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Inside the October 1999 print edition of
Canadian Healthcare Technology:


Feature Report: Developments in telehealth


Canada lags behind other nations in use of CTs, MRIs

While Canada is one of the world’s top healthcare spenders, it has fallen into the bottom ranks of industrialized countries when it comes to the acquisition and use of high-tech medical equipment such as MRI and CT scanners.

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Wireless home care

Several companies and a university have teamed up in Newfoundland to devise an ambitious tele-homecare solution that will use cellular-based technologies such as smart-phones and communicators.

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Medical call centres

Nurse-run telephone call-centres are steadily springing up across Canada. They’re providing the public with medical information, and advising people whether a trip to an inevitably overcrowded hospital emergency room is really necessary.

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Global radiology readings

Diagnostic imaging columnist Thomas Hough suggests that with the rise of the Internet, radiology exams could be read and interpreted by the lowest-cost source.


NWT network

The Northwest Territories have created a computer system that connects the majority of its health and social services caregivers.


What’s a SAN?

First there were LANs, WANs and even MANs. Now there are SANs – short for storage area networks. Because they solve important problems, they’re worth knowing about.


Rise of the flat

Flat-panel displays have been standard fixtures in portable computers. They’re starting to appear in desktop computers, too, a trend that’s expected to escalate.

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PLUS news stories, analysis, and features and more.

 

Canada lags behind other nations in use of CTs, MRIs

By Jerry Zeidenberg

VANCOUVER – While Canada is one of the world’s top healthcare spenders, it has fallen into the bottom ranks of industrialized countries when it comes to the acquisition and use of high-tech medical equipment such as MRI and CT scanners.

According to a new study released by the Fraser Institute, a public-policy think-tank, the lack of access to advanced medical equipment could lead to poorer medical outcomes for Canadians, compared with patients in other countries.

“The failure of the medical technology infrastructure means that surgery and diagnostic procedures are delayed, and this results in declining patient health,” said Dr. Bill McArthur, a practicing physician and author of the report, titled The Availability of Medical Technology in Canada: An International Comparative Study.

Canada is the fifth highest healthcare spender in the 29-member Organization for Economic Cooperation and Development (OECD), as a percentage of GDP. But it ranks twenty-first out of 28 countries in the availability of computed tomography (CT) scanners. The average accessibility among OECD nations is 12.9 CT scanners per million persons, well above Canada’s 8.1 scanners per million persons.

Moreover, Canada is nineteenth out of 27 countries in making magnetic resonance image (MRI) scanners available to the public, and nineteenth out of 22 when it comes to lithotriptors (devices that use shock waves to break down kidney stones, making surgery unnecessary.)

Generally, Canada is among the bottom third of OECD nations in availability of technology, the study found. The author based his results on information from the OECD, and by comparing British Columbia with the U.S. states of Washington and Oregon. Other sources included the American Hospital Association, the B.C. Ministry of Health, various federal government agencies and interviews with 400 British Columbia physicians.

According to the report, the smaller installed-base of medical technology in Canada does not reflect a lack of demand for these services. On the contrary, there are waiting lists of weeks to months for many of the major diagnostic and treatment procedures, such as MRIs and CT scans.

The paper argues that the central problem is an insufficient supply of equipment stemming from deficiencies in Canada’s healthcare system, and the way in which purchasing decisions are made, authorized and financed.

“This pervasive technology deficit points to the need for a serious re-evaluation of the way in which healthcare is funded and provided in Canada,” said Dr. McArthur.

According to the study, expanding access to technology in Canada is difficult under the existing system. Administrators of acute-care hospitals receive their budgets from provincial health ministries. They have little leeway in spending, as up to 85 percent of their budgets are consumed by staff and union wages.

Of the remaining 15 to 20 percent, much is consumed by overhead and maintenance, leaving a minuscule amount for capital spending.

Moreover, even when a publicly funded hospital has raised funds to purchase equipment, it is not permitted to charge patients in order to recover operating costs and often the government refuses to pay these.

As well, the private sector is largely excluded from purchasing and operating high-technology equipment because the government-funded payment schemes prevent most private entrepreneurs from billing for services provided.

The study notes that not only are most OECD countries ahead of Canada in the use of advanced medical technologies, but so are nations like Singapore and Israel – countries that maintain very high standards in healthcare technology but are not part of the OECD. (These countries were not included in the survey.)

