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Inside the September 2003 print edition of Canadian Healthcare Technology:

Feature Report: Internet and connectivity trends

Canada Health Infoway begins a new round of funding

To kick off its third round of investments, the Canada Health Infoway has partnered with organizations constructing region-wide Picture Archiving and Communication Systems (PACS) in Southwestern Ontario and British Columbia.


Quebec’s RIGIC

An $8 million pilot project in Trois-Rivieres and Shawinigan is enabling physicians and other healthcare professionals to quickly access lab, diagnostic imaging and medication information about patients on browser-like systems.


Integration, BC-style

The Interior Health Authority’s integration of 19 different business systems into a unified entity involved an investment of $3.2 million but has led to annual savings of $4.3 million.


Web-based medicine

In a large-scale project spread across many U.S. states, insurance companies have been compensating physicians for delivering healthcare to patients using the Web. The project has benefits for patients, doctors and payors.

Ultrasound trends

Ultrasound technology has rapidly improved in recent years, delivering better imaging quality and enhanced features. The size of the machines has also decreased, enabling technologists such as John Peacock to fly into remote communities to provide U/S services.


PLUS news stories, analysis, and features and more.


Canada Health Infoway begins a new round of funding

By Jerry Zeidenberg

TORONTO – To kick off its third round of investments, the Canada Health Infoway has partnered with organizations constructing region-wide Picture Archiving and Communication Systems (PACS) in Southwestern Ontario and British Columbia.

The investments are of an undisclosed size – details are still being worked out and the final contributions to the projects will likely be announced this fall.

The projects are part of Infoway’s latest wave of partnerships that will see the agency invest $135 million in a total of nine diagnostic imaging and pharmaceutical systems.

The two regions that won funding – the Thames Valley group of hospitals in Southwestern Ontario and the Fraser Health Authority in British Columbia – are seen as prototypes for ‘shared services’ projects that can bring the benefits of electronic medical images across wide geographical areas.

They’re also seen as purveyors of cooperative ‘governance’ structures that could be replicated in other regions of Canada.

For its part, Infoway would like to see the creation of a ‘pan-Canadian’ system of interoperable health records in five to seven years. The network, as envisioned, will connect various types of healthcare providers, including hospitals, physicians and continuing-care centres. And if all goes according to plan, the system would consist of various components, such as medication histories, lab reports and diagnostic imaging results.

Infoway has so far been funded with $1.1 billion by the federal government. It’s using the money to seed the growth of electronic health-record projects that show great potential for improving patient care and whose methods could be transferred to other sites across the country.

Regarding the planned investments in Southwestern Ontario and British Columbia’s Fraser Health Authority, “These are optimal places for us to help put diagnostic imaging networks in place,” said Myrna Francis, interim president and CEO of the Canada Health Infoway.

“They’ve already had experience with a shared services model, they’re widely dispersed geographically, and they’ve got large enough populations to adequately test the systems and produce meaningful results.

“They’ve also had a good deal of experience with change management, and they both have physician leadership that’s supportive of the projects.”

Ms. Francis explained that Infoway favours geographically large projects as a way of extending the benefits of electronic systems – which to date have largely been concentrated in large, urban hospitals – to medical centres across the country. “PACS in particular is quite an expensive technology,” she said. “Yet, most of this country is comprised of small hospitals. A shared services approach allows you to bring the technology and all of its benefits into the smaller centres.”

She noted that with hospitals assembled into shared services organizations, the overall cost of the systems can be reduced, as well, much in the way that a buying group can obtain steep discounts.

She agreed that technology is only one component of an IT project, and that the human factors – support, training and change management – are critical to the success of any implementation.

If the technology goes in, and people aren’t using it for one reason or another, the project can hardly be deemed a success.

That’s why 20 percent of the amount contributed by Infoway will be dedicated to areas such as change management and knowledge management.

Ms. Francis said that a good deal of on-going assessment and monitoring has been built into the business plans of the projects, to ensure that the networks meet their expectations at each step of the way – and that taxpayers’ money has been invested wisely.

She stressed that the funding is ‘gated’, meaning that project managers must meet certain agreed-to targets – such as end-user adoption and impact on care – in order to receive the next tranche of funding. “We don’t want a situation where the systems are implemented and no one is using them,” she commented.

