Inside the May 2009 print
edition of Canadian Healthcare Technology:
produce order sets quickly, using web
Open Source Order Sets (OSOS), a web-based resource for quickly
producing and sharing high-quality order sets, is catching on with
Canadian hospitals from coast-to-coast.
Ultrasound at the
bedside benefits patient care and the bottom line
In many acute care units, patients needing diagnostic ultrasound
exams must be transported to the ultrasound department for imaging.
Unfortunately, moving any critically ill patient places the patient
at great risk.
READ THE STORY
imaging improves surgical outcomes
New imaging technologies are enabling surgeons to peer inside the
bodies of their patients as they operate, allowing them to check
their work during and immediately after a procedure.
READ THE STORY
Radiologists, GPs and specialists at nearly 30 hospitals in
southwestern Ontario will soon be able to access and exchange
patient RIS reports and PACS images, regardless of which maker’s
machines generated them.
Cutting the paper
Hospitals in Montreal and Kingston, Ont., are using document
management systems that dramatically reduce the amount of paper
circulating in their facilities. The solutions improve workflow and
reduce storage costs.
READ THE STORY ONLINE
Smarter, safer pumps
Later this year, hospitals in Sherbrooke, Que., will start using
smart infusion pumps. The systems make use of error reduction
technology, and will alert users whenever a selection is made
outside normal parameters.
St. Paul’s Hospital, in Vancouver, found that substantial savings
are attained through the use of bedside ultrasound scanning, instead
of wheeling patients to the diagnostic imaging department. Bedside
scanning is safer, too.
PLUS news stories, analysis, and features and more.
Hospitals produce order sets quickly, using web
By Jerry Zeidenberg
TORONTO – Open Source Order Sets (OSOS), a web-based resource for
quickly producing and sharing high-quality order sets, is catching on
with Canadian hospitals from coast-to-coast.
The brainchild of an innovative physician and nurse practitioner at
Trillium Health Centre, it appears that OSOS is in take-off mode –
largely because it enables hospitals to create order sets rapidly and at
lower cost than on their own.
“We’re providing an ecosystem for the development of order sets,” said
Dr. Christopher O’Connor, a critical care physician at Trillium Health
who has been working on order sets for nine years. Dr. O’Connor, who is
also the director of medical informatics at the hospital, launched the
collaborative web site in 2006 with nurse practitioner Kathy De Caire.
Since then, over 80 hospitals in four provinces have joined the network.
“Everyone on the network can see everyone else’s order sets,” noted Dr.
O’Connor. Member hospitals can use the order sets developed by OSOS,
along with those produced by other organizations as they develop their
own order sets – effectively reducing their costs and speeding up
development. “It prevents them from re-inventing the wheel,” he
Dr. O’Connor estimates the cost of producing an order set from scratch,
without the help of other organizations, at $15,000 to $60,000, as the
exercise requires the time and effort of physicians and other
professionals. By utilizing order sets developed by others, a great deal
of time, effort, and resources are saved.
Kathy De Caire estimates it can take a hospital, working on its own,
nine months to a year to develop a single order set. But there’s an
extraordinary change when they work with OSOS.
“We have members who’ve gone to our master repository order sets and
after making small changes, they’ve been able to approve and start using
them within a week.”
It’s a quick way for a hospital or health region to enter the world of
order sets. “We’ve had situations where members have started with no
order sets,” said De Caire. Through OSOS, they obtained what they needed
and were up-and-running in a few weeks.
Usually, the only delays are matters of fine-tuning, she said, such as
customizing the medications to adhere to the local formularies.
OSOS has attracted member hospitals from across the country, mostly by
word of mouth. The province of Prince Edward Island and its eight
hospitals signed on earlier this year. Another Maritime member is the
Atlantic Health Sciences Corporation, the largest group of hospitals and
medical centres in New Brunswick.
Meanwhile, on the West Coast, Vancouver Island Health Authority has been
using the service for over a year.
Numerous hospitals in Ontario have become members since the inception of
OSOS in 2006 – including the Central East Local Health Integration
Network (LHIN), of which the 800-bed Scarborough Hospital is a part.
Trillium Health Centre, a two-hospital organization with facilities in
Toronto and Mississauga, Ont., is also on board – after all, it’s the
place where Dr. O’Connor and De Caire first began the concept of online
order sets. What’s more, in December 2008 OSOS gained its first U.S.
member, the Wayne Memorial Hospital, in Honesdale, Pennsylvania.
Order sets have become hot commodities in hospitals across North
America. In the wake of studies showing a high incidence of deaths and
injuries due to preventable medical error, hospitals are scrambling to
improve outcomes and order sets have been shown to dramatically enhance
the quality of patient care.
In a nutshell, order sets consolidate the best practices and procedures
for treating medical problems – from pneumonia to pre- and post-op
treatments for hip fractures, and hundreds of others. They act as
decision-support tools, guiding doctors as they treat patients with
myriad problems each day, ensuring the right steps are taken and that
important procedures are not forgotten.
The challenge for physicians, of course, is that there are countless
medical problems and knowledge about them is skyrocketing. “If you try
to keep all of this inside your head, you’ll never remember,” commented
That’s why a printed order document, using the best current practices –
based on evidence in literature and clinical experience – can be of
immense aid to the working physician.
