Inside the November/December 2001 print
Canadian Healthcare Technology:
Feature Report: Developments in surgical systems
produce better outcomes using image-guided technologies
Surgical technologies can increase the cost of operations, but the
results may be worth it.
Incubators will develop wireless healthcare solutions
Hewlett-Packard and its partners are devising the wireless applications
at Mobile E-Services Bazaar centres around the world.
New tool for care planning
A newly devised database/mapping tool will allow care providers and
managers to analyze and compare their current performance against local, regional,
provincial, national and international best practices.
Portable PC innovation
ViewSonic has released its ViewPads, calling them the latest
development in the evolution of portable, personal computing. The devices are lighter than
notebook computers, but offer much larger viewing screens.
Total Care assets acquired
AD OPT Technologies Inc., a developer and vendor of advanced workforce
management applications, is acquiring certain assets of Total Care Technologies Inc., the
developer of staff scheduling solutions for healthcare organizations.
DR for general radiography
Mount Sinai Hospitals test of a general-purpose digital
radiography (DR) system said to be one of the first units installed worldwide
has shown the technology to be so useful that the hospital may acquire two more of
the systems during the next year.
PLUS news stories, analysis, and features and more.
Surgeons produce better outcomes using image-guided technologies
By Andy Shaw
Dr. Lloyd Smith is keen to show visitors his two, state-of-the-art
operating rooms for minimally invasive surgery. A general surgeon at the Toronto Western
Hospital campus of the University Health Network (UHN), Dr. Smith points with pride to
each ORs feature attraction, a voice-activated Hermes laparoscopic surgical system
from Computer Motion.
The new ORs, which opened for business in September, were a year in
research and development followed by five months of renovation and construction. They came
with a $800,000 price tag. Recently Dr. Smith, who heads up UHNs minimally invasive
program, led an in vivo tour of one suite during a gall bladder operation conducted by a
colleague. In the OR were a journalist and the architect who designed the rooms,
accompanied by the latters two school-aged children.
You know, as modern as all this is, by the time your kids are
grown up you may see me flipping burgers at McDonalds, said Smith with a
Yet to come, say some futurists, will be surgical systems using
injected surgi-bots. Theyll zoom about the inside of the body under
remote control and attack targeted trauma and lesions with nothing more invasive than a
needle prick. Shades of the Hollywood sci/fi flick, Fantastic Voyage. And that will soon
put surgeons like Smith out of work.
Well, maybe not quite so soon.
Author Mario Apicella, a senior test analyst for InfoWorld.com,
predicts that such minute medical robots will need another 10 to 20 years of development.
In the meantime, Smith and his laparoscopic ORs are the future
and a model for how they were designed.
Generally, we now do almost any surgery a general surgeon would
do, but we do it using laparoscopy, said Smith. And I think thats the
way all surgery will eventually go despite higher original costs for suites like
Smith and architect Dominic Meffe, the UHNs Director of
Facilities Renewal, agreed that a laparoscopic suite costs about $150,000 more than a
regular OR but the benefit in terms of costs savings, patient comfort, and recovery
time make them compelling.
With regular surgery, the average stay in hospital for a gall
bladder patient was 6.9 days. But this patient, came in here this morning and will be home
this afternoon, said Smith.
Four small holes in the patients CO2 inflated abdomen one
for a camera cum light probe, and the other three for a cauterizing L-hook scalpel,
specialized clamps, and other instruments are all that are needed in a laparoscopic
gall bladder removal that normally incurs no more than 5ccs of blood loss. (A
special mother-in-law clamp that just wont let go, finally drags the
gall bladder out through one of the holes.)
But though bloodless, the creation of the new ORs was not sweat-less.
We looked at what others had developed, then we did a lot of work
with what turned out to be a large but extremely helpful team of about 20 people in first
selecting the equipment and then designing the rooms, said Smith.
Consulted were electrical, mechanical, and structural engineers, the
hospitals own medical engineers, medical gases specialists, vendors of the
systems startlingly clear flat screen monitors and their supporting arms, and
naturally the doctors and nurses whose workplace the new ORs have become.
