Inside the September 2002 print edition
Canadian Healthcare Technology:
Feature Report: Electronic commerce in healthcare
Ontario launches large-scale radiology network
A new, computerized network for sharing medical images in Northern
Ontario is expected to save many sick patients from car trips that are up to five hours
long when they need to see radiologists at the regions major hospital in Timmins,
Canadas first PET/CT
St. Josephs Health Care and the Lawson Health Research Institute,
in London, Ont., have together acquired an integrated PET/CT scanner. The device takes
both types of images, and fuses them into a single, 3D picture.
IT in Quebecs clinics
Public health clinics (CLSC) throughout Quebec have started using a
computerized tool that allows them to monitor their patient-case performance by using
graphical charts. Its believed the system will improve both patient care and
New Brunswicks Atlantic Health Sciences Corp. has developed an
intranet-based system providing 24/7 access to courseware across a multi-site,
geographically widespread region.
READ THE STORY ONLINE
QUAIL researches wireless
Queens University Anesthesiology Informatics Lab, working in
conjunction with the Kingston General Hospital, has devised methods of using wireless,
mobile computers that save time for physicians and improve patient care.
PLUS news stories, analysis, and features and more.
Northern Ontario launches large-scale radiology network
By Jerry Zeidenberg
A new, computerized network for sharing medical images in Northern
Ontario is expected to save many sick patients from car trips that are up to five hours
long when they need to see radiologists at the regions major hospital in Timmins,
Not only will the system eliminate uncomfortable and hazardous drives
in harsh northern weather, but it will also result in faster medical diagnosis and
treatments for patients, doctors say.
Nine medical centers are participating in the NORrad (Northern
radiology) network, launched earlier this year, in an area of 150,000-square-kilometers
that reaches as far as Moose Factory on James Bay. Other hospitals are located in Hearst,
Kapuskasing, Kirkland Lake, Cochrane, Iroquois Falls, Matheson, and Smooth Rock Falls.
There are only two radiologists serving this territory, and both are
based at the Timmins & District Hospital.
In the past, when patients turned up at a remote hospital emergency
room with complicated ailments, the local ER physician was unable to obtain a diagnosis
from a radiologist because there was no way to send high-quality images to Timmins.
As a result, doctors would often send patients directly to Timmins
by car or air ambulance. Patients would receive the attention of radiologists, but
the process could take hours.
However, with this years installation of the NORrad Picture
Archiving and Communications System (PACS) said to be the largest medical imaging
network in North America images can be sent over high-speed telecommunications
lines, while the patients remain in their hometowns.
Radiologists in Timmins can receive the pictures in seconds, make sense
of them, and report back to doctors in Moose Factory, Cochrane and other centres
all at the touch of a few computer keys.
This means were moving the patients information
instead of the patient, said Dr. Claude Vezina, director of diagnostic imaging for
the nine hospitals making up the NORrad network. Its a huge benefit, because a
family doctor in a small center suddenly has access to a radiologist 24 hours a day, 365
days a year.
If something doesnt look right with a patient, the
physician can send images to us in Timmins, said Dr. Vezina. Actually, if we
want, three or four physicians can view the images at the same time on computers, all in
different places, to determine whats wrong with the patient and to decide on the
best course of treatment.
In the end, it often means the patient can stay where he or she
is, said Dr. Vezina, which saves the patient a good deal of time, worry, and the
expense of the trip. And as a result of the quick feedback from radiologists, treatment of
the patient can also begin much sooner.
NORrad is the result of four years of planning and fund-raising.
Its a $10 million project, with money chipped in from the federal and provincial
governments, along with hospital budgets.
The partners evaluated several systems, but decided on PACS technology
from Agfa Inc., of Toronto. Interestingly, Agfas PACS software was developed by a
company it owns in Waterloo, Ont. Sold worldwide, the Canadian-designed technology has
made Agfa a leader in the fast-growing medical imaging marketplace.
Indeed, a study conducted by Toronto-based Canadian Healthcare
Technology magazine in 2001 discovered that while only 15 percent of Canadian hospitals
had a PACS network last year, 48 percent said they would have one by the end of 2002.
Sending computerized medical images over long distances such as
in Northern Ontario is much easier when high-speed telephone lines are available.
