ELECTRONIC CHILD HEALTH NETWORK (eCHN)

 September 1999, as Andrew Szende prepared for the Electronic Child Health Network’s (eCHN) upcoming board
of directors’ meeting, he wondered how he could expand the scope of eCHN’s services and membership in a
financially profitable way.

 The Hospital for Sick Children (HSC), in partnership with IBM and four member organizations, designed eCHN
to provide both the public and registered health care providers with Web-based access to children’s health
information and services

 HSC, eCHN’s most prominent partner, saw the Network’s development as a major step toward fulfilling HSC’s
objective of being a “hospital without walls” and a leader in the delivery of health care to children

 ANDREW SZENDE envisioned eCHN as a not-for-profit organization committed to improving health care
delivery to children

 Needed to present the eCHN’s board of directors with a plan that would allow the Network to grow in a
financially profitable way that would benefit both eCHN’s member organizations and children’s health.

HOSPITALS IN ONTARIO

 Hospitals in Ontario were struggling.

o Fiscal constraints, technological advancements, and increasing public scrutiny of the health care system
were forcing hospitals to find new ways to provide high quality, accessible health care at a lower cost.

o In addition, initiatives implemented by the Health Services Restructuring Commission (HSRC) were
changing the nature of health care delivery in Ontario.

 The HSRC had a four-year mandate to restructure hospitals in Ontario, and develop policies
that increased the level of coordination and cooperation among health care providers.
 The HSRC estimated that hospitals could avoid spending $900 million annually on acute
care services that were being used inappropriately.

THE HOSPITAL FOR SICK CHILDREN

 1875, the Hospital for Sick Children was first opened in an 11-room house in Toronto, Ontario, “for the admission
and treatment of all sick children.
o First year of operation: 44 patients were admitted to the new six-bed hospital, and another 67 children
were treated in outpatient clinics

 1951: the HSC moved to its current location where it has developed into one of the largest pediatric teaching
hospitals in the world, with a 1998 operating budget of $305 million and 383 beds in service.
o Mission statement: Health care community dedicated to improving the health of children” that would
“provide the best in family-centred, compassionate care, lead in scientific and clinical advancement, and
prepare the next generation of leaders in child health.”

 As a children’s academic medical center, the HSC served as a:

o (1) resource to the local, regional and international communities in managing highly specialized
children’s healthcare problems
(2) site for training of specialists and primary care providers
o (3) site for clinical research.
 Envisioned itself in the new millennium as a “hospital without walls”, and through its collaboration with others,
aimed to become the “best pediatric academic health science centre in the world.”
o As a “hospital without walls,” HSC would serve not only the health needs of those children who
visited the hospital, but also children around the world.
 The HSC developed seven strategic imperatives that would allow the hospital to achieve its vision:
 o 1. We will lead in the delivery of exemplary patient care and the development of new forms of treatment
so that children who come to HSC continually experience the best results.
o 2. We will become the preeminent research enterprise for children’s health worldwide continually
generating new ideas and innovations for patient care.
o 3. We will build an outstanding education and knowledge dissemination capability that allows what we
have learned to improve children’s health around the world.
o 4. We believe passionately that our greatest resource is the people who choose to work at HSC and we
will develop new ways to support, develop and retain staff and attract the best recruits.
o 5. We understand that success in this new world will not be possible alone and so we will lead and work
cooperatively with viable responsive networks and partnerships.
o 6. We will continually challenge ourselves to improve by measuring and evaluating the value and
effectiveness of what we do and then sharing our results with others.
o 7. To become the best, we will need to enhance existing and develop new sustainable sources of funding
so that our horizons will not be limited by financial barriers.

THE CHILD HEALTH NETWORK

 In 1994, HSC first described a new systems approach to the provision of child health services.
 This approach recommended the development of a seamless continuum of child health services.
o In 1997, the HSRC mandated the development of a Child Health Network for the Greater Toronto Area
(CHN).
 The CHN had a vision.
o Its goal was to provide an integrated and consistent system of maternal, newborn and child health services
that would improve the health and quality of life for children independent of geographic location.

o The CHN’s services would be provided through the alliances and partnerships among its members.

o The CHN was organized on a regional basis, with Regional Pediatric Centres (RPCs)designated in each
region of the Greater Toronto Area to coordinate the provision of children’s health services.
 RPCs worked with associated hospitals, other health care providers and consumers to ensure that
the unique health needs of their region were being met.
 The development of a communications infrastructure would, therefore, be a critical enabler of the CHN’s goals.

