Tele-radiology reading services launched in Canada

By Jerry Zeidenberg

A new tele-radiology reading service, called Real Time Radiology Canada, has been launched in Canada to provide expert reading of diagnostic images to hospitals and clinics.

The service is a response to the dire shortage of radiologists in some areas of the country – which has resulted in reading and reporting delays of days or even weeks. In turn, that has meant delayed decisions and treatment for many patients, particularly in rural areas of Canada.

The company has been two years in the making and started with the working name of CanadaRAD. That name was recently changed to avoid confusion with a similar-sounding service. And while Real Time Radiology was slated to officially start in January of this year, demand for its services was already so great that it started work in December, completing its ‘go live’ ahead of schedule.

“This is the first, Canadian-driven, national teleradiology initiative in the country,” commented Ian Maynard, CEO of Real Time Radiology, formerly of GE Healthcare and a twelve-year veteran of the Picture Archiving and Communication System (PACS) marketplace.

Already, 20 radiologists have signed on with Real Time Radiology, “making it the largest independent group of licensed Canadian radiologists practicing teleradiology in Canada,” said Maynard.

The company expects the number will increase to 50 in two to three months. Maynard says the business plan calls for bringing on as many as 500 radiologists within five years. “This will provide on-site radiologists in every region, province and territory with better and broader options for backup coverage from colleagues licensed to practice in their jurisdiction.”

Typically, small hospitals and clinics must incur large costs to augment their radiology capacity. They must attract and equip additional staff with the necessary IT infrastructure, or pay the associated travel, living and accommodation costs to fly in additional radiologists to serve their community.

Flying in a radiologist is often expensive, inconvenient and an inefficient use of the radiologist’s time.

Use of Real Time Radiology, says Maynard, will result in improved medical care for patients across the country. “We’re providing improved access to care and equalization of service, especially for patients in remote communities,” he said. Maynard noted there are some regions where a radiologist only visits every couple of weeks, and referring physicians and patients must wait for their studies to be reported.

Other regions simply don’t have as many radiologists as they need, which is also a problem. When these radiologists leave for the day, go on vacation or get sick, referring physicians and their patients simply have to wait – and the level of medical care suffers.

However, using this secure teleradiology service, images can be transmitted to Real Time Radiology’s data centre where they are routed for reading to credentialed radiologists. What’s more, the system allows the radiologists to work from any part of the country, at any time of the day or night and even from their homes.

“The goal is that no exam goes unread for any significant period of time,” said Maynard.

The radiologists maintain their affiliations with their own organizations, such as hospitals and independent imaging centres, and provide interpretations in off-hours, evenings and weekends. A subscribing Real Time radiologist is paid for every exam read.

“Radiologists are able to practice on their own terms,” said Maynard. “Many have told us that they welcome the opportunity to be paid for exactly what they read in their off hours, thereby supplementing their income. It’s one of the reasons we’ve seen such a high pre-launch and pre-advertising subscription rate.”

One may wonder, given the longstanding shortage of radiologists in many Canadian communities, why a service of this sort hasn’t been launched before.

The answer, said Maynard, is that it required the creation of a service and technical infra-structure on a national scale. Most teleradiology companies are regional 2-5 person operations with limited capacity.

And while point-to-point teleradiology has occurred in Canada before – typically involving a hospital and a specific radiology group – no one in Canada has ever created a system that allows any number of hospitals and clinics to interact with a large number of radiologists licensed to practice in their jurisdiction.

Real Time Radiology has created its own workload management, coverage request and response system. “It includes automatic routing of exams based on the applicable jurisdictional credentials of the radiologist, their capabilities and subspecialties, along with their scheduled availability,” said Maynard. “The system can also respond to unanticipated on-demand requests, providing radiologists and the institutions they serve, with an unprecedented real time resource.” The creation of this system constitutes a significant innovation on the part of Real Time Radiology.

