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Inside the October 2010 print edition of Canadian Healthcare Technology:

Feature Report: Developments in teleahealth

Telepathology poised for rapid growth
“Faster, better and cheaper,” is the promise of a telepathology pilot network currently operating between Toronto’s University Health Network and a number of rural and northern Ontario hospitals.


Proper credentials?
A web-based service is starting in Canada that will enable hospitals and other healthcare organizations to check the credentials of vendors who visit their sites. An added attraction: for healthcare providers, the service is free.


Remote monitoring
Remote monitoring technologies are proving to be extremely useful, according to recent tests and trials. What’s needed now, however, are leaders willing to roll-out the technology in large-scale implementations.


How green is eHealth?
A new program in Calgary is studying the environmental effects of eHealth. Not only do discarded computers contain hazardous materials, data centres consume more electricity than many may realize.


Robotic helpers
The University of Toronto and Baycrest, a renowned seniors’ centre and hospital, have teamed up to develop robots that can assist the elderly, infirm and those with dementias. The helpers on wheels are being programmed to provide reminders and verbal cues.

PLUS news stories, analysis, and features and more.


Telepathology poised for rapid growth

By Paul Brent

“Faster, better and cheaper,” is the promise of a telepathology pilot network currently operating between Toronto’s University Health Network and a number of rural and northern Ontario hospitals.

The first such system of its kind in the province, the network links physicians in remote locations to UHN’s roster of 45 pathology specialists in real-time via the Internet, instantly transmitting digital images of tissue samples.

The goal of the network is to give physicians access to the resources of big-city hospitals, regardless of the size of their facilities.

“It is more than just about the technology,” said Dr. Sylvia Asa, medical director of the Laboratory Medicine Program and pathologist-in-chief at UHN, who stressed that patients are the immediate beneficiaries of the new network. “Faster, better, cheaper is what I like to say. We are getting samples faster, we are producing better results and it is actually cheaper for the people of Ontario.”

The project has been strongly supported by Canada Health Infoway, the provincial government’s OntarioBuys program and eHealth Ontario.

Telepathology promises to improve the current system, which often relies on a general pathologist who serves one or several remote hospitals and must often send off tissue samples from challenging cases to city laboratories.

With turnaround times of at least 48 hours, that makes intra-operative consultations all but impossible – meaning more patient visits and delays for critical treatment.

That’s no longer the case with telepathology, where consultations can be done in minutes. The telepathology program started modestly enough about five years ago as a way to better shift resources between the three facilities that comprise UHN (the Princess Margaret, Toronto General and Toronto Western hospitals). To date, almost 2,000 digital slides have passed through the system with about 10 percent coming from the northern hospitals, a percentage Dr. Asa expects to grow.

“As with any other technology, you start it for the most critical things,” she said. “We have been supporting intra-operative consultations where they need the answer immediately. But now that we are comfortable with the technology and we have it working well, we are hoping to do everything this way in the long term.”

Currently, the UHN-linked hospitals still send glass slides – those deemed not critical or urgent – south for specialist evaluation. “I’m dreaming of the day, which hopefully will not be too far down the road, when we won’t need to send slides all around the province,” said Dr. Asa. “That is a risk for everybody, it’s expensive and it slows everything down.”

The network now links the UHN to a dozen northern and rural hospitals. Three of them, in Timmins, Sault Ste. Marie and Kapuskasing, are linked 24 hours per day.

The UHN’s interest in telepathology dates back to 2002 when staff pathologist Dr. Andrew Evans began to investigate a digital system. He has served as the telepathology coordinator since the program’s inception in 2004, first utilizing remote-controlled microscopes.

In 2006, the UHN implemented digital slide-based telepathology to link its Toronto Western wing to the Toronto General, where the bulk of its pathologists are based. Dr. Evans stated recently that while various forms of telepathology have been used internationally since the late 1980s, the UHN program is the first in the world to use cutting-edge virtual slide telepathology for primary diagnosis in patient care.

In Quebec, a telepathology network based in Laval aims to link more than 21 sites in eastern province, which would vie with the UHN project for the largest of its kind in the country.

