System at SickKids archives all clinical images

By Jerry Zeidenberg

TORONTO – A new image management solution at The Hospital for Sick Children (known as SickKids) is computerizing all types of clinical images and making them easily accessible to care-givers. The world-renowned medical centre now centrally archives electronic images from over 40 different specialties – including pathology, dermatology, ophthalmology, medical photography and plastic surgery.

“We’re making the benefits of computerized images available to all clinicians,” said Daniela Crivianu-Gaita, vice-president and chief information officer at SickKids. “It’s part of our journey toward the complete electronic patient record.”

The hospital digitized diagnostic images such as X-rays, MRIs and CT scans over a decade ago – in fact, it was one of the first in the country to install a Picture Archiving and Communication System (PACS). It also computerized its cardiology and pathology images.

But more recently, when talking to clinicians, Crivianu-Gaita and her colleagues learned that all specialists were experiencing challenges with images. They needed help organizing what they were collecting and also with accessing them.

“Some departments would keep images on CDs, and then would spend valuable time looking for them,” she said. “Others would have special workstations and archives for different pieces of equipment. But the clinicians would have to move from one workstation to another to look at different types of images.”

That was time-consuming and inefficient. “It also added to the wait-times for patients,” said Crivianu-Gaita.

The hospital began sounding out vendors for solutions. Some of the PACS vendors said they could do it, but only if all images were in DICOM format, a diagnostic imaging standard. Unfortunately, not all images are produced in that way – including the standard images from digital cameras that are used by so many departments.

Other companies offered an ability to store all images, but weren’t able to provide workflow improvements – such as linking current and historical images to patient files.

One company insisted it could do both – Apollo PACS Inc., of Falls Church, Va. As it happened, Apollo is the company that already supplied the hospital’s digital pathology system, one of the most advanced in the country.

“We have a lot of experience in dealing with different types of images because of our background in pathology,” said Tom Campbell, chief operating officer for Apollo. “Unlike diagnostic imaging, in pathology the standards are just being defined. So we’ve developed a core competency in non-standard imaging formats.”

That includes expertise in manipulating very large files – such as those gathered by whole slide scanners and electron microscopes – as well as streaming video. “For hospitals, bandwidth is a big issue,” said Campbell. “We use solutions that minimize their bandwidth needs.”

The company also has solutions for improving workflow – ideas that reduce the time and effort needed for clinicians to carry out their work. “Workflow is really the key,” said Campbell.

Confident that Apollo had the abilities to devise an all-encompassing solution, the hospital decided to join forces with the company and launched a pilot project in the dermatology department.

The system was up and running in May 2009. “We started with a single department that produces a lot of images to see if we had the right system in place,” said Crivianu-Gaita. Dermatology served as an excellent test-bed, as the department acquires and compares images that are taken over a period of time – resulting in a great number of pictures that must be managed in a well-coordinated fashion.

Not only were solutions found for consolidating and storing images in an intelligent way, but workflow improvements were built into the capture and accessing of images.

“We mapped out the processes that needed to be computerized,” said Sandra Moro, a senior project manager at SickKids who heads the Enterprise Patient Media Manager (EPMM) project. “We found that processes were needed for obtaining patient consent and for physician review.”

Also, by speaking with clinicians, it was found that it would be extremely useful in some cases to have a workstation in each exam room. “Physicians wanted to review images with patients and their parents,” said Moro.

All of this was built into the design and workflow of the system – leading to positive feedback from clinicians and the patients. “We’ve had a significant increase in patient satisfaction,” said Crivianu-Gaita. “It has helped them to become more active participants in the care process. And when patients and their families are more actively involved, outcomes also improve.”

In December 2009, the hospital expanded the Enterprise Patient Media Manager to include a total of six departments – dermatology plus plastic surgery (which made eminent sense, as dermatologists and plastic surgeons often work closely together), along with gastroenterology, medical photography, ophthalmology and SCAN – the Suspected Child Abuse and Neglect program.

SickKids and Apollo have put a special emphasis on the security of the Enterprise Patient Media Manager. “We’ve got complete auditing and role-based access,” said Crivianu-Gaita. “We can also tell who has looked at images and who has made copies.”

She noted that in rolling out the system to the various departments, there are human issues to deal with. These challenges often take longer to sort out than the workflow and technological needs of various departments.

