Inside the October 2002 print edition
Canadian Healthcare Technology:
Feature Report: Developments in telehealth
monitoring of cardio-pulmonary patients
Andromed of Montreal has launched a wireless telehealth system that
allows caregivers to monitor the vital signs and symptoms of cardiac patients from a
Academics to produce new e-Learning technologies
A consortium of university researchers is seeking to create new
technologies and methodologies for e-Learning using broadband networks.
Low-cost clinical messaging
Toronto-based Easy Pax Inc., a company created by a radiologist, has
found international demand for its messaging system that enables medical images and
reports to be sent securely over the public Internet or private intranets.
Teaching computers to share
Physicians at Mount Sinai Hospital and the University Health Network,
in Toronto, are gaining shared access to oncology records, through a pilot project that
uses e-services to bridge the gap between their separate clinical data
Digital photography for docs
The new generation of high-resolution, low-cost digital cameras has
given physicians a new tool. The cameras are particularly helpful for recording changes in
a patients condition over time.
Evaluating help desks
Baycrest Hospital improved the way computer problems are solved by
initiating a study of its own help-desk department. Its now able to measure user
satisfaction, successful closure rates, average time to completion, early warning bugs,
among other things.
PLUS news stories, analysis, and features and more.
Montreal researchers and developers
test tele-cardiology applications
By Andy Shaw
You could say that Montreal is at the heart of Canadas telehealth
development, if youll pardon the pun, because nowhere else are there more research
and pilot projects involving the remote monitoring and care of cardiac patients.
Long known for their telehealth investigations at local universities,
Montreal researchers and developers have recently taken their telesmarts to the streets.
In suburban Laval, for example, theyre recruiting 500 residents
with high blood pressure to be part of a $ 1 million pilot program to control hypertension
at home via an automated telephone system. Across town meanwhile, officials at Andromed
Inc., in St-Laurent are about to pilot their unique Home Telemonitoring System
that enables caregivers to wirelessly monitor the vital signs of thousands of unseen
cardio-vascular patients at once. Both developments promise to become powerful weapons in
the war against cardiac disease, the one sickness that kills and costs us the most.
The leaders of the Laval pilot, the first of its kind in North America,
have given their project the acronym LOYAL for its goal of: Lowering
blood pressure by improving cOmpliance with hYpertension therapy through the Assistance of
technoLogy. Supporting their nine-month undertaking is Pfizer Canadas
million-dollar contribution as well as the co-ordination of the Centre hospitalier de
lUniversité de Montréal Research Centre and the systems of Tagge Medical Solutions
of Montreal, among other contributors.
Tagges interactive support system will link patients, physicians,
and pharmacists with automated reports of how well patients are controlling their
hypertension. If needed, automated voice calls will go out to patients reminding them to
adhere properly to prescribed drug treatment.
Andromeds wireless Home Telemonitoring System enables remote
caregivers to monitor patients pulmonary artery pressure and breathing regularity.
It also beams them graphic representations of the patients cardiac sounds and
electrical activities. Using Andromeds patented electronic stethoscope,
physicians can also auscultate or listen to an individual patients lungs
and heart with great clarity from afar.
Wearing non-invasive sensors, cardiac patients can go about their
lives, confident their vital signs are being constantly transmitted to a telemonitoring
centre. There, specially trained nurses can often catch changes in patients
conditions before they feel any symptoms. When needed, physicians can access
patients encrypted data via the Internet and also perform a remote evaluation
speaking to the patients directly through a built-in audiovisual link.
Andromed filed patent applications for the Home Telemonitoring System
early this summer in the United States, aware that the potential market for patient
monitoring there is huge. Over 112 million Americans suffer from some form of
cardio-vascular disease and account for 14 percent of all hospital admissions.
Compared to Americans, Canadians are only about half as good at keeping
their cardiac cool.
Only about 13 percent of Canadians who are hypertensive have
their blood pressure under control while about 25 percent of Americans do, says
Farzad Ali, a LOYAL project leader and outcomes research manager at Pfizer.
Were not really sure why that is, but its clear that in both countries a
very large percentage of people with the disease do not have it under control.