For its part, the Southwestern Ontario group of hospitals – which includes London Health Sciences Centre and St. Joseph’s Health Care in London – will link eight hospitals into a PACS network over the next 18 months. Its preliminary plan anticipated an investment of $35 million, but part of the funding includes updated modalities – such as digital x-ray systems – for some of the hospitals.

That’s because getting full benefits out of a computerized network for diagnostic images means that hospitals must be able to quickly send digital images. Older equipment in some locations still relies on film.

It’s yet to be decided how much of the investment will be contributed by Infoway, but in any case, the project can be considered a large-scale investment in digital imaging systems. It’s also slated to get even bigger, as the plans call for extending the shared service to a total of 22 regional hospitals in a subsequent phase, noted Diane Beattie, vice president and chief information officer for LHSC and St. Joe’s.

On first glance, the most difficult part of a project of this size might appear to be coordinating the partners – especially in Ontario, which hasn’t ‘regionalized’ its hospitals into formal groups or health authorities. As a result, provincial hospitals – in some cases – guard their independence.

However, Ms. Beattie observed that in the case of the eight hospitals launching the PACS network, the CEOs had already decided to cooperate on a wide variety of issues and meet monthly as the Thames Valley group of hospitals.

“When working together in groups, small hospitals are always worried that the big hospitals will dominate, but at the same time, the larger hospitals are wary of the small centres – they worry that they will bear the total cost and responsibility to establish systems across the continuum of care.”

She said that the Thames Valley hospitals have been working on procedures that make all parties comfortable. “We’re developing a mutual understanding and lessons that can be passed on to others,” she said.

Ms. Beattie is a member of the Thames’ executive coordinating committee, and notes that it already had plans in place to create common IT platforms before winning the Infoway funding. “Diagnostic imaging is just the start of where we want to go,” she said. “We’re planning common platforms in business and clinical systems.”

She noted that cooperation and technology transfer has already worked between London Health Sciences Centre and St. Joseph’s Health Care, London. Recently, LHSC established its PowerChart results viewer – for lab and radiology – at St. Joseph’s Acute Care site. “We put 1,200 new users onto the system at St. Joe’s, in addition to more than 8,000 who are using it at LHSC,” she said. “It was all done in four months, even with the SARS crisis in full force, and the project still went through smoothly.”

Now, said Ms. Beattie, the technology transfer will flow the other way. St. Joseph’s has been using a PACS, and the know-how gained with it will be transferred to LHSC and the other partners.

She pointed out that the Thames Valley hospitals already have a secure, high-speed network called LARGnet that can be used to transmit radiological studies, along with other files. When the PACS is expanded further to reach an additional 14 hospitals, the plan is to use the government of Ontario’s Smart Systems for Health network.

At the Fraser Health Authority, in British Columbia, there was agreement among executives and staff at the 12 hospitals that a region-wide PACS was the way to go. “We’re well past the stage of trying to convince people that PACS is a good thing,” said Bill Dow, administrative director, medical imaging. “People here know that we need it – from clerical staff to senior radiologists. They’re totally excited about it happening.”

Mr. Dow noted that there’s also a good deal of support from physicians in many departments – such as emergency and family physicians. For these doctors, images will be available much faster in the emergency department, and reports will be accessible more quickly for general practitioners.

For its part, the Fraser Health Authority – which conducts some 600,000 diagnostic imaging exams a year – is seeking to implement a PACS as cost effectively as possible, while striving for the best quality obtainable. To do this, it’s making Web technologies a big part of the solution.



RIGIC project allows quick access to a variety of patient information

By Jerry Zeidenberg

TROIS-RIVIERES, QUE. – Few healthcare professionals would turn down the chance to access patient lab results, radiology reports and medication information from a single computer workstation. Especially if the data could be reached quickly and easily – using the point-and-click techniques of a browser.

It would mean that instead of waiting for paper reports that often take hours or even days to arrive, doctors could rapidly obtain the information they need to order the next round of tests or therapies for their patients.

While many hospitals and health regions are talking about implementing this kind of integrated system that provides fast-access to various types of computerized information, the Centre hospitalier regionale de Trois-Rivieres now has a solution up and running.

About 50 physicians, nurses and other professionals in the oncology department have been using the system to reach lab, diagnostic imaging and medication information about their patients on a browser-like system. Doctors can also order lab tests. In the future, they hope to add radiology tests and medication orders to the system, as well.