Some clinicians, for example, are worried about the privacy of the images they house in their departments.

It can take months of discussions to persuade them that the central archive is more secure and useful than previously-used methods of storing patient images.

Nevertheless, most clinicians eventually agree that the system is not only secure, but it also helps them find what they need quickly and from a single workstation.

The system deployed at The Hospital for Sick Children is the first of its kind for Apollo, which is now offering the Enterprise Patient Media Manager to other medical centres worldwide. “SickKids is our flagship site,” said Campbell.

For its part, SickKids plans to continue developing the system to give it more functionality. For example, in the next year, there will be a secure web site developed that enables police, physicians and social workers to upload photos in cases of suspected child abuse. “SCAN currently receives many images on disks,” commented Moro. “A secure web site will allow professionals to send in their images faster than before, which also means they can be reviewed here at SickKids more quickly.”

Moreover, the clinicians using the system are always acquiring new types of scopes and scanners, which they would like to have connected to the system. “We expect to be continually developing new interfaces, to connect the new equipment to the imaging solution,” said Moro.

Training on the system will also be expanded in the New Year. “Clinicians have found there is a great deal of value in the system,” said Crivianu-Gaita. “They want colleagues and staff who are new to the department to use the solution, so we’re seeing an increasing volume of requests for training.”

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Lower radiation doses, new hybrid technologies take centre stage at RSNA

By Andy Shaw

CHICAGO – Make it low and make it flow. Those watchwords for lower radiation dosages and for quicker, more co-operative workflow were much in evidence at the massive annual November gathering of the Radiological Society of North America (RSNA) in Chicago. Indeed, just so over 700 exhibitors, 2,400 presenters, and more than 60,000 visitors who filled the soaring halls of McCormick Place edging Lake Michigan, got the message clearly – the RSNA formally launched its new “Image Wisely” campaign. That initiative won the blessing of many, including featured speaker Bill Clinton, who appeared for a reported $100,000 fee.

But other sub-currents also ran through McCormick this year, including “personalized medicine”. Back again for what some said was at least its 10th annual appearance as the “new age” in healthcare. Indeed, there were some significant advances towards that seemingly ever-receding horizon at the 2010 show.

On the gizmo front, Apple iPads – showing off diagnostic-quality images that can be read and manipulated from afar – were the RSNA 2010’s scene stealers.

As usual, the radiological heavyweights dominated exhibitor space. Philips Healthcare loomed largest with its football-field-sized “booth” in McCormick’s North Building, where Agfa HealthCare was also prominent. Across the way in the equally spacious South Building, GE Healthcare, followed by Toshiba Medical Systems Corp., took up the largest acreages, while Siemens Healthcare and Carestream Health, Inc., in the third Lakeside Center exhibitor hall, staked out the most carpet.

At its booth, Philips unveiled a plethora of new products under a giant “Imaging 2.0” banner proclaiming a new approach to its healthcare customers.

“The wide range of new equipment we have here reflects a whole new way in which we are now thinking about our customers and our products,” said Joe Robinson, senior vice president, sales and marketing, imaging systems, as he led a show-and-tell trek through the vast but jammed Philips farm. “Before we settled on the Imaging 2.0 approach, we had talked intimately with 1,000 of our customers and three key findings came out of that effort: they wanted to be more collaborative; they wanted to be more patient-focused, particularly on safety; and they wanted our products to give them better economic value.”

Robinson went on to say that those criteria, plus the innovations produced by a number of Philips’ recent acquisitions, combined to produce the record number of unveilings this year. Among them, is a completely re-designed, bigger bore line of Ingenia magnetic resonance imaging (MRI) machines that Robinson said very much reflect the company’s new customer-aware Imaging 2.0 approach. “With them, you get 40 percent more signal, about 30 percent more throughput, and over the lifetime of the magnet, which can be from five to 10 years, it is going to cost you about 50 percent less to buy upgrades. With their bigger bore, they are also more comfortable for the patient.”

Among the most notable new products was Philips’ new hybrid imaging Ingenuity TF PET/MR combo – one the company says is so ground-breaking that it is calling its PET/MR a “new imaging modality.” True to its name, the two-headed device ingeniously combines an Achieva 3.0T MRI with its keen eye for anatomical detail at one end of a short track with a molecular-function-focused PET scanner at the other end. In between is a travelling table that can pass a patient from one machine to the other and swivel the patient 180 degrees en route.