Whats more disturbing, says Ali, is that too many people
everywhere dont remain faithful to their drug regimen. Somewhere between 50 to
70 percent of hypertensive people in Canada, for instance, go off their drugs after the
first year of treatment. They see it as a short term disease rather than a chronic
Better patient education would seem to be the answer, but its
been tried and found wanting.
Studies show that educating patients only helps a bit, says
Ali. Having them monitor their blood pressure at home helps some more. So do
telephone reminders to take their drugs. But the LOYAL project is the first to combine all
three of those techniques.
In effect, LOYAL is an attempt to take the discipline of private
clinical drug trials and apply it to the general public.
In clinical trials, youve got the best doctors working with
the most suitable patients and their compliance is virtually guaranteed, says Ali.
But once you move beyond trials and take your drug or treatment out into the public,
normally you lose that kind of control.
In LOYALs case, the control begins with the participating
physicians, all general practitioners, who began recruiting 500 willing patients this
summer. As they sign the patients on, the Tagge system divides them into two equal groups
at random: an experimental group for LOYAL-assisted care and a comparison group that will
receive normal medical care.
In the experimental group, each patient receives advice on how to take
better care of their condition, a home blood pressure monitor, and access to Tagges
integrated telephone and database support system. Once notified by the physician that the
patient is a LOYAL subject, the Tagge system in turn automatically notifies the monitoring
centre as well as the patients pharmacy.
Ali says that previous studies have shown that patients are not
terribly accurate when reporting their pill-taking. So in our case were
putting compliance in the hands of the pharmacies, instead. The pharmacy will flag LOYAL
patient records so the system will know if those patients are renewing their prescriptions
The telephone system will also keep watch on the experimental patients
by polling them regularly for their blood pressure readings with automated calls. When the
phone is answered, the system will know whether it is the patient on the line, thanks to a
voice-print the system made of the patient at the outset.
The LOYAL project will continue for nine-months after the last patient
is recruited. The organizers will release the projects results some time in 2004.
But Ali admits it could be all for naught if LOYAL makes no significant
impact on patient compliance. But if it does, given the ubiquitous nature of the
telephone, similar automated prompting could be available to virtually all hypertensive
If we can eventually bring compliance up to say 25 percent or
even 40 percent of all hypertensive patients this way, just think what that could mean to
the number of strokes that will be prevented across the country and the consequent savings
there will be to healthcare costs , says Ali.
Ali says Pfizer has agreed to be the financial backer of the LOYAL
project for something other than pure commercial reasons. It fits with our long term
mission to be a most valued company by investing in projects that may lead to
long term solutions to healthcare problems, says Ali. So, in the LOYAL
project, for example there are no Pfizer drugs directly involved.
The drugs involved in LOYAL will be whatever the physician has already
prescribed for his or her patients.
Once the patient has signed a consent form in the doctors office,
the physician or nurse calls the Tagge system and then passes the phone to the patient for
a conversation with a remote computer.
The system asks for details about the patient including their
name, their pharmacy, when theyd like to be contacted as well as other preferences
and then automatically makes a random decision assigning the patient to either the
experimental or the control group, explains Stephen Maislin, Tagges president.
For those in the experimental group, the first call out to the patient does the full
enrolment in the project.
Again, in conversation with a computer, the experimental patient
answers questions about when and how often they would like to receive reminders and other
information about their treatment, as well as what day each week they would like to report
their blood pressure readings.
The physicians office has already informed the system about
what the patients current and target blood pressure readings should be. So each
week, the system looks at the readings as they are phoned in and can make its own
decisions, explains Maislin. If the readings are somewhat elevated, the system
will go into more active coaching of the patient. Or if the readings are clearly high, it
will notify the physicians office, all automatically.
In other words, the LOYAL project aims to improve overall patient care
more patient awareness of their disease and its proper
better patient compliance with their drug regime, and
timely physician interventions.
And while at the back end of that automated process will be handled by
Tagges state-of-the art communication platform, the front end will largely eschew
modern technology such as the Internet in favour of a much older piece of equipment.
There is a small Web element in LOYAL that will enable physicians
to track the progress of their patients, but otherwise we are relying completely on the
telephone, says Maislin. Weve found in our other work that people really
do prefer a verbal interface.
