Inside the February 2008 print
edition of Canadian Healthcare Technology:
Philips, Toshiba and GE have all pushed the envelope when it comes
to Computed Tomography. At the recent RSNA meeting in Chicago, the
vendors announced leading-edge CT systems. We provide coverage of
this and other DI developments.
patient flow for UHN’s ED
Since implementing an Emergency Department Transformation Project,
the University Health Network’s ED has seen a 20 percent reduction
in length of stay for patients going home and an overall 6 percent
reduction in length of stay.
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Hospitals of the
A hospital building boom is under way across Canada and the United
States, as medical centres build new facilities and refurbish old
ones. They’re all re-thinking traditional hospital designs in a bid
to improve patient care.
A group consisting of brainy doctors and technologists are
objectively evaluating new systems in Montreal. They’re determining
whether the technologies deliver what they’re supposed to, in a cost
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Sole sourcing your IT?
The way you source your equipment, by open tender or sole sourcing,
can have serious legal repercussions. Our legal columnist takes a
look at issues that should be considered.
PLUS news stories, analysis, and features and more.
Breakthrough technologies shown to attendees at key conference
By Jerry Zeidenberg
CHICAGO – Funny how physicians are often pictured as conservatives
who cling to old tools and methods of working. It’s hard to make this
argument when you see radiologists flocking to the annual RSNA
convention, anxious to kick the tires – so to speak – and acquire the
newest medical innovations.
The meeting surely didn’t disappoint them, as the show floor was rife
with technology developers showing off their latest marvels – many of
which were truly new and potentially ground-breaking.
Computed Tomography: Perhaps the biggest buzz was generated by
new developments in CT scanning. Just a year or two earlier, machines
capable of scanning 64 slices at a time were seen as incredibly
advanced. This year, Philips announced its iCT – which grabs 256 slices
in one rotation – while Toshiba startled the meeting even further with a
device that acquires 320 slices at a time.
At a press conference, Toshiba vice president of marketing, John Zimmer,
explained that the company had also been developing a 256-slice scanner,
but during the testing phase various radiologists asked if the coverage
could be boosted just a bit further.
What the physicians really wanted was a scanner that could image the
entire heart with a single rotation of the circular gantry. That
feedback prompted Toshiba to push the envelope and produce a 320-slice
machine with a 16-cm coverage area.
“That’s what differentiates us from the others,” commented Behram
Engineer, vice president of Toshiba Canada’s medical group. “The slice
is the thinnest in the market – at 0.5 centimetres – and the coverage is
It wasn’t done just for bragging rights in the slice war, notes
Engineer. With the 16-cm coverage area, you can image the heart or brain
faster, resulting in lower X-ray dosage. “We’ve cut the dose by up to 80
percent,” commented Engineer.
The low dose is particularly useful for children, whose growing bodies
are especially vulnerable to radiation. “Every pediatric hospital will
want an advanced CT scanner,” said Engineer. “It would be immoral not to
have one, because of the dosage issues.”
What’s more, the new AquilionONE CT captures so much information, you
may reduce or eliminate the need for other types of scans. For example,
cardiac patients may not need an angiography exam, which carries with it
the possibility of disrupting plaque and causing an embolism. Instead,
they could have non-invasive CT angiography performed.
And Engineer suggests this new generation of CTs could also replace many
nuclear med applications, meaning that patients wouldn’t require
radioactive tracers – a particularly poignant observation, given the
recent shutdown of the nuclear reactor at Chalk River, Ont., and the
resulting shortage of medical isotopes.
Just as significantly, by producing such detailed information in a
single exam, the new CTs can speed up treatment for patients. That’s
especially important for heart and stroke victims, as treatment in the
first three hours – the golden window – can be critical to their
Engineer pointed out that Toronto has become the first site in the world
to install an AquilionONE. The University Health Network has a machine
up and running at its Munk Cardiac Centre, and its Toronto Western wing,
a site renowned for neuro treatment and research, will be getting one
Of course, Philips’ 256-slice iCT scanner is no slouch, either, when it
comes to lowering X-ray doses and gathering more detailed information.
The company is projecting shipments of 20 – 25 scanners in the four
months following the RSNA – a good indication of demand for the
It’s not just about the scanner, of course. At a press conference, Jim
Fulton, general manager of CT for Philips, noted that software advances
must go hand-in-glove with the scanner improvements, as a single CT exam
of this kind can generate 5,000 images. You need software that not only
reconstructs the slices into 3D images, but does it quickly, in a form
that assists the radiologist.