Dr. O’Connor stressed, however, that order sets do not force the
physician to follow set procedures. “It’s not cook-book medicine,” he
said, “where the physician is simply following the recipe.” An order set
will typically provide 80 percent or more of the treatments that a
patient will require. It is expected that the physician, for the other
20 percent, will need to adapt to the individual needs of the patient
and his or her disease and modify the treatment accordingly. He will
then need to draw on his own background and experience, along with the
expertise of colleagues.
It has been found that most physicians are happy to have a ‘check-list’
before them, ensuring that nothing important has been forgotten.
“That’s why we’ve got a 100 percent retention rate from the
organizations who have joined OSOS” he said.
So far, OSOS has created over 350 different order sets, with 10 to 20
new ones produced each month. Dr. O’Connor estimates that OSOS will
eventually offer a library of some 1,000 different order sets.
There are nearly 1,200 order sets in use across the network, but many
are different versions for the same problem, created by different
hospitals and health regions. Interestingly, noted De Caire, a user can
click on a link for one type of order set, such as pneumonia admission,
and all the order sets for that problem across the OSOS network will pop
up. “You can compare practices across the country, and adopt the parts
that you find most useful.” That’s a quick way of boosting the quality
of an order set.
Dr. O’Connor asserted that studies of hospitals using order sets have
shown impressive increases in quality and patient safety.
• order sets have led to an over 300 percent increase in the ordering of
• they have reduced the mortality of patients with sepsis by over 35
• Order sets were one of only two strategies found to improve the care
of children with asthma in Ontario emergency departments, significantly
reducing return visits. (The other was referral to a pediatrician.)
As used now, order sets are typically downloaded from a hospital’s
section on the OSOS web site (www.ordersets.net)
and printed as needed. They’re made up of various parts, including
check-lists that can be filled-in by the physician and then handed off
to nurses and other allied healthcare professionals – such as colleagues
in the lab and DI departments. They also include areas for free-text
input and educational notes.
While most medical centres are currently using order sets in paper
format, the creation of such documents sets the stage for computerized
order entry and routing – commonly known as CPOE, or computerized
practitioner order entry.
Dr. O’Connor stressed that paper-based order sets are “critical enablers
“You need them for computerized solutions,” he said. “They’re the
Very few hospitals in Canada or the United States currently have CPOE,
but as Dr. O’Connor said, most have put it on their road maps, as it’s
widely believed that computerized ordering systems will further reduce
the incidence of medical errors and provide numerous decision support
For its part, OSOS is designed to work with all electronic health record
systems, the company said, and its order sets can form the content for a
Hospitals and health regions that join OSOS pay a monthly subscription
fee. They are set up with their own section on the web site, and they
receive access to the work produced by OSOS and that of other hospitals.
They also receive order set development and project methodology, and
unlimited remote project support from the OSOS team.
Costs hinge on a variety of factors, including the size of the
organization and the number of order-set projects under way that will be
supported by OSOS.
One of the first users of OSOS was the Grey Bruce Health Network, an
alliance in rural Ontario that includes one regional hospital and 10
small hospitals. Before joining OSOS in 2007, the group had struggled
for five years to produce 10 clinical pathways, documentation packages
which included physician order sets. But in the next two years, by using
Open Source Order Sets, it produced and implemented 88 more order sets.
“It has really helped us,” commented Jessica Meleskie, evidence-based
care program coordinator for the Grey Bruce Health Network. “We might
have just one specialist in a given area, but they (OSOS) have developed
order sets that incorporate the expertise of hundreds of specialists. It
has been an effective way to get access to the best practices in
Meleskie noted that the service becomes even more useful as it adds
members, as it helps to be able to see the order sets developed by a
variety of hospitals. “You can pick and choose what you find best from,
say, five order sets dealing with the same problem.”
Six months after joining OSOS, Grey Bruce conducted an audit to see how
much use doctors were making of the new order sets. There was variation
in usage, but some sites had up to 80 percent usage of the order sets.
Some departments were heavy users of the documents – for example, there
was close to 100 percent usage in the OB/GYN department, and 90 percent
usage by surgeons, while only about 30 percent of internists were using
“The patients and procedures on the medical floor can be much more
complex,” said Meleskie. On the other hand, she said, “OB patients tend
to be more routine and lend themselves to the use of order sets.”
Grey Bruce is about to conduct another audit to see how usage may have
changed 18 months after the previous survey.
As it is committed to bringing best practices and evidence-based
medicine into standard use at its hospitals, Grey Bruce has fine-tuned
its own methods of developing and implementing order sets. In the past,
each of the 11 member hospitals would review the work through their own
committees; now, there is a centralized committee for order sets, which
greatly speeds up the whole process.
Meleskie noted that using a centralized web site for downloading order
sets also helps ensure that all of the organization’s hospitals are
using the latest documents. As a practical measure, the 11 centres are
urged to download order set documents on an as-needed basis, to ensure
they’re using the latest versions.