Dr. Vezina noted that Northern Telephone Ltd. recently upgraded its lines in the region to
include high-capacity ATM capabilities, largely to accommodate the needs of the medical
community and their plans for sending and receiving big diagnostic imaging files.
Without high-speed lines, a medical imaging system can sputter to a
crawl when trying to process large picture files.
A layperson might wonder why specialized PACS software is needed for
storing and transmitting medical images, when it seems a standard database might do the
Brian Fullan, informatics business manager for Agfa, explained that the
software contains many features that make it easier for radiologists to conduct their
For example, when the radiologist in Timmins receives a patient file on
his computer, the PACS network will automatically query a centralized image archive
containing hundreds of thousands of pictures to retrieve the patients previous
images called studies for comparison.
This way, the radiologist can compare current X-rays, ultrasounds or
MRI scans with those taken three months ago or even a year ago. He or she can more easily
determine if there have been changes in anatomical structures such as improper
healing or the emergence of tumours.
This pre-fetching of images eliminates hours of searching on databases for the
radiologist, said Fullan.
Moreover, the PACS software contains dozens of specialized tools for
viewing images on workstations, including the ability to display multiple images, to
zoom-in and out on structures, and to adjust the contrast. As well, there are different
tools for various types of exams such as X-rays, MRI, ultrasound and CT.
Each of the nine participating hospitals will receive an Agfa IMPAX
medical imaging system, as well as computed radiography technology for automatically
converting X-ray images to digital format.
Other medical imaging scanners, such as ultrasound, CT and MRI, are all
based on computerized technology and mesh well with PACS systems.
However, X-ray systems have traditionally used cameras and film.
Agfas computed radiography system replaces the film, and converts the X-rays to
digital format, making the images ready for storing and transmittal on computerized
According to Agfa, the hospitals will also receive specialized
workstations for viewing images. While any computer monitor can display the pictures, the
workstations will offer much higher resolution and more tools for reviewing and analyzing
According to Dr. Vezina, the advantages of NORrad have attracted the
attention of other hospitals in Northern Ontario, and plans are now being made to expand
the network to include additional medical centres.
He stressed that the technology is helping to dramatically improve the
quality of care for patients. NORrad will reduce the barriers created by geography,
so that the level of care will be closer to that provided in Ontarios urban
centres, said Dr. Vezina.
Hybrid technology helps diagnose patients earlier, more accurately
By Neil Zeidenberg
LONDON, ONT. St. Josephs Health Care, a teaching hospital,
and the Lawson Health Research Institute have together acquired Canadas first
machine that combines PET and CT technologies. By amalgamating the two systems, doctors
can acquire scans that contain more information than before, enabling them to see and
diagnose diseases much more accurately.
We are very excited to be the first hospital in Canada to provide
this type of diagnostic technology, said Cliff Nordal, CEO of St. Josephs
Health Care. While there are many CT scanners in Canada, there are only about a dozen PET
machines scattered across the country, and no others that actually use the two
technologies together to create a single picture.
By way of background, CT technology produces a type of X-ray image that
shows physicians the structure of bones and tissue in the body. PET technology, on the
other hand, shows metabolic differences in the body, and requires doctors to inject traces
of radioactive isotopes into the bloodstream.
These isotopes are attached to sugar molecules, which are absorbed more
quickly by fast-growing cancer tumours, for example, than by healthy tissue. As a result,
the PET scanner will detect a burst of radioactivity at the site of the tumour, thereby
allowing doctors to determine the location of the problem and a course of treatment.
Many radiologists believe that merging the two types of pictures
actually superimposing one on top of the other provides a powerful tool for
diagnosing and treating cancer, heart disease, and a host of other ailments.
Initially, the machine at St. Josephs Health Care will be used in
research trials. These tests will involve oncology, cardiac and neurology patients, and
will be used also to develop a reimbursement structure for doctors and the operating costs
for the machine.
The PET/CT scanner, called the Discovery LS, was provided by GE Medical
of Mississauga, Ont. The system incorporates GEs LightSpeed CT Plus with its Advance
NXi PET system.
The device captures a patients functional and anatomical
information in a single examination. At sites in the United States which have both CT and
PET scanners, this information typically requires multiple procedures, in separate
machines, that are performed over days or sometimes weeks.
