Surgeons control OR images using hand motions
TORONTO – Surgeons have been using diagnostic images in the operating room for years, but manipulating the pictures on monitors in the ultra-sterile environment of the OR has always been a difficult business.
Now, however, a Toronto company called Gestsure Technologies has produced a solution that enables surgeons and interventional radiologists to manage PACS images much more easily. It’s done by borrowing ideas from consumer products like the Wii and Kinect, and adapting them for the OR.
In a nutshell, infrared waves are used to capture the hand motions of surgeons, allowing them to quickly change the diagnostic pictures on screen, and to do things like zoom in and out. “After they’re scrubbed, surgeons and IRs can’t touch computer equipment in the operating suite,” commented Dr. Matt Strickland, a partner in Gestsure and a surgical resident at the University of Toronto medical school.
He explained that other solutions for controlling on-screen images without the use of touch, like voice-controlled systems, are awkward to use – the systems don’t respond with the speed and exactness that surgeons are looking for. Sometimes, assistants are used to change the images, but many surgeons find that it’s just as frustrating to bark out requests to alter the images to nurses and techs.
And the practice of wrapping keyboards and monitors in plastic to keep them sterile is clumsy at best – it’s very difficult to work the keys or use touch-screens through a layer of plastic.
Strickland says that in many cases, diagnostic images have been so difficult to use in the operating room that many surgeons simply don’t bother.
By contrast, the hand-motion-controlled solution from Gestsure has been tested during the last year at Sunnybrook Health Sciences Centre, in Toronto, and has been found to work. It gives surgeons “fine control” of the medical pictures they need to see, allowing them to fly through the image stacks.
Because the system is easy to learn and use, surgeons who have deployed it are viewing diagnostic images during operations more frequently than before. “We believe that will improve the quality of outcomes and patient safety,” said Strickland.
Indeed, for its part, Sunnybrook is now rolling out to more surgical suites – at the time of writing, they were about to start using the solution in neurosurgery ORs. Gestsure has been working closely at Sunnybrook with Dr. Calvin Law, a surgical oncologist.
Gestsure demonstrated its solution at the November meeting of the Radiological Society of North America, a medical conference that attracts 60,000 attendees from around the world. According to Dr. Strickland, there’s currently nothing else on the market like their system.
“There’s nothing that is so far along, or even close to commercialization,” he said, adding that most of the solutions currently under development are academic projects. He commented that a team from Harvard University was demonstrating a rival system at the RSNA conference, but it was simplistic compared with the Canadian technology.
“We made the guys at Harvard cry when we told them about what we were doing,” quipped Strickland. “But we spent some time with them, and gave them a lot of pointers.”
His partners in Gestsure are Jamie Tremaine, an engineer specializing in machine vision, and Greg Brigley, a computer scientist. Their system makes use of an infrared camera that measures space, distances and gestures.
Virtually any off-the-shelf infra-red camera can be used, such as the Microsoft Kinect or the Asus Xtion Pro, as the intelligence of the solution is in the software. The team says it will work with virtually any PACS.
At the RSNA, Gestsure showed how the system works with Client Outlook, an innovative company based in Waterloo, Ont., whose eUnity system ties into multiple PACS and displays images on a variety of platforms. The Gestsure team was part of the Client Outlook booth on the show floor.
Gestsure has worked out a specialized system for the operating room, with enough gestures to enable surgeons to use the diagnostic images on-screen in a meaningful way, but which is also easy to learn.
“We’ve concentrated on a small set of gestures for most of what’s needed,” said Dr. Strickland. “There’s a core set of five to six gestures that enable you to do most of the work.” The gestures also needed to be natural. “You don’t want to start doing jumping jacks in the operating room,” he quipped.
The team plans to launch the system commercially early this year. For more information, visit www.gestsure.com
On a related front, there has been exploding usage of the Kinect in the medical and healthcare fields. Doctors are using Kinect to help stroke patients regain movement. Surgeons are using it to access information without leaving the operating room and in the process sacrificing sterility. Healthcare workers are even using it to help with physical therapy and children with developmental disabilities or Attention Deficit Hyperactivity Disorder (ADHD).
“Everywhere I go in the world – every hospital, college or public health organization, people are already doing something with Kinect or they plan to,” said Dr. Bill Crounse, Microsoft’s senior director of worldwide health, referring to medical uses of Kinect. Launched at the end of 2010 as a controller-free gaming device for Xbox, Microsoft sold a world-record 8 million Kinect devices in its first 60 days on the market. This made Kinect the fastest-selling consumer electronics device in history, according to Guinness World Records.
