchange" (University of Manchester). "The RIM is an essential part of the HL7 Version 3 development methodology, as it provides an explicit representation of the semantic and lexical connections that exist between the information carried in the fields of HL7 messages" [HL7].

EDIFACT Developed by the United Nations, this is a generic standard to exchange standard messages. It allows multi-country and multi-industry adoption. Variants of this standard have been developed by both Sweden and Denmark for their national EHR standards.


4. Competitive Structure

4.1. Picture Archiving and Communication System Vendors Healthcare Information and Management Systems Society (HIMSS), a reputable

business journal catering to the healthcare market, conducted a global survey in 2005 to

understand PACS market share breakdown [33]. The results show that GE Healthcare

Technologies commands the largest share of the market. However, the high degree of

market fragmentation suggests that each vendor has comparable value propositions and

that none has yet captured the market.

GE Healthcare Technologies, 20%

Phillips Global PACS, 12%

FUJIFILM Medical Systems, 12%

Siemens Medical Solutions, 11%

Others, 45% Other vendors with roughly 10% market share each include:

• AGFA-Gavaert

• Mortsel

• McKesson Corp


4.2. Electronic Health Record Vendors There are a number of EHR vendors also yet none has managed to capture any

significant share of the market. The following table lists a subset of the many vendors in

this sector.

A4 Health Systems AllMeds, Inc.

Companion Technologies Draeger Medical, Inc.

eMedical Files, Inc. Systems GE Medical Systems Information

Technologies

IBM Integrated Medical Records iMedica Corp.

JMJ Technologies, Inc. McKesson

MEDCOM Information Systems, Inc. NextGen Healthcare Information Systems

Siemens Medical Solutions Health Systems SolCom, Inc.

VantageMed Corp. VitalWorks

WebMd Intergy IDX Systems Corp.

A number of factors have promoted fragmentation of this market but the most

significant factor is the lack of interoperability. One of the basic EHR requirements is

that systems communicate seamlessly. Even slight implementation differences between

two systems using the same standard will impair communication. As noted earlier, the

Baltic Health Network is experiencing such problems even though member countries use

the EDIFACT standard.

4.2.1. HIMSS EHRVA Recognizing the importance of interoperation, 21 enterprising vendors decided

that collaboration is the key to success for all. To this end, they have created the HIMSS

Electronic Health Record Vendor Association (EHRVA) with the intent to promote a

certification process, interoperability, performance and quality measures, and to deal with

other EHR issues [34].


This attempt at collaboration presents some interesting strategic issues. Firstly,

by promoting a certification process, EHRVA is attempting to raise barriers for those

vendors unwilling or unable to join their collective. Secondly, EHRVA is chaired by

Charlene Underwood of Siemens Medical Solution. Regardless of their intent, it will be

interesting to see if competitive pressures challenge this alliance.

4.2.2. OpenEHR OpenEHR, an open source community of developers, has also attempted to solve

the integration issue [35]. OpenEHR is a fully functioning EHR system which also

addresses interoperation between both HL7 and EDIFACT standards. If successful, this

may help to bridge systems using either standard. With chapters across the globe,

OpenEHR has already been deployed in many facilities. Most notably, in 2002 the

Australian government selected OpenEHR as the basis for their national EHR

deployment project.

While open source may appear to be a great way to promote interoperability, open

source projects of this magnitude and scope have limitations. As a related example, if a

company chooses to migrate to the open source UNIX operating system, the code often

needs to be frozen so that the firm can provide internal support. This is particularly

important if a firm sells an operating system as part of an integrated product. Open

source software changes too frequently to provide the level of stability often needed.

Furthermore, open source software is rarely supported by the development community.

4.2.3. IBM In May 2005, IBM launched Federated Records Management System [36]. This

system allows companies to manage electronic health records generated by a variety of

vendors. Once the system reads a record, it converts it to human and machine readable

XML and then converts it back to the required format. Moreover an operator can manage

multiple systems from a unified access point. The system can also link to both structured

and unstructured data, such as related documents. IBM would also like to eventually

integrate this system with other IBM software such as Lotus Notes to provide even


greater flexibility. Even if IBM fails to gain majority market share, this product may be

the critical link required to harmonize multiple systems.

To test the effectiveness of their solution, IBM launched an internal EHR

initiative for its employees in 2005. Initially employees will input their own data

manually through a web portal. Later the system will begin to integrate insurance claim

systems to automatically update employee information.

4.3. Optical Network Vendors Despite the pioneering efforts of optical engineers in the field of e-healthcare,

optical networks are no longer application drivers. Today, optical networks are much

easier to deploy than their predecessors and they can support virtually unlimited

bandwidth. As a result networks are no longer bottlenecks and teams of specialists are

not needed for deployments. As a consequence they are increasingly viewed as

commodities. To curb commoditization, vendors have adopted some unique strategies.

Since there is natural synergy between the network infrastructure and the application

layer, some vendors have entered into informal alliances. Others have leveraged other

integrated product lines to provide a more comprehensive solution.

Major optical equipment vendors serving the healthcare market include:

• ADVA Optical

• Alcatel

• Cisco Systems

• Nortel Networks


5. Canada

5.1. Canada Health Infoway

5.1.1. Background Similar to other federal governments, Canada is committed to implement a

national Electronic Health Record (EHR) strategy. The Canadian government’s goal is to

have electronic health records available for over 50% of Canadians by the end of 2009.

The Canada Health Infoway is an independent organization tasked with managing $1.2

billion of public funds specifically for EHR projects [37].

Infoway Corporate Members are Deputy Ministers of Health appointed by each

province. The Board of Directors is comprised of members from various public and

private organizations.

Infoway has determined nine investment programs that will lead to the desired

national EHR network:

1. Registries: comprehensive identification of patients, healthcare practitioners, and

healthcare facilities

2. Diagnostic Imaging Systems: migration of digital images to a PACS system

3. Drug Information Systems: database to compare prescriptions with patient history

to avoid adverse interactions.

4. Laboratory Information Systems: electronic communication of lab results.

5. Telehealth: health care delivery regardless of distance.

6. Public Health Surveillance: national identification, management and control of

infectious disease.

