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Inside the October 2000 print edition of
Canadian Healthcare Technology:

Feature Report: Developments in telehealth

CFI research funding fuels diagnostic imaging, informatics

Quebec healthcare projects and McGill University are the big winners in the latest round of Canada Foundation for Innovation (CFI) grants.


Capsule for bowel imaging

Physicians are testing a new device for imaging the small intestine – a camera-in-a-capsule that takes pictures of the bowel and transmits them to a collection device worn on the belt. The innovation may reduce the need for endoscopies.

Decision support software

Software developed by hospital spinoff company Continuum Solutions has been adopted by several healthcare organizations, including a growing suburban hospital and a sprawling health region.


Planning for Bill C-6

Canadian healthcare practitioners now face onerous, new responsibilities under Bill C-6, which empowers individuals to control how information about them is collected, used and disclosed. This requires Canadian healthcare providers to develop and implement a method for the patient to give consent.


Roundtable on telehealth

Telehealth experts discussed the present state and future of wired and wireless medical care in Canada, at a session held near Toronto’s Sunnybrook Hospital.


PLUS news stories, analysis, and features and more.


CFI research funding fuels diagnostic imaging, informatics

By Andy Shaw

Quebec healthcare projects and McGill University are the big winners in the latest round of Canada Foundation for Innovation (CFI) grants. In July, the Ottawa-based CFI announced infrastructure grants to 59 Canadian universities, colleges, hospitals, and not-for-profit research institutions totaling $363 million dollars for 214 development projects. Of these, six Quebec universities won grants of about $68 million for 26 healthcare related projects. McGill researchers will lead 10 healthcare projects involving $40 million of CFI money plus matching provincial and private sector funding.

“We didn’t do all that well in the first round of CFI grants, but this time it looks as if we topped everybody,” says a delighted Robert Marchessault, a polymer chemist who holds the E.B. Eddy chair in McGill’s chemistry department. As the on-campus CFI co-ordinator, professor Marchessault oversaw 22 successful CFI grant applications in all fields from McGill, topping the University of British Columbia’s total of 19. About two-thirds of the McGill money will go to healthcare research initiatives including:

• $2,633,600 for the Quebec Regional High Field Nuclear Magnetic Resonance (NMR) Facility
• $3,000,000 for the Montreal Centre for Experimental Therapeutics in Cancer Research
• $3,200,000 for the Montreal Network for Pharmaco-Proteomics and Structural Genomics
• $11,302,048 for the Quebec Integrated Health Research Network (IHRN)
• $11,589,844 for the Montreal Consortium for Brain Imaging Research (MCBIR)

Among these, says Marchessault, the IHRN grant was the hardest fought for.

“This originated with a woman who wouldn’t take no for an answer. Robin Tamblyn is at the Montreal General Hospital, which is one of McGill’s teaching hospitals and she has long been interested in epidemiology. Now there is no greater source of epidemiology data in the province than RAMQ, the Réseau Assurance Maladie Québec (the provincial health insurance scheme), but everyone in the business here told her RAMQ would never share any of its information because it is confidential. But she persisted and eventually convinced RAMQ to put up a matching grant so she could conduct an ongoing major epidemiological study. And that’s a real coup. It is not easy to convince provincial bureaucrats to go along with university researchers.”

Researcher Tamblyn will have a mother lode of data to mine. Without compromising confidentiality, Tamblyn and her team will create an infrastructure that will allow Quebec to monitor the incidence and prevalence of disease in the province as well as identify the trends and efficacy of treatments.

By comparison, the MCBIR money was the easiest won.

“Dr. Alan Evans was behind that one. He’s one of the outstanding brain imaging researchers in the world and he’s especially known for his cataloguing of infants’ and childrens’ brains. He’s really the star of our show here. His project was picked as the number one project by our Quebec committee (that screens CFI grants) and it sailed through Ottawa too,” says Marchessault.

The CFI funds Evans will oversee will go into individual clinical research projects that target the major neurological disorders including Parkinson’s disease, Alzheimer’s, multiple sclerosis, and stroke. Better brain imaging of the effects of psychiatric disorders such as schizophrenia, drug addiction, and stress is also the goal. Specifically, the funding will go towards research into the technology of scanners and developing improved trace elements that make for enhanced imaging of different regions of the brain.

