Doctors and nurses at Mount Sinai access clinical apps on iPhones

By Jerry Zeidenberg

TORONTO – To provide nurses and doctors with a solution that offers quick, mobile access to patient information, Mount Sinai Hospital has created VitalHub, a system that makes virtually all clinical applications available on one device – the Apple iPhone.

The hospital has written iPhone interfaces to 66 different clinical applications – including lab, radiology, pharmacy and clinical alerts, along with many administrative systems, too. It means that clinicians can readily access the information they need anywhere in the hospital or while they’re outside the medical centre.

Doctors, for example, can review what happened to their patients overnight before conducting rounds in the morning – or even while rushing to the bedside.

VitalHub is being rolled out this month (July) after a six-month pilot program last year. The project was spearheaded by the hospital’s VP and chief information officer, Prateek Dwivedi, who joined the hospital in 2008 and immediately saw that it took too much time and effort for clinicians to enter or access computerized information.

“My first day on the job, I saw a nurse write information on a folded sheet of paper at the bedside,” recalls Dwivedi. “She then walked back to the nursing station to enter the data, only to find the computer was locked down. She found another computer, but had to boot it up and wait for the applications to load. All she wanted to do was log the patient’s blood pressure and temperature.”

Stymied by the technology, the nurse was clearly flustered. “I assured her that we would fix things,” said Dwivedi.

Dwivedi did set out to fix things – especially after hearing similar stories from other nurses and doctors about the trials and tribulations of the existing computer system.

He also noticed that clinicians were accessing too many devices – cell phones and smartphones, pagers, large, clunky nurse-call devices, plus desktop computers at various workstations. Far better, he realized, to have one device that could serve as a gateway to everything. And the more portable the device, the better.

That’s where the Apple iPhone came in.

“The only organization I’ve seen that has actually made technology easier to use is Apple,” said Dwivedi, who believes that healthcare should look to other industries and the consumer sector to help solve its problems.

For his own part, in the past Dwivedi has worked in the IT departments of large companies and has also started and run his own entrepreneurial businesses. He never worked in healthcare before.

While he admits to having a lot to learn about healthcare, he is amazed by the lack of innovation in the hospital IT sector. It’s imperative, he says, to learn from other industries and from the fast-paced world of consumer technologies.

Impressed by what Apple has done for consumers and businesses, Dwivedi called Apple at its headquarters in Cupertino, Calif., and asked if they’d be interested in a project that would change the face of healthcare. An Apple VP soon called back, and Dwivedi and a few colleagues flew to California for a meeting.

Long story short: they launched the VitalHub project at the end of 2008, and showed a preliminary version at HIMSS 2009 in Chicago. Even Apple was surprised at how fast the work was done.

“In five months, we had the prototype working,” said Dwivedi. “We called it VitalHub because it would form the hub of all the applications and information that clinicians needed.

“It was important to be able to get information into the applications quickly, or in many cases, just to view these apps quickly.”

And as Dwivedi observed, it was also crucial that information could be accessed in the same way on the iPhone as on regular computers. “Or else you’d spend too much time figuring things out and searching,” he said.

The hospital tested the application with a group of 20 doctors and nurses from July to December 2009. It then temporarily shut down the pilot program so that what was learned could be incorporated into the next version of VitalHub.

It’s this new system that’s being rolled out this month on a larger scale. It’s going to be made available to some 200 doctors and 1,300 nurses.

While having a smartphone capable of accessing all major hospital applications is seen as a breakthrough – indeed, it’s believed that Mount Sinai Hospital is the first teaching hospital in North America to do it – the question some ask is, Why the iPhone, especially when the BlackBerry is so well-entrenched in medical circles?

Dwivedi notes that Mount Sinai will create versions of VitalHub for the BlackBerry, as well as for other platforms like Google’s Android smartphone operating system and the Microsoft smartphone OS.

“But to start, we didn’t have the resources to develop on all platforms,” said Dwivedi. “We had to pick one.”

The team went with the iPhone, he notes, because of its ease of use and its closed case that’s without a physical keyboard. “You can dip it in Virox and it still works,” commented Dwivedi. (A keyboard appears on the iPhone as an application on the touch screen.)