At first glance it might look like an unwieldy team but we found
that virtually everyone made a contribution that proved to be important, said Meffe,
whose architectural design pulled all the inputs together.
One surprising aspect of the new laparoscopic ORs theyre
Even though the equipment itself is more compact, we made the
rooms bigger so we could include more technology, said Smith. We know
well be adding things such as ultrasound scopes but we dont know what all the
new technology is going to be exactly. For sure, though, theres going to be more and
more technology in surgery. Thats why we left room for it.
So in future surgery, it seems, both smaller and bigger is better. The
question is: Will the surgeons be any better as a result?
Authors of a definitive report on medical imaging technology for
Industry Canada (http://strategis.ic.gc.ca/SSG/hm01516e.html)
conclude theres lots of encouraging surgery-related technology around now including
robotics, high speed volume rendering, virtual reality displays, and haptic feedback to
name a few but we humans still havent grasped how to fully interact with
these new tools.
A contributor to that report, however, said were making strides.
Bruce Davey of Cedara Software Corp. in Mississauga, Ont., sat on the reports
analysis and visualization work group. He is a PhD engineer in charge of advanced
technology and market development for Cedara, a pioneer of image-guided surgery software.
Were starting to see customization of image-guided software
and systems for different parts of the body, but they are all in different stages of
development, said Davey. In neurosurgery, for example, image guidance has
become the standard of care and the technology is quite mature. Its use in spinal surgery
is not yet as pervasive. And now, systems designed specifically for orthopaedics are
coming on the market. Then there is the potential for the soft tissue areas.
The problem for soft tissues is that they tend to slop around. As a
result, organs dont look the same to an operating surgeon as they did in the image
captured before the patient was wheeled in. So Cedara and others are developing systems
that make images in the OR itself, using fluoroscopic technology, which provides a much
more immediate and accurate picture.
We move in on the patient with a scanner very briefly then back
away again, explains Davey. So the images are only a few seconds or a minute
Not quite real time, but close.
For close to four years now, Dr. Walter Kucharczyk, a radiologist at
the Toronto Hospital campus of the UHN, has been developing and using a real-time imaging
system for neurosurgery. Its an open-style, two-panel MRI that scans continuously.
Since its launch in February of 1998, the system has guided over 100 neurosurgeries,
mostly for brain tumours. But surgeons early on paid a price.
At first, everything had to be compatible with a magnetic
environment, so they couldnt use a lot of the tools they were used to, said
Dr. Kucharczyk, who also chairs the department of medical imaging at the University of
Toronto. But we have developed a lot of new tools for the magnetic environment. And
weve also realized that for many procedures you dont need continuous imaging.
So weve developed techniques that switch off the magnet and allow surgeons to now
bring in their surgical microscopes or neural navigation systems like Stealth, BrainLab,
or ISG (now Cedara). Before they would back-off from using MRI if they had to give up
their familiar tools.
Having accommodated todays image-guided systems, Kucharczyk is
planning for tomorrow.
Were striving to make sure, first of all, that no matter
what system comes along, surgeons will be able to use them close to the magnet, said
Kucharczyk. Were developing our own neural navigational system that will work
with any other system. So the surgeon can go into the operating room and know that he can
use any tool he wants. That will broaden the spectrum of procedures that can be done using
The challenge for the next version of the open MRI that Dr. Kucharczyk
and others elsewhere are working on involves a wrestling match with MRI physics.
Theres always a struggle between image quality and
accessibility. You get the best, most uniformly strong field and hence the best images in
an enclosed MRI system, said Kucharczyk. The more you open up the traditional
cylindrical system to allow the surgeon better access to the patient the more you lose
field strength and uniformity. So those are the competing influences and its not
quite clear on the world level yet in what direction MRI development is headed.