In the early days of the initiative, the UHN implemented the telepathology network without fanfare, in part to see whether physicians in the participating hospitals would even notice that their team of UHN consulting pathologists had adjusted the regular visiting rotation and were now only consulting virtually.

Dr. Asa recalls an instance at the Timmins and District Hospital earlier this year in which a surgeon in one of the operating rooms had an intra-operative consultation over the telephone with a pathologist. The Timmins doctor concluded the call with a promise to “walk by your office” to speak with the pathologist about another case, having no idea that he was in fact sitting in downtown Toronto.

“Honestly, the biggest compliment for us is when they say they haven’t noticed a big difference between when we are there or not,” she said.

The Timmins hospital was the first facility to sign on with the telepathology network. It is one of the strongest backers for expanding its use and capabilities in the future. “We’re very strongly supportive of the initiative,” said Roger Walker, chief executive of the Timmins and District Hospital.

The hospital currently sends about 10 to 12 slides digitally every month, however it is anticipating a massive ramp-up in capability and utilization of the system once more robust equipment is installed and configured. “We are looking at upward of 200 to 300 (images) a day when we move into this new rollout of the technology that is being developed and we are essentially piloting with UHN for evaluation purposes,” said Walker. “So it will be dramatically different in terms of volumes.”

The benefit for rural hospitals is the access to a team of specialist pathologists such as those at UHN. “A hospital of this size would have one, maybe two (general) pathologists,” said Walker. Much of the evaluation work those local pathologists do is cancer-related and referred to specialists in larger hospitals. For a facility like Timmins, that can mean delays of 10 days to two weeks, he said. “That’s a long time for somebody to sit and wait.”

The main factor which has delayed the use of virtual pathology is not the size of digital slides (which are quite large), or the space they take up on UHN servers, but rather the technological limitations of the digital scanners.

“The limiting factor is the time it takes to scan the slides,” said Aline Letourneau, regional general manager of lab services at Timmins. “Today’s digital scanners offer low throughput and require a technician to run slides through one at a time. But advances in scanning technology will be able to handle as many as 100 slides at a time and scan high-quality images far more quickly.”



Web solution enables hospitals to automate credentialing

Should representatives from pharmaceutical and healthcare supply companies be permitted to patrol hospital corridors randomly when visiting executives and department managers?

Wouldn’t it help hospital managers if they knew whether vendor reps had current, validated credentials – including proper vaccinations and the absence of a criminal record? Most hospitals say they want to know who’s there – but it seems there hasn’t been a workable solution to this serious challenge.

With the responsibility hospitals and healthcare centres have for patients and communities, healthcare vendor credentialing is becoming more critical than ever.

For years, hospitals have printed and distributed ‘vendor access policies’ to sales reps calling on their facilities – to no avail. Traditionally, these policies stated that sales reps were required to check in with purchasing or pharmacy departments prior to calling on other personnel.

As a result, it fell on overworked purchasing managers to prevent sales personnel from approaching clinicians to demonstrate products; it was their job to update a multitude of aggressive reps on new hospital policies. Any assertive rep could always find loopholes or claim they “did not know” about newly tightened hospital procedures that might hinder their access to doctors, nurses, technicians and others.

With the desire to be sure that patients receive the safest care, vendor management and credentialing must be addressed by every hospital administration, especially with the rise of Canada’s SARS-generated pandemic regulations.

Hospitals differ in their willingness to manage vendors’ behaviour – and how they communicate rules and regulations to them. In Canada, neither governments nor professional associations have established codes or protocols for vendor credentialing – individual hospitals must set and communicate wide-ranging vendor policies.

The credentials that suppliers must present to one hospital or hospital system are often different than those presented at another. Many healthcare organizations are now calling for a uniform Canadian standard establishing the criteria vendors must meet for each level of hospital access, from loading dock to operating room—and it’s about time.