Only one part of McGill’s funding from the CFI proved to be a disappointment.

“We didn’t get all the funds we asked for the NMR facility,” explains Marchessault. “It’s a project conducted jointly between our biochemistry department in the faculty of medicine and the University of Montreal. We were after a high-field NMR instrument so we could start getting at the structure of proteins, because proteomics is the next big thing after genomics.

“We got funding for other NMR equipment but not the high-field unit. The CFI keeps its focus on infrastructure that benefits society generally once it is in place, and it apparently felt we weren’t ready yet to make effective use of a high field machine. We’re going to fight the decision because NMR machines can look at proteins in solution, which is closer to their true environment than when you use the traditional approach of capturing them in a crystal.”

From previous experience, Marchessault is not optimistic, however, that he will get the CFI to change its mind. Given what else the institution was granted, he concedes that even McGill can’t win them all.



Continuum software lowers costs and improves patient management

By Andy Shaw

Decision-support software produced by hospital spin-off Continuum Solutions now improves the quality of patient-care and reduces hospital stays at the Credit Valley Hospital on the western outskirts of Toronto. The software has also been implemented at the Carleton Place and District Memorial Hospital in eastern Ontario and in the sprawling Mistahia Health Region of Alberta, north-west of Edmonton. These are the first deployments of the electronic version of Continuum outside the St. Thomas-Elgin General Hospital in southwestern Ontario, the tool’s birthplace.

According to its creators, early reports indicate that Continuum is living up to expectations in what could not be a greater range of operating environments. Credit Valley is an expanding 300-bed hospital that is one of the country’s most highly automated. Carleton Place is a 24-bed hospital with the temerity to be leading edge. The Mistahia Health Region is making Continuum work over parts of a wide-area network (WAN) that is truly wide. Anchored by Queen Elizabeth II hospital in Grand Prairie, the six other Mistahia healthcare facilities are spread as much as 300 kilometres apart.

But it was tiny Carleton Place that took the lead. It was the first to go live with Continuum using a simple Paradox database. The result has not only been improved monitoring of patient care, but also the elimination of four beds – a significant 14 percent reduction in unneeded capacity.

“Carleton Place was an early user of our manual care evaluation process and a few years back, their CEO came down to see us and said they would be interested in the computerized version as soon as it was available. So Carleton Place became one of our first beta test sites,” says Larry Vanier.

Vanier, one of the principals of Continuum Solutions, was on the original development team and remains St. Thomas-Elgin’s director of information services. For over eight years, he has worked with doctors and nurses to create first a manual process and then one that care-givers could boot up on their computer screens.

And the team’s premise was this: Despite a long-entrenched bias that individual acute healthcare was too complex for systematizing, it could be – if care providers were able review the progress of patients against carefully selected care criteria consistently every day.

Further the team reasoned, not only would paying daily heed to these criteria improve care quality, it would also reduce costs. Judging a medical or surgical patient daily against the criteria, providers would automatically know when that individual patient was ready to move on to less costly non-acute care. Non-acute care patients need no longer take up expensive acute care beds.

Under the leadership of Dr. David Atkinson, the team brainstormed with physicians and representatives of all disciplines at St. Thomas-Elgin. The result was ACTIV, a criteria based index of what constitutes effective patient care. When patients are judged non-ACTIV, they are ready to move on. (Just to make sure they are, Continuum’s computerized version displays a final Readiness for Discharge Assessment Screen) Not surprisingly, the criteria and the ACTIV index and its accompanying manual soon caught on elsewhere. Not only Carleton Place, but also Credit Valley, and several health regions of Alberta all adopted the process.

“The Chinook health region centred in Lethbridge has been the very best spokesperson for us out west. They’ve been using the manual system for four or five years and that’s how Mistahia found out about us. But Mistahia wanted to jump right over the manual process and go right to the software stage,” says Vanier. “We installed it at the Queen Elizabeth and one of their other sites and they have since set it up at another. The other day they called us to say they were amazed at how quickly the software performs over their WAN.”