A tool that solves the accessibility issue and is new to Canada is now
at the disposal of surgeons at the Jewish General Hospital in Montreal. FluoroTrak from
Visualization Technology Inc. (VTI) in Lawrence, Massachusetts, is the worlds first
fluoroscopy-based navigation system to employ electromagnetic tracking technology. Used
for cranial, spinal, and sinus surgery, the FluoroTrak system at the Jewish General is the
Its a third-generation no-block tracking system,
explains Natacha Treskin, VTIs Canadian territory manager. And what that means
is that there are no line of sight restrictions for surgeons or nurses. They can walk
around the patient without fear of blocking the imaging. So neurosurgeons can stand at the
head of a patient where they normally do and not have to pull away for the imaging.
Originally developed at the renowned Massachusetts Institute of
Technology, the FluoroTrak system dominates the U.S. market for sinus surgery where
precision is paramount.
When youre working in the sinuses, youre working in
an area where the skull is the thickness of an egg shell, said Treskin. One
wrong move can lead to a puncture and consequent meningitis infection or even death. So
our system is very accurate. It is a kind of GPS for the human body.
As a Canadian Centre of Excellence, the Jewish General will be using
its new system for research as well, linking it with ultrasound technology aimed at
developing real time imaging.
At another Centre of Excellence in Windsor, Ontario, the Hôtel-Dieu
Grace Hospital, neurosurgeons are working with the first Ontario installation of a
$500,000 German-made BrainLab platform, mostly to root out brain and spinal tumours.
BrainLab is purely a software company. It doesnt sell other
things so the software is very accurate and high quality, said Dr. Susan Brien,
Hôtel-Dieus chief of neurosurgery. With BrainLab we can combine just about
every kind of two-dimensional image such as CT scans and MRI with functional images from
PET and nuclear medicine scanning and then fuse all those images. So we can plan the
surgery on a workstation then put the images on a zip drive and take them into navigation
station in the OR. There we use a special laser pointer called a Z-Touch to outline the
patients face and the computer morphs the facial features on to the patients
Having such capabilities in a regular hospital, said Dr. Brien, is
breaking traditional boundaries of surgical system use and development.
We used to think that a centre of excellence for surgery had to
be on a university campus. But those days are gone now, said Brien who gained her
early experience in image-guided surgery as an assistant professor at McGill University.
With the first systems, you had to have a PhD student along to run them. They
werent very user friendly.
But now BrainLab is making much easier work not just of complex brain
procedures but also of the routine tasks of lumber fusions and placement of spinal
instrumentation, added Brien.
At a centre of excellence in Norway, researchers there are striving to
give surgical systems even greater ease of use.
In 1995, the Norwegian health ministry established the Center of
Excellence in 3D Ultrasound in Trondheim, recognizing that the ultimate ease technology
can give surgeons is to let them see in real time what they are working on not just
images of it. Ultrasound holds that potential.
Since the 1970s, Trondheim has been recognized as a hotbed of
ultrasound development. No less than five local institutions now contribute to ultrasound
innovation including the Norwegian University of Science and Technology, the University
Hospital of Trondheim, and the research and development organization, SINTEF Unimed
Toril N. Hernes, with doctorates in biophysics and medical technology
behind him, is SINTEFs research director. Dr. Hernes and his staff spearheaded the
development of an ultrasound-guided neurosurgery system that was due for launch in
September by Mison AS, a spin-off company.
Its the first system in the world that integrates high
quality 3D ultrasound with navigation technology, said Hernes.
According to Hernes, the system addresses the main challenge of
neuronavigation: changes in patient anatomy that occur during surgery. Computer based
systems do a fine job of imaging the patients before surgery so that it can be mapped out
in great detail. However, they are of less value during the operation then they might be,
because the moment any part of the brain shifts, the map then no longer corresponds
to the road.
The current Mison model, like the opened-up MRI of Dr Kucharczyk in
Toronto, provides tracking of any anatomy shifts that occur during surgery in near real
time. But ultrasound devices will be much cheaper than their MRI counterparts, said
Hernes, and newer versions to come from Mison will track changes in real time.
