Mac’s new biomedical school will collaborate to create innovations

By Jerry Zeidenberg

HAMILTON, ONT. – Bell Canada is contributing $450,000 over three years to McMaster University for the creation of an integrated systems laboratory, a facility that will be part of the upcoming McMaster School of BioMedical Engineering.

The university is currently in the midst of an $8 million fund-raising campaign for the School of BioMedical Engineering, which it intends to open in the fall of 2005 with a new building on campus. It’s to be run as a 50-50 partnership by the faculties of engineering and health sciences.

According to engineering Dean Mo Elbestawi, the university has already reached 70 percent of the funding target, and will announce several new sponsors by the spring of 2005.

Dean Elbestawi told Canadian Healthcare Technology that the School of BioMedical Engineering will contain eight to ten labs, including integrated systems, medical devices, biomaterials, biomechanics, and diagnostic imaging. The school will also delve into surgical robotics and telemedicine.

Last September, the project received a $450,000 donation from MDA, the company that developed the Canadarm used in space by NASA. MDA’s contribution is to be used for a medical robotics lab.

Dr. Elbestawi said the upcoming biomedical school will focus on graduate education and research, and will conduct its work in conjunction with the university’s medical school and with private-sector technology companies.

In this respect, the school will be unique. “There’s no other biomedical school in Canada that’s based on an equal partnership with a medical faculty,” said Dr. Elbestawi.

The aim, he said, is to create one of the top biomedical schools in North America using a synergistic approach that results in technological breakthroughs. Dr. Elbestawi said researchers at the university are already leaders in areas such as tissue engineering, synthetic materials for artificial bones and joints, and hearing aid advances.

Assisted by partners in the faculty of health sciences and the private sector, he expects the bioengineering school to produce innovations in these areas and many others. In the area of surgical robotics and telemedicine, the university has been working with Dr. Mehran Anvari at St. Joseph’s Healthcare, Hamilton, which operates the Centre for Minimal Access Surgery. It’s a centre of excellence for the use and development of keyhole and robotic surgery, and telesurgery using sophisticated telecommunication systems.

“Dr. Anvari is one of our key partners and we’ll continue working with him,” said Dr. Elbestawi.

In the realm of diagnostic imaging, the engineering school has been collaborating with the Brain and Body Institute at St. Joseph’s, which is using powerful imaging modalities – including PET/CT – to investigate a wide range of medical problems.

Dr. Elbestawi said the biomedical school is currently seeking private-sector companies to partner with in diagnostic imaging. Overall, the Hamilton area is building capabilities and synergies to become a powerhouse in the creation of biomedical technologies. “We’re very ambitious people,” he said.

Bell’s $450,000 donation will be made through Bell University Labs, a private-public partnership between Bell Canada and universities across the country. Through alliances, Bell University Laboratories contributes to the development of communication technologies in Canada and allows for the development of new discoveries. “Bell is at the forefront of innovation and is well positioned to support important biomedical engineering advancements in tele-robotics, tele-informatics, and other complex IP-based technologies,” said Bell Canada vice president Brian O’Shaughnessy.

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IMPROVE-IT plans methods for measuring value of healthcare IT

By Kevin Leonard and Dean F. Sittig

TORONTO – The IMPROVE-IT Institute held its first conference last November at the University of Toronto, and involved people from a wide variety of stakeholder groups to define how to best measure the impact of IT on hospitals and large healthcare organizations.

The newly formed Institute is a collaborative research initiative that attempts to provide evidence that increased IT availability and use leads to improved clinical quality, safety, and effectiveness with an emphasis on the inpatient hospital setting.

For specific consideration, we have defined measurement indicators in three areas:

• IT spending (both initial and on-going investment);
• technology infusion (i.e., system availability, adoption and deployment), and;
• health outcomes (e.g., clinical efficacy, efficiency, quality, and effectiveness).