Using the new system, however, the patient first receives a CT scan, a
procedure that takes roughly two minutes. Next, a PET scan is performed and completed in
about 20 minutes. Finally, within five minutes, the two images are fused together to
create a 3D image.
This all takes place with the patient housed in a single machine.
Weve cut the procedure times down from between one-to-two
hours to about 25 minutes, a dramatic improvement, said Tom Hook, general manager,
functional imaging, at GE. The result is less movement by the patient, hence better
In CT and PET scans, the less the patient moves, the less blurring in
the image produced.
According to Hook, test results on patients have been excellent. The
ability to pinpoint the exact location of tumors in the body has improved by 60 percent,
and diagnosis of the type of lesion has improved by 40 percent. Moreover, hybrid scans can
alter the course of treatment and management of cancer patients in one of three cases.
Its very helpful to know exactly where that cancer is. You
may have a sense of its location with a CT, though not all tumors are cancerous. And not
all cancers are clearly positioned by PET alone, said Nordal. By having a
clear and accurate picture, it should really help the surgeon determine how exactly
theyre going to proceed during the operation.
For the patient, it means potentially fewer invasive procedures and
unnecessary surgeries, reduced anxiety, and shorter examination times. For the physician,
the combined image can provide more information more quickly, leading to fast, accurate
diagnosis, treatment planning and treatment monitoring.
Currently, patients in London must travel to Hamilton to receive PET
scans and then return to London for their CT scans. The trouble here is that the
radiologist or oncologist would then superimpose the images together in their minds, since
theyre done at different times. As a result, the images may not be calibrated
identically, which can lead to inaccuracies. However, the new, hybrid technology
eliminates these problems.
Its an interesting technology, Nordal said. I
think this is the area where scanning is moving forward for certain types of work.
Certainly brain scans, cardiac and cancer will be the top three areas that this will be
A cyclotron, which is needed to manufacture the radioactive isotopes
necessary to perform PET scans, is currently located at McMaster University in Hamilton.
However, London will eventually have its own cyclotron, thereby giving it rapid access to
According to Nordal, cyclotrons are becoming much smaller and compact
and dont require nearly the space and resources that they did decades ago.
They are becoming instruments that are more affordable and will be required as
PET/CT scanners are licensed in various academic centres across the country.
Though exact numbers were not disclosed, the price of the Discovery LS
is upwards of $5 million and includes some very powerful software to help operate the
scanners. The software platform, called eNTEGRA, allows for preventive, predictive and
corrective maintenance of the scanner online from a remote center.
At the time this story was written, 65 Discovery LS hybrid scanners had
been installed throughout the globe, though 100 have been sold.
Intranet-based e-Learning strategy developed at Atlantic Health Sciences
By Anne Kilfoil
In these times of reduced resources and increased demands, the Atlantic
Health Sciences Corporation (AHSC), like most other Canadian healthcare institutions, has
explored options to improve learning opportunities for its staff. The launch of the AHSC
corporate Intranet in 2000 offered an opportunity to meet this challenge through the
introduction of web-based learning.
The AHSC Intranet provides the infrastructure to effect internal
business advantages, acting as a single entry point for access to existing legacy
databases and systems and enabling business processes, knowledge sharing and access to
just-in-time information. The e-learning strategy is an integral component of the AHSC
Intranets overall goals and directions.
The AHSC e-learning strategy aims to provide:
24/7 access, especially relevant in a hospital environment
equal access across AHSCs multi-site, geographically
just-in-time, on-demand learning for busy staff unable to attend
scheduled classroom training
a cultural shift in empowerment of users (i.e. pull versus
the ability to illustrate systems relationships by hyperlinking
related resources, such as corporate policies and other business applications
A registration process is built into each learning program.
Participants are prompted for online registration only after successful completion of the
learning quizzes. This registration data is automatically submitted to a training
database. Periodic reports are compiled and sent back to managers to facilitate monitoring
of compliance with required learning programs.
E-learning initiatives are managed by the Department of Organizational
Learning. To date, 20 programs have been developed, including blended clinical programs
(advanced nursing competencies and delegated medical functions), management development
and culture development (Ethics, Time Management, Presentation Skills), and required
safety training (WHMIS, Codes Training).
