London, Ont. hospital to launch centre of excellence for robotic surgery

By Dianne Daniel

This year, the London Health Sciences Centre (LHSC) intends to launch a world-class facility for robotic surgery, all in the name of advancing minimally invasive surgery techniques. “Not only will we feature the latest technology, but we will also have the infrastructure money to pay post-docs and researchers to make this a state-of-the-art facility,” said Dr. Douglas Boyd, LHSC’s director of minimally invasive cardiac surgery and robotics.

Dr. Boyd, who is credited with performing the world’s first closed-chest, beating heart single bypass surgery, is the lead investigator behind the National Centre for Minimally Invasive Robotic Surgery, which is being made possible by $17 million in federal and provincial government funding, as well as private enterprise support. Since his landmark operation in September, 1998, Dr. Boyd has successfully performed robotic surgery on more than 100 patients, 36 of those using an innovative telerobotic system called Zeus from Santa Barbara, Calif.-based Computer Motion Inc., and says he currently gains two to three new cases each week.

The new centre will house anywhere from five to seven robotic surgical systems at an approximate cost of US$1 million each. According to Dr. Boyd, advances in robotics and digital computing are allowing average surgeons to become great surgeons – and great surgeons to do what’s never been humanly possible before.

“Right now, we’re doing things that were [formerly] beyond the realm of human dexterity,” he says. “We tried in the lab for over a year or two to sew bypasses through little tiny pencil-head incisions using conventional instruments, and we could not do it.”

By contrast, robotics make this procedure possible.

The Zeus Robotic Surgical System combines three technologies: robotics, embedded computer systems and speech recognition. Built by a team of in-house robotic experts under the guidance of Computer Motion founder and chief technology officer Yulun Wang, it represents 10 years of research and collaboration between scientists and surgeons.

The two main components are a surgeon’s console and an intelligent robotic device, which are connected via the embedded computer system.

The console is where a doctor sits, manipulating conventional surgical instruments to position tiny instruments attached to the robotic arms. The movements made at the console are digitized and filtered by the computer before being sent to the robotic device, enabling very large movements made at the console to be scaled down to very fine movements inside a patient’s chest.

For example, during bypass surgery, Dr. Boyd makes three five-millimetre incisions between a patient’s ribs. A robotic camera is inserted through one, a harmonic scalpel through the second and a grasper through the third. The camera is voice-activated so he can control where he’s going inside the chest by watching his movements on a monitor. He can change the position of instruments at any time by using voice commands like: “Move up. Move Down. Move Left. Move Right.”

“If you imagine yourself trying to pick up a piece of rice with two chopsticks, you’ll have a bit of a tremour and shake. The same occurs with surgical instrumentation and what the computer is able to do is filter out the human tremour by applying a 6Hz filter,” explains Dr. Boyd. “I can have 10 Tim Horton coffees and my hands will be rock stable because the computer filters out any shaking that occurs.”

In addition to cardiovascular surgery, Zeus is also being used in France to perform radical prostatectomies in men suffering from prostate cancer. In both procedures, the statistics are overwhelmingly in favour of the minimally invasive techniques when compared to conventional open surgical methods. Patients are healing faster, with less pain and, in the case of the prostatectomy, they’re experiencing much better outcomes with less change of impotence or incontinence.

Wang, who has dedicated his company to advancing minimally invasive surgery, is confident intelligent robots are the way of the future. While Dr. Boyd and others are busy advancing the operating room techniques, Computer Motion’s team is equally occupied with advancing the underlying technology.

One development currently in the works is Socrates, a telementoring system that will enable surgeons to perform robotic surgery remotely. By sending the digitized information from a surgeon’s console over a telecommunications line, Socrates will make it possible for surgeons to be physically removed from the operating room. Not only will this help over long distances – surgeons in London, Ont., can assist on procedures in Yellowknife, for example – but it will also enable imaging methods such as CAT scans, MRIs, x-ray or ultrasound to be used during a surgical procedure to give surgeons a better view. “For the surgeon who’s in there doing five procedures a day, that radiation is cumulative,” points out Wang. “So if you can remove the surgeon from that, it’s a big deal.”