South of the border, there are very clear existing regulations and position statements from U.S. federal and state governments, the Joint Commission, CMS, the Association of periOperative Registered Nurses (AORN), the American College of Surgeons, Association for Healthcare Resource & Materials Management (AHRMM), and the Strategic Marketplace Initiative.

The Joint Commission standards require that: “Healthcare organizations need to be aware of who is entering their organizations and what these individuals are doing in their organization. Accredited healthcare organizations need to take steps to ensure patient rights are respected, and that infection control precautions and other organization specific policies and procedures are followed.”

There are several major reasons why hospital supply chains should not wait for governmental regulations to credential and track vendor representatives calling on their organizations:

• Hospitals are physically and operationally complex entities with multiple entry points and often maintain offsite purchasing departments;

• Sales representatives must agree to follow a hospital’s infection control practices – and be properly vaccinated, healthy and free from criminal backgrounds;

• Sales representatives often interrupt physicians, nurses, technologists to demonstrate products, some of which are not under hospital contracts;

• Patient safety demands that vendors follow patient privacy laws requiring reps to understand confidentiality requirements (specifically, those established by Personal Information Protection and Electronic Documents Act, PIPEDA)

What would help tremendously in Canada is a central portal that provides the necessary tools to assess vendor credentials and track vendor entrance and exit to the healthcare facility. The web-based program would also keep updated information (service hours and product monographs). This solution is coming soon.

VCS Canada’s ( web-based system ensures patient safety, confidentiality and quality of care, while also ensuring that providers gain access to innovative medical technology and skilled sales professionals to demonstrate proper use of their technologies.

“Vendor management should function as a communication hub for purchasing, legal, risk, medical, security and infection control with vendors,” said Michelle Floh, VCS Canada’s president and CEO. “Our solution – at no-cost to hospitals – drives down the cost to vendors and shifts the hospital’s individual burden of driving compliance to a community-wide effort.”

Managing the credentials of hospital vendors is an important but often overlooked task. The VCS software platform manages the work for healthcare organizations, freeing them from a large-scale task.

“It enables them to achieve higher compliance with credential requirements, as well as other policies, such as signing in/out, wearing a photo ID, having an appointment, and receiving permission before showing products,” said Floh.



Remote patient monitoring technology no longer a remote possibility

By Andy Shaw

We’ve been piloting remote home care technology and techniques in Canada for quite some time now. But now there’s evidence that we could be entering a new healthcare era – one of technology-enabled remote care that is ubiquitous.

Such care-everywhere promises to save our healthcare system from foundering under the ever more costly and growing cargo of an aging population. In the vanguard of that rescue attempt sails RPM, remote patient monitoring.

The strong wind in the rapidly rising sales of RPM technology, says David Doyle, the vice president of marketing and business development for Philips Lifeline Canada, is the desire of more seniors to live independently and safely in their own homes. Philips Lifeline provides pendants and wristbands with buttons that the wearers can push if they need help in the case of a fall or accident.

“Seniors, and often their families or adult children, are naturally concerned though about a fall or other incident that would prevent the senior or aging parent at home from getting to the phone. So in June we launched Lifeline with Auto Alert – which means if they fall and are unconscious or for some other reason can’t press the button on the Lifeline device they’re wearing, after a very brief period of 30 seconds we get an automated signal. We then call the patient, and if there is no answer, we then make sure they get immediate medical help.”

Mr. Doyle says the benefits of that automated ability to detect a fall, both to senior and to the healthcare system, are compelling.

“When a patient falls and is unconscious or can’t respond, the so-called ‘lie time’ can be critical. If they aren’t reached by a caregiver within an hour or so, the medical impacts start becoming severe quite quickly: dehydration, disorientation or even hypothermia if they’ve fallen in the bathtub, for instance.”

Also, chances of recovery from a stroke worsen greatly if the fallen patient is not treated within the hour.

“From the healthcare system point of view, the impact can also be huge. Just consider the difficult job of judging when to discharge a patient. If discharge planners know the patient is going home with a fall-detecting auto alert system, they’ll have more confidence in discharging the patient sooner. They’ll have more trust that they’ll be safe at home.”