Nonetheless, Hernes sees a future for surgical systems that combines
MRI, ultrasound, fluoroscopy and other image guidance technology.
And no doubt larger ORs, like UHNs laparoscopic suites in
Toronto, in order to hold all that gear.
Incubators will develop wireless healthcare solutions
By Jerry Zeidenberg
MISSISSAUGA, ONT. Its a disaster that happens all too
frequently. A proud, elderly woman living on her own suddenly collapses, the victim of a
stroke or myocardial infarction. Ordinarily, it might take hours for her to be discovered
and rushed to hospital.
But in another scenario, the woman could be wearing a high-tech
wristwatch capable of monitoring her vital signs. The watch transmits a stream of signals,
via low-power Bluetooth technology, to a receiving station in the house or apartment. From
there, the signals could be wired through the telephone to a nurse-run monitoring centre.
When the alarms are triggered at the call centre, an ambulance is
immediately dispatched and paramedics are treating the woman within minutes. They can even
obtain a quick readout of vital signs from the computerized wristwatch, again by wireless
Bluetooth technology. In the end, the elderly womans hopeless situation has been
transformed by a low-key technology that operates in the background.
In fact, its just one of the technological solutions currently in
development by Hewlett-Packard Co. and its partners, through a number of Mobile E-Services
Bazaar centres located around the world.
Earlier this year, HP opened one of six international Mobile E-Services
Bazaar facilities at its Canadian headquarters in Mississauga, Ont. E-Bazaar partners
collaborate at these centres, which are essentially high-tech incubators, to develop and
integrate new and sophisticated solutions using wireless technologies.
Were bringing together technologies in new ways, driven by
the needs of our customers, said Bob Miller, business development manager for HP
Canada. And wireless systems are capable of solving many problems encountered by the
The Mobile E-Services Bazaar centres are coordinating this and other
wireless research in ambitious ways. HP hopes to have 20 E-Solutions Bazaar facilities
running at sites around the world by the end of 2002, and it is forging alliances with an
increasing number of wireless technology companies. There are currently more than 400
partners working together on wireless solutions including everything from medical
applications to chain-store retailing and auto manufacturing and the numbers are
Hewlett-Packard is playing a role as an aggregator and
facilitator in this, said Miller. He added that the company is bringing its own
research to the mix, such as its own work on wearable appliances.
The solutions are customer-driven, he added. Meaning
that the research and development are answers to real-world problems that plague
enterprises. For its part, Hewlett-Packard intends to learn what the most
intractable problems are for hospitals, physicians, and community health organizations,
and will attempt to solve some of them through innovative wireless technologies.
Through the Mobile E-Services Bazaar, a wireless partner in Boston has
produced technology capable of accessing various computer systems in a hospital on a
wireless device, such as a handheld computer or cell phone. The user can access these
systems with a single log-on, and obtain the information for example, from an ADT
system or lab system through a single interface.
Other partners have created a mobile locating system that helps an
organ transplant organization in Minnesota. Using the solution, the organization can find
the closest of its representatives to pick up organs across the mid-western United States.
These representatives are constantly moving throughout the country, so
it is often difficult to find out where they are at any given time. Using the cellular
technology, however, signals from their phones or computers are picked up and charted.
Since organ transplants must often be performed within hours, its important to find
the nearest person to pick up a liver or heart, and deliver the organ to the proper
There are many potential solutions using wireless technology that could
assist hospitals, nursing homes and home-care organizations. Bedside or wearable wireless
devices in the hospital can alert doctors and nurses more quickly when the vital signs of
a patient have changed and the person needs fast medical attention. Conversely, various
types of wireless monitoring devices could keep tabs on long-term care patients,
monitoring the person remotely, and reducing the need for visits by nurses and doctors.
And some care could be transferred outside of institutions, assisted by
wireless devices. Some births, for example, could be conducted in a patients home
if that is the parents choice. A caregiver could deliver the baby in
the mothers home, with wireless links to a hospital for advice and backup,
Miller noted. This could provide a socially responsible solution that saves money
for the healthcare system, and offers people more choice for healthcare procedures.