New workflow solutions are rescuing Operating Rooms from FRED – frantically running every day!
But FRED is under attack like never before. At home and abroad, FRED’s time-wasting, delay-causing, and even potentially life-threatening scurrying about is being targeted by new perioperative systems, notably ones that keep anesthesia, in particular, FRED-free. Battle plans for annihilating FRED range from a relatively inexpensive make-better-use-of-your weapons-at-hand approach to a budget-busting clinical information system re-armament.
Determined to put FRED on the run affordably, Sunnybrook Hospital in Toronto, for example, with the help of consultants from Connexall, is judiciously applying workflow technology and techniques to all parts of Sunnybrook’s perioperative path.
“In effect, to eliminate the need for FRED as the nurses in particular call it, we have been helping Sunnybrook remove both their OR and surgical patient flow bottlenecks – so that people pretty much automatically have what they need when and where they need it, including both clinicians and patients,” says chief marketing officer Mary Baum for Connexall, the Toronto-based workflow consultancy and communications integrator with over 600 healthcare, education, retail, and other clients worldwide.
“At the Disney Cancer Center in Burbank, California, for instance, we have been working with Disney’s ‘imagineers’ to take a close look at how patients can better flow through the Centre. In particular, we’re looking at how we give patients the ability to control their environment, including the temperature of the room,” says Baum. “If you are going through cancer surgery and therapy, you likely don’t have much hair on your head; so you often feel cold. The idea of you sitting in rooms where you are freezing and not able to even read a book or watch a film, but just sitting waiting for something to happen to you, as so often happens in hospitals, is not the kind of ideal environment that Disney is so good at envisioning and creating.”
At the Disney Centre, cancer patients in waiting have a whole new set of attractive alternatives, including being free to go out for a walk and warm themselves in the Centre’s lush garden. Thanks to the RFID tag the patient is wearing, no one has go out in a frenzied search for a missing patient.
Cerner Corporation, a market leader in clinical information systems, has what it describes as a “fully integrated anesthesia solution” installed at over 400 sites around the globe. It doesn’t lose track of anybody. The anesthesia module is part of a Cerner’s larger SurgiNet management solution, which stretches the full length of the perioperative process.
Cerner’s SurgiNet modules offer automated help at critical points of the perioperative care path including:
• Scheduling, enabling staff to book both examinations and operating rooms before or at patient admission with the promise of reduced wait times, more timely use of staff, rooms, and equipment, and consequent reduced costs as well as fewer cancellations
• Case tracking, allowing staff along with patients’ families to follow a patient’s every stop along the perioperative process on large-screen, eye-level monitors hung on hospital walls
• Electronic Documentation, creating one record which transits the whole perioperative process with the patient from beginning to end
• Supply Chain, generating preference cards and pick lists for specific procedures that save time and effort including last-minute phone calls to find missing supplies crucial to the operation
• Anesthesia Management, providing automatically recorded, detailed anesthesia flow-sheet records for each patient from pre-op planning to post-anesthesia monitoring.
In reality, it has improved the accuracy of our charting … And really what the anesthesia record has done for us is to take better care of the patient,” concludes Dr. Doug Arbittier, a happy Cerner user who is chairman of anesthesiology as well as head of perioperative services at the multiple-site WellSpan Hospital group in Gettysburg, Pennsylvania.
Meanwhile, iMDsoft in its stunning and continuing sweep through Europe, the USA, Asia, and even Australia, last year saw 50 major hospitals adopt various versions of its patented MetaVision perioperative care system, adding to the 45 client institutions world wide who signed on in 2010.
Founded in 1996 by Israeli entrepreneurs Phyliss Gotlieb and Dr. Ido Schoenberg, the now Massachusets-based iMDsoft sells, in effect, a longitudinal electronic medical record.
“With MetaVision, we get a complete record of an anesthesia case from the pre-operative through the intra-operative and including the post-anesthesia care unit. So we get an accurate and comprehensive record that covers all the actions throughout the perioperative period,” explains professor Dr. Azriel Perel, who chairs the Department of Anesthesiology and Intensive Care at the Sheba Medical Center in Tel Aviv. “But the other important aspect of such a system is that it improves the safety culture in the department. It makes every anesthesiologist feel more accountable for everything that goes on throughout surgery.”