Moreover, it was the only existing smartphone that could do everything needed – like email and accessing records – while wearing surgical gloves.

Meanwhile, hundreds of Mount Sinai Hospital clinicians are ready and willing to make use of VitalHub on the iPhone. From the look of things, so are clinicians at other sites. Indeed, it turns out that 50 other hospitals in Canada, the United States and around the world are already interested in acquiring the VitalHub system for their own doctors and nurses.

To help commericialize and distribute the system, and fuel ongoing development, Mount Sinai Hospital has spun-off the project as a company that’s now called VitalHub, Inc.

Its new CEO is Neil Closner, who is also a vice president at Mount Sinai Hospital.

Together, Dwivendi, Closner and the team at Mount Sinai hope to make it easier to access computerized information at hospitals around the world. Amazingly, it can all be done using smartphones that can slip into a pocket and be carried around anywhere, anytime. using smartphones that can slip into a pocket and be carried around anywhere, anytime.

BACK TO CONTENTS LISTING

Slowly, in some jurisdictions, progress is made on interoperability

By Jerry Zeidenberg

Remember that scene in Cool Hand Luke where Paul Newman is told, ‘What we’ve got here is a failure to communicate’? It comes to mind when looking at the efforts of regions and entire provinces that are trying to connect hundreds – even thousands – of healthcare IT systems. Many of the systems don’t talk to each other, which leads to no small problem. It means that doctors, nurses and other caregivers can’t get the information they need to treat patients.

Luckily, progress is being made. Some jurisdictions have found the ‘translators’ needed to get the systems speaking the same language.

For its part, Manitoba is betting on a solution that’s been used with great success in Israel, Belgium, Pittsburgh and New York City.

The province last year announced a $22.5 million investment in an integration solution from dbMotion, with project management from IBM. The technology will connect the myriad health IT systems used across the province. Significantly, it will do it by consolidating the information in central repositories.

“It pulls together all of the disparate data and displays it in a viewer,” explained Peter van der Grinten, vice president for dbMotion, during a meeting at the HIMSS conference in Atlanta. The February conference attracted nearly 28,000 attendees, all seeking to learn about the best ways of computerizing their healthcare systems, or to promote solutions that promise to do so.

Manitoba has already built its main data centres as part of an ongoing eHealth program. The dbMotion component that’s being added will act like a giant conveyor belt, shuttling data from various information silos to the central repositories and back to the users who need the data.

The newest information can then be used to update the records of hospitals, long-term care facilities, doctors and other caregivers.

From a practical point of view, the chief advantage of the dbMotion technology is that it has already been proven to work in other jurisdictions. And it is sold as ‘packaged’ software rather than a custom-made solution – very little code has to be written.

“Other provinces have taken the approach that they’re unique, and that they need to custom-build a solution,” said Giovanni Vatieri, national health practice leader at IBM Canada’s Global Business Services. But he pointed out that building healthcare IT applications from scratch is not so easy. It can be time-consuming, expensive, and the-made-to-order product may not work – lessons that other provinces and organizations in the United States and Britain have recently learned.

Manitoba, however, is leveraging the success of dbMotion in Israel, Belgium and several U.S. sites. “With dbMotion, everything is ready to use,” said van der Grinten. “It’s COTS, commercial off-the-shelf software, so we’re not developing anything new.”

The software is now being installed and tested. “Ninety-four percent of what we need is available right out of the box,” said van der Grinten. “The rest of the work involves configuration.”

The first phase of the project – called Release 1 – will integrate electronic records from five medical labs, a large drug information repository and five emergency departments at acute-care hospitals in Winnipeg.

Release 2, scheduled for 2011, will add diagnostic imaging, hospital information systems, ERs, long-term care facilities and doctors’ offices across the province.

Of course, integration isn’t just a technology problem. That’s why a considerable investment is being made in training and change management. Van der Grinten noted that other dbMotion clients are putting about 20 percent of their project budgets into change management, and that Manitoba will be in the same ballpark.