“At the moment, it’s mainly available in oncology, but it could easily be expanded to the rest of the hospital,” said Dr. Christian Carrier, chief of hematology/oncology service and a director of the information technology project. “Cardiologists, internists, family physicians and others are all asking for access.”

Called the Clinical Portal, the $8 million pilot project was developed by the hospitals in Trois-Rivieres and Shawinigan, in partnership with MediSolution Inc., with the involvement of the Regie Regionale de la Mauricie et du Centre du Québec and with partial backing from Health Canada’s CHIPP – the Canada Health Infostructure Partnerships Program.

Using the portal, oncologists in Trois-Rivieres can access patient information from any point in their two-campus hospital, and also from the Centre-de-la-Mauricie in Shawinigan. Dr. Carrier says the system could easily be expanded so that clinicians at area hospitals in Athabaska and Drummondville have access, too.

Systems could be connected using Quebec’s high-speed network, the RTSS, which currently links all of the province’s hospitals.

For its part, MediSolution had a team of 50 persons working on the project at its peak, commented Diane Bouchard, vice president. That figure is currently at about 20. The company installed its MediVisit regional master patient scheduling product, and MediResult, an order entry and results information application, and did a great deal of integration with existing systems.

“We worked closely with staff at the hospital, who also have a great deal of expertise in computer technology,” said Ms. Bouchard. She noted that as part of the project, 17 new servers were added and 38 interfaces were created between applications.

The integration project in Trois-Rivieres and Shawinigan is formally known as RIGIC – short for Reseau Integre de Gestion des Informations Cliniques. It was officially begun in the fall of 2002, and runs until the end of 2003. A process of evaluation will then be completed, and the project managers are optimistic they will be able to launch a second phase.

A key feature for the users, stressed Dr. Carrier, is ease of use. While doctors and nurses can tap into lab results, radiology reports and other systems, they don’t have to know how to operate these particular applications.

“I don’t have to learn the RIS (Radiological Information System) or the laboratory information system,” noted Dr. Carrier. “I can get all of the information just by using my browser.”

If the RIGIC project gets the go-ahead for an additional phase, Dr. Carrier said the management team would like to add access to diagnostic images to the mix, to complement the text-based radiology reports that are currently available. This would involve a tie-in to the Picture Archiving and Communication System (PACS).

In addition, the team would like to build drug orders into the system.

“This is a natural application for us,” said Dr. Carrier. “When you’re doing chemotherapy, you’re using drugs that are complicated, costly and dangerous if you make mistakes. If you use computers, you can become more efficient.”

Dr. Carrier noted that RIGIC makes use of a patient registry that’s an important part of the system: “It ensures that the right data always goes with the right patient.”

He added that security has been a major concern in the development of the system. “We pay rigorous attention to all the confidentiality issues. We use a double identification system, with user name and PIN, and all accesses are journalised.”

Dr. Carrier said that along with physicians and other healthcare professionals, patients have also given RIGIC the thumbs’ up: “Patients feel safer when they see that their physician can guide the decisions regarding their healthcare with all the relevant information.”



Interior Health reaps the rewards of a large-scale I.T. implementation

By Tara Wyllie

In a climate where the reins on spending are pulled tight, the task of embarking on a large, healthcare I.T. initiative can be fraught with risk management issues.

That challenge faced the Interior Health Authority, when five health regions and 14 health councils with 19 different business systems needed to operate as a single organization.

Following a sound project management methodology and using a common sense, business-case approach, Interior Health has proven its I.T. expenditure to be a worthwhile investment.

The need for integration became critical as the I.T. department tackled the variances within this new organization. The solution was to integrate 19 different business systems and over 100 non-integrated financial applications into one, while providing internal control, a consolidated financial statement, and standardization for consumable products and business processes.

This enterprise-wide system needed to meet the operational and information needs of financial services, purchasing, logistics and facilities planning and involve accounts payable, e-mail, fixed assets, general ledger, materials management and payroll software modules.

Pat Ryan, chief information officer and Mal Griffin, director, applications & information development for Interior Health spearheaded this project. Keenly aware that many IT projects are typically over budget and behind schedule, they realized that this initiative required enterprise-wide support and accountability.