At present, the following members have expressed support for the initiative:

• Johns Hopkins Bloomberg School of Public Health
• University of Victoria
• Park Nicollet Health Services
• Kaiser Permanente Northwest
• University of Washington
• University of Virginia Health System
• Regenstrief Institute, Inc.
• New York-Presbyterian Hospital
• University Health Network, Toronto
• Calgary Health Region, Calgary
• Partners Health System – Boston, MA
• Mayo Clinic, Rochester, MN

One objective of the conference was to illustrate that many lessons could be learned from investments that have been made to date in healthcare. Unfortunately, we have not found an easy way of documenting this experience so that hospitals (as well as other health service providers) can access the lessons learned. As a result, the healthcare field continually builds information systems for the first time, so to speak.

In other industries, experience grows over time when generations of systems are developed. In healthcare, due to its late start with the intensive use of IT, there is very little longitudinal history.

Therefore, much of our experience must come from other organizations within healthcare that are designing or implementing similar systems. Unfortunately, this sharing is not happening!

Many IT implementations are fraught with failures, and people associated with these lessons are reluctant to have that information publicized. What must be emphasized is that this was the case with many other industries as well – failures within the realm of IT implementation are not unique to healthcare. IMPROVE-IT believes that this experience sharing can best be done through objective measurement, with the emphasis on lessons learned and not on laying blame.

Consequently, the first day of the conference was spent discussing failures across the stakeholder groups. The presentations demonstrated, first hand, the strategy and the implementation of many information systems initiatives throughout North America. Each of these perspectives brought some soul-searching and lessons learned, as every one of the initiatives had significant hurdles to overcome.

The second day of the conference focused on measurement, with two presentations emphasizing the relationship between strategy and measurement and the potential of metrics in detailing both the successes and the failures.

IT investment measures: In a breakout session, we asked the group to produce three indicators for the financial resources that an organization puts toward creating the information and communications technology (ICT) infrastructure.

The first measure deals with current ongoing investment in hardware. The second investment measure will incorporate the human resources needed to operate and manage the new technology. The final investment indicator relates to the length of time that there has been a commitment to new technology.

ICT use measures: The first clinical information system use measure we decided upon was: percentage of clinicians with an active user-ID and password combination who actually login to the system more than once each day. For the second use measure, we chose to focus on the “timeliness” of the use of the system. In the end we selected: percentage of patients with a completed chart (as defined by all data needed entered and signed by all the appropriate clinicians) within 24 hours of their hospital discharge or outpatient visit.

Currently, there is tremendous emphasis on the use of computer-based provider order entry to reduce the number of errors in the ordering process. Therefore, we chose to measure the percentage of all orders entered directly by the patient’s primary care provider.

IT – health outcome measures: Here, we decided not to re-invent the wheel and selected three outcome metrics that have been proposed within other healthcare evaluation initiatives.

The first measure attempts to provide some insight into the IT system’s ability to catch errors or adverse events before they happen. The second metric for health outcomes is related to the system’s ability to send home patients at the most appropriate time – not too early and not too late – both of which can lead to negative outcomes. The final outcome measure pinpoints the length of stay in hospital. The thinking is that with better information, patients are seen faster and better decisions are made, allowing the patients to be sent home sooner.

Kevin Leonard, PhD, is an Associate Professor, Department of HPME, University of Toronto; Dean F. Sittig, PhD, is Director, Applied Research in Medical Informatics, Kaiser Permanente.

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Computerized simulation helps BC hospital improve OR throughput

By Peter Cech

Until recently, BC Children’s Hospital in Vancouver faced the same heart-wrenching problem that plagues many hospitals across Canada: there simply weren’t enough operating-room resources available to cope with the overflow of young patients waiting for surgery. With staff pleading for more access to ORs, Dr. Geoffrey Blair, chief of surgery, felt increasingly boxed in.

There was never a shortage of suggestions to get more kids through surgery, but making changes was always seen as too risky. “Large organizations have a ‘cautious inertia’ that encourages maintaining the present system and resource distribution, even when everyone can see that the status quo stopped working,” says Dr. Blair.