7. Interoperable EHR: integration of medical information among disparate systems.

8. Innovation and Adoption: rapid deployment of EHR.

9. Infostructure: interoperability and standard harmonization.


5.2. Alberta SuperNet

5.2.1. Background The Alberta SuperNet represents a public-private partnership between the

Government of Alberta and Bell Canada to create a provincial high-speed IP health

network [38]. There are a number of similarities between the Alberta SuperNet and the

various other national networks presented in this report. Namely, the network has the

primary objective of integrating rural and urban communities. Clearly

telecommunications equipment will not eliminate this divide but it is a good first step.

The SuperNet project had the following objectives:

• Reduce the “digital divide” by providing rural locations with the same quality of

resources enjoyed by their urban counterparts.

• Provide reasonably priced internet access to residents, regardless of their location,

with bandwidth comparable to xDSL or Cable.

• Provide rural schools with access to specialized teachers through video

conferencing equipment.

• Integrate communication needs of both rural and urban healthcare facilities

through a common network.

• Connect all provincial government offices together through a highly reliable and

secure dedicated network.

• Provide a common telecommunications platform for communication between all

public libraries.

The Alberta SuperNet is now operational in most of the targeted communities.

Shortly, SuperNet will connect all 4,200 facilities within 429 communities. These

facilities include libraries, schools, government offices and healthcare centres.


The Alberta SuperNet

is particularly distinctive

from other such health

networks in one regard:

SuperNet has been opened to

private competition. In other

words, any business can

connect to SuperNet for a fee

and resell the bandwidth

commercially. As an

example, an ISP such as TELUS could connect SuperNet to its own equipment and sell

commercial internet connections to any residential or business customer that is linked to

SuperNet. A SuperNet subcontractor, Axia and the Network for Emerging Wireless

Technologies (NEWT) have created the Alberta SuperNet Certification and Showcase

Lab. The Lab provides smaller ISPs, without technical sophistication, the guidance they

need to connect their equipment to SuperNet’s.

Furthermore, public institutions do not automatically gain high speed connections

for free. They must pay a capped government rate to connect to Alberta SuperNet.

Presumably this is to reduce free-riding and to promote financial stewardship. However,

in the case of libraries, which provide public-good services, this focus on financials may

arguably be diametrically opposed to the initial project objectives.

The Government of Alberta hopes that the resulting competition will help to

provide competitive access to remote users as well as provide enough revenue to cover

the cost of network operation and maintenance.

Obviously the Alberta SuperNet differs in political ideology from the

Scandinavian networks. The Scandinavians follow socialist leanings while Alberta has

more capitalist tendencies. Interestingly, both have arrived at the similar conclusion

regarding the need for rural /urban telecom integration. Differences in implementation

could provide insights regarding which combination of approaches will yield the most

optimal results.

PoP

Health Facility

Library School

GovernmentHomes Businesses

PoP

Health Facility

Library School

GovernmentHomes BusinessesHomes Businesses

Source: www. albertasupernet.ca


5.2.2. Implementation Strategy SuperNet is touted as one of the most sophisticated communications networks in

North America. The 12,000 kilometre network consists of both fibre optic and

microwave links. Clearly the fibre optic links provide the greatest reliability and

bandwidth but some regions are characterized by adverse landscapes that make fibre

installation problematic. These landscapes are traversed by microwave systems. Such

microwave links represent only 16% of the network infrastructure.

A number of private companies were responsible for bring SuperNet to life. The

Government of Alberta designated Bell Canada as the prime contractor. In turn Bell

Canada partnered with 27 subcontractors with various specializations. The network itself

was design by Axia NetMedia and implemented by Bell Canada. Due to its role, Axia

holds a prominent position as well.

Products from various manufacturers resulted in the functioning physical layer.

The fibre optic cables with standard single mode fibres were purchased from Alcatel.

Their EZ-Prep cables were chosen due to their high reliability. In some locations, Bell

Canada simply purchased fibre previously installed by 360Networks. Cisco’s ONS

15454 SONET Multiservice Platform lights up

these fibres using Gigabit Ethernet. Hence the total

core bandwidth is 1Gbps. Also, Cisco’s MPLS

routers were used for the routing layer. Nortel’s

WIMAX transponders were deployed for the

wireless connections.

The Government of Alberta allocated $193

million for SuperNet’s construction. The

remaining $120 million was invested by Bell

Canada.

As an investor, Bell Canada enjoys various

privileges and has specific responsibilities.

SuperNet has both a Base Area Network (shown as

bold in the figure) and an Extended Area Network.

Bell Canada owns the Base Area Network which Source: www. albertasupernet.ca


connects 27 of the larger cities and communities. The Alberta Government owns the

remaining extended network. As contractors, Bell Canada and Axia NetMedia are

responsible for the operation and maintenance of the entire network.

As part of the agreement, Bell Canada is designated as the Provider of Last Resort

(POLR). Under the terms of the agreement, if no other ISP provides high-speed service

by April 2006, Bell Canada must provide access comparable to xDSL to any resident

upon request. The offered rate must also be equivalent to urban rates. Due to this

disincentive, Bell Canada announced that all residential rural communities will be

connected by April 2006. All public institutions will be connected by June 2006 and the

network will be fully operational by September 2006.

5.2.3. SuperNet Users As a result of open competition, a number of large network providers have

already connected to SuperNet. TELUS, for example, currently provides various services

to rural customers including VoIP. Smaller ISPs including Xplornet are also attempting

to provide internet to these underserved areas. CA*NET has estimated that a rural

business currently spending $2,000/month on a T1 line would pay about $820/month as a

result of SuperNet [39].

Alberta Health and Wellness recently announced that it is migrating to digital

images. It intends to become completely filmless by 2008 and has set aside $177 million

for this task. Alberta Health and Wellness plans to use SuperNet for its telecom

infrastructure. Transmitted images will include x-ray and MRI images. Mammography

scans present greater technological challenges so they will not be immediately digitized.

In Alberta, Electronic Health Records are communicated over the public internet

(like in Denmark). Therefore, while the Alberta SuperNet is not used as a dedicated EHR

network, SuperNet does facilitate internet connections for rural communities.

The expediency with which organizations such as Alberta Health and Wellness

proceeded to utilize SuperNet suggests that many other Health facilities will follow.

Applications may include image transfer, administration or simply internet connection.


5.3. North Network Ontario launched a provincial network to connect underserved and rural

communities in Ontario in 1998 called North Network [40]. Prior to installation, Ontario

spent $20 million a year on air ambulance services alone. The initial network was

dedicated to video conferencing applications. This allowed remote physicians to consult

specialists unavailable in their locale before administering treatment.