“We can have 50 different senders, generating studies at all hours of the day and night,” said Maynard. “We have the capacity to handle this because of the scale of the service”.

The compensation model is also new for Canadian teleradiology. Other services typically require radiologists to leave their current place of work and commit to a full-time position.

At Real Time Radiology, radiologists can continue to serve their current institution and provide services on a per exam basis.

Real Time Radiology was launched by a team that includes Mr. Ian Maynard, as well as radiologists Dr. David Koff, Dr. Nadine Koff and Dr. Greg Butler.

The company recently announced a multi-year, multi-site contract win to provide evening, night, weekend and on-demand coverage to the Huron Perth Healthcare Alliance.

In addition to providing teleradiology services across Canada, international hospitals have requested the company’s services.

“Canadian radiologists enjoy outstanding reputations internationally and are thought of as providing uncompromising quality and good value,” said Maynard.

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Hybrid imaging the talk of the town at RSNA conference in Chicago

By Jerry Zeidenberg

CHICAGO – Much of the buzz at the Radiological Society of North America (RSNA) conference – held here last December with some 58,000 attendees – was about the fast-developing field of hybrid imaging. These innovative systems combine different types of imaging – for example, they mix ultrasound with CT or MR, and nuclear medicine with CT.

The benefit? In an instant, hybrid systems are delivering multi-dimensional information to radiologists and physicians about the anatomy of their patients – enabling them to make faster, more accurate diagnoses and to more effectively conduct interventional procedures.

Of course, hybrid imaging systems are also demanding new skills from the technologists and physicians who are running the machines, as well as from radiologists reading the exams.

As just one indication of the surging importance of hybrid technologies, the Canadian Association of Medical Radiation Technologists (CAMRT), based in Ottawa, is now conducting a ‘gap analysis’, to find out which cross-modality skills its members have and those which they may be lacking. The information will be used to create new training programs to make sure that techs are up to speed with these new hybrid systems, which are taking the medical world by storm.

“Hybrid imaging is having a big impact on our profession, and we’re taking steps to address the trend,” commented Fiona Mitchell, president of CAMRT. She said that radiation technologists are facing similar challenges in the United States, the United Kingdom and Australia, but these countries haven’t yet conducted a study of the impact of hybrid systems on technologists. “They’re very interested in what we’re doing and they’re eager to see our results,” said Mitchell, adding that a paper based on the survey should be ready next spring.

Not only does hybrid imaging provide physicians with high-quality information, but it also boosts patient satisfaction and throughput in the hospital system, she observed. “When you can provide two exams at the same time, you’re providing a form of one-stop shopping for the patient,” said Mitchell, who is the provincial professional practice leader with the British Columbia Cancer Agency, in Vancouver, as well as serving as president of the CAMRT.

The RSNA is held annually, right after the American Thanksgiving holiday in late November. It’s said to be the largest medical meeting of the year in the United States. In addition to the busy seminar and lecture schedule, the trade show component is a much awaited annual event, as it’s the place where global DI suppliers show off their latest developments – and this year there were plenty. On the hybrid side, they included a new ultrasound system from GE Healthcare that can display and merge live U/S with CT and MR images; a SPECT camera from Philips that adds CT in a compact design; and new PET/CT systems from Siemens, GE and Philips that conduct scans in five minutes – instead of the conventional 20 minutes.

As well, several of the leading vendors showed off improvements in their CT systems, with a key development being the reduction of X-ray doses to patients – Siemens, in particular, announced its new Somatom Definition Flash CT, a dual-tube system that combines fast imaging with very low X-ray dose.

A major advance was also announced for MR, with Philips introducing a system that provides clear imaging of the body using 3.0T MR. This had been a difficult task in the past, and as a result, MR has been mostly used for brain and musculoskeletal imaging; now, it can be used to obtain high-quality images of the heart, liver and lungs.

