Inside the November 1998 print edition
Canadian Healthcare Technology:
New centre aims to accelerate interventional radiology
The Hospital for Sick Children has launched the Centre for Image Guided
Therapy, a facility where interventional radiologists and other experts will have quick
access to a variety of medical imaging modalities all in the same room, without
moving their patients.
IMN scores in Alberta
Integrated Medical Net-works (IMN) of Irving, Tex., has jumped into the
Canadian healthcare market with its hospital information software. The Capital Health
Authority of Edmonton, and the David Thompson Health Region of Red Deer recently purchased
Home care and IT
The Eighth National Canadian Home Care Association Conference will be
held in Toronto in December. Speakers will address issues regarding the use of technology
in home care in areas of client treatment and information management.
By the spring of 1999, the $12.9 million Chatham-Kent Health Alliance
network will link up two hospital campuses in Chatham, a 40-bed rural hospital, an
outreach centre, a mental health clinic and a long-term care facility.
Doctors in Canada and the United States are experimenting with
virtual endoscopy, a technique that may reduce the need for traditional,
fibre-optic-based endoscopy. Instead of pushing scopes into the body, images are collected
using a CT scanner, and reconstructed in 3D on a computer screen.
PLUS news stories, analysis, and features and more.
New centre aims to accelerate interventional radiology
By Jerry Zeidenberg
TORONTO The Hospital for Sick Children has launched the Centre
for Image Guided Therapy, a facility where interventional radiologists and other experts
will have quick access to a variety of medical imaging modalities all in the same
room, without moving their patients.
The $20 million centre is expected to result in better treatment for
children, who can be imaged and have certain types of minimally invasive surgeries
performed all at once. This combination of imaging and surgery is a rapidly developing
branch of medicine known as interventional radiology.
For example, a child with a suspected tumour could be wheeled into the
centre to receive a diagnostic CT scan followed by a biopsy conducted under image
guidance, either with ultrasound, CT fluoroscopy or through laparoscopic surgery. At the
same time, a central venous line would be inserted using imaging techniques.
In one fell swoop, the patient gets three different procedures. He or
she can then begin to receive treatment for the cancer earlier, instead of waiting for
each procedure to be scheduled and performed separately.
Its one-stop shopping, commented Dr. Peter Chait, the
pediatric interventional radiologist who heads the new centre. Dr. Chait explained that
imaging and operating on a patient at the same time can significantly improve outcomes.
In particular, trauma patients who arrive in serious condition
shouldnt be moved much. At the Centre for Image Guided Therapy, they can receive
several different diagnostic scans to determine the nature of their injuries.
Surgery can even be performed on the spot using minimally
invasive techniques or open procedures since the centre has been built to meet
operating room standards. This can all be done without moving the patient.
The Centre for Image Guided Therapy is the first facility of its kind
in Canada and perhaps the world to bring so many imaging modalities to one
room and to provide the opportunity for surgery at the same time. Dr. Chait notes that the
Hospital for Sick Children has already been a world leader in interventional radiology and
conducts some 3,000 to 4,000 procedures a year.
Moreover, he predicts the numbers will quickly increase.
To make it all happen, specialists from several disciplines within the
hospital will work together. They include radiologists, surgeons, endoscopists
The centre consists of four rooms for imaging and surgery. Three of
them will support multi-modality imaging.
A ceiling-mounted fluoroscopy machine, supplied by Toshiba of Canada
Ltd., will be installed in each of the three rooms. The huge machines, with their dramatic
C-arms, are traditionally floor-mounted. IGT has gone the ceiling-mounted route, however,
to keep the floor clear for other equipment and medical staff.
Whats more, the Toshiba CT fluoroscopy machines are said to contain leading-edge
features. They provide totally digital, real-time imaging powered by charge-coupled
device (CCD) technology. Theyre also motorized, and ergonomically designed,
commented Dr. Chait, making it easy for medical professionals to work around them.
State-of-the-art ultrasound machines will be incorporated into the
imaging tables, instead of sitting alongside the patient again freeing up floor
space. The ultrasound box will be built right into the table, said Dr. Chait.
There will be no wires hanging out. The special imaging tables are being
designed and delivered by Toshiba.
Whats more, sub-second helical CT scanners allowing rapid
3D reconstruction will be rolled into the suites on rails. This means the patient
doesnt have to be shuttled out to a special CT suite the work can be done
right in the Centre for Image Guided Therapy.