What was needed was a new computer-based tool to simulate and test how proposed changes would alter throughput and patient waiting times, and how those changes might impact a variety of hospital operations. Unfortunately, no such tool existed.

Luckily, Dr. Blair’s interest in operations research, a branch of mathematical analysis known as “the science of decision making”, convinced him it was possible to simulate the complexities of delivering surgical care to the children of British Columbia.

After searching the Internet, he found help at his doorstep. The Centre for Operations Excellence (COE) at the Sauder School of Business at the University of British Columbia had the expertise to develop computer models that would simulate actual patient flows at BC Children’s.

Dr. Jacques LeBlanc, the assistant head of surgery at Children’s, had been simultaneously corresponding with a company in the United States that also had some simulation experience. However, one meeting with COE director Dr. Martin Puterman and Mats Gerschman, the director of industry at the COE, was all it took to convince Drs. LeBlanc and Blair that an all-Canadian partnership with UBC would be far more productive and potentially innovative in the development of new patient flow simulation tools.

Drs. Blair and LeBlanc found the necessary seed funding, a team was formed under the leadership of project manager Susan Bockhold, and work began in the spring of 2004.

“We asked for something that would simulate the system from the moment a patient enters BC Children’s for surgery, to when they leave,” said Dr. Blair. “The COE team delivered a model that knows how long we take to prep an OR, how long it takes each of our surgeons to do a procedure, what steps are involved in moving patients from our ICU to the appropriate unit, available bed space in our wards and actual recovery times.”

COE teaches the use of simulation software and extensive operations research methodologies, leading to a Masters’ degree in management operations research.

The COE team used off-the-shelf Arena simulation software as a platform to develop the model. Their challenge was to study the hospital system and convert it into a computer model using operations research methodologies.

They produced a computerized system that was validated by running a one-year simulation of patient flows and comparing the results against what actually happened.

Next, “We added a number of random factors such as unscheduled patients coming in through our emergency department and unplanned fluctuations in staff levels due to illness,” says Dr. LeBlanc. “It accounts for everything our staff could think of.”

The COE team, bolstered by Dr. Eric Cope from the Sauder School of Business, and project analyst Craig O’Neill, a student in the COE Masters’ program, is now also working with Children’s staff to develop a block schedule analysis tool to simulate more complex operating room rearrangements.

Drs. Blair and LeBlanc consulted other surgical staff and administrators at BC Children’s for their ideas on how to improve patient throughput. The team then agreed on 10 “scenarios” to test. “Our starting point for any scenario is quality of care,” said Blair.

One-year simulations of the chosen scenarios were then run through the computer models over 50 times, with the results subsequently analyzed.

The results of those simulations were presented to the Board of the Provincial Health Services Authority, which oversees Children’s and other agencies serving the entire province of British Columbia. Board members liked what they saw, and funding was secured to extend the project.

Ideas that already show some promise include having BC Children’s surgeons perform some non-urgent procedures off site. This would free up operating rooms at BC Children’s for the more difficult procedures that can only be done by their surgeons and pediatric support staff.

The simulation project has also confirmed that some ideas may not be as effective as hoped.

For example, BC Children’s surgical staff have talked for 10 years about how a “scramble room” to absorb emergency procedures would help by eliminating the need to bump scheduled operations. Dr Blair says, “When that scenario was run, the Simulation Tool and Block Scheduler indicated that our naïve plans for shifting resources to a ‘scramble room’ would fail to show any benefit.”

“Without these computer models, we could very well have made some drastic and expensive changes to our OR schedule, only to find a few years from now that there was no benefit,” said Dr. Blair.

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What’s new in imaging? Find out at the RSNA

By Jerry Zeidenberg

CHICAGO – Over 60,000 radiologists, technologists and vendors converged at the RSNA conference for an educational brush-up, to transact business and to tap into the latest industry gossip.

This reporter, for example, had to travel to the United States to find out that Ontario had embarked on its own diagnostic imaging strategy – a phone call to the Ministry of Health, in Toronto, confirmed the project is now in the preliminary stages.