Tagges software is at work for clients elsewhere, including an
automated telephone support system for a post-surgery discharge program at a large
hospital in the United States.
Rising American demand for such remote patient care has Montreals
Andromed also betting its future on home telemonitoring systems. U.S. studies have shown
that home monitoring of patients would reduce cardiovascular patient hospital stays by
eight days on average, thereby slashing hospitalization expenses by $20,000 US per
patient. Home telemonitoring would also cut readmission frequency in half.
Before invading the U.S. market, however, Victor Lonzo, vice president
of research and development for Andromed, says the company is launching a pilot study this
fall in Quebec. The pilot will test all the elements of the Home Telemonitoring System,
including its scalable sensing and telecommunications components. The systems key
hardware component is Andromeds Biological Sound Monitor (BSM).
The BSM is less like a medical device and more like an electric
guitar, says Lonzo of the BSMs acute acoustic sensitivity.
Patients in the pilot will wear a lightweight wireless transmitter at
home that connects using Bluetooth wireless technology with small BSM sensors on their
chests. The sensors will constantly measure pulmonary arterial pressure and lung
ventilation while relaying the findings to the transmitter. ECG sensors will similarly
relay data for phonocardiograms of heart sounds as well as electrocardiograms of heart
rhythms. The transmitter, in turn, will encrypt both the BSM and ECG feeds before sending
the data on from the patients home over high-speed DSL phone lines.
The hard part was not the hardware, however says
Lonzo.The hard part was deciding how to move the data out. So first, we settled on
Bluetooth for the short-range transmission because it works very well and consumes the
least power. But then we had to figure out a new way to transmit data over the long range
to the monitoring centre.
The centre is designed to eventually handle thousands of patients, so
we have to move the data cheaply if the system is going to be economic.
What Andromed developed, as a result, was a modified version of the
TCP/IP protocol that can move encrypted medical data faster and at less cost than ever
As the data from each patient stream into the monitoring centre, the
patients readings can be monitored by nurses before piling up neatly in
Andromeds SEQUS e-Survey database.
In the case of an abnormal reading, an alert message automatically
appears on screen, prompting the nurse if needed to call the doctor. With his or her
electronic stethoscope plugged into a computer, the physician can remotely listen to the
patients vital signs and also communicate with the patient in real time via
streaming audio and video.
If the situation is critical, the doctor can tell the patient to go to
the hospital or have an ambulance dispatched then lift the patients clinical
information from the database and transmit it to the hospital in advance of the
In the end, if such patient telemonitoring techniques and technologies
developed by the likes of Andromed and the LOYAL project truly work, then a lot more
people than just Montreal researchers can take heart.
Academics to produce new e-Learning technologies
By Jerry Zeidenberg
A consortium of university researchers is seeking to create new
technologies and methodologies for e-Learning using broadband networks.
Called the Pan-Canadian Health Informatics Collaboratory, the
two-year-long project is focusing on the development of new, online learning techniques
for health informatics.
The researchers believe the technologies they produce could be applied
to many other types of e-Learning, involving a wide variety of content. (See the web site
Were re-tooling e-Learning, to move the envelope
forward, said Dr. Francis Lau, associate professor and director, School of Health
Information Science at the University of Victoria. UVic is the lead contractor for the
$1.6 million project, which obtained $750,000 in funding from CANARIE, the Ottawa-based
economic development agency.
Were experimenting with innovative features that have not
been tried before, he said. Currently, there are systems for e-Learning that
have been around for six to eight years. Were attempting to build a second or third
generation platform for online education.
The new technologies will emphasize interactivity, including students
working together as groups linked by their computers and making use of
various forms of conferencing and videoconferencing systems. The researchers are also
building systems that bring advanced Internet search engines into the courseware, making
use of sophisticated technologies such as object repositories and metadata tags.
(Object repositories are storehouses of coded routines that can be
shared by developers across the country, meaning they dont have to re-invent the
wheel every time they build a new application. Metadata is data that describes data, and
is important for locating information on the Internet.)
Perhaps more importantly to the end-users, the emphasis is on creating
systems that stimulate students much more than previous on-line courseware.
