The University of Ottawa Heart Institute (UOHI) is one of Canada's largest and foremost cardiovascular health centers, serving the local as well as the national and international communities. As a subsidiary of The Ottawa Hospital, with several facilities located at different  sites, the Heart Institute is responsible for all cardiovascular care and dedicates itself to pioneering a new era in heart health by understanding, treating and preventing heart disease. As part of its mission, the Heart Institute strives to deliver high-tech care with a personal touch to shape the way cardiovascular medicine is practiced and to revolutionize cardiac treatment and understanding. To accomplish this mission, Dr. R. Roberts, the CEO of the Heart Institute, felt strongly that clinical data should be captured in a centralized database, both to improve patient care and as a basis for future research. 

To take on this challenge, UOHI initially launched a project to study available applications. The organization found a commercial software solution that could potentially address its needs. But the cost would have been as much as $750,000, and UOHI likely would have been required to make adjustments to the software to meet its specific needs. 

Fortunately, at the same time, one of its Cardiologists, namely. Dr. Ross A. Davies, was developing a solution that could meet its needs at virtually no cost to the Institute. Dr. Davies, currently President of the Medical and Scientific Staff at the Heart Institute, has been involved with the Heart Transplant program for years. Years before, he looked for commercial software to manage the patient data, but when he could not find it, he then developed a Heart Transplant database on his own. However, he soon he realized that apart from the surgical procedure and a few specific medications, what he had really developed was a general patient database. Increasingly, he became frustrated by the limitations of the application development software tools he was using, so he hired a computer consultant, Stephan Donati. They selected PowerBuilder from Sybase to develop the current application, now called the Patient Database Management System (PDMS).

Dr. Davies found that commercial software purchased by the hospital administration met their accounting needs and served as a database for procedures and lab results, but was poor at recording and communicating clinical care. This was particularly true for outpatient activities. Hence, he focused on clinical records. One of the challenges that he faced was a reluctance of physicians to modify their style of practice. They were busy and not interested in entering information using a computer keyboard. Traditionally they dictated clinic notes. The challenge was how to capture this information in a useful manner.

The overall solution includes a process by which physicians dictate clinic letters  into a digital voice recorder. Then the voice files are sent to a central server that UOHI transcriptionists access to transform the audio into typed information within the database. Letters documenting patient visits are then automatically generated and mailed to each patients primary physician. UOHI soon plans to add fax technology to PDMS so doctors will receive these letters on the same day of care. The clinic letters are linked to the encounter number in the hospital electronic health record, which  allows for quick retrieval so that doctors can call-up entire records at any time. If a patient checks-in to the emergency ward at 3 am, the doctor on-call can immediately see what the attending physician was planning for treatment and whether any visits to specialists recently took place. 

The Patient Database Management System (PDMS) relies on several technology components. The system pulls varied medical information from several sources including a relational database into a SQL database through a database linked-server object. Using an FTP process, information on doctors is pulled from MDSelect, a nationwide web-based database of 70,000 Canadian doctors, via a flat file through a DKS package into the SQL database. Stored procedures then update the doctor information.

But the key technology involved in the building of PDMS was the Sybase PowerBuilder development environment. PowerBuilder allowed Donati to build the system at a cost approximately 75 percent less than buying a commercial software package that would offer similar features but which would also require additional programming. If not for the ability to build the application with PowerBuilder, UOHI may not have been able to complete the project successfully.

PowerBuilder streamlined the process through several capabilities, such as the PowerBuilder DataWindow that allows developers "to do anything they need it to do" in the words of lead developer Stefan Donati, who has also developed applications for financial and educational organizations. 

PowerBuilder's programming features also include functions such as manipulating data straight from data stores and the ability to write code easier when executing data access. Donati says, "The data window is the most powerful feature that PowerBuilder offers. With most other development environments, the data-access object is a nightmare to work with because you have to bind everything. But PowerBuilder binds everything automatically. Programmers can point to any data source, including Web services, and PowerBuilder automatically paints a template to that data source."

Managing large sets of data, it was critical to easily provide criteria for columns of data, leveraging data windows with automatically-bound fields. Other tools force developers to bind every control and indicate which object points to each column and data source. This is very complicated and tedious compared to the way PowerBuilder handles the same function. The IDE development tool is also segregated well. With separated objects, it makes it easy to manage and find objects. 

Donati estimates that the development time for PDMS was reduced by as much as by 75 percent. The time savings was particular critical when he integrated PDMS with third-party tools and other systems, a programming task that required significant time. He found that changes to the application itself were quickly implemented. 

