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Inside the  November/December 2009 print edition of Canadian Healthcare Technology:


Feature report: Hospitals of the future


Success eludes many large healthcare IT projects
It’s not just eHealth Ontario that has run into trouble of late. Large-scale healthcare IT projects in many locales – including Britain and the United States – are floundering. Often, they’re missing deadlines by years, running over-budget or simply failing to work.

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Technologically advanced Osler gets back on its feet
Ken White says his goals as supervisor of the William Osler Health System, in Brampton, Ont., have been accomplished, as the hospital corporation is now operating effectively and efficiently. Its flagship Brampton Civic Hospital had opened in October 2007 amid controversies concerning shortages of staff and beds, wait times, quality of care and lack of proper training.

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Infection monitoring system
A new pandemic surveillance system in Hamilton, Ont., that connects five major hospitals to the city’s public health computers is up and running – just in time for the possible resurgence of the H1N1 swine flu.

READ THE STORY ONLINE


Lab, radiology convergence
The move to early diagnosis and the identification of ‘pre-disease’ will drive the merging of laboratory medicine and radiology into a super-specialty, according to lab science experts at a recent Toronto conference.

READ THE STORY ONLINE


Anti-coagulant self-testing
Since June, a group of cardiac patients in Montreal have been engaging in anti-coagulation self-testing from the comfort of their own homes, using a pocketbook-sized kit from Roche Diagnostics.


Bedside info-tainment
A new generation of bedside terminals,using a single communications network, is delivering both clinical information and entertainment. The systems can connect to electronic patient records and display X-rays, and also run the latest episode of Grey’s Anatomy.


PLUS news stories, analysis, and features and more.

 

Success eludes many large healthcare IT projects

By Jerry Zeidenberg

It’s not just eHealth Ontario that has run into trouble of late. Large-scale healthcare IT projects in many locales – including Britain and the United States – are floundering. Often, they’re missing deadlines by years, running over-budget or simply failing to work.

It all goes to show how complex these massive projects really are, and how difficult it is to succeed at them. Perhaps there is something to be said for a ‘small is beautiful’ philosophy in healthcare IT, a strategy that concentrates on modest-sized ventures and carefully scales up.

In October, the auditor general of Ontario reported that the province had spent $1 billion on e-health projects over the past seven years, with virtually nothing of value to show for the investment. The impact of the report sent the provincial government reeling and resulted in the resignation of the minister of health.

But other organizations and jurisdictions are having their share of disasters with large scale healthcare technology projects – what might be called over-arching healthcare IT solutions.

The Veterans Administration in the United States is a case in point.

Just a few years ago, the Vista health information system at the U.S. Department of Veterans Affairs (VA) was touted as the very model of a modern EHR system. The VA is a huge organization – it runs 153 hospitals and 1,140 outpatient clinics – and the Vista system was credited with boosting quality and customer satisfaction, along with reducing medical error.

Lately, however, it seems the VA can’t do anything right when it comes to IT.

In July, the VA suspended work on 45 IT projects with a total value of US$200 million, as they were running late or over-budget. One project was 17 months behind schedule and 110 percent more costly than planned. The department is re-evaluating the projects to see if they should be cancelled or re-started.

Even earlier this year, the VA scrapped a US$167 million project to build a new patient scheduling system. The project, known as the Replacement Scheduling Application (RSA), has been in the works since 2000. But by 2007 it had run into serious trouble. That year, the VA brought in a sister agency – the Space and Naval Warfare Systems Command – to help out. That effort, too, ran into logjams and the project was finally cancelled in March of this year. The project spent $120 million and has little to show for it.

A review of the RSA project, published in August, was particularly damning. It found there was a lack of program and requirements planning throughout the nine years of the project. Moreover, it concluded that the VA didn’t have the in-house expertise to execute large-scale IT projects. Finally, it found that management of the project changed too often – four times between 2000 and 2009.