Including the unwanted FRED.
“In our hospital we use the MetaVision anesthesia information management system, which automatically collects vital signs; collects, lab results; collects various data that stream in from ventilators, from monitors, from IV pumps; and collects from the hospital information system itself – all this on a minute-by-minute basis,” says Dr. Perel. “So we get a clear and complete picture of the patient’s condition throughout surgery.”
MetaVision’s automated capturing of data, Dr. Perel further points out, has two other important benefits: physicians need spend less time manually entering data and thus give more time to providing care; and it also makes for better decision making during surgery.
“It facilitates the recognition of any change in the patient’s condition and it alerts us to potentially critical events throughout surgery,” says Dr. Perel. “In fact, you can configure the system to provide alerts that can be administrative, physiological or guidelines-related.”
One patient-safety alert, for example, that the Sheba Medical Center has put into its anesthesia system reminds its anesthesiologists to turn on other alarms after a cardiac patient is taken off bypass.
Cape Breton’s Jim Maclean, however, has been working for years to counter the effects of ‘frantic running’ in the operating rooms.
“Going back to the mid-1990s at the Victoria General Hospital, we had a Dräger anesthesia information system installed called Clinidas and we were one of the first hospitals to use any kind of clinical information system,” says Maclean, who is now IT project manager for Nova Scotia’s merged Capital District Health hospitals in Halifax. “To be Y2K compliant, we upgraded in 2000 to another Dräger product called Saturn and that’s when I came into the anesthesia picture. Then, after more than 10 years of service, we replaced Saturn with our third Dräger product called Innovian Anesthesia.”
While Maclean and Capital Health have pioneered the use of innovative computer systems in and around the operating room, he says anesthetists are further ahead in this regard than many departments in hospitals.
“I find that when it comes to information technology, a lot of people in healthcare are stuck in their thinking when it comes to change, legacy thinking if you will. But I certainly wouldn’t put anesthesia people in that category. They don’t think that way. Indeed, I find they like to be on the cutting edge of technology,” says Maclean.
Consequently, Maclean quickly won full anesthesia support when a change of database was proposed.
“We wanted to be able to do advanced reporting from our system. Our older system involved a Sybase database that was not easy to extract data from,” explains Maclean. “In fact, it had over 100 million records stored in one table. So today if you queried that table – you’d come back and it would still be running tomorrow.”
Now Capital Health is gathering its information on two readily-accessed SQL server databases including one dedicated to Innovian and looking at putting Microsoft Reporting Services in the middle to tie the main fields in both databases together.
One of the reasons, reasons Maclean, that anesthesiologists like to see information sources tied together is that they are literally faced with data staring at them every working day: “They see patient information coming off their patient monitors all the time and they understand that technically, its just a simple dump of that data into an information system and, Presto!, you have your patient record.
“That makes the record a true one you can audit. And in our case, we take a snapshot of data from the monitors every 15 seconds. So you can track in near-real time what’s happening to the patient from an anesthesia perspective. That’s something you could never do very well on a piece of paper with the doctor charting.”
As with the MetaVision system in Tel Aviv, anesthetists in Halifax using the Dräger system can manually enter or “time stamp” the moment they administer any medication and then see what changes that subsequently made in the patient’s vital statistics.
“And all of that is being recorded; so it delivers a huge benefit to the anesthetists,” says Maclean. “They can concentrate more on watching how the patient is doing rather than staying heads down on their charting. Then at the end of the case, it is just a simple ‘Print’ and their part of the patient record is automatically pumped out full and complete.”
Though the usage of Capital Health’s anesthesia information system was already high – 95 percent of all cases were being recorded by anesthetists even with the less nimble Saturn system, reports Maclean – when Innovian was introduced in September 2010, word came down that all cases would be recorded and passed on to the Innovian database henceforth.
Complete records piling up one after the other in any easily retractable database also provides good fodder for reports and further research, Maclean points out.
“Our anesthetists are seeing such benefits from Innovian that they have hired an analyst to generate reports for them from it,” says Maclean. “The reports are used to support their proposed research projects. For example, we’ve just recently had a research project proposed to look at what medications patients are on prior to surgery in order to see if there are complications that develop from each medication either before or after surgery. Also they can look at and compare the recovery rates for each medication.”
Despite the relative ease of pulling such information together, privacy and confidentiality are watched over by the system, Maclean says: “You know who has accessed the record when, what they saw, and how long they looked at it. So you have auditing that is far better than any paper system can give you.”