To be sure, many significant announcements were made at the week-long Radiological Society of North America show, which started in late November and segued into December:

Connectivity and integration: Hospitals have complained for years that their departments have trouble sharing data. If departmental servers have evolved over time as incompatible, best-of-breed solutions, integration becomes an exasperating and expensive proposition.

However, Agfa Healthcare demonstrated a couple of breakthroughs in this area.

First, the company is offering a portal-based Electronic Patient Record solution that provides single sign-on and accesses data contained in disconnected departmental systems.

Jason Knox, marketing manager for Agfa Healthcare, noted that the Enterprise Clinical Portal solution is currently being implemented at the two-campus Scarborough Hospital, in Toronto, in partnership with AccessPt Inc., of Jackson, Mississippi.

The system is designed to give clinicians real-time access to all kinds of data – radiology, lab, pharmacy, ADT, and others. (Scarborough General and the Hamilton Health Sciences Corp. are the first two medical organizations in Canada to sign-on for the solution.)

Unlike the repository approach used by some vendors, in which departmental data are unified by dumping them into new servers and constantly updating the information, the AccessPt solution ties together existing servers – in real-time – without requiring the acquisition of new hardware.

“We keep the costs down, because you don’t have to invest in new servers or maintenance,” said Knox. He demonstrated how the system displays departmental solutions on a single screen by using folder tabs. Click on the tab, and you call up a patient’s information from that department – such as radiology, lab, pharmacy, or others.

The software is displayed on a Netscape browser and can be used with wireless networks. The solution was even shown running on a wireless Personal Digital Assistant (PDA), a solution designed to give clinicians easy access to data while on their rounds.

Agfa also demonstrated a region-wide solution to integrating radiological data across a group of hospitals. In large, multi-site implementations, different IDs are often used for the same patient, making it very difficult to see a unified view of the patient’s information across all sites.

As an answer, Agfa is has produced an Enterprise Master Patient Index (powered by Initiate Systems of Chicago).

The company is currently implementing a solution that will integrate RIS and PACS data at 15 sites in Northeastern Ontario. Known as the NORrad hospitals, the sites are trading radiological images and data through their own network, but have run into trouble as they’re using three different information systems – Meditech, MediSolution and Momentum.

Moreover, each of the hospitals has its own patient ID numbering schemes. Guy Guindon, manager of diagnostic imaging at the Timmins and District Hospital, and PACS manager for NORrad, said the solution will create a unified system that allows clinicians to call up the DI records of a patient all at once, wherever the patient sought treatment.

It does this through the use of probabilistic algorithms. For example, it can automatically determine if the records for John Smith, Johnathan Smith, Jonathan Smith and J. Smith, stored in different hospitals, are for the same person by using birth dates, home addresses, and other information.

This will allow radiologists and other clinicians to call up multiple records for a patient, stored at hospitals throughout the region, letting them make faster and better diagnoses.

Guindon said the 15 hospitals were scheduled to go live with the system in early 2005 and plan to extend the solution to a total of 31 sites over the next two years – all of the hospitals in Ontario’s new LHIN 13. The term LHIN refers to the 14 Local Health Integrated Networks recently created by the Ontario government.

Computed Radiography: There’s lots of activity in the CR area. Christie Group of Montreal, the Canadian reseller and integrator of Fuji systems in Canada, announced it had made two large-scale sales. The company is currently installing 34 CR systems at the Thames Valley Hospital Planning Partnership – Cooperative for Diagnostic Imaging, based in London, Ont. It amounts to what Christie’s marketing manager John McColl called “one of the largest CR awards ever in Canada.”

The equipment purchased includes 21 single-plate readers and 11 multi-plate readers.

Moreover, in another big deal, Christie will also install 34 Fuji CR units at Interior Health in British Colombia – 28 single-plate readers and six multi-plate readers.

Direct Radiography: Calgary-based Imaging Dynamics Corp., once considered an underdog in an industry dominated by giants, announced the 100th sale of its innovative, Xplorer direct radiography system.

