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Inside the February 2000 print edition of
Canadian Healthcare Technology:


Feature Report: The State of Diagnostic Imaging


Health Canada web site aims at health promotion

Health Minister Allan Rock helped launch the Canadian Health Network (CHN), a web site that is designed to be a trusted source of information on the Internet.

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Ontario hospital produces clinical cost-cutting software

How do you cut costs while maintaining – indeed, ideally improving – the quality of patient care?

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Entrepreneurial hospitals

Futurist and economic forecaster Nuala Beck urges healthcare executives to think of their hospitals as “engines of the economy” that are capable of generating wealth through the licensing of new ideas and export of new products.


Internet addicts

Saint Elizabeth Health Care has developed an Internet misuse and addiction program to help children and adults, and their schools, parents and employers, to manage and prevent problem Internet usage.


Seniors on the web

Tendercare Living Centre has launched a program to give residents access to the Internet. It’s said to be the first nursing home in Canada to provide both the technology and continuous computer training for seniors.

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Diagnostic Imaging: Getting to the heart of merging images and information

Dr. Steven Tishler sees the immediate future of diagnostic imaging as clearly as anyone. The youthful Dr. Tishler is a practising cardiologist in Mississauga, Ont., where he also played a key role in planning the Trillium Health Centre’s enviable catheterization suite.

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Smart teledialysis

A home-based peritoneal dialysis machine is now available that automatically records 25 to 30 different variables, such as the volume of fluid delivered through the peritoneum. Data is captured on a smart card or through a telecommunications link.


PLUS news stories, analysis, and features and more.

 

Health Canada backs new web site

By Neil Zeidenberg

TORONTO – Health Canada and more than 400 health organizations have together launched the Canadian Health Network (CHN), a web site that is designed to be a trusted source of information for Canadians.

The site, found at www.canadian-health-network.ca, is said to be one of the first in the world that brings together both government and non-government organizations as partners.

“Getting access to what you want, when you want it can be a challenge,” said Health Minister Allan Rock at a CHN launch event late last year. He was referring to the thousands of sites available on health-related issues.

“The Canadian Health Network brings order to health information, from organizations you can trust,” said Rock.

The focus of the information is on health promotion and disease prevention. The resources are intended to help people lead healthier lives by providing them with accurate information on how to take care of themselves and others, and to help prevent illness and disease. However, the site does not replace medical consultation with a doctor.

CHN’s partners come in three categories:

• Regional Operating Partners (ROP) – coordinate the collection and dissemination of regional resources on health promotion and disease prevention,

• Affiliate Partners – provide leadership and expertise in a health topic or population group area. They support the ROP’s by identifying and selecting the resources, responding to consumer and health inquiries in both official languages,

• Associate Partners – assist in enhancement of consumer access to their resources.

The CHN is a non-profit service funded by and developed in partnership with Health Canada, and will receive $32 million in government funding over three years.

The CHN works with government health ministries and organizations in every province and territory. The information on the site is said to have a Canadian perspective.

Topics include AIDS/HIV, cancer, heart health, healthy eating, substance use/addiction, environmental health and alternative medicine. New topics and partners will be added as the CHN continues to grow.

Recent additions to the list of partner organizations include the Samuel Lunenfeld Research Institute of Mount Sinai Hospital in Toronto, the Hepatitis C Society of Canada, Canadian Palliative Care Association, and British Columbia Ministry for Children and Families.

As not everyone has access to or can use a computer, the Canadian Health Network is currently working on a 1-800 number. Since July of 1999, the site has recorded 1.8 million hits just through word-of-mouth.

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Ontario hospital produces computer software to reduce clinical costs

By Andy Shaw

How do you cut costs while maintaining – indeed, ideally improving – the quality of patient care?

That’s the conundrum puzzling hospital and healthcare providers just about everywhere these days. Caught between the irresistible force of governments bent on reducing their healthcare spending and the immovable object of public and professional concern about the impact of budget cuts on the quality of care, responsible healthcare managers are turning to technology for an answer. They look to new computer systems for getting more and better healthcare done with less.