Dr. Davies emphasizes how having the ability to optimally use a programming resource like Donati that was a key technology element to PDMS becoming a reality. "The IT budget simply would not have allowed UOHI to spend up to $750,000 on such a system," Davies says. "But by using an available resource that was able to create the application, the cost over the years of development was significantly less.

Yes

Yes

The UOHI PDMS system delivers critical information to doctors as they are treating and interacting with patient, which has significantly improved patient outcomes. 

The system also helps because patients expect doctors to have information at their fingertips. But information on medications, lab results and patient histories tend to be stored in separate databases by healthcare organizations, and in some cases the information may only exist in hard-copy format within a patient file. This type of process forces doctors to spend extra time assimilating information, and in the case of an emergency, it could cause a significant delay in a patient receiving critical care.

But with the PDMS solution, doctors within the Ottawa Hospital network that are treating cardiac patients have immediate access to this information. In the presence of patients, doctors can access patient information immediately that comes from multiple sources, even if the information was recently recorded. This type of access allows the doctors and their patients to have immediate communication on up-to-date data pertaining to the patient's condition. This ultimately leads to doctors being able to make more accurate diagnoses that lead to more effective care and improved patient incomes.

Additionally, thousands of paper records that previously were not accessible are now instantly available to doctors that are part of UOHI and the Ottawa Hospital campus. The system also often helps reduce the occurrence of duplicate tests. This not only improves the efficiency of healthcare services, but also helps reduce healthcare costs. 

In addition to improved care delivered by doctors and improved patient outcomes, the technology behind PDMS solution has also delivered internal benefits to UOHI that made the project affordable and feasible:

>>Decreased development costs 75 per cent by enabling available  application development rather than spending up to $750,000 on commercial software. 
>>Reduced application development time by as much as 75 percent compared to other development environments.
>>Stores all patient information in one database rather than multiple, separate databases.

The system also often helps reduce the occurrence of duplicate tests. This not only improves the efficiency of healthcare services, it also helps reduce overall healthcare costs.

Most importantly, the system has improved patient care and outcomes. Davies says that the PDMS database has revolutionized the care for cardiac patients at UOHI and has "saved lives by helping UOHI compile and create thousands of charts detailing patient care that can now be accessed fast and easily by doctors."

From the internal sponsor of the program, Dr. Ross Davies: "The PDMS database has revolutionized the care for cardiac patients at UOHI and has saved lives by helping UOHI compile and create thousands of charts detailing patient care that can now be accessed fast and easily by doctors."

From the application developer of PDMS, Stefan Donati: "The PowerBuilder technology we used to develop the solution decreased development time by as much as 75 percent, which helped us justify the solution on a cost basis. This was a critical factor to our success because many healthcare organizations are forced to postpone or even cancel IT deployments because of the cost. But in our case, we were able to proceed because the cost was relatively low."

From Terrence D. Ruddy, MD, Head of Cardiology at the University of Ottawa Heart Institute: "Before implementation of PDMS, the cardiologists dictated their outpatient clinic letters onto a tape using a dictating machine and then had their notes transcribed. The turn around time for this was approximately two to four weeks. Sometimes the tapes were misplaced or lost. But by using PDMS and digital technology, the cardiologist now dictates his clinic letters using a handheld digital voice recorder and immediately downloads them from any of the many docking stations in clinic or in cardiology offices. The files are automatically and directly downloaded to the transcriptionists thereby eliminating the several steps that used to be necessary to get the dictation from the cardiologist to the transcriptionist. The whole process now takes less than 48 hours. As the Chief of Cardiology, I believe I speak for all of us when I say that this innovative endeavor has been a resounding success, and we look forward to the additional capabilities that Dr. Ross Davies has begun incorporating into an already wonderful technological advance."

From Carol Anne Marleau, Administrative Assistant in the Division of Cardiology: "A number of cardiac patients frequent the Ottawa Hospital Emergency Rooms, and thanks to the PDMS solution, emergency physicians at each campus are able to access the patient letters, which can provide first-hand knowledge of their cardiac and medical history and for developing a treatment plan. By utilizing PDMS, we have an effective tool in collecting patient information quickly and efficiently, which provides pertinent cardiac and medical history in order to triage patients to cardiologists and other specialty physicians in the Heart Institute. This system is used on a day-to-day basis in the Acute Cardiac Referral Office. In the past it would take time and more effort to locate the hospital chart. Now we have an innovative tool for viewing and collecting patient information immediately. This drastically reduces wait times as we are better able to triage patients both with the PDMS records and referral notes."