Companies also demoed exciting systems for the operating room – in particular, Medtronic showed off a low-field, 0.15T MR system for intra-operative imaging during neurosurgery, and a mini-CT-like system for orthopedic and general surgery that provides quick, 3D scans in the operating suite. In greater detail:

Ultrasound: GE Healthcare announced an innovative new ultrasound system – the Logiq E9, which can display images from other modalities, such as CT and MR, directly beside live ultrasound images during the examination of a patient. What’s more, the imported images can be fused with the real-time ultrasound, giving the ultrasonographer a greater amount of information to work with.

Image fusion is achieved by marking a common point on two images – the live ultrasound image, and, say, the imported CT image. A GPS-like technology then keeps the images in synchronization. The images can even be overlaid, with one on top of the other.

It’s among the first systems of its kind – merging live ultrasound images with pictures from other modalities. “This helps address the biggest challenge in ultrasound radiology and vascular care – how to leverage clinical images from previous diagnostic imaging studies for interventional or diagnostic procedures,” said Terri Bresenham, GE’s vice president of diagnostic ultrasound and information technology. “We worked closely with a global team of radiologists and sonographers to develop this new ultrasound architecture, giving clinicians the advantages of imaging modalities – MR, CT and PET – and it is already reigniting the imagination of the ultrasound industry.”

As her team demonstrated the Logiq E9 at the massive GE Healthcare booth, Ms. Bresenham noted that it will be especially helpful to physicians conducting biopsies and ablations. It will also be useful for verification of lesions and to track various conditions over time, giving physicians more comprehensive views of the patient’s anatomy as they conduct exams or interventional procedures.

On a related front, Toronto-based Traxtal Inc. demonstrated a similar system at the RSNA – an ultrasound workstation that can import CT and other types of images, and then merge the pictures so that sonographers and physicians gain a more complete view of the patient’s anatomy.

Traxtal’s PercuNav system, which it calls a computer assisted, image-guided diagnostic and interventional system, has been cleared by the FDA in the U.S. for all imaging modalities. Interestingly, it also features a broad range of flexible and rigid “tip-tracked” instruments. Using minute electro-magnetic sensors embedded in the tips of these instruments, the software superimposes the precise, real-time location and orientation of the instruments on pre-operative and live images of the patient.

Neil Glossop, PhD, company founder and president, explained that the PercuNav system is designed for soft tissue navigation using tracked instrumentation. As such, the system is optimized for accurately conducting biopsies and ablations, inserting lines, and conducting other intricate procedures.

“CT and MR images provide physicians with terrific tools for identifying areas of interest, but are often impractical for navigation purposes,” said Dr. Glossop. “Ultrasound is a great live imaging modality, but images can be difficult to interpret. We set out to combine all available imaging data with real time tracking of the tips of flexible instruments on one screen to allow the physician to accurately target and navigate directly to areas of interest with confidence. We are delighted with the extremely positive physician response to the PercuNav.”

The PercuNav system consists of the Traxtal Tx mobile system cart, PercuNav software, and a wide range of instruments, including flexible needles, biopsy devices and RFA introducers. The system also incorporates advanced techniques for compensating for patient motion and respiration. Overall, it acts like a GPS system for medical instruments, and according to the company, it is the only such product available that allows accurate tracking of flexible instrument tips inside a patient’s anatomy.

The company will start shipping units with the capability to import and manipulate CT, MR and other images to customers in the U.S. in the first quarter of 2009.

Traxtal is currently seeking Canadian approval for the system from Health Canada; meanwhile, several Toronto-area hospitals have expressed interest in testing the unit once it is ready for use in Canada, said Dr. Glossop.

Nuclear Medicine: At the mammoth Philips booth, the Dutch-based company was showing off a hybrid innovation of its own – a SPECT/CT system that combines images from these two modalities. “It’s a new kind of hybrid,” commented Dominic Smith, VP of global marketing for nuclear medicine. “Others use CT and add SPECT,” he said. “This takes SPECT and adds CT panels.”

