Inside the June/July 2010 print
edition of Canadian Healthcare Technology:
Feature Report: 2010 Directory of Healthcare
Mount Sinai makes clinical apps available on
To provide nurses and doctors with a solution that offers quick,
mobile access to patient information, Mount Sinai Hospital has
created VitalHub, a system that makes virtually all clinical
applications available on one device – the Apple iPhone.
Integrating health systems
The real benefits of EHRs won’t emerge until disparate systems are
meshed together. We look at how various jurisdictions across Canada
are attempting to make their solutions talk to each other.
READ THE STORY
A recent conference looked at the future of surgical technologies
and unveiled many of the changes that are in store. They include a
greater reliance on robotics and medical imaging. Using new systems,
some forms of brain surgery may even become day procedures.
READ THE STORY
Telus unleashes new PHR
Telecom giant Telus announced that its personal health record is now
ready for prime time. It is making the system, called Telus health
space, available to organizations who will, in turn, offer it to
their patients or members.
Risks of radiation?
Demand for X-ray tests, especially CT scans, has been growing
steadily. But studies have shown that as many as 30 percent of the
exams are not medically necessary. Is the radiation harmful, and can
the number of tests be reduced?
PLUS news stories, analysis, and features and more.
Doctors and nurses at Mount Sinai access clinical
apps on iPhones
By Jerry Zeidenberg
TORONTO – To provide nurses and doctors with a solution that offers
quick, mobile access to patient information, Mount Sinai Hospital has
created VitalHub, a system that makes virtually all clinical
applications available on one device – the Apple iPhone.
The hospital has written iPhone interfaces to 66 different clinical
applications – including lab, radiology, pharmacy and clinical alerts,
along with many administrative systems, too. It means that clinicians
can readily access the information they need anywhere in the hospital or
while they’re outside the medical centre.
Doctors, for example, can review what happened to their patients
overnight before conducting rounds in the morning – or even while
rushing to the bedside.
VitalHub is being rolled out this month (July) after a six-month pilot
program last year. The project was spearheaded by the hospital’s VP and
chief information officer, Prateek Dwivedi, who joined the hospital in
2008 and immediately saw that it took too much time and effort for
clinicians to enter or access computerized information.
“My first day on the job, I saw a nurse write information on a folded
sheet of paper at the bedside,” recalls Dwivedi. “She then walked back
to the nursing station to enter the data, only to find the computer was
locked down. She found another computer, but had to boot it up and wait
for the applications to load. All she wanted to do was log the patient’s
blood pressure and temperature.”
Stymied by the technology, the nurse was clearly flustered. “I assured
her that we would fix things,” said Dwivedi.
Dwivedi did set out to fix things – especially after hearing similar
stories from other nurses and doctors about the trials and tribulations
of the existing computer system.
He also noticed that clinicians were accessing too many devices – cell
phones and smartphones, pagers, large, clunky nurse-call devices, plus
desktop computers at various workstations. Far better, he realized, to
have one device that could serve as a gateway to everything. And the
more portable the device, the better.
That’s where the Apple iPhone came in.
“The only organization I’ve seen that has actually made technology
easier to use is Apple,” said Dwivedi, who believes that healthcare
should look to other industries and the consumer sector to help solve
For his own part, in the past Dwivedi has worked in the IT departments
of large companies and has also started and run his own entrepreneurial
businesses. He never worked in healthcare before.
While he admits to having a lot to learn about healthcare, he is amazed
by the lack of innovation in the hospital IT sector. It’s imperative, he
says, to learn from other industries and from the fast-paced world of
Impressed by what Apple has done for consumers and businesses, Dwivedi
called Apple at its headquarters in Cupertino, Calif., and asked if
they’d be interested in a project that would change the face of
healthcare. An Apple VP soon called back, and Dwivedi and a few
colleagues flew to California for a meeting.
Long story short: they launched the VitalHub project at the end of 2008,
and showed a preliminary version at HIMSS 2009 in Chicago. Even Apple
was surprised at how fast the work was done.
“In five months, we had the prototype working,” said Dwivedi. “We called
it VitalHub because it would form the hub of all the applications and
information that clinicians needed.
“It was important to be able to get information into the applications
quickly, or in many cases, just to view these apps quickly.”
And as Dwivedi observed, it was also crucial that information could be
accessed in the same way on the iPhone as on regular computers. “Or else
you’d spend too much time figuring things out and searching,” he said.