To make it speedy, Mistahia runs Continuum off a central SQL server at Queen Elizabeth, but the software is also installed on local servers at the other regional sites. So the PCs running off those servers need only to send out to the centralized server for the specific data needed by the user.

Continuum passed another important test rather unexpectedly this past spring at St.Thomas-Elgin and other locations when a flu epidemic hit. “Our tool was used to ensure that discharges were appropriate and done when required. And that became crucial because all the hospital beds were full and the long-term care facilities were not accepting more patients because they were also down with the flu. Continuum proved then it could add a lot of strength to decision making about patient care.”

Vanier and the development team continue to make improvements to the Continuum software with hopes of broadening its use.

“You can use the data from Continuum, for example, to identify where you need to develop a care map,” says Sandra Jenkins, a former nurse manager of pediatric care at St. Thomas-Elgin and now also a principal of Continuum Solutions. “And wherever you make changes to that care map for patients, you can monitor through the data you collect to determine if you have made the change you want. You can look at variances that adversely affect hospital stay or the effectiveness of care and decide what interventions you need to make to overcome them.”
Among other projected uses of Continuum, Jenkins says there’s a patient language module that’s been developed. It lets patients and their families know what is going to happen to them on a given day. “They’ll know what tests they will undergo, so you as the caregiver can then decide on the educational material they’ll need.”

Also in the works, says Vanier, are prototypes to provide Web-based and Palm Pilot access to Continuum. Improved graphics of the Windows-based application have enhanced its analytical components. In the longer term, Continuum will move beyond acute care into chronic, rehab, psychiatric, and outpatient care. Continuum Solutions also hopes to add on some American buyers soon. Its ability to identify “conservable days” of hospital stays should make it particularly attractive in the managed care environment. Also, similar U.S. products are far more complex and expensive.

“They are very sophisticated and can drill down to a great depth at any spot in the care cycle and do very detailed analysis,” explains Jenkins. “But it would overwhelm the resources of a hospital to use them to look at every patient every day as Continuum does. So, really, Continuum can complement such a system rather than compete with it.”



Federal privacy law C-6 has many implications for healthcare providers

By Jeanne Bickle, Judee Sibbit and Meredith Appleby

Many readers were surprised by the implications of Bill C-6 in our September report. It may be appropriate to begin with a few hard numbers. You may not be aware, for instance, that south of the border, the United States is ablaze with new privacy legislation, having passed more than 140 new privacy laws in 1999. Currently, there are over 1,400 bills on the legislative agenda for the year 2000.

In Canada, Quebec was first off the mark with a private-sector privacy law in 1994. Bill C-6 was enacted at the Federal level in April of this year, and the provinces now have their own processes under way. British Columbia released its privacy consultation paper last fall. The Ontario Ministry of Consumer and Commercial Relations has just released its privacy consultation paper, and the Ontario Ministry of Health and Long Term Care will release a similar document shortly. Ready or not, privacy legislation is indeed a reality. If the provinces fail to introduce privacy laws that are substantially similar to the Federal legislation within three years, they must comply with Bill C-6.

Because of the circumstances of vulnerability and trust under which healthcare information is collected and used, most would agree that personal healthcare details are very sensitive. The protection of an individual’s personal health information denotes a special kind of trust. With this in mind, consider some of the short-term operating challenges that lie ahead.

Consent. As reported earlier, Canadian healthcare practitioners now face onerous, new responsibilities under the Federal legislation. Bill C-6 empowers the individual to control whether, and how much, information about them is collected, used and disclosed. This requires Canadian healthcare providers to develop and implement a method for the patient to give consent. Consent is time limited, so a tracking mechanism is also required.

Access. Having received the patient’s consent, the legislation goes on to say that organizations must provide a mechanism for the individual to be informed of the existence, use and disclosure of their personal information, and shall be given access to that information.

Amendments. In addition to their right to access, patients may also challenge the accuracy and completeness of their information. Participating organization must correct wrong or incomplete details, and send amendments to third parties where applicable.