Current cost of the Lifeline with Auto Alert service in Canada is $55.50 a month – a bargain for seniors and their families when measured against the costs of alternatives to living in their own home. It’s a point not lost on ready-to-pay consumers and caregivers who recommend the service.

“Our challenge right now is keeping up with the enormous demand for the Lifeline with Auto Alert service since its launch,” says Doyle. “We had what we thought were fairly aggressive sales forecasts, but it turns out the demand has been three or four times greater than we had planned. And not just in Canada but in the United States, too.”

According to KLAS, an independent healthcare technology research firm in the United States that keeps tabs on vendors like Philips and others, economics are behind the surge in such remote monitoring devices for the home.

“This is an area that’s bound to grow because we have that huge Baby Boomer section of the population that’s aging and it’s becoming impossible to justify sending bodies out to monitor all of them,” says Canadian-born Mark Wagner, director of ambulatory research at KLAS headquarters in Orem, Utah.

KLAS will be looking into remote monitoring devices more intensively next year, but this year, while conducting research on home care software designed for visiting nurses and other caregivers employed by home care groups, KLAS researchers picked up plenty of anecdotal feedback on remote monitoring and telehealth devices – past, present, and future.

Their first impressions were that there are some serious challenges clouding the horizon of remote monitoring’s otherwise promising future.

“What I kept hearing during our interviews was: We tried a telehealth device years ago. It was rudimentary and it didn’t work very well, so we don’t want to go back to it,” says Wagner. “Also, if you’re talking about having a whole fleet of remote devices out there in the hands of thousands of patients, you own a herd of technical devices that need to be tracked, maintained, serviced, cleaned when they come back in, and then re-deployed. And then think further about warehousing all those units and the staff required to just manage the in, turnaround, and out again.”

As well, Wagner points to the ongoing information integration problem: “Though most of these remote monitoring devices do capture data, their information is not integrated back into the wider home care record-keeping solution.”

But Wagner also sees encouraging signs among the vendors that KLAS studies so carefully. “They are now asking themselves, how do we spruce up our old remote care products that haven’t had much use and add new value to them? And one of the early answers is: we can video.”

While Wagner applauds that renewed interest, he warns vendors, “The home care group is not your cutting edge, rapid adopter of new, and fancy, and exciting technology.”

To drive them back to telehealth systems they found wanting before, says Wagner, is going to take something very compelling.

Looks like, though, Philips has found something very compelling in its renewed Lifeline with Auto Alert service. So have several other Canadian providers.

FacilicorpNB, a public sector agency that manages shared healthcare services for New Brunswick, has chosen the Onsight Collaboration system from Winnipeg-based Librestream. The agency will use the collaborative tool to link patients as well as other caregivers to specialists – both clinical and non-clinical – via Onsight’s Expert desktop software and its mobile video devices.

Already at work in New Brunswick in a trial mode, Onsight video can enable:

• remote consultations by staff at The Stan Cassidy Center for Rehabilitation in Fredericton, the province’s only neurological rehab centre – eliminating as much as eight hours of back and forth driving either for patients or home care providers.

• remote emergency repair of a broken pump on an operating room anesthesia machine by a technical expert in another hospital 135 kilometres away. Via the two-way Onsight video cameras he guided the repair then helped the OR nurse go through the safety checks to make sure all was in working order with the anesthesia machine. The result: three surgeries that happened without delay, as scheduled.

Librestream officials see such capabilities as a leap up to a more compelling form of remote care.

“Traditional telehealth is room based. You have your patient in one room in one location and your physician or nurse or specialist in another room somewhere else, and they connect through two-way video conferencing,” explains Doug McCartney, a Librestream telemedicine applications engineer. “But for us telehealth has become what we have coined ‘bedside to desktop’. With our bedside-to-desktop system we are already connecting patients in their homes to their doctors or to the hospital.

“We can even connect to the physicians’ homes if they are working at night or off-hours. And that is all done securely, so that patient health information is always protected.”