THE ELECTRONIC CHILD HEALTH NETWORK

In 1998, the Electronic Child Health Network (eCHN) was developed from a partnership between HSC,
IBM Canada and four other health facilities with significant pediatric components in Ontario (St. Joseph’s
Health Centre, St. Elizabeth Health Care, Orillia Soldiers’ Memorial Hospital and Centenary Health Centre
of the Rouge Valley Health System). The eCHN, a not-for-profit organization, provided the
communications infrastructure that was required to support the development of the CHN. This
communications infrastructure consisted of two Web sites that allowed health care professionals, parents
and children to access children’s health information 24 hours a day. In addition, eCHN provided a secure
system (not connected to the Internet) that allowed eCHN-associated health care providers to electronically
share a child’s medical records stored on a common database. Both the HSC and the Ontario Ministry of
Health ($7.5 million each) provided funding for the $15 million eCHN, and the products and services
supplied by IBM were provided at cost.
The eCHN provided both public and registered health care providers with Web-based access to children’s
health information and services. While other telehealth networks had been developed in Canada and the
United States, eCHN was unique in its focus on children. Andrew Szende, eCHN’s chief executive officer,
(Appendix 1) envisioned eCHN playing a key role in the development of a common standard of care for children among
its member organizations, no matter where those services were delivered. Szende said that
eCHN’s goal was to “electronically link hospitals, local pediatricians, home care agencies and other
organizations that provide child health services in Ontario.”
The eCHN enabled not only its member organizations to exchange secure, electronic patient information
but also children to receive the right care at the right time as close to home as possible. For example, a
young cancer patient in Orillia, Ont., would no longer have to travel to Toronto for regular chemotherapy
treatments. Instead, the child could go to a local hospital where a physician could access the patient’s
clinical data on-line that included radiographic images (e.g., x-rays), laboratory data and medical chart
notes. Physicians would also be able to share in clinical protocols and obtain the latest information on a
wide variety of health issues related to their patients’ care. It also meant that parents would not have to
retell their child’s painful medical history every time they saw a new doctor, and would have easy access to
information related to their child’s health.
Michael Strofolino, president and CEO of the Hospital for Sick Children, emphasized the importance of
communications technology in the future of health care. Strofolino said that the necessity for a system
such as eCHN became clear about five years ago, when hospital administrators realized that many children
were not getting the medical services they needed. “When we looked at the symptoms, it became clear that
there were many, many services out in the community that we had yet to utilize. In fact, many patients
were showing up at the hospital, and while it was very complimentary, they were not appropriate to be
seen here; they could have been seen in other locations.”
The eCHN’s services were provided in three separate components (Exhibit 2): (1) a Web site designed
specifically for parents and children (“Your Child’s Health”); (2) a Web site that allowed Ontario health
care professionals to share resource materials and exchange opinions (“PROFOR”); and (3) IBM’s “Health
Data Network”, a secure electronic database that allowed health care providers in different facilities to
share children’s health records.

“Your Child’s Health”

“Your Child’s Health” provided parents and children with Web-based access to health information
prepared by health care professionals from eCHN’s member organizations.
The “Your Child’s Health” Web site was divided into three components:
“For Parents”: this section provided parents with health information on common childhood illnesses such
as asthma and the basics on tonsillectomy.
“For Kids”: this section provided children from three to 18 years of age with health information (e.g.,
asthma and tonsillectomy) in formats appropriate to specific age groups. Interactive games and stories were
developed to allow children to participate in the discovery of health information, and parents to work with
their children to help them understand a visit to their physician or hospital.
“My Child is Sick”: this section provided parents with information that would help them decide whether a
health problem was really an emergency. In order to avoid long waits in emergency, parents could review
information about common childhood illnesses (e.g., asthma, diarrhea, fever, febrile seizures, ear
infections) at home. Parents could then decide whether their child required emergency help or could waitfor their family
physician or pediatrician to be available. If emergency help was needed, the locations for
all of the Emergency departments in the Greater Toronto Area were listed.
In 1998, “Your Child’s Health” was awarded a Canadian Online Product Award for the Best New
Consumer Product in the category of Health/Medicine. Shala Aly, vice president and general manager, Ebusiness
and ERP, IBM Global Services, said that “the site [was] an excellent example of how health care
organizations [could] effectively use the Web to better serve their community. Combining the Hospital’s
medical expertise with IBM’s e-business capabilities — in designing, building and hosting the site — has
produced a valuable online resource for children and parents alike.”
Szende was aware of the public’s concern over the availability of high quality health care wherever and
whenever it was needed. He saw “Your Child’s Health” as a valuable resource for both parents and
children that could be accessed free of charge. Szende knew, however, that the maintenance costs for this
Web site would be high. The health information available through “Your Child’s Health” had to be
updated and new information added on an ongoing basis. Szende wanted to look for ways in which “Your
Child’s Health” could generate revenues that would offset the costs associated with site maintenance, and
generate the profits that would allow the eCHN to grow.

