April 22, 1998

 Enquiry: Christine Archibald

Secretariat

2nd Floor, City Clerk's

carchib@city.toronto.on.ca

 To:Budget Committee

 From:Interim Contact, Board of Health for the City of Toronto Health Unit

 Subject:Transition Funds Required to Realise Efficiency Savings in the Vaccine Preventable Diseases Program

  Recommendation:

 The Board of Health at its meeting on April 21, 1998 adopted the report dated April 8, 1998 from the Medical Officer of Health requesting transitional funding of $711,505.00 necessary to realize the savings associated with the re-design and amalgamation of the Vaccine Preventable Diseases Program and forwarded this report and its recommendations to the Budget Committee for consideration.

 Background:

 The Board of Health had before it a report (April 8, 1998) from the Medical Officer of Health respecting transition funds required to realize efficiency savings in the Vaccine Preventable Diseases Program.

 The Board of Health also requested the Medical Officer to Health to provide Robert Davies with more information regarding the hardware standards for the notebook computer purchases.

   Interim Contact

Board of Health

for the City of Toronto Health Unit

Transition Funds Required to Realize Efficiency Savings

in the Vaccine Preventable Diseases Program

 The Board of Health recommends

 The Board of Health submits the following report (April 8, 1998) from the Medical Officer of Health regarding transition funds required to realize efficiency savings in the vaccine preventable diseases program:

 Purpose:

 To secure transitional funds for information technology in 1998 required to realize the savings associated with the re-design of the Vaccine Preventable Diseases Program (VPD).

 Source of Funds:

 1998 transition capital budget.

 Recommendation:

 (1)That the Board of Health adopt this report requesting transitional funding of $711,505.00 necessary to realize the savings associated with the re-design and amalgamation of the Vaccine Preventable Diseases Program.

 (2)That the Board of Health forward this report and its recommendation to the Budget Committee for consideration.

 Background:

 On March 31, 1998 Budget Committee approved the 1998 budget estimates for Public Health including an expenditure/budget reduction of $400,000.00 annualized to be achieved through the re-design and amalgamation of the Vaccine Preventable Diseases Program. In order to achieve key conditions required to achieve this targeted savings, before September 1998, there is a requirement to develop and implement automated information systems for the program. This condition was noted in Section E "Actions Required and/or Assumptions Made in Achieving Target" of the budget package.

 Comments and/or Discussion and/or Justification:

 In order to realize the $400,000.00 annualized savings associated with the redesign and amalgamation of the Vaccine Preventable Diseases Program, it is imperative that four consolidated information systems be established and implemented before September 1998. The new City of Toronto has over 400,000 students in 1,000 schools, and approximately 30,000 children in 700 licensed day cares, who are monitored each year to ensure that they have received required vaccinations. The City also has 27,000 grade-7 students in 416 schools who are offered hepatitis B immunization series each year by public health staff and over 3000 physician offices that must be annually monitored with respect to vaccine handling and storage for publicly funded vaccines. All these activities and services depend on data managed through these information systems.

A key budget reduction proposal approved by the Board of Health and the Budget Committee was the consolidation and re-design of the VPD Program. Vital to the success of this activity is the development and implementation of these four systems.

 Attached is the Appendix which details the justification and costing for the development of the four consolidated systems for the VPD Program.

 Conclusions:

 This capital investment in the information systems to support the VPD Program is essential to achieve the $400,000.00 designated savings.

 Contact Name:

 Bill Mindell, York Office

Tel:394-2851

Fax:394-2907

 Peter Oliver, Toronto Office

Tel:392-1560 x87018

Fax:392-7418

 Appendix

 Detailed Justification Regarding Information Technology

Expenditures and Savings in the Vaccine Preventable Diseases Program

 Development, redevelopment and consolidation of six independent versions of various information systems (one for each of the previous municipal health units) are required to support the Vaccine Preventable Diseases Program. These systems are also needed so that Public Health can achieve its previously committed and approved budget reductions beginning September 1998. They include the Immunization Record Information System (IRIS), the Biological Inventory System (BIOS), a Vaccine and Drug Ordering System, and a Physician Vaccine Monitoring and Inspection System.

