International teaching centre for keyhole surgery opens in Hamilton

By Jerry Zeidenberg

HAMILTON, ONT. – McMaster University and St. Joseph’s Hospital have together created an international centre for teaching surgical techniques in the fast-growing area of minimally invasive therapy.

Located in a new wing at St. Joseph’s Hospital, the non-profit Centre for Minimal Access Surgery (CMAS) has already attracted Canadian and international experts in ‘keyhole’ surgery. These experts will, in turn, train surgeons from across Canada and abroad, and continue to coach them once they are back in their own hospitals by using telehealth videoconferencing equipment.

This program of ‘tele-mentoring’ for surgery is said to be a world first. It’s being done because keyhole surgery requires a new set of skills, and physicians who are new to this field must usually perform some 50 operations before becoming adept. Using two-way videoconferencing equipment, an expert from CMAS can monitor a procedure in a remote operating room, and offer advice and commentary to the working surgeon while the procedure occurs.

“We’ll provide live mentoring and advice in the operating room,” said Dr. Mehran Anvari, a professor in McMaster’s department of surgery, a leading North American laparoscopic surgeon, and the director of CMAS. “It’s the first telementoring project in the world, and we’re hoping to lead the way in this area.”

CMAS has established a full set of courses to be taught in the New Year, ranging from keyhole techniques for bowel and back problems to head and heart surgery. The faculty members include leading surgeons from Canada, the United States and other countries. Among them is Dr. Douglas Boyd, of the London Health Sciences Centre, who earlier this year conducted the world’s first closed-chest cardiac bypass operation without stopping the heart of the patient.

Minimally invasive therapy has taken off since the first keyhole gallbladder operations were performed in the late 1980s. More recently, procedures have been developed for a wide variety of medical problems.

Keyhole operations require smaller incisions – a few centimetres are usually all that is needed – resulting in less pain and trauma to the patient, along with reduced incidence of infection and morbidity.

Recovery times are much faster, too. In many cases, the patients are up on their feet in a matter of days, instead of weeks or months.

In addition to improved medical outcomes, the shorter stays in hospital that are associated with keyhole surgery translate into financial savings for the health system. Moreover, if patients return to work earlier, that also leads to a productive gain for the Canadian economy.

Dr. Anvari noted that an important thrust of the CMAS project is to disseminate the skills needed for keyhole surgery so that patients can receive treatment close to home. And while Hamilton has become a top centre for many minimally invasive procedures, such as bowel resections, Dr. Anvari said, “Patients shouldn’t have to come all the way to Hamilton for an operation.”

He mentioned that he recently travelled to Yellowknife, and said there are very good facilities and surgeons who are interested in providing keyhole procedures. By training the surgeons there, local patients won’t have to travel to large urban centres for operations.

CMAS is also training nurses, since they will require new skills to participate in keyhole operations. Moreover, they must learn to counsel patients, who will be staying in hospital for shorter periods of time. “The patient has to feel comfortable about earlier discharges,” said Dr. Anvari.

CMAS has started up with $600,000 in funding, along with an operating budget of $200,000. The revenues from teaching will be re-invested in the centre.

Along with McMaster University and St. Joseph’s Hospital, two private-sector corporations have become partners in the centre. Johnson & Johnson Medical Products, of Peterborough, Ont., and Stryker Canada of Burlington, Ont., have provided financial support to the facility, in part because it is a national centre that will have an impact on every region of the country.

Both companies produce surgical instruments for endoscopic operations. Endoscopes are flexible tubes through which surgeons can control cameras and instruments, such as graspers and scalpels.

As part of its program, CMAS has opened a lab for teaching keyhole surgical skills to physicians. The equipment includes simulators and the latest robotic gear, which enables the surgeon to remotely control the instruments placed inside the patient’s body. Endoscopic cameras can be commanded to zoom in or out, and to turn right and left, with simple voice commands.

The lab enables surgeons to refine and master the visual and motor skills required in a specific procedure.

In the future, the centre plans to acquire virtual reality systems – allowing surgeons to practice on ‘virtual’ cadavers. These software systems, which allow the surgeon to simulate the operation, are even appearing with haptic features – that is, the sense of touch, in which a surgeon can feel the difference as he or she cuts through different organs, blood vessels, etc.

Rebecca Repa, regional project officer and new business development manager for CMAS, noted that it has taken about three years of work to get the facility up and running. She observed that telehealth technology is a key part of the project, as it enables surgeons to provide ‘telementoring’ to their students from remote distances in a cost-effective manner.