PROFOR
PROFOR was a secure Web site that was designed to facilitate communication and collaboration among
health care professionals affiliated with eCHN’s member organizations. The PROFOR Web site offered
opportunities for dialogue on child health issues, updates on current research projects, bibliographies on
health topics, and parent education information that could be provided to parents after consultation with a
health care professional. The information available on PROFOR’s Web site was provided by health care
professionals from eCHN’s member organizations and reviewed by the PROFOR Editorial Board prior to
posting. The information was then organized by clinical discipline, e.g., dentistry, anesthesia, and posted
on the PROFOR Web site.
To access the site, health care providers needed a password that could only be provided through the
PROFOR User Coordinator at one of the CHN’s member facilities. Once health care professionals logged
into PROFOR, they could access any of the following sections:
Presentations: this section provided health professionals with access to video presentations and discussions
including rounds for medical, nursing and other professional services.
Collaboration: this section allowed professionals on the network to share information and ask questions online.
Standards: this section provided health care professionals with immediate access to “Standards of Patient
Care” and “Clinical Practice Guidelines” for a variety of specialty areas including anesthesia, bioethics,
and critical care (Exhibit 3). Health care professionals used these standards and guidelines to treat
common childhood illnesses. Health care professionals could compare the clinical outcomes associated
with their treatment methodologies to the standard approaches used by colleagues in member
organizations.
Research: this section provided information about ongoing research projects involving eCHN members.
This section also presented the status of clinical trials and other research being undertaken by eCHN
members.
Journals: this section provided brief bibliographies of current literature on selected topics in pediatric
medicine, surgery and related child health fields. Some of the bibliographies were annotated to indicate the
reason the article was chosen and its strengths and limitations.
Parent Education: this section contained parent educational material that could be printed off PROFOR and
given to parents and children for their reference after their office or hospital visit (Exhibit 4). Being able to
print materials on demand ensured that up-to-date information was available to parents and children at low
cost.
Szende knew that physician buy-in was required for PROFOR to be successful. Physicians functioned with
considerable autonomy, and their primary concerns focused around the efficient and effective delivery of
high quality patient care. From the physicians’ perspective, eCHN’s effectiveness rested on its ease of use
and the availability of updated, relevant health information. In addition, many physicians felt that the
practice of medicine could not be achieved through the standardized protocols and guidelines that
PROFOR offered. In contrast, sections such as “Parent Education” and “Presentations” provided
physicians with reference material that they could integrate into the way they provided patient care.
Szende knew that he would have to sell PROFOR to physicians based on the Web site’s value as a clinical
tool that could be used to improve clinical outcomes and avoid unnecessary health care costs.

Health Data Network

IBM’s “Health Data Network” (HDN) system provided health care professionals from eCHN’s member
organizations with access to children’s medical records. Unlike “Your Child’s Health” and “PROFOR”,
the HDN was not connected to the Internet and all information remained private within eCHN. The child’s
medical history that appeared on the screen looked much like a standard medical file with tabs for lab
results, medical imaging reports and other documentation. The information contained in these electronic
patient records included laboratory results, doctor’s notes, x-rays, visit information and personal
information such as addresses and contact persons. The information was presented in the same format
regardless of where it originated. Data could be input into the system directly or collected from multiple
legacy systems from different institutions and organizations.
The HDN provided eCHN members with instant access to patient records when a patient arrived in their
location. Paper files were no longer required to follow a patient from location to location, where the
opportunity for loss and misplacement existed. Szende felt that the HDN ensured the security of children’s
confidential, and sometimes highly sensitive, health information. Szende also felt that the Network’s goal
to expand membership to include health care organizations other than hospitals made the material available
on HDN broader than information on any individual hospital record. Szende also felt that health care
providers would have faster access to patient records, and more opportunities for research studies of
children’s illnesses and treatment.
Szende knew that the HDN site had the potential to generate significant revenue. eCHN’s partners agreed
upon a membership fee of $150,000 per organization per year. Most of the network’s costs were fixed
costs associated with the network’s maintenance. As a result, Szende figured that the network’s costs
would be modestly incremental once membership in the Network moved beyond 10 institutions. Szende
knew, however, that the membership fee would represent a significant portion of the operating budgets of
many community hospitals, long-term care agencies and rural health facilities. These were the facilities
that Szende hoped the Network would eventually include. The administrators in these facilities needed to
be convinced of HDN’s value. Value for them would be defined as an improved quality of patient care and
ability to avoid the health care costs associated with the unnecessary duplication of laboratory and
diagnostic tests. Szende knew, however, that the administrators’ definitions of “value” were not always
aligned with the physicians’ or patients’ perspectives of value.
Szende also knew that hospitals and other health care facilities in Ontario were at various stages in
implementing new or updating existing information technology (IT) systems. Although the HDN could
easily interface with many different legacy systems, many hospitals would have to modify their existing
systems if they wanted to become Network members. These IT costs were not included with the $150,000
eCHN registration fee. In addition, Szende wanted to expand eCHN’s membership to include physicians’
offices, community hospitals, homecare organizations and teaching hospitals. Unfortunately, less than 10
per cent of physicians had electronic charts, and there was no real economic incentive for them to do so.
Szende felt that the current membership fee and IT requirements might prove to be prohibitively expensive
for some of the health care organizations he hoped eCHN would expand to include. Szende was also
uncertain how quickly it would take for HDN expansion to occur.