Accountability. Healthcare organizations must be able to describe what personal information they possess and provide an account of how it is used.

Response. When individuals wish to access their personal information, healthcare organizations must assist them and respond to such requests within 30 days. Failure to do so is deemed to be a refusal.

Identity. Policies and security mechanisms must be developed to identify healthcare professionals who have a right to access patient information files, and the security level of information therein. In addition, all patients requesting access to their information must be authenticated to confirm their identity, and to ensure that the requested details go to the appropriate individual.

Withholding. Procedures need to be developed and published to deal with cases where information has been severed, and also to cover instances where information can or must be withheld.

Training. Healthcare staff must be trained to respond to patient requests so as not to violate new privacy rules.

This abbreviated list will serve to illustrate some of the new challenges facing organizations that collect, store, use, or disclose personal information in the normal course of business.

But there is an even bigger dimension to all this – the sharing of information between participating organizations. Healthcare information is not kept in one place by one organization. It is scattered throughout the system – in hospitals, doctors’ offices, walk-in clinics, home care offices, pharmacies, laboratories, and so on. For the new privacy legislation to protect consumers as intended, there will have to be operating standards and guidelines, and cooperation across the wide range of information collectors and users. Implementation of privacy legislation throughout Canada’s network of participating healthcare organizations is a daunting task.

The privacy ball is clearly in the court of participating healthcare organizations. They must work quickly and collaboratively to develop approaches and solutions that are in compliance with privacy legislation. Complying with legislation will earn the public’s trust and cement the integrity within the patient/provider relationship.

For information on privacy solutions in health care, contact Jeanne Bickle or Meredith Appleby at 905 857 9493.



Canadian physicians and industry experts on the future of telehealth

In June, a panel of physicians and industry experts convened in Toronto to present their views on the future of telehealth in Canada. Moderated by Andrew Sage, marketing manager for Cisco Systems Canada Co., the participants were:

• Dr. Edward Brown, Program Director, NORTH (Northern Ontario Remote Telecommunications Health) Network, Sunnybrook & Women’s College Health Sciences Centre.
• Dr. Michael Guerriere, Private-sector healthcare consultant and former CIO and COO of the University Healthcare Network.
• Paul Howarth, General Manager, Bell Canada.
• Steve Lawrence, Healthcare Manager, Cisco Systems Canada Co.

The following is an abbreviated transcript of the proceedings.

ANDREW SAGE: I have to say that healthcare, in terms of adopting Internet technologies, would be considered a laggard industry in some respects. It hasn’t adopted IT in terms of the Internet as quickly as some of the other sectors that we are involved in.

Everyone agrees the Internet is going to bring tremendous change in healthcare, both from an administrative standpoint and from a clinical standpoint. On the administrative side, there are lots of applications that have been adopted by other sectors in the industry based on Internet technologies that are ‘mature’, if you want to call it that in inverted commas, and they’ve been around for one or two Internet years, which is quite a long time.

Those will enable the healthcare sector to speed up the processing of claims, prescriptions, bring together communities to solve a lot of the administrative issues and drive some costs and inefficiencies out of that part of the sector in general. Also, the potential is there to automate supply chains and do other things that have now become quite common practice in some of our private-sector areas. Contrary to popular belief, it isn’t the sort of customer-facing, e-commerce application of the Internet that is fundamentally changing businesses and creating value; it’s the back-end stuff we don’t see as much of, the supply-chain integration and things, that are really driving value for these companies. The opportunity is really there in healthcare to do the same.

STEVE LAWRENCE: The new Internet economy is certainly here. The statistics are quite staggering when you think about it. There are more than 70,000 new Web sites that start up every single hour, global Internet traffic doubles every three months, and Internet commerce revenues are increasing 100 per cent annually. That’s up from 1998 when there was probably around $35 billion U.S., and by 2003 it’s estimated to be nearly $3.2 trillion.

The reality is that the Internet is being adopted faster than any previous technology, and it’s really astounding when you consider it took the television 13 years, it took the PC 16 years, and the radio 38 years to get to 50 million users. The Internet took four. So that’s sort of the backdrop of the environment in which we are working.

