When the SARS virus hit Ontario in the spring of 2003, it wasn't only patients and hospital staff that suffered through the crisis. The province's healthcare information systems were put to the test as well - and they did not fare well.
With a multitude of providers using disparate information systems, it's no wonder SARS proved to be an enormous challenge. The healthcare system includes hospitals, doctors' offices, pharmacies, labs, home-care providers and other organizations, delivering services at 24,000 locations in the province, staffed by about a quarter of a million workers.
When the crisis hit, communications among these providers became vital. But at the hour of greatest need, it seemed that the clock had turned back ten years. Diskettes had to be hand-carried from one place to another because there were no interfaces between systems. Doctors and other healthcare workers had to send faxes back and forth, and waste precious time comparing faxed documents to determine differences.
And of course IT workers were in the thick of things as well. Many of them spent countless sleepless nights, transcribing information from one application to another. Recalled Linda Weaver, a healthcare IT manager at the time, "I had 35 of my people off on quarantine. It was the most painful ten days of my life because we had work to do and I couldn't get the information to release them from quarantine. On top of that we were trying to help with the incredible stress experienced by our people who had been placed in quarantine. It was absolutely frustrating."
When it came to IT, as with other aspects of the healthcare system, SARS was a huge eye-opener. Physicians, for example, had been asking for years, "Why do I need a network and email? Who am I going to talk to? Why do I need access to the Internet?" Suddenly the answer was clear. During the SARS crisis, at any hour of the day or night, physicians could have gone to a central Web site to get much-needed information, instead of hunting through mail and faxes and calling 1-800 numbers.
It was as if a light had been switched on. The importance of IT-enabled collaboration was apparent to everyone.
a remedy in the making
Even while the healthcare system was flunking its SARS test, work was already well under way to remedy the problems that became so evident during the crisis.
Long before SARS, many of the shortcomings of healthcare IT were already well understood, such as the lack of common security practices and lack of common ways to move information between the many thousands of IT systems in the province. It was apparent that there was a huge need to pull together a very large infrastructure incorporating the same kind of best-of-breed approaches that existed in the private sector.
Recognizing this, the Ontario government initiated a project in the late 1990s to find ways of addressing these problems. The project was initially staffed largely by contractors, but by 2003 it gained official agency status, and at that point the Smart Systems for Health Agency (SSHA) began transitioning about 60 percent of its contractors to full time staff.
Among them was Linda Weaver, whose involvement with the initiative dated back to 1997/98, when she was seconded to the project from the private sector for nine months to help develop the business case for the agency. In 2001 she came on board as a contractor, helping to build their network, and she has been there ever since. In January, 2004, she made the transition from contractor to Chief Technology Officer.
SSHA's mandate was to go out and find the best players in the private sector, bring them together, and get them to work with each other to build the common infrastructure and start to deploy it.
"We spent two years, from 2001 to 2003, essentially doing that," said Weaver. "Once we figured out what core services we'd provide and the requirements for them, we procured specific services from several key vendors. They came to the table with various sub-vendors and then we had to knit them all together in a large collaborative framework."
The task was not an easy one.
managing the vendors
SSHA decided to provide seven core services: the network; the messaging system, based on email; a data-centre for hosting; a portal environment for common access; a registration and access management system; a shared directory service; and a PKI (public key encryption) system for security.
Delivery of the core services was to be undertaken by the main vendors and sub-vendors through a mutually supportive collaborative process. That was the theory, anyway. The reality turned out to be something quite different.
"We had a very naC/ve view of the world. We thought that if we made a strong definition of what the vendors were to do, they would all play nice," said Weaver. "But rather than being collaborative, it started out as quite combative. When you get six or seven big vendors in the room they all want to outplay everybody else. We literally spent all of our time refereeing, because the systems had to be fully integrated in order to work."
Weaver had worked on large projects before, though nothing of this size. Still it came as a surprise for her to realize that SSHA was going to have to take a tough line with its major vendors.
"We weren't able to be very pretty in our language. We got the whole suite of them in a room and we were very direct with them about what it was we were trying to achieve and what our expectations of them were," she explained. "We told them that no vendor was going to be the lead player on this objective. There would be many lead players at any given time, and the work must be done collaboratively. Everyone had to agree to play together and to disclose information on interfaces and other things to each other. We essentially told them, if you don't want to play, tell us now because we will find somebody else."
This straight talk had the desired effect. Once the vendors understood where they fit in the big picture, things fell into place and really began to click.
A good example of vendor cooperation happened around the Microsoft Exchange environment. In the event of another medical crisis, it was possible that 60,000 healthcare workers might try to get access to their secure mailboxes within a 15-minute window. The systems would have to be able to support that, even if there was a physical problem, such as a power outage.
SSHA asked various key providers if they knew how to design for that kind of situation, and each of them said that it would not be a problem. However, when all of the pieces were put together, the system crashed and burned at a quarter of what was needed.
"If we hadn't established the fact that this was not a problem for any one of the vendors, it was a problem for all of them, it likely would have resulted in a lot of finger pointing," said Weaver. "But the vendors knew that if they started doing that, we would immediately be in their face saying, b Guys, you all signed up for the same thing'."
So the vendors worked with SSHA's integration team and architecture team, and came back with solutions before it became necessary to apply pressure.