Another direction is to combine minimally invasive surgery with gene therapy in support of preventative medicine. If a patient shows signs of developing heart problems in the future, it may be possible for surgeons to prevent or delay the trouble by using robotics to perform a preventative procedure, suggests Wang. “If there’s something I can do to reduce your odds of developing heart trouble, but I say, `Sorry, I have to split your chest open,’ you’d probably take your chances,” he says. “But if I said I could go in through three tiny holes, then that might be worth it.”

With all the future promise, health institutions currently focused on laparoscopic and endoscopic surgery are keeping an eye on developments in robotics as well. In November, 1999, St. Joseph’s Hospital in Hamilton, Ont., created its Centre for Minimal Access Surgery (CMAS) as a means to provide hands-on training in minimally invasive surgery techniques and has plans to move more into the area of robotics.

“There’s a critical shortage of experts in this area,” says CMAS manager Jennifer Briand. “We’re trying to train people in order to attain a critical mass in Canada. Patients are beginning to ask for minimally invasive techniques and surgeons who don’t have the training had better find some or they’ll lose business.”

In its first year of operation, CMAS held approximately 16 courses, with 12 students in each. Supported by Johnson & Johnson Medical Products, Stryker Canada, DePuy Canada, St. Joseph’s Healthcare Foundation and McMaster University’s faculty of Health Sciences, it offers training in general surgery, obstetrics and gynecology, urology, pediatric surgery and ears, nose and throat surgery. This year it will add plastic and reconstructive surgery and orthopedics, with plans to eventually get into cardiovascular, neurological and thoracic surgery as well.

The CMAS skills lab uses virtual reality technology to simulate a variety of laparoscopic and endoscopic techniques, as well as artificial cadavers and other realistic fluid-filled soft tissue assemblies. Telementoring and telerobotics are two areas it hopes to expand into. “In very remote areas, robots will be able to provide surgical intervention in the absence of an on-site laparoscopic surgeon,” says Briand.

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Montreal-area hospital goes electronic, ends paper records

By Andy Shaw

David Dorrance stands proudly in the middle of a large but completely empty “Medical Records” room at Saint-Eustache Hospital just north of Montreal. The room is now devoid of the 400,000 paper patient records it once held. Next door, tucked discreetly in a corner behind a flat-bed scanner, back-ups of that 38-year collection of records stand almost unnoticeably in a waist-high rack of CD-ROMS.

Nearby, in the confines of the hospital’s new Medical Records room, now not much bigger than a walk-in closet, the active versions of those 400,000 records lie at the ready either in a compact Unix-based Hewlett-Packard (HP) 9000 server or on an adjacent HP optical jukebox for immediate distribution throughout the 120-bed hospital and its 26 clinics.

“You might see a scene like this in some American hospitals I have visited,” says Dorrance, as his words echo in the emptiness, “but if you look for it, usually in another building somewhere, you’ll still find the paper. Here, all the paper records have been destroyed. So, Saint-Eustache is the first hospital in North America that I know of that you can truly call paperless.”

Dorrance should know. As the director of healthcare services for the Toronto-based imaging and consulting firm, Lason Canada, the peripatetic 40-year-old has visited hundreds of hospitals in the United States and Canada. Wherever he has roamed, he has tracked down any hospital that is even rumoured to be paperless. And found them all not to be.

“That’s partly because in a lot of jurisdictions, the paper form is the only legal version of the patient record,” explains Dorrance, “but here at Saint-Eustache, the hospital worked with the Quebec medical, privacy, and access to information authorities as partners while we were developing the system.”

The result was a ringing endorsement and full certification.