Paper order sets are also setting the stage at Grey Bruce for CPOE, as
the organization is in the process of rolling out an electronic health
record system from Cerner. Meleskie said that virtually everything is
computerized now, including nursing documentation, but the physicians
have yet to use the system in a comprehensive way. That will change, as
the doctors’ ordering system will be ramped-up in the next few years.
“It may start even sooner,” said Meleskie, “because some of the doctors
are eager to get started.”
Ultrasound at the bedside benefits patient care and
the bottom line
By Cathy Fix, RDMS; RDCS
In many acute care units, patients needing diagnostic ultrasound exams
must be transported to the ultrasound department for imaging.
Unfortunately, moving any critically ill patient places the patient at
great risk. And at St. Paul’s Hospital (Vancouver, British Columbia),
this practice also left the intensive care/cardiac care units (ICU/CCU)
frequently short of skilled staff while disrupting the normal workflow
and revenue generation of the ultrasound department (USD).
St. Paul’s Hospital is a 520-bed acute care, teaching
and research hospital that is home to many world-class medical and
surgical programs, including cardiac services, HIV/AIDS, and kidney
care. St. Paul’s is part of Providence Health Care, a large Canadian
faith-based healthcare organization operating 14 sites in Vancouver, BC.
Aware that emerging technology, including
miniaturization, has allowed for faster, smaller portable ultrasound
systems with excellent image quality, St. Paul’s Hospital decided to
investigate changing current practice by bringing the ultrasound exam to
the ICU/CCU patient’s bedside. Wireless connectivity, also now available
on these smaller systems, could remotely connect the sonographer at the
bedside to the radiologist in the ultrasound department, further
improving patient care by generating timely diagnostic reports.
But would the obvious advantages of scanning at the
bedside also translate into cost benefits and greater efficiency for St.
Paul’s Hospital? That was the crucial question.
A high stress environment: In 2008, current practice at
St. Paul’s Hospital was to transport critically ill patients from the
ICU/CCU to the USD for ultrasound exams. A fatal event during transport
was a grave concern, as was spread or cross-contamination of infectious
diseases. In 2007 (the most recent statistics available), at least 25
percent of St. Paul’s ICU/CCU patients were infected with methicillin-resistant
Staphylococcus aureus (MRSA) and/or vancomycin-resistant enterococci (VRE).
If a patient could be moved, ICU/CCU teams (comprising
nursing staff, a respiratory technician and porter) needed to accompany
the patient during transport, leaving the units critically short-staffed
during their absence. Preparation and transport back and forth took at
least 60 minutes, and all monitoring equipment (including respirators)
had to be portable and connected to the patient during the move.
The USD prepared by leaving a room ready for the patient
for at least an hour. If the patient became unstable at the last minute,
the exam would be cancelled, leaving nursing staff, porters,
technicians, and the USD with unproductive time. Further, the USD, with
a workload of approximately 25 percent inpatient and 75 percent
outpatient, was struggling with increasing wait times for booked
outpatients, and the waiting list was growing. The wasted hour of a
cancelled ICU/CCU exam meant two outpatients did not get scanned and the
USD lost billable revenue.
If the ICU/CCU were unable to transport the patient, the
USD would send a radiology resident to the bedside with a large,
unwieldy, old technology ultrasound unit that had poor image quality. As
a result, a repeat ultrasound or additional diagnostic imaging was
sometimes required, causing delay and increasing costs.
These factors were creating a high stress environment
with little or no control of patient workflow and poor management of
Stakeholders and concerns: Stakeholders in this process
at St. Paul’s included ICU/CCU teams, an information technology (IT)
team, sonographers, radiologists, and the ultrasound vendor. Patients
were also considered stakeholders, their interests represented by nurses
who work closely with them.
Among the concerns were exams being done in a timely
matter with little or no disruption to patient workflow, possible lack
of nursing support for USD while scanning in the critical care units,
proper triaging of exams, and increases in the number of ultrasound exam
requests upon arrival on the ICU/CCU wards. Other concerns included
image quality, stable networking, and difficult or complicated cases
requiring radiologist support. All stakeholders, of course, were intent
on reducing risk to patients and improving patient care.
The plan takes shape: St. Paul’s Hospital chose a small,
battery-powered ultrasound unit (z.one ultra Convertible Ultrasound
System, ZONARE Medical Systems) with excellent image quality that was
capable of wireless networking. The vendor lent the USD an ultrasound
unit worth approximately $80,000 for the six-month pilot study.
The ultrasound vendor worked with IT to establish stable
networking. The cost of upgrading the ICU/CCU departments to support
wireless networking was $24,000.
Protocols and guidelines were established by the
stakeholders and distributed to all concerned. Participants kept in
daily contact, whether in meetings or by phone calls and emails,
everyone working to support positive outcomes, especially for the
Senior sonographers (with five years’ experience or
more) who would be performing the bedside exams familiarized themselves
for a month with the new ultrasound unit.
The pilot program would evaluate:
• Efficiency and cost of not transporting patients to
and from the USD
• Effect of bedside exams on USD outpatient wait lists
• Image quality of portable ultrasound unit (any repeats scans
• Reliability of remote wireless networking to ensure timely reports
Up and running: The ultrasound system arrived on July
14, 2008. On August 18, 2008, the first portable ultrasound was
performed in the ICU. The USD went live with wireless networking on
September 23, 2008, delivering diagnostic reports directly to the
bedside. Since then, St. Paul’s Hospital has been regularly and
successfully scanning ICU/CCU patients in the units with the new
portable ultrasound machine.
