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Inside the November/December 2013 print edition of Canadian Healthcare Technology:


Feature Report: Canada’s innovative hospitals


Alberta’s personal portal
After three years of development, Alberta is getting ready to launch its personal health portal. The province-wide system will give consumers access to their health records, including medication histories and lab tests.

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Titan Medical readies cutting-edge surgical robot
Titan Medical, a Canadian company, is on the verge of leapfrogging the competition in the $4 billion marketplace for surgical robotics.

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A new approach to improving the lives of complex care patients
At Bridgepoint, in Toronto, the focus is on transforming the lives of people living with the most complex health conditions.

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Innovative Health Links
Instead of issuing plans for improving the healthcare system from top-tier government mandarins, Ontario is experimenting with a program that lets grass roots groups come up with their own solutions.

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Community care telehealth
Ontario’s Community Care Access Centres (CCACs), with the help of the Ontario Telemedicine Network, have been running pilot tests of tele-home care systems that monitor patients in their residences. The solution is now ready for a rollout.

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Bridgepoint’s human touch
Bridgepoint Health, in Toronto, has constructed a brand new hospital to provide services to complex care patients. The facility has been completely re-thought to stimulate recoveries and accentuates both high-tech and a human touch.

 

PLUS news stories, analysis, and features and more.

 

Alberta Netcare system is preparing rollout of personal health portal

By Jerry Zeidenberg

Alberta is investing in technology to give patients improved access to their health information and to offer medical professionals better tools when providing primary healthcare services.

Consumer-directed care is high on the agenda of Alberta policy makers, and a Personal Health Record (PHR) has been developed as a portal in the provincial Alberta Netcare system.

“Increasingly, patients must take more responsibility for their health,” said Susan Anderson, assistant deputy minister and CIO with the health information technology and systems division at Alberta Health. “They’ve got five minutes in their doctors’ offices, and then they have trouble remembering what went on.” A personal health record can go a long way in helping.

For example, medication lists in the personal health record can provide additional information, such as contraindications. And lab information can provide context and meaning to the data; it can also flag abnormal test results.

The personal health portal has been in development for the past three years, and the province is using Microsoft’s HealthVault as the basis of the system. (In Canada, Telus offers HealthVault under its own branding as Telus health space.) Canada Health Infoway has been an active partner in the creation of Alberta’s personal health portal.

“We’re currently working on some issues with the privacy commissioner, but we believe that within the next year we should have a launch,” said Anderson.

The personal health record will be able to pull medication information from the provincial drug information repository, along with lab reports, giving patients extensive access to their medication histories and test results.

But the system will also have strong auditing abilities. “It will enable you to see who has accessed your content,” said Anderson. “That’s especially important if you share access to the record with family, friends and caregivers.”

Along with the rollout of the personal health portal, Alberta Health Services plans to launch an educational campaign. “We want to inform the public about what the portal is, what their rights are and what their obligation is,” said Anderson. “After all, we’ve never asked people to maintain their own records before.”

She emphasizes that education will be important, as people treat information and privacy issues in different ways. “People under the age of 30 have a different idea of privacy – many of them post everything on Facebook.”

These individuals may need instruction on the dangers of sharing too much information, while others may want to know more about the benefits of enabling family, friends and care-teams to access their records.

Anderson emphasizes that each individual will be in charge of his or her own record. He or she will be able to provide others with permission to view the record, and in that way will be able to build more informed support teams.

Still, there will be context and explanations offered that allow patients to take better care of themselves. “We want patients to have enough information to self-manage their conditions and to be part of the care team,” said Anderson. “We have to recognize that patients are part of the care team, too.”

Alberta Netcare is a secure and confidential record of data collected from health facilities across the province and used by healthcare professionals to provide accurate, complete and timely health services to Albertans. The system is a well-established EHR with more than 40,000 users including over 5,000 physicians serving almost 4 million Albertans. The EHR, with foundational software developed by eHealth company Orion Health, has been implemented to improve patient safety, increase the efficiency of the healthcare system, facilitate team-based care and improve patient outcomes.