The hospital tested the application with a group of 20 doctors and
nurses from July to December 2009. It then temporarily shut down the
pilot program so that what was learned could be incorporated into the
next version of VitalHub.
It’s this new system that’s being rolled out this month on a larger
scale. It’s going to be made available to some 200 doctors and 1,300
While having a smartphone capable of accessing all major hospital
applications is seen as a breakthrough – indeed, it’s believed that
Mount Sinai Hospital is the first teaching hospital in North America to
do it – the question some ask is, Why the iPhone, especially when the
BlackBerry is so well-entrenched in medical circles?
Dwivedi notes that Mount Sinai will create versions of VitalHub for the
BlackBerry, as well as for other platforms like Google’s Android
smartphone operating system and the Microsoft smartphone OS.
“But to start, we didn’t have the resources to develop on all
platforms,” said Dwivedi. “We had to pick one.”
The team went with the iPhone, he notes, because of its ease of use and
its closed case that’s without a physical keyboard. “You can dip it in
Virox and it still works,” commented Dwivedi. (A keyboard appears on the
iPhone as an application on the touch screen.)
Moreover, it was the only existing smartphone that could do everything
needed – like email and accessing records – while wearing surgical
Meanwhile, hundreds of Mount Sinai Hospital clinicians are ready and
willing to make use of VitalHub on the iPhone. From the look of things,
so are clinicians at other sites. Indeed, it turns out that 50 other
hospitals in Canada, the United States and around the world are already
interested in acquiring the VitalHub system for their own doctors and
To help commericialize and distribute the system, and fuel ongoing
development, Mount Sinai Hospital has spun-off the project as a company
that’s now called VitalHub, Inc.
Its new CEO is Neil Closner, who is also a vice president at Mount Sinai
Together, Dwivendi, Closner and the team at Mount Sinai hope to make it
easier to access computerized information at hospitals around the world.
Amazingly, it can all be done using smartphones that can slip into a
pocket and be carried around anywhere, anytime. using smartphones that
can slip into a pocket and be carried around anywhere, anytime.
Slowly, in some jurisdictions, progress is made on
By Jerry Zeidenberg
Remember that scene in Cool Hand Luke where Paul Newman is told, ‘What
we’ve got here is a failure to communicate’? It comes to mind when
looking at the efforts of regions and entire provinces that are trying
to connect hundreds – even thousands – of healthcare IT systems. Many of
the systems don’t talk to each other, which leads to no small problem.
It means that doctors, nurses and other caregivers can’t get the
information they need to treat patients.
Luckily, progress is being made. Some jurisdictions have found the
‘translators’ needed to get the systems speaking the same language.
For its part, Manitoba is betting on a solution that’s been used with
great success in Israel, Belgium, Pittsburgh and New York City.
The province last year announced a $22.5 million investment in an
integration solution from dbMotion, with project management from IBM.
The technology will connect the myriad health IT systems used across the
province. Significantly, it will do it by consolidating the information
in central repositories.
“It pulls together all of the disparate data and displays it in a
viewer,” explained Peter van der Grinten, vice president for dbMotion,
during a meeting at the HIMSS conference in Atlanta. The February
conference attracted nearly 28,000 attendees, all seeking to learn about
the best ways of computerizing their healthcare systems, or to promote
solutions that promise to do so.
Manitoba has already built its main data centres as part of an ongoing
eHealth program. The dbMotion component that’s being added will act like
a giant conveyor belt, shuttling data from various information silos to
the central repositories and back to the users who need the data.
The newest information can then be used to update the records of
hospitals, long-term care facilities, doctors and other caregivers.
From a practical point of view, the chief advantage of the dbMotion
technology is that it has already been proven to work in other
jurisdictions. And it is sold as ‘packaged’ software rather than a
custom-made solution – very little code has to be written.
“Other provinces have taken the approach that they’re unique, and that
they need to custom-build a solution,” said Giovanni Vatieri, national
health practice leader at IBM Canada’s Global Business Services. But he
pointed out that building healthcare IT applications from scratch is not
so easy. It can be time-consuming, expensive, and the-made-to-order
product may not work – lessons that other provinces and organizations in
the United States and Britain have recently learned.