The first iteration of North Network connected 4 communities but today 111

communities are interconnected by this network. Similar to Scandinavia, this network is

publicly funded. The Ontario Ministry of Health and Long Term Care provides the

largest contribution towards annual expenditures. Extra funds required for upgrades and

improvements come from a variety of federal and provincial sources. Unlike Alberta,

this is a closed network exclusively for healthcare use.

Since its introduction, the network has been upgraded to IP from ISDN. The

infrastructure was provided by Cisco using a MPLS routing layer. This 2002 upgrade has

allowed delivery of other services

including Electronic Health Records

(EHR) and digital radiology image

transfer. Agfa’s IMPAX system has

been installed for the PACS

application layer. End sites now

experience data rates from 400kbps

to 1Mbps. Compared with Alberta’s

more recent network, North Network

is rather slow. However, the

benefits of the technology are so

great that users happily accept the

longer download times.

Source: www.northnetwork.com


5.4. MBTelehealth Launched in 2001 by the Winnipeg Regional Health Authority, MBTelehealth is

an IP network connecting 26 rural and urban sites [41]. Winnipeg is the province’s

medical hub and prior to MBTelehealth, patients requiring significant medical treatment

had to travel to Winnipeg, where 95% of clinical specialists reside. Reducing this travel

time was the prime motivator for the project. Connected facilities include hospitals and

other larger health centres. MBTelehealth has focused on the areas of clinical diagnosis

and education via videoconferencing. The province would like to become a leader in e-

healthcare training.

While the project is deemed successful by any measure, Manitoba’s diminutive

economic climate presented a number of challenges. For example, loss of key medical

professionals delayed or terminated projects. Also, since IBM is among the few high

tech companies in the region, internal IBM restructuring led to substantial delays as an

alternative could not be found.

MBTelehealth is also publicly funded with contributions from Canada Health

Infostructure Partnership Program (CHIPP)

as well as Manitoba Health. Major project

vendors included Manitoba Telecom

Services AMD, Adcom, and Cisco

Systems.

Over time, there has been much

collaboration and sharing between

MBTelehealth and North Network.

CA*Net has acted as the bridge between

the two networks. Clinical and educational

services were shared with 11 northwestern

sites in Ontario. With integration in mind,

Canadian Health Infoway initiated the

telehealth starter toolkit. The toolkit will further promote knowledge sharing between

these two networks.

Source: www.mbtelehealth.ca


6. Canadian IT Survey

6.1. Methodology First, we shall review the results of an IT survey conducted by Canadian

Healthcare Technology in 2002 [42]. The survey is relatively recent and includes 104

stratified random hospitals across Canada. Respondent were CIOs and senior IT

healthcare professionals. Clearly we do not have access to such individuals so we must

rely on the results of this previous report.

6.2. IT Budgets On average, hospitals have an operating budget of $92.5 million dollars and

approximately 2% of this budget is allocated to IT expenditure. The following table

breaks down the budgets for different IT activities.

Mean Annual Expenditure per facility

Allocation Total Per bed

Hardware Acq. 28% 486,920 1,689.23

Software Acq. 21% 365,190 1,266.92

Support 42% 730,380 2,533.84

Misc. 9% 156,510 542.97

Total IT Budget 100% $1,739,000 $6,032.96

There appears to be clear indications that IT budgets are under funded by over 2%

of the annual budget and budgets need to double to significantly gain from the

productivity IT offers. For example, 36%-37% of respondents did not have a disaster

recovery program in place. Furthermore, security and confidentiality programs appeared

to lack funding as well. In an attempt to curb these potential threats, IT budgets were

targeted to increase by 20% for 2003.


It is important to mention that simply increasing budgets is only part of the

solution. Arguably, the most important factor is the formulation of a well-planned

strategy backed by dynamic individuals to implement it. However, these other factors are

much more subjective and such reports assume that the facility will use the funds in an

appropriate manner.

6.3. Satisfaction Levels Satisfaction with Vendor Support

Software application / No. of users Satisfied (%) Neutral (%) Dissatisfied (%)

Core Patient Information / 88 68 16 16

Financial / 96 68 19 14

RIS / 53 64 30 6

Pharmaceutical systems / 78 63 22 15

Patient Care Systems (EMR) / 52 62 19 19

Laboratory Systems / 64 58 23 19

PACS * / 19 47 32 21

Decision Support Systems / 36 53 33 14

Community Health Systems / 29 48 38 14

HR Systems / 61 44 31 25

Educational training / 36 28 56 17

* Caution: Small base

Vendor satisfactions in Eastern Canada seem to be somewhat higher than

satisfaction levels in the west. Generally the size of hospitals is larger in the East with

correspondingly larger budgets. Clearly these budgets would invite greater vendor

attention.

Generally, it appears as though vendor satisfaction levels have room for

improvement. The surprising result is that of PACS. Our discussion with healthcare

professionals and our research indicates that PACS has been well received by the medical

community. New PACS initiatives appear to be quite frequent. Either, as the survey


indicates, there were not enough samples to make a confident conclusion or earlier PACS

vendors did not have the resources to provide adequate support.

The survey found that the first seven software applications are considered by IT

decision makers as adding tremendous value to the operation of the hospital. These

applications have also been quickly accepted by users.

6.4. Barriers to IT Implementation Barrier to IT implementation / No. of respondents

Barrier (%)

Neutral (%)

No Barrier (%)

Mean (Rank)

Lack of operating funds / 104

79 10 11 1.9 (1)

Lack of capital funds / 104

77 12 12 1.9 (1)

Shortage of IT personnel / 104

59 23 18 2.4 (2)

Shortage of Clinical personnel /103

49 28 23 2.7 (3)

Lack of capacity to change / 104

39 31 30 2.9 (4)

Shortage of administrative staff / 104

39 25 37 3.1 (5)

Technical inability to provide quantitative benefits / 104

35 29 37 3.0 (6)

Lack of understanding of IT by top management / 104

31 23 46 3.2 (6)

Lack of organizational vision or strategic direction / 104

23 37 40 3.2 (6)

Legislation (i.e. security & privacy laws) / 104

22 30 48 3.4 (7)

These results reflect senior IT executive’s perception that they are under funded.