But in southwestern Ontario, an enterprising doctor-nurse-administrator-information system group of people at the St.Thomas-Elgin General Hospital instead first turned to old-fashioned logic. Faced in the early 1990s with an Ontario government that would no longer finance the hospital’s deficits, the group reasoned that their biggest cost-saving could come from reducing the days of non-acute treatment that patients received at their acute care facility.

They also firmly believed, despite some skeptics among doctors, that if certain criteria were addressed consistently by providers, the quality of acute care could be raised. Further, they knew that nothing helps with consistency better than a computer program.

The development team’s key players were Paul Collins, vice-president of operations and information at St.Thomas-Elgin, Dr. David Atkinson, chief of pediatrics and the physician-coordinator for quality-utilization at the hospital, Sandra Jenkins, the director of quality-utilization management, and Larry Vanier, the director of information services.

After eight years of development, the team has publicly announced Continuum Solutions, a unique software answer to the cost-versus-care conundrum. The tool enables St. Thomas-Elgin’s staff to provide a continuum of more effective daily care to patients while dramatically reducing the high cost of unnecessary hospital stays.

“The prevailing idiom is that healthcare for each individual is too complex for consistency,” said Dr. David Atkinson at a Continuum solutions conference in St. Thomas last fall, as he described the challenges of developing the program. But by brainstorming with physicians from all disciplines at their hospital, Dr. Atkinson and the rest of the Continuum project team came up with a convincing, criteria-based index of effective patient care. Dubbed ACTIV, it enables Atkinson and other users to consistently judge and monitor the intensity of service each patient needs daily.

It also tells them when patients become non-ACTIV – in other words, when they are ready for discharge or in need of having their care plan adjusted. The result is fewer days spent unnecessarily in hospital.

These “conservable” days are grist for the Continuum mill, says Sandra Jenkins, an original development team member along with Atkinson and a former nurse manager of pediatrics at St. Thomas-Elgin. “At most hospitals, about 40 to 50 percent of their days are conservable. With Continuum, we’ve got that down to about 30 percent so far at our hospital and we think the program will can take conservable days down to at least 22 percent.”

Jenkins says Continuum helps make every day of care count. “When a patient comes into a unit at the hospital, nurses use the program to identify what has to be done for that patient in an acute care setting. They make that judgement against five basic criteria or considerations the program presents, and they do that every day the patient is with us.”

The nurses also monitor Continuum’s ACTIVITY Index as it evaluates each patient’s progress each day and identifies which patients remain ACTIV or have become non-ACTIV. Then in consultation with physicians, clinical staff, and outside services they can determine what to do with the non-ACTIV patients.

“It’s important to note that Continuum is not a prescriptive tool,” says Jenkins. “But it is definitely a decision-support tool that enables the healthcare team to set priorities and advance the patient towards their discharge home or to a more appropriate care environment.”

Larry Vanier, St. Thomas-Elgin’s director of information services, reports that the Continuum software was written in Delphi computer language and will run off any ODBC-compliant database structure. “It can also run off of any SQL server,” says Vanier, who was a member of the development team. “It’s also very flexible in terms of use. It can run multi-user in a networked mode throughout the hospital or stand-alone on a notebook.”

Indeed, users can follow Continuum’s logic of determining and monitoring care without the software. But it is much more convenient and consistent when done on-screen.

“It’s Windows-based and it’s operated by the point and click of a mouse. Most importantly it has one simple primary screen for data entry,” explains Vanier. “And it has bright visual indicators when changes are to be considered for the patient’s care.” From a management perspective, Vanier says Continuum readily interfaces with other hospital systems and delivers reports to help make boardroom decisions about the best use of hospital resources.

As a result, St. Thomas-Elgin is not hiding its Continuum light under a bushel. Under the banner of a separate Continuum company (www.continuumsolution.com), the hospital is marketing the software as well as the assessment and consulting services that go with it. It has found early Canadian buyers in the Chinook Health Region in Alberta and the Joseph Brant Memorial Hospital in Burlington, Ont.

Startup costs are in the $16,000 to $20,000 range for the software, installation and training.

“It’s an affordable system that we think can be marketed to any Commonwealth or other country with a healthcare system similar to Canada’s, and with some modifications to HMOs in the United States,” says Jenkins.