“The Alberta Netcare EHR has been viewed as a tremendous success within Canada and internationally,” said Gary Folker, senior vice president, Orion Health Canada. “The EHR Portal provides up-to-date patient information at the point of care, supporting better care decisions and laying the groundwork for increased patient involvement.”

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Titan Medical readies cutting-edge surgical robot

By Jerry Zeidenberg

TORONTO – Titan Medical, a Canadian company, is on the verge of leapfrogging the competition in the $4 billion marketplace for surgical robotics. Titan’s managers say they’re just two years away from releasing a robotic system that requires only one incision in the patient, in contrast to the three or four incisions required by other surgical robots.

“We’re starting tissue and cadaver studies later this year,” said John Hargrove, CEO of Titan Medical. “The plan is to commercialize and start marketing the system in 2015, in Europe and the United States.” Those are the world’s biggest markets for surgical robots, but the company also plans to make the system available in Canada.

The innovative robot, knows as SPORT (Single Port/Orifice Robotic Technology), will benefit patients as it is less invasive than cutting several openings. A single incision will result in reduced pain and blood loss for patients, and it also lowers the risk of infection.

The system consists of a workstation for the surgeon and the actual robot, which is positioned beside the patient. Together, they take up less space than today’s surgical robots and will also be far less expensive.

The current leader in surgical robotics is Intuitive Surgical, of Sunnyvale, Calif., which has sold about 15 of its Da Vinci systems in Canada and some 1,500 in the United States. “Intuitive is the elephant in the room,” said Hargrove about the company Titan is taking aim at.

A system from Intuitive costs about $2 million, while a SPORT system from Titan will list for about half of that. That kind of price tag will make surgical robotics much more affordable for most hospitals.

Another advantage: Titan’s system can be moved around in hospitals, from one operating suite to another, while Intuitive’s larger Da Vinci footprint normally remains where it has been set up – even if it isn’t being used during an operation.

Creating a new surgical robotic system doesn’t come cheap – Titan Medical has invested about $35 million in the project. But in doing so, it has created innovations that may be game-changers in this field.

The single-port system is a key innovation. Once Titan’s robotic arm is inserted through a 25 mm incision, three arms emerge from the instrument – two for clasping and cutting, and one with a 3D camera system. The ultra-slim arms resemble metallic snakes, and amount to a technological breakthrough in their own right, as they’re strong, flexible, and accurate.

“We’re creating a system with unprecedented dexterity,” said Dr. Reiza Rayman, president of Titan Medical and a former assistant professor of surgery at the University of Western Ontario. Dr. Rayman is a world leader in robotics – in 1999, he conducted the first beating heart robotic bypass surgery.

Dr. Rayman noted that the snakelike arms are only 5 mm wide, but are capable of lifting a pound. What’s more, they offer the surgeon ‘seven degrees of freedom’, which is important, because you want the instruments to offer as much flexibility as the human arm, elbow and hand. “It enables precise dissection,” commented Dr. Rayman.

(The seven degrees of freedom refer to up and down movements, right-left, triangulation, as well as pitch, yaw, roll, and opening and closing of the instruments.)

The robotic arm technologies were acquired by licence from Columbia University in New York. Just recently, Dr. Dennis Fowler, director of the Center for Innovation and Outcomes Research in the Department of Surgery, Columbia University, joined Titan Medical, becoming its director of clinical affairs. Dr. Fowler is the co-inventor of the single-port Insertable Robotic Effector Platform – the snake-like arms used by Titan’s robot.

Another remarkable technology is the vision system that’s under development by Titan. It positions two tiny cameras and lenses at the top of the third arm used in surgery, thereby creating three-dimensional images and giving surgeons highly accurate views of the operating site. “It’s a chip on the tip,” said Dr. Rayman.

Right now, Titan has produced a working prototype of the SPORT robot. Once it’s ready for marketing, the company plans to target two main areas, general surgery (specifically gall bladder and appendix operations) and ears, nose and throat (ENT). Currently, surgical robots are used primarily in hysterectomies and prostatectomies.

Now that the base technologies have been devised, further refinements are being produced by Titan’s commercialization partner, Ximedica of Providence, R.I. “There’s no shortage of hospitals willing to assist us,” said Dr. Rayman.

