Question and Answer with Sarah Kramer of Cancer Care Ontario

Q. You’re leading the implementation of a new information management strategy at Cancer Care Ontario. How do you approach something as vast and broadly defined as this?

A. At Cancer Care Ontario our job is to improve the quality of cancer care services delivered in Ontario. I’m building on the information architecture to support one of the first data warehouse efforts (known as iPort) to provide quick, detailed and accurate access to information about: what is going on in the cancer care system, how different components of the cancer care experience are being provided against what the quality guidelines say they (healthcare providers) should be doing, and understanding what the experiences of cancer patients are across the province. This is being done so that information can be immediately used to improve the quality of care received.

Another effort is to roll out a product that is already used by 50 per cent of everyone in Ontario who receives chemotherapy, which is the Computerized Physician Order Entry (CPOE) system. Physician order entry in the healthcare world is kind of the nirvana of information technology because it’s had proven benefits to patient safety. Instead of a physician writing a prescription on a piece of paper, it is direct entry into a system that has alerts, cautions and advisories about what chemotherapy should be delivered, and how it should be delivered.

Q. What is the status of the CPOE system and what plans do you have for its future?

A. CPOE has been in place in eight sites now, for about five years. Currently it’s being re-architected and rolled out in three additional locations, and we’re aiming for another five next year. We are planning to reach that next 50 per cent over the next little while.

Q. The Ontario Ministry of Health and Long-Term Care recently contracted Cancer Care Ontario to develop and implement the information architecture to support its Wait Times Strategy. Can you speak about the work you’re doing on that?

A. Dr. Alan Hudson is leading Ontario’s Wait Times Strategy in a concerted effort to reduce wait-times for some key clinical services in Ontario. This is happening nationally in healthcare and Ontario is taking a particularly aggressive tack to reduce wait-times experienced by patients in four surgical areas: cardiac, cancer cataract removal, and hip and knee joint replacements, as well as diagnostic MRI and CT scans. Two years ago, surgeons kept their own patient wait-lists in their office, on paper, and hospitals had no idea of who was waiting for what services. The public and the government could not really understand how bad the situation was, or wasn’t, because there just wasn’t a level of information to allow that.

Q. Why did you focus on these four specific surgeries?

A. It was the premiers of Canada and the prime minister a couple of years ago that decided to focus on those specific surgeries, and I’m assuming it’s because their voters were telling them that these were the areas of most concern. It’s very public-oriented as opposed to being selected by physicians. Another thing that characterizes this work is it’s completely driven by business objectives; this is an IT project supporting a big business improvement effort, not the other way around.

Q. How far are you from having the wait-time information system completely implemented?

A. This component of it [the four key surgical areas] was just finished at the end of November. We do have a few additional, smaller hospitals to complete next spring. We’ve also been given approval and funding to roll out our next task, which is to capture all surgeries, not just these few. So that’s our next piece of work: to build on what’s already out there to make it more comprehensive.

Q. Another component of the system is the Enterprise Master Patient Index (EMPI). How did you address the issue of privacy within this index?

A. Both systems have considerable privacy issues. We have solid health privacy legislation here in Ontario that sets a good framework for what can and cannot be shared. There was no prohibition to get that information into the client registry with a data-linking piece of technology – which is what this is: it’s basically linked at the point of care.

We worked very closely with Ontario’s information and privacy commissioner, Dr. Ann Cavoukian, who has been a big advisor. We went back and forth on a number of technology, legal and policy issues, and communication approaches to make sure the patients know what is and is not being done with their information. The privacy commissioner did a full review on what we were doing with EMPI, as opposed to just advising us as we went along. It’s now on their Web site that they’re pleased with the level of security and privacy, and are supportive of this work.

Q. It sounds like you’re at the forefront of a lot of cutting-edge and innovative projects within Cancer Care Ontario as well as the work you’re doing for the Ministry of Health. What do you envision as being the future of e-health in Ontario?

A. Ontario is actually a bit of a laggard in the country and has been for some time. It’s partly because it’s just so big, and at some point size does matter. It’s not just whether the technology is scalable or not; it’s how do you bring all of these players to the table? Most technology, as we all know, is really not about technology. Yet, I think for wait-times we’re leapfrogging because we didn’t have some of the groundwork that others had done before. Seven other provinces have started to put into place the EMPI, which is a cornerstone to do anything around e-health provincially. You need to be able to take client information from different systems, match it and be able to use it. It’s a background piece of technology you need in order to do anything else.

We just hadn’t done it. Why? Because it’s big; and it can be expensive when it’s big and it doesn’t have immediate business value. Basically when you deliver it on its own, it’s a very expensive Yellow Pages. What we did that was innovative was we said, “Look, we need it for a whole bunch of things, but we need it to deliver on wait-times, which has a real business value, so let’s do both at once.” That was the success factor for getting this very big, cumbersome product out the door and getting it used, so that it wasn’t just sitting there. That’s where we have been innovative and I think that’s where we need to be innovative in the future.

Q. You were also CIO with the Department of Health in Nova Scotia. What do you feel was your biggest accomplishment there?

A. I think it was starting, pretty much from scratch, a single hospital-based electronic health record for the entire province of Nova Scotia. It was bringing together the same kind of multiple stakeholder and multiple jurisdictional interests. I did a fair bit of work across Atlantic Canada as well, really gained some skills and learned about how to best understand what everyone needs, deliver that and make decisions effectively and quickly so that you can get the product out the door. There is now a single hospital system in Nova Scotia, and that’s certainly not only the result of my effort, but it is something I’m very proud of. I also learned that you need transparency, accountability, clear decision-making, and good clinical leadership…I was able to translate that knowledge and bring it to Ontario.

Q. You were recently awarded the Leader-ship in the Field of Health Informatics Award by Canada’s Health Informatics Association (COACH). How did that feel to be recognized for the work you’re doing?

A. Without sounding too much like Sally Field at the Oscars…it truly is an honour when you are nominated for something by your peers, who in my case I respect so much. This is such a collaborative effort – every single thing you do, particularly in healthcare, just requires so many hands in the pot. I was surprised and very pleased. It’s quite a smart group to be recognized among.

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