Feedback has been positive among all stakeholders, and
the hospital already has plans to expand the program to the emergency
department and eventually the medical and surgical wards.
The bottom line: Scanning ICU/CCU patients at the
bedside clearly alleviates the considerable risks involved in moving
critically ill patients. But is it also cost effective? What is the
approximate cost of moving a critically ill patient? Or the cost of
leaving an ultrasound room open for ICU/CCU patients while
revenue-generating outpatients are waiting in line? Would the costs
outweigh the cost of a portable ultrasound unit? Could these costs even
be estimated? These are some of the questions the stakeholders had to
After reviewing the available data, St. Paul’s Hospital
found that in 2007, before USD began scanning in the critical care
units, the total costs for moving these patients was $35,809.18, and the
total loss of USD revenue was $49,804.32. The elimination of these costs
due to bedside scanning could easily offset the cost of the new handheld
In addition, if emergency, medical, and surgical
patients were also scanned on the wards (as is planned), cost recovery
could easily cover the equipment and wireless networking setup costs
within a year, and would certainly cover the salary of one full-time
healthcare worker. Moreover, the additional bedside scanning could
create the availability of at least 400 outpatient appointments that
could help with current USD wait lists.
The additional time saved in room clean-up could also be
significant. The 2007 statistics revealed that 25 percent of ICU/CCU
patients had MRSA or VRE. This number is likely underestimated but is
significant enough to cause concern regarding the time required for
proper cleaning and the risk of spread.
A lean, green imaging machine: Several sonographers
noted that the ultrasound system has no heat output. It turns out the
unit uses less power than standard units, which are larger, and can be
considered a green machine. This alone has meant a great deal to the
staff – the fact that the hospital is creating a better environment.
In addition, sonographers who scan at the bedside do not
have to be concerned about finding a plug or unplugging the unit and
pulling it away from a patient during a critical event in the ICU/CCU.
A beneficial mode of service delivery: There has been
nothing but positive feedback from the ICU/CCU teams (including nurses
and physicians); the ultrasound department has generated respect for
providing timely exams; and everyone is relieved that patients are not
placed at risk and the ICU/CCU departments are not left short of staff.
Due to the success of this pilot project, St. Paul’s Hospital USD will
start scanning at the bedside of patients in the ED in April 2009,
eventually followed by the medical and surgical wards.
The future applications of this technology could include
house calls, i.e., going to patients within the community. With wireless
connectivity, images could be sent to the hospital’s radiologist and
interpreted in minutes, just as is now done in the hospital. Further
investigation of the costs of inpatient care versus using the new
technology in the community setting needs to be done.
In the final analysis, St. Paul’s Hospital has found
scanning at the patient’s bedside to be a beneficial mode of service
delivery with a favourable cost impact.
Cathy Fix, RDMS; RDCS, is a Clinical Instructor,
Department of Radiology, Faculty of Medicine, University of British
Columbia. She is also Ultrasound Section Head, Providence Health Care,
Assisted by real-time imaging systems, surgeons can
improve the quality of results
By Andy Shaw
Dr. Ivar Mendez, surgeon and chairman of the Brain Repair Centre in
Halifax, can see better than any other neurosurgeon in the country. But
that has little to do with his own eyes. Enhancing Dr. Mendez’s sight
and consequent surgical decision-making are two real-time imaging
marvels – the PoleStar iMRI Navigation Suite and the O-arm Imaging
System, both from Medtronic. Equally enhancing his view are the human
newcomers Dr. Mendez brings into the OR with him.
“On the equipment side, the PoleStar is a low-field (0.15T)
intra-operative MRI which can guide us in real-time as we proceed with
cranial operations,” explains Dr. Mendez who also heads up neurosurgery
at Dalhousie University. The O-arm, he noted, is a three-dimensional
imaging system for the spine that provides surgeons with real-time
images in the operating suite, allowing to perform complex work – such
as putting in screws and bars to stabilize the spine – with great
Dr. Mendez believes that the PoleStar and the O-arm, and especially the
technical people who now venture into the OR with them in Halifax, are
harbingers of a new surgical era.
“Having real-time intra-operative imaging means we can do much more
complex operations and much safer operations in future,” says Dr.
Mendez. “Also, as we’re doing here now in the Brain Repair Centre, part
of the surgical team will be computer experts, imaging technologists,
and biomedical engineers. People who know the equipment and what it can
do intimately. So in future operating rooms, there will be not just
clinicians, but a whole multidisciplinary team.”
These new OR team members, according to Dr. Mendez, provide two great
“First, they help you get the best out of the equipment. They know how
to generate the clearest images – so you can do the best possible work
on the patient,” says Dr. Mendez. “But also, as we all gain experience
with the real-time imaging, we are tending to develop other instruments
and other applications that enhance what PoleStar and the O-arm do. It
happens naturally. You have the technical and engineering experts right
there in the OR with you, and you work with them every day. So new ideas
just emerge. One of them, for example, is the ‘Halifax Injector’.”