In addition to helping with technological and clinical development of the SPORT system, hospitals and surgeons worldwide would like to see new competitors and alternatives arrive in the field of medical robotics. “They really do want more choice, and they’d like to see more competition,” said Hargrove.

That’s good news for Titan Medical, which will have a solution ready for them in two years, if all goes well. “We’d like every hospital to say they’re a SPORTs fan,” quipped Hargrove.

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A new approach to improving the lives of complex care patients

By Janak Jass

At Bridgepoint, in Toronto, our focus is on transforming the lives of people living with the most complex health conditions. This year, we realized a tremendous milestone in achieving that goal with the completion of our brand new state-of-the-art hospital and the introduction of our active healthcare model.

We didn’t just build a new hospital of 464 beds and 680,000 square feet; we engineered a new approach to treating a growing patient population. The approach is called active healthcare because patients themselves – and their families and support networks –play the central role in defining and achieving their own care goals. Patients don’t live their lives in hospitals, and most of the events that lead to complex conditions don’t happen in hospitals. So active healthcare takes a sustained and lifelong view that treats the whole person.

Active healthcare is based on an integrated and customized solution for each patient. It draws on an inter-disciplinary team that extends beyond our own walls, and addresses all the factors that contribute to the patient’s health. It is this collaborative approach that allows patients to receive active rehabilitation and return home.

The opening of our new hospital represents a critical step in delivering active healthcare. And strange as it may sound, it is a milestone in helping us to become more than a hospital. In designing and developing the new Bridgepoint, we challenged the most basic assumptions about what a hospital should be and what role it should play in healthcare.

We have deliberately blurred the lines of public and hospital spaces in a calculated move to reduce the barriers to the outside world and maintain a patient’s connection to the community. We achieved this by using cutting-edge innovations in the hospital’s design – features such as our floor-to-ceiling windows in every patient room, our calming labyrinth, our internet café, roof-top garden, patient lounges and our grand west terrace all play a significant role in keeping the connection with our environment, parks and green space.

Nothing in our new building is ornamental or accidental. From the floor-to-ceiling windows, which preserve a patient’s link to the community and inspire health and healing, to the rehabilitation spaces on every floor that accelerate each person’s functional improvement, it is designed to enable restorative care for real life in real time, and to support our patients’ return to the community.

We have embraced many forms of new technology to accelerate patient recovery times. Our controlled multi-sensory environment room, more commonly known as a Snoezelen room, is a therapy space specifically designed to deliver stimuli to various senses using special lighting effects, sound, scent and colour. This therapy is primarily used for patients with various types of brain injuries or trauma.

The therapy pool is another area where patient recovery times are excelling – it is our oasis of healing. The innovative glass wall feature allows for better observation of a patient’s response to treatment. The therapist monitors a patient’s range and motion and can immediately make the necessary adjustments.

Patients are at the core of the hospital design and our active healthcare model; they enjoy computers in every patient lounge, the internet café and the patient library.

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Ontario’s Health Links: Grass roots movement on track to transform healthcare

By Dianne Daniel

One year after the Ontario Ministry of Health and Long-Term Care (MoHLTC) announced Health Links – a program aimed specifically at delivering co-ordinated care to patients with complex needs – 26 projects are fully approved and starting to work, with another dozen expected to be operational before the end of 2013.

The program is based on a new approach to collaboration that brings together local healthcare providers, community services, hospitals, specialists, additional support groups, as well as family members to address high users – patients who account for only 5 percent of Ontario’s population but consume two-thirds of available health dollars.

“There’s something about this that has captured the imagination of the provider community,” says Helen Angus, associate deputy minister, MoHLTC Transformation Secretariat. “We find they are stepping up pretty quickly to be a part of Health Links.”

That something isn’t necessarily a fancy new technology platform. Nor is it a structured set of pre-conceived regulations and governance to follow. What makes Health Links innovative is that this time, the province is counting on complexity science to be the agent of change, replacing the rule book with “elbow room to innovate,” says Angus.