To that end, Philips has produced CT software that automates
reconstructions and analyses for cardiac exams and brain perfusion
studies, advanced vessel studies, lung and liver analyses, and virtual
Again, it all boils down to making faster, more accurate decisions, with
improved safety for patients. “We can screen for coronary artery disease
in a shorter time, with a lower dose, than ever before,” commented Steve
Rusckowski, CEO of Philips Medical Systems. “That’s what’s important
about the iCT, not that it has more slices.”
For its part, GE Healthcare announced a new set of CT technologies
dubbed ‘High Definition’ that it will add to future products. “We’re on
the threshold of re-inventing CT,” asserted Gene Saragnese, vice
president for global CT at GE Healthcare.
The company is seeking to increase imaging speed, resolution and
coverage area without resorting to adding additional detectors and
At the core of this ‘rethink’ of CT is a brand new detector material.
It’s based on the garnet gemstone, because of the gem’s unique optical
properties. According to the company, X-ray processing is much faster
and the images more accurate – with fewer artifacts – by using the
Interventional Radiology: Exciting developments in IR were on
display at the RSNA convention. Of note was the robotic, fluoroscopic
C-arm, complete with motorized table, all devised by Siemens. The giant
arm is designed like its human counterpart, with joints at the ‘wrist’,
‘elbow’ and ‘shoulder’, with each joint providing three degrees of
Already, there are three clinical sites installed – at the University of
Virginia, St. Luke’s Hospital in Houston (part of the Baylor health
system) and at the Grosshadern hospital in Munich, Germany.
Called the Artis ‘zeego’, the system resembles the robotic arms seen in
the automotive industry, but is designed to solve problems besetting
Interventional Radiologists in the IR suite. Namely, using existing
systems, it’s difficult to see the whole area of interest.
“There have always been limitations in IR, in getting complete
coverage,” said Dr. James Williams, a leading developer of the project.
“Either you have to move the patient, or you have to add a huge
detector, and then you can’t angulate as well.”
He added that in IR procedures, “You need to see both the entry point
and the target, but in the past, sometimes you couldn’t get these in the
same image. “With this solution, you can see both,” he asserted, noting
the 45 cm coverage of the detector provides, for example, full liver
coverage and full lumbar spine imaging.
By providing better control of the C-arm, radiologists can access what
they need to observe and obtain close access to the patient – without
moving the patient.
The table is also motorized and coordinates its movements with the
C-arm. Dr. Williams said the cost of the Artis zeego system is
approximately US$1.5 million – a price tag, he said, about 10 percent
lower than a biplane system.
Meanwhile, over at the Philips pavilion, a team demonstrated a software
breakthrough on a C-arm. The company has developed software that
converts fluoro images into real-time 3D, giving radiologists a much
better picture of their instruments inside the patient.
“We’re creating CT-like images from fluoro by using CT algorithms,”
commented John Desch, vice president of marketing and strategy for
Philips in North America. He noted that Philips is a worldwide leader
when it comes to interventional radiology, with annual sales of about $1
billion worth of IR solutions.
Molecular imaging: GE Healthcare has targeted molecular imaging
as a growth market, and is supplying customers with entire solutions,
including the supporting infrastructure. And the results are reaching
At the RSNA, the company noted that it recently won orders to build and
equip two cyclotrons, in Halifax, N.S., and London, Ont. The cyclotrons
are being constructed to provide radioactive tracers for use in local
Positron Emission Tomography (PET) scanners, which are widely considered
to be the imaging ‘gold standard’ for identifying cancers in the body
and determining whether tumours are advancing or shrinking during
PET scanners are also proving useful in the identification of various
cardiovascular and neurological disorders.
In Halifax and London, GE Healthcare is leading the complete
implementation of the cyclotron and chemistry systems, including FASTlab
technology, an automated synthesis system for streamlining the
production of radiotracers such as FDG. The two sites will be
operational in 2009.
Peter Robertson, general manager of GE Healthcare Canada, based in
Mississauga, Ont., said the combined cyclotrons, FASTlab systems and
related equipment at the sites each represent investments of between $5
million to $10 million.
“We’re providing them with an end-to-end offering, including training on
how to use the systems,” said Robertson.
3D imaging: TeraRecon, of San Mateo, Calif., pioneered the ‘thin
computing’ model in medical imaging, in which three-dimensional
processing is done on a central server rather than the radiologist’s
workstation. This means a radiologist can work from any location and
still perform sophisticated reconstructions, as a remote computer is
actually handling the heavy-duty lifting.
Without much fanfare, TeraRecon (www.terarecon.com)
has won over an impressive array of Canadian radiology departments.