“The privacy commission concluded that compared to paper records our system was more secure,” says Michel Morin, Saint-Eustache’s CIO and project chief. “A paper document can be modified after it has been signed by a physician, and of course it can be misfiled or lost. On our system, once one of our 180 physicians has put his or her digital signature on a lab report, or on a transcription document, for example, it can’t be changed. It’s permanent. Any additions or amendments to the record appear as a second document.”

The nature of those records have also won the whole-hearted support of the hospital’s clinical staff. “As we worked towards the roll-out, we established a medical advisory committee, and sub-committees for every function and area in the hospital,” says Lyse Chagnon, the assistant director of professional and hospital services. “We asked them how they would like to see the records presented and which ones they were likely to want most often.”

As he advised on the implementation process, Dorrance also knew from a lifetime of experience in medical record keeping just how narrow the parameters of accessing sought-after records were going to be.

“A hospital this size has about 400 different record types, and large ones might have as many as 1500, but we knew that physicians would not tolerate making more than three clicks to get to the precise document they wanted to see,” explains Dorrance, “so we were faced with two challenges. We had to index all those former paper records and new ones right down to the individual document level and we had to minimize the training needed for users.”

Now Saint-Eustache’s physicians, nurses, and other authorized users need only 15 minutes of show-me-how before they can sit down at any terminal in the hospital. As their thumb touches the mouse, the built-in biometric reader instantly identifies who they are. A further security pre-caution, a typed in password, gains them access to the encryption-protected patient records held on the hospital’s ChartMaxx Enterprise-wide Patient Record System from MedPlus Inc.

A pop-up advises the physician of the number of charts he or she has standing by for digital signing. (Dorrance reports that this has reduced the usual three-month backlog of unsigned charts down to a few days.) Pressing on, one click gets the user to the right patient. Another click finds the desired visit. And the third click locates the EKG, lab result, or other specific record sought that resulted from that visit.

Graphically, the ChartMaxx records that appear on screen look exactly like their paper predecessors – right down to the same colours. But even for the 100 pages of records that one hospital stay might generate for an individual, or the thousands of records “frequent flyers” like cardiac and dialysis patients can produce, never is a page out of sort or missing. Also a click or two away in Saint-Eustache’s fully integrated environment are the hospital’s lab, radiology, transcription, and other electronic systems that feed directly into the HP 9000 server.

The gains in productivity are enormous and savings significant, says CIO Morin. “Once a physician has signed a report, it is instantly available to other physicians. And being electronic, the record can be viewed by more than one clinician at a time.

“Every time a document is dealt with in any way or even just looked at, we have a complete audit trail of who saw or did what. Also, we were able to self-finance the system, as is required in Quebec, over a period of seven years largely by greatly reducing the number of clerk positions required in medical records. (Although no jobs were lost, as careful work with the unions and the hospital’s human resources division saw every clerk re-trained and placed in another job.)

“As well, we’ve gained all that old medical record space (valued at about $1500 a square foot, according to Dorrance) for other purposes – including regaining our own Board Room.”

While Saint-Eustache has already attracted much attention as a model since its November roll-out, Dorrance is first to admit, that while its medical records division may be that way, no hospital will ever be completely paperless.

“There will likely always be handwritten orders, and for a very long time, someone new to Saint-Eustache is going to bring in their paper records from where they lived before. So that’s why we keep our three scanners up and running here.”

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E-health companies jostle for attention at OHA’s annual convention

By Jerry Zeidenberg

TORONTO – E-health vendors were out in full force at the Ontario Hospital Association’s convention in November – all of them trying to gain ‘mindshare’ and marketshare in the newly emerging business of on-line supply-chain management.

Canadian hospitals purchase an estimated $4 billion worth of medical and surgical supplies annually, and the e-health companies claim they can reduce the time and money spent on product acquisition by using Web-based techniques. Here’s a brief look at some of them:

• Rogue Data Corporation. This Ottawa-based vendor raised its national profile with its first appearance at the OHA convention. The company says it has developed a universal translator that enables hospitals, clinics and suppliers to exchange data over any network, including the Internet. According to Rogue Data, the problem in the healthcare sector is that every organization has different platforms, software and processes, making it difficult and expensive to connect with each other.