“We didn’t have to sell this to the sector,” she said. “It was their idea in the first place and we managed to find a way to make it happen.”

Simply put, complexity science recognizes that complex systems like healthcare are unpredictable by nature and therefore need freedom to problem-solve in a more dynamic and creative way.

Applied to the Ontario Health Links program, it means that no two Health Links projects will necessarily look alike or operate in the same way, yet they all share a collective goal: to improve patient well-being and reduce costs by ensuring the medical, functional and social needs of complex patients are met.

Joining or establishing a Health Link project is voluntary. To get off the ground, a Health Link must first complete a readiness assessment that demonstrates the willingness of its various participants to work together. From there, each individual Health Link is free to move forward in a way that makes sense for its community.

Health links are currently under way in the following Ontario LHINs: Toronto Central, Central, Central East, Central West, Erie St. Clair, Hamilton-Niagara-Haldimand-Brant, Mississauga Halton, North East, North Simcoe Muskoka, South East, South West and Waterloo Wellington.

The South East Local Health Integration Network (LHIN) has seven Health Links under development, each with its own vision statement. Dr. Jonathan Kerr, a family physician in Belleville, Ont., and South East Primary Care LHIN lead, is helping to establish the various links. He likens the process to creating art.

“The ministry has given the Health Links the canvas, the brushes, the paint, and then said paint what makes sense. They haven’t said paint clouds, trees and some grassy knolls. The Health Links are able to paint what they think is best, but they have to produce a painting,” he explains.

Each of the South East Health Links has received $600,000 in initial funding to get up and running. As they move forward with identifying high-use patients and designing co-ordinated care plans to better treat them, they are also working together on a common IT strategy.

Phase one is what Dr. Kerr refers to as the ‘low-tech’ IT solution. Each link will use existing electronic medical records to identify high-use patients at the primary caregiver level, based on simple criteria such as number of emergency room visits or hospital admissions in the previous year. Phase Two will leverage an existing Ontario Public Health surveillance system to flag high use patients based on similar criteria. Right now the system is primarily used to notify family physicians of outbreaks and other alerts.

In Phase Three, a more proactive approach will apply specific demographics to identify potential high-use patients so that preventative measures can be put in place to keep them healthy. And in Phase Four, the Health Links plan to work with Queen’s University students to develop predictive computer models for more rigorous identification of at-risk patients.

“One of the failings of healthcare planning is that they build a better mouse trap, implement it and then evaluate it a year later,” says Dr. Kerr. “Let’s say we identify 10 patients. We’re going to sit down with them, develop a co-ordinated care plan for those 10 patients, and then pause and say what worked, what didn’t, what do we need to improve in the process? We’re going to have iterative cycles of learning, testing, learning and I think part of that will be learning about what IT solutions are needed,” he explains.

A similar approach is under way in the Central West LHIN where five Health Links are united by a common steering committee and have agreed to share an IT platform despite their individual differences. It’s too soon to tell what that platform might entail, but Matt Anderson, president and CEO of William Osler Health System, which is serving as the administrative lead for two of the five links, says it makes sense to unite on the technology front.

“Across Ontario, in many jurisdictions, we’ve gotten ourselves into trouble by leaping a little bit too quickly into the IT solution,” says Anderson, noting that the LHIN’s Health Links are starting off by focusing on changes to care delivery first.

“That is by far the smarter way to go. Then, as you learn what exactly you need from an information exchange perspective to support those people, then you can start to introduce technology.”

The Health Links have yet to decide on a technology platform, but Anderson is confident it will be shared. For now, they are relying on Excel spreadsheets and other reporting tools to identify complex patients. Though low-tech, it’s already proving beneficial.

Early on in the process, for example, some of the Central West Health Links discovered the algorithm being used to identify their high user populations needed refining because many of the patients selected were palliative and those with other illnesses and circumstances were being overlooked. They’re also taking baby steps in order to better understand their high user population and why patients are struggling with their care plans in the first place.

“This is not some grandiose, multi-year, big dot change kind of process that becomes esoteric,” notes Anderson. “This is about their patients getting additional services that likely already exist in the community and because it’s that grass roots, you can touch it, feel it. We’re talking about a person as compared to statistics.”