Were trying to engage the learners in different ways,
said Dr. Lau. Instead of the rote learning thats found in many e-Learning systems
today, the Collaboratory researchers are taking a more hands-on approach, called
constructionism in educational theory. For example, to teach students about
establishing telehealth networks, a course might ask the student to go through the steps
of setting up a telehealth project.
Were going to build simulations, some of which will use
animation, said Dr. Lau.
Other members of the consortium include the British Columbia Institute
of Technology, Dalhousie University, the University of Calgary, the University of Alberta,
the University of Sherbrooke, the University of Western Ontario, the University of
Waterloo, and the Michener Institute, in Toronto.
The Canadian Health Records Association and COACH, the Canadian
Organization for the Advancement of Computers in Healthcare, are also members of the team,
and will help test the applications.
In terms of technology, the partners are building on e-Learning systems
provided by Open Text Corp. of Waterloo, Ont. They include products such as LiveLink and
MeetingZone. Konova Solutions Inc., of Montreal, is also involved as a collaborator, and
is assisting with software development.
Dr. Lau noted that university groups are devising pilot courseware that
will incorporate new learning techniques. In brief:
Researchers at BCIT are working on the telehealth module, in
which students will learn how to set up a telehealth project.
At the University of Western Ontario, an introduction to
electronic health records is being produced.
The Michener Institute is developing a course dealing with
Picture Archiving and Communication Systems (PACS).
At the University of Alberta, the thrust is on patient research.
And at Dalhousie University, researchers are producing a module
on HL7, a standard for transmitting healthcare information.
All of this is being designed to work on broadband networks in
particular, CANARIEs new CA*net3, the organizations latest computer network
that boasts very high speeds. It will make real-time video conferencing, and other
technologies such as telepresence, available to the application developers.
However, Dr. Lau mentioned that while many universities and some
hospitals have access to CA*net3, not all do. One of our challenges consists of how
we will connect to some of the learners who dont have access to this high-speed
network, he said.
Easy Pax provides cost-effective messaging system for images, reports
By Jerry Zeidenberg
TORONTO A Canadian company has started to score international
successes with a low-cost messaging system that enables healthcare professionals to send,
receive and analyze medical images and reports over the public Internet or private
The system boasts a mixture of security measures, including a patented
feature that prevents images from being sent to anyone but the intended recipients.
Easy Pax Inc., which has developed the application since 1998, started
marketing the technology earlier this year. So far, it has sold two large systems,
including one to a radiology group in Houston which reads diagnostic images for 30 clinics
and hospitals in rural Texas that have no radiologists on staff.
Instead of waiting for a radiologist to visit their clinics and
hospitals, or sending their patients to Houston, the rural medical centers can now
transmit computerized ultrasound, X-ray, CT and other images directly to the specialists
for interpretation. The Houston-based radiologists, who are reading 1,200 cases a day,
have promised a two-hour turnaround for reports, once the images are received.
The cost of the Texas implementation, which includes a server and 50
licences, is less than $500,000. That compares with Picture Archiving and Communication
Systems (PACS) that can require an investment of $5 million or more.
While the Easy Pax solution doesnt come with its own archive or
certain specialized functions that are found in full-scale PACS networks- such as
pre-fetching it does connect with all types of DICOM-standard radiology and
computer equipment and can query archives when a radiologist needs to see a patients
It also has sophisticated viewing tools built in such as zoom,
contrast and calibration of structures contained in images.
David Koff, a French-trained radiologist who practiced medicine for 20
years before turning his attention to creating and leading Easy Pax in Toronto, noted that
other types of information can be easily appended to files such as pathology
reports, endoscopic or dermatology images, or even a complete electronic patient record.
This gives the physician more context when interpreting the images of patients.
Radiologists can annotate images, using text thats superimposed
on the pictures, so details are highlighted for referring physicians.
Weve developed a very low-cost, secure messaging system
that can help referring and consulting physicians, and also helps patients, said Dr.
Koff, president of the 11-person company.
He explained the system not only provides faster delivery of readings
for patients and physicians, saving them time, trouble and traveling expenses, but it also
reduces costs for hospitals, health regions and clinics.
