Inside the September 2009 print
edition of Canadian Healthcare Technology:
long last, Ontario
starts funding PET exams
The Ontario Ministry of Health and
Long-Term Care announced in July that after seven years of tests and
evaluations, it will begin remunerating physicians for scanning
patients using positron emission tomography (PET) equipment.
aims to produce more lab techs
The University of Ontario Institute of Technology, which produces
lab professionals with degrees, intends to train more students and
give them access to new resources through an agreement with
Lakeridge Health, a hospital corporation, and Holburn Biomedical, a
READ THE STORY
DI in the developing
Toronto-based SIMMS, a medical imaging software developer, is
supplying PACS and other systems that will connect clinics in
Jamaica, the Cayman Islands and Africa with radiologists and
cardiologists around the world.
READ THE STORY
North York General Hospital, in Toronto, is one of the first sites
in North America to implement a new generation of mammography
equipment. Tomosynthesis provides leading-edge images through 3D
READ THE STORY
It’s estimated that putting William Osler Health Centre’s systems on
a single, converged network saved it between $3 million and $5
million in setup costs. It will now produce ongoing operating
savings – primarily for IT and phone functions.
Automating the lab
Northern Health has implemented an automated lab solution that not
only includes a centralized analyzer, but also makes use of testing
equipment at 26 geographically dispersed labs. Middleware is used to
upload and consolidate results.
PLUS news stories, analysis, and features and more.
At long last, Ontario starts funding PET exams
By Andy Shaw
TORONTO – The Ontario Ministry of Health and Long-Term Care
announced in July that after seven years of tests and evaluations, it
will begin remunerating physicians for scanning patients using positron
emission tomography (PET) equipment.
Even so, the funding will be on a qualified basis – only for certain
medical problems where the use of PET has been shown to offer a clinical
benefit, according to the Ministry of Health.
Critics say the Ministry has been far too cautious and slow to endorse a
technology that provinces like British Columbia and other health
jurisdictions long ago welcomed into their clinical fold.
And it took an international embarrassment for Ontario and Canada to
prompt the decision. The Ministry’s wait-and-see position that prevented
doctors from being paid by the Ontario Hospital Insurance Plan (OHIP)
for any use of PET was jolted when the aging, medical isotope-producing
nuclear reactor at Chalk River, Ontario sprung a leak and its federal
government owners shut it down indefinitely.
Not much later, by chance, the international Society of Nuclear Medicine
(SNM) and all its PET and other molecular imaging experts from 72
countries were gathering in Toronto for their 56th annual meeting and
Once in town, SNM leadership was quick to react to the dead reactor. As
TV news cameras from every major Canadian network rolled at their
mid-June conference-opening press briefing, SNM officials, including one
Canadian former president, politely but firmly urged the province and
Canadian governments to get off their bureaucratic butts – and do
something about molecular imaging in general and the isotope shortage in
And some shortage it already is.
“Canada, specifically Chalk River, supplies nearly one-third of the
world’s medical isotopes and 50 percent of those we use in the United
States,” said SNM’s out-going president, Robert Atcher, PhD, of New
Mexico, at the briefing. “We do about 16 million nuclear or molecular
procedures a year down there using medical isotopes – so that means
roughly half or eight million of them will have to be done by some other
means at least for the foreseeable future.”
An SNM poll of 1,100 of its members revealed by Atcher showed that 90
percent said their practices had already been affected adversely by the
shortage – forcing cancellations and postponements of patient
Atcher also pointed out that the 52-year-old Chalk River reactor was
typical of the reactors in five other countries (Australia, Belgium,
France, South Africa, and Holland) producing medical isotopes. All are
nearing the end of their useful lives, are prone to breakdown, and were
never designed in the first place to produce medical isotopes.
They were built to do research with weapons-grade materials. Medical
isotopes are for the most a profitable sideline. Australia is building
the world’s first reactor dedicated to medical isotope production and
which doesn’t need weapons-grade raw materials – but it won’t be
operational until 2011.
Consequently, in its June 15 “Leader’s Communiqué” the SNM called on all
heads of state and other political leaders to “modernize medical isotope
production facilities around the world.”
And perhaps with an eye to Ontario’s stubborn stance on PET, the
Communiqué also urged healthcare regulators to “.. ensure a clear
pathway, free of unreasonable and cumbersome bureaucratic obstacles, so
that new and improved facilities can become operational.”
In response, Ontario first came up with $3 million dollars for research
into alternative isotopes that don’t need the horsepower of a Chalk
River reactor to produce them.