The reputation of the VA IT shop was further damaged during the year by revelations of misspending on bonuses and awards, as well as nepotism

The VA’s Office of Inspector General found $24 million in questionable awards and bonuses were handed out to staff during 2007 and 2008. According to the OIG’s report, “The frequent and large dollar amount awards given to employees were unusual and often absurd.”

Four high-level employees received about $60,000, $73,000, $58,000, and $59,000, respectively, according to the report, without sufficient justification. Another employee received a $4,500 performance award within the first 90 days of her employment from a manager who said that she did not even remember her.

On a related note, one high-ranking VA official is currently being investigated for using her influence to have a friend hired, and to have her office transferred to Florida when most of her work needed to be done in Washington. The VA was picking up the tab for her commuting.

Nevertheless, Washington is pouring even more funds into the VA’s information technology efforts. In July, the Senate Appropriation Committee proposed that US$3.3 billion go into the 2010 budget for IT at the VA. That’s nearly US$767 million more than in the current year.

The money is to go into modernizing the VA’s electronic health record system, process claims electronically, and integrate medical records from the Defense Department with those of the VA – something that is proving harder to do than first thought.

But change is under way at the VA. New management has instituted an oversight system to deal with runaway IT projects. The Program Management Accountability System, according to the VA, will “ensure that progress is demonstrated and non-performing projects are identified and quickly stopped.”

Across the pond, the ‘Connecting for Health’ program in England is also a source of frustration. To borrow a phrase from the Queen, it appears that Britain’s national programme for healthcare IT is having an ‘annus horribilis’. The £12.7 billion programme – billed as the world’s largest civilian IT project – is running four to five years late, possibly more. It suffered several highly publicized and embarrassing site failures in 2008 and 2009. And to top it off, the opposition Conservative party boffins are now saying they’ll scrap much of the program if they’re brought to power in the next general election – an increasingly likely event, given the unpopularity of the current Labour government of Prime Minister Gordon Brown.

“Quite clearly the government went about it entirely the wrong way, this centralized top down system,” said Andrew Lansley, the shadow health secretary, in a report published in the Daily Telegraph newspaper in August.

In a policy statement published that same month, the British Tories critiqued the existing healthcare IT programme, now known as ‘Connecting for Health’, and asserted that if it wins the next general election, expected in June 2010, a Conservative government will:

• Seek to dismantle the IT central infrastructure, delivering its benefits through local systems instead.

• Allow hospitals to use and develop the IT they have already purchased and developed, within a rigorous framework of interoperability.

• Encourage the use of open source across the public sector.

What’s more, the Tories are saying that much of what the Labour government has tried to accomplish with its expensive and bureaucratic IT program could be implemented far more easily – and cheaply – by using personal health record solutions like Google Health and Microsoft HealthVault.

To be sure, the Conservatives may be jumping the gun on personal health records, as Google Health and Microsoft HealthVault are still works in progress, and generally unavailable outside the United States.

Nevertheless, numerous reviews and observers have made the point that despite years of work and substantial spending, the British healthcare IT programme has fallen far short of its original goals and has missed its timelines by a long shot.

At the core of the whole system will be the electronic health record, housed in centralized databases that are referred to in Britain as the spine. In theory, they’re designed to give caregivers throughout England access to the charts of all patients. Two providers have been awarded responsibility for installing EHRs across the realm – iSoft, with its Lorenzo system, and Cerner, which is delivering its Millennium system to hospitals.

However, here is where a great deal of the difficulty lies. Very few Lorenzo and Millennium systems have been implemented in hospitals.

According to analysts, Cerner has a respected EHR in its Millennium system, but the Kansas City-based company has had to revise its administrative systems to suit the British way of doing things – a time-consuming process. And while iSoft had excellent administrative software, it lacked a clinical record. It has taken the company years to produce one, and they’re just starting to be introduced to English hospitals.

Not only have there been software delays, but according to observers, the National Health Service has failed to adequately invest in training and change management. It has been pointed out that organizations like Kaiser Permanente in the United States, which has had some success with its EHR, have invested as much in training as in hardware and software.