The result is a much smaller system – and a much less expensive hybrid solution. Smith explained the cost of the new device, called the BrightView XCT, will be on the order of US$600,000 to $750,000. That contrasts with the much higher price of a CT device which adds nuclear imaging, since the price of a 64-slice CT machine typically starts at $1 million.

The combination of price and the power of SPECT/CT imaging may be a winner for the Canadian market, which is seeking innovative imaging solutions but is strapped for cash. Moreover, higher-energy PET/CT hasn’t yet made major inroads in the Canadian marketplace, largely because of cost constraints and the reluctance of jurisdictions such as Ontario to reimburse physicians for the exams. As such, SPECT/CT may be an ideal solution for Canada. Smith noted the system is aimed at such nuclear medicine applications as cardiac exams, bone implants, and checking for infection. “It’s a good, multiple purpose system,” said Smith.

On the PET/CT front, there was lots of excitement – it’s clearly a field that’s undergoing rapid development. And while the market in Canada has been flat of late, for the reasons cited above, many observers feel that will change in the years to come. That’s because PET/CT is becoming the ‘gold standard’ in oncology imaging, and as care is shown to improve in other countries as a result of PET/CT, the pressure will mount in Canada to adopt such solutions.

Siemens showed its new Biograph mCT, a PET/CT scanner that can take whole body scans in five minutes. It can be outfitted using a 40, 60 or 128-slice CT scanner. It has a 78 cm bore – quite large, and ideal for imaging larger patients or those with tubes and equipment attached, such as oncology patients.

For its part, Philips was touting a new PET/CT scanner with an 85 cm opening; it too, is capable of five-minutes scans.

GE Healthcare also announced a new PET/CT scanner that images in less than five minutes. At a pavilion where GE discusses technologies under development, the company also discussed some work in progress concerning PET/CT.

In particular, it’s doing a great deal of research on ‘4D’ PET/CT, which accounts for the motion of the heart and lungs while the patient is in the scanner for five minutes or more. Jean-Luc VanderHeyden, PhD, global molecular imaging leader, explained that because the scan time is much longer than in other modalities, there’s a challenge in obtaining clear images of lesions in moving organs such as the heart and lung.

“If the tumour is small, and it’s moving, it will be lost in the image – it won’t be detected,” said Dr. VanderHeyden. Alternatively, it may not be accurately positioned, and during radiation treatment, “you end up treating normal tissue.”

“In PET, motion management is the biggest challenge,” he said. As such, GE Healthcare is investigating methods of ‘phase management’, so that imaging is done during rest stages, resulting in clearer and more accurate pictures.

Magnetic Resonance Imaging: Aside from the new hybrid technologies, progress is also being made in more traditional imaging modalities, such as MR and CT.

For its part, Philips Healthcare announced a new 3T MR scanner and an innovation for MRI that dramatically improves the way 3T MR machines can be used.

According to spokesmen from the company, the new technology eliminates the image problems that 3.0T systems have experienced in the past when scanning the body. As a result, the company believes that 3.0T systems will achieve even greater acceptance in the marketplace and that they will become the de facto standard for MR imaging. Currently, 1.5T scanners are the workhorse systems in hospitals and clinics.

In the past, 3.0T imaging has been challenging for certain clinical procedures due to dielectric shading effects and local specific absorption rates (SAR). Philips’ new, proprietary, MultiTransmit technology addresses these issues at the source with multiple RF transmission signals that automatically adapt to each patient’s unique anatomy. As a result, the new Philips MRI scanner delivers clear diagnostic images for even the most demanding high field applications such as breast and liver imaging, the company said.

“3T as a modality has not been embraced by the larger [imaging] community,” commented Stephen Mitchell, senior director, MR, for Philips Healthcare in North America. “This innovation moves MR into broader applications, such as breast imaging, liver and cardiology.”