The company says that its technology provides the connection and translation – enabling one organization to receive data in the way it is accustomed, while others receive the information in the format they are used to.

Rogue has installations at the Childrens Hospital of Eastern Ontario (CHEO), Shared Hospital Support Services in Toronto (a hospital purchasing consortium that includes the University Health Network and Mount Sinai Hospital,) and St. Joseph’s Health Centre, of Toronto.

For its part, St. Joseph’s will be using Rogue’s new Application Service Provider (ASP) service to perform Electronic Data Interchange (EDI).

Rogue was started in 1996 as R&D Connections, and changed its name to Rogue Data Corp. in August, 2000. The company also provides technology to Canada Customs and Revenue, where it is used in the government agency’s electronic commerce platform. According to the company, co-founder Marcel Roy brought 10 years experience in designing and coding electronic commerce architectures to Rogue, and is responsible for creating the core technology.

• Global Healthcare Exchange. The U.S.-based e-health venture, established recently by vendors such as Johnson & Johnson and Baxter Corp., announced the launch of its Canadian operations with its presence at the OHA convention. The Canadian unit is headquartered in Mississauga and is led by Gary Hutton.

Hutton said GHX intends to begin a few pilot projects with Canadian hospitals in the first quarter of 2001. In Canada, it will work with a partner to provide the actual systems integration of the GHX technology into hospitals.

• e-HM Electronic Health Market, of Toronto, conducted a hospital-to-supplier transaction at its booth at the OHA show. Ron Dunk, manager of purchasing for the Hotel Dieu Hospital, of St. Catharines, Ont., sent a purchase order over the Internet to Grand & Toy’s electronic order desk, from the e-HM booth.

According to e-HM, a hospital manager can click on a product in the e-HM smart catalog. The requisition travels electronically to the purchasing department for approval. Once approved, the requisition is converted into an e-PO. This goes via the Internet to the supplier and drops directly into the automated order-processing system.

• Ormed Information Systems Ltd. of Edmonton, demonstrated its e-health system, called Ormed X. Scheduled for launch in the first quarter of 2001, Ormed X makes use of Microsoft’s BizTalk technology, a universal translator. BizTalk is a new technology that was recently released by Microsoft, and is said to seamlessly integrate various electronic formats.

Ormed president and CEO Chris Sherback gave a presentation at the OHA convention outlining his view of future directions in e-health.

According to Sherback, web browsers like Netscape and Explorer may not be the interface of choice for e-commerce in the future. “Browsers don’t allow you to do sorts on the Internet, they’re slow, they’re not feature-rich, and their addressing to reach different sites is text-heavy and clumsy,” said Sherback. What’s more, he noted that browsers aren’t integrated with financial systems, making it difficult to conduct e-commerce on the Web.

In the future, he said, power users of e-commerce on the Web probably won’t use standard browsers, but web-enabled financial systems.

He asserted that financial systems are likely to be integrated with decision support systems, so that hospital managers can more easily determine the most cost-effective and clinically effective procedures. This could be done within hospitals, or across whole regions, determining the centres of excellence in a region or province for everything from heart bypasses to tonsillectomies.

Sherback predicted that once e-commerce takes root in the hospital sector, invoices will disappear in the transactions between vendors and hospitals. Hospital staff will no longer spend hours poring over thick invoices, trying to reconcile them with their purchase orders. That’s because, says Sherback, the systems can determine as the goods come in, whether the transaction was approved, whether they’re the right goods at the right price, and if the taxes are correct, among other things.

“All this [invoice checking] takes place now because the customer and vendor are not online, they’re not electronically integrated,” said Sherback. As they become wired, the paperwork will be reduced. “One of the benefits will be more time for data analysis,” said Sherback. “Today, a lot of the accounting done by hospitals is historical. If they’re not spending as much time reconciling invoices, they’ll be able to be more pro-active about their accounting.”