Meanwhile, GE Healthcare was showing off to similar crowds roving the South Building what it had learned from its major support for and technology trials at the Vancouver Olympics.

“I think what Vancouver really allowed us to do and show was how this initiative to bring healthcare to the patient, rather than the patient to the hospital, can be realized,” said Peter A. Robertson, vice president and general manager for GE Healthcare in Canada. “And you can do that as we did on Whistler Mountain and elsewhere by bringing smaller, intelligent, Wi-Fi enabled devices to where patients or in the Olympics case, athletes first need them. With the digital backbone we had in Vancouver, we could get ultrasound images right from the hill back to radiologists in the city, who could make an immediate determination whether that knee and that skier could continue to compete or had to be taken away for surgery.”

Robertson said that this new ability to provide immediate expert care where it’s most needed has since served as a model for further GE Healthcare developments, some of which were on view at RSNA 2010.

“I think this remote care notion translates particularly well into the realm of home care and what can be done to help keep chronic disease patients, for example, away from needless and very expensive stays in the hospital,” said Robertson. “But the mobility that wireless gives devices is also translatable to hospital safety and workflow. So we’re unveiling a new wireless X-ray technology here.”

The technology is called FlashPad, and is embodied in a flexible, wireless detector that can be placed easily, thanks to its thinness and its two handles, under and manoeuvred beneath a patient. GE says it provides up to 8 percent more coverage and maintains high image-quality at low dose levels.

But GE Healthcare has not forsaken developments of its big weapons, and not to be outdone by rival Philips, it too unveiled a heavyweight hybrid imager that combines not two but three imaging modalities.

On the opening Sunday afternoon, as many visitors were still inbound, GE announced it had installed the first of its PET/CT+MR machines at the University Hospital in Zurich. Collaborating Swiss technicians and clinicians can capture multi-modal images from just one visit by a patient.

Meanwhile, according to vice president Andy Hind of Agfa HealthCare Canada, Agfa has been thinking low dosage and digital flow for its customers, too, both big and small. He helped the Belgian-based company introduce its new motorized and mobile DX-D 100 digital radiography unit, along with complementary DX-D 400 and DX-D 500 models.

“We developed new software to enable these machines to be much more integrated into a hospital’s communications and PACS systems, as well as its overall workflow,” said Hind.

But perhaps more importantly, the DX-D 100 can also be better integrated with its human users and patients. It is small and narrow enough for a single caregiver to wheel into an ICU, an emergency room, an operating room, or a patient’s room. The unit can store up to 4,000 images, so it enables an attending physician to make comparisons between a patient’s latest and prior digital images right at the bedside.

The DX-D 400 is a more affordable solution aimed at giving private radiology practices and hospitals a financially comfortable path to transitioning from analog to digital imaging. Depending on the user’s circumstances, it can be configured to work with traditional film, computed radiography (CR) or direct radiography (DR) detectors.

For those clients cramped for floor space, the DX-D 500 is a ceiling-suspended digital solution.

The new Agfa image processing technology, dubbed MUSICA, also contributes to lower dosages. Clinicians can use the needle detectors it runs to reduce exposure by as much as 50 percent, according to Agfa. Users can manipulate multiple levels of contrast and density within low-dose generated images that might otherwise remain murky.

Toshiba also enjoyed large crowds both at its booth and at its much anticipated annual evening reception, held for RSNA 2010 in the Presidential Suite atop Chicago’s Intercontinental Hotel. The event attracted a number of intercontinental guests of note in the radiological world – who between ample hors d’oeuvres, a side of beef, and a Scotch tasting could reflect at their leisure on Toshiba’s highlight offerings back at the show.