 In 1998 we have requested $711,505.00 to complete these four information systems. Full year staff savings will be $400,000.00

 I.Immunization Record Information System (IRIS)

 IRIS is a system that is used by Toronto Public Health to monitor and enforce the mandatory Vaccine Preventable Diseases Program and the Immunization of School Pupils Act . The new City of Toronto has over 400,000 students in 1000 schools who are monitored each year by this system to ensure that they have received required vaccinations. If they are not up-to-date and do not have a valid exemption, then they are not permitted to attend school (suspended by order of the Medical Officer of Health). The system also monitors the immunization status of 30,000 children in 700 licensed day cares, a provincially mandated activity for the health unit, and a small number of high risk seniors and homeless people who receive vaccinations at community clinics.

 Consolidation of six separate IRIS databases through this proposal will save time, staff resources and space while improving customer service as there is considerable movement of students among the six districts. All pricing and purchase or leasing recommendations described below are based on corporate standards in place at this time and include relevant taxes.

 (1)Forty-five PCs will be required for this program. Since 35 existing PCs are technically adequate, 10 new PCs must be obtained. At $4,025.00 each, this totals to $40,250.00.

 (2)Fifteen notebook PCs are required primarily for use in the mandated hepatitis B clinics offered to all grade 7 students. Since 5 existing notebooks can be used for this purpose, 10 new notebooks are required. At $5,980.00 each, the cost of notebooks is $59,800.00. These notebooks also have other uses, including inspections of physician offices in cold chain monitoring (using the Physician Vaccine Monitoring and Inspection System), and use in the event of mass immunization clinics (such as in an outbreak of meningococcal meningitis). The new city has 27,000 grade 7 students in 416 schools. The program requires nursing staff to give immunization needles three times over a six month period to each student. The average turnover (students switching schools) in the new city is estimated at 40 percent per year. It is difficult and time consuming through phone calls (to parents, other schools and other health units) and manual searches to find the consent forms and previous immunization records necessary for subsequent needles when there is turnover. Notebook PCs, with communications technology (through cell phones) can eliminate this problem, and improve customer service and vaccine completion rates, by allowing direct access to the IRIS record for each student. It also allows immediate and direct access to update the record as the needle is given at the clinic location. The old system proved to be very inefficient as the records were updated later (often weeks or months after the needle) back at the office.

 The notebook PCs have also been very useful in community clinics for homeless people and high risk seniors to protect against the risk of over-immunizing. Transient people and some seniors often do not recall when they have had their last influenza vaccination or if they have been given pneumococcal immunization (only required one time after age 65). These records are entered into the IRIS system and are accessible through this technology at these high risk clinics.

 Through the use of notebooks in the past, the former City of Toronto has demonstrated greater efficiencies in administering school-based clinics and community clinics due to the ability to connect to the IRIS server. Through this connection staff at the clinics were able to access up-to-date immunization history for each person regardless of where they lived in the City and without relying on costly printed and sometimes inaccurate reports. In conjunction with the consolidation of the 6 IRIS systems, the purchase of these notebooks can ensure that the savings already achieved in the former City of Toronto can be demonstrated throughout the New City. Added benefits include the reduced need for office space for these staff since they are able to do more work out of the office.

 (3)Fifteen cell phones with notebook PC connections at $1,150.00 each ($17,250.00 total) are required to support this application because most schools do not have dedicated phone lines that can be made available and accessible to immunization clinic staff (most clinics are held in gyms). Single, dedicated phone lines are necessary for the computer connection to work.

 (4)Communication equipment (called Winframe) to support the link of the 15 cell phones to IRIS is estimated at $69,000.00 as required by corporate standards. Included in this price is the cost of a cable and card for each notebook to connect the notebooks to the cell phone and telephone line feature that allows multiple users to share one telephone number.

 (5)Three printers are needed. These will have to be high reliability, high speed, high volume dedicated laser printers because approximately 100,000 students each year will be contacted with one to five forms which will have to be produced in multiple copies. At $5,750.00 per printer this totals to $17,250.00.

 A suggested alternative arrangement which has been used by other city departments is to contract out bulk printing. However, this cannot be done because of the confidentiality of health information contained in immunization records, notices and orders. Also, a quick turn around time for documents related to individuals is required for suspension orders (and subsequent re-admissions) of students to schools.

 (6)One network server is required to support 45 concurrent users and the IRIS data base. It will also be used to support some smaller data bases associated with the infectious disease program. Back-up systems and data mirroring are essential (a crash would idle up to 45 staff and significantly interrupt program delivery). Corporate standards must apply. The cost of such a server has been specified at $115,000.00.

 (7)NetWare Licensing for a 100 user package will be required. This will cost $7,130.00 for the package.

