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Inside the May 2005 print edition of Canadian Healthcare Technology:

Feature Report: Developments in surgical systems

Chatham-Kent hospitals test on-line appointments

A new, online Patient Appointment Request Service (PARS) is ensuring a hassle-free booking experience for patients of the Chatham-Kent Health Alliance – a partnership of hospitals located in southwestern Ontario.


Comprehensive portal

30,000 patients each month are using the web portal at Boston-based CareGroup – a five-hospital organization – to communicate online with doctors, make appointments, obtain referrals to specialists and renew their prescriptions.


Stent revolution

High-tech manufacturers are now producing drug-coated stents that disperse the medication over time, greatly reducing the need for repeat surgeries in balloon angioplasty patients.


Niagara region enhances care with 64-slice CT

Ontario’s Niagara Health System has acquired two 64-slice CT scanners, which use a high-powered technology that’s expected to revolutionize the DI world.


Cash for information

In order to obtain the data needed to build complete and accurate wait lists, Ontario has decided to pay hospitals for additional surgical and diagnostic procedures only after the centres have provided valuable information.

CCD-based DR

When evaluating a variety of direct radiology systems, the Ottawa Heart Institute found that a CCD-based technology came out best on image quality, ergonomics, ease of use and price. It opted for the systems of Calgary-based IDC.

PLUS news stories, analysis, and features and more.


Chatham-Kent hospitals test on-line appointments

By Karen Gersohn

A new, online Patient Appointment Request Service (PARS) is ensuring a hassle-free booking experience for patients of the Chatham-Kent Health Alliance – a partnership of hospitals located in southwestern Ontario. The service is enabling patients to book their own non-urgent appointments, such as diagnostic tests and cardiac and respiratory tests.

Previously, patients had to call a Patient Appointment Office or rely on their doctor’s office to set up an appointment. And that meant battling to get through their busy lines, or sitting on the phone waiting for assistance, or calling back and forth trying to juggle schedules.

But now, says Marilyn Cadotte, project leader for the PARS application and I.S. co-ordinator for Chatham-Kent Health Alliance (CKHA), patients are able to input requests for procedures, tests and appointments electronically 24 hours a day, seven days a week, from the comfort of their own homes. “We are able to serve the patient when it is convenient for them,” says Cadotte. “Office hours are not always convenient for the workforce.”

The service has also made appointment-setting less cumbersome for hospital workers.

Sharon Pfaff, chief information officer for Chatham-Kent Health Alliance (CKHA), points out that in order to make this service possible, the hospitals first needed to centralize their booking process. “We didn’t want to have that person in the middle transferring information from one system to another. Now, it’s possible to see the procedures that are booked and the available spots in multiple sites,” she says.

According to Pfaff, the idea for the PARS project came about at a forum where key individuals discussed the fact that hospitals were so far behind in computerization.

“The rest of the world functions with electronic processes, but a simple thing like booking a hospital appointment over the Internet was impossible,” says Pfaff. “You can book your hotel room electronically across the other side of the world, you can do all your banking online, you can pay your bills, but you couldn’t even book a simple appointment online for your procedure. Certainly, when there was a funding support that covered online scheduling as a possibility, we decided to move forward.”

PARS is funded in part by the Ministry of Economic Development and Trade through a Connect Ontario grant. Concept Interactive Inc., the builder of the Chatham-Kent community portal and the PARS application, also made an in-kind contribution.

Pfaff stresses that the project was a joint undertaking with the Municipality of Chatham-Kent. “We actually tapped into their system, since we didn’t have the funds to build the system from the bottom up,” she says.

The service, launched in January, is accessed via the Chatham-Kent community portal (

Users first complete an online information form and are asked to enter personal health information, including a health card number and the name of a referring physician. The creation of a unique user ID and password ensures that this information is protected.

Patients are able to book appointments online for the full range of tests and procedures offered by the hospitals in Chatham and Wallaceburg, including diagnostic imaging, nuclear medicine, cardiology tests, respiratory tests and others. However appointments for CT scans still have to be scheduled by physicians in collaboration with the radiologists at the hospital.