Miller explained that these technological solutions often involve
several companies or organizations working together, as they bring a variety of skills.
Whats more, theyre often complex applications, consisting of hardware,
software and middleware the systems that glue everything
together. Said Miller: Hewlett-Packard is creating the ecosystem, where all of
this can come together.
Innovative new tool created for care planning, analysis and benchmarking
By Ron Brown
A strategic alliance consisting of GE Medical Systems Canada, the
Kingston General Hospital and Queens University has created an innovative
database/mapping tool that will allow care providers and managers to analyze and compare
their current performance against local, regional, provincial, national and international
Whats more, the computerized system will enable hospitals to
place their experience within the context of regional socio-demographic profiles and
The tool will be ready for pilot projects in early 2002, and the
partners believe the system will be ready for production and wider release in April 2002.
The new system is a solution to a growing problem in Canadian hospitals
the mismatch between revenue and expenditure. For most hospitals, demand for
healthcare services is soaring. This will only intensify during the next 10 to 25 years as
the oldest baby boomers have now hit 55 and will demand a higher level of service from
With these pressures on hospitals, the need for efficient use of
resources, the development of methods to identify and disseminate best practices and the
prediction of required resources to meet the needs of the population has never been
The partners believe that efficient use of resources requires a
collective regional vision, which is difficult to achieve if the focus is the individual
hospital. Hence, they argue the tool must be web-based to encourage wide participation and
enable hospitals to understand the dynamics of their operation in a regional, national and
even international context.
The groups experience, coupled with recent database software and
Internet mapping developments, makes the vision practical and immediately achievable.
The Tool: At present, the tool will be based on three core data
Canadian Institute for Health Information (CIHI) hospital
hospital financial reporting (Ontario Hospital Reporting System
(OHRS)) in Ontario;
Statistics Canada population measurements and projections.
Other data sources can be added as they are developed and become
available on a system-wide basis.
At the heart of the tool are two integrated software components. The
first, a dynamic database analysis package, allows multi-level and scalable analysis of
individual hospital performance by both internal hospital comparisons and benchmarking
Performance benchmarks and best practices can be chosen from regional,
provincial, national and international databases.
The second component, an Internet mapping software package, provides an
alternative window on the data to assist hospitals in understanding demographic pressures,
and predicting and planning to meet needs resulting from demographic and other changes in
their regions. Both packages will be linked to available socio-demographic databases.
The tool is designed to assist physician managers, hospital managers
and system managers in maximizing quality and efficiency of service delivery, in ways that
follow clinical and management logic.
The Background: Over the past eight years, Kingston General Hospital
(KGH) has developed, through its Strategic Information Development (SID) group, a regional
database of the CIHI data for the 14 counties of eastern Ontario that make up Region 2 of
the Ontario Hospital Association.
SID has developed an intense understanding of the data and its
potential for in-hospital dynamic analysis. As well, in collaboration with Queens
University Geographic Information Systems (GIS) Laboratory and Autodesk Canada, they have
developed tools to allow on-line mapping of a populations utilization of specific
hospital services and individual hospital provision of the same services to populations.
Kingston General Hospital, Queens University and General Electric
Medical Systems Canada (GEMS) entered into a Strategic Alliance in May of 1999. Among
other issues covered under this alliance was the potential for KGH to act as a
demonstration site for GEMS Healthcare Solutions consulting services.
As a result of the alliance GEMS became aware of the work done by the
SID group and the GIS Lab and KGH became aware of the DYNAMO (Dynamic Analysis of Measured
Outcomes) product widely distributed in the United States by GEMS.
Components of the Prototype: There are three functional components to
be integrated into the proposed prototype.
The CIHI and OHRS data sets contain more then 350 reportable data
elements. The proposed link with financial data will enable cost profiling, trending,
comparisons and certain types of benchmarking.
The tool, to be known as cDYNAMO, will be on display at the GE Medical
Systems booth during the OHA Convention, Toronto, November 5 and 6, 2001.