Key to all of this is the ‘intra-operative’ nature of the PoleStar and
the O-arm real-time images – you can see things ‘live’, as they happen.
“With the (PoleStar) intra-operative MRI, we can take a picture just
before we close up the head after brain surgery – to make sure we don’t
have a haemorrhage going on in there,” says Dr. Mendez. “In the past we
would do the surgery based on pictures we took perhaps four or five
hours before the surgery – and then we look at them again right near the
end of the operation to help us judge how well we think we’ve done. But
those pictures are not real time. After they were taken there could have
been some shifts or other changes in the brain. And there could have
been a haemorrhage.
“But when you can take real-time images of the patient’s brain right
there in the OR, you are much more likely to fix that haemorrhage on the
spot and prevent the patient from returning to the operating room in a
few hours or to the hospital days later.” In other words, said Dr.
Mendez, systems like the PoleStar and the O-arm provide better quality
outcomes for patients – and they are going to save the healthcare system
Dr. Mendez said the O-arm cost about a half-million dollars to acquire,
while the PoleStar MRI came in at over $2 million. “But we also
recognize that PoleStar and O-Arm are pioneering systems. So we know
they will eventually go down in price as demand for them goes up.”
One feature of both systems that seems sure to drive that demand up is
“The PoleStar is a portable system that can be put in a closet in the
operating room, and then it can be wheeled out when you need it and put
back when you don’t. Similarly, the O-arm can also be wheeled in and out
of the OR,” says Dr. Mendez. “So that means the operating room doesn’t
have to be dedicated to spinal or brain work. The OR can be used for
other types of surgeries as and when needed.”
Dr. Mendez reports that since the O-arm became operational at the Brain
Repair Centre over a year ago, “hundreds” of spinal patients have had
their surgeries done with it. The PoleStar, just installed last fall, is
put to use once or twice a week in its current work-up phase.
“Eventually, though, the PoleStar will be used for all the brain tumour
operations done in Halifax,” predicts Dr. Mendez.
That will certainly make the folks at Medtronic happy. And they think
hospitals will be happy with them too.
“The two systems certainly enhance the surgeon’s ability to get things
done,” says Bruce Leggett, senior product manager for Medtronic
Navigation. “But from the hospital’s point of view, it’s their mobility
and the low-field of the MRI that make the devices especially appealing
in these difficult economic times.”
As Leggett points out, the immense size and power of traditional
high-field MRIs usually demand that a hospital make extensive, costly
renovations or even build whole new wings to accommodate them.
“But with the PoleStar and the O-arm there are no construction costs.
They can normally be accommodated by existing structures,” says Leggett.
They are also less dangerous to users.
“We are starting to see reports now of surgeon’s getting cancer, which
can be traced to radiation exposure over their career,” says Leggett.
“And surgeons know when they are approaching their maximum allowable
radiation dosages. However, with the O-arm and the PoleStar they can
continue to work comfortably without exposing themselves high levels of
It’s a pragmatic approach to image-guided surgery that Medtronic is
proud of and which Leggett says has already won wide acceptance.
“We have 27 PoleStar installations in the U.S. and 50 around the world,
as well as over 100 O-arms installed mostly in the U.S. And we have both
O-arm and PoleStar together in about a dozen sites. So as the Brain
Centre in Halifax is demonstrating, they are complementary systems,”
says Leggett. “But I think what makes Dr. Mendez and the Brain Centre
unique is that they are not driven by the profit-motive. So they are
free to brainstorm and develop new procedures and prototypes. That’s
really what we like to help our users do.”
Though he is a 13-year veteran at Medtronic Navigation headquarters in
Louisville, Colorado, Leggett is familiar with non-profit approaches to
healthcare. He is a Canadian who began his career with ISG, the Toronto
airport-area company that took their aircraft navigation systems and
flew them into the human body. What ISG and radar did for pilots and
passengers, Leggett sees Medtronic and real-time imaging doing for
surgeons and patients – saving lives.
But Medtronic and the Brain Centre are not alone in that mission.
At the University Health Network (UHN) in Toronto, the Guided
Therapeutics (GTx) Program is aiming to do nothing less than
“revolutionize the way that cancer is treated.” Based at the UHN’s
Princess Margaret Hospital and at the nearby MaRS Centre, the country’s
top oncology surgeons, biomedical engineers, and medical physicists are
researching, collaborating on, and applying real-time imaging to real
patients. That’s leading to greater precision in the surgical removal or
radiated ablation of tumours. And like the Brain Repair Centre in
Halifax, they are making room for teams of techies in the OR.
“This is not over the horizon research. GTx is a concerted attempt to
develop the next generation of image-guided procedures and supporting
technologies,” says principal investigator Dr. David Jaffray, the head
of radiation physics at Princess Margaret and who pioneered the patented
Cone Beam CT.
He strongly supports the GTx credo that the convergence of imaging,
computers, and minimally invasive or, better yet, non-invasive
techniques can “..turn surgeons into sharp shooters who are able to
view, track and treat disease with precise, patient-specific therapies
guided by intra-operative 3D imaging.”