A bank of four computer monitors will hang on each side of the patient
table, enabling physicians to monitor images and to call up historical images from an
archive. GE Medical is supplying a picture archiving and communication system (PACS).
A fourth room will contain a GE bi-plane angiography machine. The room
will be dedicated to angiography and some interventional neuro procedures.
In the future, the centre plans to install interventional MRI scanners
enabling doctors to image their patients while conducting surgery. This can be
useful in neurosurgery, for example, to determine the position of tumours and other
lesions, and to ensure that as much as possible of an unwanted structure is removed.
Research will also play an important part at the centre. Doctors will
test new interventional imaging therapies and measure the efficacy and economics of their
And because the Hospital for Sick Children is a teaching hospital with
a mandate to spread its knowledge, the centre will use interactive video technologies to
demonstrate the techniques that it is pioneering. This will include live video posted on
the World Wide Web.
The Web site will enable children and their families to learn about the
procedures. This whole component involving children and their families is extremely
important, said Dr. Kevin Baskin, pediatric interventional radiology fellow at the
hospital. It makes them active in the process, instead of rendering them passive
recipients of care.
Dr. Baskin said the live video and Web site projects will also become
valuable teaching tools for other hospitals and medical professionals: Theyll
allow other healthcare providers, either on-site or remotely, to learn about these
developing procedures through real-time, collaborative interactions.
The Chatham-Kent Health Alliance: A model of innovation and cooperation
By Andy Shaw
Not every bankruptcy is a bad thing. One indeed helped launch
whats likely to be the countrys most advanced regional healthcare system. The
thin-client based Chatham-Kent Health Alliance network will serve over 700 users and a
wide-spread urban and rural population of 110,000 people in south-western Ontario. By
spring of next year, the $12.9 million project will link up the Alliances two
hospital campuses in Chatham, a 40-bed rural hospital, an outreach centre, a mental health
clinic and a long-term care facility. It will also extend the network into patients
homes through the Victorian Order of Nurses (VON). Next to come on line will be a pilot
group of the areas physicians.
But the project did not start out in such happy circumstances.
We were on the verge of crisis in May of 1996 because the major
systems vendor for two of our hospitals went bankrupt, explains Jerome Quenneville,
vice president of finance and corporate systems for the Alliance. That left us with
very little support. Just the few people we could take on from the vendor. We also knew
that our systems were not going to be Year 2000 compliant. So we got the project under way
Alliance CEO Bernie Blais, however, says the timing couldnt have
been worse: We were and are capital poor and resource poor. So spending nearly $13
million on a hospital our size (about 250 beds all told) makes the project a very risky
Yet Blaiss experience told him it was worth the risk. His
background includes years spent at senior levels with both British Columbias and
Albertas ministry of health. There he took a direct hand in extending healthcare
systems to serve far flung populations, despite cutbacks and other healthcare
As the healthcare system is restructured, the hospitals that will
face up to its demands best are going to be the ones that are part of a regionally based,
integrated system, says Blais with conviction.
True to his view, Blais put the re-vamping of Chatham-Kents
systems on hold when he first came East to take over the CEO reins in 1996. He had the
project re-tendered to ensure that whatever was built could be plugged into from outside
hospital walls. That ability to connect to others was fundamental, says Blais. We
didnt want to get caught and realize later that we should have done it right from
Now, adds Blais, all the regions health agencies and providers
can think about connecting to an information sharing system that was built for that very
purpose. In the end, no matter what institution a patient is sent to in Kent County, he
says, the system will be able to pass that patients data from one site to the other.
Also, the project is aiming to develop high-speed, telemedicine links with its further
flung referral centres in London, Ont. and elsewhere.
That means we will be able to bring services into the community
we dont have now. We will improve the quality of life for people like our diabetics,
or our cancer patients or our dialysis patients who now have to travel extensively to get
follow-up care, says Blais.
Such savvy has caught the eye and budgets of other officials.
Ontarios Ministry of Science and Technology gave the project a $1 million dollar
boost through its TAP grants, specifically to integrate the VONs home visits and the
Copper Terrace long-term care facility. The Ontario Ministry of Health also selected
Chatham as one of just five primary care pilot project sites in the province.
The initiatives aim is to wire-up the offices of general practitioners and other
local doctors with regional systems.
Aside from Blaiss plug-in or perish dictum, the Alliance project
team made two other clever decisions. They opted for thin-client hardware from Data
General, a project partner, as well as for a regional software license from HBOC, another
project partner. It all makes for an Alliance network that should be speedy, secure,
economical, and readily expandable.