Manitoba, however, is leveraging the success of dbMotion in Israel,
Belgium and several U.S. sites. “With dbMotion, everything is ready to
use,” said van der Grinten. “It’s COTS, commercial off-the-shelf
software, so we’re not developing anything new.”
The software is now being installed and tested. “Ninety-four percent of
what we need is available right out of the box,” said van der Grinten.
“The rest of the work involves configuration.”
The first phase of the project – called Release 1 – will integrate
electronic records from five medical labs, a large drug information
repository and five emergency departments at acute-care hospitals in
Release 2, scheduled for 2011, will add diagnostic imaging, hospital
information systems, ERs, long-term care facilities and doctors’ offices
across the province.
Of course, integration isn’t just a technology problem. That’s why a
considerable investment is being made in training and change management.
Van der Grinten noted that other dbMotion clients are putting about 20
percent of their project budgets into change management, and that
Manitoba will be in the same ballpark.
While Manitoba’s project is consolidating records and information in a
central repository, there are other ways of linking databases. In the
United States, three of the largest providers of healthcare have
launched a pilot project in San Diego that connects electronic patient
records in a ‘virtual’ way. Data stays in its original location, but
it’s pulled into the record of a doctor or caregiver when he or she
“We don’t believe in creating massive repositories,” said Dr. John
Mattison, chief medical information officer at Kaiser Permanente, which
in the San Diego area is connecting its electronic health records to
those of the Department of Defense and the Veterans Health
Administration. “Philosophically and morally, we don’t want to aggregate
patient records in that way. As well, by avoiding huge repositories, we
reduce the need for terabytes of additional storage.”
Instead, the project has deployed an integration engine that pulls data
from charts at the other organizations when ordered to do so by a
physician working with a record. “Updates are done on demand,” said Dr.
Mattison. “They’re triggered by caregivers at the decision-point.”
Interestingly, the project is using Open Source software called Connect
Gateway as the glue that ties everything together. Kaiser is currently
using its own integration engine, one that was written in-house, but
plans to soon adopt the Open Source solution, like the DoD and the VA.
Dr. Mattison says the integration of records is working well and has
proven extremely useful to physicians who are using it. “Patients will
tell their doctor, ‘I’ve got five diseases, but I can’t remember name of
the little red pills I’m taking.”
It’s extremely useful for doctors at Kaiser to be able to see the
patient’s records at the VA or the DoD to quickly find out what those
diseases are, along with the identity of those little red pills. The
patients enrolled in the pilot have multiple care-givers at Kaiser and
the two military organizations.
Dr. Mattison pointed out that Kaiser Permanente has integrated numerous
systems across its 36 hospitals and 431 medical offices – contrary to
the belief of some that it uses just one big Epic system. “We have
scores of different applications, including lab, radiology and pharmacy,
that required integration,” said Dr. Mattison. “We’ve done it largely
through the use of international standards, such as HL7, SNOMED and
The Kaiser-DoD-VA project is funded by the Nationwide Health Information
Network (NHIN). Dr. Mattison says his group has been “assessing the
rough spots in their solution, and creating an industrial strength
version.” That work is nearly finished, and he says that the system will
be rolled out to other sites starting this fall.
While the project is experiencing a high opt-in rate among patients, Dr.
Mattison said there will always be 5 percent to 10 percent of the
population who simply won’t want to participate.
Many don’t want their records to be shareable and easily accessed. They
often include patients with HIV or psychiatric issues who, for various
reasons, prefer not to have doctors accessing their charts.
Dr. Mattison noted that patients who decline to have a shareable
electronic record can always keep a Personal Health Record. It would be
a form of the EMR which they could control and provide to care-givers at
He observed, however, that physicians must view Personal Health Records
with caution, as patients may omit certain types of information. “It’s
up to the patient to verify or falsify the record,” he said. “The
physician will have to treat that record somewhat differently.”
While Dr. Mattison’s team in California is fine-tuning its
interoperability solution, creating an industrial strength system,
others at HIMSS already claim to have products that can do the job. Like
dbMotion, some have made inroads into Canada.
Carefx is implementing interoperability solutions that leave data in
their original locations, much like the Kaiser-DoD-VA system, pulling
information together when needed. “We use a federated model,” said
company CEO Andrew Hurd. “Our solution makes real-time queries.