From Lawrence Wong, MD, Senior Cardiology Fellow. I have been serving in the front line of cardiac care for the past 2-3 years. Cardiac fellows assume a wide spectrum of responsibilities in cardiac care at the Institute; including  on-call service for the busy emergency department. As you can imagine, the need for accurate and speedy clinical decision is paramount. In my opinion, and many of my colleagues, PDMS is central to our daily practice of the whole spectrum of cardiac care. When pushed to make a good clinical decision (such as should I activate the whole catheterization team at 3 in the morning?, or should I embark upon this line of investigation and treatment for this patient), PDMS allows us to have access of relevant information in a timely and often critical manner. The information (as opposed to data) available through PDMS contains the digested thoughts of physicians. In terms of clinical care, these thoughts are simply superior to any single piece of data on any given patient.

PDMS was developed by a clinician to fill a void in patient care. Now a clinician can record and retrieve a concise summary of all important clinical data from one source. It has been quickly adopted by the clinicians and is now widely used by all members of the health care team from nurses to administrators. 
Previously a clinican had to search through multiple different databases to assess patient information or the clinical component was simply not available. Paper records that previously were not accessible are now instantly available to doctors that are part of UOHI and the Ottawa Hospital campus. Davies says that he seldom has to retrieve paper charts stored off site, reducing duplicate testing for the patient and costs to the health care system.

PDMS has also succeeded by bringing together many disparate silos of information into one seamless record, and the database now includes more than 60,000 letters that detail treatments given over time to cardiac patients. The letters use a structured template making it easier for doctors to keep track of patient histories, medications, lab tests and diagnosis. 

What is amazing is how access to clinical information, rather than administrative or lab data, has so quickly become important and used in day to day patient care both at UOHI and the adjacent Ottawa Hospital campus. For example, now when a patient is referred to the regional heart catheterization referral office or to the outpatient acute cardiac referral clinic, the triage nurses can review the clinical history. They can determine if the patient has a drug allergy or is receiving a medication such as an anticoagulant that requires adjustment. Anesthiologists at the adjacent Ottawa Hospital routinely review the cardiac history of patients on the hospital electronic health record before non cardiac surgery. The emergency rooms physicians find it invaluable to access the complete clinical record in one place rather than searching for information across multiple databases. They can find opinions and care plans that are not easily obtained from administrative data. For example, the Cardiologist may note that a coronary bypass graft is occluded but the distal vessels are small and not suitable for further surgery in the event a patient deteriorates.

But now that UOHI has been successful in creating an outpatient database, Davies plans to create structured templates for discharge letters related to inpatient care. This is a natural extension of the PDMS solution since patients that are treated on an inpatient basis eventually transition to care provided on an outpatient basis. The information collected during the inpatient treatment can be reused seamlessly during outpatient care.

Historically, healthcare organizations have focused on inpatient care because of how expensive it is. Outpatient care is also not nearly as big of a revenue generation and cost-consideration area. But UOHI feels strong that patients need to be treated and managed the same whether they are outpatients or inpatients and while they make the transition from one mode to another.

The focus on the development of an electronic management solution of outpatient records truly makes UOHI unique among healthcare organizations. This is especially true given that PDMS was developed internally as opposed to an off-the-shelf commercial application.

The solution has been so successful that UOHI hopes to expand the solution and provide access to other doctors throughout the Ottawa area. One of the major reasons for the project's success is that UOHI chose to focus on outpatient clinical records, an area that is been underserved. Most hospital database solutions focus on financial and administration data related to inpatient care. 

For many years UOHI had searched for a way to bring all cardiac patient information from separate sources into one database that doctors could access instantly while visiting with and treating patients. But information on medications, lab results and patient histories tended to be stored in separate databases, and in some cases the information existed only in hard-copy format within a patient file. This type of process forced cardiac doctors at UOHI to spend extra time assimilating information, and in the case an emergency, it caused significant delays in patients receiving critical care.

In creating PDMS, which was the answer to this challenge, integrating all of the data, which existed primarily on legacy and proprietary systems, was the biggest technical obstacle. The integration and making sure all of the data fed properly into the central system took a lot of programming time. 

To pull information into the PDMS database, UOHI had to create a database link to communicate between the two different database management servers. When integrating between disparate databases, there are numerous issues involving data types, and depending on the driver, the transfer of data might not work a certain way unless programmed properly.

From an organizational perspective, prior to the deployment of the PDMS system, many doctors within UOHI had developed informational databases of their own on which they liked to rely and were reluctant to share for confidentiality reasons. To overcome this challenge, Dr. Davies introduced the PDMS solution simply as another option as opposed to a system that doctors had to use. This helped gain enough support from other doctors so that they began to use the system more often. 

It's also generally difficult to get doctors to adapt to any new technology. Many don't want to use computers, but because PDMS proved it could facilitate providing documents and making them available across all the hospitals, Dr. Davies was able to gain acceptance. 