Technologies examined in Dr. McArthur’s report include diagnostic imaging, cardiac and transplant procedures, and intensive care procedures.

The study found that MRI is a particularly weak area in Canada. In the early 1980s, Canada had a high stock of MRIs relative to other industrialized countries. However, since that time Canada’s position has slipped.

At 1.7 MRIs per million persons, Canada is well below the OECD average of 3.9 per million. “The lack of MRIs in Canada is delaying the diagnosis of many conditions and causing some patients to undergo surgery without a properly defined diagnosis,” asserts the report.

The study notes that in France, the increase of MRIs occurred more rapidly in private hospitals than public hospitals.

In the United States, rapid diffusion of MRIs occurred in clinics not connected to hospitals. Some countries with faster diffusion have also implemented new types of devices, including ‘open’ MRI scanners that do not require complete enclosure of the patient. This reduces the occurrence of claustrophobia, which causes up to 10 percent of examinations to be aborted due to a panic reaction by the patient.

Lithotriptors are also in relatively short supply in Canada. The devices provide physicians with a non-invasive method for removing stones lodged in the kidney or ureter. A lithotriptor bombards a stone with shock waves and breaks it down into finer particles, which the body can then excrete naturally.

However, Canada has only 0.4 lithotriptors per million persons, versus an OECD average of 1.4 per million – more than three times the Canadian level. Italy, for example, now has more than 10 times the number of lithotriptors per capita as Canada, although it spends a smaller share of its GDP on healthcare than Canada does.

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Newfoundland project to test wireless technologies for tele-homecare

By Jerry Zeidenberg

Several companies and a university have teamed up in Newfoundland to devise an ambitious tele-homecare solution that will use cellular-based technologies such as smart-phones and communicators. What’s more, the sophisticated project is likely to implement a variety of leading-edge software tools like Java and Jini from Sun Microsystems, and the EPOC operating system from Symbian.

Called the Wireless Homecare Project, the plan just got off the ground this fall and will involve ‘proof of concept’ testing through one of Newfoundland’s major home-care organizations.

The core partners providing technology and expertise to the project are Siemens Business Services and two Newfoundland information technology companies: Collaborative Network Technologies Inc. and Computers and Communications Ltd.

Siemens Business Services will provide expertise in the development and deployment of healthcare applications as well as play the lead role in the commercialization of the completed product.

For its part, Collaborative Network Technologies brings expertise in the development of distributed Java-based applications and rural information technology deployment, while Computers and Communications offers technology for resource scheduling, accounting and financial management.

The other partners in the project include Telesat Canada, the Communications Research Centre, Futureworks Inc. and Memorial University’s TETRA/Telemedicine group.

Together, they intend to create mobile software for management of home-care organizations and clients, using both ‘back-end’ office software and ‘front-end’ clinical, data capture, and reporting software tailored for cellular and other mobile devices.

And while the system will initially be focused on low-speed text-based information transfer, it will be built to provide additional functionality as new high-speed mobile communications services become widely available, including diagnostic imaging and video.

“By 2002, we expect high-speed mobile technology to be in place, running at 256Kbps to 384Kbps,” said Keith Sheppard, project manager of the Wireless Homecare Project and principal with Collaborative Network Technologies Inc. (On the web at www.colabnet.nf.ca) “That’s fast enough to run video for remote consultations,” he said.

Sheppard noted that the project is designed to solve a problem that plagues home care in Newfoundland and many other parts of Canada. In short, it’s very difficult for a home care provider to support nurses and other staff over a wide geographical area.

In many rural regions, high-speed land-lines simply aren’t in place. But powerful cellular devices can be carried anywhere – and with high-speed capabilities around the corner, nurses will be able to attach medical devices and cameras to their mobile computers and establish real-time conferences with doctors, nurses and administrators from remote locations.

“You could go into the home of a chronic care patient, set up an exam camera or probe, and do a remote exam with a doctor at a hospital or clinic,” said Sheppard.

The partners haven’t yet decided on the type of device with which nurses in the pilot project will be outfitted. Possibilities are the Palm Pilot (handheld computers) or similar Microsoft CE-based handhelds, smart phones (a new generation of voice phones that also have data capabilities), or communicators (small computers that can attach to cellular phones or modems).

The system will be Java-based, meaning that virtually any type of computerized device will be able to tie into it, regardless of the operating system. The network will be an ‘open system’, not tied to the products of any single vendor. Java software was created by Sun Microsystems, and it’s likely that Sun’s Jini software will also be used.