And at the RSNA, amid a good deal of fanfare at their booth, Philips unveiled its new 3.0T MRI scanner that incorporates the new MultiTransmit technology. According to the company, the Achieva 3.0T TX enhances image quality, provides up to 40 percent greater scanning speed and helps ensure fewer retakes through increased image uniformity.

MR is, of course, an extremely useful imaging technique and many hospitals wish to acquire a scanner – or additional machines, if they’ve already got one. However, finding space in the hospital for an MR scanner can often be a problem.

A solution was offered at the RSNA by MedBuild, a division of Modular Space Corp. The company designs and constructs pre-fab imaging buildings that can be trucked to a site – say, next door to a hospital – where a unit can be lowered into place. It then becomes an extension of the imaging centre.

In 2009, MedBuild plans to start offering this solution to Canadian hospitals. “It’s designed for centres that have run out of space, and for organizations that discover renovating an existing space is too expensive,” said Jim Gabriel, director of business development.

The company took visitors on tours through a 14’ x 50’ prototype building right on the floor of the RSNA trade show. The building has all the requisite shielding needed for MRI suites. Gabriel says the company aims to provide a turnkey solution to Canadian hospitals in 2009 for less than US$400,000.

CT: Siemens festooned a CT scanner with fruits and flowers, to signify the life-affirming features of its new Somatom Definition Flash CT. In particular, the new unit generates very low X-ray doses while providing very fast and clear imaging – all to the benefit of the patient. It was quite a sight in halls that are typically filled with cold, hard metal and plastic equipment.

Essentially an improved version of Siemens’ previous high-end CT machine, the Somatom Definition Flash is a dual-source CT featuring two X-ray tubes that simultaneously revolve around the patient’s body. According to the company, it offers the fastest scanning speed in CT (i.e., 43 cm/s) and a temporal resolution of 75 ms, enabling, for example complete scans of the entire chest region in just 0.6 seconds.

The speed of imaging has important implications for patient care. Perhaps most importantly, the system operates at an extremely reduced radiation dose. For example, a spiral heart scan can be performed with less than 1 millisievert (mSv) of radiation, whereas the average effective dose required for this purpose usually ranges from 8 mSv to 40 mSv. And the scanning is so fast, patients no longer have to hold their breaths, as they did with CT in the past or on slower machines.

X-ray dose has become a huge issue in healthcare. Significantly, in the United States, the Alliance for Radiation Safety in Pediatric Imaging has launched a campaign called ‘Image Gently’, which provides protocols for delivering the lowest doses when imaging children. The Canadian Association of Radiologists is a backer of the movement, and the Canadian Association of Medical Radiation Technologists is climbing aboard soon. (More information is available at: http://www.pedrad.org/associations/5364/ig/)

Of course, a good deal of innovation has been occurring in the CT sector – in 2007, Philips announced a 256-slice scanner, while Toshiba announced a scanner that acquires 320 slices in a single rotation of the gantry. These scanners also significantly reduce the time needed to conduct a CT exam, and they, too, reduce the X-ray dosage to patients.

How have they fared in the market?

For its part, Philips has sold 50 of its 256-slice scanners worldwide since the announcement, with two sales so far in Canada – one has already been installed at the Centre hospitalier de l’Université de Montréal (CHUM), while another will be delivered shortly to the Rouge Valley Health System, just east of Toronto.

“It’s been a successful launch,” commented Brent Shafer, president and CEO of Philips Healthcare, North America. Shafer noted that the CT market in general declined about 14 percent in 2008 from a year earlier, but the outlook appears good for 2009, despite the worldwide economic downturn. “We’re looking for a recovery in CT in 2009,” said Shafer.

Joe Robinson, senior vice president of sales and marketing for Philips in North America, pointed out that imaging speed and technical capabilities in CT are only half of the equation for hospitals. “It’s all about workflow,” he said, pointing out there must be software tools to smooth the flow of information from the imaging suite to the radiologist and then on to the referring physician. “It doesn’t matter if you’re doing 256 slices or 320, you really need these workflow tools.”