PDMS has facilitated physician change management seamlessly. Doctors would never enter patient information into a database using a keyboard. However, by making use of their clinic letter dictations which they were already doing, we were able to capture the entire clinical process. It was easy for them to adapt to dictation based on a structured template with headings including reason for visit, history and physical examination, medications, lab results, diagnosis list and opinion and plan. 

A selling feature for the physicians was their ability to reduce dictation time since they could instruct the transcriptionist to re-use information in a previous letter, even authored by a colleague, since much of what they dictate is repetitive including lists of medications and diagnoses. 

Obtaining funding for the PDMS solution initially was a struggle as Dr. Davies invested hundreds of hours of his personal time and worked to secure funding through research grants provided by private foundations and through pharmaceutical companies. This was necessary since internal funding and IT resources at UOHI needed to be allocated towards other projects.  But Dr. Davies' skill at applying for and earning grants was successful. His fundraising efforts played a major role in the project's success. The popularity of the system, once deployed, made it possible for Dr. Davies to receive internal funding for the project rather than having to continue relying on outside research grants. The internal funding became possible once other doctors realized the value of the PDMS solution and began to support funding further development.

PDMS in now in full production. More than 30,000 clinic visits per year are now recorded in the database. The next step is to include discharge records so there will be a seamless transition from in-patient to out-patient care. 

Exceeded

Although PDMS has the capability of being a complete electronic health record, it has been successful by focusing on what has been missing from other commercially available solutions, namely an emphasis on clinical records, particularly on an out-patient basis. The increased use of the system by physicians and their requests to provide additional services has proven that it has exceeded expectations. Next steps that have been requested include development of FAX server technology working so that authenticated clinic letters reach the referring doctors faster and a digital dictation template for hospital discharge letters so there will be a seamless transition from inpatient to out patient care. In addition, programming has been developed for automatic coding of medications and diagnoses on the fly as they are being transcribed.
Referring physicians now receive letters on patient visits within two days rather than waiting a week or more. Once the fax service is deployed, they will receive the letters on the same day of service.

Demonstrating the success of PDMS is the 2008 Life Sciences Health Innovation Award which Dr. Davies received from the Ottawa Centre for Research and Innovation. The organization awards exceptional achievements of life science researchers, innovators and companies from Ottawa and Eastern Ontario.

The solution adopted by UOHI could also potentially be adopted by other healthcare organizations that provide any type of medical service that relies on compiling data from multiple sources into one central database so that doctors have all the information they need at the time they are meeting with patients.. UOHI realizes that by sharing its solution, it will also receive valuable feedback so that the PDMS solution won't remain static. This approach will allow the developers  to incorporate additional enhancements as it learns about the experiences of other healthcare organizations.

Over the time that the PDMS solution has been deployed, UOHI has received positive feedback from multiple sources. During a recent practice review by the Province of Ontario that was administered as part of the medical licensing renewal process, the reviewers liked the PDMS solution so much they wanted to know if it was commercially available so they could use it themselves. 

Becoming commercially available would not be too much of a stretch for PDMS. The solution is easily portable because it is platform-independent and could be applied by other healthcare organizations providing care to heart patients as well as any other type of outpatient care. 

To further illustrate the solutions success, other departments within UOHI such as the Cardiac Rehabilitation, have started to use PDMS. And Dr. Davies has also been asked to present the solution at conferences hosted by the American College of Cardiology as well as the TEPR (Towards an Electronic Patient Record) Symposium. 

Prior to the deployment of the PDMS system, many doctors within the UOHI network had developed informational databases but they could not share the information for a number of reasons: it was limited to a specific patient group, was not network enabled or was not interfaced with the hospital electronic health record. To overcome this challenge, Dr. Davies introduced the PDMS solution as a general patient database available over the UOPHI network and linked to the hospital electronic health record. This helped gain enough support from other doctors that they began to use the system. The popularity of the system also made it possible for Dr. Davies to receive internal funding for the project rather than having to rely on outside research grants. 

Another key to success was the way that Dr. Davies approached the other 25 cardiologists at UOHI. Since doctors are notoriously slow to change, he identified one doctor as a "champion" to work with first. He then worked with a second doctor. As these two early adopters realized the benefits of PDMS, they spread the word to the other cardiologists, and the rate of acceptance dramatically accepted.

Another key aspect was the bottom-up approach taken by Dr. Davies. Most IT solutions are driven from the top-down for financial and accounting reasons. But by taking a bottom-up approach that was patient centered and presented to one physician at a time, the PDMS solution had a much greater chance of success. Dr. Davies was also careful to secure a senior level administrative champion, but he primarily relied on working with one doctor at a time to get physicians on board and then allow those doctors to spread the word to their colleagues.