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Inside the  February 2010 print edition of Canadian Healthcare Technology:


Feature report: Developments in medical imaging


Manitoba begins $22.5 million EHR project
As the next step in its plan to create a province-wide Electronic Health Record, Manitoba has launched a $22.5 million project that will consolidate in a centralized repository the various types of patient information that have already been computerized across the province – including lab results, medication histories and immunization data.

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Canadian health system needs better linkages, chief of the CMA contends
Speaking in Toronto late last year at the Economic Club of Canada, Dr. Anne Doig noted that patients in this country suffer because so many healthcare providers are disconnected from one another and can’t share information.

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Revolutionizing pathology
Pathology is on the verge of great changes, with automation hitting it the way that computerization changed medical imaging departments. New slide scanners and other systems are on the way.

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Hôpital CSSS de Trois-Rivières goes with lean solution for the ER
When healthcare facilities can’t keep up with demand for their services, the traditional solution has been to add resources – namely, doctors, nurses, support staff and equipment. Lately, however, a new approach has appeared.

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Quality control in DI
News of suspected errors made in reading exams in diagnostic imaging departments has raised the issue of quality control in radiology. Dr. David Koff of Hamilton Health Sciences suggests a possible solution – one that is computerized.


I’ll take Finland?
Finland, another northern country with a cold climate, has reached almost 100% usage of electronic health records by hospitals and physicians. How did they do it, and what can Canada learn from the Finnish experience?


Lean replenishment
A Montreal-based company is pioneering a novel way of improving the flow of supplies in hospitals. It’s combining a Japanese, two-bin approach with radio-frequency identification (RFID) technology to achieve superb results – supply bins are never empty.


PLUS news stories, analysis, and features and more.

 

Manitoba begins $22.5 million EHR project

By Jerry Zeidenberg

WINNIPEG – As the next step in its plan to create a province-wide Electronic Health Record, Manitoba has launched a $22.5 million project that will consolidate in a centralized repository the various types of patient information that have already been computerized across the province – including lab results, medication histories and immunization data. The plan is to move quickly on this project, with the pieces connected in a working EHR by the end of 2010.

One of the problems that care-givers face in most parts of Canada – and around the world – is that computerized patient data in one hospital can’t be accessed by physicians located at another facility. According to a spokesman in Winnipeg, the EHR in a centralized repository will allow authorized physicians and care-givers across the province to quickly obtain the information they need to make complete and accurate diagnoses.

In a second stage, the system will be connected to an existing repository of radiological images and reports, giving healthcare professionals access to another key source of patient information. This phase of the project is expected to be working by 2011 or 2012.

Manitoba is going full steam ahead with its provincial EHR at a time when the wheels have slowed or even stopped in other provinces, due to widely publicized problems with eHealth initiatives. In particular, Ontario was burned by a scathing report from the provincial auditor-general, who concluded last fall that a $1 billion investment by the province in eHealth had produced little of value.

But Manitoba eHealth’s chief information officer, Roger Girard, says that what’s come under fire in Ontario and other parts of the world is not eHealth itself, but how some jurisdictions have tried to implement it.

“There’s little disagreement among the public about the need for eHealth,” said Girard. “The criticism is about the means which some have used on the journey to eHealth, but it’s not with eHealth itself. The EHR is widely considered to be a foundational element in improving healthcare.”

He added that, “The public agrees that it’s time to get on with it.”

For its part, Manitoba has been working on an eHealth strategy for several years, involving an investment of $150 million.

The existing drug, lab and immunization databases, which have emerged as part of the eHealth strategy, will be consolidated in two data centres. The data centres have already been developed, also as part of the provincial eHealth plan.

In December, the province announced that IBM Canada had been tasked with leading the $22.5 million integration and EHR development project. IBM will be working with a number of partners, including dbMotion, which is supplying the health information exchange software.

“The dbMotion technology integrates information from different sources and represents it [in the EHR],” commented Giovanni Vatieri, partner in IBM Global Business Services. “It will be the core technology in the solution.”

He said dbMotion has had success in health exchange projects around the world, including Pittsburgh, New York, Israel and sites in Europe.

Vatieri noted there are other partners in the project, including Microsoft, Momentum Healthware, and xwave.

Data will be made available to healthcare professionals in real-time using common browser-based interfaces, creating a portal-like solution for the end-users.

Girard said the system will rely on the intelligence of a sophisticated client registry that has been developed with the help of Infoway. The client registry is able to identify patient information in different repositories, and working with the solutions from IBM and dbMotion, will consolidate it all in the EHR.