Surgical imaging: Medtronic showed a fascinating pair of systems designed for intra-operative imaging. The company, perhaps best known as a maker of cardiac pacemakers and defibrillators, is offering an innovative O-arm, which provides CT-like imaging using a ‘telescoping’ gantry – it looks like a big C when open, and gives physicians access to the patient while conducting operations. When imaging, the C closes, forming a ring around the patient – hence the term O-arm.

The surgeon or interventional radiologist is able to quickly check his or her work using the system, which offers 2D and 3D imaging. It’s said to be advance over traditional C-arms in the operating room, which may not provide 3D imaging. It also has advantages over an intra-operative CT, which doesn’t allow easy access to the patient.

And while a standard CT will cost on the order of $1 million or more, and typically requires siting in a dedicated room, the O-arm is selling for approximately US$700,000 and can be positioned right in the OR. Worldwide, 100 of Medtronic’s O-arms are now being used, including two in Canada – they’re at the QE II Health Sciences Centre, in Halifax. Top applications for the system include spine, neuro and orthopaedics.

“Typically, in the OR, they use C-arms, but you can obtain better 3D with the O-arm,” commented Leslie McConnon, marketing manager for Medtronic’s Navigation business unit. She said it takes 13 seconds to perform a scan, and 10 seconds for the 3D reconstruction.

Medtronic also displayed its Polestar iMRI Navigation Suite – essentially a mini-MR system for intra-operative imaging. Whereas standard hospital MR scanners use a field strength of 1.5 Tesla, the Polestar generates a field of 0.15T.

And instead of the big doughnut-style design used by traditional MRs, the Polestar makes use of two large disks – the patient’s head fits inside, allowing for ease of access by the surgeon.

Due to the low field strength, “The image quality isn’t as good as a standard MRI scanner, but it’s excellent for surgeons in the operating room,” said Bruce Leggett, who handles marketing of the Polestar for Medtronic.

He explained that the brain is a gelatinous mass that can move around during neurosurgery. If surgeons are navigating using only pre-op images, they might miss parts of a tumour as it shifts during the actual operation. Using the Polestar, they can constantly check during the procedure to see if they’ve excised the entire lesion.

The system is selling for US$1.6 million, and the company has sold 50 worldwide – including 27 in the United States. A system was recently sold to the QE II Health Sciences Centre, in Halifax, where surgeons starting using it last November.

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New medical imaging research centre at McMaster University

By David Koff, MD

HAMILTON, ONT. – An innovative initiative at McMaster University is coming to life, combining medical imaging with a range of disciplines such as medicine, medical physics, biomedical engineering, computer science, nuclear medicine, e-health, statistics, and psychology.

The Medical Imaging Informatics Research Centre at McMaster University (MIIRC@M) is the result of the efforts of the radiologists at Hamilton Health Sciences, and researchers and scientists at McMaster University and the University of Waterloo, along with other prestigious Canadian and international universities.

At the practical level, we have secured funding for our initiative for two years, plus office space, from McMaster University’s Faculty of Health Sciences. This funding has allowed us to recruit a manager with invaluable experience in computer sciences, medical sciences, and project management.

The team is moving into offices at the McMaster Innovation Park in February. Also Agfa, a leading PACS vendor, has generously agreed to donate a licence for their web-deployable image and information management solution (IMPAX 6) for our research purposes.

Why a Medical Imaging Informatics Centre?: The idea of creating a Centre came from many years of partnership with engineers on a number of research projects. During this partnership it became apparent that computer scientists have brilliant ideas plus the time and resources to build exciting research projects, but they lack a clinical background and the validation and guidance from physicians.