But appointments that need to be scheduled within two weeks cannot be booked on-line.

According to Cadotte the system is set up so that it automatically defaults to two weeks in advance. “If there is anything urgent, we want the patient to call. When they sign in, a message tells them that if the appointment is of a critical nature, they need to call.”

Patients are able to choose a day and time-frame for their appointment, and they can make more than one suggestion. The procedures on the paper format of the doctor’s order form are duplicated in drop down boxes on the electronic form. The patient must access the service again within two days to receive an appointment verification. They can then accept the proposed time or decline and suggest an alternate time.

Cancellations or changes can only be made by phone.

So far, the feedback from both patients and doctors has been positive. “Things are working well, but our volumes are not high at this time,” says Cadotte. “We are going to publicize it a bit more and we are in the process of enhancing some of the features to make it easier for the patients to use.”

Pfaff added that physicians’ offices seemed to be excited about this opportunity. “We are going to be doing some more marketing as we move forward, particularly honing in on physicians’ offices,” she says.

According to Cadotte, future plans include the possibility of physicians’ offices being able to access the scheduling package directly.

“We will also be setting up an evaluation form for the users to complete, and we will base how we move forward on the feedback from that.”

The PARS application is the only one of its kind in the Canadian environment. According to Sean Bredin, vice president, Concept Interactive Inc., two other municipalities are scheduled to follow Chatham-Kent. “There has been quite a bit of buzz created from this application,” said Bredin.



Boston’s CareGroup hospitals pioneer the web-based patient portal

Canadian hospitals interested in building their own patient portal would benefit from examining the PatientSite Project, created by the Boston-based CareGroup Healthcare System, a Harvard-associated, five hospital system of 12,000 employees, 2 million patients, and 1,700 medical staff. Its flagship is the Beth Israel Deaconess Medical Center (HMFP).

PatientSite ( is a sophisticated web portal for patients and physicians that’s been up and running since April 2000. Its features include requesting appointments, obtaining prescription renewals, and requesting care referrals.

The PatientSite project began in 1999, when I.T. and general medicine staff first discussed the concept of “patient relationship management” – the idea that patients should be able to view their medical records on line and communicate electronically with their physicians.

In early 2000, PatientSite was piloted with a small number of highly motivated, early adopter physicians and patients. By August 2000, over 1,000 patients were enrolled, along with 43 physicians in 10 practices.

Currently, over 30,000 patients, 200 primary care clinicians and 300 staff use Patientsite every month, commented Dr. John Halamka, CIO of Harvard Medical School and Beth Israel Deaconess Medical Center.

The project achieved this degree of adoption by ensuring PatientSite is compatible with all browsers, is easy to use and is highly customizable. For example, physicians work with their patients to enable specific features, such as how messages are routed to nurse practitioners, prescription clerks and appointment clerks.

For security, PatientSite uses a Secure Sockets Layer with 128-bit encryption. Users access it by logging in with a username and password. All accesses are audited and all audit trails are available for review by patients.

One of the features of PatientSite is secure messaging. Users (patients, staff, and providers) have a mailbox on PatientSite that enables them to send messages to other users on PatientSite. No clinical information ever leaves the secure website: when a message arrives, recipients are alerted via an unencrypted e-mail message sent through regular e-mail.

Recipients can then click on the PatientSite URL, their web browser will open, and they can then log in to read their message.

The functions of the PatientSite mailbox are in many ways similar to that of an ordinary e-mail program. Each message has a subject and a body. Messages can be composed, read, sent, and forwarded to others.

Other features differ from e-mail. Each message has a classification, such as “clinical,” “referral,” “prescription.” Because messages have a classification, they can be automatically routed to those who can best handle them (e.g., prescription requests to the prescription staff).

PatientSite allows physicians to dictate routing of these various message types. By default, clinical messages would be handled directly by the physician.