None more spectacular in their clarity and variety than those images
from the Cone Beam CT. During an interview, Dr. Jaffray demonstrates
with a “dashboard” of images drawn from one CT scan of a patient’s head.
The range from left to right, through traditional shadow and light
images to high-definition colour views of the head and neck muscles,
(with a tumour evident in red) to a bones-only skull shot. Rotate them,
flip them, any way you like to plan and track your approach.
In another interview, surgeon Dr. Jonathan Irish, the head of surgical
oncology at UHN and also a GTx principal investigator, takes a 3D image
of cancerous lower-jaw bone and “prints” it on a so-called 3D printer,
that’s more like a Star Trek replicator. Out comes an exact black-coloured
mould of the jaw-bone that he hands over for examination.
“Using our technical people in the OR to call up computer databases and
algorithms, we can now image the exact contours and even make
patient-specific models of what we are targeting. And by combining
different real time imaging modalities we can be even more precise. We
can see for sure where to cut and where not to cut, so that only the
cancer is removed and nothing else,” says Dr. Jaffray. “Or in
non-surgical radiation therapy, say for a thyroid or a prostate cancer,
if the patient moves on the table, we can see how to re-target the
shifted position of the tumour. Our physicists in the OR can now even
shape the radiation beam so that it attacks the more virulent part of
the tumour more than the rest.”
Less radiation going astray, lower levels of radiation, and fewer side
effects are among the patient benefits. Such innovations are what GTx
investigators and supporters hope will soon emerge as regular practices.
Likely they will first in the spacious ORs of another UHN institution,
the Toronto General Hospital (TGH).
“We started out in 1997 to replace all our ORs,” says TGH chief surgeon,
Dr. Bryce Taylor. “Of course we didn’t know then what technologies would
appear in the next 10 years. But we knew imaging had to play a role in
the OR of the future, so we built them big enough to accommodate lots of
new equipment. We planned and built 19 new such ORs but as a hedge
against the future we simply walled off the space for three or four
more, about 4,000 square feet in all and just left it.”
Now the walls are coming down, and under Dr. Taylor’s supervision and
support, GTx is creating the first of three state-of-the-art,
image-guided to the hilt ORs in the vacant space. Called Translational
Image-Guided Operating Rooms or TRIGORs for short, they will be
dedicated to clinical development and trials.
Not to be outdone by all those smart Torontonians, Dr. Mendez and his
practical Haligonians are proceeding with the Halifax Injector project.
“It will eventually work with our intra-operative imaging systems to
deliver cells or drug compounds into the brain and treat diseases there
without any cranial surgery,” says Dr. Mendez.
Providing, of course, Dr. Mendez keeps his biomedical engineers and
other technical wizards happy with their work in the OR.
Southwest Ontario leads way on DI connectivity and
By Andy Shaw
W hen it comes to obtaining the big benefits from eHealth solutions,
interoperability of the systems used in a region are prerequisites for
success. On this score, regions across the country should take a look at
the Southwestern Ontario Digital Imaging Network (SWODIN).
Begun as an eight-hospital pilot project just four years ago with Canada
Health Infoway help, SWODIN in its current phase will soon enable
radiologists, referring physicians, and specialists from nearly 30
hospitals to access, exchange, and store patient RIS reports and PACS
images – regardless of which maker’s machines generated them.
“We’re the second regional network in the world, after one in Norway, to
prove out interoperability among multiple PACS vendors, and we are the
first in North America,” said Babette MacRae, SWODIN’s project manager.
“So, I believe we are leading the way.”
When MacRae and other project leaders finish SWODIN’s final phase,
hospitals on the network will climb to 60 or more and cover a vast
geographic area stretching from Windsor in the west, to Hamilton in the
east, to Owen Sound on Lake Huron in the north – ignoring the boundaries
between four regional health authorities and leaping the technical gaps
between multiple RIS/PACS systems.
That reach and agility is enabled by GE Healthcare’s Centricity
Enterprise Archive, which is housed in two separate and anonymous London
locations, for redundancy, and its Centricity OneView software.
“In simple terms, the project has been about creating a central
repository for the records of radiological encounters with patients that
can be shared across a variety of connected sites,” explains John
Letterio, project manager for GE Healthcare. “There are three layers to
the architecture. The top layer is a patient normalizing solution that
matches up patient information.”
That’s so the patient record emanating from, say, Windsor for “Bobby
Jones”, is recognized as the same patient as the “Robert Jones” on
record in Owen Sound. The first layer can do this by finding the same
birth dates and other identical data on both records.
“That first layer then feeds the confirmed information on the patient to
the OneView application,” continues Letterio. “And that’s where the user
begins to interact with the system and pull up what we call a
“longitudinal” view of the patient’s records from all the sites the
patient may have visited in Southwestern Ontario.”
And that view is not clouded by whether his or her innards were
captured, described, and their images held by a RIS/PACS system from GE,
Philips, Cerner, Siemens or Carestream.