Continuum’s market potential may even be far greater, says Vanier. “The criteria in the program used are changeable. We’re using it for acute care. But it can be used for chronic care as well. In fact, it doesn’t have to be restricted to healthcare. It could be modified for any field where conditions have to be monitored daily against a set of criteria.”

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Nursing home establishes innovative WWW program for seniors

By Jerry Zeidenberg

TORONTO – Tendercare Living Centre, a 234-bed seniors’ facility, has launched a program to give residents access to the Internet and the World Wide Web. It’s said to be the first nursing home in Canada to provide both the technology and continuous computer training for seniors.

“Computers have been installed in other residences for seniors, but this is the first time we’ve seen a full training curriculum for volunteers developed as part of the program,” said Judith Limkilde, dean of applied arts and health sciences at Toronto-based Seneca College. “We hope it will serve as a model and ‘how to’ guide for other seniors residences.”

Not only do residents have access to a PC, but they can also obtain the one-to-one instruction, feedback and encouragement that’s necessary for learning computer skills.

Since November, seniors at the facility have been able to communicate with relatives and friends by e-mail, and to develop their interests and hobbies by visiting a variety of web sites. Limkilde said that access to the Internet could help many senior citizens communicate with loved ones in far-flung places and contribute to their pursuit of knowledge, arts and entertainment.

Seneca College and IBM Canada Ltd. are working together to organize the Internet project. Three students from Seneca’s Gerontology Social Service Program are teaching residents at Tendercare how to use the personal computer, software and Internet link, which were donated by IBM Canada as part of the company’s community service program.

Susan Adamson, a consultant working with Seneca College, noted that the academics will study how seniors take to the technology at the Tendercare site, and will present their findings at a conference called Seniors in Cyberspace, to be held in Toronto in June. As well, they will produce a ‘how to’ manual for Internet computing that could be used at other seniors residences.

Bob Morine, vice president for public sector activities at IBM Canada, said that Internet technology could very well “broaden and enhance senior’s lives.” He lauded the project as a pioneering step in 1999, the international year of older persons, and as a useful program for the new millennium. In Ontario alone, the number of persons over the age of 65 is expected to double in the next 20 years, while the number of those over 85 will double in the next 10 years.

One of the first residents at Tendercare to participate in the Internet project is 62-year-old Robert LeFeuvre – who notes that he is also the youngest resident there. LeFeuvre has been using e-mail to keep in touch with his daughter, who recently moved to Edmonton. Moreover, he’s using the World Wide Web to investigate personal interests such as music, motor racing and classic cars. “I’m not a TV person,” said LeFeuvre. “I used to go regularly to the library, and this is like having a library in your pocket.”

LeFeuvre notes that not all residents at the facility will be interested in using the computer, and some will not have the mental capacity for it. But for many, he said, it will be a useful and welcome piece of equipment. “It’s great for people in wheel-chairs, who have difficulty getting around. It brings the world to them.”

Moreover, he believes the computer and Internet will help keep the minds of seniors active. “The brain is like a muscle,” said LeFeuvre. “If you don’t use it, you lose it.”

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Diagnostic Imaging: Getting to the heart of merging images and information

By Andy Shaw

Dr. Steven Tishler sees the immediate future of diagnostic imaging as clearly as anyone. The youthful Dr. Tishler is a practising cardiologist in Mississauga, Ont., where he also played a key role in planning the Trillium Health Centre’s enviable catheterization suite. Trillium’s four partner hospitals built the ultra-modern cath lab at its Mississauga site as the foundation for Canada’s first fully digital and networked heart disease centre. When operational later this year, Trillium’s Advanced Cardiac Service will have added cardiac surgery and angioplasty to its already functioning cath lab services. But that will not be the end of their development.

“We’re planning to have a common database for the cath lab, the surgical program, and angioplasty,” says Dr. Tishler who graduated from the University of Toronto medical school in 1990 before a specialist internship and then three years of post-graduate cardiology training at the Toronto General Hospital and St. Michael’s Hospital. “So from the database we will be able to add information to the images from our cath lab and all our other imaging sources. We will be able to take, say, a physicians report, or a physical exam, or a little patient history, or any angiogram images, and paste them in as still frames to create a fully integrated cardiac report.”