Also better is how Innovian and similar anesthesia systems can track who does how much work.
“Like a number of other hospitals, the physicians working here at Capital Health are not employees. So they bill the provincial government for the work they do,” explains Maclean. “They use a third-party billing system meaning that every time they are finished in the OR, they fill in little slips of paper to bill for the procedures they did. But what we have been doing is comparing what they bill to what has been recorded on the Innovian system. And what we are finding is that they are not billing nearly as much as they should.”
Small wonder then that anesthetists offer little resistance to such automated information systems or to expanding their use.
“We’re currently exploring implementing Innovian Web Forms, which would allow us to capture data in the pre-op area,” says Maclean. “So right now when the patient goes to pre-op and meets with the anesthetist, the information produced is captured on paper.
“Using Web Forms,” adds Maclean, would enable us to provide the anesthetist with all that pre-op information electronically, whenever he or she walks into the operating room. Similarly we’re working on getting that paper report that’s automatically printed out at the end of the operation back into electronic format for inclusion in the patient’s electronic record.”
It’s the kind of thing that comes with the all-encompassing systems provided by the likes of leading-edge, high-end vendors, for those that can afford them.
But more likely in Canada, where healthcare budgets will likely be eternally restrained, the expansion of automation to the full perioperative path and indeed to other processes in the hospital will likely follow Sunnybrook Health Sciences and Capital Health as models.
“Hospitals are still very much a collection of technology silos,” observes Connexall’s Baum. “So it is challenging work to fully integrate them.”
To lessen the challenge, says Maclean, healthcare needs more and better interfaces – interfaces that work with just about every other system in the hospital.
“For instance, one of the things we are working on right now that our anesthetists are very keen about is an interface for lab results.
“So let’s say a patient’s lab results all of a sudden become available during surgery. A notice will come up instantly on Innovian in the OR, say with the patient’s blood gas results, that are important to the care of that patient while under anesthesia,” says Maclean.
“Interfacing like that has been growing for past 15 years. But it is going to continue to grow because it is the only way we are ever going to eventually have just one chart for one person.”
BI enhances turnaround time in pathology reporting in Kitchener
Waiting for pathology test results doesn’t only create anxiety for patients. It can also cause strain in the hospital laboratory, particularly when it seems clinical staff can never get ahead of the reporting backlog and really don’t understand why it’s there in the first place.
But what if it were possible to pinpoint exactly where things were breaking down? What if staff members could identify problem areas at a glance and make real-time changes to increase workflow while reducing errors and ensuring high quality results and service delivery?
At Grand River and St. Mary’s General Hospitals in Kitchener, Ontario, that what-if scenario is quickly becoming an evidence based reality.
The combined pathology service for both hospital sites is the first in Canada to use a business intelligence and analytics solution from San Francisco-based Viewics Inc., to augment workflow as part of a comprehensive “leaning” or six sigma exercise. Designed with the requirements of a busy laboratory environment in mind, the innovative software-as-a-service is supporting ongoing efforts to shorten the service’s turnaround times and improve productivity and overall efficiency.
“We were not consistently meeting our patients’ needs in terms of reporting our pathology testing results,” says Vince D’Mello, administrative director, laboratory medicine, who spearheaded the lean project. “It was quite obvious to all of us that our current state was not sustainable.”
“Staff were eager to move away from the status quo and support value-added process changes in the interests of improved patient care,” says Shelley Owen, manager of pathology. “Without their involvement and dedication we could not have achieved this level of success in such a short time frame.” There is now a clearer understanding of the relationships between the pre-analytical, analytical and post-analytical phases of the operations.
As part of its leaning exercise, the pathology service began to rely on visual measurement techniques to improve workflow, performing manual calculations each day and posting them on large white boards. The visual control of performance metrics is important, says D’Mello, because it alerts staff to react quickly to potential problem areas and variances in meeting desired targets.
After implementing Viewics’ software-as-a-service, those manual updates will soon be replaced by digital dashboards. “The dashboard will have a combination of operational indicators, productivity indicators and quality indicators, which will help us to design or modify our workflow so that we’re meeting our benchmarks,” explains D’Mello, who operates under the mantra: “God we trust. Everyone else, bring data.”