According to Serge Letourneau, eastern Canada sales manager for
TeraRecon, there are 18 installations of the system in Canada, including
Sunnybrook Health Sciences Centre in Toronto, as well as sites in
Sherbrooke, Que., St. John’s, Newfoundland, the Atlantic Health Sciences
Centre in New Brunswick, the QE II in Halifax, and the CHUM and MUHC in
More are on the way, Letourneau noted.
It’s impressive to see the range of procedures that TeraRecon has
available – all as thin computing applications that can be run from any
computer by accessing central servers.
As well, TeraRecon introduced a new super-server capable of rendering
500,000 CT images – an important product, according to the company, in
light of the new 256-slice and 320-slice CT scanners announced at the
show. Others are sure to follow, and the need for high-charged servers,
ready and able to handle large image sets, will be required for fast, 3D
Computer-aided Detection (CAD): Recently, in the United States,
demand for breast MR exams has surged. The modality has been recognized
as an effective way to detect breast cancer and to check on it after
chemotherapy or surgery. In March 2007, the American Cancer Society
recommended that women with a 20 to 25 percent or greater lifetime risk
of breast cancer undergo an annual MRI, in addition to conventional
Because it’s such an accurate tool, especially for high-risk women with
dense breast tissue, the use of MRI for breast exams has made its way
into Canada, too.
The problem with breast MR, however, is that it can generate hundreds of
images in a single study. It takes intensive reading by a trained
radiologist to go through the images, searching for tell-tale signs of
One of the ways to handle the challenge is through the use of
Computer-aided Detection software.
“Breast MR generates 1,200 to 1,800 images for every case,” commented
Dr. Ian Gardiner, a radiologist specializing in breast imaging. “What if
you miss the images with the problem?”
To improve the odds of catching every lesion, Dr. Gardiner has been
using Confirma’s CADstream software for breast MRI at his clinic – the
Canada Diagnostic Centre, in Vancouver, B.C. Confirma is based in
Bellevue, Wash., near Seattle.
Dr. Gardiner says that he and two colleagues have been the first
radiologists in Canada using CAD for breast MRI in Canada, and strongly
recommends that others start using it, too.
He stresses that CAD software isn’t making the diagnosis. Rather, it’s a
tool for improving the whole procedure – from diagnosis, to reporting,
to surgical planning. “A lot of people are trying to get away from the
term CAD, because it’s a misnomer,” says Dr. Gardiner. “It’s evaluation
and planning software.”
Indeed, on the diagnosis side, the software appears extremely helpful
–even to the on-looking layperson. That’s because the software
highlights suspicious lesions in colour. “You’re much less likely to
overlook a red blob than a grey mass,” commented Dr. Gardiner.
The Confirma software can do this by taking cues from the MRI and
contrast agents, which are used to spot the areas of greatest blood flow
– using the principle that cancers are faster growing than normal tissue
and thus require more blood flow.
Automating areas of concern in this way has resulted in faster readings.
Dr. Gardiner says that his reading time has been reduced to 15 to 20
minutes for even the most difficult cases, down from 90 minutes. That’s
enabling him to read more cases each day – a gain for his clinic and for
the Canadian healthcare system, which is plagued by shortages of
radiologists and long waiting lists for diagnostic exams.
On an optimistic note, Dr. Gardiner believes that with early detection,
deaths from breast cancer could be eliminated. “Early detection is the
key,” he says. “There are too many women today in hospices.”
The best tool for early detection, he adds, is MR. “It can accurately
assess the true extent of the disease, something that’s underestimated
by mammography and ultrasound.” More information about Confirma is
available at www.confirma.com
Ease of use: You might invent the world’s greatest gizmo, but if
people find it difficult to use, they’ll likely fling it aside and do
things the old way.
That’s been a typical story with computerized technologies – especially
for software solutions, which have been plagued by busy interfaces and
complex operating procedures.
The result? Computerized systems are often implemented that few people
actually use. In project management circles, that’s called project
Enter Carestream Health, the former Kodak health group that was recently
purchased by Toronto-based Onex Corp.
Carestream has put time and effort into creating refreshingly simple and
easy-to-use interfaces for a variety of solutions. “In a crowded
marketplace, software is becoming a key differentiator for us,”
commented Diana Nole, president of digital capture solutions for the
Rochester, N.Y.-based company.
Carestream has also been working at automating numerous processes for
radiologists and technologists – that is, letting the computerized
solutions do more of the low-level work, leaving more time for the
professionals to do higher-value procedures.
A case in point: the latest iteration of Carestream’s voice-enabled RIS
(whose worldwide development team is based in Summerside, Prince Edward
Island) automates the time-consuming task of entering demographics and
other patient-related data when dictating reports.