Also, on the day after the SNM press conference, federal Minister of
Health Leona Aglukaq appointed former SNM president Alexander J. (Sandy)
McEwan as her special advisor on the medical isotope problem. Dr. McEwan
is the director of oncologic imaging at the Cross Cancer Institute in
Edmonton, as well as professor and chair of oncology at the University
of Alberta Faculty of Medicine.
That appointment didn’t do a lot, however, to soothe the sting felt by
many just days before the SNM meeting when Prime Minister Stephen
Harper, frustrated with Atomic Energy of Canada’s inability to get its
new MAPLE reactors working, announced Canada would soon be out of the
medical isotope business altogether.
What SMN officials felt Mr. Harper failed to grasp was the compelling
advantage of isotope-tracing molecular imaging procedures.
“They can catch life-threatening diseases at a much earlier stage than
other forms of imaging. What a molecular image shows is a change in the
metabolism of tissue so it can pinpoint a cancer hot spot, before a
tumour even forms,” explained Dr. McEwan.
He further pointed out that other imaging modalities don’t see the
cancer until some sort of malignant construct arises. Similarly, in
cardiac work, molecular imaging can reveal “flow reserves” in arteries
indicating potential trouble long before plaque build-ups and other
blockages are visible to other imaging systems.
But so far, Ontario’s 10 PET machines have been used almost exclusively
for clinical trials and research, and not often put in the hands of
doctors to do potentially life-saving scans of regular patients.
Why in heavens not? – asked one former Ontario doctor, now head of
nuclear medicine at BC Children’s Hospital in Vancouver.
“Ontario has taken a side road and gone looking too long for proof of
PET’s cost-effectiveness,” said Dr. Helen Nadel, a widely recognized
expert in low-dose PET-CT for paediatric examinations. “But in BC we
long ago recognized its clinical effectiveness.”
Ontario legislation announced in late July has now put PET under the
umbrella of OHIP, giving the OK to scans that “… have been proven to be
clinically effective.” They include seven cancer-catching procedures for
lung, colorectal, and thyroid cancers as well as lymphoma. Scans to
assess “myocardial viability” of transplant patients are also approved.
Alliance formed to train lab technologists in
By Jerry Zeidenberg
OSHAWA, ONT. – The University of Ontario Institute of
Technology has announced a partnership with a large hospital and a
private-sector lab to improve the skills of its lab medicine students.
The school also hopes to train and graduate larger numbers of skilled
technologists, thereby addressing Canada’s looming shortage of lab
In July, the UOIT signed a letter of intent with Oshawa-based Lakeridge
Health and Holburn Biomedical of Bowmanville, Ont., to make use of the
facilities of the hospital and the private lab to train lab medicine
students in advanced techniques and technologies.
The project will initially focus on immunohistochemistry (IHC), which is
used in the diagnosis of cancer and other diseases, and can predict
whether a patient will respond to certain therapies – a technique known
In turn, this work could lead to improvements in treatments offered at
the R.S. McLaughlin Durham Regional Cancer Centre, within the Central
East Local Health Integration Network area, as well as across Canada.
Dr. Ronald Stead, president of Holburn Biomedical, said the partners
could in the future train students in other areas, as well – such as
microbiology and clinical chemistry. “As this evolves, there may be
other technologies that we can set up for the students.”
Dr. Stead noted that lab medicine is quickly progressing, with new
techniques and technologies appearing all the time. Not only will the
students learn such advanced techniques through time spent in the
private lab and the public hospital, but they may also help devise new
approaches through research projects.
For its part, the University of Ontario Institute of Technology runs a
program that’s unique in the country – it’s said to be only
post-secondary institute that offers university degrees in lab medicine.
Students can then go on jobs in the lab sector or pursue graduate
Canada faces a severe shortage of laboratory technicians in the near
future – according to some estimates, 50 percent of the country’s 20,000
lab technologists will be eligible for retirement by 2015.
Clinical labs are already hard-pressed for skilled lab professionals,
and the situation may become critical in the future unless new programs
to train and develop skilled technologists are developed.
Dr. Stead commented that private labs like Holburn Biomedical could step
in, creating simulated labs where students can be educated in
conjunction with hospitals, universities and community colleges. He has
just such a partnership in mind for UOIT and Lakeridge Health: “We could
double the number of students in their lab medicine program,” he said.
UOIT currently trains 40 students in clinical lab medicine a year.
Careers in lab medicine should be of interest to young people, as
they’re virtually guaranteed to find work once they complete a training
program. “There’s a real benefit if they choose to go into a lab
program,” said Dr. Stead. “There’s a job at the end of it.”