The thin-client has a long list of advantages, says
Quenneville. First of all it is very secure. There are no external disk drives on
the terminals, for example, so there cant be any unauthorized copying and
downloading of confidential data. Also, because the data and the apps are stored centrally
(on 12 fat Terminal Servers from Data General) the data is not really being transmitted to
the terminal, just their images. So you cant intercept the data either.
Just as importantly, says Quenneville, stripped down thin terminals
simplify use and speed authorized access. A physician doesnt need much
computer knowledge at all to operate the terminal, he says. And because
its operating from the server, physicians can move from one terminal to another and
no matter where they are, their screens will come up just how theyd left them at the
Those terminals are also a lot cheaper than the level of PC needed in a
fat-client, thin-server environment. Quenneville says terminals can be added on to the
Alliance WAN for about $2,200 each, less than half the cost of an appropriately powerful
Also, adding on another software seat doesnt add to costs.
We negotiated a regional license with HBOC for the
software, says Suzanne Flett, the project leader and consultant from Healthtech Inc.
of Toronto, a healthcare systems implementer. So that means we can go to physicians
or potential community partners and entice them to get on the network by saying,
Heres the software you need and theres no charge for it no matter how
many people use it.
Most users are sure to care less about the technicalities of the
network (a switched 10/100 to the desktop network with a collapsed backbone hooked to a
gigabit Ethernet switch) than what it can do for them. Doctors can log into the system
remotely from their offices without making any changes to their PCs, other than adding the
From their homes, VON nurses can download their case load for the day
and then troop out to their patients, toting the systems ruggedized notebooks. In
the hospitals, cart-born, wireless point-of-care devices will instantly update the
patients clinical information, which then is immediately available to their remote
doctors. To make this happen, Data General is integrating the wireless technology with the
hospitals local area networks and with a wide area network encompassing all Alliance
For other regions contemplating similar systems, theres a unique
point worth noting about the partnership arrangement sustaining Chatham-Kents
network especially if they too are resource poor and far from IT hotbeds. Flett,
the project leader from Healthtech (and the president of the 15-year-old firm) is not only
implementing the network but will continue to manage and develop the system as the de
facto CIO of the Alliance.
Were not in a full outsourcing relationship, we have a
hybrid arrangement which I think is unique and a win-win for both parties, says
Flett. The Alliance had a very small IS department, so we went to the market
jointing and looked for additional staff. So now we have a department of 10 full-time
people. Healthtech supplies the two senior people (Flett and a systems administrator). But
the rest of the staff can be seconded to Healthtech projects in the future.
What this means for me is that I have a staff I know well, that I
have worked with before and that I can call on. For them, it provides professional variety
in their work. For the Alliance, the arrangement enables it to retain good IS people after
implementation, says Flett.
But as much as Flett and Blais may be proud of such innovative
approaches, they remain realists about how far along the road of modernization the
healthcare community has come as a whole.
Our information systems in healthcare are absolutely
terrible, says Blais. We may have good systems in hospital by hospital
stand-alones. But when you compare us to other sectors such as banking, the connections
between our institutions, our hospitals and other healthcare providers are very poor.
You cant amalgamate or think of bringing hospital systems
together, when they are all on disparate systems no matter how good their individual
technology is, says Blais. You need to use technology to integrate them into a
region. Thats what the vision should be.
Blais acknowledges its easier to see how that can be done in
urban/rural communities such as the city of Chatham and its surrounding Kent County
farmlands. We already have good co-operation with all our partners and stakeholders.
Were not battling each other for resources and we have all the players at the table
as part of our steering group. That makes it easier for us to provide a seamless continuum
It will also make it easier, adds Blais, to ensure the Alliances
future. I think a regional system such as ours will be a draw to at least the young
generation of physicians coming out. They will be looking for up-to-date information
system tools and we will have them. Given that kind of information-to-the-desktop
available to them and given the lifestyle in a community of our size, I think they will
find it a very attractive place to work and live.
Endoscopies could be replaced by a computerized technique
By Jerry Zeidenberg
TORONTO Doctors in Canada and the United States are
experimenting with virtual endoscopy, a technique that may eliminate the need
for traditional, fibre-optic-based endoscopy.
That could spell a great deal of relief for many patients, since
old-style, endoscopic exams require a flexible tube equipped with a viewing scope to be
pushed down the throat, or up the rectum and into the bowels.