According to the company, the RIS has the ability to pre-populate
radiology reports with patient and exam information captured during
order entry, so radiologists do not need to spend valuable time
dictating patient and exam information that is already available. This
includes: patient name, date, type of exam, referring physician,
symptoms, and other data.
At RSNA 2007, Carestream also demonstrated its work on image fusion –
fusing in perfect registration, for example, CT and MR images on the
same workstation. “We can do this with images from different modalities
and vendors, and the software merges them automatically,” commented Ulf
Andersson, worldwide general manager of enterprise solutions. The
benefit, of course, is that varying modalities will capture different
types of information; a fused image can provide more information to the
radiologist in a single reading.
Another automated solution: Carestream demonstrated as a
work-in-progress a ‘dashboard’ that automatically determines which
technologists are taking the best images on the various modalities in a
hospital. Using a variety of measurements – such as rejects,
underexposed, overexposed, patient movement and image blur, etc., the
dashboard will automatically compile statistics about the effectiveness
of the departmental workforce.
“It tells you how they’re doing, and where they need to improve,”
commented Nole. As a result, hospitals gain quick feedback about who
needs additional training. In turn, they can reduce the need for
re-takes and also improve the quality of images sent to radiologists.
Significantly, the analytical system is an objective way of measuring
image quality in a radiology department. “Many departments have techs
doing their own quality control – but that isn’t the best situation,”
commented Eileen Heizyk, worldwide marketing manager for digital capture
solution. She noted that people will often give themselves high ratings,
when they could really benefit by brushing up their skill sets.
PACS: Industry-giant McKesson showed how it’s integrating images
from different departments into its solutions. In particular, at RSNA
2007 it announced the integration of bronchoscopy and gastrointestinal
imaging with its PACS. (A year earlier, it demonstrated the inclusion of
ENT images in this way.) “By using the PACS for storage, you’re not
adding another silo to the hospital,” commented George Kovacs, director
of product marketing. “The CIO is happy, because you’ve extended PACS to
departments that weren’t able to benefit before from this kind of
system. And the radiologists are happy, too, as they can see images from
To better link various departments, and their generalists and
specialists, McKesson is incorporating technologies such as unified
communications into its solutions. You can build intelligence into such
systems, says Kovacs. For example, “The system will know who the on-call
radiologist is,” and will automatically route images to him or her.
As a work-in-progress, McKesson showed how giant touchscreens, which
radiologists can use without a keyboard or a mouse, will be incorporated
into hospitals. All of the necessary tools are at hand – such as PACS
and the rest of the HIS – using high-res images and videoconferencing. A
demonstration showed how a physician can quickly manipulate the various
tools, all by tapping various points on the jumbo screen, without a
keyboard or mouse. There’s quick connectivity to colleagues, including
those who might be at home.
Philips, for its part, demonstrated similar technologies as part of its
‘Reading Room 20/20’ concept, also a work-in-progress. A whole pavilion
was dedicated to demonstrating this concept, which included a giant,
futuristic desk whose surface included multiple screens on the
expansive, white surface. On a wall, a super-sized screen allowed for
videoconferences with colleagues – who appeared as large as life.
Meanwhile, Agfa demonstrated new features in its upcoming IMPAX 6.4
release. One of the more interesting components: an ‘active target’
feature for CT and MR navigation, in which the radiologist can target a
location on one plane, and also view the corresponding anatomy in other
planes. For example, you can pinpoint a spot in the kidney whilst
peering at a coronal view, and the software will automatically link to
and display the same location in the axial and sagittal views. If no
corresponding location is available in a co-planar series, the series
will darken and inform the user by means of overlaid text.
The company also showed its virtual colonoscopy software, which offers
‘one-click’ reconstructions and simple structured report creation, which
can include images. “You don’t have to wait for techs to do the
reconstructions,” commented Dave Wilson, marketing director.
As a work-in-progress, the company demonstrated an application called
‘registration fusion’, in which exams from different modalities such as
CT, MR and PET can be overlaid on each other, with differences in
anatomy highlighted for the user. The software enables comparison of
functioning tissue to anatomical structures, for easier identification
Agfa also showed its ‘radiologist dashboard’, which pipes patient data
from other departments onto the radiologist’s workstation. The
information can include vital signs, pathology and lab data, pharmacy
and medications, and others, all in real-time. “We want to give
radiologists the tools and information they need without requiring them
to move anywhere else, or to rely one anyone else,” commented Jason
Knox, product manager. That access to information can be particularly
important when the radiologist needs answers and his or her colleagues
Data for the radiologist dashboard may be obtained from any number of
disparate sources within the hospital. Agfa has been refining this kind
of multifarious integration through its alliance with MEDSEEK; together,
the companies have been building large-scale physician portals for
hospital corporations in Canada, tying together dozens of applications
so that doctors can gain quick access to the information they need.