 (8)Disaster recovery is estimated at $17,250.00. This is a one time up front cost of having a consultant write a program that will be used to transfer data to a replacement server in the event of a major server failure. It is critical that the server not be inoperable for more that 3 hours.

 (9)Technical consulting is required for design, coding, testing and installation. This cost is estimated at $46,000.00 for all of the above.

(10)A sophisticated programmable telephone system will be required for at least 60 people. The system must receive calls through one number and then allocate them in sequence to all immunization staff that are logged in. This system needs to be integrated with the Access Toronto project so that calls can be easily routed to the Toronto Public Health when appropriate. It needs to have messaging capability after hours in order that people may leave immunization information when the offices are closed. This system cost is estimated at $115,000.00.

 Thus, all the transition IT budget components related to IRIS and the mobile notebook PCs (which will be shared but not costed in some of the other VPD systems described in this document) total $503,930.00.

 II.Biological Inventory Ordering System (BIOS)

 The BIOS is a provincially supported system that is designed to enable health units to efficiently monitor and track the use of publicly funded vaccines in the province. In Toronto, BIOS is used for monitoring our own supplies of vaccines such as hepatitis B vaccine for grade 7 and clinics. Some (but not all) offices also had small amounts of childhood and adult vaccines on hand. Toronto and Scarborough offices have also used BIOS to monitor the use of sexually transmitted disease (STD) drugs which all offices provide to physicians at no cost.

 In the new city, BIOS will be used to monitor all biologicals maintained by Toronto Public Health which include: hepatitis B, influenza, pneumococcal and all childhood vaccines; rabies vaccine and rabies immunoglobulin; STD drugs used in our clinics and distributed to community physicians; tuberculin purified protein derivative (PPD); tuberculosis drugs that we administer (through Directly Observed Therapy (DOT)) or distribute to physicians; and drugs for rare conditions (e.g. leprosy) that we occasionally supply to physicians.

 The BIOS will not require any additional hardware and will reside on the same server that supports IRIS. It will be accessed through existing PCs that can be connected to the server. The only IT cost required is an estimated $11,500.00 for consulting to consolidate the existing data bases, set up the system for the new City and test the system.

 III.Vaccine and Drug Ordering System

 Toronto Public Health currently does substantial ordering, on behalf of Toronto physicians, to the Ontario Government Pharmacy (OGP) of hepatitis B vaccine for individuals at high risk, tuberculosis drugs, STD drugs and occasional other drugs for rare diseases such as Leprosy. The OGP has an old computer ordering system, called CAMMS, which we could potentially use. However, it has many problems including the fact that it cannot maintain patient history. Thus each time a physician phones, especially for a TB drug reorder, it is necessary to collect all the basic information again rather than simply pull up a patient history screen.

 We believe that we can save additional staff time city-wide by properly automating this system. This would primarily affect orders for TB drugs and hepatitis B vaccines for high risk individuals. Staff would still have to take phone orders from physicians, but subsequent paper processing is greatly reduced and information is exchanged with physicians from a real-time screen. This will vastly improve customer service and save physician office time as well.

 This new system would be installed on the new IRIS server and would require $115,000.00 in development costs (design, coding, testing and installation). While no major equipment costs are required we would need an additional three PCs at a cost of $4,025.00 each for the staff handling the orders (total $12,075.00).

 IV.Physician Vaccine Monitoring and Inspection System

 This system would support a new mandatory Public Health function of inspecting and monitoring the publicly funded vaccines that physicians get directly from the OGP. The requirement is that we inspect annually each of the 3000 office delivery locations and vaccine refrigerators in the new city and investigate any cold chain failures. Many of these sites have multiple refrigerators to monitor, e.g. the Toronto Hospital is one site. We estimate we will have 100 investigations of cold chain failures annually. The development of this system represents a cost avoidance of one to two additional FTEs. Use of the notebook PC equipment, described in an earlier section of this report, will enable nursing staff to input results directly.

 The costs of development of this system, which will be maintained on the IRIS server, is $69,000.00.

 Savings:

 Annual savings in the Vaccine Preventable Diseases Program directly related to amalgamation have been identified at $400,000.00 with $100,000.00 achieved in 1998 if IRIS and BIOS is consolidated and the 2 new systems developed by September 1998. After the six previous municipal programs are fully integrated, other efficiencies may also be possible.

  Vaccine Preventable Disease Systems Information Technology Costs