Moreover, many in England feel that the NHS has imposed Connecting for Health and its systems on hospitals. Many physicians and allied professionals haven’t bought into the program, another ingredient needed for success.

Indeed, due to mounting political pressure on top management, the National Health Service has informed its two major system integrators, British Telecom and Computer Sciences Corporation, that they must achieve a working installation at a major acute care hospital by November 2009 and March 2010 respectively. If they don’t, the NHS says it will “look at alternative approaches.”

Christine Connelly, the NHS director general for informatics, was reported in the Guardian newspaper as saying: “If we don’t see significant progress by the end of November 2009, we will move to a new plan for delivering informatics to healthcare. “

Meanwhile, back in Canada, Quebec’s province-wide EHR is experiencing labour pains. The $563 million project appears to be running late. Initially, the project was scheduled to be deployed over four years, from 2006 to 2010. The completion date has been postponed to June 2011, but some doubts have been raised as to whether that deadline will be met.

This spring, the auditor general of Quebec released a report on the Dossier de Sante du Quebec, the name by which the project is known, and stated that, “All of the projects that make up the DSQ have fallen behind by several months, even years, and a good portion of these projects will not be completed before December 2010.”

What’s more, the auditor general questioned whether doctors, nurses and pharmacists will buy into the new system. He noted that several regions are moving forward with their own electronic health record systems as they’re seen as offering more short-term benefits than the DSQ.

The Auditor commented that the $563 million budget of the project needs to be reassessed in the light of scope and timetable changes. As well, a previous investment of $327 million should be added to the total.

Finally, the Auditor points out there will be recurring costs of some $85 million annually which will have to be budgeted for. Overall, the Auditor General is saying, it’s going to be a more expensive project than originally suggested.

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Renamed William Osler Health System looking for a ‘new beginning’

By Martin Slofstra

BRAMPTON, ONT. – The man appointed by the Ontario government two years ago to sort out problems with the opening of the new Brampton Civic Hospital says his job is done, while re-affirming a commitment to the huge role technology will play.

At an event last month called New Beginnings – intended to herald a new start for the hospital and attended by 700 local people – Ken White provided an update and introduced a new long-term vision. The changes also include a new name, William Osler Health Centre is now called William Osler Health System.

The flagship Brampton Civic Hospital opened its doors in October 2007 amid controversies concerning shortages of staff and beds, long wait times, poor care and lack of proper training. (William Osler also includes Etobicoke General Hospital in west Toronto.) Soon after his arrival, White embarked on a program of reform featuring a shake-up of hospital management, measures aimed at increasing efficiency and improving patient care.

A final report will be submitted to government later this year.

“As we found out when we opened the new building here, the technology component is much bigger than people expect,” says White, the government-appointed supervisor in an interview immediately after the ceremony.

White outlined several technology initiatives:

“The biggest challenge is keeping up with the manpower needs. As the technology expands, we need more training programs.”

“But there is more to be done,” he added, “especially in emergency care, not just here, but province-wide, the whole network and interface with service requirements.”

“The province is working towards the electronic health record, and we will establish that sort of linkage across the province.”

White said he put out a vision for advanced, ambulatory (walk-in) care and it was a tough push because the government was not totally sold on the concept. “We now have a leading-edge ambulatory care centre that they come from all over Canada and the world to see. This one I think we can take further. I believe it is the future of healthcare.”

And information technology will be a big part of the hospital’s strategy going forward, he confirmed.

“The organization has just started a transformation project, and it’s going to look at every major business process that we have in the place. IS really has to step up to plate for it to be able to do that,” says Stephen Hall, chief information officer at William Osler Health System.

“The vision behind that is the quality of the patient experience is going to be optimal or as best as possible,” says Hall, who took over the CIO position at William Osler in March of this year.

Hall says the hospital is now in a good position to leverage its IT systems.

“It’s pretty much a state-of-the-art hospital from a data and voice perspective,” he says.