In addition to secure messaging, PatientSite allows patients to perform convenience transactions online. This includes requesting appointments, obtaining prescription renewals, requesting managed care referrals and viewing their bills.

Patients wishing to have a non-urgent appointment may (if their physician has permitted it) view the physicians schedule and fill out a web-based form specifying when they would like the appointment.

The appointment request is sent and reviewed by whomever the physician has designated as being responsible for managing these requests. The patient is contacted either through secure messaging or by telephone to complete the booking.

PatientSite similarly allows patients to request prescription renewals using online forms. In this case, the patient specifies not only details about the prescription, but also delivery instructions for the prescription. Prescription information is automatically completed when the patient uses the refill button next to a medication on their medication list screen.

The prescription can be left for the patient to pick up, or the patient can specify that the prescription should be called in or mailed to a specific pharmacy. Each patient’s favorite pharmacy is the default, but other pharmacy information may be entered, and a pharmacy lookup is provided as a reference.

In addition, when patients need specialty referrals, online referral forms enable them to request the referral from their primary care physician.

Every patient’s “home page” on PatientSite contains customizable health education links. These may be “prescribed” or suggested to a patient by a physician through a message (often to support a response to the patient) or they may be selected directly by the patient.

Discrete links may be added, but patients can also select predefined collections of links, clustered by category. These collections are managed by our patient education committee.

Patients may also view drug information monographs about each of their drugs by clicking on the drug of interest that appears on their medication list. In this way they can better understand their medications, how to take them, and what adverse effects can result.

All patients registered on PatientSite have links to their patient records that are established at the time of registration. Once this is done, it is possible for patients to view their records online.

Patients may see most aspects of their record online, including medication lists, problem lists, allergies, and all test results (except for initial HIV test results). If the patient’s physician does not use computerized patient records or does not have tests performed through one of CareGroup’s affiliated medical centers, then these elements will not be viewable.

Clinicians can view all messages sent through PatientSite through a “Messages” section of the clinical information system. All PatientSite messages are archived as long as the rest of CareGroup’s clinical information.

Patients can maintain a health record on PatientSite. They can input their own medications, problems, allergies, and notes. They can also track and graph data over time, for example, blood glucose measurements, weights, blood pressure, symptom scores, and any other quantitative information. Finally, they can upload files, including images, documents, and spreadsheets.

Since the implementation of PatientSite in April 2000, CareGroup has monitored its use both by patients and providers. It only counted as active users patients who logged on and signed the usage agreement after they were enrolled.

The median age of PatientSite users is 43, with 4 percent over the age of 70. Fifty-seven percent are female.

One of the things that concerns physicians about electronic communication is that they will be flooded with e-mail. The PatientSite data do not support this. Looking at the volume of clinical messages, the number of messages handled by physicians is quite modest, on the order of 20 to 40 messages per month per 100 patients. If we imagine a busy practitioner who has 1,500 patients using PatientSite, the maximum number of messages he can expect to handle from patients each day would be 15.

Even as it has been well received by many patients and physicians, PatientSite has raised controversial issues that are worthy of future discussion:

• Should certain types of data be restricted?

• Is it necessary for physicians to review results before patients can view them?

• How should information from the medical record be presented to patients to enhance their understanding of their health without needlessly alarming them?

• PatientSite has three major stakeholder groups, patients, physicians, and practices. How can we best balance the needs and concerns of each group to guide development?

• What should happen to patient-entered information in the personal health record?

• Should physicians be able to view the patient’s personal health record? Should they be required to do so?

• In a teaching environment, how should preceptors oversee their trainees’ use of electronic messaging with patients?

• Should physicians be reimbursed for using PatientSite? If so, who should pay? How much should they be reimbursed?

Online health consumers are increasingly prevalent, and are therefore important to healthcare providers. Organizations must fulfill their needs for communication, information, convenience, and access to their health records.