The Viewics’ solution is a good fit for the laboratory, he adds, because it doesn’t require any additional hardware or software, and most of the measurements on the lab’s wish list are already provided in standard reports. It also removes pressure from the internal IT department, which would have had to develop custom reports in order to provide the same information on a daily basis. The operational team will have an authoring tool which allows them to easily slice and dice the data and perform root-cause analysis in the areas that matter most to them.
Viewics, on the other hand, operates as a third-party service. Rather than relying on back and forth queries with a hospital’s existing information system, the analysis takes place in Viewics’ proprietary cloud architecture using information “pulled” from the hospital database on a nightly basis. Although the company can pull any data from their system, they are aware of Canada’s privacy legislation and therefore only rely on test-level data that is in no way linked to a patient’s identity.
“What we do is very low touch on hospital IT departments and systems,” says Viewics co-founder Tim Kuruvilla. “Given the SaaS model, Viewics takes the hosting, support, maintenance, and other heavy lifting off of IT. When a user runs an analysis, it hits our cloud computing architecture which is optimized to perform data analysis; it’s not hitting their hospital information system and slowing it down.”
Another advantage is that the user interface provided by Viewics is extremely user friendly. It incorporates drag and drop features and identifies variables using language that is familiar to the laboratory staff so that they can quickly create custom reports that interest them. For example, they can gain a better understanding of physician ordering patterns, quickly identify turnaround times that fail to meet a pre-set threshold, or examine health trends within specific patient populations.
“You can slice and dice through the data that matters most to you,” says Kuruvilla. “When someone comes into the office in the morning, we want them to quickly see the five priorities they need to spend time on.”
From the outset of its lean exercise, the pathology service at Grand River and St. Mary’s set a goal of having 90 percent of all case types reported within five days and eliminating all backlogs. Prior to implementing the Viewics business intelligence solution, it was already well on its way to meeting both objectives and is now looking forward to setting even stronger performance targets based on the new information it will be able to glean once the service is fully rolled out.
“We typically receive from 150 to 170 pathology cases each day and in the pre-lean model we would have a minimum of 20 cases left over each day,” notes D’Mello. “That backlog went down to zero.”
The service is currently reporting 88 percent of its workload within five days, a number that used to hover at 52 per cent. And, in pre-lean days, 30 percent of reports were taking 10 days or more to leave the lab, a statistic that is now down to two percent.
Moving forward, the goal is to drill down to a more granular level of data to deliver even richer information so that further improvements can be achieved while raising the quality bar. According to D’Mello, the Viewics service is extremely knowledgeable about the inner workings and parameters of a lab environment; so much so that he and his staff will be able to innovate and measure things they haven’t even thought of yet.
“When Viewics did the demo, we recognized they were ahead of the curve,” he says. “…My vision is if this could be broadcast on every screen in real-time or as close to real-time that staff uses in the pathology department, we would all be aware at the click of a button where things stand.”
While Grand River and St. Mary’s Hospitals are the first to use Viewics in Canada, Kuruvilla has received significant interest after speaking at the Executive Edge Conference in Toronto last fall, and is also in discussions with other Canadian healthcare institutions.
Smart Condo uses ‘avatars’ to assess rehab patients for return home
A first-of-its-kind approach to assessing seniors’ abilities to perform their daily activities independently at home began in 2011 at Edmonton’s Glenrose Rehabilitation Hospital.
A self-contained independent living suite within Glenrose uses IBM software to monitor day-to-day activities of post-rehab elderly patients to test if they are ready to go home.
This pilot project, which represents the first real-world trial of the concept, is part of the Smart Condo initiative, a multi-year research collaboration with the University of Alberta, the IBM Alberta Centre for Advanced Studies, Natural Sciences and Engineering Research Council of Canada (NSERC), Olsonet Corporate Communications, a wireless networking company, Alberta Innovates Technology Futures (AITF) and the Alberta government.
The project involves sensors and smart devices installed throughout the suite to monitor and record the occupant’s activities, such as cooking, taking medications, and number of bathroom trips at night.
Sensors have been placed in numerous spots, including doors, mattresses, cupboards and even coffee pots and cups. No cameras are used, but the project has devised a unique method of visually assessing the abilities of the participants.
“People don’t want to be monitored with cameras,” said David Dyer, Glenrose’s director of nursing. “The data obtained of the occupant performing activities is run through software and turned into avatars (cartoon images), so there are no images of the patients themselves.”
To date, six volunteers have participated, typically staying two to three days. They were being treated for illnesses that included stroke, Alzheimer’s and bone fractures.