While Manitoba’s project is consolidating records and information in a central repository, there are other ways of linking databases. In the United States, three of the largest providers of healthcare have launched a pilot project in San Diego that connects electronic patient records in a ‘virtual’ way. Data stays in its original location, but it’s pulled into the record of a doctor or caregiver when he or she needs it.

“We don’t believe in creating massive repositories,” said Dr. John Mattison, chief medical information officer at Kaiser Permanente, which in the San Diego area is connecting its electronic health records to those of the Department of Defense and the Veterans Health Administration. “Philosophically and morally, we don’t want to aggregate patient records in that way. As well, by avoiding huge repositories, we reduce the need for terabytes of additional storage.”

Instead, the project has deployed an integration engine that pulls data from charts at the other organizations when ordered to do so by a physician working with a record. “Updates are done on demand,” said Dr. Mattison. “They’re triggered by caregivers at the decision-point.”

Interestingly, the project is using Open Source software called Connect Gateway as the glue that ties everything together. Kaiser is currently using its own integration engine, one that was written in-house, but plans to soon adopt the Open Source solution, like the DoD and the VA.

Dr. Mattison says the integration of records is working well and has proven extremely useful to physicians who are using it. “Patients will tell their doctor, ‘I’ve got five diseases, but I can’t remember name of the little red pills I’m taking.”

It’s extremely useful for doctors at Kaiser to be able to see the patient’s records at the VA or the DoD to quickly find out what those diseases are, along with the identity of those little red pills. The patients enrolled in the pilot have multiple care-givers at Kaiser and the two military organizations.

Dr. Mattison pointed out that Kaiser Permanente has integrated numerous systems across its 36 hospitals and 431 medical offices – contrary to the belief of some that it uses just one big Epic system. “We have scores of different applications, including lab, radiology and pharmacy, that required integration,” said Dr. Mattison. “We’ve done it largely through the use of international standards, such as HL7, SNOMED and LOINC.”

The Kaiser-DoD-VA project is funded by the Nationwide Health Information Network (NHIN). Dr. Mattison says his group has been “assessing the rough spots in their solution, and creating an industrial strength version.” That work is nearly finished, and he says that the system will be rolled out to other sites starting this fall.

While the project is experiencing a high opt-in rate among patients, Dr. Mattison said there will always be 5 percent to 10 percent of the population who simply won’t want to participate.

Many don’t want their records to be shareable and easily accessed. They often include patients with HIV or psychiatric issues who, for various reasons, prefer not to have doctors accessing their charts.

Dr. Mattison noted that patients who decline to have a shareable electronic record can always keep a Personal Health Record. It would be a form of the EMR which they could control and provide to care-givers at their discretion.

He observed, however, that physicians must view Personal Health Records with caution, as patients may omit certain types of information. “It’s up to the patient to verify or falsify the record,” he said. “The physician will have to treat that record somewhat differently.”

While Dr. Mattison’s team in California is fine-tuning its interoperability solution, creating an industrial strength system, others at HIMSS already claim to have products that can do the job. Like dbMotion, some have made inroads into Canada.

Carefx is implementing interoperability solutions that leave data in their original locations, much like the Kaiser-DoD-VA system, pulling information together when needed. “We use a federated model,” said company CEO Andrew Hurd. “Our solution makes real-time queries.

Carefx is currently used at the two-site Trillium Health Centre, in the Toronto area, where it integrates a host of solutions from different application providers.

“It’s like Google,” he explains. “Google points you in the direction of the information. It retrieves the information, but doesn’t warehouse it.” With the federated system, Carefx also avoids troubling governance issues. “We don’t have the politics that go along with huge repositories,” said Hurd. “We don’t have to worry about where the data sits and who owns it.”

The system can link any number of applications, says Hurd, such as order entry, lab, document management and diagnostic imaging. “Carefx sits on top of all of them. Its context management and workflow engine act like the glue that pulls together everything the user needs.”

Medseek also has an integration solution that’s used in several Canadian hospitals, including Hamilton Health Sciences, the William Osler Health System, and Credit Valley Hospital. Most recently, the system went live at Headwaters, in Orangeville, Ont.