PatientSite, a Website developed and implemented at CareGroup Healthcare System, is an excellent way to meet these needs. It has been vigorously adopted by both patients and providers, and yet the demand on physician time is modest. The system has introduced controversial and interesting issues that CareGroup continues to work through. PatientSite is also a useful platform for future projects, such as patient-computer interviewing, disease management, healthcare quality, and patient safety.



New developments in cardiac stents lead to improved ‘keyhole’ surgeries

By Karen Gersohn

In one of the latest surgical technology revolutions, cardiac stents are now being coated with drugs to produce dramatically better outcomes for patients. The time-released medications are preventing blockages from re-occurring in the arteries surrounding the heart.

That will mean far fewer return visits to the catheterization lab or operating room for cardiac patients – something that will be welcomed by health-conscious patients and over-burdened hospitals alike.

For several years, stents – tiny mesh tubes made out of soft but sturdy metals have been used in surgical procedures to prop open arteries after the blood vessels have been cleared of blockages by balloon angioplasty.

As physicians can accurately insert stents into the body on the tips of catheters, guided by real-time images from scanners, the small mesh coils have become a leading-edge therapy in minimally invasive surgery.

Unfortunately, scar tissue often forms near the implanted stent and can cause the artery to re-clog or restenose in approximately 10 to 40 percent of patients, depending on patient and vessel characteristics. That has resulted in return visits to the catheterization lab or OR for patients.

With drug-eluting stents, however, the rate of restenosis plummets.

“Drugs embedded in a polymer on the stent itself modify the healing process, so that scar tissue does not build,” commented John Groetelaars, vice president for Boston Scientific Canada, a leading developer of drug-eluting stents. “The polymer has a time-release mechanism, so that the drug can be dispensed or eluted into the tissue nearby. This has dramatically reduced the rate of restenosis and repeat procedures to just 3 or 6 percent.”

In the past, the traditional treatment for coronary disease has been bypass surgery. In this procedure, the breastbone is cracked open, the heart is stopped and the blood is sent through a heart-lung machine. An artery is taken from the groin or arm of the patient, and grafted into the cardiac artery, thereby circumventing the blockage.

The recovery period for this major procedure is four to six weeks, after a hospital stay of about a week. And 20 to 30 percent of patients will need a second procedure within 10 years.

Contrast that with the less-invasive angioplasty or stent placements – a small slit in the groin or arm, an overnight stay in the hospital and back to work within two days. And with the insertion of drug-eluting stents, the prognosis is even better, as restenosis rates tumble.

Dr. Eric Cohen, director of cardiology at Sunnybrook and Women’s Health Sciences Centre, in Toronto, says that more people with coronary disease are now being treated with angioplasty and contemporary stenting than with by-pass surgery.

“If you can avoid a surgery, have a quick recovery and a relatively low risk of complications up front, it is more desirable, as long as the need for a repeat procedure is relatively low,” he said.

And when it comes to drug-eluting stents, Dr. Cohen adds that, “The response from doctors has been enthusiastic. The clinical trials have been consistent and fairly dramatic.”

As the technology is still young, Dr. Cohen offers a caution: “There have been some lingering concerns in the background about safety, because we don’t know that much about the long term effect of putting these drugs against the artery wall.”

But that’s quickly changing, he said. “Every year that we get additional data or follow-up on earlier patients provides more reassurance.”

According to Ken Spears, business unit manager for cardiology at Boston Scientific Canada, “there are an estimated 35,000 PCI’s (Percutaneous Coronary Interventions) being done in Canada annually, and virtually all of these patients receive coronary stents. In 2004, three-out-of-ten Canadian patients and eight-out-of-ten U.S. patients received a drug-eluting stent. The cost of each drug eluting stent is approximately Cdn$2,000.

For its part, the Ministry of Health in Ontario has invested $12.5 million annually for the past two years to pay for drug-coated stents.

The only other drug-eluting stent on the market at this time is made by Cordis Corp., a Johnson and Johnson company. As well, Medtronic is poised to enter the market with a drug-coated stent.