Among their picks:

• the Toshiba Kalare digital X-ray system’s new lightweight DR panel detector. Caregivers can position the 8-pound, 14-inch by 17-inch panel when working with hard-to-examine wheelchair and stretcher patients. It comes with a new rotating “bucky” tray that allows technologists to easily switch the detector from portrait to landscape view, all making for more efficient exams and faster workflow

• upgrades across Toshiba’s ultrasound product line, including improving their 4D image quality. As Tomohiro Hasegawa, head of ultrasound for Toshiba explained: the better 4D imaging during biopsies enables wins for all involved – seeing anatomy more clearly means more accurate guidance of the biopsy needle for the clinician, safer exams for the patients, and more patients seen in the daily flow for hospital managers

• Toshiba’s SureExposure dose reduction technologies, available in all its Aquilion CT systems, that automatically adjusts the dose level to the patient’s size, lowering traditional exposure levels by as much as 40 percent; as well as the similar SureExposure Pediatric that adjusts for lighter weight and younger age. Also now available in the Aquilion Premium and the Aquilion ONE is what Toshiba is calling “Adaptive Iterative Dose Reduction” software, or AIDR for short. AIDR intuitively removes image-clouding noise as images are processed until the picture is optimal.

But such innovation is not the prerogative of just the big boys. “If you want to see the really new and innovative stuff at the RSNA, you go see the smaller exhibitors,” said Dr. Patrice Bret, head of radiology for the University Health Network, Toronto’s three-hospital conglomerate.

Companies like IMIX Americas Inc., or Canada’s own Calgary Scientific.

IMIX, based in Sterling, Virginia, introduced an entry-level digital radiography system, DRxpress, to what the company’s president believes is a waiting and under-served world of private practices, walk-in clinics, and small hospitals.

“We, like other companies, talk to our customers, too, but I think a lot of our competition is not listening to what they say,” commented Rick Spordone, IMIX CEO, during a mid-morning interview at the company booth. “What we are hearing them say is: They want something that they can update whenever technology changes.”

Low-volume facilities, Spordone further explains, have been traditionally hard pressed to justify the purchase price of digital radiography and also overcome the fear of soon being stuck with outdated equipment too expensive to replace.

“So what we are offering is a low-cost, yet high quality entry point system that gives them a seamless path to more full-featured and automated systems,” said Spordone. “As technology changes, we’ll make it easy for our customers to either trade up or, more often, simply swap components.”

Even from the outset, Spordone promised that users of DRxpress will get the benefits of core digital radiography functions including immediate image display and easy sharing of images, at a price comparable to CR or film.

Incomparable is what some very choosy healthcare technology observers are saying about Calgary Scientific, and its advanced visualization and real-time collaboration innovations. Frost & Sullivan, a well-known technology market-research firm, formally conferred upon Calgary Scientific officials attending RSNA its “2010 North American Medical Imaging Remote Medicine Healthcare Innovation of the Year Award” for the company’s patented zero-footprint PureWeb platform technology and resultant ResolutionMD products.

“It’s very flattering,” said J. Ross Mitchell, PhD, one of the founders of Calgary Scientific and a professor in the department of radiology and clinical neurological sciences at the University of Calgary. “But what we have produced in concept is really quite simple. All our images sit on our server in Oregon and thanks to our patented algorithms, they can be accessed virtually. So radiologists don’t need to download anything, there’s no proprietary software involved, and they can access as well as manipulate the images with standard browsers from just about all the communication devices we are using today.”

Including iPads, which dotted the Calgary Scientific booth, now grown substantial after several years of exhibiting at RSNA.

That growth from a tiny Canadian spinoff to an international player was confirmed not just by awards, but by a dollars or perhaps euros and cents business deal with Siemens Healthcare, significantly Calgary Scientific’s next-booth neighbour at RSNA 2010. “They are already using our software in one of their new diagnostic suite offerings,” said VP of research, Glen Lehman, as he nodded towards Siemens while demonstrating on this observer’s iPad the wonders of the PureWeb platform and its crystal clear images.

A clearer crystal ball is what Siemens Healthcare CEO Hermann Requardt wishes he’d had a decade ago as he spoke this year at a RSNA media breakfast on the oft-heard theme of personalized medicine.

“We were talking about it as a company 10 years ago, but I admit we were wrong about how quickly it would come,” said Herr Requardt, who is also Siemens’ chief technology officer (CTO) for healthcare. “What we couldn’t see clearly back then was how much more intelligence we needed in our systems to make personalized medicine a reality. “We knew that personalized medicine is really knowledge-based medicine. But what we see and understand far better now is that it needs to work in a rich, computerized environment – one that can acquire knowledge and learn from it.”

Perhaps the chief reason that diagnostic systems need to learn from the images they capture is because of the devious ways of cancer, in particular. “The same cancer can be different in its effects and appearance in different patients,” said Requardt.