That will be no small feat. As the medical world knows, the merging of images and information is needed if ever a shareable electronic patient record is to become a reality. But the lack of standards among other technical barriers has stubbornly stood in the way of the merger. Hope runs highest, however, with the cardiology community. It was the American College of Cardiology (ACC), after all, that developed the DICOM standard that, for example, allows the radiological images captured on CD by the Philips equipment at Trillium to also be seen by downtown Toronto hospitals on their Siemens gear. What’s more, cardiologists are playing a prominent role in the international IHE (Integrated Health Enterprise) initiative that began last year to take a five-year crack at creating a common image/information standard. And as others have observed, if this integration can be achieved in cardiology, which involves the most complex images of all, it can be done for any discipline.

More tangibly at the moment, a major commercial drive to merge diagnostic images and the information that interprets them surfaced at the annual November gathering in Chicago of the Radiological Society of North America (RSNA).

“It was a pivotal show,” says Alyn Ford. “It clearly indicated both for diagnostic imaging generally and cardiac imaging specifically what the new industry trends are.” Ford is the vice president and general manager of the image management group for the newly named Cedara Software Corp. of Mississauga. Cedara was known until recently as I.S.G. Technologies and it remains the world’s largest independent producer of software for medical imaging equipment.

Says Ford: “At the show it was evident that information and images are being merged together in one consistent offering. And that’s something hospital IS managers should be aware of.”

In keeping with the trend, Cedara, in a joint venture with ADAC Laboratories of Mt. Pitas, Calif., unveiled a prototype in the RSNA’s Workflow Theatre of an integrated PACS (picture archiving and communication systems) and RIS (radiology information systems) system. Dubbed ENVOI, the system is aimed at an OEM world market that Ford estimates at $US 700 million and growing at 20 percent annually.

ENVOI and its Intranet Image Server promise to deliver real time access to images and reports for radiologists, referring physicians, and staff in the emergency room, intensive care, or cardiac care units. It uses both DICOM and telecom protocols to distribute images and reports, via an intranet or the Internet, throughout an enterprise.

The RSNA show also indicated that the urge to merge reached beyond the technology. It featured a major coming out of the merger between American-based Sterling Diagnostic Imaging Inc. and the Belgian-based Agfa-Gaevart Group announced earlier in the year. Now known simply as AGFA, it has emerged as a world leader in medical imaging equipment. Its IMPAX picture archiving system is storing and distributing images at 400 sites around the world, more than any competitor.

“Our merger with Sterling has turned out to be a marriage made in heaven,” says Julian Sale, vice president of medical imaging for AGFA Canada. “Sterling had focused on printer networks, by taking all the digital imaging modalities, CT, MRI, ultrasound etc., and connecting them all to a single printer network. Now, we’ve added a two-way gateway to their technology and can take all the non-DICOM modalities, or about 90 per cent of the legacy equipment in the Canadian market place, make a DICOM image out of them, and plug them into our IMPAX network.”

With 2300 Sterling printer networks installed worldwide, adds Sale, AGFA now has a huge new entry point to the market.

Not content with that advantage, AGFA also announced at the RSNA a joint venture with Waterloo, Ontario-based Mitra Imaging Inc. Mitra provides connectivity software to all the major OEMs in imaging, including AGFA, Kodak, Philips, GE, Siemens, and Fuji. Mitra and AGFA have spun off a jointly owned company called IMPAX Technology Inc. It will develop and market products to all OEMs that bring the functions of PACS and RIS systems ever closer together.

“For the last 10 years we’ve been producing connectivity products such as our PACS Broker that links a text protocol such as HL7 to a DICOM standard,” says Jim Herrewynen, Mitra’s marketing manager. “However, there are limitations on that text or RIS side. It’s limited in the way it can provide information. But the goal eventually is complete bi-directional connectivity.”

Herrewynen thinks Mitra has taken a seven-league step towards that bi-directional end with the next generation of PACS Broker called Connector.