“We have voice over –IP with a smattering of TDMA where high availability is required. We have wireless throughout the whole facility, not only for staff and clinicians, but for visitors.”

“We have a state-of-the-art data centre which is something not a lot of hospitals are building these days. But I’m glad that the people who conceived of it put it in the plan, because that is paying huge dividends to us.”

“And we have a huge storage-area network with 150 TB of ‘live’ data, up from 100 TB a year ago.” (The total includes diagnostic imaging.).

Hall acknowledged that there are some challenges. “As part of the LHIN we are in, Osler is by far the largest provider of health services. This is the mothership. When you go beyond Osler’s walls, the complexity and quality of IT support that is available drops off quite markedly, so many community agencies and other health service providers don’t have much in the way of capability. Part of the strategic plan is to leverage the assets for them as well, and make these services available to them on a cost-recovery basis.”

Hall affirmed that the idea of changing the name from centre to system makes sense, since these days, a hospital is much more than a building, it is all about networks and systems, and what may not be as well understood is how much depends on the central IT infrastructure.

“This is part of the build of Brampton Civic Hospital,” said Hall, “and all around that is tons of IT, from sophisticated monitoring devices beside the patient, to what the anesthetist is doing, to nurse’s applications including browsing and e-mailing, to video and images, to staff scheduling, patient scheduling, physician access to electronic records both on and off-site.”

In addition, healthcare is designed for high availability. “The systems have to work without fail,” he said. “We have dual paths between facilities, a diesel generator, back-up IT infrastructure and a 7X24 ability to recall staff. We have had 100 percent availability since we started.”

Hall says his biggest challenge is funding. “There is really significant demand for data and systems and computer services from the clinical folks and IT budgets are finite in size. Matching supply and demand is very difficult.”

“The truth in healthcare is that there is always a good reason for providing data or a service, but you just can’t get to it all.”

“The physicians and nurses we have here are really willing adopters of technology. The biggest challenge is keeping up with it. It’s a money issue.”

Hall insists also that all changes are going to be led by clinical people, and “it has to be led by clinical people. The single biggest mistake that people in IT in health are make is that they don’t ask what the clinicians want often enough.”

Hall detailed a number of initiatives now underway:

Electronic Health Records. Currently, BCH produces 1.6 million pages of patient results per year, which includes copies of results that are sent to physicians by mail. “We are trying to get automated fast. Most physicians don’t have electronic health records, but the ones that do, we will send electronically.”

Software integration. BCH has 150 specialized applications, but relatively speaking, it has only a small team that does application development. The lion’s share of development work, he says, involves integration, that is, moving data from one system to another.

Document management. BCH took an inventory and found two million documents on all of its computer hard drives. “Although it’s a huge, unmanageable number, when physicians saw this, they wanted us to do something to manage this.” To deal with the volume, the hospital is planning to implement a SharePoint Document Management System.

Business reporting. In accordance with government regulations, BCH plans to develop more reporting systems around patient satisfaction, wait times and surgical patient care. “We are re-inventing the technology under that and the intent is to provide really relevant business content right to the desktop, from doctor to clerk. No more big fat reports coming in the mail, it will be focused and relevant to what you do.” The hospital has also developed a Web-based patient satisfaction form and the results are fed into a central system.

IT-supported surgery. Surgical operations that required a huge opening are now being replaced by minimally invasive procedures using small slits in different locations, with instruments and cameras inserted on catheters and endoscopes. The benefit is that the patient recovery time is much quicker, says Hall.

Although not with the hospital at the time, Hall says the healthcare facilities’ previous problems need to be put in perspective.

A lot had to do with unanticipated volumes. Brampton Civic Hospital is believed to have Canada’s busiest emergency department, with 149,000 visits last year.

Commenting on the move in Oct. 2007, he says. “It was a nightmare. It was characterized by trying to make too many changes at one time. Even with all the training, there was too much change in one shot. They moved a hospital in 24 hours. Can you imagine?”