While endoscopic exams can spot cancerous lesions early and save lives,
most patients dread going through with the procedures. People gag during bronchoscopies,
despite being sedated, and a colonoscopy can be a painful, sloppy affair.
By contrast, with virtual endoscopy there is no poking or prodding.
Physicians can use the latest generation of computed tomography (CT) scanners to take
hundreds of images of the chest, abdomen or other areas of the body all in just a
After that, the patient is no longer involved. The physician can
reconstruct the pictures as 3-D images on a computer screen, and fly-through
the organs to look for cancerous polyps and other problems just as you might
fly-through a computerized video game using a joystick.
In the last few months, Dr. Raziel Gershater, chief of diagnostic
imaging at North York General Hospital, in Toronto, has been conducting virtual
endoscopies on an experimental basis. He has peered into the bronchi, colons and arteries
of patients, none of whom endured a conventional endoscopy.
Instead, Dr. Gershater collected CT images of the patients, and used
new software from Algotec Systems Ltd. of Israel to transform the slices into
The powerful Algotec software can extract an organ
such as the colon from the mass of structures captured in a CT scan. That means Dr.
Gershater can separate the snake-like colon from the rest of the abdomen, and display it
on the computer for close-up looks.
In some respects, says Dr. Gershater, a virtual endoscopy is
technically better than the traditional technique. For one thing, an endoscopist with a
conventional scope can only see in a forward direction by pushing the flexible tube
with its light and lens through an organ.
By contrast, a virtual endoscopist can go backwards and forwards,
checking and re-checking structures, simply by flying back and forth.
Moreover, its possible for a virtual endoscopist to examine tight
narrowings in the bowel caused by various lesions narrowings that sometimes prevent
the conventional endoscopist from passing through.
Conventional colonoscopy fails to examine the entire colon in 10
percent to 15 percent of cases, and it misses 10 percent of carcinomas in areas
viewed, said Dr. Gershater. A safe, non-invasive method of detecting colon
lesions, such as virtual endoscopy, is extremely attractive.
And by using the computer, Dr. Gershater has a better idea of the exact
location when he locates a lesion.
Flying through the bronchi of one patient the thousands of tiny
airways that line the lungs Dr. Gershater commented: A bronchoscopist might
get lost in here. On the computer screen, however, an arrow on a diagram of the
lungs marked the spot he was currently viewing in the fly-through portion of the monitor.
Still, there are currently several limitations to virtual endoscopy.
First, the resolution isnt quite good enough to see very tiny polyps and lesions.
Using CT scans, doctors have had good success in locating polyps precancerous
lesions in the colon that are 1 cm or larger. There have been mixed results, so
far, in spotting smaller polyps.
As a result, the technology will have to be further developed before
physicians abandon fibre-optic endoscopy in favour of this electronic version.
No one will do just a virtual endoscopy and nothing more,
commented Dr. Gershater. We cant see very small cancers or ulcers yet, but it
seems probable that in the foreseeable future it will become a standard diagnostic
Indeed, hes confident that the resolution will improve. I
think it will get to the point where you can see everything.
As well, when it comes to colonoscopies, the computerized image
cant yet tell the difference between a cancerous lesion and a small lump of feces
that might have been left in the bowel. (Patients receiving a CT scan of the bowel must
still drink a cathartic that clears the feces from the system, but the results are
Dr. Gershater stresses that virtual endoscopy is still in its infancy,
and that a great deal of scientific testing must be done to compare the results with
It appears likely that this work will be done, in the near future,
given the potential benefits of virtual endoscopy.
Dr. Gary Glazer, chairman of the department of radiology at Stanford
University in California, points out that colon cancer is a huge problem in the United
States and Canada. Many deaths could be prevented, he said, if men and women had regular
colon check-ups after the age of 50.
However, a colonoscopy is so uncomfortable that many people dont
bother going for an exam. Compliance is poor, said Dr. Glazer.
He believes that many more patients would comply if the exam were of
the painless virtual variety. Given that two-thirds of colonoscopies turn out
to be normal, a virtual endoscopy could be used to screen out the normal patients. Those
with abnormalities could go for a routine colonoscopy, so that doctors could get a better
look at a potential lesion and take a biopsy.
Dr. Glazer noted that a group at Stanford in a federally funded
project are researching virtual endoscopy. Several other groups at universities and
hospitals including the famed Mayo Clinic in Rochester, Minn. are also
investigating the technology.