Ron Brown is Marketing Manager for GE Medical Systems Information
Technologies, in Mississauga, Ont. John Lott, the Director of Information Management
for the Kingston General Hospital, leads the hospitals participation in the
DR system for general radiography scores high on productivity and quality
By Jerry Zeidenberg
TORONTO Mount Sinai Hospitals test of a general-purpose
digital radiography (DR) system said to be one of the first units installed
worldwide has shown the technology to be so useful that the hospital may acquire
two more of the systems during the next year.
This will enable the medical centre to run three general radiography
rooms instead of the current five rooms. Because of the high efficiency of DR, the
hospital will still be able to process the same number of patients for skeletal exams.
In our experience, there are significant advantages to digital
radiography, said Dr. Lawrence White, head, division of musculoskeletal imaging at
the University of Toronto. Image acquisition and quality review is faster than
conventional film and computed radiography, so patient throughput is higher and the
efficiency of the room is much greater.
The quality of the image is also very high, he said.
Its better than CR, and in my experience, equivalent to film. With DR,
theres information available, that may be limited with conventional film-screen
As an example, on a computer screen he displayed an X-ray image of a
patients foot that had been taken using the DR system. Dr. White could zoom in,
focus and brighten all parts of the image, showing details on all bones of the foot.
He explained that with a traditional, film-based image, that level of
flexibility afforded by the ability to alter image display would not be available. In a
conventional film-based radiograph of the foot, the phalanges might be optimally imaged,
but the hindfoot and base of the fibula and tibia might be underexposed and thus not seen.
Mount Sinai Hospital, a major acute care and teaching facility, runs
its diagnostic imaging department in conjunction with the University Health Network
the Toronto Hospital, the Toronto Western Hospital and the Princess Margaret Hospital.
A few years ago, the hospitals decided to move to a
filmless model of radiology, so that images could be more easily shared by
physicians through the use of computer networks.
In October 2000, Mount Sinai installed a Revolution XR/d digital
radiographic imaging system from GE Medical Systems.
The University Health Network hospitals already had installed systems
for DR chest X-rays and DR mammography, but this was the first implementation of a
table-based system for general radiography.
It was good timing, said Dr. White. We wanted to
learn more about DR in this area and push forward, and GE had just come out with the
Dr. White pointed out that on the road to going filmless, CR was also
an option. Indeed, the joint department of medical imaging at Mount Sinai Hospital and the
UHN has quite a few installations of CR systems for a variety of purposes. However, CR can
be slow and cumbersome compared to DR, as technologists must carry large cassettes
containing plates back and forth from camera and patient to the image reader.
Whats more, there are quality issues with the images produced by
CR systems. In a nutshell there are several technological steps involved in the collection
of a CR image and some information is lost along the way.
DR does have some drawbacks, too. First, its expensive
much more so than a conventional film-based room or CR. While the cost of typical X-ray
room with cameras and equipment for upright and table shots runs about
$130,000, the cost of similar DR room would be in the order of $550,000 for a table-top
system and $750,000 if you added an upright system for imaging the chest.
Whats more, theres less flexibility with current DR
systems. For example, theyre unable to take side views of patients on a table (cross
table radiographs) and some oblique image acquisitions, and are instead restricted to
shooting from above the patient.
That may change in the future, as manufacturers enhance the flexibility
Nevertheless, the benefits of DR namely the throughput, image
quality and ability to integrate images with the PACS and hospital information system
have made the technology attractive and valuable to Mount Sinai Hospital and the
University Health Network.
The productivity issue has become extremely important. At Mount Sinai,
the DR room currently handles about 45 non-ambulatory patients a day (patients who need
assistance getting on and off the table.) Technologists estimate theyd only be able
to image 30 such patients each day using a standard film-based system or CR.
Dr. White noted that a complete skeletal survey could comprise 16 or 17
radiographic views, which could take up to an hour to perform in a conventional or
CR-based X-ray room. With DR, we can perform a similar exam in approximately half