“We share them all in one deep archive and we’ve done that since we
began the project back in 2004, first with the Thames Valley Planning
Partnership that included two London hospitals and six community
hospitals,” explains Dianne Beattie, VP and CIO for the London Health
Sciences Centre, as well as the “executive sponsor” for the SWODIN
“We picked up another six hospitals when we began expanding to the Grey
Bruce Health Services region in our second phase. In this third phase,
we’re adding another 13 hospitals from Windsor-Essex. Those are all in
LHINs 1 and 2. But we are not stopping there. We’re just now in the
infancy of connecting up with LHIN’s 3 and 4, taking us into the
Waterloo-Wellington and Hamilton-Niagara Regions. Now, we won’t all be
sharing the same PACS, but all the records will go into that one deep
Beattie says that she and her colleagues on the SWODIN project wanted to
go big like that right from the start. But she credits the leadership of
Infoway for restraint at the outset.
“Infoway thought it was better if we began with a pilot first,” said
Beattie. And she’s glad they did.
Starting smaller allowed them to test and refine the systems before
ramping up. Favourable results gave Infoway and Ontario Ministry of
Health backers the confidence to put $50 million into SWODIN, and
Beattie expects their total contribution to be about $100 million.
Indeed investment could climb higher if private radiology clinics are
encouraged to come into the SWODIN fold – providing a connectivity cost
issue can be resolved.
“Connectivity to remote users from their offices or homes, we can do.
But in the interest of security and privacy, we have to build Virtual
Private Network tunnels, and VPNs are expensive and difficult to
maintain,” said Beattie. “So right now, we are evaluating two different
approaches that are much less costly but equally secure.”
As SWODIN grows, the challenges, Beattie expects, will not be so much
technical as human.
“Much of what we do depends on having good relationships. Before it was
easy, if you needed to see someone, you could just jump into your car
and go visit them within a few minutes. But now, we are getting further
from our home base, so people you might need to see are two hours down
the road. As a result, we have to think a little differently. We’re
putting more emphasis on interoperability planning and thinking ahead of
time about workflow.”
Ironically, it’s saving time on the road and better workflow that’s
providing SWODIN’s patients and physicians with much-welcomed benefits.
“Because we’re able to share the records, we’re saving patients many
unnecessary road trips, but also we’re seeing benefits not just to
radiologists but also to specialists,” said project director MacRae.
“The specialists are getting access to more information and that’s
resulting in better decisions.”
The network has been proving its worth in the real world, judging from
clinician reaction to SWODIN’s offerings.
“Remember that we are still in the implementation phases, but we’ve been
surprised by the number of clinicians who want to sign up and get access
to the network. There’s been quite a bit of excitement in the clinical
community,” said MacRae.
Mike Clarke knows why.
“Think about a patient in a remote area who has had a traumatic accident
with head injuries,” said Clarke, who is general manager of GE
Healthcare’s IT business. “Now, a neurosurgeon in a large centre can
take a look at the digital images coming off the network, advise if the
patient should be airlifted, and if so, have the operation planned
before the helicopter even touches down. That’s opposed to a patient
arriving unannounced with a bag of film stuck to the chest.”
Clarke mentioned other benefits of the retrieval enabled by SWODIN:
elimination of duplicate exams and comparison of say, mammography exams
taken here versus another six months ago taken there, and maybe on some
“I think that is the challenge we have met in the SWODIN project – being
able to straddle a heterogeneous environment of different RIS and PACS
providers,” said Clarke. “And its complexity is far greater than what GE
is doing in Newfoundland, for example. There, in effect, because they’ve
settled on one vendor, there’s one super-PACS in place. But in Ontario,
we’re striving to preserve the investments in legacy systems. We’re
doing just that in a northern Ontario project right now, as well.”
Making disparate systems talk to each other has been made possible by
SWODIN’s adherence to HL7, DICOM, and IHE standards for
interoperability, which together greatly facilitate third-party
integration, points out GE’s Letterio.
MacRae values GE’s Application Provider Interface (API), which enables
users to see what SWODIN terms the whole “longitudinal patient jacket”,
regardless of the system their desktop is on.
“The beauty is that they can continue to do their own workflow, on their
own PACS, but also have access to our network at the same time.”
Project leader MacRae points to a long-standing relationship with GE
that formed the initial basis of trust. And it continues to this day, in
Mike Clarke’s view, because of the focus GE keeps not just on its
Centricity archive and the OneView access to it, but on the workflow
improvements they enable.
“Anybody can put images in a bucket. That is easy to do,” said Clarke.
“And most of the vendors bring the same palette of technologies to
solving all the inherent complexities of a multi-vendor environment. But
the secret lies in careful consultation with the radiologists, the
technologists, and the specialists as to how they work best, and then,
for their benefit, masking all the complexities behind the scenes.”
For Beattie, a key to SWODIN’s success to date has been the leadership
shown by Infoway, as well as the Ontario Ministry of Health and
Long-Term Care. She points out that SWODIN was initially helped by the
province’s Network Refreshment Program. That program led to the
backbone-providing Smart Systems for Health Agency (SSHA) and its secure
Virtual Routing and Forwarding (VFR) technology, which SWODIN now rides
“The Ministry is also making sure we are leveraging what we have
learned,” said Beattie. “And already there have been some interesting
spin-offs. For instance, we’ve just set up a mini-PACS for neurosurgery
and everyone concerned with trauma cases. If someone needs a CT scan
done immediately, the request goes to the province’s central trauma case
agency, which immediately finds the resources needed to do the scan, and
the mini-PACS delivers the images to where they’re urgently needed.”