Even the costs of supplies can be greatly reduced. For example, after
reading a study, a radiologist will typically print out the images for pick-up by the
patient or shipment to a referring physician. This amounts to $20 to $30 per study, when
using high-quality printers and paper, not to mention the expense of a courier, if
Such charges are eliminated by Easy Pax, since images and notes can be
electronically transmitted directly to the consulting physician there is no need
for paper-based printouts.
Dr. Koff stressed that the system has been made easy to use, with the
assumption that family doctors and many other physicians dont want to spend much
time learning how to install and use specialized computer packages.
For that reason, Easy Pax works with common Internet browsers, such as
Explorer and Netscape. The software is browser independent, said Dr. Koff.
The doctor can view it on any platform.
The software can be used with any telecommunications system, including
regular dial-up, although Dr. Koff recommends an ADSL or cable connection. Easy Pax
contains its own compression technology, designed by the company, which squeezes picture
files by ratios of up to 15:1 while still preserving DICOM information.
This means that an MRI study often consisting of 100 slices
can be reduced in size from some 1.5 megabytes to 150K or less. Even dial-up modems
are able to handle files of this size within a minute or two.
Easy Pax also offers an ASP solution, with the server software and
processing located at a data center in Mississauga, Ont. Users can tap into the
application from anywhere in the world, exchanging images and reports with others around
The company earlier this year landed a contract of this type with the
Italian branch of a multinational insurance company thats seeking second opinions
for radiographic images of cancer patients. Theyre sending images on to
radiologists in Paris and Chicago, for another opinion, to see if theres agreement
about the diagnosis and treatments, said Dr. Koff.
If satisfied with the results, the insurance company may expand its use
of the system to corporate offices in 37 different countries, said Dr. Koff.
When it comes to the ASP model, users are charged a fee of $49 per
month, plus 45 cents for each megabyte that is uploaded. For the compressed, 150K MR
study, that works out to about 7 cents.
Several health systems in Canada are currently examining the Easy Pax
technology, including a cancer care network.
Dr. Koff said Easy Pax contains a patent-pending security system, which
prevents images from being sent to anyone beyond the intended physician. Weve
shown this feature to several radiology companies, and theyve told us theyve
never seen this capability before.
Along with radiology, the technology can also be used more broadly in
telehealth, since all types of images and reports can be appended as attachments and sent
securely over low-cost networks.
Jeff Vachon, president of telehealth company HealthworksTMS, has been
providing consulting services to Easy Pax, concentrating on market entry strategies and
broadening the capabilities of the software to create a clinical messaging system for
store-and-forward telehealth applications.
Measuring help desk effectiveness with strategies developed in call centre industry
By Stephen Tucker
Measuring the effectiveness of the help desk at Baycrest Hospital
proved to be a far more difficult problem than we had originally thought. At conferences
and in casual conversation with peers in healthcare IT, it became obvious that Baycrest
was not alone. Others were exasperated with help desk measurement, analysis, and effective
implementation of service improvement.
This article describes how Baycrest is teaming up with a call-center
provider in order to develop analysis methods appropriate and beneficial to healthcare IT.
Background: The Baycrest help desk fields a wide range
of calls. Users want help remembering a password, assistance with e-mail, or a solution to
a phone problem. With more than 10 people handling approximately 1,800 help desk inquiries
a month, we desperately wanted to be able to appropriately measure and improve not only
service but also IT system performance. Measurement can serve as an early warning system
helping to identify bugs and other system related performance issues.
Our first measurements took place a year ago. We called a percentage of
those who used the help desk and asked them about their experience. The results were all
over the map. There was no way of using the information to improve service or to develop
an early warning alert for system issues.
Part of the problem rested on unfocused survey questions and our
sampling method. Another was that we were asking the technicians to, in effect, evaluate
themselves. There was bias in the data collection, as help desk personnel tried to justify
rather than objectively gather information.
When technicians got busy, follow-up calls fell off. Sometimes one user
was called multiple times by error. This caused understandable user frustration. At the
same time, we were trying to develop a bug scorecard to help identify system
issues. The scorecard effort did not give us consistent, useable data.