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Pandemic surveillance system connects five hospitals in Hamilton

By Rosie Lombardi

HAMILTON, ONT. – A new pandemic surveillance system connecting five major hospitals in Hamilton to the city’s public health computers is up and running – just in time for the possible resurgence of the H1N1 swine flu.

The timing is fortuitous, says Nancy Greaves, surveillance unit manager at Hamilton’s public health department. The city has actually been planning the implementation for the past two years.

“This system will save us a lot of time, as we can detect patterns and syndromes popping up at hospitals sooner and we can formulate a response to prevent their spread,” she says.

The facilities using the new system are:

• McMaster University Medical Centre

• Henderson General Hospital

• Hamilton General Hospital

• St. Joseph’s Healthcare Hamilton –
Charlton Campus

• St. Joseph’s Healthcare Hamilton –
King Campus (Urgent Care)

Hamilton’s new Acute Care Enhanced Surveillance (ACES) system is the latest refinement of the original open-source system called RODS (Real-time Outbreak Detection System) developed by the University of Pittsburgh after the SARS epidemic in 2003. In 2006, it was Canadianized and implemented in nine hospitals in the Kingston region by local system integrator Cissec Corp., with the support of the Ontario Ministry of Health.

At a high level, the system’s workings are fairly straightforward. Information is collected from hospital ER triage computers and transmitted via the secure eHealth Ontario network to the public health department’s Oracle database. The ACES application then mines the data and categorizes patients’ chief complaints into eight main syndromes such as gastro-intestinal, respiratory, fever ILI (influenza-like illness) and so on, explains Justin Rimmer, director of customer relations at Cissec.

“Basically, it takes the narrative the ER nurse types in, puts it through a classification engine, compares the counts to seasonal averages, then produces reports and alerts,” says Rimmer. “The system uses algorithms to sniff out all variations of medical terms, so nurses can just type in stuff as they normally do.”

At the public health department end, epidemiologists review the hospital data on a daily basis to discern anomalies in illness patterns. This can speed up responses to potential outbreaks considerably, and creates a big picture view that hasn’t existed before.

In the past, public health officials typically had to wait weeks for laboratory tests to confirm an outbreak – which might not be conducted for minor illnesses, explains Greaves.

“For example, with E.coli, there may be people with diarrhea showing up in ER, but physicians may not necessarily order the stool tests that would confirm the cause. But if we see a spike, we can communicate that to our hospitals and ask them to get stool samples for all cases of diarrhea.”

She says sending information to a central site for processing also improves communications across the hospital network, as hospital A may not be aware of an outbreak showing up at hospital B. “The system helps us strengthen all that messaging.”

While ACES can be set up to receive electronic information from family physicians, pharmacists and other sentinel sources, many of these feeds aren’t automated yet, says Alex Carlassara, senior business support analyst at Hamilton public health. “It’s our first step in pandemic surveillance and one of many layers of defence. But other sources of information could be incorporated into the system in the future.”

Consensus is harder than technology: From a technology standpoint, implementing ACES isn’t difficult, says Carlassara. “At our end, it meant installing an application on a server in our data centre. At the hospital end, it involved writing scripts that’ll go into their databases and pull out the specific fields we need out of their records and sending HL7 feeds in the proper format.”

Hospitals are already collecting data in HL7 format, and are only involved in transmitting it to ACES, says Rimmer. “The technical components aren’t hard. But we did need to create a HL7 parser, as HL7 protocols aren’t implemented in the same way at all hospitals.”

But there are many organizational and management issues to contend with in this type of project, says Carlassara. “The biggest challenge was ensuring all parties really understand what they have to do. This is why we hired Cissec to work with our IT areas and the hospitals, to talk their talk and get the right people connected.”

Rimmer agrees most of the real work in the project was in the back-and-forth of coordination with multiple organizations: getting all parties to agree on the rules of the system, and then getting the right experts involved in the actual implementation.