Clearly there must be an element of self-reporting bias in these results. However, one

result that we found in our own research is that facilities often lack the personnel to

implement IT strategy. This has prompted vendors to provide services that require little

maintenance.


6.5. Strategic Priority of Clinical Systems Clinical System / No. of respondents Priority

(%)

Neutral

(%)

No Priority

(%)

Mean

(Rank)

Hospital-wide electronic patient

records / 104

69 19 12 3.9 (1)

Region-wide electronic patient

records / 104

58 12 25 3.5 (2)

Electronic access to outside

physicians / 103

52 21 27 3.5 (2)

Image management, PACS / 104 49 14 37 3.2 (3)

Implementing decision support

systems / 104

42 30 28 3.2 (3)

It appears as though EHR is of high priority for most hospital facilities. Since

healthcare in Canada is publicly owned and the government is planning for a national

EHR initiative, this result is not surprising. In fact, since 2002 we would expect these

numbers to increase further. An interesting consequence of this priority is that PACS

implementation has been pushed to number three.

The item “electronic access to outside physicians” is somewhat vague. Does this

mean rural access through video conferencing or does it mean remote access for a

physician working from home or other remote sites? The exact definition may be quite

important. We have dealt extensively with rural access in our report however we have

not explored remote network access through DSL or cable in the same level of detail.


7. Healthcare in Alberta

To understand the current state of e-healthcare in Alberta, we contacted a number

of patient point-of-contacts in the major cities of Edmonton and Calgary. The offices we

contacted included those of General Practitioners, laboratories and walk-in clinics. These

included both single-site and multi-site operations. Most such clinics are managed and

run by Administrative Assistants who are also responsible for the electronic systems.

Since gaining the attention of these gatekeepers is easier than obtaining an interview with

the doctor, we relied on their input. Naturally we found a lack of technology

sophistication and knowledge so the results we obtained are general and come from a

user perspective.

We have interviewed roughly 25 offices and assured them that specific

information would remain confidential. In the following sections we will report on the

general nature and direction of IT adoption in Alberta.

Office Type Edmonton Sample Calgary Sample

General Practitioner 12 2

Walk-in Clinics 3 1

Laboratories 2 1

Pharmacies 2 0

It is important to stress that the data presented is not meant to provide statistical

significance. The intent was simply to obtain a general understanding of the e-healthcare

climate in Alberta. Certainly we expect technology adoption and general trends in the

offices we interviewed to be similar to other offices in the province; however our data

cannot make this guarantee.


7.1. Paper records Office Type Number in Sample

Paper based systems 15

Electronic Health Records (partially) 6

Electronic Health Records (exclusively) 0 * Not including pharmacies

There are surprisingly many offices that are still using paper records exclusively.

More than half of our interviewees interact with their patients in this traditional way.

These offices also suggested that there is no foreseeable plan to convert to electronic

form either. Certainly for smaller sites, the cost-benefit analysis is not skewed in favour

of electronic records.

Other offices have chosen to implement electronic health records but use them

exclusively for new patient interactions. Older files are simply maintained in the

traditional way. This is not surprising since migration to a fully electronic form is a

difficult process.

No office in our sample exclusively relied on electronic methods.

Again, we stress that patterns in our data may not be statistically significant;

however, we did find some interesting results. There appears to be a clustering effect in

terms of adoption. For example in South Edmonton, many of the clinics have adopted

EHR to some degree while in other locations, customer interactions still appear to be

transacted using paper methods. This clustering effect is consistent with adoption models

including recent theories by Michal Porter [43]. Essentially, once one clinic adopts a

technology, clinics nearby benefit from observable case studies and can also benefit from

the implementation expertise of that clinic. However, it appears as though clinics still

prefer not to share electronic health records with one another.


7.2. Electronic Health Records Adoption Electronic health records have typically been well received by those who have

implemented the technology. Users have expressed that the new records both save time

and are easy to manage.

However, we must note that at least one correspondent mistook software that

helps to make patient appointments as electronic health records. Only by asking what

types of data these records contained did we uncover this confusion.

One particular chain of centrally managed clinics is particularly interesting. They

have chosen not only to adopt electronic health records, but they also exchange these

records between regional sites. The system identifies patients by their Alberta health card

number and hence each patient has a unique entry. Presumably the cost-benefit-analysis

was in favour of this electronic medium and saved document transportation costs (fax or

snail mail) between sites as patients moved. Intuitively one would expect the e-

healthcare business case for a large organization to be stronger than a single-site

operation.

Multi stakeholder integration of Danish calibre is still years away. In fact, even

some laboratories are not yet connected to other medical clinics. As a result test results

are still often faxed to the proper physician. Laboratory staff has expressed eagerness to

adopt an electronic method due to the anticipated efficiency. However, the staff was

unsure which clinics they would be connected to but they suggested that such

installations are about one year away. Unwilling to wait for the deployment of such

systems, another laboratory had chosen to simply post results on the internet. This is a

rather innovative solution that bypasses EHR but there is much manual data entry

required by both sender and receiver.

Pharmacists also operate fairly independently. Once a patient is prescribed

medicine, he/she can take the paper prescription to a local pharmacy (e.g. Shoppers Drug

Mart). The electronic networks of Scandinavia appear to be many years away.


7.3. Pharmacies We spoke with representatives from two of Western Canada’s largest retail

pharmaceutical chains. Both seem to view EHRs adoption differently.

The first chain has adopted a proprietary database within which it creates and

maintains medical information from customer interactions. Using this database a

Pharmacist can identify and mitigate potentially adverse drug interactions. However, the

individual database systems in these chains do not communicate with other outlets so a

savvy consumer should return to the same location every time. Of course over-the-

counter prescriptions or any other prescriptions that do not flow through the pharmacy

are not captured in their database so there is a very finite probability that adverse drug

interactions could still occur. Their rationale is that some information is better than no

information.

The Pharmacist we spoke with was well acquainted with the EHR effort and

validated the vision that eventually all medical stakeholders would be connected through

a common EHR portal. In the case of Alberta, the portal is called Alberta Netcare [44].