Subsequently we tried a periodic e-mail survey. The survey was sent to
all users who had accessed the help desk in the preceding period we tried various
time frames from a week to a month. Only a small percent of users replied. Questions
offered a range of answers from satisfied to dissatisfied. Most respondents went right
down the middle or gave us the highest marks. The small sample size and the way people
were answering did not provide us with anything useful.
Call centers seemed to offer a solution: The call
center industry has performance measurements. We thought their procedures might be
effectively applied by us. After talking with a few companies, we found that the
measurements were not right for an IT help desk. They did not dig out the service and the
system performance data we needed. Ultimately, we were introduced to Alchemy, a call
center company located in Sault St. Marie, Ont.
Alchemy had for some time recognized an opportunity to expand services
into the healthcare market, but they felt they needed a partner in order to fully
understand the unique measurement requirements of an IT help desk. After our initial
conversations it appeared that both sides would gain through a joint effort.
During several weeks earlier this year, Baycrest and Alchemy developed
a simple, yet highly focused survey of five to seven questions. Alchemy suggested
surveying each month a random sample of 5 percent of those served by the help desk. In our
case, that would be roughly 90 people. Alchemy said the sample is small enough to be
manageable and cost effective, while providing statistically relevant data.
The process: At the end of each month, Baycrest
e-mails to Alchemy basic contact information on everyone using the help desk during that
period. The information is contained in a Microsoft Excel spreadsheet. Alchemy reps call
Baycrest Centre personnel and conduct a brief telephone interview. They stop calling after
90 surveys have been completed. The responses to the questions are coded into a database.
Subsequently, Alchemy forwards us a detailed report. Baycrest is
charged a nominal cost for each completed survey. We are also charged a small monthly
administrative fee. We had our first report roughly 60 days after beginning work with
Alchemy. We do receive a few negative comments from those surveyed who are critical about
an outside firm calling them. But for the most part, Baycrest staff is behind this. It
requires only minutes, and the majority of the staff understand that this is being done to
help improve service.
The findings: The report shows us how we are doing in
key areas of user satisfaction, such as successful closure rate, average time to
completion, and early warning on system bugs. Importantly it provides us a trend-line
comparison with past months. This gives us a way of quickly jumping on problems rather
than letting them stray too far out of acceptable limits.
Interestingly, the survey tracks the individual performance of our help
desk technicians. This will be invaluable as a management and professional development
tool. For the first time, we will have a measurement on performance that enables us to
appropriately coach, mentor, and reward. The data will be invaluable at annual performance
One thing we learned was that our customer service skills could be
improved. We subsequently contracted with an outside firm to provide customer service
training. The help desk personnel enthusiastically received the training. After all,
Baycrest was making an investment in their future and helping them to do their jobs more
We also realized that we are asked for help in areas that perhaps we
should not be, for example, help with software applications such as Microsoft Word. We
help the caller. However, this information has stimulated us to investigate ways of
solving the problem with means other than help desk intervention.
We discovered that users are not always aware that weve solved
their problem. This typically happens when a technician works on their computer after
hours. We now have preprinted post-it notes to leave at their workstation. We also send an
e-mail alerting users that the problem has been taken care of. These are small easily
taken steps; yet closing the loop with our internal customers builds trust and confidence.
An insight we gained from this project is that we can affect help desk
performance with the questions we ask. For instance, if we begin to develop questions on
speed of response, the help desk staff will focus on improving scores in that area. Survey
construction and feedback begin to be tools for innovative ways of directing continuous
Recently, we used the trend information and other data to prepare
goals, objectives, and a budget for improving help desk operations for the upcoming year.
Having hard data to prepare an accurate budget is an important benefit and one we did not
For example, we now have facts on staffing and equipment needs to take
before senior management. And as we start looking at whats happening at the other
institutions in terms of broad-based trends, we should be able to make even better, more
As Alchemy expands its number of healthcare customers, it will begin
providing industry-wide comparative data on best practices and other performance
indicators to its clients. It is the kind of data that effective help desk management
Stephen Tucker is Director, Information Technology, for Baycrest
Centre for Geriatric Care in Toronto, Ont.