Weaver learned an important lesson from her sometimes difficult dealings with vendors. "You have to start right up front with anybody you are having a relationship with and be very open and honest. You've got to lay all the cards on the table on day one. If you don't, you are going to end up with miscommunications and misunderstandings. You have to build that honesty and openness in at the front end, and you've got to work hard to maintain it."
delivering the goods
When the provincial government launched the healthcare IT initiative, it stipulated that by the end of year three there should be real cost savings, real healthcare results, and a real impact on the system; and at the end of year five there should be system-wide and over-all reduction in IT spending, stemming from the ability to leverage off a wide variety of things.
According to Weaver, those objectives are being met. "We are finding that we are tracking pretty close to the business plan," she said.
From 2001 to 2003, the focus was on building the core services. In 2004, things began taking on more of a delivery focus.
"Now that we've got the guts of the core services, we need to expand them and deploy them out to everybody," she noted.
The services that have been delivered to date have been primarily network services, although there have been others as well. Three Telehealth or Telemedicine projects now operate on SSHA's network. These remote consultation applications have brought huge benefits to patients in more rural or northern communities by giving them access to specialized expertise in Toronto, Ottawa and London. For example, instead of a patient getting on a plane in Thunder Bay and flying to Ottawa to see a cardiac specialist, she can go to her local hospital and do her follow-up using videoconferencing and other devices.
"It often costs the system less money this way, because if patients can get access to specialists quicker, they can be treated faster and perhaps less expensively," said Weaver. But she acknowledges that finding what those cost savings are and documenting them is difficult.
Another vital application is the Telestroke initiative. When a stroke patient comes into a hospital there is a small window - mere minutes - when an assessment can be done and a drug administered that can reverse the debilitating effects of the stroke. But a specialist is needed to assess the CT scan. Without a specialist on site, the drug can't be administered, because it can be lethal if given in the wrong instance. By being able to take a CT scan in a small place like Parry Sound and instantly transport it to a specialist at Sunnybrook in Toronto, using SSHA's network infrastructure, patients can have the debilitating effects of a stroke reversed or strongly mitigated. And as an added benefit, the patient doesn't consume nearly as many healthcare dollars and resources in the future.
Again, it may be difficult to identify such benefits, but they are clearly there.
There are other costs savings, however, that are easier to estimate. A big one is eliminating the need for providers to implement and run their own applications. For example, there are about 40 public health units in the province and they all need access to systems that will enable them to gather information on communicable diseases. Putting 40 applications into 40 separate organizations, along with hardware, software and support staff to run them, would be cost prohibitive. By using SSHA's hosting environment, the overall cost can be reduced by more than two thirds. So the case is very compelling.
According to Weaver, SSHA will allow groups of hospitals to share systems instead of each individual hospital doing its own thing. This will have particular impact with respect to diagnostic imaging systems, which have huge storage and server requirements.
"Many organizations will start to leverage off of each other. Instead of building a stand-alone application, they will build an add-on to something that already exists and that will be very cost-effective and easy to do," said Weaver. "We are starting to see that now with some of the major systems. There is a very large lab initiative going on now, for example, that will provide quite substantial cost savings down the road."
pushing the train
SSHA's CEO, Mike Connolly, likes to tell a story in staff meetings. It goes something like thisb &
For 20 years we have been pushing the train up the hill. Healthcare IT has not been well accepted because there has not been enough critical mass. Things have been very costly, and sometimes they have failed with flying colours. We have been pushing this train up the hill one tie at a time; we push it and we hold it and we hope it doesn't run backwards on top of us. You've got to keep doing things and succeeding, and the more you do and succeed, the more people believe that this is actually possible, and all the failures of the past aren't necessarily the future.
But over the last two years there has been a change in the way healthcare IT is perceived. In fact, Weaver says that at a recent meeting, Connolly had this to sayb &
You know what, boys and girls? The train just crested the hill and we are running in front of it, hoping that the darned thing isn't going to catch us. We are never going to be able to stay in front of it now, there is so much demand.
Weaver confirms that this is the case. "In the early years, we had to convince people that we were for real - that the government had sent us to help them, and we were there to stay. And they kind of looked at us like we had horns on our head."
Now, people are clamouring for services. One of Weaver's biggest challenges is that there is far too much work to be done. For example, in the first two years of the initiative, 600 network circuits were put in. Now, there is a demand for 6,000 network circuits in the next 12 months.
As SARS was a turning point in the way the healthcare community viewed IT, it is fair to ask how we would do today if a similar crisis were to befall the system. According to Weaver, we'd be much farther ahead than we were in 2003.
what if SARS happened again?
"We now have a common application that is accessible to the public health units, enabling them to input information and do contact management and quarantine management," she said. The application, extended from one built by Health Canada, is now hosted in the SSHA data centre. No one had ever built such a system before because there had never been an instance of one being needed in the last 50 years.
Email is currently being deployed to healthcare providers, although at a slower rate than desired. If the need arises, however, the capability exists to ramp up quickly and support large numbers. It would simply be a matter of doing the registration.
"Now it is very much of a push," said Weaver. "In the event of an emergency there would be a very quick pull. We have designed procedures so that in the event of an emergency we don't follow the standard way of doing things. We go to an emergency process, bring in extra staff to do things, and widely deploy registration teams in parallel. We have built all the processes to support that."
A much larger number of healthcare providers are now on SSHA's network. During SARS, there were only about 120. Now there are 800, with many more coming in the next year. This number includes all of the big providers, such as the hospitals, public health units, and community care sites. What are missing are about 14,000 physicians.
"We are light years ahead of where we were," said Weaver. "We have worked quite collaboratively to put this in place - to make sure that we did whatever we could to be ready for another SARS."
That's comforting news for the people of Ontario. 053414
David Carey is a veteran journalist specializing in information technology and IT management. Based in Toronto, he is editor of CIO Canada.
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