On the workflow front, Agfa has addressed the increasingly important
critical test results management issue by integrating an automatic
alerting application from Vocada into its PACS system. If a critical
test result is found in an exam, the user can prioritize the alert,
select the caregivers to notify, and generate an audio clip outlining
their concern and care plan. Vocada will send a notification to the
caregiver’s mobile device instructing them to contact the system to
securely retrieve the message.
If there is no response within a defined timeframe, the issue can be
escalated up a chain of command. “If an alert goes without a response,
it can be programmed to go failover to the department chief, and after
him, to the chief of medicine, for example,” commented Knox. Once the
message is received, the alert creator is notified in order to close the
loop. Importantly, there’s also an audit trail, so that managers can
analyze patterns and see who isn’t responding to alerts over the long
“Radiologists can spend too much time trying to contact the referring
physicians and often don’t know if the message was received,” said Knox.
“This solution offers them a time-sensitive, secure way to manage these
Project improves patient flow for UHN’s ED
By Patti Enright
TORONTO – Since implementing an Emergency Department
Transformation Project, the University Health Network’s ED has seen a 20
percent reduction in length of stay for patients going home and an
overall 6 percent reduction in length of stay. For patients being
transferred to Alternate Level of Care (ALC) facilities, UHN has seen a
22 percent decrease in length of stay. As well, the number of discharges
now happening before 11 am to ALC facilities has increased 73 percent.
The project began in March 2006, when the University Health Network
(consisting of Princess Margaret, Toronto General and Toronto Western
Hospitals) systematically set out to significantly improve patient flow
from the Emergency Department (ED) to General Internal Medicine (GIM),
as well as to the organization’s post-acute care partners. It was all in
an effort to reduce wait times and improve access to UHN’s EDs.
More than 200 clinicians and multiple community partners collaborated
with a project management team from Shared Information Management
Services, the information management and technology department for UHN
and 12 other healthcare organizations in the Greater Toronto Area.
The result was the creation of a framework that ensures care is well
coordinated and standardized from admission to discharge across the
three hospital sites.
The ED-GIM Transformation Project consisted of two parts:
• Designing, developing and implementing process improvements to enhance
• Knowledge transfer between and to other hospitals.
A team comprised of various clinical leaders from both Toronto General
and Toronto Western Hospitals, as well as SIMS project management
experts, industrial engineers, academics and data analysts, were charged
with designing, developing, implementing and evaluating an array of
improvement initiatives divided amongst six themes:
• Care Coordination
• Care Model
• Work Environment
• Team Renewal
• Communication of Information
Results that were achieved include:
Coordination with community care
• Problem: GIM staff were not fully aware of the most
appropriate or available community services. This caused delays in
potential patient discharges, and referrals without adequate planning.
• Solution: Working in collaboration with Bridgepoint Health, a major
provider of complex continuing care, the group implemented an on-site
Bridgepoint Health Assessment Team at UHN. The team attended patient
care rounds on UHN’s GIM floor, identifying patients who may be
appropriate for Bridgepoint rehabilitation services or continuing care.
• Results: An integrated discharge planning process enabling earlier
discharges through patient prioritization and planning, ultimately
expediting patient flow. To date, there has been a 160 percent increase
in patients being transferred from UHN to Bridgepoint.
Allied health team alignment
• Problem: Physicians working in the ED and GIM units were aligned by
team, whereas Allied Health (AH) staff were located geographically by
floor. As the AH staff would regularly rotate floors, this arrangement
required them to interact with multiple physicians. Communication
between the two groups was difficult, due to the lack of a consistent
• Solution: Align AH staff with the physician-based teams.
• Results: Enhanced communication increased patient and staff
satisfaction. There was an 18 percent decrease in ALC patient days
(i.e., patients no longer requiring acute care) and a 68 percent
decrease in time between AH referral to patient discharge, due to the
gained efficiencies in the new team alignment structure.
Workflow: ED Acute – Staff Assignments
• Problem: There were no standards defining which nurses were assigned
to various patients.
• Solution: Nurses were assigned to rooms close to one another. There is
a redesigned patient chart to incorporate visual controls, so that
action is prompted in an appropriate timeframe. Finally, there is an
established process for bed cleaning to improve the turnaround time.
• Results: 57 percent decrease in time to prepare for the next patient,
59 percent decrease in time required for initial RN review of a patient
chart (i.e., from 27 minutes to 11 minutes) and 63 percent reduction in
RN travel time.