The client registry, explained Girard, uses various systems to ensure that patient information is associated with the right person.

The province has had some recent successes in creating repositories and electronic solutions, including the DI repository – which is currently used by radiologists and specialists – and a Computerized Physician Order Entry project at one of the large teaching hospitals in Winnipeg.

Realistically, Girard notes that the creation of consolidated EHR won’t be an easy task, and some errors will probably be made along the way. “That’s only normal, but we can’t turn back every time we hit a bump on the road,” he said. “We have to learn from the mistakes and move on.”

In upcoming phases, the EHR project will seek to integrate data from other sectors, including long-term care, home care and physician practices.

Of course, a province-wide system of electronic health records also needs an extensive, high-speed network. Girard said that Manitoba currently benefits from the Provincial Data Network, which delivers high-capacity bandwidth to most parts of the province.

He asserted that Manitoba is currently running the largest telehealth service in the world on a per capita basis, and that telehealth relies day-to-day on the telecommunications system.

He noted that high-bandwidth service is lacking in some parts of the province, but the network continues to evolve, just as the EHR application will be further developed. “This is a journey that will take place over the next 10 years,” said Girard.

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Physician incentives, better designs needed for EMRs: CMA president

A conversation with Saskatchewan family physician, Dr. Anne Doig, president of the Canadian Medical Association. Recently, Dr. Doig was in Toronto to speak to the Economic Club of Canada, where CHT contributing editor Andy Shaw caught up with her.

CHT: Dr. Doig, you spoke today of a CMA plan that is ‘an unprecedented effort by Canada’s physicians to reach out to patients and put their interests back at the heart of healthcare.’ Why do we need such a plan?

Dr. Doig: Speaking as a physician, I get frustrated and fed-up every day with a healthcare system that can’t seem to put the patient first, which is the reality of what I must do every day. Our so-called healthcare system is a misnomer. Really what we provide patients with is a series of episodic interventions which do not provide systematic, continuous care. Patients too are frustrated by this and particularly by overly long wait times. So the CMA is calling for a transformative change in our healthcare so that patients get good care in a timely manner.

CHT: So how do you make that happen?

Dr. Doig: Well, you make the whole system do the same things we try to provide patients with in our clinics and offices every day as physicians. I call them the four C’s. You provide comprehensiveness, continuity, co-ordination, and a community of care.

CHT: Aren’t those just the things that the EHR, the electronic health record, is supposed to facilitate across the country?

Dr. Doig: The problem is we’re not there yet. We can’t feed information into that system unless all our doctors have computers and electronic medical records in their offices.

CHT: Then why do Canadian physicians rank right near the bottom in their uptake of office computer systems and EMRs?

Dr. Doig: Doctors are healthily skeptical, so they need to see first hand how computers and electronic records make their work better, not easier, but better. They need to be shown that when you have an EMR in your office you make fewer mistakes. And that you can have better information at your finger tips more quickly, so that patients get improved and faster care. They also need to see how these systems connect to other resources such as labs, pharmacies, hospitals and specialists, so that both you and the patient can better manage the care.

CHT: Wouldn’t it be quicker for our governments to simply require physicians to have computers and EMRs?

Dr. Doig: I don’t think you could require that until there is a capacity in the system to interconnect. Also, the kind of information technology systems we’re talking about are very expensive. So we also need a different financial model that gives doctors incentive to adopt them. Therefore governments have to make a policy decision, as you pointed out they did in Britain, to provide all doctors with electronic office systems. And that’s also where patients and the public come in. We all need to start demanding that our politicians act and decide what our healthcare system pays for and what we expect from it.

CHT: Is there anything to be learned from what other politicians in other lands have decided to do about their country’s healthcare?

Dr. Doig: My predecessor as CMA president, Dr. Robert Ouellet, toured five countries overseas last year, including France, to see what could be learned. And the first thing we learned is that they all do things differently. There is no one cookie-cutter solution that can be immediately transferred and plunked down Canada and made to work exactly as it works in other countries. But there are specific lessons to be learned from abroad, such as government-mandated coverage by a private insurer. In Denmark and Israel, for example, six insurance companies are available to patients. There is a mix of employer, government, and private payment and the result is that nobody waits very long. When I was in Israel and told a cab driver that our national guidelines include getting our longest wait times down to six months, he was appalled because his maximum wait time for a knee replacement, say, would be two weeks.