Jini is relatively new software that enables devices to configure themselves into a network, with minimal fuss by the people using the gadgets. Instead, Jini-enabled devices automatically send out signals telling the network that they contain Jini software (a process called automatic polling), and perform various tasks with little additional human intervention. (For more information on this, see Sun Microsystem’s web site at www.sun.com)

For example, a digital camera could be added to the network, with no additional drivers to install, floppies or CD to insert, or keyboard commands to type. Any computer on the network could use the camera, and route the image to a disk drive.

“The advantage is that we don’t have to write specific device drivers, we just write to the Jini specifications,” said Sheppard.

The consortium is also leaning toward the use of Symbian’s EPOC technology, which provides a software platform for wireless devices that occupies little ‘space’ in terms of storage and memory requirements, and is geared to low power consumption – a major issue for portable devices that run on batteries.

The Symbian alliance consists of global giants Ericsson, Matsushita, Motorola, Nokia and British-based Psion, a maker of mobile computing devices. (The Symbian story can be found at www.symbian.com)

The latest version of EPOC includes features such as Internet e-mail, fax, multiple use folders, integration with contact managers, and integration with PCs.

The Wireless Homecare Project builds on ongoing work in Newfoundland and Labrador to provide rural telehealth services using satellite-based delivery to six communities. The cellular technology, however, means that visiting nurses can carry their computers – and later on, medical instruments and video cameras – right into the homes of their clients.

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Medical call centres relieve strain on busy emergency departments

By Jerry Zeidenberg

The trouble occurred last year when Krista Gilman’s daughter Casey switched to solid foods at the age of six months. Unable to pass a bowel movement, the infant became irritable. “She was screaming and crying for two or three days,” said Ms Gilman, 28.

Ms. Gilman and her husband, who live in Winnipeg, had already taken the child to a local hospital a few days earlier and were advised to give young Casey laxatives and suppositories. When that didn’t work, they were about to return to the emergency department.

Instead, they called Health Links, a nurse-run advice line operated at the Misericordia Health Centre, a hospital in Winnipeg. There, a nurse who specialized in pediatrics recommended feeding Casey certain solids, and keeping away from others that are more difficult for infants to digest – such as bananas and rice.

“We had been giving her all of these things,” said Ms. Gilman. “We stopped, and Casey improved in a few days.”

With a phone call, the Gilmans solved their problem – and simultaneously saved themselves a trip to a busy emergency room. What’s more, the telephone conversation with the call-centre nurse eased their minds. “It was our first child, we didn’t know a great deal about child-rearing at the time, and we were scared,” said Ms. Gilman. “But the nurse on the phone was very patient, took his time, and was very helpful.”

Now Ms. Gilman says she and her husband recommend Health Links to all of their family and friends.

Health Links, in Winnipeg, is one of a steadily growing group of nurse-run telephone call centres springing up across Canada. They’re providing the public with medical information, and advising people whether a trip to an inevitably overcrowded hospital emergency room is really necessary.

These medical call centres can take some of the pressure off emergency departments, which are often swamped by patients with minor ailments. People tend to flock to their local hospital when they don’t know what to do about their medical problems – especially after the family doctor’s office closes at 5 pm.

For its part, Health Links started fielding phone calls from the public in 1993 as a pilot project. Since then, it has expanded from one nurse answering calls to a current roster of 26.

One might ask why people just don’t telephone their local hospital for advice when hit with a medical emergency, rather than ringing up a nursing hot-line or showing up at the door of an emergency department.

“Many hospitals won’t take calls of this sort,” says Barbara Featherstone, professional advisor to Health Links. She explained that nurses and doctors at hospitals are used to assessing patients in person, and for the most part, haven’t developed methods of gauging medical problems over the telephone.

By contrast, nurse-led call-centres have devised systems for appraising the severity of symptoms over the phone, and use special software or texts with decision trees – sets of questions that quickly narrow down a problem to its essence.

As a result, if you do call a Winnipeg hospital with a medical problem, you’re likely to be referred to Health Links. “Seventy-one percent of the calls we get are referred to us by hospital emergency departments,” said Ms. Featherstone. “They don’t want to take these calls, they want to deal with the patients they have at hand.”

Similarly, hospitals in other cities are referring callers to nurse-run hot-lines to handle questions from nose bleeds and insect bites to broken bones and chest pains. The job of the telephone-based nurse, however, isn’t to discourage people from visiting an emergency department. Instead, it’s to perform ‘triage’ – an assessment of the severity of the problem – and to determine if a trip to the ER is needed.