“The researchers can watch a visual representation, which is easier and quicker than reading volumes of descriptive text,” said Dyer, “and monitoring is done in a way that protects people’s privacy. “In this controlled environment, if something dangerous happens, we know about it and can intervene immediately.
What’s more, the patient is equipped with a call button and the suite is within 100 metres of the nursing station.”
The ability to transform the patients into avatars and monitor them visually is a ground-breaking innovation.
“When you view data as diverse as heart rate monitor and electrical consumption independently, out of context, it means very little. IBM’s software enabled us to put the data together visually and actually see a patient’s ability to function independently, so clinicians can intervene when necessary and students can learn how best to care for them,” said Eleni Stroulia, NSERC/AITF industrial research chair on service systems management at the University of Alberta.
During the project, researchers identified the need to track two new activities: the use of wheelchairs and walkers, and food intake. Additionally, by monitoring subjects’ use of a medication reminder device, they have determined how to improve its usability.
As well, there is tremendous potential for new monitoring technologies in the future. Dr. Gary Faulkner, Glenrose Rehabilitation Hospital’s director of research, said “we’re investigating wearable wireless devices that will monitor vital signs including blood pressure, breathing, and oxygenation of blood, and also working at determining balance problems and reporting patterns of unbalance before a fall occurs.”
The project will test a larger number of people in more trials to determine the right mix of monitoring sensors needed to create an accurate picture of the person being observed. “We’re adding more and more features,” said Dr. Faulkner, “and expect to offer a suite of sensor packages, from basic to the most comprehensive.”
Results so far? Dyer said the project has developed better technology for monitoring and assessing seniors’ abilities to live independently at home. This is helping clinicians provide better care for patients.
“With the information gained through technology,” Dr. Faulkner adds, “therapists have more confidence that people will maintain their level of independence upon returning home. We’ve also learned what doesn’t work, what shows promise, and what doesn’t.”
The Glenrose Rehabilitation Foundation’s financial investment over the past 18 months is close to $250,000, and the trial period is far from over, as no deadline for its conclusion has been established.
Glenrose is currently renovating the Smart Condo suite through donations from the Glenrose Foundation, with up-to-date appliances and furniture and better wireless systems that reflect modern homes to offer a greater capacity for more research.
What’s more, a new Smart Condo installation is being completed at the Health Sciences Education and Research Commons, part of the University of Alberta’s new Edmonton Clinic Health Academy.
Surveillance system helps track superbugs in Ontario LTC facilities
A unique pilot project designed to assess the prevalence of antibiotic-resistant organisms (AROs) in Ontario’s long-term care homes will give Public Health Ontario valuable new insight into infection rates by region and several other measures. The unusually high response rate for this voluntary study of close to 85 percent has been attributed in part to a new surveillance system designed to protect the anonymity of participating homes.
“It allows anonymous reporting of health information, with strong security and privacy guarantees for the reporters,” says Dr. Khaled El Emam, an associate professor in the Faculty of Medicine at the University of Ottawa, where he holds the Canada Research Chair in Electronic Health Information. Dr. El Emam is also CEO of Ottawa-based Privacy Analytics, which developed the surveillance system used in the study.
AROs have a huge impact on patients, resources, budgets and care. According to Public Health Canada, knowing the incidence of healthcare-associated infections in long-term care facilities is particularly important, due to the increased morbidity, cost and negative impact on the quality of life for the elderly population.
While hospitals routinely monitor and report the prevalence of antibiotic-resistant organisms, long-term care facilities do not. Antibiotic-resistant bacteria have become increasingly common in nursing homes over the past two decades. This pilot project, the first ever Long Term Care ARO Prevalence study, focused on examining the prevalence of three AROs: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin- resistant Enterococci (VRI), and extended spectrum Beta-lactamase producers (ESBL).
“Thus far there has been no province-wide baseline to understand the rates across all the homes, so the intention was to find a way to collect the data quickly and securely,” says Dr. El Emam.
When contacted by Public Health Ontario earlier this year, Dr. El Emam and Privacy Analytics had already developed the prototype for a surveillance system. “We flipped it into a production system for use on a large scale,” he says. The protocol was customized in a month and developed to allow participants to report without letting the conductors of the study know what they reported.
Asked to describe the solution, Dr. El Emam said it makes use of a system called homomorphic encryption. “We’re using the kind of cryptography that allows you to do mathematical analysis on the encrypted data.