The company continues to surprise onlookers by attaining high marks from radiologists in evaluations of its high-quality CCD technology, and in turn from industry onlookers who thought it couldn’t be done by an independent start-up, let alone one from the Canadian hinterland.

Among Canadian sites, the technology has been installed at the University of Ottawa Heart Institute. According to Guy Morency, cardiac imaging manager for the Heart Institute, “the Xplorer stood out in blind image quality comparison studies, with unmatched levels of resolution.” Morency gave an off-the-cuff account of the system to a group at the IDC pavilion.

While some radiologists and industry members have criticized CCD technology as being not quite up to the level of other direct radiography formats, IDC asserts that recent improvements in CCD science have brought it up to par with standard DR at a fraction of the cost.

In the past 12 months, the company has expanded throughout North America and internationally, with sales in New York, Washington, Philadelphia, Los Angeles, San Diego, Pittsburgh, as well as to hospitals in Germany, Italy, France, Korea and China.

“It’s been a breakout year for us,” said Darryl Stein, president of IDC.

For its part, GE Healthcare showed off a fascinating new addition to its Innova cardiovascular and interventional imaging systems.

The new twist combines an automated technique called, InnovaBreeze, with digital flat-panel detector technology, to allow doctors to see the blood vessels from the stomach down through the legs.

During imaging, the X-ray table moves to follow an injection of contrast media from the aorta in the stomach area to the feet. What’s innovative is the real-time subtraction of the surrounding anatomy from the blood vessels, allowing physicians to follow the blood flow down the legs and to target an area of disease. As well, specialized software is used to combine different images taken down the legs into a single image of the entire, contrast-filled peripheral vasculature.

Storage: With the quantum leap in the volume of images produced by multi-slice CTs, high-res MRIs, and increased usage of DI in general, storage strategies are becoming a key issue for healthcare centres.

Even though spinning media costs have dropped in recent years, they’re still high enough to break the budget of radiology departments unless they do some decent planning. That’s why some industry experts call for a tiered solution, involving a mixture of spinning disks and tape-based storage.

“We’re advising customers to bring back tape,” said Donald Baune, global practice manager for StorageTek. “You want to be using the right technology, at the right time, at the right cost.”

For most patients, said Baune, radiologists won’t bother calling up images that are more than two years old, and added that most prior images needed for comparison are less than a year old. For this reason, it makes sense to use fast-access spinning media for images up to a year old, secondary disk storage for those up to two years old, and inexpensive tape archiving for those older than two years.

“There can be a 100-to-one cost difference between disk and tape pricing,” said Baune. And while retrieval of historical images stored on tape is relatively slow – about three minutes is required – when they’re needed, it’s usually known well in advance and they can be called up before they’re actually required.

PACS: Picture Archiving and Communication Systems have been a hot topic for several years, and were much discussed at the recent show.

Significantly, Misys Healthcare is asserting that it can provide PACS networks at half the cost of other vendors by cutting down the complexity of typical systems. It does this, primarily, by using a ‘brokerless’ system that eliminates the need for servers that translate between HIS, RIS and PACS. In the Misys world, this problem has been solved. “We bring down the cost by eliminating translation databases and servers,” said David Jones, radiology product manager for Misys Healthcare Systems (www.misyshealthcare.com)

Misys and a few other major vendors are also at the forefront of a drive to create ‘lite’ versions of PACS networks for independent imaging centres that operate outside of hospitals. Until recently, most of these centres have shied away from installing PACS, due to the perceived high cost.

However, radiologists working at imaging centres usually read studies in hospitals, too, and have become accustomed to PACS. They’re used to the productivity gains and tools they get in PACS and want the same features at hand in imaging centres.

“We’ve got a solution targeted to centres with one, five or up to seven doctors,” said Jones. “It’s got a practice management solution, too.”

3D Imaging: A good deal of work is being done in 3D reconstruction of images, taking advantage of the thousands of images now generated by multi-slice CT scanners.