Under a Health Link model, patients no longer need to answer the same question from different providers. Instead, they will have an individualized, comprehensive care plan to follow and designated care providers to call.

To demonstrate the expected benefit of the Health Links program when treating high-need patients, MoHLTC uses the example of a senior living independently at home and receiving weekly visits from her local Community Care Access Centre (CCAC). One day she falls and gashes her arm. With no Health Link in place, she calls 9-1-1, is taken by ambulance to hospital for treatment and returns home. Her family doctor isn’t notified and she doesn’t receive follow up care. Her personal support worker is surprised to discover the injury on the next visit.

With a co-ordinated care plan in place, she notifies Emergency Medical Services and her wound is treated at home. EMS contacts her primary caregiver who makes a geriatric assessment referral on the spot and her children later accompany her to the appointment to learn how they can improve her functional ability. The patient also enrolls in a falls prevention program.

The possible breadth of reach is another reason many are calling Health Links innovative. In a statement, Dr. Scott Wooder, president of the Ontario Medical Association, calls the program “a real opportunity to improve the quality of care and efficiency of Ontario’s healthcare system” and goes on to state that the OMA believes “the initiative will encourage providers across and between sectors to consider enhancing connectivity through the EMR (electronic medical record).”

As Health Links roll out across the province, the OMA is taking a facilitative role, equipping physicians and providers with the information they need to be key contributors to establishing local Health Links.

Maggie Keresteci, senior director, OMA Health System Programs, is encouraged by the fact the ministry is giving primary care room to apply the concept of a Health Link in a manner they deem best for their respective local environments.

“One of the reasons that this is innovative is that it really is a bottom up, grass roots initiative,” she says. “It’s taking system transformation and recognizing that it happens from the bottom up, even if the concepts are developed at a ministry level.”

In addition to traditional partners such as hospitals, primary care, CCAC and specialists, several Health Links are also incorporating EMS, pharmacy, and other community supports, including mental health services, food services, and social services. The co-ordinated approach means the partners aren’t only looking at the medical model, but are considering social determinants of health as well. It also means a Health Link in a rural setting can look very different from a Health Link in an urban setting.

One approach being considered by several Health Links is to create a system navigator role. Once high-need patients are identified, a system navigator meets with them and their family members to determine the issues that matter most.

For example, a diabetes patient may be flagged as a high-need user of the system for reasons other than their diabetes. Perhaps they have a very effective care program in place to manage the diabetes, but are battling poverty and unemployment. A co-ordinated care plan will be based on addressing the most pressing need and improving quality of life; the system navigator will ensure the patient is connected to the relevant supports.

“It really embraces complexity science where it’s not a linear approach, you stop thinking about direct cause and effect in a binary way and you start thinking about the complex systems as whole,” says Keresteci. “That leads to the kind of thinking where you say it’s not because x caused y, it’s because of the whole situation. That in itself is extremely innovative.”

“What’s interesting about Health Links is even from the get-go we were interested in organizing care around the person,” adds MoHLTC’s Angus. “Complex patients come with a range of needs and some are well beyond what the health care sector provides. We’re seeing a lot of engagement within the community, which I think is terrific.”

As Health Links continue to take shape across the province, more funding is expected. Over time, as IT platforms are more firmly established and communication strategies take hold, ongoing costs will most likely be absorbed by the participants.

Meanwhile, the low-tech, ground-level movement is capitalizing on EMR implementations and other communication links already in place. The South East LHIN Health Links, for example, are using an existing hospital report manager to notify family physicians whenever a patient is discharged from hospital.

Simply reconciling medication at discharge and ensuring high need patients are seen by their family doctor within seven days is proven to reduce risk of hospital readmission.

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Delivered through CCACs, telehomecare services keep patients healthier

TORONTO – A variety of new technologies are now empowering chronic disease patients to better manage their conditions while at home. Telehomecare is a magnificent example of technological innovation that’s being used to provide better care.