That’s particularly relevant to the Oshawa, Ontario area, where General
Motors of Canada is headquartered. The region’s economy has suffered
with the recent downturn in the automotive sector. Healthcare, on the
other hand, offers growth opportunities in areas like laboratory
UOIT and its partners are hoping that by developing local expertise in
lab sciences, they will also generate spin-off businesses and attract
other enterprises to the area. They are aiming for the region to become
a source of knowledge workers for hospital and private laboratories
across the country.
For its part, Holburn, which is located in the Clarington Science and
Technology Park, provides laboratory services in pathology, drug
development and target localization, particularly in relationship to
gastrointestinal diseases. In business for almost 15 years, it has
state-of-the-art facilities that were built three years ago.
Toronto imaging-software company wins contract in
SIMMS, a Toronto based medical-imaging software company, has been
awarded a contract to digitize the facilities and operations of the
Heart Institute of the Caribbean. By utilizing the SIMMS Enterprise
solution, the Heart Institute of the Caribbean will be able to
coordinate the workflow of five facilities that are geographically
dispersed across three countries.
Three facilities are located in Jamaica – two are in the capital of
Kingston, with another in Mandeville. A fourth site is situated in the
Cayman Islands, and a multi-million dollar, state of the art facility,
is currently being developed in Port Harcourt, Nigeria. The facility in
Nigeria is expected to be the first of many in Africa.
Over one hundred healthcare facilities across North America have
implemented the SIMMS Enterprise, an integrated Picture Archive
Communication System (PACS), Radiology/Cardiology Information System (RIS),
transcription and billing solution. For its part, the Heart Institute of
the Caribbean plans to streamline its site workflow, maximize
out-patient productivity and improve communications through the
Dr. Ernest Madu founded and runs the Heart Institute of the Caribbean.
Dr. Madu, a cardiologist, graduated from the University of Nigeria and
obtained further training at the Albert Einstein College of Medicine &
Medical College of Ohio, in the United States. He is board certified in
internal medicine, cardiovascular medicine, nuclear cardiology and
forensic medicine. He has also held faculty positions at the University
of California, Los Angeles (UCLA), the University of Tennessee,
Vanderbilt, and the University of Florida.
Dr. Madu believes that people in the developing world have a right to
world-class healthcare. Since its opening in 2005, the Heart Institute
has been dedicated to preventing and treating heart and blood-vessel
diseases through appropriate use of leading-edge technology, research
Patients at the Heart Institute of the Caribbean experience the benefits
of advanced technology, including telemedicine, while receiving services
that focus on their individual needs.
SIMMS has been effective in motivating their clients to adopt the SaaS
(Software as a Service) model. There is a growing demand in the market
to remove the IT headaches and back end responsibilities from the
healthcare facility, and provide services at a much more affordable
price. Most healthcare facilities do not have the extra staff or the
technology background to effectively run a complicated solution, and the
Toronto-based group has designed its software around that premise.
Since more than 20 cardiologists and radiologists will be reporting from
parts of the Caribbean, Europe, United States and Canada, HIC needed a
solution that would be easy to install on remote workstations and could
be accessed simultaneously throughout a variety of time zones.
Recently a patient was given his assessment in Jamaica and travelled to
the United States for surgery. The surgeon had already previewed the
information and test results and completed his preparation before the
patient even landed in the U.S.
Over the next 12 months, HIC will conduct approximately 10,000
diagnostic studies. The Heart Institute conducts studies in several
standard radiological modalities, including ultrasound, X-ray, nuclear
medicine, (MRI and CT are being implemented in Port Harcourt), in
addition to their complete portfolio of cardiac studies.
A new cardiology module and SmartViewer was designed and added to SIMMS
Enterprise to satisfy the requirements of the HIC cardiac facilities.
The expandable module is designed to distribute, archive, and organize
all of the Heart Institute’s cardiac-related modalities, including
echocardiograms, stress tests, nuclear scans, and angiograms from all of
their facilities and allows for immediate interpretations and
dictations. The SmartViewer reduces the amount of clicks required by
cardiologists and will decrease the turnaround time to complete accurate
The cardiology module is the second to be introduced into the SIMMS
Enterprise this year. In January, digital mammography was added to meet
rapidly growing demands.
While the demand for better healthcare in developing nations continues
to grow, it is truly exciting to see an African born, American trained,
Jamaican cardiologist select a Canadian healthcare technology product to
coordinate global expertise and diagnostic assessments.
Tomosynthesis for breast imaging approved in Canada
before the US
By Paul Brent
While digital mammography has presented clinicians
with workflow and image clarity advantages over analog film-screen
mammography, another great leap forward in finding cancers of the breast
has recently appeared in the form of tomosynthesis.
First off the mark in this area is Hologic Inc., which is marketing a
clinical application in Canada through Christie Group, of Montreal.