As you’ll hear throughout the presentation today, the pervasiveness and relatively low cost of IP will allow the delivery of healthcare services to geographically remote as well as metropolitan areas. And this is quite important.

If you are at Scarborough Centenary Hospital or whether you’re at St. Joseph’s General up in Elliot Lake you may have the same requirement for, say, a respiratory specialist. The pervasiveness of IP and Internet technology allows us to extend those telehealth services remotely as well as to local metropolitan areas.

Additionally, and probably even more importantly, is that the IP can facilitate this “remote” – and I’ll put “remote” in quotations because it could be almost local – consultation from the specialist’s home, from his office, or from the hospital. Web-enabled healthcare organizations can customize health information for patients, and, as a result, deliver high-quality care, improved customer satisfaction, and dramatic increases in efficiency.

Healthcare organizations via the Internet can allow patients and employees access to self-service tools, can cost-effectively improve the delivery of healthcare services without necessarily increasing the staffing levels.

PAUL HOWARTH: Certainly, telehealth brings a new dimension in that I see medicine as not mission-critical. When I talk to a bank and I want to put in a banking machine network, certainly that’s mission-critical to the Royal Bank that we be able to move those transactions. But when you start applying those same network architectures and concepts to healthcare, suddenly you move into a whole other area, which is that of a life-critical application. And certainly, not everything in healthcare is, but you need to move carefully and make sure that you’re aware of all of the risks.

I think that is the other role that carriers can play, in that we put an awful lot of effort into building our network’s reliability. We can work closely with the healthcare community in order to ensure that as the Internet becomes more pervasive, that we are there to guarantee the level of reliability that customers have come to expect. And to ensure that we can meet those life-critical parameters that are required to move into telemedicine.

One of the things that really intrigues me about telehealth or Internet health – and this really relates to where Bell Canada and BCE is going as a carrier, in that we are moving away from that tele-component and we are moving very quickly to the content component. And certainly, that can be seen with Jean Monty’s purchase of CTV, which is a pure content play. I don’t think anybody has the answer as to how that will work out. But one of the analogies I like to draw, and I know I’ve mentioned this to Dr. Brown a while ago, is that the funny thing about the Internet is that everybody today is paying for the access. This is a bit of an anomaly if you look at, say, cable television, or hopefully ExpressVu, where when you get your cable bill there is no fee for the cable connection; there is a fee for the channel and suite of packages that you’ve purchased.

That I think is really where we need to get to with telehealth. I think we need to move away from a carrier charging for access fees to different locations, and it’s this much per month, which sometimes can make the costs prohibitive. I really think we need to move towards an area where people are paying for the content.

DR. EDWARD BROWN: Essentially, the mission is pretty straightforward. Patients in rural areas just do not have access to healthcare that we do here in downtown Toronto and in other urban centres in Ontario, and our goal is to deliver the health professionals to their site. We want to avoid the travel. We want to get rid of their delay in receiving care. We also want to reach out to health professionals in rural areas who are pretty isolated from the academic centres. We think by bringing education to them, knowledge to them, support to them that we will reduce their professional isolation and hopefully help with retention and recruitment in rural areas as well.

We just finished a two-year demonstration project. It ended December 31st, 1999. We are now funded by the Ministry of Health in Ontario for on-going operations. We are in eight cities in northeastern Ontario. That includes Sudbury, Chapleau, Timmins, Kirkland Lake and Cochrane. We are just adding six more centres in Central Ontario.

The results are pretty good. I mean, patients basically love this. It’s an amazing thing to not have to spend the day or two days travelling for an appointment which may be as short as five or ten minutes once you get in, so that the patients basically love this stuff, and our satisfaction ratings are in the 95 per cent level. And you really find that actually across most telemedicine programs in the world; the patients just love these things.

And our physicians have also been very pleased with it. Their satisfaction ratings are almost as high, both from the referring physician’s perspective and the specialist’s perspective. We have had nearly 200 health professionals involved with this program, either sending their patients for referrals or providing medical care. And we also have quite an active education program with at least a session a week and often a lot more.