Progress, according to the Pharmacist, is slowly taking place and while many

practitioners have embraced the technology, many more have not. To exemplify the

speed of adoption, he claims that at a 1994 Pharmacist conference it was suggested that

by 1995 text based connectivity would arrive. Clearly this did not happen. Since then

the vision has grown and become more elaborate but as our own research indicates,

progress has been very slow. According to the Pharmacist, included in the vision is the

requirement that all Pharmacists will communicate using the CPha standard. This is

certainly different that the HL7 EHR standard and obviously will create even more

complexity during integration. In any case, this Pharmacy will continue to operate as

before until greater EHR progress has been made.

The second chain does not have a proprietary database. Instead it is fully

connected with Alberta Netcare and can read any current EHR. The Pharmacist

presented the same rationale: since these records contain full patient information, they are

able to make better diagnoses and reduce adverse drug interaction. Since most EHRs are

currently issued by hospitals, these records are also incomplete representations of a

patient’s medical history. The Pharmacist recognized this deficiency but pointed out that


not every stakeholder will be connected immediately. During the early stages of any

such project, this is an intuitive consequence.

7.4. Interoperability The differences in the software interfaces of the EHR implementation by the GPs

we visited suggest that there are multiple variants of EHR software currently being used.

This is yet another example of integration impediments. In fact deployments appear to be

quite isolated. For example, in private GP’s offices, the EHRs are only for internal use.

In the case of a chain of walk-in clinics, the central planner had chosen to deploy a

system that would allow all offices to share EHRs. But again, this deployment is isolated

to the clinics that share common management.

When compared to the tight standardization in Scandinavia, the organic growth in

Alberta seems to be macroscopically disorganized. It seems that individuals have made

unique choices without considering larger interoperability benefits. If systems continue

to develop disparately then integration may never be possible. Therefore, as we have

mentioned earlier, there is certainly a very strong opportunity for an application that can

enable seamless communication. Without integration, many of the macroscopic benefits

we outlined earlier, such as tracking the spread of disease, can not be realized.

Arguably these are public good applications and hence fall under the domain of

the government. While the Canadian government may not be able to set strict standards

like the Danish government did, perhaps the Canadian government can provide macro-

level leadership. A strong business case does exist for the Canadian government to

undertake this integration activity. Currently the Canadian Health Infoway is allocating

funds to promote regional electronic health record deployments but these funds are

simply helping to intensify this interoperability divide. Perhaps the next step is for the

Infoway to take an active role in designing an interoperability solution. If the Infoway

prefers a passive role, outsourcing this task to a private contractor would also yield the

desired results.


A private solution may also be viable. Much of our research has uncovered that

the primary deterrent for adoption is installation complexity and short-term inefficiencies.

If an Internet Service Provider could present a standardized package that includes the

appropriate software, internet connection and a consultant to set up the solution, they

could potentially capture a sizable market. Moreover, by centralizing this process, such a

company could ensure interoperability between sites. This solution would also inherently

be “EHR exchange ready.” Once a common infrastructure is deployed, it would be

incrementally simple to introduce the ability for EHR exchange. Such a project may also

meet the requirements of Infoway funding as explained earlier.

7.5. Infrastructure Sites can be grouped into roughly three categories regarding network

infrastructure.

1. No telecommunications equipment.

2. Basic internet services. Some laboratories make patient data available through

on-line portals. GPs with internet access can view results immediately.

3. Private networks. Multiple related sites (chain of clinics) have some sort of

private VPN that allows communication between sites but restricts internet

access.

Naturally, the Administrators were unaware how or who provided this

infrastructure. Furthermore, we did not uncover the use of video conferencing in the

offices we contacted.


8. Future Trends

8.1. PACS Networks for the pioneering healthcare applications were much slower than those

deployed today. The 1-Gbps capacity in use today seems to be adequately suited for

most applications; however, there does not yet appear to be significant surplus

bandwidth. In the coming years the available bandwidth will likely increase and the

resulting surplus will correspondingly increase. Based on the internet usage trends,

economical deployment of 1-Tbps systems may not be unreasonable within 10 years.

Once a significant surplus of bandwidth is available, application dynamics will change.

Firstly, there will likely be a shift to more user-friendly applications and

bandwidth rationing will be eliminated. The lifecycle of other technology products have

also followed this same general trend. For example, as computer processing power

increased, applications became more user-friendly at the expense of processing

efficiency. Similarly, websites now consume greater bandwidth due to complex

graphical interfaces and online databases. All these examples suggest that technology

maturity results in increased levels of user-friendliness at the expense of efficiency.

Following this trend, future PACS images will be available on-demand with the ability to

view relevant images within studies based on different criteria. A practitioner will also

be able to retrieve multiple relevant patient studies to compare symptoms before making

diagnoses. The process will be rapid with many configuration options. In other words,

the future PACS user will have much greater control over how and which images are

accessed.

Secondly, the future intra-facility user will be able to access all healthcare data

from anywhere rather than from specific terminals. Momentum Healthware [45], based

out of Winnipeg, Manitoba has come close to this vision. Their tablet interface allows

users to access electronic health records from anywhere within a facility with a wireless


network. However, there is still

much needed work. Ideally,

battery-life will be improved to

over 24-hours so a physician can

operate it for a full day.

Obviously, the monitor would

meet the grey-scale requirements

needed for imaging applications.

Reducing weight, thickness, and

heat emissions will always be beneficial so that carrying the unit does not become

cumbersome. Moreover, such units will require greater wireless bandwidth and

coverage. Not only will users be able to communicate with others but the network will

be able to triangulate the user’s position. This would allow a central dispatcher to

determine and contact that practitioner who is closest to an emergency. The positive

effects of this level of mobility are endless.

8.2. EHR The issue of most importance regarding electronic health records is that of data

management. With millions of patients, searching for the desired data becomes a

difficult task. The solution is again tied with the theme of this chapter. That is, the

creation of a user friendly interface will eventually become more important than the

current technology efforts surrounding data creation and storage. Perhaps Google can

serve as a role model; they have implemented a method that can mine and manage data

most effectively.

Anecdotal evidence, at least in Alberta, suggests that healthcare professionals

working in hospitals are quick to adopt collaboration tools that allow them to share

information in real-time. This movement began with video conferencing but the portfolio

of such real-time tools is growing. Conversations with Albertan practitioners suggest that

webcam technology combined with other on-line tools is quickly replacing conventional

video conferencing. Following this trend to its natural conclusion suggests that the EHR

infrastructure will facilitate multiple specialist opinions at the same time for any given

Source: www.momentum.ca (Jan 2006)


record. Perhaps Session-In-Protocol (SIP), the technology behind instant messaging will

connect available professionals, resulting in multiple instant diagnoses.