The bedside-to-desktop capability of Librestream has caught on in pockets right across the country. “We have installations in every province and we’re venturing into new disciplines as we go,” says Mark Ahrens-Townsend, Librestream’s executive VP of business development. “One of our customers in Sioux Lookout is doing remote geriatric care in northern communities. They’re going into patient homes remotely to do stroke rehabilitation.

“So the therapist from 500 miles away could assess things like: Are those steps we can see there dangerous for this patient and should they be fixed? Show me if there is a grab rail in the bathtub to help the patient get in and out?”

And there isn’t a more passionate advocate of RPM in the country than Donna Byrne.

For the past 14 years, this nursing degree-holder has owned and run Health Access Santé, a private home and nursing company in Beaconsfield, on Montreal’s West Island.

For three years, president and CEO Byrne and her staff have been testing the use of education and monitoring technology with chronic disease patients to help relieve the enormous burden they impose on the healthcare system.

The upshot of the pioneering work is a new company, Telehealth Access, announced by Byrne in June. Staffed by nurses and a dietician, the centre offers remote monitoring services to diabetes, hypertension, COPD, CHF, and other chronic patients. To make it all work, Byrne reached west to Saskatchewan and embraced SaskTel’s LifeStat service. Using LifeStat, Telehealth Access patients can monitor their own conditions blood pressure, glucose, and weight at home or at work on the Telehealth Access’s RPM devices. The readings they give automatically jump by Bluetooth technology to SaskTel’s secure data centre. From it, Telehealth Access care providers can see the data and contact the patient immediately if needed by phone or by a Televisit terminal installed in their home or office.

“Five years ago, I started getting interested in what technology could do for both patients at home and the nurses who visit them. And for the last three years, in co-operation with McGill University, we’ve been formally studying both,” says Byrne.

“Specifically, what we wanted to know was: Would patients be satisfied with remote care – and would nurses be happy about visiting patients remotely? And what we found was that both were strongly in favour. Patients felt they had learned more about their condition and had better access to healthcare professionals. The nurses also enjoyed their remote visits, partly because they could see so many more people.”

Her findings have convinced Byrne that remote care – and the RPM tools that go with it – is the future of healthcare.

“You can have one nurse happily visit 100 people. You could never do that if you were only going into their homes or bringing them to clinics.”

Clearly, remote patient monitoring tools are no longer a remote possibility. They exist, they work reliably now, and they are producing better outcomes – but still just here and there. However, as all parties interviewed for this story agree, if we are going to save our sinking healthcare ship with an uplifting new era of remote care – our healthcare Ministries and our physicians in particular have to stop just re-arranging the deck chairs, and make the leap into remote care leadership, too.


Calgary research program studies environmental impact of e-health

By Richard E. Scott

A colleague performed a successful e-health research project a few years ago. Now she is faced with an increasingly common dilemma – a pile of dated videophones that are now ‘surplus to requirements’. They are analog, not digital, and therefore require landlines, restricting their potential use; they are also old and require major software and hardware upgrades.

What to do? Contact the manufacturer and ask them to take back outdated and redundant equipment into their inventory? Contact colleagues in developing countries and send the videophones abroad? Leave them in the corridor and see what happens? Toss them into the local landfill?

None of these solutions are optimal. This dilemma probably occurs far more frequently than we care to realize, particularly when you consider our tendency to constantly ‘evergreen’ our technology as newer, more innovative solutions are devised!

Consider, for example, that the average life of a cell phone is now around 18 months, and a laptop is around three years. It is almost as though planned obsolescence has been built into e-health and other ICT equipment – great for a company’s bottom line, but what about the environment’s bottom line?

The reality is simple. e-health is ‘ICT-intensive’ – i.e., it uses extensively many forms of Information and Communications Technologies (ICTs). The literature is replete with evidence that ICTs have environmental impact (both good and bad); ergo – e-health has environmental impact (both good and bad).

In response to greater environmental awareness, recent years have seen a trend for the industry sector to become ‘green’. That is, to portray, and in some cases overtly demonstrate, greater stewardship of the environment through change in business practices.