“This could lead to some additional options in terms of the arteries that the stent can be delivered into,” said Dr. Cohen. “It will also lead to more competition, and hopefully, more price reductions.”

What’s next, in terms of stent technology? “On the horizon, I see biodegradable and reloadable stents coming to the market,” said Dr. Cohen.

Boston Scientific is currently working on gaining approval in Canada for their second generation of stents, which should be available in the next six to nine months. “In addition we are working on being able to reach vessels that are at the bifurcation point,” said Groetelaars. “Frequently, that juncture point is where there is disease.”

When it comes to neurosurgery, Boston Scientifics’ Neuroform stent is now being used as a less-invasive alternative to neurosurgical clipping for patients with wide-necked brain aneurysms. Used in combination with platinum micro-coils, which are used to fill the aneurysm, the stent isolates the aneurysm and reduces the risk of rupture.

According to Groetelaars, “the coils are used as the primary way to treat the aneurysm, and the stent is put in place to essentially create a backdrop for the coils to sit up against.”

‘The aneurysm is stuffed from the inside of the blood vessels with coils, and that relieves the blood pressure of the sacs. But with a wide-necked aneurysm, the coils could fall out without the stent to hold them in place,” he said.

Dr. Karel TerBrugge, head of neuroradiology at the Toronto Western Hospital, believes that coiling and stenting is a fast and effective method of saving the lives of neuro patients.

“Coiling and stenting can usually be done within hours of the patient’s arrival at the hospital,” he commented. “Surgery has to be booked and negotiated. During the delay, patients can re-bleed and that can be fatal. From the patient’s point of view, not having to have the head cut open and the brain retracted and pushed around is obviously better tolerated, and the wound is not an issue.”

The Neuroform stent was first used in Canada in May 2003. “Since then approximately 200 procedures have been done with the stent. Usage is predicted to rise to about 25 to 30 percent, representing about 200 procedures per year,” said Peter Aikins, Boston Scientifics’ business unit manager for Interventional Neuroradiology.

“The U.S. adoption rate is already at about 25 percent, given that funding is not a barrier,” he added.

The price of the stents, at approximately $4,000, is much more expensive than surgical clips. But shorter hospital stays and recovery times offset this cost. And the ability to perform procedures more quickly, and saving more lives, is a monumental benefit.

Dr. TerBrugge predicts that in the future stents will be used alone to treat aneurysms.

“Eventually, we will probably use a stent that has a tighter mesh and we will not need coils anymore,” he said. “There is no doubt that intracranial stenting is here to stay. It is clearly a good evolution and is obviously working.”

The Neuroform stent is the only intracranial stent approved for use in Canada. The Leo stent from Bolt is licensed for sale in Europe, South America and Asia.

A third area of the body where stents are proving useful involves the colon.

Colorectal cancer can cause complete or partial colonic obstruction due to tumour growth. However, colonic stents can be implanted to open up the stricture and allow waste to be cleared naturally. They are deployed with a colonscope and catheter via the anus, and there is no need for open surgery.

According to Dr. Laura Targownik, assistant professor of medicine, Gastroenterology, University of Manitoba, “the advantage of doing a stent procedure is that you save a lot of patients from having to have an ostomy and having to undergo emergency surgery.”

When a patient presents at emergency with acute bowel obstruction, the standard of care has been to do a Hartmann’s procedure (two-stage surgery). The abdomen is opened and a stoma bag is attached for the draining of stool. The patient then requires six to eight weeks of recovery time before the next stage of surgery can be attempted.

“Stent insertion allows you to get rid of the obstruction, let the patient settle down, and when the surgery is done to remove the tumor a few days later, you can hook the two ends of the bowel together and bypass the need for a bag,” Dr Targownik said.

She uses Boston Scientifics’ Wallstent. “It has a through-the-endoscope delivery system, which means that you can deploy the stent under direct visualization.”

Colonic stenting can also be used as a palliative measure where the cancer is too far gone to make tumor removal feasible.