Unlike Engineering, the healthcare profession seems to lack a centralized and

global repository of technical information such as the IEEE journal. There appears to be

great progress being made in biomedical engineering and nanotechnology applications

for healthcare. The resulting combined body of knowledge is distributed among varied

sources but many of these sources are managed by engineers. Clearly the complexity of

the healthcare profession warrants a global dedicated peer-reviewed database. The global

infrastructure provided by EHR naturally promotes such connectivity and it may provide

the impetus for this kind of collaborative change.

8.3. Privacy Issues As with any centralized database, the issue of privacy always remains of

paramount importance. The fundamental question is that of ownership and who has

access to the data. If the state owns the data then can the state access private information

to locate and identify potential criminals? If a private firm owns the data can the data be

mined or sold for marketing purposes?

There are some key problems associated with e-healthcare privacy issues. Firstly,

recall that one motivation for large scale electronic health records is the ability to track

the progression of disease. This requires on-going access to patient data and restrictive

privacy laws would reduce the effectiveness of this tool. Secondly, e-healthcare involves

a number of stakeholders. It is simple for a GP to ensure data privacy but policing all

related professionals is a very difficult task.

One method to mitigate such problems is to provide the patient with control over

which parties can access their data. This could be provided in the form of a blanket

waiver or access can be provided on a case by case basis. For specific data mining

applications, an automated search tool could be used to access patient information. The

tool would return only pertinent aggregate results without individual information. This is

largely the model that Google currently uses to place advertisements in their email

service and has so far been very effective.


8.4. Implications for Practitioners Firstly, we must make a distinction between private clinics and hospitals. As our

investigations within Alberta uncovered, clinics use EHRs in their most basic form. In

fact most doctors still favour paper-based records. In clinics with EHRs, it appears that

doctors are responsible for entering prescriptions and diagnoses but much of the

administrative work such as entering lab results are left for Administrative Assistants.

Previously these Assistants were responsible for filing paper documents so it would

appear as though their work load has either stayed constant or perhaps slightly decreased.

Our conversation with hospital physicians uncovered a different situation. These

physicians appear to be responsible for both clinical and clerical work. They seemed

very quick to adopt technology that increases their productivity. Moreover, they appear to

be collaborating with multiple stakeholders so they are also quick to experiment with new

collaboration tools.

A recent 2005 commentary by Lori Rosmus addresses many of the changing

professional roles due to healthcare technology [46]. Her comments may help to explain

the relatively slow rate of adoption in private clinics. As we have mentioned earlier,

short term inefficiencies due to training and installation is perceived as a primary

deterrent.

Ms. Rosmus also notes some interesting political challenges. For example, some

pharmacists are unwilling to join a centralized system because doing so would give

physicians complete access to their patient information thereby “intruding into their

scope of practice.” Based on our interviews with the Pharmacists, their professional roles

may certainly be evolving. Currently, they describe their primary function as making

medical diagnoses and attempting to reduce adverse drug interactions. However, if

Doctors and Pharmacists both have access to the same information, would the Doctor not

be able to make such diagnoses prior to writing the prescription? In fact modern EHR

software often automatically scans for conflicting prescriptions. Eventually would

Pharmacists simply be double checking the advice of GPs and their software? This

potentially bleak future may certainly explain Ms. Rosmus’ comments. Divisive

developments between these two professionals are already beginning to take place in

Alberta. Pharmacists can now refill medication if the Physician is unavailable.


Pharmacists may soon be able to write new prescriptions as well. Moreover, in

Newfoundland, Pharmacists are implementing an on-line pharmacy network. These

activities, which are undoubtedly empowering Pharmacists, seem to challenge the

collaborative spirit and intent of EHR. Assuming that these independent solutions and

dedicated databases can be integrated in the future, the process will certainly pose

difficulties.

Ms. Rosmus also examines the effect of EHR for nurses. Systems such as EHR

also require significant data entry and Nurses, for example, may be resistant to adopting

the technology since “the burden of data entry” may fall upon them. Again, this is a very

likely, though unfortunate consequence of digitization.

8.5. Interoperability When studying both EHR and PACS we found that though there is a strong

degree of protocol standardization taking place, there are still interoperability issues.

Most notably, the Baltic nations found that while all systems used the EDIFACT

protocol, customized implementations resulted in a lack of seamless communication.

Currently in most of the world, it appears as though HL7 is emerging and a dominant

standard but even HL7 has multiple variants. There continues to remain a strong

opportunity for a vendor to develop a versatile interface tool that can harmonize multiple

systems.

While most PACS implementations are currently regional there is every reason to

believe that with technological maturity and the elimination of bandwidth rationing,

PACS will merge with EHR systems. In other words, once text-based communication is

deployed and proven, national systems will begin to share other types of files including

the images from PACS. This will create even greater data sharing complexities. For

example, some sort of “digital wrapper” will be required that can both aggregate and

extract different data types.

A key factor is also that of language. The Rosetta Project is an ambitious venture

to catalogue all human languages and they have currently reached a count of 2,376 [47].

If one only considers the word’s dominant languages [48] they are:

1. Chinese (937,132,000)


2. Spanish (332,000,000) 3. English (322,000,000) 4. Bengali (189,000,000) 5. Hindi /Urdu (182,000,000) 6. Arabic (174,950,000) 7. Portuguese (170,000,000) 8. Russian (170,000,000) 9. Japanese (125,000,000) 10. German (98,000,000)

The point is that even if perfect electronic interoperability can be reached on a

global scale, the issue of language interoperability still remains. Despite being touted as

a global society the world is still highly segregated. Will English emerge as a standard

document communication language? Or can we bypass language barriers altogether by

communicating only important numbers and standardized lists of symptoms? Then

different user interfaces can simply translate the common numerical data and display the

information in any language. Of course not all symptoms and categories can be

anticipated so there must be some user-defined flexibility. However by standardizing

most common database fields, we may come close to the universal ideal.

While creating this global standard may seem like a daunting task, the formation

of the internet is proof that global databases are possible. The key requirements include

engaging all stakeholders, and having a versatile platform. Google’s success seems to

indicate that such objectives can be met commercially. However, there is an equally

strong business case for an open source community and openEHR is proof that progress

can be quickly made through non-commercial community efforts.