Along with teaching, CMAS will also study, develop and evaluate new techniques in minimally invasive surgery. The centre will promote multi-centre studies to evaluate the effectiveness of new technologies and newly developed instrumentation.

It will also cooperate with the Royal College of Physicians and Surgeons of Canada to standardize the use of new techniques and monitor their development throughout Canadian hospitals. Information on a wide range of minimally invasive surgical and diagnostic techniques will be made available to the public via a web site and information line.

“We’ll be developing methodologies for surgeons, and we’ll conduct research to evaluate the cost-effectiveness of this form of surgery,” commented Dr. Raelene Rathbone, associate vice-president, Faculty of Health Science, McMaster University.

Allan Greve, CEO and president of St. Joseph’s Hospital, commented that “minimal access surgery is at the cutting edge of where surgery is going.” He asserted that the techniques refined and taught to others by CMAS will enable patients to get back to work sooner, significantly reduce the length of hospital stays, and reduce complication rates.

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BC company uses breakthrough to produce lower-cost MRI scanner

By Jerry Zeidenberg

VANCOUVER – After five years of development, a Canadian company is now marketing a mid-field strength MRI scanner that can perform 80 percent of the work of a high-field machine, but at less than half the cost.

It’s done this by perfecting a small but powerful permanent magnet – said to be the strongest field-strength available for a magnet of this kind. By contrast, most traditional MRIs require large magnets, massive electrical supplies to keep the magnets energized, and helium-based coolants.

Millennium Technologies Inc., which has worked closely with the Vancouver General Hospital, the National Research Council and other organizations, is officially launching the sales campaign for its 0.35 Tesla Virgo MRI machine this month at the Radiology Society of North America (RSNA) conference in Chicago. The company also exhibited at the Ontario Hospital Association’s annual convention in November.

With a list price of $1.25 million, the Virgo is selling for less than half the price of traditional, high-field MRI machines, which typically operate with a field strength of 1 to 1.5 Tesla. These machines normally fetch $3 million or more.

And instead of the $200,000 in annual maintenance costs for super-charged magnets that need heavy-duty electrical power supplies and cryogen coolants, the yearly service for the Virgo is more like $100,000.

Millennium is hoping the combination of lower cost and high performance will appeal to the cash-strapped Canadian healthcare system, which has fallen far behind other industrialized countries in the availability of MRI machines for diagnosis of medical problems.

Some doctors fear that a shortage of diagnostic machines could lead to relatively poorer levels of general health in Canada, if medical problems – such as cancer – take longer to detect. Delays in diagnosis can occur due to long waiting lists for MRI and other scans.

A recent report by the Fraser Institute in Vancouver found that Canada has dropped behind most other industrialized countries in the use of MRI machines, computed tomography (CT) scanners and lithotriptors (devices that use shock waves instead of surgery to eliminate kidney stones.)

“In Canada, there’s only one MRI scanner for every 550,000 people, compared with an MRI machine for every 65,000 persons in the United States,” commented Ryan Males, PhD, business development manager for Millennium. “The lower cost of our MRI system could make it easier for Canada to catch up.”

He said Millennium also plans to market the device in the United States, Asia and Latin America.

Males pointed out that the Virgo is an “open” system. Unlike traditional closed-bore systems, in which patients must lie still in a tunnel for long periods of time, the Virgo is open on three sides – a feature that will appeal to claustrophobic patients. Indeed, the Fraser Institute study estimated that 15 percent of all MRI exams must be aborted due to claustrophobic patients.

The open nature of the device also makes it suitable for interventional radiology, since doctors can have access to the patient for surgery or minimally invasive therapy while simultaneously conducting MRI scans and monitoring the images.

Physicians in Canada are now starting to use MRI-guided surgery. One example is occurring at the Toronto Hospital, where a team is using an open MRI scanner while conducting neurosurgery.

The benefits of open MRI systems have led to increasing demand in many countries. In the United States, for example, industry observers have pointed out that open devices now comprise nearly 50 percent of all new installations of MRI machines.

Males added that the lower-cost Millennium device may appeal to smaller hospitals, which have avoided purchasing an MRI device not just because of the capital cost, but also because they don’t have a radiologist on staff.