While the physicians involved would be very enthusiastic about participating in more research and turning their ideas into real applications, they are overwhelmed by the amount of day to day clinical work. Added to which they have very limited academic time, and don’t always know where to find the appropriate partners and resources to build successful projects. This disconnect helps to explain the low number of research grants generated by many radiology departments.

MIIRC@M development and goals: The mission of MIIRC@M is to create an environment to bring together these groups and use their skills to create and implement a support infrastructure and develop the necessary tools. The physicians will benefit from the computational and analytical skills from the scientists involved, and the scientists will receive guidance and validation as well as access to clinical data from the physicians.

Both groups will collaborate when it comes to writing grant applications and publications. As an example, one of the tools we plan to build is a resource database of relevant anonymized medical images, which will be created by archiving diagnostic images of disease conditions using various modalities (e.g., CT, Ultrasound, and MRI). This image library will be accessible by modality, pathology, and type of image under approved research protocols. The images may be licensed for use as a learning resource for the MD and residency training programs.

Paramount among the goals of the Centre is the development of successful projects, and the list of potential topics is long:

• Advanced image processing; image segmentation; image registration; image fusion.

• Human-computer interface; visualization; workflow; image compression.

• Quality Assurance; Quality Control.

• Data mining and neural networks; content-based image retrieval; evidence-based guidelines; cross-modality visualization of disease entities; report-driven image understanding.

• Psychophysics and reading environment.

We have already begun work on a number of projects involving different skills; image compression with the Mathematics Department, and body compression with the Kinesiology Department, both at the University of Waterloo; and a joint project with Agfa on radiation safety.

Conclusion: While MIIRC@M has been created to foster research and education in Medical Imaging Informatics, and to create new opportunities for talented people, we hope to achieve this in a spirit of collaboration with other specialties who are also image producers and who may wish to participate; such as cardiology and pathology.

We are of course always looking for more research and partnership opportunities, especially those that help solve medical imaging-related issues or which create innovative and original ways to approach imaging.

Dr. David Koff is Chief, Department of Diagnostic Imaging, Hamilton Health Sciences and Chair, Department of Radiology, Faculty of Health Sciences, McMaster University.

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Innovative system collects and transfers patient data during EMS calls

By Dianne Daniel

Does electronic access to information save lives? Absolutely. Can it enhance patient outcomes? Without a doubt. And, as two recent IT efforts related to emergency services in Toronto indicate – one at the Sunnybrook-Osler Center for Prehospital Care (SOCPC) and the other by The Hospital for Sick Children’s (SickKids) Acute Care Transport Services (ACTS) team – electronic access to information can also enhance decision making, reduce room for error, and provide a vital communication link at times when paper-based information just isn’t good enough.

In September, 2008, the transport team at SickKids, which only deals with emergent cases and handles roughly 800 inter-facility neonatal transports each year, launched Transport Remote Access Care (TRAC), an electronic information gathering system that provides portable telehealth capabilities. The goal was to extend the process of electronic bedside monitoring out into the field so that paper-based charting during transport could be eliminated, and patient information could easily be shared between a referring and receiving facility.

“We wanted to start the process of electronic data gathering as soon as we made patient contact in the community hospital and continue that process throughout stabilization, and on follow-up in the admission process here,” explains Dr. Hilary Whyte, neonatologist and medical director, ACTS. “We were maintaining a paper record for patients during resuscitation and stabilization, including documenting vital signs, and it was a lot of work when you only have two people there and, invariably, a sick, fragile baby.”

Partnering with Dapasoft Inc. of Toronto, a provider of custom healthcare solutions, and consulting with clinical staff, the hospital undertook to develop TRAC, a system that mirrors bedside electronic patient monitoring in the field, automatically downloads patient information from a referring hospital, and incorporates a web camera (webcam) to provide enhanced communication with receiving physicians.