Their business objectives were clear; invest $3.2 million into a 14-month project and deliver $4.3 million in annual savings back to the organization.

They applied project management methodology (PMM) stressing communication, efficiency, teamwork, and issue resolution throughout the process. Many of the team members came to the project as representatives of their specific program areas. Mal Griffin handled the business of aligning the expectations and contributions from each of these team leaders.

Project accountability was established by a governing steering committee which reported to the executive sponsor, Chris Mazurkewich, chief operating officer, strategic & corporate services. The steering committee included managers, directors and key executives from integral departments including: accounting services, purchasing, logistics & facilities development, purchasing & capital planning, information & technology, accounts payable and payroll.

This committee met bi-weekly to review project progress. Project progress reports were prepared monthly and distributed to the project teams, steering committee, directors of business support and the executive sponsor. Quarterly project updates were distributed and presented to the board finance committee.

The project was organized by business area (e.g., accounts payable, e-mail, payroll, inventory, etc.) with each assigned a business manager.

That business manager then assembled a project team (technical/applications and training specialists) who were responsible for implementation and training of their respective project area. These teams met weekly and sometimes daily through the duration of project planning and execution. Communications, targeted to executives, facility administrators, managers and staff were frequent and focused.

The project objectives were SMART (specific, measurable, attainable, realistic and timely) and documented before the project was initiated. Changes to the scope of the project were reviewed and approved by the steering committee only when absolutely necessary and critical to the success of the project. Costs were controlled and overruns prevented through ongoing reviews by the initiative project manager, Mal Griffin.

Griffin combined this project management approach with key software vendor partnerships to accomplish project objectives (The partners included Meditech, Microsoft and Total Care Technologies.) The total project investment was $3.2 million and was completed $0.5 million under budget.

The execution of this project was virtually seamless and the result is a single business system that now generates permanent annual savings of $4.3 million which can now be redirected to direct patient care.

This integration has resulted in cost and time savings and efficiency improvements, for example: pay statements are now distributed to more than 13,000 employees using confidential e-mail, management reports are distributed to more than 1,200 managers using internal e-mail, 106 pre-existing bank accounts have been effectively closed and now operate out of one. Interior Health has also benefited from this implementation with improved organizational effectiveness and customer service to its employees and departments.

The Interior Health Integrated Business Systems Implementation demonstrates that large IT projects can be completed successfully, on time, on budget, and providing direct benefits that reach across the entire organization.

The key, says Ryan, is “having great people, applying practical, common sense approaches and working hard to ensure I.T. alignment with all levels of the organization. What we’re really doing is laying a foundation for business intelligence to support the organization as a whole.”

Interior Health certainly seems to have accomplished this. The business system inventory now includes accounts payable, e-mail, general ledger, materials management, fixed assets, payroll and staff scheduling. Accounts receivable, human resources and data repository are the only remaining elements to be integrated into this solution.

Project leader Griffin says, “Our business systems implementation was an enormous task. We were successful because we had executive commitment, healthy vendor partnerships and the expertise of our internal partners. We went to work and built a smart and practical solution that boasts savings of $4.3 million annually. These savings are now being applied to direct patient care. Our launch was ahead of schedule and executed seamlessly.”

More information about Interior Health is available at

Tara Wyllie is an independent consultant based in Westbank, B.C., specializing in marketing and web content management.



Ultrasound machines ever-smaller, offering higher resolution and more features

By Andy Shaw

Greater mobility and sharper resolution – they’re two trends in ultrasound that have been constantly improving since the technology first emerged in the 1970s from under the hulls of ships for submarine detection and were deployed as effective tools for diagnostic imaging.

Since then, few have lived with those trends as closely as John Peacock. For nearly nine years now, Peacock, an independent ultrasound technologist who is based in Sioux Lookout, Ont., has been servicing the diagnostic imaging needs of 18 fly-in only communities in the wilds of northern Ontario. As many as three times a week, every week, rain or shine or snow, Peacock grabs his SonoSite 180Plus portable ultrasound machine and jumps into a small airplane. In single hops as short as 15 minutes and as long as an hour-and-a-half, he wings his way to work in remote community nursing stations that are as far flung as Fort Severn near the shores of Hudson’s Bay.