Learning programs have been adapted to meet the requirements of
individual programs delivered as a 100 percent self-directed program, as a
pre-requisite to classroom learning, or as a component of blended learning,
which combines self-directed e-learning with a real-time or virtual classroom.
Getting Started: Following the positive feedback
arising from a six-week Intranet pilot evaluation, an assessment of e-learning acceptance
was initiated on two nursing units.
Conducted over a period of five weeks, this Virtual
Classroom pilot provided participants with a choice of five e-learning programs
developed by a third party vendor. Surveyed on their interest in future e-learning
opportunities at the conclusion of the pilot, 38 percent of participants said that they
were very interested, 48 percent were highly interested, 13 percent were somewhat
interested and 0 percent indicated no interest. Further assessment indicated that
self-directed web based learning was preferred over classroom-based learning.
In addition to readiness, technical competence was also assessed. An
organizational computer-literacy assessment indicated that potential users possessed the
required skills to move forward. Basic web skills training opportunities are ongoing.
The first program introduced to the corporation was the WHMIS training
program. Because WHMIS training is an annual requirement for all AHSC staff, it offered
the greatest cost-benefit potential. Other programs soon followed. In addition to the 20
programs available to date, a dozen more are currently in development or undergoing
pre-launch user testing.
Resourcing: The Learning Facilitators, trained adult
educators, developed competency in e-learning program design and management through
self-directed reading and attendance at conferences. One facilitator, Barbara Mannette,
received certification in web based training and acts as the e-learning facilitator.
There is a full time web developer dedicated to facilitating e-learning
and a partnership with the New Brunswick Community College and other training institutes
to provide work experience opportunities to web design students.
Front Page is used as the development tool. Because most of the PCs in
the organization are not equipped to accommodate multimedia, we are not incorporating
streaming at this time.
Almost half of all e-learning programs are developed in partnership
with a clinical or subject specialist content owner. The content owner is
responsible for the currency and accuracy of the information presented. The e-learning
facilitator develops the program, working with the web designer. In most cases,
Organizational Learning staff also act as content owners.
While the department explored the option of purchasing web-based
learning programs, it decided to develop its programs in house. This decision was reached
following a cost-comparison analysis that indicated greater efficiencies could be realized
at AHSC with in-house development.
It also allowed for customization of the programs with regards to
integration of organizational policy, values and culture, and, hyperlinking with other
Intranet resources such as policies. In-house development is not cost-efficient in every
case, however. Economies of scale require minimum participant numbers to realize the cost
Evaluation: All e-learning programs are beta tested
for content and navigation for six weeks by the e-learning facilitator, utilizing online
Some programs are also subjected to focus-group testing. Again,
feedback is encouraging, as 91.5 percent of users rated navigation of the e-learning
programs as excellent or good.
Anne Kilfoil is Project Lead, AHSC Web Applications and Director,
Researchers model for wireless medical computing offers many benefits
By Dianne Daniel
KINGSTON, ONT. Researchers at Kingston General Hospital and
Queens University have created a model for wireless, medical computing that not only
saves time and money, but also improves charting timeliness, order tracking and
prescribing, drug error and data collection.
One pilot project shows we can collect 30 percent more data in a
standardized format in a third less time, so that means technically, I can see more
patients, said Dr. Goldstein, medical director of the two-year-old Queens
University Anesthesiology Informatics Laboratory (QUAIL) project.
Dr. Goldstein, an anesthesiologist and professor in the Departments of
Anesthesiology and Surgery at Queens, said: At a time when doctors have no
time, no money, no beds and no resources, anything we can do to be more efficient is
The QUAIL project originated as a peri-operative anesthesia acute pain
study, with the aim to create a database of crucial patient information that can be
accessed by nurses, pharmacists, anesthesiologists and physicians at various stages of a
patients surgical treatment using a secure wireless infrastructure supported by
various mobile devices.
Working closely with hospital staff, researchers have developed
wireless point-of-care clinical applications in the areas of Patient Self-Assessment,
Pre-Operative Consultation, Intra-Operative Monitoring and Post-Operative Care.
For example, patients participating in a QUAIL study were asked to fill
out self-assessment questionnaires prior to surgery using either a PC in their
surgeons office, a laptop, personal digital assistant or large tablet kiosk,
creating electronic files that were stored in a central server at the hospital.