Producing three-dimensional images rather than the 2-D images of
conventional analog or digital systems, the first-of-its-kind system
creates its unique view of the breast by taking a series of low-dose
exposures – about 5-10 percent of a normal mammogram dose – which taken
together have a total radiation dose in the range of a single
It is not the similar radiation dosage, however, but far better clinical
images that have medical professionals excited about Hologic’s system.
“Tomosynthesis is the next generational method of doing X-ray imaging of
the breast,” said Andy Smith, director of imaging science with Hologic.
The great promise of tomosynthesis is the detection of smaller cancers,
which conventional systems just can’t find. Hologic estimates that only
about 70 percent of breast cancers are found with conventional
screening, and that number is even lower for patients with dense breast
Hologic’s next-generation system utilizes a selenium detector to capture
multiple images at a number of different source angles. The slices can
be viewed individually or stacked to create a three-dimensional view.
The promise of tomosynthesis is excellent visibility of lesions, which
includes the reduction of “structure noise” from dense tissue.
On a related note, there’s a difficulty in distinguishing healthy tissue
from cancers with conventional screening, which results in a relatively
high rate of patient callbacks for re-examinations, something that
Hologic hopes to address with its new system. The Bedford, Mass.-based
company estimates that the callback rate in the U.S. for conventional
breast exams is 10 percent. Based on nationwide statistics, out of 1,000
average mammograms, just 5 will actually result in cancer detection, but
100 will result in patient callbacks.
“Approximately 995 of the patients that you are looking at don’t have
cancer, and yet for 100 there is something going on where the mammogram
is not clear enough,” said Smith.
Hologic predicts that its new system, which has been in clinical use in
Europe for less than one year, will reduce the callback rate by between
25 percent to 40 percent.
That might not sound like a huge issue until one considers that most
women over 40 have an annual mammogram and that an average of one in
eight will develop breast cancer in her lifetime.
“When you think of how many times they get a mammogram from age 40 to
age 70, the doctor in the screening population has to look at a whole
lot of images to find true cancer in just a few,” said Smith.
Hologic and other equipment manufacturers have been racing to develop
tomosynthesis for a number of years. The first prototype was developed
by a team of researchers at a Boston hospital, which published a paper
on the approach. “That was really the inspiration for our company trying
to commercialize it,” said Smith.
Advances in computing speed were also essential: the complex mathematics
behind processing the images demanded far more powerful computers to
handle the profusion of information-rich images. In the end, it was
computer systems designed for processing heavy gaming and video uses
that would power the Selenia Dimensions unit. “The original images took
maybe a day, 24 hours worth of computer time to generate a single
image,” said Smith. “We have now got that down to one second.”
Hologic has yet to receive U.S. FDA approval for its tomosynthesis
system, which has limited its spread in that country to about 15
locations and research-only use. However, tomosynthesis was approved by
Health Canada in March and a facility in Calgary already has the
technology in use.
North York General Hospital made headlines in May when it became the
first hospital in Ontario to purchase Hologic’s system.
A $2-million donation from Charlotte and Lewis Steinberg, of the famed
supermarket family, has funded the purchase of three mammography
systems, two with tomosynthesis capability and a third that will be used
The Steinberg’s donation was not just a random act of philanthropy:
Charlotte Steinberg was once an X-ray technician at a Montreal hospital
where she worked with breast cancer patients.
The Steinberg’s donation is “allowing us to transform our entire
mammography department in two hospitals over to digital imaging,
including our biopsy capability and tomosynthesis,” said Dr. Liz LaMere,
chief radiologist and director of medical imaging at North York General.
While excited about the promise of greater detection capability and
reduced callbacks, Dr. LaMere also noted that tomosynthesis should make
the procedure easier on the 9,000 patients that her seven-radiologist
mammography unit sees each year.
“It can reduce the amount of time required for the patient to have the
overall experience of having her mammogram taken, not just the actual
moment of time when the image is taken, but also knowing women are left
in the room by themselves while the tech goes outside to process the
film,” she said. “It also helps keep them more comfortable during that
time period, because they have someone with them all the time.”
North York General’s three digital mammography machines, two with
tomosynthesis capability, will be operational by fall 2009. The
approximately 9,000 patients who are tested annually for breast lesions
include those referred by their family physician for routine screening,
patients referred through the Ontario Breast Screening Program (OBSP) at
the hospital’s Branson site, as well as those referred for a diagnostic
assessment, encompassing patients referred to the BMO Financial Group
Breast Diagnostic Centre, which opened at the hospital’s General site in
This centre was one of Canada’s first centres for rapid assessment of
breast patients, offering a multidisciplinary approach to diagnosis of