Carefx is currently used at the two-site Trillium Health Centre, in the
Toronto area, where it integrates a host of solutions from different
“It’s like Google,” he explains. “Google points you in the direction of
the information. It retrieves the information, but doesn’t warehouse
it.” With the federated system, Carefx also avoids troubling governance
issues. “We don’t have the politics that go along with huge
repositories,” said Hurd. “We don’t have to worry about where the data
sits and who owns it.”
The system can link any number of applications, says Hurd, such as order
entry, lab, document management and diagnostic imaging. “Carefx sits on
top of all of them. Its context management and workflow engine act like
the glue that pulls together everything the user needs.”
Medseek also has an integration solution that’s used in several Canadian
hospitals, including Hamilton Health Sciences, the William Osler Health
System, and Credit Valley Hospital. Most recently, the system went live
at Headwaters, in Orangeville, Ont.
Rich Grehalva, senior vice president, noted that Medseek can be used in
either a federated format or through a centralized repository. What’s
more, it can be set up to give the public access to their information,
forming the basis of a personal health record. A solution for diagnostic
imaging is being touted by MEDecision, of Wayne, Penn. The company has
won a place in the Toronto West diagnostic imaging repository project,
which is centralizing the images and DI reports of 25 hospitals.
MEDecision is working as part of a consortium, but is supplying a key
piece for solving the integration puzzle. “We have expertise in IHE
standards like XDSi,” said Dr. Elliot Menschik, general manager. “We can
take images from legacy systems and convert them into the XDSi format.”
What’s more, the company’s InFrame system also works with various
versions of HL7, including version 3, which adds to its versatility as
an interoperability solution.
Message from image guided therapy conference: The
future is now
By Andy Shaw
Dr. Robert Bell is not given to flights of over-the-horizon fancy. He’s
a practical, former orthopaedic surgeon turned president and CEO of the
University Health Network (UHN) who is paid, at least in part, to keep
his head down on running the country’s largest grouping of research
hospitals. But after some 13 of the best and brightest image guidance
researchers and surgeons in the world spoke about their developments at
a sold-out UHN conference at the University of Toronto’s venerable Hart
House in April, Dr Bell, said by way of advice to other hospital head
honchos: “Better keep your eye firmly fixed on the horizon.”
Clearly looming on that horizon are robots – ones that will bring
profound changes in the way diagnostic images are merged with surgical
procedures. Changes that will eventually take surgery beyond what the
human hand can do by its unassisted self and even beyond what the human
eye can see now. This blending of richly detailed, three-dimensional
pictures of our insides with deft, robot-planned and guided dissection,
conference attendees were told, will alter dramatically how acute care
But just as clearly we’re not quite there yet.
The most amusing moment of the conference came when the last speaker,
Dr. Catherine Mohr, the director of medical research at the world’s
foremost surgical robot maker, Intuitive Surgical Inc. in Sunnyvale,
Calif., put up a slide showing one of her company’s “state of the art”
da Vinci surgical robots – festooned with photocopies of a patient’s
diagnostic images taped to the robot’s exterior panels.
“What we’re working on now for the next generation of our machines is
how to get those pre-op images inside the robot with a heads-up
display,” said Dr. Mohr once the laughter subsided.
Dr. Mohr knows about heads-up displays from when she worked as an
engineer in the aerospace industry. A mid-life change vectored her into
a medical degree and a medical device career where she continues to use
her inventive engineering skills.
Also amusing and inventive was the multiple award-winning Dr. John
Trachtenberg, a urologist and the director of prostate service centres
at both the UHN’s Princess Margaret Hospital and nearby Mount Sinai
“I may be a research scientist and all that, but my kids know me as a
‘pee-pee’ doctor,” Dr. Trachtenberg told the conference.
To his peers, Dr. Trachtenberg is better known as a missionary for
image-guided, robot-assisted,“focal therapy” laser treatment of prostate
“We need better prostate treatment. Most treatments now damage the
prostate and have very bad side effects like loss of urinary functions
and sexual problems. And the more damage you do to the prostrate, the
greater are the side effects,” said Dr. Trachtenberg. “So we decided to
take a Buck Rogers approach to the problem and use MRI guidance to map
out precisely the cancerous part of the prostate – that’s the focal part
of focal therapy – and then use the robot to guide a laser that ablates
very precisely only the tissue within the map, so the side effects are
Dr. Trachtenberg said that in the first human trial of the new system,
he achieved what he believes is a world first.