CHT: In terms of the electronic records that would track such an operation, is there something our EMR vendors aren’t doing to increase uptake by Canadian doctors?

Dr. Doig: What they need to do is involve the end-user more in the design of the system, and not just some clever person in IT who has a wonderful idea. We need those latter types because they make the systems work, but I can tell you about the RFP for a province-wide, front-line EMR we’ve just come through in Saskatchewan. We had 30 plus vendors respond to the RFP, but for a good number of them the immediate reaction of the doctors involved in our selection said: “There’s no way that one will work! It just isn’t my business process.” So it would be good for vendors to go to a bunch of doctors who are techies and let them play before they build the final version of the system. Let the pros help them decide how to make it work properly.

CHT: In terms of other forms or electronic record keeping, do you think that personal health records or PHRs that patients maintain themselves are worthwhile?

Dr. Doig: It would be a very good thing if people could own and control at least some of their healthcare data elements. If you could have a smart card with a microchip on it, for instance, that you could carry around with some of your vital data. The problem no one has really decided yet what that data set would include and not include. Most of the data available has a very short shelf life. If a person has had a head injury for example, it is important at the time to know when they are in the ICU what his or her blood gases were, or what their electrolytes were doing. But once the patient has recovered and left the ICU, all that information is just historical. It is of no further or very limited use.

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Breakthrough imaging solutions on horizon for digital pathology

By Jerry Zeidenberg

Pathology appears to be on the verge of the kind of computerization that hit the radiological world some 20 years ago with the advent of Picture Archiving and Communication Systems (PACS).

Instead of archiving banks of glass slides, pathology is making the transition to digital images. However, one of the roadblocks has been the slowness of acquiring the high-resolution images needed of digital slides. One could literally set up the scanner, go for a coffee and be back before a single image was completed.

But in recent months, both GE Healthcare and Philips have announced breakthroughs in acquiring high-res slide images in rapid fashion.

“There are digital slide scanners on the market, but they’re slow,” commented John Wellbank, senior director of sales, North America, for Philips Healthcare’s digital pathology unit. “They typically take two to four minutes at 20x [magnification of the slide] and from two-and-a-half to eight minutes at 40x, for each slide.”

By contrast, Wellbank said that Philips has a new scanner under development that scans a slide each minute at 40x magnification – a remarkable breakthrough in speed and resolution.

“Philips has a lot of technology in imaging,” said Wellbank. “Headquarters in Eindhoven is a world centre in optics and imaging.”

He said the technology is now out of the labs and into clinical trials with four university partners. If all goes according to plan, a commercial product should be available in the middle of 2010 – at least in the United States, pending FDA approval.

Wellbank noted that it’s not only the high-powered scanner that’s being offered, but a workstation for image processing, along with transfer and workflow software that’s designed to improve the productivity of pathology departments.

Meanwhile, GE Healthcare is also making waves in digital pathology through Omnyx, its joint venture company with the University of Pittsburgh Medical Centre. Last November, Omnyx won a Growth Strategy Leadership Award from technology market research firm Frost & Sullivan.

The award recognizes Omnyx for making strides in digital pathology systems by creating and refining solutions in conjunction with pathologists at UPMC – a real-world test lab.

Tony Melanson, vice president of strategy and marketing for Omnyx, commented that, “We are developing a complete system that includes scanners, imaging software and workflow software. We are approaching digital pathology by looking at the challenge through the eyes of pathologists, histotechnicians and the information technology managers.”

He added that, “We recognized immediately that the transition to digital would only be successful if the products were developed based on a complete understanding of the user in the context of their clinical working environment.”

The products from Omnyx – which await FDA approval in the United States – address the major technical challenges that have historically existed in digital pathology: scanning speed, image quality, image viewing performance and image storage.

On the scanning side, in 2009 the company was awarded a U.S. patent for its new digital slide scanning technology. The patent covers a system that uses two image sensors in a digital microscope, with a primary sensor for acquiring images at a fast rate and an auxiliary sensor that acquires focus data at a faster rate.

“Traditional digital pathology systems use only one sensor to perform both tasks. This new concept uses two sensors which allows the whole process to be faster while still taking a huge amount of focus points, thereby creating high-quality images at a faster rate,” said Michael Montalto, PhD, vice president of instrument development for Omnyx.

“Although the concept seems reasonably simple, it requires sophisticated timing algorithms between the two sensors and light source, all while in continuous motion.”