8.6. Network Availability Whether we consider the world class networks presented in this report or even

smaller deployments such as the Atlantic telei4 Network [49], they all show a disturbing

lack of consideration with regards to network availability.

Network availability is the long-term probability that a system will be operational

at any given instant. Consider two nodes (locations) that are connected by a single

network path. The availability measure is now a function of the reliability metrics of the

one path. We can substantially increase network availability if multiple paths connect the


two nodes. This is intuitively obvious; if one path breaks down, data can simply be

routed along another path. If multiple paths exist, the outage that the system will

perceive given one failure is the time required to switch data along a different path

(~50ms). On the other hand, if only one path exists, the outage that the system will

perceive given one failure is the time required to send a maintenance crew to repair the

damage (~days).

Many of the network topologies that we have researched for this report have only

one path connecting two nodes. Sjunet in Sweden appears to have the greatest built-in

robustness and redundancy as evidenced by its mesh-like architecture. It is unclear why

others have not followed this example. Either other implementers are unaware of proper

availability design techniques or are unwilling to spend the extra related infrastructure

costs. Both situations are cause for alarm. While sort-term costs may be lower, such

networks will require higher on-going maintenance charges and also result in more

dissatisfied users.

As we indicated earlier, most current deployments seem to be offered with

99.999% availability. These networks appear to be campus networks that integrate

multiple physical buildings into one seamless network. They do not appear to be

dedicated for PACS or EHR. Rather, these networks facilitate all healthcare applications.

Here is the list of current deployments once again:

Facility Beds Core speed Availability Vendor

Central DuPage 394 10-Gbps 99.999% Cisco

Clarian Health 1340 10-Gbps 99.999% Cisco

Austin Radiological Association 1.25-Gbps 99.999% LightPointe

Aurora Health Care 129 1-Gbps N/A Enterasys

Orlando Regional Healthcare 1,640 1-Gbps N/A Nortel

Peninsulas Health Care Corp 305 1-Gbps 99.999% 3Com

Queens Medical Center 526 1-Gbps N/A N/A

San Antonio Community Hospital 330 1-Gbps N/A N/A

North Kansas City Hospital 351 622-Mbps N/A N/A


As we have noted previously in this report, Cisco appears to be a prominent

player in healthcare networks. Not only have they deployed networks in the United

States, but they are responsible for the infrastructure needs of Canadian projects as well.

In particular, they provided the optical network and routers for the Alberta SuperNet.

This is particularly interesting since Nortel is the incumbent supplier.

Moreover, our research did not uncover regional deployments where the core

bandwidth was greater than 1-Gbps. Certainly there are networks such as CA*Net that

have 10-Gbps cores, but such semi-public networks facilitate many users and are not

dedicated to one site. However, these networks are interesting since they may be

signalling future direction. Recall that Alberta Health and Wellness announced that it

would be using the Alberta SuperNet to facilitate a PACS strategy. Certainly as more

advanced semi-public networks such as SuperNet allow organizations to lease bandwidth,

dedicated deployments may no longer be required. The additional complexity of

designing, sourcing and deploying networks can thus be avoided.

8.7. Legacy Data Converting all the old paper based records and transactions into electronic format,

is a very complex task. In Alberta, old documents are stored in Adobe Portable

Document Files (*.pdf). Though time intensive, scanning documents into such formats is

not very difficult. The problem is that such documents lack the flexible properties of an

original EHR document. Since they are not linked to database fields, searching for

specific data becomes very difficult: a more elaborate mechanism is required.

One strategy is to outsource the task of data entry to the patients themselves.

Since most EHR systems are web-enabled, a patient can access his/her records through

the internet. Then by answering a few guided questions, a user interface can help to fill

in most of the information. One would expect that a patient would be more

knowledgeable and precise about their history than any other party. Once entered, a GP

can simply verify the data and even release the old paper documents to the patient.

Certainly there will be special situations but these can be handled on a case-by-case basis.


9. Conclusion

In conclusion, despite the great e-healthcare advancements in Scandinavia, it

appears as though other countries face some unique challenges. These include

competitive pressures of a free market economy, decentralized deployments and the

changing roles of established professionals. However, the relative freshness of this

global industry represents some very strong opportunities for both public and private

ventures. It appears that e-healthcare technology is ready for the next step of evolution.

Namely, now that proof of concept is no longer an issue, strong industry standards and

guidelines can be set. Any firm whether public or private that can lead this

standardization effort will likely emerge as a dominant participant. As we have

demonstrated through case studies, some of the major gains can be realized through

standard messaging systems. Moreover, while today there are multiple e-healthcare

applications, this industry will likely see application convergence. In other words,

eventually there will be only one user-friendly interface to PACS, EHR and other related

applications. However, getting to this ideal vision will require great tenacity and

innovation.


10. References

[1] Goldstein, Douglas E. E-Healthcare: Harness the Power of Internet, e-Commerce & e-Care. Jones & Bartlett, 2000. [2] "SPIE—the International Society for Optical Engineering." 9 May 2006 <http://spie.org/>. [3] Fisher, Susan E. "The Facts About PACS." Health IT World. 9 May 2006 <http://www.health-itworld.com/emag/060104/205.html>. [4] "Medical Record." Wikipedia. 17 May 2006 <http://en.wikipedia.org/wiki/Medical_record>. [5] Mazurowski, Jay. "PACS: Planning for ROI." Decisions in Imaging Economics (2005). 10 May 2006 <http://www.imagingeconomics.com/library/200512-02.asp>. [6] Hujsak, Jonathan T. Digital Libraries and Corporate Technology Reuse. Tyrian Corporation. D-Lib Magazine, 1996. 11 May 2006 <http://www.dlib.org/dlib/january96/01hujsak.html>. [7] Ratib, O. "From PACS to the World Wide Web." Health on the Net (1997). 10 May 2006 <http://www.hon.ch/Library/papers/ratib.html>. [8] "One Network. A World of Choice." Advertisement. 11 May 2006 <http://www.nortel.com/solutions/enterprise/collateral/nn101480-0802.pdf>. [9] Nagy, Paul, and Jacob Farmer. Demystifying Data Storage: Archiving Options for PACS. Applied Radiology. 11 May 2006 <http://www.appliedradiology.com/articles/pdf/AR-05-04_nagy.pdf>. [10] Nagy, Paul, and Jacob Farmer. "Demystifying Data Storage: Archiving Options for PACS." Applied Radiology May (2004): 18-22. [11] Rosenfeld, Ken. "Adding Intelligence to Archiving of Data." Health Management Technology (2005). 10 May 2006 <http://www.healthmgttech.com/archives/0505/0505adding_intelligence.htm>. [12] "National Electrical Manufacturers Association." NEMA. 10 May 2006 <http://medical.nema.org/dicom/2004.html>.