• The Canadian Health Marketplace (CHM) announced that two hospitals will start testing its Internet-based e-health procurement system in January, making it one of the first ‘live’ sites for electronic commerce in the Canadian health sector. One hospital is located in Ontario, while the other is in the Atlantic provinces.

Moreover, CHM has allied with Neoforma.com Inc of San Jose, Calif., which runs a Web-based exchange for purchasing medical supplies and has invested heavily in the technology. “There was no reason for us to re-invent the wheel,” said Doug McVeigh, president and CEO of MedBuy, the London, Ont., company that created CHM. “We believe that Neoforma already has technology that’s more advanced than anyone else’s.”

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Web-based imaging management offered to Canadian healthcare providers

By Jerry Zeidenberg

TecKnowledge Healthcare Systems Inc. is partnering with Amicas Inc. – a company spun-off by the Massachusetts General Hospital – to provide a web-based image management system to medical centres across Canada.

Called eP@CS, the TecKnowledge system is offered via an application service provider (ASP) model, using Internet technologies to realize the benefits of Picture Archiving and Communication Systems (PACS) at significantly less cost. As well it will provide access both within and outside hospital walls.

“85 percent of hospitals in North America cannot afford a traditional PACS,” said Linda Weaver, chief technical officer for TecKnowledge, which is based in Dartmouth, N.S. “Yet, there’s a need for electronic management of patient images, for efficient care and patient turnaround.”

She noted a study commissioned by the government of Nova Scotia determined that $35 million in capital costs would be required to install conventional PACS networks in hospitals across Nova Scotia (with the exception of the Queen Elizabeth II Health Sciences Centre, which already has a PACS.) As well, this network would require an additional $14 million in annual operating costs and $5 million for yearly upgrades.

By contrast, TecKnowledge’s web-based eP@CS system, using the ASP model, would reduce the initial capital outlay to $10 million (to implement infrastructure supporting the DICOM standard), and incur about $8 million total for annual operating expenses and marginal upgrade costs.

Weaver noted that most of the operating expenses would be offset by the reduction in film and chemical use, as hospitals move from using and storing films to electronic filmless networks.

Using the ASP model, TecKnowledge says it will deliver a complete image capture, archive and distribution management solution. The company is proposing to install servers and storage equipment on hospital premises, upgrade existing modalities for DICOM compliance and perform systems integration to enable interoperability. The equipment and software would be upgraded and maintained by TecKnowledge.

The hospital’s diagnostic images would be stored in the system, with optional offsite disaster recovery provided as a value-added service. Pricing would be based on each captured or archived study maintained on the eP@CS network.

TecKnowledge has ambitious plans for the technology, and currently has discussions underway with four provinces as part of a North American launch.

TecKnowledge is no stranger to teleradiology. It currently runs 67 teleradiology sites in Canada. It operates the Nova Scotia Telehealth Network, a province-wide telehealth system that includes 42 hospitals, and the Children’s Telehealth Network that connects medical facilities across the Maritimes.

To develop the new web technology for teleradiology, TecKnowledge has partnered with Amicas Inc., a company spun-off by the Massachusetts General Hospital in Boston. Doctors and technologists there created the company in 1995, developed their Internet-based products, and received U.S. Food and Drug Administration (FDA) approval for it in 1997.

Amicas already has 60 clients using their products, including the Massachusetts General, Boston University Medical Center, New York University Medical Center, and the University of Chicago.

Amicas, through an alliance with eFilm Medical Inc., a Toronto-based company spawned by the PACS group of the University Health Network and Mount Sinai Hospital, is acquiring technology for high-end diagnostic viewing workstations. For its part, eFilm develops open-architecture medical imaging solutions. Its technology has been adopted by both the University Health Network and Toronto’s Mount Sinai Hospital in helping these hospitals go completely filmless.

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