Consequently, as a first fundamental step towards more intelligent imaging, Siemens unveiled at RSNA 2010 what it thinks will be a revolutionary system that comprises a Magnetic Resonance (MR) scanner and an integrated Positron Emission Tomography (PET) scanner, but with an architecture that allows the system to perform as one.

“Merged imaging information allows physicians to understand disease and its progression significantly better,” said Dr. Bernd Montag, head of imaging & therapy systems for Siemens Healthcare.

This new 3-Tesla hybrid system – introduced as the Biograph mMR – is already at work in Germany at the Munich Technical University hospital, simultaneously capturing whole-body MR and PET data.

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Toronto area hospital improves patient safety with CPOE and eMAR

By Neil Zeidenberg

TORONTO – North York General Hospital (NYGH) – a 419 bed community teaching hospital that’s affiliated with the University of Toronto – has taken a leap forward in reducing medication errors by implementing CPOE and eMAR. It is also bringing the latest evidence-based medicine directly to the bedside.

“A significant proportion of preventable errors involve medications prescribed and administered using traditional, manual systems,” said Dr. Jeremy Theal, director of Medical Informatics and a gastroenterologist at NYGH. “By integrating the latest medical literature and implementing barcode scanning with electronic orders, we’re raising the bar on patient care and preventing errors to significantly improve patient safety.”

NYGH is the first in Canada to use electronic order sets with built-in links to the latest evidence-based medical literature. Patients benefit by receiving treatment that’s linked to the most recent medical research, while care providers win by knowing their decisions were based on the very best information available.

It’s also the first hospital in Ontario to achieve HIMSS Stage 5 – a scale developed by HIMSS Analytics, the research division of the Healthcare Information and Management Systems Society. The level indicates how hospitals rate in adopting electronic health records.

Reaching Stage 5 is impressive, considering that in the United States, less than 1 percent of all hospitals have achieved this status. More specifically, it means a hospital has implemented a closed loop medication administration environment that integrates barcoding with eMAR, CPOE and pharmacy. Care providers are alerted immediately if they’re about to make a mistake.

The eMAR (electronic Medication Administration Record) contains a list of all prescribed meds, and uses barcode technology to monitor the administration of meds at the bedside, while the CPOE (Computerized Provider Order Entry) allows providers to enter their orders electronically, eliminating errors associated with handwritten notes.

Acquired from Cerner Corp., the CPOE uses the latest medical knowledge available and a library of over 300 evidence-based order sets, developed with Zynx Health (www.zynxhealth.com), a leading provider of evidence-based and clinical decision support solutions headquartered in Los Angeles, Calif.

These order-sets cover the most common conditions seen in patients, and can be accessed by physicians in a matter of seconds. According to Dr. Theal, the evidence may also help doctors determine if a patient needs to be admitted or kept in the hospital at all.

At the announcement in November, the technology was demonstrated by nurse consultant for eCare, Erin Landry. As she explained, a nurse or clinician would visit the patient bedside with their WoW (workstation on wheels). Using a mobile device, they scan the patient’s wristband containing a unique barcode and the screen displays the patients’ profile. Next, the medication barcode is scanned to confirm the right drug and dose is to be given to the right patient at the right time. “If anything fails to match the prescribed order, care providers are alerted immediately and any potential harm to the patient is eliminated,” said Landry. Moreover, upon administration of a med, the patient’s profile is automatically updated.

Other tools being used to ensure patient safety include: Medication Reconciliation and Prescription Writer. The Medication Reconciliation records all medications a patient was taking prior to and since entering hospital, and helps to determine what he/she should take upon discharge. Prescription Writer provides an electronic script to the patient upon their release from hospital.

Although nothing is fool proof and accidents can happen, the electronic solutions in place at NYGH help put safety first and make the best care available to patients. “Ultimately, we have tools that research shows will help people get better faster and save lives,” said Dr. Theal.

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Emphasis on needs of clinicians drives EHR at Hamilton Health Sciences

By Mark Farrow

At Hamilton Health Sciences, the road to the Electronic Health Record (EHR) has been a long but rewarding journey. As we enter the third year of this initiative, it has become clear that the bumps in the road are much less about technology than they are about process change.