ED work environment
• Problem: Prior to the project, up to 21 percent of a nurse’s time
(about one full day every two weeks) was spent searching for equipment
and supplies, coping with equipment breakdown and using supply carts
that were not stocked consistently.
• Solution: Using an approach from the car company Toyota that
emphasizes working together to improve the environment, staff sorted,
de-cluttered and organized their environment so that less time is spent
searching for and/or repairing equipment.
• Results: 72 percent decrease in time searching for equipment/supplies
in the Toronto General Hospital’s ED and 44 percent reduction in Toronto
Western Hospital’s ED.
Communication of information: Electronic IP whiteboard
• Problem: Relevant information was not being shared with appropriate
staff due to the large number of different data sources. In addition,
some information was lost or not documented, causing communication gaps
• Solution: Working with SIMS technical specialists, the group
implemented a centralized electronic whiteboard, allowing
interdisciplinary information to be inputted and displayed on a large
monitor near the ED’s nursing station.
• Results: The electronic inpatient whiteboard serves as a centralized
communication tool, capturing and displaying information such as a
patient’s estimated discharge date in real-time. ED staff report
improved interdisciplinary communication, continuity of care, improved
discharge planning and reduced time searching for patient information.
For more information on the project, visit the toolkit at
Patti Enright is a Communications Specialist with Shared Information
Management Services (SIMS), of which the UHN is a member.
When expanding, hospitals are putting thought into ‘smart’ designs
By Neil Versel
It has been widely documented that patient handoffs and transfers are
chronic sources of medical errors, but reducing these weak spots in a
large hospital likely requires a comprehensive redesign of workflow. The
construction of a new facility or major renovation of existing space
provides just the opportunity some innovative institutions have been
While it might be hard to picture a 150-year-old institution as an
innovator, leave it to venerable Brigham and Women’s Hospital in Boston
to rethink the idea of a centre of excellence.
The Harvard teaching hospital needed more inpatient beds for cardiac
care, as well as an overhaul of its surgical and imaging areas, so it
decided to create a cardiovascular centre in order to maintain
competitiveness in a cutthroat marketplace.
A “major philosophical and cultural question” was whether this was to be
a free-standing heart hospital or a true part of the BWH campus,
according to executive vice president and chief operations officer Kate
Walsh. “This serves as a core component of the Brigham and Women’s
Hospital integrated campus,” Walsh says. “It is not a heart hospital
The space also had to be acuity-adaptable to reduce handoffs, and had to
support innovation and translational research. Thus, cardiovascular
imaging was located in this new building, scheduled to open in the
spring, and each new inpatient room can convert to intensive care if
“This is a big change for our staff,” Walsh explained at the 2007
Healthcare Facilities Symposium, a meeting of architects, engineers and
healthcare executives held in Chicago.
It was a big change for everyone, actually.
Construction of Shapiro Cardiovascular Center gave the hospital the
chance to improve the traffic flow inside the facility, grouping like
services together and, significantly reducing the number of potential
handoff points. “We build spaces all the time but we don’t always
consider patient flow through those spaces,” Walsh says.
For the architects, it was a challenge to develop a 120,000-square-foot
space before the service line was fully developed, on a campus that has
evolved over a century and a half. “We worked very diligently to keep
the zones pure,” says André Aoun, a principal of Cannon Design, the
architecture firm that designed Shapiro.
For Walsh, part of the plan was about “way finding,” such as how to get
a patient from the emergency department to the cardiac catheterization
lab. Under an early plan, this path went through the waiting room for
radiation oncology, already a highly stressful area for patients. The
final design has three distinct connections across Francis Street from
the main hospital: a sky bridge for the public, an underground route for
patients and a lower passage for service operations.
The new building will have the hospital’s self-developed electronic
medical records, even though cardiology isn’t fully up on the system.
Hospital leadership did not want to move paper charts over from the old
facility, but they did include space for paper just in case I.T. was not
During the design phase, BWH held a technology summit. Walsh says staff
wanted help integrating technology they already had, rather than
scramble to learn new systems during and after the move. “We are testing
new things like wireless [connectivity] and flat screens in the old
space first to encourage integration,” she says. “I.T. needs to be
involved sooner rather than later.”
All of this planning and integration is so that BWH can further its goal
of multidisciplinary, patient and family-centred care. As Walsh puts it,
what happens when a family member isn’t just a visitor, but is in the
room during a code?
Other forward-looking institutions are heading in a similar direction.