When those same patients arrived at the Consult Clinic days, weeks or
months later, their personal information was automatically available via handheld devices
to the clinic nurses and pharmacists who performed the pre-operative assessments using
handhelds at the bedside to update the computerized files with the new information
all of which was later available to the anesthesiologist, simply by scanning a
patients barcode bracelet or entering their hospital ID number on a PDA.
So when I ask my questions, I dont ask the first questions
anymore, notes Dr. Goldstein. In other words I wouldnt ask Do you
have high blood pressure, because the patient would answer that themselves on a
Web-based device. And I wouldnt ask Is your pressure well controlled or what
medications are you on, because that would be asked by the nurse and the pharmacist.
What I would ask is Have you ever had any problems with high blood pressure
resulting in stroke or heart attack?
Then, during surgery, the same pre-operative assessment information
automatically populates software called the Automatic Record Keeper, alleviating
anesthesiologists of the pain-staking task of recording such information by hand. The
Automatic Record Keeper is also linked to the anesthetic machine, so that physiological
variables like heart rate, blood pressure and temperature are automatically downloaded to
the patient record as well, which is integrated to the hospitals main network
including lab, pharmacy, imaging and operating room booking software.
According to Dr. Goldstein, quicker access to more accurate information
not only helps anesthesiologists develop better strategies related to which anesthetic to
use on which patient ultimately leading to pain-free recoveries with little or no
side effects but will also help to create best practice, evidence-based approaches
to peri-operative pain management in the future.
The intent is to create a wireless model that can potentially be used
by any hospital, with the hope of creating one large database QUAIL refers to as the
Portable Health Intelligence Network. While the goal is to remain technology-independent
so that QUAIL-developed applications will work on any device under any operating system,
the model currently in place at Kingston General uses wireless access points from Avaya
Corp., Compaq iPAQ Pocket PCs from Hewlett-Packard Co. and the Windows CE operating system
from Microsoft Corp.
The informatics laboratory is a research-based group thats
looking at possibilities for introducing wireless technology into healthcare settings
through the use of PDAs, says Dr. Goldstein. What weve shown is a model
thats tested for use by the acute pain service at the Kingston General where
patients can benefit from the use of PDAS in a wireless environment.
Other areas currently being investigated by QUAIL include using
wireless information to improve the treatment of stroke patients, as well as to create
better communication channels between palliative care doctors and community workers like
the Victorian Order of Nurses.
The hope of the researchers is that other hospitals will begin to take
note of the work being done, and will begin to investigate handheld technology for their
For its part, Mount Sinai Hospital, in Toronto, is one facility
conducting several different studies, primarily in the areas of critical care and
respirology, in an effort to find out what information doctors find useful on a handheld
computer and what format is most effective for delivery of that information.
There are a lot of people out there (in healthcare) using
handhelds, says Dr. Stephen Lapinsky, associate director of the intensive care unit
(ICU) at Mount Sinai Hospital in Toronto, who estimates somewhere between 30 and 50 per
cent of physicians currently carry some type of PDA. We believe it does help them,
but it would be nice to have the data to prove it.
One study, co-sponsored by the Ontario Hospital Association Change
Foundation and Bayer Pharmaceutical Co., involves the intensive care units of four Toronto
hospitals in an effort to ascertain whether or not mobile access to reference information
actually improves patient care. Under the study, critical-care doctors at the four sites
are being supplied with handheld units and given access to a critical-care database
created and maintained by Mount Sinai.
As Dr. Lapinsky explains, the intent is for doctors to connect to the
Internet before beginning critical-care rounds in order to download the latest information
from the database, including up-to-date information on unusual diseases and management
guidelines. Mount Sinai researchers will then run case scenarios in a simulated
environment to determine whether access to the information ultimately impacts patient
care. While the premise is the handheld computers will ultimately lead to better care, Dr.
Lapinsky is quick to point out that isnt always the case.
It all sounds very good and theres a lot of hype out there
that this is the way to go, but we have found some challenges, he says. Not
everyone finds this is optimal for them.
According to Steve Goldberg, a management consultant with INET
International Inc. of Thornhill, Ont., one of the significant challenges as hospitals move
forward with efforts to implement handheld technology is getting collaboration from all
interested parties, including physicians, research centres, government associations, IT
management and IT manufacturers, so that any new handheld implementation will complement
existing mobile strategies.