Rich Grehalva, senior vice president, noted that Medseek can be used in either a federated format or through a centralized repository. What’s more, it can be set up to give the public access to their information, forming the basis of a personal health record. A solution for diagnostic imaging is being touted by MEDecision, of Wayne, Penn. The company has won a place in the Toronto West diagnostic imaging repository project, which is centralizing the images and DI reports of 25 hospitals.

MEDecision is working as part of a consortium, but is supplying a key piece for solving the integration puzzle. “We have expertise in IHE standards like XDSi,” said Dr. Elliot Menschik, general manager. “We can take images from legacy systems and convert them into the XDSi format.”

What’s more, the company’s InFrame system also works with various versions of HL7, including version 3, which adds to its versatility as an interoperability solution.

BACK TO CONTENTS LISTING

Message from image guided therapy conference: The future is now

By Andy Shaw

Dr. Robert Bell is not given to flights of over-the-horizon fancy. He’s a practical, former orthopaedic surgeon turned president and CEO of the University Health Network (UHN) who is paid, at least in part, to keep his head down on running the country’s largest grouping of research hospitals. But after some 13 of the best and brightest image guidance researchers and surgeons in the world spoke about their developments at a sold-out UHN conference at the University of Toronto’s venerable Hart House in April, Dr Bell, said by way of advice to other hospital head honchos: “Better keep your eye firmly fixed on the horizon.”

Clearly looming on that horizon are robots – ones that will bring profound changes in the way diagnostic images are merged with surgical procedures. Changes that will eventually take surgery beyond what the human hand can do by its unassisted self and even beyond what the human eye can see now. This blending of richly detailed, three-dimensional pictures of our insides with deft, robot-planned and guided dissection, conference attendees were told, will alter dramatically how acute care is delivered.

But just as clearly we’re not quite there yet.

The most amusing moment of the conference came when the last speaker, Dr. Catherine Mohr, the director of medical research at the world’s foremost surgical robot maker, Intuitive Surgical Inc. in Sunnyvale, Calif., put up a slide showing one of her company’s “state of the art” da Vinci surgical robots – festooned with photocopies of a patient’s diagnostic images taped to the robot’s exterior panels.

“What we’re working on now for the next generation of our machines is how to get those pre-op images inside the robot with a heads-up display,” said Dr. Mohr once the laughter subsided.

Dr. Mohr knows about heads-up displays from when she worked as an engineer in the aerospace industry. A mid-life change vectored her into a medical degree and a medical device career where she continues to use her inventive engineering skills.

Also amusing and inventive was the multiple award-winning Dr. John Trachtenberg, a urologist and the director of prostate service centres at both the UHN’s Princess Margaret Hospital and nearby Mount Sinai Hospital.

“I may be a research scientist and all that, but my kids know me as a ‘pee-pee’ doctor,” Dr. Trachtenberg told the conference.

To his peers, Dr. Trachtenberg is better known as a missionary for image-guided, robot-assisted,“focal therapy” laser treatment of prostate cancer.

“We need better prostate treatment. Most treatments now damage the prostate and have very bad side effects like loss of urinary functions and sexual problems. And the more damage you do to the prostrate, the greater are the side effects,” said Dr. Trachtenberg. “So we decided to take a Buck Rogers approach to the problem and use MRI guidance to map out precisely the cancerous part of the prostate – that’s the focal part of focal therapy – and then use the robot to guide a laser that ablates very precisely only the tissue within the map, so the side effects are absolutely minimal.”

Dr. Trachtenberg said that in the first human trial of the new system, he achieved what he believes is a world first.

“We used the robot and laser to treat five volunteer prostate cancer patients just recently. All their cancer is now gone. We had 100 percent kill and there have been no side effects, whatsoever,” reported Dr. Trachtenberg. “Also, instead of four hours or more, the operations took only two hours each.”

Dr. Trachtenberg believes that his “robotic solution,” with practice, could be done in even less time and simply be a walk-in, walk-out same day procedure. Given that prostate cancer is the leading cancer among men and most get hospitalized, the savings to the healthcare system are potentially enormous.