At Grey Nuns Community Hospital in Edmonton, family-centred care is the
mantra for the consolidation of women’s health programs. “A key
principle is that women need to be cared for in the context of their
families,” says Gail Cameron, patient care manager for postpartum care,
the intermediate care nursery and pediatrics at regional health
authority Capital Health.
In renovating the third floor to handle an explosion of births and to
put all women’s programs on a single floor, the hospital is adding five
new labour and delivery rooms (LDRs) to the existing seven, and
re-allocating other space. The project also seeks to improve safety by
reducing patient handoffs and movement – and by mitigating other risks.
There’s a direct, secure, non-public link from labour and delivery to
the neonatal intensive care unit (NICU). The LDR area includes a
combination of single rooms and pods, plus quiet areas to minimize noise
transfer between rooms. Family lounges are situated to provide security,
acoustic control and infection control, as well as comfort, according to
Robin Snell, vice president of lead designer Parkin Architects.
The majority of mechanical services run through the corridor of quiet
zones, and there is a single penetration of electrical and HVAC lines
into each zone to reduce infection risk. A goal of this redesign is to
incorporate only technology that does not separate the baby from the
family, unless absolutely necessary, such as in the neonatal ICU. “There
are no newborn nurseries in this new design,” says Cameron.
The NICU will have day-night light patterns to promote regular sleep,
and noise will be minimized to help detect problems as they occur.
In non-critical postpartum areas, there are plans for 24-hour access to
food for mother and newborn. Their families will have menu service in
café-style waiting rooms, including Second Cup coffee. There will be a
cyber café as well, for educational as well as entertainment purposes.
Overhead paging is being eliminated from the nursery. Instead, staff
will carry pagers or cell phones. For further quiet, the hospital has
installed a two-stage fire alarm, with the first stage visual, all in
the name of patient comfort.
Even though the new space won’t be fully ready until winter 2009, the
hospital already has set up a social committee to help integrate new
hires, a change team to serve as liaison between staff and management,
and an equipment team to select medical devices, monitors and
communication systems, including I.T.
When it comes to comfort, flexibility and adaptability, few recent
projects can compare to the Richard M. Ross Heart Hospital at the Ohio
State University Medical Center, which opened in Columbus in late 2004.
“We’re a very technologically friendly building,” administrative
director Richard B. Davis says matter-of-factly.
The entire medical campus now is unified, and a fleet of 42 robots roams
the hallways, passing out meals and fresh linens, restocking supplies,
removing trash and generally doing the work of 200 full-time staffers.
Within Ross, rooms are standardized on all inpatient floors and
adaptable to varying levels of acuity. Nursing stations are
decentralized. Curved hallways in D-shaped inpatient wards minimize the
steps that nurses have to take, and the corridors are uncluttered.
Ross has what Davis calls a “high-tech floor,” which can support
equipment as heavy as 14 tonnes, and provides easy access from outside
to a wide, main hallway for delivery of future technology. Installation
of a Stereotaxis catheter took just 2½ months, beating the vendor’s
previous best by 6 weeks, according to Davis. Typical installation time
is six months.
A single cardiologist can cover five stress tests simultaneously and
still monitor catheterization across the hall.
Nursing documentation and electronic medication administration are done
at the bedside with a Clinicomp EMR, though OSU is entertaining bids for
a new inpatient system. “What we wanted to do is untether the nurse from
a centralized nursing station,” Brown says. There is a nursing support
area behind the scenes for charting when the patient might need a little
more privacy to recover.
Davis says patient satisfaction is 84.2 percent in Ross, compared to
76.8 percent across the University Health System. “We didn’t distinguish
ourselves when we were just two floors in the main building,” he says.
Faculty and staff satisfaction also is higher, and nursing turnover was
a minuscule 2 percent in 2006 and 4 percent for the first nine months of
It’s hard to argue with numbers like that.
Technology assessment unit helps hospitals make informed decisions
To paraphrase Gilbert and
Sullivan, James Brophy is the very model of a modern healthcare
technology assessor. Dr. Brophy, a practicing cardiologist with both an
engineering degree and a PhD in epidemiology behind him, is the director
of a joint effort by two of Canada’s largest university hospitals in
Montreal to rigorously evaluate any healthcare technology that’s being
considered for use.
Since 2001, as the founding head of a shared Health Technology
Assessment Unit (TAU), the bilingual Brophy has been easily crossing
cultural and linguistic differences between the mostly-English McGill
University Health Centre (MUHC) and the mostly-French speaking Centre
Hospitalier de l’Université de Montréal (CHUM).
As such, Dr. Brophy and his team conduct evaluations and make
recommendations based on painstaking research to their respective
decision-makers about what healthcare technology to buy and what not to
buy – be it a piece of hardware, a process, or even a drug.