“We used the robot and laser to treat five volunteer prostate cancer
patients just recently. All their cancer is now gone. We had 100 percent
kill and there have been no side effects, whatsoever,” reported Dr.
Trachtenberg. “Also, instead of four hours or more, the operations took
only two hours each.”
Dr. Trachtenberg believes that his “robotic solution,” with practice,
could be done in even less time and simply be a walk-in, walk-out same
day procedure. Given that prostate cancer is the leading cancer among
men and most get hospitalized, the savings to the healthcare system are
There’s one minor drawback, for the claustrophobic at least, to this
potentially revolutionary procedure – the patient is operated on while
he remains inside the donut hole of the magnet.
“So the technical challenge,” says Dr. Trachtenberg, “was to build a
system that was entirely non-magnetic.”
Which is precisely what Dr. Andrew Goldenberg, PhD, and his Engineering
Services Inc. company, in Toronto, did for long-time collaborator Dr.
The system will be used also when the five patients have needle biopsies
done of what remains of their prostates, four months, and again one year
after their focal therapy operations.
The acceptance of this potentially miraculous marriage of imaging and
surgery may not happen overnight, but in a piecemeal manner.
“I think what you’ll see is that surgical robots will evolve and not be
the kind of Swiss Army Knives that da Vinci robots are now, which can do
a pretty good job at a lot of different operations,” said Dr. Mohr.
“Certainly, all the devices will allow the surgeon to see 3-D images of
their surgical plans in front of them as they operate. That will be
common, but more and more, I think, the machines will become specialized
for specific procedures. But in the end, I believe, just about all
surgery will be done this way with robots.”
Even the tiniest procedures.
“Already, we have a confocal microscope adapted to one of our
microsurgical robotic probes, so in effect we can operate even on
individual cells if needed,” said Dr. Mohr. “
She added that the full scalability of robotic hand control has yet to
be exploited. But it can make a surgeon’s hand steady even at the level
Among other highlights of what’s on the imaging-surgical horizon these
days and revealed at the Hart House conference:
• David Jaffray, PhD, the head of UHN’s radiation therapy physics
department and the world-renowned developer of the cone-beam CT,
predicted that the computerized individualized breast and other cancer
treatments he is involved with at Princess Margaret will lead to
planning of a patient’s surgery that is automated. Today, even with
computer help, those surgical plans can take up to two-and-a-half hours
and more. But in future, as the planning software Jaffray has under
development learns from repeated use, those patient-specific plans will
be reduced to eight or nine minutes.
• Dr. Kieran Murphy, an interventional radiologist and deputy chief of
the University of Toronto’s medical imaging department, says Canada will
have to step up its imaging research and development – if it wants its
medical device industry to keep pace. In a survey he conducted of the
10,000 member International Society of Radiology, he found that Canada
trailed badly, producing only 16 patents over seven years while the
United States researchers filed over 1,600.
• Dr. Kazuhiro Yasufuku, an internationally renowned thoracic surgeon
from Japan, now with the UHN, said the trend in image-guided surgical
instruments has gone beyond minimally invasive to “mini-invasive”. For
example, a new convex probe he has developed with the help of Olympus
Corporation of Japan can guide him through a tiny hole to inside the
lung, where he can spot and put a needle in tiny, cancerous lesions.
• Dr. Garnett Sutherland, professor at the University of Calgary and the
author of five patents, has specialized in what MRI-guided surgery can
do for neurological diseases. He has developed a ceramic neurosurgery
robot arm that works on patients while their head is inside the guiding
magnet. It’s enabled delicate brain operations through what he terms
“mini-craniotomies”, which reduce skull openings to postage stamp size –
and make brain surgery for some a simple outpatient procedure.
• Medical physicist, Dr. David Hawkes from University College in London,
England, told the conference that the most promise for the better mating
of imaging and surgery is held by optical technologies. For his own
part, Dr. Hawkes has been able to produce sharp, real time,
artifact-free images of the liver and other motion-prone organs, while
the patient lies in the MRI machine, without taking a gulp of air and
holding it, but rather just breathing freely during the exam.
Of course, patients won’t see all of these innovations immediately. “You
don’t see much change happening day-to-day. But the changes coming soon
in image-guidance and surgery that we have heard about here today are
going to change your world. They are going to change the nature of your
imaging departments. They are going to change the size, shape, scope,
and use of your ORs, too. And they are going to change the way you
educate, train, and keep your surgeons current.”