For its part, GE Healthcare demonstrated Xtream FX, a technology that quickly and automatically reconstructs hundreds or thousands of CT slices into 3D images, reducing the need for a radiologist to direct this procedure. It’s expected to do wonders for the workflow of radiology departments.

According to GE Healthcare, physicians have faced trade-offs between high-resolution images and time required to manage the large datasets. Studies have demonstrated that Xtream provides thin-slice image reconstruction that is 3.7 to 6.9 times faster than other industry standard platforms, and nearly three times faster than the existing Xtream engine.

A team from Voxar, a company recently acquired by display-systems specialist Barco, demonstrated a new 3D blood vessel software package at the RSNA.

Voxar had acquired a reputation in recent years as one of the leading 3D software developers for medical imaging; their VesselMetrix system should be of interest to radiologists, vascular surgeons, and others who diagnose and repair aneurysms and blocked arteries.

The software automates a good deal of the reading of CT angiography studies and MR angiography exams. It also provides fast-sizing of vessels, allowing for the optimal sized stent to be selected and placed.

Computed Tomography: One observer quipped that CT and MRI technologies are engaged in a back-and-forth rivalry, with one temporarily gaining the upper hand through technological breakthroughs, only to be surpassed when the other sustains its own technological triumph.

It’s certainly not slowing down the popularity of MR, but CT is currently enjoying a moment of glory, due to the emergence of 64-slice scanners. The major modality producers – Philips, Siemens, Toshiba and GE all showed their latest 64-slice CT offerings at the RSNA.

For its part, GE Healthcare basked in the limelight of several awards and records for CT.

The company’s LightSpeed VCT, with its .35 second gantry rotation and 40 millimeter coverage, is said to provide volumetric scanning of the heart in only five beats—a record, according to GE Healthcare. It can scan the whole body in just 10 seconds.

Monitors: There’s plenty of buzz about CT, MRI, nuclear med and other fancy technologies for taking pictures. But radiologists need very high-resolution monitors to read the scans properly.

On this note, NEC/Mitsubishi, a joint-venture of the giant Japanese electronics companies, announced its entry into the medical market with diagnostic-quality flat-panel LCDs. The company, whose North American unit is based in Itasca, Ill., started shipping a 3-megapixel grayscale monitor and a 2-megapixel grayscale monitor. Both are 21-inch LCDs that are designed for radiologists.

NEC/Mitsubishi’s market research shows that worldwide, healthcare providers are now junking their outmoded CRT monitors, which use heavy, TV-style tubes, and are replacing them with thin-panel LCDs. The folks at NEC/Mitsubishi have built self-calibration into their MultiSync MD series of monitors, which automatically maintains the luminance of the ‘white’ in the displays to the right level. To properly compare images, a radiologist using two or three monitors side-by-side must also have each monitor set to the same ‘whitepoint’. The self-calibration feature makes it easier to re-arrange monitors in a radiology department, since all of the MultiSynch MD units will provide the right luminosity, said Todd Fender, product line manager, NEC/Mitsubishi.

Also addressing the calibration issue, Konica/Minolta has produced a new line of camera-like meters that can be used to check the luminance of monitors in radiology departments. National sales manager David Robitaille also demonstrated the meters at the Ontario Hospital Association HealthAchieve conference in Toronto, about two weeks before the RSNA show. Robitaille noted that older monitors can degrade or simply get out of whack when it comes to luminance, colour temperature, and other variables.

The company’s Chroma Meters enable diagnostic imaging departments to keep tabs on the performance of their display systems, to the benefit of their radiologists.

Refurbished systems: For DI departments looking to save money on equipment and service, one can turn to suppliers of refurbished gear. A Canadian company, CCE Medical Equipment, of Mississauga, Ont., is a specialist in restoring used ultrasound scanners to tip-top condition. It’s been doing a roaring business in this area, much of it in export sales to overseas nations.

CCE exhibited at the RSNA, which attracts a global crowd. But it also has a steady client base in Canada, particularly among imaging centres outside of hospitals, which have smaller equipment budgets and are more bargain-conscious.

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