He said Millennium has developed software for the Windows NT-based Virgo that allows images to be sent over the Internet. “If a rural hospital doesn’t have a radiologist, it can send the MRI images to a remote radiologist, who can read the studies and send back a report.”

Moreover, larger hospitals with an existing MRI machine might want a second, lower-cost device because many existing MRI units are already backed-up with long waiting lists. “They could put in a second system that can handle 70 percent of the work, and reserve their high-field magnet for special cases,” said Males.

Millennium is working with software developers such as Sun Microsystems and Computer Associates. Sun’s Java software enables the images generated by the MRI to be viewed on a variety of workstations – not just the Unix boxes that radiologists have typically relied upon.

Males estimated that Millennium could sell 20 units in Canada over the next two to three years, and possibly more. He points out, for example, that British Columbia has only seven MRI machines for a province of 4 million persons. To reach a level of care equivalent with the United States, there should be 61 MRI machines!

He noted there are serious shortages across the country, as well.

Millennium has installed one working Virgo at the Vancouver General Hospital, which helped develop the system. Assistance was also received from the National Research Council of Canada, the BC Cancer Agency and Simon Fraser University.

All in all, the creation of an MRI machine is an ambitious, even gutsy achievement for a Canadian organization, since it will be butting heads in the marketplace with multinational giants like GE Medical, Siemens and Toshiba. But the combination of a new technological approach and much lower prices could give the Canadian upstart a winning edge. Said Males: “We’re not wedded to old technologies and old ways of doing things. A lot of multinationals just rely on their momentum.”

For more information about Millennium Technologies and the Virgo MRI, check the company web site at www.millennium.ca

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Ontario revives concept of smart card, including computerized health data

By Jerry Zeidenberg

TORONTO – For a few years, it seemed that interest in healthcare smart cards had died, at least in Canada. But in October, the Ontario government signaled in its Throne Speech that it is re-visiting the topic.

The government announced that a card containing a computer chip or magnetic stripe could contain personal information and consolidate a number of cards carried by citizens, including birth certificates, driver’s licenses, health cards, hunting permits, and more.

The single card would reduce administrative costs for Queen’s Park. And when it comes to healthcare, it would offer many advantages for consumers, healthcare providers and the government.

First, it would provide vital information about the person for use in emergency care. If a person is rushed to an emergency department and is unable to speak, the card could be scanned to discover whether there are drug allergies or adverse reactions in the patient’s history. That could reduce complications and morbidity when it comes to treatment.

Cards could also be used as part of pharmaceutical plans, to ensure both compliance and to reduce double doctoring and double prescribing. When a patient visits his or her physician, the doctor could add the prescription to the medical record contained in the health card. The patient would, in turn, take the card to a pharmacist to have the prescription filled.

This procedure would also lead to clearer information about dosages and other instructions for both the pharmacist and the patient.

The health card could also be used for health insurance validation.

The announcement of renewed interest in smart cards by the Ontario government was quickly assailed by critics of such technologies. In the Globe and Mail, David Jones, a professor of computer science at McMaster University, was quoted as saying: “The major concern over the government’s proposal is the possibility of comprehensive electronic surveillance of all Ontario residents.”

Professor Jones added that, “Canada and Ontario aren’t that kind of society. We have the right to privacy and one of the components of the right to privacy is the right to be left alone.” Professor Jones is also president of Electronic Frontier Canada, a group that examines the impact of information technology on individuals and society.

However, in the Netherlands, the healthcare companies in cooperation with the government intend to launch a test of smart cards for healthcare in the region of Amersfoot. What’s more, the European Union has initiated a multi-country test of healthcare smart cards. “The proof of concept is already under way, and the implementation plans should be finalized by the end of the year,” said Sam Boutros, chief technology officer for ACI Worldwide (Canada) Inc., in Toronto. ACI Worldwide is a major developer of card management systems; healthcare claims processing, electronic commerce and payments solutions. Interac, government and financial institutions around the world use these solutions.

ACI is involved in the Dutch healthcare project, and the European Union healthcare pilot, through its Smart Card Division, which is headquartered in Gouda, the Netherlands. Since 1995, ACI’s MONAD-healthcare product has been used by two large insurance companies in the Netherlands, to implement a smart card based portable patient record.

Mr. Boutros explained that the European Union project, called InterCare, includes six nations. As in the Dutch program, two cards are needed to make the system work – one is held by the consumer, the other by the physician or health professional. The service provider’s card determines the security access level allowed for accessing the consumer’s card, and allows him or her to view, or if authorized, modify the contents.