“It’s the only program of its kind that I know of in the country,” says Peacock, who first came north for only a three-month assignment not long after graduating as a sonographer from Mohawk College in Hamilton, Ont.

“The radiologist at the time in Sioux Lookout was from McMaster University, and he had worked in Nicaragua and Africa. He was a man with a conscience,” says Peacock. “He had started doing x-rays in the fly-in communities where they were badly needed, but he thought it would be much more useful if we could get an ultrasound program going for them. So, he was looking for someone who had some training in high-risk obstetrics, and of course, he was also looking for an ultrasound machine small enough to fit in an airplane.”

He found both in Peacock and the now venerable Hitachi 405.

“So we began with the Hitachi, which was a fine machine for its day,” says Peacock. “But since then mobile systems have been getting much smaller and much better. Back then, no mobile machine had spectral Doppler, or colour Doppler, or tissue harmonics, or directional M-mode capabilities because the software to run them just didn’t exist. Now it does, so now they do.”

Those new capabilities means Peacock can do a much wider range of work than when he first started out.

“I was originally brought up here only to do obstetric ultras. And that made sense since the birth rate in the communities I serve is about two-and-a-half-times the national average. But now I can do much, much more,” says Peacock who is also trained to do gynecological, abdominal, and neurological examinations.

Wider still are the range of ultrasound uses these days in the largely urban setting of Ontario’s golden triangle. There Dr. Alex Hartman is chief radiologist for RDS Diagnostics Ltd., a company that runs community diagnostic imaging centres stretching from the towns of Markham in the east to Cambridge in the west, with a lot of Toronto in between.

Dr. Hartman is an expert in the recent trend of using injected substances to enhance the sharpness of detail in an ultrasound image. But he is struck most by the built-in capabilities and diminishing size of today’s most advanced machines.

“It’s worth a quick review of the basic function of an ultrasound machine to appreciate how far they have come,” says Dr. Hartman. “In simple terms, sound is sent out from a transducer usually embedded in a handheld device. It goes into the body and is reflected off different types of tissues at different speeds. Judging from those speeds, the machine’s built-in computer has a way of figuring out the depth and composition of what was hit and thus can differentiate between different types of tissue.”

As the sophistication of the software inside the ultrasound computer has grown, so too has the resolution of the machine.

“The machines can convey incredible resolution nowadays,” says Dr. Hartman, “to the point where if there is something in there as small as one fiftieth of a millimetre, I can probably see it. Things are now that good.”

Even the simplest of today’s ultrasound machines are good for another reason: they capture images in two directions.

“Essentially, an ultrasound, like some other modalities, takes pencil-thin cross-section images of whatever the transducer is aimed it. But that is all along one plane. Standard machines today also take another image along another plane at 90 degrees to the first. These are today’s two dimensional or 2D machines.”

The two images taken at right angles enable the trained viewer to get a sense of the three-dimensional shape of a soft tissue object by combining the two in their mind’s eye. Now 3D machines have come along in the last year or so to remove the inevitable inaccuracies of that mental gymnastic.

As electronics have miniaturized, the number of transducers in the business end of an ultrasound machine has risen from one in the early days to as many as one thousand today. That many more sonic ears in a 3D ultrasound enables the machine to assemble more sophisticated pictures.

“In 3D machines, the software inside builds a three-dimensional model,” explains Dr. Hartman.

But those 2D and 3D images take some time to emerge from the machine as pictures. So it’s not hard to guess what has just loomed over the ultrasound horizon – 4D, as some call it.

“The very newest machines have added the fourth dimension of time,” says Dr. Hartman, explaining that 4D ultrasound allows sonographers to see the form and motion of structures inside the body – including the fetus in expecting women. “Companies like GE in their most advanced ultrasound equipment have added the ability to see a moving 3D image in real time as you scan the body.”

But both 3D and 4D are barely out of their infancy as ultrasound developments. Hartman reports that RDS has only obtained four 3D machines to complement the 50-60 2D machines now in their clinics.

Diane Protz, vice president of operations for RDS, says 2D is here to stay for some time: “It’s still the mainstay of ultrasound. And with 3D there’s quite a steep learning curve for the operator. So I don’t think you’ll see people for the next little while at least running out to replace their meat-and-potatoes machines.”

But as a technology, ultrasound may be on the verge of replacing other imaging modalities.