Dr. Targownik participated in a theoretical study in which a computer program simulated a patient who had a colonic obstruction. “The study found that not only is putting a stent in cheaper, but it also lowers hospital stays, prevents additional surgeries and prevents patients from needing an osotomy,” she said.

According to Stephane Taillefer, business unit manager for endoscopy at Boston Scientific, colonic stents were first used about three years ago. Approximately 300 procedures were done in 2004.

“However, the response has been slow in Canada, especially in Ontario, as compared to the United States or Europe.”

Dr. Targownik added that the use of colonic stents by Canadian doctors is patchy.

“Generally, patients with obstructions are referred to surgeons. Because there is already a standard of practice of doing surgery, it is hard to convince surgeons not to do surgery, especially if they are not trained to put in stents.

“For the future, we have to encourage the visibility or the knowledge that stents are available, encourage people to learn how to use them and encourage referring physicians that they are out there and that this is something that can make the lives of their patients easier,” she said.


CT technology enhances patient care at the Niagara Health System

NIAGARA FALLS, ONT. – The acquisition of two 64-slice Computed Tomography (CT) scanners by the Niagara Health System (NHS) is dramatically extending diagnostic imaging capabilities and enhancing services for patients.

Diagnostic imaging experts at the St. Catharines General Site of the NHS say the benefits of the new 64-slice CT scanner – the first in Canada – have been numerous since the unit went into full use in November 2004, and include faster diagnosis of patients, earlier treatments and discharges, improved image resolution and increased scanning speed.

A second 64-slice CT scanner went into operation at the NHS’s Greater Niagara General site, in Niagara Falls, in March 2005, and it is anticipated that wait times and throughput will also improve. The Greater Niagara General site is the fifth healthcare facility in Canada to acquire a 64-slice CT scanner.

“The tremendous speed of acquisition has made a difference in imaging the sickest patients. For example, respiratory motion is no longer a significant issue,” said Dr. Amit Mehta, acting chief of diagnostic imaging at the St. Catharines General Site. “The improved throughput has allowed for the faster diagnosis of both inpatients and ER patients, thus allowing for earlier discharges or treatments.”

CT is a versatile modality which provides important clinical information on a wide range of medical problems. In a general hospital setting, it is used for cancer diagnosis, monitoring of cancer response to treatment (surgery, radiotherapy, chemotherapy), imaging of traumatic injuries, imaging of inflammatory or infectious diseases, vascular disorders, and neurological disorders. The new scanners will continue to provide information in the above conditions, but will do so faster and with greater precision.

“Images obtained with the new scanners will contain more detailed information because of improvements in image quality, “said Dr. Tom Li, chief of diagnostic imaging at the Greater Niagara General site of the NHS. “The new CT’s powerful computers also allow further manipulation of the raw information into newer methods of displaying the information, such as 3-dimensional reconstructions. The newer methods of image display will not only improve the radiologist’s ability to correctly diagnose conditions, but will allow other specialists to easily recognize and understand conditions that they have referred their patients for.”

Faster scanning speed not only increases throughput, but also addresses problems encountered with patients who cannot remain still for long periods of time, moving body parts such as a beating heart, and the challenges of scanning the rapid movement of injected intravenous contrast material through blood vessels and organs.

The increased versatility and image quality of the new scanners will lead to improvements in patient care by improving the diagnostic certainty of tests and expanding applications into new areas not possible with older technology.

The CT scanners, from Siemens, are used to provide diagnosis for a broad spectrum of disorders covering the entire body. Routine studies include the head, lumbar spine, chest, abdomen and pelvis. Musculoskeletal CT, CT angiograms (of the carotids, Circle of Willis, chest, abdomen and limbs) are also routinely performed.

This permits radiologists and technologists to avoid traditional invasive diagnostic angiograms in a significant number of patients. The unit is also used to perform CT-guided intervention, including biopsies and percutaneous drainages with the use of the CT fluoro package.