eCHN’S STRATEGIC CHALLENGES

Szende knew that the eCHN could be an integral part of Ontario’s health care system. He did not want the
Network to be viewed as a luxury item tailored to physicians’ on-going professional development. Rather,
he felt that eCHN would play a key role in allowing hospitals to avoid unnecessary health care costs, and
in improving patients’ access to high quality, efficient health care. Szende knew that he would have to
present a strategy that would allow him to achieve buy-in from health care administrators, physicians and
the public.
Szende also knew that there were many ways in which eCHN could grow both in the scope of its
membership (i.e., hospitals, physicians’ offices, and long-term care facilities), and the geographic locations
of its member organizations. At the same time, although Szende wanted to ensure that this growth was
financially profitable, he did not want the current membership fee to limit access to the Network to only
those organizations that could afford to pay this fee. He, therefore, felt that the membership fee might have
to be changed to make the Network accessible to a wider range of health care organizations.
In addition, Szende knew that eCHN’s current governance would have to change to reflect the Network’s
growth. For example, HSC was a major partner in eCHN and Szende wondered if this arrangement should
last as the Network grew. Szende knew that he needed to determine the most appropriate structure and
composition for eCHN’s board of directors. In addition, he needed to identify performance measures that
would determine whether eCHN’s mission and strategic goals were being met. Szende also knew that the
board’s structure would have to ensure representation, participation and collaboration with the medical
staff of eCHN’s member organizations.
As Szende prepared for eCHN’s upcoming board of directors’ meeting in September, he knew that he
needed to present the board with a clear plan that outlined his strategy for eCHN’s growth. More
specifically, he knew that the board would want to know who eCHN’s “customers” were, how Szende
planned to access them and achieve buy-in, who would be paying for access to eCHN’s services, and how
he would price eCHN’s services. Szende also knew that the board would want to know if and how he
planned to expand eCHN’s scope of its membership and the Network’s geographic reach. As Szende
reviewed a recent consultant’s report, he knew that he had the next 90 days to prepare his own strategy for
eCHN’s growth

ANDREW SZENDE
Prior to joining the eCHN, Andrew Szende, CEO of the eCHN, was a management consultant specializing
in health services. Szende facilitated the creation of the Rouge Valley Health System, considered by
professionals in the health care industry to be one of the HSRC’s restructuring success stories. He also
worked for other hospitals, the Ontario Hospital Association, and the HSRC. Szende was formerly an
assistant deputy minister and head of the Health Economic Development in the Ministry of Health. In
addition, he served as the associate secretary of the Ontario Cabinet and the province’s chief economic and
trade representative in Asia. He obtained a Bachelor of Arts degree from the University of Toronto and a
master of social science from the National University of Singapore.