Some companies have made major changes in their product development. For example, using ISO 14040 and ISO 14044 guidelines and requirements, Apple monitors its 10.2 million metric ton environmental greenhouse gas (GHG) footprint from cradle to grave. It claims recent reductions in greenhouse gas emissions of 38 percent in its manufacturing activity, 5 percent in its transportation activity, 53 percent in product use, 1 percent in recycling, and 3 percent in running its facilities.

Related to these positive environmental impacts, they claim significant advances in making smaller, thinner, and lighter products, requiring less raw materials (a first generation 15” iMac used 55 percent more material than the current 20-inch iMac). Importantly, this also means a reduction in pollutants harmful to the environment and to health, such as lead, arsenic, brominated flame retardants (BFRs), mercury, phthalates, and polyvinyl chloride (PVC).

Apple is certainly not the only company pursuing green initiatives, but it serves as a notable example. Sadly the main motivation for implementing green ICT initiatives is not environmental stewardship, but to reduce costs, establish a green market image, and increase profit.

Given the enormous global growth anticipated for e-health and the accepted environmental impacts, the University of Calgary established in 2009 the world’s first Environmental e-Health Research and Training Program. Its goal is to ensure the environmentally appropriate use of e-health solutions, which will be achieved by pursuing three objectives:

• to provide the e-health sector with the necessary knowledge, skills, and tools related to environmental e-health;

• to reduce or eliminate negative environmental impacts of e-health;

• to enhance and promote positive environmental impacts of e-health.

The program has just completed a SSHRC funded scoping review to understand the significance of environmental e-Health. There was very little literature on ‘environmental e-health’, so the literature linking ‘ICT’ with ‘environmental impact’ was reviewed with a new lens – that of e-health (i.e., any use of ICT in the health and healthcare sectors).

Our review has clearly demonstrated that e-health has an environmental impact. It is convenient to separate environmental impacts into three stages of the life-cycle of e-health equipment. ‘Upstream impacts’ (applying to the extraction, processing, or synthesis of materials, the manufacture of the e-health components, and the packaging and distribution of these products); ‘midstream impacts’ (referring to design, implementation, and the period of actual use of the e-health solution); and ‘downstream impacts’ (considering the ‘end-of-life’ aspects of disposal, and the four components of minimizing waste; rethink, reduce, reuse, and recycle.)

However, the three most notable findings were the significance of energy consumption (which straddles all three stages,) the growing problem of e-waste (potentially a looming humanitarian crisis) and, perhaps most importantly, the need to assess the overall environmental impact of any e-health solution in a holistic ‘life-cycle’ manner.

Energy consumption occurs during material extraction, manufacturing, packaging, distribution, use, and recycling. Consider our current efforts to establish ‘lifetime’ e-records requiring capture, storage, and transmission of huge and growing quantities of data. Greenpeace suggests data centres will, on average, consume 1,963 billion kilowatt hours of electricity by 2020, which would be more than the current power consumption of France, Germany, Canada, and Brazil combined – e-health will be one component of that impact.

If e-health is to be implemented in an environmentally sensitive manner, an understanding of the environmental benefits and harms associated with e-health, and modeling and mitigation (harms) or leveraging (benefits) of these impacts, is essential.

But what of the future? We believe our research will lead to results of significant socio-political, economic, and environmental relevance and impact.

Maybe “Environmental e-health Impact Assessment” legislation, tools, and practices will become the norm. Whatever the future may bring, we intend our Environmental e-Health Research and Training Program to be there to help us all become ever more environmentally sensitive and responsible in our growing e-health practice.

Richard E. Scott is Director, Office of Global e-Health Strategy, International Health and Global Partnerships; and Associate Professor, Faculty of Medicine, University of Calgary. The article was contributed on behalf of the Environmental e-Health Research and Training Program team – Dr. Richard E. Scott, Dr. Chad Saunders, Dr. Mone Palacios, Duyen Nguyen, and Dr. Sajid Ali; and our SSHRC study collaborators – Sharlene Stayberg, Liz Loewen, Andrea Battcock, and Tanya Twynstra.