Where are we going? I guess the future – my timeline is pretty short. The future for us is sort of December, 2000, not too far away. We are hoping to begin to expand this network. We have been working very hard in Northwestern Ontario, visiting hospitals and First Nations communities up there, to create a pretty large partnership to begin to expand this network out. We are hoping to grow to about 42 sites by the end of the year if all goes well.

We are also kind of working hard at the home front. We think the natural evolution of this is to take telemedicine out of a single studio in a single institution and to begin to deliver that out to wherever those health professionals and patients are such as an urban centre like Toronto where we should be able to get all kinds of bandwidth, or a place like Thunder Bay where we can also get bandwidth. We would like to bring this stuff out to the desktop so that you don’t have to run down to that video room, you can just see the patient at your desk. And that’s really part of integrating this into the healthcare system, which is the ultimate goal: make this part of what you do.

What I believe is that guys like me won’t be standing here anymore in a couple of years because telemedicine will have essentially disappeared as a unique item. We don’t really hear people talking about telephone-medicine anymore because it’s just part of what you do every day, and I think you’ll flip on that screen in your office every day like you do the phone right now and connect to your patients as a physician, whether they’re in downtown Toronto or Upper Rubber Boot, somewhere far away. It will just become part of what you do every day, and we will all go away and leave the technology guys to install them and do that.

But we have a ways to go. The biggest challenge, from my perspective, is not necessarily the technology. I think we have that. I think the biggest technology is – sorry, the biggest barrier is the policy issues: how does this fit into the healthcare system, how do we make it fit, how do we make it relatively cost-efficient, what are the decisions that we have to make, the sacrifices that we have to make, or the choices to make sure that this actually works in our existing healthcare system?

But I think we are getting closer to that. I think as more people get exposed to this they inherently see the value in what this technology can do, and it’s pretty exciting once you get out there and see that it’s real, it’s not just a wild idea, it’s actually real healthcare that is being delivered this way, and I think this will eventually just become part of what we do every day.

DR. MICHAEL GUERRIERE: When I think about healthcare, especially healthcare information and healthcare on the Internet, I’m hard-pressed to think of anything that’s exponential, except for consumers accessing health information on the Internet, but that’s really nothing to do with the whole healthcare enterprise in Canada. In fact, most of those Internet sites where they’re getting their information are U.S.-based.

The other thing that might be growing exponentially is the concern about the sustainability of the Canadian healthcare system, and I wonder if these things have some relationship to one another.

When you think about the economy that’s supporting the Canadian healthcare system, it is moving to improve productivity at a huge rate because it is adopting these technologies and moving onto the Internet. It is supporting a healthcare system that still functions largely manually and on paper, and this is a major issue for us now as Canadians, as to whether we can sustain a healthcare system that’s operating in that fashion.

And this is where I think Steve’s comments about IP, and using Internet-protocol applications, and building telemedicine capabilities into a PC desktop will change this profoundly and have specialists and GPs communicating that are two blocks away, not just having to think about remote access.

But there’s one driver that has not been discussed very much, and that’s our demographic situation. I’m not talking about the demographics of the population. You hear about that all the time; the aging population will require more care and put demands on the system. That’s old, old news.

It’s the demographics of the professions that concern me more. Their demographic profile is exactly the same as the rest of our population.

It was either last year or the year before that the nursing profession in Canada crossed a very important milestone, and that was the milestone where the number of nurses retiring each year exceeded for the first time the number of new graduates entering the profession. That gap is getting wider and wider, and the Canadian Nurses Association has looked at this and projected a 60,000-nurse deficit by 2011 in this country.

Now, 60,000 over a total of 240,000 nurses for the country. We are not talking about five per cent shortages here; we are talking about massive shortages. And some of the solution we have had in the past, like recruiting from abroad, will be difficult to do because all the G-7 nations face exactly the same demographic profile. And in the physicians it’s the same story.

So what do you do in a situation where demand is increasing and the labour pool is shrinking? Well, you look to the U.S. economy as an example of that and you look to major productivity improvement. It’s the only way that we will meet patient expectations in the midst of this significant labour shortage.