“Everybody recognizes that for patient safety and quality of care, we need a system that provides an automatic data dump so that we’re not transcribing information,” says Whyte. “Also, when you want physiological data, you want it particularly around the time of an acute deterioration in patient condition and that’s the very time you can’t chart.”

The hardware component of the TRAC system consists of an OQO minicomputer running a full version of Microsoft XP and a Microsoft webcam, both of which are installed on the neonatal transport deck. The software component, developed by Dapasoft, is an HL7-based integration engine that collects physiological data such as temperature, heart rate, blood pressure and oxygen levels from the patient monitor, stores it on the OQO and feeds into hospital-based electronic charting systems. The system is also designed to work over a wireless network.

“Since not all hospital sites are WiFi-enabled, we took the unorthodox stance of saying, ‘If we don’t have WiFi available to us, we’ll bring it with us,’” notes SickKids systems manager Loreto Lecce. As Lecce explains, the transport team is equipped with a WiFi access point that it connects to a receiving hospital in order to establish a secure VPN tunnel back to SickKids. Referring physicians can then access the most current patient information from a web portal, whether at the hospital, at home or in their office, and can also view images of the infant using the web cam.

Another example of an emergency services team that has found an innovative way to deal with paper is the Sunnybrook-Osler Center for Prehospital Care. As the quality assurance arm for the Emergency Health Services Branch of the Ontario Ministry of Health, the SOCPC provides medical oversight and clinical direction to roughly 1,800 paramedics operating across a 12,000 square-kilometre region near Toronto. A large part of that responsibility relies on the auditing of Ambulance Call Reports (ACRs) to look for protocol violations and determine whether intervention or training is required.

The challenge is that the majority of ACRs in Ontario are still paper-based. To fulfill its requirement to the Ministry, the SOCPC used to maintain a carbonless paper copy of each report and perform random audits on a representative sample size, using off-duty paramedics to search for protocol violations.

To improve efficiency and ensure that every ACR would be involved in its auditing process, the SOCPC developed a Data Abstraction System that relies on an SQL database. Important patient data such as history, chief complaint and EMS response is stored in the database and predetermined filters are then used to automatically search the information for variations in medical protocols. For example, nitro-glycerine is an appropriate medical act for a chest pain complaint, but it shouldn’t be administered when a patient’s blood pressure is below 100.

The SOCPC turned to Scarborough, Ont.-based INOFAS Integrated Systems Inc. to perform the necessary data entry into the Data Abstraction System. However, whenever a “variant” report was flagged by the electronic filters, auditors still had to search through boxes and boxes of stored paper to retrieve the original copy.

That’s when the SOCPC made the decision to scan the paper-based reports and maintain the scanned images in an Alchemy fixed content repository from Captaris Inc. In addition to performing data entry, INOFAS provides the scanning service, using a Fujitsu fi-5650C sheet-fed scanner and Kofax Virtual ReScan (VRS) software, and hosts the images on a server in a secure data centre. A key requirement, says INOFAS president Mike Harrison, was to find a scanner that would deliver clear electronic images given the poor quality of the ACR, which is a four-part carbonless form completed by hand. It also had to accommodate electrocardiogram strips.

“At first we thought the VRS would slow us down; now we wouldn’t live without it,” says Harrison, noting that the VRS software detects and stops a poor image, enabling scanners to adjust the quality at the point of scanning. “Our images are better than the paper,” he says.

“When you’re getting 500 to 700 sheets every day, filing them and retrieving them was a nightmare,” says Bryan Pett, SOCPC director, corporate development and strategic planning. “Now the retrieval is instantaneous and foolproof.” By providing electronic access to ACRs, the SOCPC has reduced the cost of auditing by 80 percent, he adds, and is addressing potential violations up to 85 percent faster. “Under the old system it could be weeks or months before calls were audited, which was very problematic,” says Pett. “Now, rather than spending a lot of time and money searching through the haystack for the needle, we have this big magnet that we can lower onto the haystack and it pulls up the needle for us.”

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