Inside the October 2000 print edition
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 Torontos Sunnybrook
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 didnt 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 McGills 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 Columbias 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
This originated with a woman who wouldnt take no for an
answer. Robin Tamblyn is at the Montreal General Hospital, which is one of McGills
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 thats 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. Hes one of the
outstanding brain imaging researchers in the world and hes especially known for his
cataloguing of infants and childrens brains. Hes 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 Parkinsons
disease, Alzheimers, 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 McGills funding from the CFI proved to be a
We didnt get all the funds we asked for the NMR
facility, explains Marchessault. Its 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 werent ready yet to make effective use of a high
field machine. Were 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 cant 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 tools 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 countrys 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
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-Elgins 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 teams 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,
Continuums 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. Theyve been using the manual system for four or
five years and thats 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 theres a patient language
module thats been developed. It lets patients and their families know what is going
to happen to them on a given day. Theyll know what tests they will undergo, so
you as the caregiver can then decide on the educational material theyll 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
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 individuals 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
Access. Having received the patients 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
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
Canadas 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 publics trust and cement the integrity within the patient/provider
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 & Womens College Health
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 hasnt 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 theyve 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 isnt the sort of customer-facing, e-commerce application of the Internet
that is fundamentally changing businesses and creating value; its the back-end stuff
we dont 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
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. Thats
up from 1998 when there was probably around $35 billion U.S., and by 2003 its
estimated to be nearly $3.2 trillion.
The reality is that the Internet is being adopted faster than any
previous technology, and its 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 thats sort of the backdrop of the environment in
which we are working.
As youll 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 youre at
St. Josephs 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 Ill put remote in
quotations because it could be almost local consultation from the specialists
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 thats 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 youre 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 networks 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 Montys purchase of CTV,
which is a pure content play. I dont think anybody has the answer as to how that
will work out. But one of the analogies I like to draw, and I know Ive 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
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
its 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
The results are pretty good. I mean, patients basically love this.
Its 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 physicians
perspective and the specialists 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 dont have to run down to that
video room, you can just see the patient at your desk. And thats 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 wont be standing here anymore
in a couple of years because telemedicine will have essentially disappeared as a unique
item. We dont really hear people talking about telephone-medicine anymore because
its just part of what you do every day, and I think youll 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 theyre 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
its pretty exciting once you get out there and see that its real, its
not just a wild idea, its 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, Im hard-pressed to
think of anything thats exponential, except for consumers accessing health
information on the Internet, but thats really nothing to do with the whole
healthcare enterprise in Canada. In fact, most of those Internet sites where theyre
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 thats 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 thats
operating in that fashion.
And this is where I think Steves 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 theres one driver that has not been discussed very much, and
thats our demographic situation. Im 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. Thats old, old news.
Its 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
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 its 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. Its the only way that we will meet patient
expectations in the midst of this significant labour shortage.