“We’re able to collect encrypted data, perform calculations on that encrypted – not raw – data, compute the rates and aggregate it by regions, and bed size [number of beds), get the final results and then decrypt those,” explains Dr. El Emam. In this study, he says, “We are not asking participants to trust us.” By design, there was very little risk of being able to identify individual patients or homes. Instead, the system can pinpoint groups of homes with low or high rates by region or size of facility, but is unable to identify individual homes.
The original idea was to produce and analyze sensitive data for public health surveillance, says Dr. El Emam. Asked how long it took to set up the surveillance system, he said, “We were able to set it up very quickly. We were brought in a month before and knew we could set it up within a month. There was no paperwork. Since it was not a ‘human study’, but ‘subject research’, no ethics approvals were needed.”
From October 17 to 21, 2011, participating homes were asked to share their current known numbers of MRSA, VBE, and ESBL positive residents.
Participating nursing home representatives would use the system by simply typing a URL they were given into their browser and entering their responses. The values were encrypted using a special encryption method right in the user’s browser.
Responses would be sent securely in an encrypted format to the servers used for the study at the McGill University Surveillance Lab, under the supervision of Dr. David Buckeridge, an assistant professor of epidemiology and biostatics at McGill, where he holds a Canada Research Chair in Public Health Informatics. The information was held there in encrypted form.
Average infection rates were computed on the encrypted values. An advantage for the participating homes, notes Dr. El Emam, is that they would also be able to benchmark themselves very quickly and compare their own rates to the aggregate – or average of other homes. At the time of publication, the results of the survey had not yet been made public.
This pilot test of the anonymous reporting surveillance system is already generating interest from other health agencies. “We’re talking to some other public health units in Ontario, and hopefully also outside Ontario, eventually,” says Dr. El Emam, adding that they now are being asked to use the system for tracking influenza and other kinds of infections.
In a crisis situation, such as a sudden flu pandemic or other health risk, this type of anonymous reporting would enable faster data collection, providing a quick big picture and breakdowns by regions.
E-referral solution aims to improve flow of patients to specialists
Why are you here? Four words a healthcare specialist dreads asking and four words a patient – who may have waited up to six months for an appointment – dreads hearing. And yet it happens.
Perhaps the referring physician hasn’t provided the appropriate information. Maybe the visit is premature because necessary preliminary tests have yet to be completed. Or it could be that after reviewing the patient file, the specialist has decided that he or she isn’t the most suitable candidate.
It’s about getting the right information into the hands of the right specialist at the right time and when you’re relying on phone or fax, the process isn’t always as efficient as it could be. But that’s about to change, says Patrick Parato, Vice-President, Healthcare, at Toronto-based Navantis Inc. Parato points to recent developments in electronic referrals (e-referrals), a strategy that leverages ongoing investments in electronic health records to improve communication.
“I would say e-referral is going to be the number one healthcare application in about three to five years,” says Parato. “E-referral takes the notion of the electronic health record and really allows care providers to start sharing information, but with context.”
Still in the early stages of adoption, e-referral platforms are designed to streamline medical referrals by managing the data and workflow processes. Some solutions are hard-coded to a specific referral pathway, while others, like the Navantis AccessToCare Referral Framework, are designed to accommodate all types of referrals, including primary caregiver to specialist or hospital to long-term care facility.
One of the first to implement the Navantis AccessToCare Referral Framework is Ontario’s South East Local Health Integration Network (LHIN), which is currently using the technology to manage referrals between two family health teams and nine specialists in the area of Kingston and Brockville, specifically for total joint hip and knee replacements. A web-based, collaborative solution that leverages Microsoft SharePoint and Dynamics xRM, the Navantis Framework integrates with the LHIN’s existing electronic health record.
“There are significant benefits in choosing the Microsoft platform,” says Peter Jones, Healthcare Industry Lead for Microsoft Canada. “Organizations see more value from these applications as they integrate easily into their current infrastructure. Customers can also leverage their technology investments to create new applications to meet their changing business needs.”
All in all, a dramatic transformation has occurred. “We’re going from what’s a very manual process…
To make a referral for hip or knee replacement, primary caregivers within the participating family health teams click on an e-referral icon in the patient EHR. The Navantis application comes up on the screen, already populated with core information such as patient demographics and relevant clinical data.
As it continues to roll out its e-referral strategy, the South East LHIN is working with other Ontario LHINs, including Champlain and Central East, to outline the key components that make up a successful
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