“It will take patient data from virtually any department, integrate them, and move them out to the rest of the enterprise,” says Jeff Hendrikse, the other half of Mitra’s marketing staff. “So a cardiologist can review a case in a remote location and then send the data out to other doctors in the hospital or potentially to the referring physician base.”

Herrewynen says Mitra is in discussion stages with various OEMS about Connector and expects to make a major announcement at the upcoming ACC cardiology meeting in Anaheim, Calif., in March.

“That kind of integrating function is particularly needed in cardiology. It is quite like radiology was before PACS and RIS,” says Hendrikse. “You do have your cath labs which tend to be rather well connected. But then you have echo, ECG, and other systems all collecting information yet nothing is really bringing their data together.”

To start bridging those islands, the prestigious Brigham and Women’s Hospital (associated with both the Massachusetts General Hospital and the Harvard Medical School) has selected Mitra to provide its cardiology solution.

“They’ll be providing us with the resources of their cardiology specialists and their IT group as we develop software for them,” says Herrewynen. “And this is an important step in cardiology imaging because what we’re really after is to understand the hospital’s workflow. From there we can come up with something that will not only meet their needs but also be generalized for other institutions down the road. We’ll be saying more about those prospects and our partnership with the Brigham and Women’s at the ACC meeting in Anaheim.”

In the meantime, outside of meetings and conventions, it’s also evident that imaging and information systems are melding.

For instance, Agilent Technologies, the new Hewlett-Packard subsidiary, has managed to merge ultrasound images and related information using standard computer platforms. Its new EnConcert product is an echo information and image archiving management system that runs on Windows NT and Microsoft SQL server.

“It brings everything into one place for the consulting physician,” says Susan Clair, marketing program manager for imaging systems at Agilent Canada’s Healthcare Solutions Group.

“Traditionally, the echo images are recorded on video tape. So the image gets degraded. Then there’s a lot of time spent winding and re-winding the tape looking for the right section. After that, the physician usually dictates a report on to a tape recorder and that has to be transcribed.

“But with EnConcert all that is done with a mouse click. The image is digital, so the image is not degraded, and any spot in the recording can be found instantly with the mouse pointer,” says Clair.

Agilent has also produced a way of combining images and text, saving time and trouble for physicians and other medical professionals. “The physician can add a report as part of the process by selecting and clicking on a list of words that describe that patient’s condition,” says Clair. “They transform automatically into standard sentences in the report.”

At the time of writing, Canada’s first networked version of EnConcert was being installed by the Capital Health authority in the Edmonton region.

“The system is also Web-enabled, so physicians can share the images and the report with physicians at other sites via a secure Internet connection,” adds Clair.

Beyond this current and promising era, there are prospects in at least one imaging discipline that the line between image and information will one day completely disappear.

At the Ottawa Heart Institute, Dr. Rob Beanlands, the chief of cardiac imaging, is keenly awaiting the start-up of the Institute’s new cyclotron. With it, Dr. Beanlands and his associate researchers and clinicians will be able to produce the Heart Institute’s own carbon, nitrogen, and oxygen isotopes. These traceable elements will greatly enhance their PET (positron emission tomography) capabilities and work.

“All other forms of cardiac imaging, give you a good idea about the structure of the target organ but not much information about its function. But the activity of the isotopes used in PET can be tracked and measured very precisely,” says Dr. Beanlands. “They can tell you exactly about glucose levels and blood flow pressures in the heart – things that are very difficult to detect with conventional imaging or without some form of intervention (such as a catheter) into the tissue.”

Beanlands sees PET breaking new ground as complementary technologies get both better and cheaper. “The cameras we use now, for example, have a lot better resolution and are much less expensive than they were five years ago. So one of the things I foresee is that we will be able to understand drugs like we never have before. We’ll be able to say that this drug in this patient is going to this part of the heart and causing this effect. We’ve never been able to do that. With better resolution we’ll also be able to confirm the results of new techniques such as molecular biology therapy. It enables new blood vessels to develop. And we’ll be able to prove that new blood vessels have indeed formed and that there is blood flow through them.”

Imaging and information in one.

 

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