“Quite often, we urge callers to rush to a hospital, and we’ll ask if we can help arrange the transportation,” said Dr. James Broad, chief operating officer of Fonemed Canada Inc. of Toronto. In January, the company opened a medical call centre in St. John’s, Nfld., that serves Canada and the United States.

However, Dr. Broad noted that, “In 40 percent of the cases, we can encourage people to do something less intensive,” such as waiting until the morning to see their family physician.

He noted that many of these callers have low-grade infections, fevers or aches and pains from sports injuries. Their first instinct is to rush to hospital, when often enough, treatment could wait until the next day.

Dr. Broad said these people simply need to be reassured that their dilemma isn’t life-threatening. “They have anxiety, because they’re uncertain about their situation. We give them enough information to reduce their fears, and we match them with the right intensity of service.”

Fonemed currently employs 13 nurses at the facility in St. John’s. So far, the company has been marketing its services to U.S.-based health maintenance organizations (HMOs) seeking to reduce the pressure on their hospitals, as well as private companies, such as electrical utilities, who offer it to their customers as a value-added service.

Fonemed is currently gearing up for more activity in Canada, as provincial governments here fund medical hot-lines to reduce non-urgent visits to hospital emergency departments.

In February, for example, the government of Ontario launched a $4.9 million tele-triage pilot-project in North Bay. The 35-person facility handles health-related calls from the province’s 705 and 807 telephone exchanges – a region with about 900,000 residents.

Trained nurses, assisted by medical software, provide service 24 hours a day, seven days a week, to callers over 1-800 lines.

The North Bay nursing hot-line is expected to dramatically improve the workings of local hospitals, as they won’t be slowed down by as many minor cases, said Christopher Dean, president of Clinidata Corp., of London, Ont., the company that operates the call centre.

Residents of northern Ontario will also save time, inconvenience and expense when they discover a visit to the hospital is not needed, he said.

“There’s a high cost for a person to go to an emergency department,” asserted Mr. Dean. “Many calls are pediatric-related, and the parents of young children often have to leave work early, get a baby sitter and take a cab to the hospital. It can become expensive.”

He noted that a call to a tele-triage nurse could determine, in some cases, that a child can be monitored at home or taken to the family doctor the next day.

Knowing when to offer advice, and when to urge a patient to see a doctor, requires professional training.

“We’re not diagnosing the origin of problems over the phone, but we are assessing the severity of problems and advising people about the best action to take,” commented Heidi Bilas, who is program supervisor at Toronto-based Centennial College for one of Canada’s first ‘tele-nursing’ programs. The Telehealth Nursing Program, which started in September, is training professional nurses how to assess symptoms and provide advice over the phone.

She noted that when callers complain about certain symptoms, such as chest pain, tele-triage nurses are likely to urge immediate medical attention and help arrange transportation to a hospital. But in other instances, the caller might need instructions about how to administer Tylenol to an infant, cope with a bee sting, or provide first aid to another person. “All of this can be done over the telephone by a trained nurse,” said Ms. Bilas.

As well, telehealth nurses can play an important role as information brokers. “Some people need referrals to other sources of information, such as breast feeding clinics, poison lines, or health promotion services,” said Ms. Bilas.

She emphasized that nursing lines are not intended to replace emergency rooms for those who need them. “They assess the seriousness of a caller’s problem, and direct people to the most appropriate level of care,” she said.

She added that telephone-triage lines sometimes provide help to people who otherwise wouldn’t receive it. For example, family members might call about a relative who is showing serious symptoms but won’t go for emergency care.

“Many people will deny that they’re having trouble, such as chest pain,” said Ms. Bilas. “A tele-triage nurse will recognize serious symptoms right away, and will offer to call an ambulance or a relative on behalf of the person.”

Some nurse-run call-centres even assign medical devices to patients for quick monitoring of chronic conditions. MediNovum, a Montreal-based unit of Bell Canada, provides portable electrocardiograph (ECG) devices to clients with heart ailments.

If these clients have any unusual feelings, they can take a reading and download the information – over the telephone – to a nurse at the MediNovum call centre. The nurse can then determine if the ECG is abnormal and advise the person about seeking help.