There’s one minor drawback, for the claustrophobic at least, to this potentially revolutionary procedure – the patient is operated on while he remains inside the donut hole of the magnet.

“So the technical challenge,” says Dr. Trachtenberg, “was to build a system that was entirely non-magnetic.”

Which is precisely what Dr. Andrew Goldenberg, PhD, and his Engineering Services Inc. company, in Toronto, did for long-time collaborator Dr. Trachtenberg.

The system will be used also when the five patients have needle biopsies done of what remains of their prostates, four months, and again one year after their focal therapy operations.

The acceptance of this potentially miraculous marriage of imaging and surgery may not happen overnight, but in a piecemeal manner.

“I think what you’ll see is that surgical robots will evolve and not be the kind of Swiss Army Knives that da Vinci robots are now, which can do a pretty good job at a lot of different operations,” said Dr. Mohr. “Certainly, all the devices will allow the surgeon to see 3-D images of their surgical plans in front of them as they operate. That will be common, but more and more, I think, the machines will become specialized for specific procedures. But in the end, I believe, just about all surgery will be done this way with robots.”

Even the tiniest procedures.

“Already, we have a confocal microscope adapted to one of our microsurgical robotic probes, so in effect we can operate even on individual cells if needed,” said Dr. Mohr. “

She added that the full scalability of robotic hand control has yet to be exploited. But it can make a surgeon’s hand steady even at the level of nano-machines.

Among other highlights of what’s on the imaging-surgical horizon these days and revealed at the Hart House conference:

• David Jaffray, PhD, the head of UHN’s radiation therapy physics department and the world-renowned developer of the cone-beam CT, predicted that the computerized individualized breast and other cancer treatments he is involved with at Princess Margaret will lead to planning of a patient’s surgery that is automated. Today, even with computer help, those surgical plans can take up to two-and-a-half hours and more. But in future, as the planning software Jaffray has under development learns from repeated use, those patient-specific plans will be reduced to eight or nine minutes.

• Dr. Kieran Murphy, an interventional radiologist and deputy chief of the University of Toronto’s medical imaging department, says Canada will have to step up its imaging research and development – if it wants its medical device industry to keep pace. In a survey he conducted of the 10,000 member International Society of Radiology, he found that Canada trailed badly, producing only 16 patents over seven years while the United States researchers filed over 1,600.

• Dr. Kazuhiro Yasufuku, an internationally renowned thoracic surgeon from Japan, now with the UHN, said the trend in image-guided surgical instruments has gone beyond minimally invasive to “mini-invasive”. For example, a new convex probe he has developed with the help of Olympus Corporation of Japan can guide him through a tiny hole to inside the lung, where he can spot and put a needle in tiny, cancerous lesions.

• Dr. Garnett Sutherland, professor at the University of Calgary and the author of five patents, has specialized in what MRI-guided surgery can do for neurological diseases. He has developed a ceramic neurosurgery robot arm that works on patients while their head is inside the guiding magnet. It’s enabled delicate brain operations through what he terms “mini-craniotomies”, which reduce skull openings to postage stamp size – and make brain surgery for some a simple outpatient procedure.

• Medical physicist, Dr. David Hawkes from University College in London, England, told the conference that the most promise for the better mating of imaging and surgery is held by optical technologies. For his own part, Dr. Hawkes has been able to produce sharp, real time, artifact-free images of the liver and other motion-prone organs, while the patient lies in the MRI machine, without taking a gulp of air and holding it, but rather just breathing freely during the exam.

Of course, patients won’t see all of these innovations immediately. “You don’t see much change happening day-to-day. But the changes coming soon in image-guidance and surgery that we have heard about here today are going to change your world. They are going to change the nature of your imaging departments. They are going to change the size, shape, scope, and use of your ORs, too. And they are going to change the way you educate, train, and keep your surgeons current.”

BACK TO CONTENTS LISTING

HOME - CURRENT ISSUE - ABOUT US - SUBSCRIBE - ADVERTISE - ARCHIVES - CONTACT US - EVENTS - LINKS