There have been a number of factors contributing to our successes to date. First and foremost is a solid strategic plan that was accepted, endorsed and supported by all levels of the organization. Painting a clear picture of where we were going and what milestones to look for along the way ensured a smooth start to our journey. It was about having a vision that clearly defined where technology and practice change could take us.

As in driving, we use the rear view mirror not as the method to move us forward, but to see where we have been on our journey; we needed to focus on what was coming at us as we designed the systems and processes and look to the past for confirmation, not direction.

Once we had the commitment of the organization, the next key component was to put a Clinical Informatics team in place. Making the journey to an EHR had to be about the clinical areas and their needs and not about Information Technology (IT). We looked for those individuals from the various professions who could champion the system and ensure that our design was appropriate, utilizing the tools and software that we had available to us. We also put in place a Medical Director of Informatics and worked to ensure that physician representation was in place for all projects.

With this team in place, ensuring that the structure of a good foundation was built was key to our strategy. We rebuilt the base Order Entry system and made sure that we were covering all of the main clinical areas. We also looked for starter projects, such as creating electronic order sets, as one of the major foci for us as we started down the road to Computerized Physician Order Entry (CPOE). We felt that we will need to be at 80 percent of all orders coming in the form of an Order Set before we would move to the full CPOE. This process has created an improved adoption rate, and with the forms all available on-line, the physician group is getting used to going and using the computer to access their orders.

The order sets, along with the progress in getting the documentation online, has created value and uptake. When information is available and easily accessible, usage increases and starts to drive a sustained momentum forward. We now have clinical documentation live in many inpatient units, plus the Emergency Departments, complete with instrument interfaces. Our next challenge will be to find suitable systems for the Ambulatory clinics, although we do have a number of clinics up and running already.

The road is not straight but a winding path that requires us to predict in many cases what will be around the next bend. Having a strategy that can accommodate and adapt to the changes that are coming our way is what will make us successful. Three years ago, we were not preparing for the onslaught of mobile devices and tablets, but now we are working hard to integrate them into the rollout. We built the plan on the fact that no one technology would work for all people in all areas, but that flexibility was the key to successful adoption of the technology.

I foresee that we will be embracing a “Bring Your Own PC” philosophy as we move forward as one of the next major trends. This will continue to be a pressure point, and along with meeting the privacy and security issues, will take a concerted effort by the IT department to ensure that we have the right technologies in place to support this.

Gone are the days when we can dictate to physicians and other clinicians which devices they can “drive” on our highway. Supporting the productivity of our staff means ensuring that we are giving them the options that work for them. The technology is available to allow us to protect our resources while giving the options that meet the needs of a more consumer-driven client base.

Another area I see that will change our landscape is the use of web/portal technology. Rather than replacing legacy systems, utilizing web-based technology is where we need to be on this journey to provide a single point of contact for clinicians, and integrating the systems that they need to access into one easy and convenient location.

Our portal is also optimized for use on portable devices such as the iPhone, BlackBerry, Android-based devices, or iPad and other tablet devices. As part of the Local Health Integration Network (LHIN) activity, the portal has now been rolled out to over 23 hospitals, Family Health Teams, Community Care Access Centres and Community Health Centres for access and data feeds. Along with our online data, this is providing the basis of an EHR for over two million patients, today!

As we move forward, this technology will provide the foundation that will allow access to information designed to manage chronic diseases and even open up better interaction directly with the patient via patient portals. By having developed the data feeds, it will now be a matter of creating views of this data rather than reinventing the wheel as we strive to meet the needs of different groups of patients and providers.

While all of this is very exciting for us, the largest fear is ensuring that it is sustainable. Our focus has been on keeping our costs down and the support manageable. Funding within the healthcare system is not going to improve dramatically in the next few years, and yet, it will be the adoption of the new technology that will help us better manage the system and control those costs. But this will require startup capital and sustained funding to keep the e-health agenda moving forward.

The consumer has seen the benefits of these investments in other industries and they will see those benefits in healthcare as well, but we need to be vigilant in keeping up the investments. Just like our cars, failure to invest will result in an unsustainable journey in the long run.

Mark A. Farrow is Chief Information Officer and AVP, ICT, at Hamilton Health Sciences. HHS consists of a family of six unique hospitals and a cancer centre; the organization is a teaching hospital that is affiliated with McMaster University and Mohawk College.

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