Under the guidance of Ontario’s Community Care Access Centres (CCAC), telehomecare has been deployed as a self-management program that provides heart failure or chronic obstructive pulmonary disease (COPD) patients with weekly health coaching and daily monitoring of vital signs in their own homes. A patient is on the program for six months, on average, and the goal is to help them to achieve the best possible quality of life through learning to manage their conditions.

Registered nurses trained in telehomecare use simple home-based technology to monitor key health indicators and provide health education and coaching. This can include discussing the symptoms of a patient’s condition and how the patient can manage his or her own diet, exercise and other factors for optimal health.

Telehomecare is supported by the Ontario Telemedicine Network (OTN), which provides the technology and trains Registered Nurses in chronic disease self-management, as well as best practices in COPD and heart failure.

At present, two CCACs deliver telehomecare. North East CCAC delivers telehomecare on behalf of the North East Central Local Health Integration Network (LHIN), and Toronto Central CCAC delivers it on behalf of the Toronto Central LHIN. The program complements the CCAC’s objective of helping patients stay at home as long as possible, and takes advantage of a technology platform to ensure that nurses have access to up-to-date information about the patients in their care.

Telehomecare is also currently available in the Central West LHIN, where it is delivered by the William Osler Health System. The program is set to expand gradually through LHINs across Ontario, beginning with the North West LHIN, where it will be delivered by the North West CCAC, and Central LHIN, where it will be delivered by Southlake Regional Health Centre.

The most important partner in the healthcare system is the patient. By engaging patients as partners in their care plans, right in their own homes, telehomecare helps them better manage their conditions and take control of their own lives. This in turn reduces the costs of chronic disease management, and in so doing, provides a benefit to the overall healthcare system in Ontario.

Currently, 800 patients are enrolled in telehomecare. They are being cared for by 16 telehomecare nurses over North East, Toronto Central and Central West LHINs.

The pilot project for telehomecare in 2007 found that:

• Monitoring patients in their own homes with the support of a nurse coach resulted in a 73 percent reduction in emergency room visits.

• Hospital admissions were reduced by 65 percent.

• Walk-in clinic visits were reduced by 96 percent.

Local impact: Jenny, who has chronic heart failure and a pacemaker, takes part in the telehomecare program offered through Toronto Central CCAC. The program follows people with chronic heart failure and chronic obstructive pulmonary disease for six months, monitoring their vital signs daily and providing weekly health self-management coaching sessions each week.

Jenny at first had hesitation about using the equipment. “I didn’t even have a computer in my home,” Jenny says. But with some guidance, Jenny has become adept at checking her blood pressure, weight, heart rate and pulse.

Next, using a touch-screen tablet, she answers a few simple questions, such as, Are you more tired today than yesterday? Are you short of breath today? Do you have any pain? Jenny’s daily results go directly to her telehomecare nurse, Linda. An alert automatically draws Linda’s attention to anything outside of Jenny’s normal range.

One day, Linda noticed Jenny’s heart rate was lower than her normal range, but her blood pressure was normal. “I decided to follow the trend,” Linda recalls. By the second week, Linda says, “I could hear how short of breath Jenny was on the phone.” She advised Linda to go see her family doctor. Linda sent Jenny’s information directly to the doctor. After examining Jenny, the doctor adjusted her blood pressure medication.

But back at home, Jenny felt no better. “She was really tired, couldn’t go for her walks. She was worried.” Linda now called Jenny’s cardiologist at the pacemaker clinic and arranged for an appointment. At the clinic, the cardiologist reviewed her symptoms and increased her pacemaker rate.

The effect was almost immediate. “I felt like someone had lifted something off me,” Jenny reports.

Benefits of Telehomecare:

• Empowers patients to take control of their own health and life by teaching them how to better manage their conditions at home, preventing exacerbations of their illnesses. It also reduces the need for tertiary care services.

• Telehomecare brings healthcare to a patient’s home with special equipment that helps to monitor their condition and remotely connects them to Registered Nurses. If something goes wrong, the nurse can take quick action.

• Improves and enables equal access to care, especially for those living in remote areas.

• Improves patient self-management, medication compliance, clinical outcomes, patient and provider satisfaction, best practice care for chronic disease, data integration.

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