There are many data-sharing and governance agreements to hammer out, says Greaves. “How the data is used and stored, what communications routes will be used and so on – those are all issues that need to be worked through. And there are privacy issues: Although we don’t get personal information about individuals, hospitals have to meet privacy legislation requirements in Ontario. Also, we had to develop partnership arrangements between two hospital corporations and public health so all parties could sign a data sharing agreement.”

The agreements developed in the previous Kingston pilot implementation were useful, but there are some differences in Hamilton’s scenario that had to be worked in, she says. “We did actually use significant chunks from Kingston as templates, but the 10 percent that’s different in Hamilton required work. There have been changes in privacy legislation since Kingston did its implementation, and it was also set up as a research project whereas ours is an ongoing one. All of that had to be integrated.”

The Niagara region and other jurisdictions are considering a similar system, says Rimmer. While future implementations will likely be easier for hospitals building on Kingston’s and Hamilton’s experience, there will still be differences to work through. “What’s different in each region are the hospital structures and their relationship with public health. Establishing and developing that relationship is a big part of the work,” says Carlassara.

Panoramic future: There are many questions about the rollout of Panorama, a public health surveillance system being developed by the BC Ministry of Health (MoH) for Canada Health Infoway, and how systems such as ACES will fit in later.

As Panorama is still in the works, Hamilton’s ACES and other systems can serve as interim, stop-gap measures that can likely be used as a foundation later with Panorama.

According to the BC MoH, hospitals should go ahead with interim systems and measures.

In an e-mail exchange, Ministry staff said: “Hospitals should not wait for Panorama, since it very unlikely that Panorama would be implemented in a hospital acute care setting. Panorama has been developed to address the needs of public health in Canada, not the needs of hospitals.”

No definitive timeline for Panorama’s rollout was provided in the exchange. “Panorama will be offered to each Canadian jurisdiction, who will implement Panorama based on their own timelines and roll-out schedules.”

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Experts predict closer collaboration among radiologists and pathologists

By Jerry Zeidenberg

TORONTO – Radiologists and pathologists will probably merge their specialties in the future, creating a super-specialty called ‘diagnostic medicine’, says Dr. Bruce Friedman, professor emeritus of pathology at the University of Michigan in Ann Arbor, Mich.

Dr. Friedman spoke in October at the Executive Edge forum (www.exec-edge.com), an event organized regularly in Toronto by QSE Consulting, and the Dark Report, of Austin, Tex., consulting and intelligence companies that concentrate on issues of laboratory management.

Dr. Friedman asserted that medicine is moving from the treatment of disease to the promotion of wellness. Part of that process will be the very early diagnosis of disease – something he refers to as the discovery of ‘pre-disease’ – so that treatment and preventive measures can begin at the earliest stages.

The techniques used will involve a combination of lab-based molecular diagnostics and genetic testing with radiological modalities like PET scanning, to uncover abnormalities and growths in their earliest stages.

He observed that outfits like GE Healthcare and Siemens, traditional titans of the radiology world, have both acquired laboratory companies to prepare for this development.

“We’re entering the golden age of diagnostics,” said Dr. Friedman. “We’re starting to diagnose disease before it becomes symptomatic.”

“And who are the specialists diagnosing pre-disease?” he asked. “It’s radiologists and pathologists, so the prize is there for us to take.”

Dr. Friedman noted that patients are trying to seize control of their health, saying they’re becoming “proactive and pre-emptive”.

“Yuppies want to know what’s going to happen to them downstream, and what preventive actions they can take.”

Drilling down, he explained that when cells are diseased, they communicate by releasing proteins. “In proteomics, that’s what we’re detecting,” he commented, referring to a newly developing branch of laboratory medicine.

He said the rise of diagnostic medicine will require much more workflow integration, with the melding of IT systems in hospitals – namely, the laboratory information systems (LIS), radiology information systems (RIS) and picture archiving and communication systems (PACS).

All of these, he said, will be connected to the electronic medical record.

At the moment, there isn’t a good deal of integration of this sort, at least in the U.S. “EMRs in the United States are not capable of integrating complex data from lab and pathology systems,” he said.