PROFOR CLINICAL PRACTICE STANDARDS FOR PHYSICIANS

Management Guidelines for Children Having Tonsillectomy and/or Adenoidectomy on the Same
Day Discharge Basis
Tonsillectomy and/or adenoidectomy with the patient being discharged home the same day of surgery
may be completed safely. Guidelines for this format of management are not intended to either replace a
physician’s clinical judgment or to be applied to all patients in a rigid fashion.
A. ELIGIBILITY GUIDELINES
1. Patient greater than two years of age at the time of surgery.
2. Absence of history of bleeding disorder in patient and immediate family.
3. Absence of systemic disease disorder or airway abnormality that increases perioperative risk for
the patient.
4. Absence of significant obstructive sleep disorders.
5. Absence of extended travel time, weather conditions, social/economic factors that will make
return of the child to the hospital for possible emergency care difficult.
6. Parent has insight and understanding of recommended surgery and care required in the post
operative periods. Parent has no barrier (i.e., language, no phone, etc.) if emergency assistance
is required in the home during the first 24 hours following surgery. It is recommended that
patients remain in hospital for a minimum of six hours of nursing observation following surgery.
Under certain circumstances, it will be appropriate to admit patients for overnight observation.
The following guidelines for discharge or admission are not intended either to replace a physician’s
clinical judgment or to be applied to all patients in a right fashion.
B. DISCHARGE GUIDELINES
1. Patient able to drink and not vomiting.
2. Absence of significant bleeding.*
3. Clinical signs stable and normal.
4. Discharge instructions understood by parent.
C. ADMISSION GUIDELINES
1. Blood loss during surgery exceeds 5% of blood volume.
2. Significant bleeding during the period of observation following surgery.
3. Patient has vomited more than three times or less than two hours prior to the scheduled
discharge time.
4. Patient febrile (>39 degrees Celsius) or abnormal clinical signs.
5. Excessive parental anxiety.
*It is recommended that a child with any evidence of bleeding post operatively be examined by a
physician prior to discharge from hospital

Exhibit 4
PROFOR CLINICAL PARENT EDUCATION GUIDELINE
CROUP
Contents:
What is croup?
Signs & symptoms to watch for
How to help your child get better
Follow-up arrangements
What is Croup?
Croup is a throat infection, caused by a virus that results in swelling and narrowing of the breathing
passages. It usually begins quite suddenly and often at night when the child is asleep. The most
noticeable symptoms are a barking, seal-like cough and a hoarse voice. Children continue to cough for
four to seven days.
Signs and Symptoms to Watch For
1. Breathing
some difficulty breathing
noise with each breath taken in (stridor)
chest indents (caves in) with each breath (indrawing)
breathing faster than normal for your child
2. Cough
a congest, “barky” or seal-like cough
frequent and/or troublesome coughing
3. Behaviour
your child is sleepy, lacks energy or your child is cranky, fussy, restless or crying a great deal (this
may be a sign of increasing difficulty in breathing)
4. Drinking
your child is not drinking normally, for example less than ____ oz. in 8 hours.
How to Help Your Child Get Better
If the sound of the cough frightens you, remember it is important to remain calm. There are things you can
do to help. First, try turning on the water in the shower or tub until the bathroom is steamy. Close the bathroom door
and sit with your child for about 10 to 15 minutes. You should see a big improvement in your child’s
breathing during this time but if not, then try taking your child outdoors for the same length of time. In
winter it will be necessary to wrap your child in a warm blanket, but often the cold air is of great benefit.
Your child should be kept as quiet as possible. Hold your child upright sitting on your knee. When in bed,
elevate the head of the bed by placing books or newspapers under the legs of the bed—this helps make
breathing easier and helps to lessen the cough while sleeping.
In winter, when our homes are heated, a cool mist vaporizer is helpful at your child’s bedside, while
sleeping at night and during daytime naps. Extra humidity is very important to help your child breathe
easier.
Making sure that your child is drinking well will help his/her temperature remain normal. Any increase
should be recorded and brought to your doctor’s and/or nurse’s attention. Keep your child comfortably
dressed. If your child is shivering or complains of being cold, add warmth with a sweater. Remove extra
clothing if your child becomes too warm.
When Should I Call the Doctor?
Call your child’s doctor if you observe any of the following:
your child’s breathing has not improved after the bathroom steaming and/or the time outside in the cold
air
your child is upset and breathing fast
your child is fussing, restless or more tired than usual
your child’s chest caves in with each breath
breathing is noisy with each breath taken
your child is not drinking well
When Should I Take My Child to the Hospital?
Take your child to the nearest hospital if he/she has any of the following symptoms:
is still having difficulty breathing after you have tried the actions described above
has a very sore throat and is unable to drink
is drooling and unable to swallow his/her saliva*
begins to look blue or grey around the lips, toenails or fingernails*
*The last two conditions require immediate attention. Call 9-1-1 if you feel the distress is such that you
cannot make it to the hospital without help.