“It took us several years in the concept feasibility phase just to prove we could acquire a high-quality image at a fast speed,” said Robert Filkins, PhD., co-inventor and digital pathology program leader at GE’s Global Research Center. “The technology allows for image acquisition to be 2 to 4 times faster than existing technologies.”

On another front, by working with GE engineers in Israel, Omnyx has developed a streaming technology optimized for pathology images that will allow pathologists to navigate digital pathology images with near zero-latency over standard hospital networks, and even from home.

Image storage has been an obstacle and Omnyx is designing their storage system to scale to the needs of large scale clinical operations like UPMC. Omnyx is also working closely with the GE Enterprise Archive team to interoperate with that product for long term medical image archiving.

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Hôpital CSSS de Trois-Rivières goes with lean solution for the ER

When healthcare facilities can’t keep up with demand for their services, the traditional solution has been to add resources – namely, doctors, nurses, support staff and equipment. Lately, however, a new approach has appeared.

Many healthcare centres are now borrowing ‘lean methodologies’ from the manufacturing sector. They’re learning to do more with existing resources.

Using this lean approach, emergency room doctors at a hospital in Trois-Rivières, Que., are now able to see 40 percent more patients each day – without increasing their own working hours.

Moreover, “they didn’t need to add staff or increase the budget,” commented Camil Villeneuve, vice president, Lean Solutions at Fujitsu Canada, the consulting company that helped the hospital analyze bottlenecks and produce solutions. “Instead, they found more efficient ways of working.”

The hospital, the Centre de santé et de services sociaux de Trois-Rivières (CSSSTR), first investigated lean solutions because management was troubled by long wait times, quality and the average stay for patients in its emergency room.

It wanted to remain attentive to its most important customers – the patients – who were making over 30,000 visits each year to the ER.

The management group at CSSSTR worked with Fujitsu Canada Lean Solutions consultants to help reorganize their work and optimize processes in the ER. After only four months, the project was a success – patients on beds stay on average only 4.2 hours in the ER instead of 17.4 hours previously; and average ambulatory patient wait times have been cut from 4.9 hours to only 2.7 hours.

“We were able to redesign the ER layout in a way that not only optimized patient flow, but balanced the workload for all staff”, said Dr. Valérie Garneau, chief of the emergency room. Prior to embracing lean healthcare concepts, patient satisfaction was waning and there was great stress on doctors and medical staff.

How did they do it?

Using a variety of lean analytical techniques, including statistical analysis and simulations, some of the biggest bottlenecks were spotted. In these cases, smarter ways of working were determined.

For example, it was found that patients took a long time to go through triage and registration before seeing a doctor – a process that was frustrating to both patients and care-givers. It also meant that the waiting room was backing up.

As Villeneuve notes, delays resulted because patients first reported to a triage area, where they explained their problems to a nurse and returned to the waiting area. They would then see a nurse for admission, who repeated many of the same questions.

As a solution, “We combined triage and admission in one step,” commented Villeneuve. “Patients see the triage nurse and admissions clerk at the same time. This means they have to tell their story just once instead of twice.”

The ‘work cell’ concept, where staff members with complimentary jobs work in teams, has been extended to the doctors and nurses. Originally, patients in the ER might be seen quickly by a doctor, but would then have to wait for certain tasks to be completed by a nurse. Similarly, if they were first seen by a nurse, they would then wait for the doctor.

Now, doctors and nurses work in tandem and see patients at the same time. Diagnosis, paperwork and orders are all done without delay, greatly speeding up the rate of patient turnover in the ER.

Non-clinical tasks – such as procurement – have benefited from lean solutions, too. It was found that nurses were spending a good deal of time counting and ordering ER supplies.

As solutions, the level of inventory was halved, and automated replenishment systems were installed.

“The more stock you have, the more time you spend counting it,” observed Villeneuve. By reducing the inventory, and automating replenishment, less time was needed for managing procurement. “Nurses could spend more of their time with patients,” said Villeneuve.

Now that patients are seen and discharged much more quickly, the ER waiting rooms are less crowded and patients rarely have to wait anymore.“We have more time to care for patients who need it most,” Dr. Garneau said.

“The work of emergency room staff is much easier and productive – all this was accomplished without adding additional resources of people or technology,” she said.

Fujitsu Canada Lean Solutions specializes in operational strategy, business transformation, operational performance, and has industry expertise in implementing integrated Lean Six Sigma. Visit www.ca.fujitsu.com/solutions for additional information.

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