The winner of the Information Technology Association of Canada’s Ingenious Award in the Large Public Business category for 2017 brings new efficiencies to primary health care. The electronic Canadian Triage and Acuity Scale (eCTAS) solution from Canada Care Ontario is making emergency room triage more accurate, leading to better patient outcomes.
Triage – the process of sorting patients into levels of urgency – is a difficult challenge for emergency department nurses under pressure. Nurses in Canada use the five-point Canadian Triage and Acuity Scale (CTAS) for making these decisions, but those working at the sharp end of the process must categorize patients under pressure.
Research found an ineffective triage process in which many patients are underserved. In fact, only 37 per cent of patients were appropriately triaged, according to a 2010 Ontario auditor general report on the issue. Of those that were incorrectly categorized, the majority were under-triaged, meaning that they were seen later than they should have been, given their ailments.
In March 2015, the Ontario Health Ministry announced that it was taking on the problem and appointed Access to Care, a division of Cancer Care Ontario, to create a system that would improve triage processes in the province.
The team building the system faced several challenges. The first was the Ontario healthcare system’s technology debt. Its hospitals were using a diverse set of legacy systems that could not be easily integrated. There were 13 different vendors, and almost one in five of the systems were paper-based. They also used different emergency department workflows, with some using a single-stage process and others a two-stage triage model).
It solved this problem by offering its system in three configurations. The first, known as Application Basic, is designed for a hospital with no mature application system, including the paper-based users. These hospitals would install the application directly and use it for the triage calculations.
The second, called Application Complex, was for hospitals that had information systems in place that didn’t cover triage events. These used a triage application to generate a score that would then be sent to the hospital’s own emergency department system using a link. Once opened, this link would populate the legacy hospital system with the appropriate triage data.
The final option, which required more work, saw the CTAS triage algorithms integrated directly into the hospital’s own software. “We’d just certify the fact that they have the same triage brain now built into their system so that they can generate the same CTAS scores,” says Steve Scott, director of the eCTAS program at Cancer Care Ontario.
All these options drew their functionality from an application provided in the public cloud. The team chose to host the application on the Azure cloud, in Microsoft’s public data centre. One of the primary reasons for choosing a cloud-based infrastructure was its ability to handle varying workloads.
“We know that patient influx can vary significantly. From an IT perspective, we’d have to build for the worst-case scenario,” says Scott, adding that this presented a problem for on-premise systems based on purchased hardware. “From an efficiency and cost perspective that’s not a good approach because for most of the time, the traffic is much more consistent. So it lent itself well to a cloud-based solution.”
The organization had to work closely with the Ontario Information Privacy Commissioner’s Office and the Government of Ontario because the province had not explored cloud-based solutions before.
“Before we even got into the technical part of it we had to go through some of the more cultural barriers involved with PHI and just the cloud in general when it comes to the security of information,” he says.
“To build the kinds of security and protection that the cloud offers locally would cost a fortune, and wouldn’t be able to keep current with cloud solutions because of their ability to scale up and their ability to consistently update those security controls.”
The team resolved any concerns around the privacy of the cloud by using Microsoft’s Canadian data centre and not allowing patient information to travel across the border, Scott added.
Cancer Care Ontario involved medical staff early on in the project, understanding that usability is key in a fast-moving, high-pressure environment. Traditionally, public sector development projects skew towards more traditional waterfall-style developments, but the team couldn’t risk producing a system that didn’t match the expectations of healthcare practitioners.
“We went with user stories,” says Scott. This user-centric approach explores the tasks that users encounter in an everyday working environment and works backwards, building the functionality around them. “From that perspective, when we were ready to move forward with this three-option integration model, all fundamentally sitting in the cloud, we actually went to the market in a very non-traditional way.”
CCO picked Accenture as a vendor to develop and test the code that satisfied those user stories, although the internal team controlled the technical direction of the project.
“One of the other first major milestones we had was a prototype that was initially established with a clinical working group of nursing and emergency department administrators,” said Scott. “We had a prototype where we showed it to multiple hospitals for feedback right from day one.”
One of the CTAS system’s other benefits was a new influx of real-time public health data. “We recognized that triage decision is not just limited to triage decision. Infection control is another thing that happens when you walk into ED,” said Scott.
In the traditional workflow, emergency departments would send their records to a central store, which would take weeks to incorporate and report on that data. The CTAS software delivers the information instantaneously to a central system where it is aggregated and made available for analysis. This optional feature enables hospitals to spot emerging problems more quickly.
“Today I can see how many people were put on infection control precautions and how many walked in in the last five, 10, or 15 minutes,” says Scott. “I can see the reason why. Did they go to a country? Was it at risk of a virus? It’s good for syndromic surveillance.”
The eCTAS system is now in use across 13 hospitals. It increased correct triage rates to 92 per cent in post-launch research audits and the first two hospitals, and as of June this year it had triaged over 80,000 patients. By next year, 90 per cent of emergency department patients will benefit from the system.