Healthcare centres use less paper with document
By Dianne Daniel
To scan or not to scan? That’s the question facing healthcare
institutions as they implement document management strategies. And while
the answer seems to be a clear ‘yes’ when referring to paper created
today, it’s not so cut and dried when determining the best way to handle
storage rooms filled to capacity with legacy paper charts.
“What do you scan, why do you scan it and how do you make it accessible
in the best possible way to your clinical community?” asks Jean Huot,
chief information officer (CIO) at Centre Hospitalier de l’Université de
Montréal (CHUM) and McGill University Health Centre (MUHC) in Montreal.
“Every clinician has a different view... ranging from scanning
everything in the paper record from the start of the hospital to
In October, 2009, CHUM and MUHC are going live with an integrated
document management and workflow solution from Telus Health (formerly
Emergis) and Streamline Health Solutions Inc. At that point, anything
created on paper – including discharge summaries, clinical notes,
referral notes and follow-up notes – will be indexed, scanned and made
available for on-line viewing through the healthcare facility’s existing
clinical information system, Telus’s Oacis.
The project is being undertaken for two reasons. First, the health
centres must deal with the challenge of how to provide centralized
access to patient information across a multi-site facility. Right now,
they move a lot of paper around at a cost and it seems the “paper file
is never at the right place,” says Huot. Second, they need to prepare
for a future move to a new location at which point the goal is to
progressively implement a digital hospital strategy that won’t
necessarily be paperless, but will use less paper.
For the past year, CHUM and MUHC have been working diligently with Telus
and Streamline Health to design a multilingual version of Streamline’s
accessANYware software. They’ve also spent a great deal of time
formulating a document indexing strategy that will rely on barcoded
forms to ensure information such as medical record number, visit number
and form type are scanned and entered correctly.
User empowerment is key throughout the process, says Huot, noting that
the information technology (IT) department relies on the collaboration
of chief clinical officers – doctors who are leaders in their fields,
respected by their peers and whose role is to ensure clinical needs are
When it comes to decisions about back-scanning, however, those needs
aren’t so apparent. Together, the CHUM and MUHC health centres serve
more than two million patients per year from eight different hospital
locations. “So essentially, when we’re talking about indexing and
back-scanning and trying to create a uniform approach, it gets very
tricky,” says Guy Mathieu, director, information systems. “We realized
soon enough that you couldn’t just build a new standard record from old
records that were standing in different hospitals.”
As they prep for a final decision on what to scan from the past, CHUM
and MUHC are continuing to seek participation from clinicians and are
also conducting extensive studies to determine the best approach to
take. For example, the centres have looked at patient flow to determine
the likelihood of a repeat visit from an old patient, as well as the
number of charts per patient and number of pages per chart to determine
the feasibility of scanning. “The merits of back-scanning are not yet
publicized sufficiently to know if there’s a definite avenue we should
follow,” says Mathieu.
At Kingston General Hospital (KGH) and Hotel Dieu Hospital (HDH) in
Kingston, Ont., the question of back-scanning has once again been put on
hold after a review by a patient records committee earlier this year. In
July, 2007, the hospitals launched a forward-scanning document
management strategy using Synergize, an imaging and indexing system from
Richmond, Hill, Ont.-based Microdea Inc.
All paper notes are now indexed, scanned and integrated into the
Quadramed health information management system for viewing, and are
destroyed by confidential shredding after a period of 60 to 90 days has
That means no new paper is being added to the medical records storage
area, currently housed in a basement facility at Hotel Dieu, but the
question of what to do with the legacy paper charts remains. “If we have
to move from there, then we would have to look at what we would do,”
says Barbara Nayler, director, patient records, registration and
privacy. “For now, the committee doesn’t see any real clinical value in
scanning the information that’s down there.”
Part of the reason for the decision not to back-scan is that KGH and HDH
have been using Quadramed since 1995 and 1997 respectively, and all
transcribed notes, lab results, X-ray results and PACS images occurring
since then are already available on-line for viewing. Most of the older,
typed notes in storage are accessed for research purposes only and in
the case of Hotel Dieu Hospital, are available on microfilm readers and
printers maintained by the Medical Records department.
Meanwhile, the forward-scanning effort has more than paid off, says
Nayler. It used to be that anywhere from 700 to 800 paper charts would
be pulled from the Hotel Dieu storage area on a daily basis and now that
number is down to 80 or so. Rather than hiring couriers to deliver paper
charts pulled for Emergency physicians during off-hours – on weekends,
statutory holidays and midnight shifts – the midnight security
supervisor now handles the job, and it only happens once or twice every
two to three days.
“We used to have five to six shifts of four-hour clinical people a
night, pulling records for the next day’s clinics, and now we’re down to
two,” adds Nayler, noting that physicians themselves stopped requesting
paper charts earlier than predicted.
Both the Kingston and Montreal health centres have approached scanning
as a necessary interim solution on the road to a completely electronic
health record. Right now they rely on barcoded forms to ensure the right
information gets attached to the right patient chart, but the hope is to
implement an e-doc strategy so that some day paper may disappear