[13] Horii, Steven. Interview with National Committee on Vital and Health Statistics. Testimony by Steven Horii. 10 Oct. 2001. 10 May 2006 <http://www.ncvhs.hhs.gov/011010p3.htm>. [14] "Phillips Global PACS Business Unit." 10 May 2006 <http://www.stentor.com/pacs/>. [15] Baldwin, Fred D. "An Action PACS Market." Healthcare Informatics Nov. 2005. 11 May 2006 < http://healthcare-informatics.blacklabs.biz/issues/2005/11_05/cover_baldwin.htm >. [16] Richardson, William C. "To Err is Human." National Academy of Sciences (2000). [17] Walker, Jan. "The Value of Health Care Information Exchange and Interoperability." Health Affairs 24 (2005): 10-19. [18] Romanow, Roy J. The Future of Health Care in Canada. Commission on the Future of Health Care in Canada. National Library of Canada, 2002. [19] Rasmussen, Lars L. National IT Strategy for the Danish Health Care Service. The Ministry of the Interior and Health. National Board of Health, 2003. [20] Martin, Shelley. "Canadians Don’t Appear to Fear Electronic Medical Records." CMAJ 164 (2001): 1739. [21] Baker, M. L. "Patients Willing to Pay for Electronic Medical Records, Surveys Show." EWeek 22 July 2005. 10 May 2006 <http://www.eweek.com>. [22] "Medcom - Det Danske Sundhedsdatanet." 10 May 2006 <http://www.medcom.dk/> [23] Case Study: MedCom - the Danish Healthcare Data and Information Network. Empirica GmbH. Bonn, Germany, 2005. [24] Reding, Viviane. The Cost Benefit of Electronic Patient Referrals in Denmark. European Commission Information Society Directorate. Danish Center for Health Telematics. [25] "Silicon Valley's San Jose is the World's Most Knowledge Competitive Economy." Robert Huggins Associates 13 Dec. 2005. 10 May 2006 <http://www.hugginsassociates.com/latest_news.php>. [26] Sjunet - the Swedish Healthcare Network. Carelink. 2003. 10 May 2006 <http://www.itsweden.com/docfile/31930_Sjunet_the_swedish_healthcare_network.pdf>.


[27] Health and Social Sectors with an "e": a Study of the Nordic Countries. Nordic Council of Ministers. Copenhagen: TemaNord, 2005. [28] Current European Practices in Ehealth: Survey of CARElink. European Commission. Sweden: RIDE Consortium, 2006. 17 May 2006 <http://www.srdc.metu.edu.tr/webpage/projects/ride/deliverables/RIDED.2.1.1 - CurrentPracticesSweden.pdf>. [29] Ehealth in the Context of Rural Broadband. a-bard. 2005. 10 May 2006 <http://www.abard.org/Repository/A-Bard_e-Health_topic.pdf>. [30] "Baltic E-Health." Danish Centre for Health Telematics. 10 May 2006 <http://www.baltic-ehealth.org/>. [31] Reding, Viviane. "Introduction to the Ministerial Round Table." E-Health 2005 Conference. Tromso, Norway. 23 May 2005. 10 May 2006 <http://europa.eu.int/comm/commission_barroso/reding/docs/speeches/ehealth-2005-round-table-intro.doc>. [32] Pedersen, Claus D. "An [sic] Baltic Healthcare Network and Interoperability Challenges." Cisco E-Health Think Tank Meeting. Brussels. 25 Jan. 2005. 10 May 2006 <http://www.baltic-ehealth.org/news/Ehealth-thinktank_25_01_05.ppt>. [33] Baldwin, Fred D. "An Action-PACS Market." Healthcare Informatics Online Nov. 2005. 10 May 2006 <http://www.healthcare-informatics.com/issues/2005/11_05/cover_baldwin.htm>. [34] "EHRVA." 10 May 2006 <http://www.himssehrva.org/>. [35] "OpenEHR." 10 May 2006 <http://www.openehr.org/>. [36] "IBM Federated Records Management." IBM. 10 May 2006 <http://www-306.ibm.com/software/data/cm/cmgr/rm/federated.html>. [37] "Canada Health Infoway." Government of Canada. 10 May 2006 <http://www.infoway-inforoute.ca/>. [38] "Alberta Supernet." 10 May 2006 <http://www.albertasupernet.ca/>. [39] Beaton, Mary. "Village Broadband in Hungary – Fantasy or Feasible?" BUTE-UNESCO Information Society Research Institute (2005). 10 June 2006 <http://istri.hu/english/docs/village_boradband_beaton.pdf>. [40] "NORTH Network." 10 May 2006 <http://www.northnetwork.com/>.


[41] "MBTelehealth - Linking Care Providers and Patients." 10 May 2006 <http://www.mbtelehealth.ca/>. [42] Irving, Richard. 2002 Report on Information Technology in Canadian Hospitals. Canadian Healthcare Technology. Thornhill Ontario, 2002. [43] Porter, Michael E. "Clusters and the New Economics of Competition." Harvard Business Review (1999): 77-90. [44] "Alberta Netcare." Alberta Government. 18 May 2006 <http://www.albertanetcare.ca/>. [45] "Momentum Healthware." 10 May 2006 <http://www.momentum.ca/>. [46] Rosmus, Lori. "Electronic Health Records: Benefits and Drawbacks." Faculty of Medicine and Dentistry (2005). 11 May 2006 <http://www.uahsj.ualberta.ca/files/Issues/2-1/html/38.htm> [47] "The Rosetta Project." 10 May 2006 <http://www.rosettaproject.org/>. [48] Languages of the World. Summer Institute for Linguistics. 1999. 10 May 2006 <http://www2.ignatius.edu/faculty/turner/worldlang.htm>. [49] "Health Infostructure Atlantic." Provincial Government of Nova Scotia. 10 May 2006 <http://www.gov.ns.ca/health/hia/>.

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