“What we do is separate the wheat from the chaff,” says the no-nonsense
Dr. Brophy. “Some technology that appears can seem very exciting, but
often it is based just on hype. Some of it, on the other hand is really
good stuff. And that’s what you want to make sure you are spending your
Early on in his tech assessor existence, Dr. Brophy concluded that the
OACIS electronic medical record (EMR) system was very good stuff. The
open, interoperable nature of OACIS with its fully configurable clinical
data repository at its core, made it ideally adaptable to the quite
different cultures of MUHC and CHUM. A joint OACIS project team
continues to adapt and extend the reach of the EMR at both hospitals.
With nearly 30 assessments of various technologies behind them, Dr.
Brophy and and his TAU team now includes two full time researchers and
several part-timers who collectively have medical, engineering, and
economic expertise. Together they field requests from both CHUM and MUHC
departments and these days are putting newer, mostly clinical
technologies under the microscope.
“There are two elements in our process,” explains Dr. Brophy. “One is to
review the literature on all the evidence that is out there and ask:
What is that evidence telling us about that particular technology’s
safety, and about its effectiveness versus its cost? That’s the
evaluation element. The second element goes beyond the evaluation and
makes a recommendation as to what the two hospitals should be doing, or
not doing, with this technology.”
Brophy is quick to point out, however, that he and TAU are not treated
“We know that not everyone is going to share our opinion, so we make our
recommendations to a special executive committee that represents both
hospitals,” says Dr. Brophy. “On that committee sit reps from
administration, from nursing, from the doctors, from the pharmacists,
from other allied health workers, and it also includes a patient
representative. There are seven people from MUHC and seven from CHUM.”
The committee then debates the recommendation, and can alter it before
passing it on to the director general of each hospital.
“Sometimes we will present reasons we see for adopting and not adopting
the technology, so there can be an informed debate,” says Dr. Brophy.
“There may be good clinical reasons for adopting it, but administrative
or cost reasons for not.”
In almost all of their work, Dr. Brophy’s unit involves an interested
clinician right from outset.
“The epidemiologist or cardiologist or whoever the clinician may be, is
going to be aware of the nuances of their speciality that the technology
may affect. And if we end up recommending adoption of the technology,
it’s going to make buying in by the executive committee much easier,
since the clinician has been involved from the start,” he says.
Currently, the TAU is examining the worth of technologies connected
• Patient wait times at MUHC and CHUM
• Neuromodulation to control urinary and fecal incontinence
Followed likely by:
• Non-invasive cardiac valve replacement
• Natriuretic peptide testing for excessive sodium in breathless
Typical of TAU assessments (submitted in English and French) are the
The use of image-free computer-assisted systems in total knee
replacement surgeries (March 2007) – Recommendation: “There is no
convincing evidence that demonstrates improved clinical outcomes with
the computer assisted navigation systems in total knee replacement
surgery. However, expert opinion believes that this technology is likely
to decrease malalignment in some patients. For this reason it is
recommended that funding for a limited number of cases (Max. 40)
annually should be approved for use in patients at the highest risk of
malalignment. This will also allow the MUHC and the CHUM to fulfill
their role as educational institutions.”
Spinal Monitoring: Use of Intraoperative Neurophysiological Monitoring
During Spinal Surgery (July 2005) – Conclusion: “There is good evidence
to support the conclusion that intraoperative spinal monitoring during
surgical procedures that involve risk of spinal cord injury is an
effective procedure that is capable of substantially diminishing this
“In the absence of any precise estimates it is reasonable, for the
purpose of this decision, to assume that an expenditure of approximately
$46,000 per year (or $460 per patient) might prevent one patient
suffering serious permanent spinal cord injury and less serious
complications or sequelae in approximately 2 other patients. Even if the
cost of maintaining such patients is excluded, this is a highly
acceptable cost to benefit ratio.”
Dr. Brophy offers several cautions about such conclusions and
recommendations found in his reports.
“First, we could be viewed as a barrier to technology uptake, but we are
not. Indeed, I think if you broke down all our assessments, so far you’d
find that for about one-third of them we said, no we don’t think this
(technology) gives you good bang for your buck, another third we said,
yes we’ll get considerable health benefits out of it at an acceptable
cost and it should therefore be adopted. And about a third we said,
maybe for targeted kinds of patients this would be a useful addition,”
says Dr. Brophy. “Also it’s important to note that we are not a
decision-making body. We’re simply here to improve decision-making and
help ensure we are getting value for our money.”
Note: All of the TAU’s reports are available online at