Mr. Boutros explained that various levels of security can be built and managed by the system. For example, pharmacists may have a level of security access that only relates to the prescription history of the patient.

What’s more, the consumer can determine what is contained in the card. “He or she may not want certain information to be there at all, and that’s up to the patient,” said Steve Lawrence, business development manager, eBusiness Management Services, for Compaq Canada Inc. of Markham, Ont. Compaq has been working with ACI Worldwide in the development of various smart card systems, as a natural extension of the companies’ implementations of credit, debit and drug claim processing systems around the world. “The patient has to agree to what goes on the card,” said Lawrence.

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Transcription solution translates speech-to-text for quicker turnaround

By Jerry Zeidenberg

Speaking into a computer and getting a quick print-out of what you’ve just said sounds like something out of a Star Trek episode. But the application is available to earth-bound businesses right now, and some hospitals in the United States and Canada have been using the technology to straighten out their medical transcription problems.

Several companies produce this type of voice-recognition software for standalone PCs, but Lernout & Hauspie Corp., of Burlington, Mass., is marketing an enterprise-wide solution for hospitals. In one of its recent installations, the Duke University Hospital, transcription turnaround-time was reduced by 70 percent.

Judging from the demand for computerized speech solutions, it looks like the technology is no longer a pet project for hobbyists and R&D departments. Specializing in computerized voice solutions for a variety of industries, Lernout & Hauspie has seen its worldwide sales jump from US$2 million in 1994 to over US$300 million this year.

Until recently, Lernout & Hauspie focused on departmental solutions to medical transcription, but in September, the company purchased Fonix Healthcare Solutions Group of Salt Lake City, Utah, which has produced enterprise-level software for medical dictation. The company is now using this newly acquired software, known as PowerScribe, as the foundation of its own offerings to the healthcare sector.

The software has a number of interesting features. It’s said to allow physicians a good deal of latitude in the way they dictate notes (unlike Lernout & Hauspie’s previous offering, which required them to conform to a certain method.)

The PowerScribe software works on client/server networks with Microsoft NT and the SQL Server database. It automatically tags data with the XML standard, making it easier to conduct database searches and to share the data with other computer platforms.

Moreover, it converts speech to text with about 98 percent accuracy. Physicians then have the option of checking the text themselves and fixing mistakes – thereby completing the report immediately.

Otherwise, the file can be sent either to the hospital’s transcription service or to a service bureau outside the institution. The report consists of both the doctor’s voice (digitally recorded) and a text file that is translated from voice by the software.

Instead of keying in the voice report, the transcriptionist only has to listen to the aural report while watching the text version on a computer screen. Rather than keying-in text, he or she simply checks for errors. This process is said to greatly speed up the process of transcription.

“This makes transcription more efficient,” said Rich Oldach, director of product management, healthcare solutions, for Lernout & Hauspie. “The voice is synchronized with the text on-screen. The transcriptionist sees it and hears it.”

Oldach says that labour shortages are one of the biggest bottlenecks in the medical transcription industry. Oftentimes, hospitals and transcription companies are backlogged with medical reports because they can’t get people to do the work.

“Many of the transcriptionists are pieceworkers, and companies can’t get enough of them. The people just aren’t there,” said Oldach.

But the need for this type of labour is reduced both by physician self-editing and the use of combined voice/text files for the transcriptionist, which require checking instead of inputting a whole lot of text.

“Seldom do we have to convince a customer of the business case for this,” said Oldach.

Lernout & Hauspie’s technology is a twist on the standard transcription technologies, which most often use straight voice files that must be converted to text by a transcriptionist. It automates much of this process with its own speech-to-text translation software.

Recent estimates peg the North American medical dictation marketplace to be worth US$6 billion a year. Of this, US$4.5 billion of the work is done in house – inside hospitals or other large medical institutions – while the other US$1.5 billion is outsourced.

Oldach says that enterprise-wide solutions are appealing to hospitals because in many institutions, different departments run their own transcription service, with wide variances in levels of efficiency. “In some hospitals, the radiology department might outsource, pathology might do it internally, and in emergency there might only be handwritten notes,” he said.

Enterprise-wide solutions provide hospital management with a uniform level of turnaround and medical-report quality throughout the institution, Oldach noted. More information about the company and its solutions is available at www.lhsl.com

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