“Ultrasound can do cross section imaging like CT scanning and MRI and can examine a very tiny and precise area,” says Hartman. “But [CT and MRI scanners] can be 10 times and more the cost and are very big machines. They’re not at all portable. Consider, too, that the next generation of ultrasound machines will be the size of a Palm Pilot.”

They’re even wearable.

Master Sgt. Cheryl Vance of the United States Air Force has helped develop an ultrasound “vest” that she and other instructors are now using to train military sonographers and other technicians. Soon it will move out for use on the battlefield and likely from there to “civvy” street.

The vest Vance wears in class has a central processing unit stitched in and connected to an ultrasound wand and a wristband keyboard as well as a hand-held mouse and a single, head-mounted eyepiece. Jointly developed by the Air Force and two private companies, the US$36,000 device will have this kind of mobility and utility in the field: a military sonographer will be able to take a sonogram of an injured soldier and immediately transmit the image by satellite to a radiologist for interpretation who is perhaps a continent away. And since the vest-born CPU is running Windows, it is also a regular computer, so the specialist can send back an interpretation by e-mail, which the user can read in his or her eyepiece.

One can also picture what vest-borne ultrasound might mean to a civilian hospital: no more wheeling a big ultrasound cart into an already overcrowded room and scurrying around for a convenient plug-in. The examining sonographer can simply strap on the battery-driven vest, go immediately to bedside, and from there wirelessly download the images to hospital network storage.

Meanwhile in a Cessna high over northern Ontario, John Peacock will likely be bringing back his ultrasound images on a storage system he helped devise. Working with Sonoplex, a Brantford, Ont. company, and its Medical Imaging Digital Archiving System (MIDAS), Peacock developed an adaptation of the program for mobile use. With a stroke of his “Print” key on a laptop attached to his SonoSite machine, MIDAS downloads his sonograms, which can then be sent down the Internet for a remote radiologist. More often, Peacock packs the images into what he describes as a ruggedized “U.S. military lunchbox” unit filled with digital storage hardware by a London, Ont. firm and plied with software by Sonoplex especially for him.

Peacock’s innovation is part of a larger trend that is taking ultrasound out of its analog origins and into the wider and rapidly expanding digital world.

Last fall in Chicago, for instance, Esaote, the Italian-based ultrasound machine maker and one of the world’s largest, unveiled its SuperDAM digital storage and compression system. It eliminates the need for tape, film, or even CD storage of ultrasound images. Sonograms are stored digitally on the system, so that when they are recalled by radiologists and sonographers, they can instantly jump to any point in the examination without having to watch it play through to that point. Also, with the click of a button, they can compress their ultrasound images to a fraction of their original size and without any appreciable loss of image quality, making storage and transmission that much easier.

Such technological advantages, of course, come at a cost. But there is a pay back. Peacock, for example, estimates that for the approximately $80,000 a year needed to keep him flying and making sonograms, the region he serves probably saves over $500,000 annually.

“It means, for example, that a woman does not have to find baby sitters or get off work and be flown out of her community for two days stay just for a pre-natal examination,” says Peacock.

And while much of his work still does involve babies and their aftermath, ultrasound’s traditional use, the technology is broaching new diagnostic frontiers elsewhere.

RDS’s Dr. Hartman says ultrasound, because of its increasing portability and resolution, is moving beyond its traditional grounds in obstetrics and gynecology.

“As you can see on some of the hospital TV shows, they’re depicting quite accurately how ultrasound is rolled into the ER and used to detect free fluid in the abdomen and other internal catastrophic injuries that might not be obvious. You’re also seeing increased use of it to diagnose sports injuries. In neurosurgery and in spinal cord operations, there are some tumours and tissue that can only be evaluated by imaging once you are in the operating room. And you just can’t wheel in other modalities like CT or MRI, but ultrasound you can. Cardiologists are also now swearing by it to produce echocardiograms, which are basically ultrasounds of the heart. It’s also being used to assess the danger of blood clots in the legs or elsewhere.”

Recently, Dr. Hartman was mightily impressed by another possible use that was presented by researchers from France – ultrasound-based angiograms. A non-invasive, painless, risk-free angiogram that would no longer have to snake through the arteries would indeed be a medical breakthrough and keep ultrasound’s stock rising.