In the future, however, the fusing of radiology, laboratory medicine and pathology into a super-specialty will drive this kind of integration forward.

Additionally, he pointed out that ‘nighthawk’ services, in which remote radiologists perform readings of studies for hospitals whose rads have left for the evening, are already expanding to daytime services, becoming ‘dayhawk’ service providers. They’re filling gaps at hospitals that have shortages of skilled radiologists around the clock.

Dr. Friedman said that in the future, such remote services could be provided for laboratory and pathology services, as well. “We could have a super-national diagnostic network,” he said, providing both tele-radiology and tele-pathology services.

On a more ominous note, Robert Michel, editor of the Dark Report, observed that Canada’s continuous under-funding of laboratories over the years is now wreaking havoc with the delivery of medicine across the country.

Michel, a respected analyst, asserted that lab medicine is the lynch-pin of the medical system, with up to 80 percent of the medical records of patients made up of lab test results. Physicians, he noted, rely on lab information to make their diagnoses and to prescribe various treatments and therapies.

However, he said, “For the last two decades, Canada has underfunded lab medicine, and we’re now seeing the disruption that happens.”

He outlined some of the lab catastrophes that have occurred in recent years in Canadian provinces:

• 2005: breast cancer testing errors in Newfoundland and Labrador;

• 2008: pathology testing problems in Ontario, Manitoba and New Brunswick;

• 2009: breast cancer testing problems in Quebec, with serious quality defects.

Michel explained that labs are complex operations, with hundreds of different assays being performed. “When the budget knife cuts too deep, there’s damage to the lab’s ability to produce accurate results and patients pay the price.”

Dr. Jagdish Butany, director of autopsy services with the University Health Network in Toronto, and past president of the Canadian Association of Pathologists, further analyzed the problems that Canadian labs have experienced in recent years. He also outlined the challenges that will face lab professionals in the future.

Until very recently, commented Dr. Butany, medicine has been dominated by a ‘blame and shame’ culture, in which mistakes were hidden. He contrasted that with the airline industry, which analyzes each and every plane crash to help prevent similar crashes in the future.

What’s more, quality control systems weren’t in place in many Canadian labs, especially in eastern Canada. “Quality means doing it right, every time, even when no one is looking,” commented Dr. Butany. As well, Canadian labs have been plagued by morale problems. Often, they’re located in basements with no windows. “They’re lumped in with the kitchen and the laundry,” he said, adding that “salaries have been the pits, positions have been cut, there’s been a lot of blood-letting with lab budgets cut. There is antique equipment, and of late, university medical schools have de-emphasized pathology.”

All of these problems have combined, said Dr. Butany, to create a ‘perfect storm’. The result has been medical error and mistakes in several Canadian labs – mistakes that have taken a toll on the health of patients.

However, Dr. Butany said moves are afoot to increase salaries and improve working conditions, which will raise morale. In addition, there is a plan to accredit all labs in Canada, to improve quality. As well, there are recommendations to design quality frameworks for all tests and to improve the instruments used in labs, to produce uniform results.

Dr. Butany did emphasize that there will be serious challenges in the future – which will continue to stretch the resources of labs.

He noted the field is quickly evolving with the rise of personalized medicine – the genetic and molecular testing to which Dr. Friedman also referred. This will require new skills and equipment in the near future.

However, Dr. Butany observed that it takes a great deal of time to become a skilled pathologist, and Canada’s cohort is up in years. Most pathologists in Canada, he said, are over 50 years of age – while some are working past the age of 75 and into their 80s. “A few are 40 to 50, and none are under the age of 30.”

The pressure will be on them to stay current, as pathologists are going to be hit by the coming of many new technologies – genomics, proteomics, informatics and robotics.

In the face of these developments, and to remain at the centre of medicine, Dr. Butany said that pathologists will have to re-invent themselves by learning new skills, including working more closely with the diagnostic imaging departments.

Pathologists must also work in new ways with other physicians and patients. “We must go back to being consultants,” he said. “We must meet with physicians, and we must meet with patients.”

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