MediNovum is using medical devices and its call centre to monitor a range of chronic ailments, including asthma. Patients use mobile spirometers – which measure lung capacity – to keep tabs on their conditions, and send the results to nurses at the call centre for interpretation.

Dr. Geoffrey Heseltine, executive vice president of MediNovum, said the tele-monitoring service could shift a good deal of patient care from hospital emergency rooms to family physicians – a less expensive form of care for the health system.

According to Dr. Heseltine, many patients with chronic ailments delay going to their general practitioner when they have a problem, because they feel that sitting in the waiting room takes too much time. However, they often wind up in emergency departments because they let their conditions deteriorate.

By contrast, patients are more likely to check on the status of their heart or asthma condition if they can get attention through a quick phone-call to a nurse-run call centre. “If the problem turns out to be serious, he or she is more likely to seek immediate medical attention from a family doctor when the telephone-triage nurse urges this course of action,” said Dr. Heseltine.

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Flat-panel displays in desktop workstations will become popular

Flat-panel displays have long been used in notebook and other portable computers. But now they’re being built into desktop systems, as well, to reduce the amount of space taken up by computers in the work area. These systems may be particularly useful in the medical field, since hospital and healthcare rooms are typically cramped for space.

Overall, the ‘flat-panel’ desktop computer appears poised for rapid growth. According to a new study by California-based Stanford Resources Inc., the value of the flat-panels used in desktop applications will grow at a compound annual rate of 32 percent from 1999 to 2005, increasing from US$2.3 billion to US$12.1 billion worldwide.

The report, Flat Information Displays 1999, notes portable computers are currently the largest application area for flat panel monitors, but that shipments of desktop computers outfitted with the flat displays will overtake them by 2003.

Overall, the value of flat-panel monitors currently being shipped will jump from US$12.9 billion in 1998 to US$16.9 billion in 1999.

Among other trends noted in Flat Information Displays 1999 are the following:

• The gas plasma display panel market will grow rapidly, reaching US$5.2 billion in 2005, when it will surpass the passive matrix LCD market to become the second largest segment (behind active matrix LCDs).

According to the report, the colour plasma display panel (PDP) has arrived at the close of this century to offer one of the most highly anticipated products of our generation: the hang-on-the-wall high-definition TV set. Besides the well-entrenched market for televisions with conventional CRT technology, PDP technology, in sizes up to 60 inches diagonal, has a strong lead over other flat panel displays in the battle for the enormous consumer television market.

• Rapid developments in organic light-emitting diode (OLED) technology are driving a high-growth forecast for this new display type, from US$3 million in 1999 to US$717 million in 2005.

An OLED is a type of flat panel display that uses organic material as a diode type of light-emitting material. Key advantages include low power consumption, high luminance, vivid colours, and capability for integration on silicon integrated circuits to provide a system-on-a-chip capability.

Some observers say that OLEDs may eventually overtake and replace the LCD technology in the flat-panel display marketplace.

Because of the potential of this technology, the U.S. government has been funding U.S. companies developing OLED to re-establish American leadership in the production of flat-panel displays. Over the last two decades, companies in East Asia have become the dominant producers of flat-panel displays, chiefly in the area of liquid-crystal technologies.

• Electroluminescent (EL) displays are expected to remain at US$110 million throughout the forecast period. The primary reason is the increased competition from the active matrix LCDs in medical and industrial applications.

• The field emission display (FED) forecast has been scaled back and is now projected to reach US$65 million in 2005. This is due to manufacturing problems in 1998 and early 1999, as well as the decreasing price/performance ratio offered by active matrix LCDs.

• The value of microelectromechanical systems (MEMS) displays is estimated to be US$85 million in 1999, rising to US$217 million in 2005. This new technology category has growth potential for business presentations and televisions.

Flat-panel displays using MEMS is an exciting technology that could significantly alter the monitor business in the years to come.

Using this technology, tiny moving parts are actually built onto the surface of a silicon chip. When stimulated by electrical signals, and illuminated by appropriate optics, these micro-machined parts can create a high-definition display.

And while traditional LCDs are costly to produce in large formats (anything over 15-inches diagonally seems to create problems for the manufacturers), MEMS displays are in theory easy to build in large sizes.

One developer notes that an LCD screen for high-definition TV would require the production of 2 million physical pixels. By contrast, a MEMS display would require only 1,000 pixels to deliver the same image quality.

Stanford Resources can be reached by telephone at 408 360-8400 or via the web at www.stanfordresources.com

 

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