London Health Sciences Centre tests new telesurgical technologies

By Andy Shaw

Surgeons at the London Health Sciences Centre (LHSC) in south-western Ontario have scored yet another world first by using a telementoring video system during actual surgical procedures. Off-site physicians used the Socrates system – on loan from Computer Motion Inc. of Santa Barbara, Calif – to assist surgeons in an operating room 10 kilometres away conduct eight surgeries, including a plural biopsy, two cardiac bypass procedures, a cardiac valve procedure, and an appendectomy.

During the appendectomy, surgical resident Winston Hewitt remotely assisted Dr. Brian Taylor, the LHSC’s chief of general surgery.

“It was just like I was standing beside him,” said Dr. Taylor. To effect that sensation, the Socrates system provides both doctors with two-way audio communication and gives remote advisors like Dr. Hewitt direct control of an overhead camera so that both physicians can see exactly the same views of the patient’s insides. It also comes with a telestrater, enabling the remote physician to illustrate procedures or to point out anomalies on the video image the surgeon sees, much in the way television sports broadcasters can superimpose explanations of football plays for viewers at home. The system also has the potential to allow remote positioning of endoscopic probes.

“There are two benefits I can see,” said Dr. Taylor. “The first is probably the savings that can come from not having to bring people all the way in here for complex surgery, if we can assist with doing it in their home towns remotely. But I think the best thing about the system is that it is a superb teaching tool.

“I could be in an operating room, for example, talking to the surgeon about what he is doing, while a remote classroom of medical students could be watching and therefore be in on the operation.”

Dr. Taylor is less enthusiastic about prospects for the next level in surgical robotics, actually making the cuts and doing the surgery from afar.

“What happens if the people with the patient can’t do the procedure and something goes wrong with the system? It just smacks too much of danger,” said Dr. Taylor.

Even the telementoring system is not yet quite as risk free as some would like. In the London operations, at least one physician reported “a bit of a time delay” before the remote doctor’s comments got through to the surgeon.

Nonetheless, LHSC management is confident of robotics’ future in Canadian medicine and are betting a good chunk of their bottom dollars on it.

“I think we have a very innovative spirit in Canada when it comes to medical technology and particularly here in London,” said LHSC’s chief executive officer, Tony Dagnone. “We really like to push the envelope here when it comes to finding better and less painful ways to treat the patient. Just over three years ago at LHSC, we took a serious look at how we could mitigate the shortages of talented people that we would be facing in medicine and decided that robotics, with its ability to widen the reach of medical expertise, was a big part of the solution.”

One embodiment of that vision is the National Centre for Advanced Surgery and Robotics at LHSC under the direction of Dr. Douglas Boyd, one of the first surgeons in the world to conduct a robot-assisted heart bypass on a closed chest. The promise of similar minimally invasive techniques is to transform long hospital stays to one-day or even outpatient procedures.

Dagnone said he hoped that his facility, in co-operation with London’s St. Joseph’s Hospital, will break ground this fall on a much expanded laboratory and test bed for robotic and computer assisted surgical techniques.

“We want to create a facility where our medical industry partners and ourselves can both do testing and validating of new procedures in a non-threatening environment,” said Dagnone. “It would also be a centre for medical students and medical staff to come and upgrade their skills. It will also be a place where surgeons, somewhat like airline pilots, can come and have their skills in advanced techniques certified.”

Inspiration for the centre, and possible private sector partners in the venture Dagnone hints, may come from Canada’s efforts in space.

“We marvel at what the Canadarm has done and I think its technologies can be readily adapted to the medical field,” said Dagnone. “Why not take advantage of the hundreds of millions of dollars we’ve invested in space research, and why not apply that knowledge to the good of society?”

For answers, we suggest you watch the latest news.

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CAR seeks probe of government’s $1 billion program for imaging

By Jerry Zeidenberg

MONTREAL – The Canadian Association of Radiologists is urging Ottawa to create a task force that would assess how the federal government’s $1 billion radiology fund was spent by the provinces.

Prime Minister Jean Chretien announced the high-profile fund last September, shortly before calling the federal election. Some $500 million was handed out to provincial governments in the fall – ostensibly to upgrade the nation’s stock of aging and malfunctioning diagnostic imaging equipment. Another $500 million was given out in April.

Recently, however, reports have surfaced in the national media stating that much of the money wasn’t used to purchase new high-tech equipment, but was diverted to pay for beds, standard medical equipment, long-term care and other services.

Normand Laberge, president and CEO of the Canadian Association of Radiologists, asserted the $1 billion was to be used to fight the crisis in radiology – to reduce the waiting lists for MRIs and other exams, and to modernize Canada’s imaging equipment so that doctors can make the best diagnoses possible.

Meanwhile, it has been discovered that no reporting mechanisms were put in place by the federal government to track how the $1 billion was spent. Nobody knows how many new MRIs or X-ray machines were acquired with the money.

According to Laberge, the task force would include the CAR, the Canadian Medical Association, Health Canada and possibly some members of the diagnostic imaging industry.

In addition to assessing how the $1 billion radiology fund was actually spent, Laberge said the task force would have three other functions:

• To establish an expert panel that would produce diagnostic imaging standards. These standards would serve as guidelines to be met by provinces and hospitals across the country. The panel would determine, for example, which modalities are needed to diagnose the most prevalent and serious diseases, how many of these machines should be in operation in relation to the population, and the number of exams that should be provided, based on the population.

• The expert panel would also set standards regarding the life cycle for diagnostic imaging equipment. The CAR, along with other organizations, has conducted surveys that found much of Canada’s radiological equipment is old and outmoded. Some of it breaks down during exams, creating risks for patients.

“Just as in aviation, you have rules that after so many flights you must replace the tires on an airplane, you should have regulations governing replacement cycles for diagnostic imaging equipment,” said Laberge. “This would apply to whole machines and their parts.” The panel would also assess how various jurisdictions are meeting the guidelines and would issue report cards to this effect. “The panel would do the follow-up,” said Laberge, “to determine how well the guidelines are being implemented.”

• The task force would also establish a five-year plan for radiology in Canada, to deal with additional investments in equipment and human resources. Laberge said the federal government’s $1 billion fund was a valuable concept, but that further spending is needed to upgrade the country’s stock of radiological equipment. For example, he noted that while PET scanning has become important for detection of cancer and other diseases in the United States and Europe, there is little access to PET scanning in Canada. If planning isn’t implemented soon for this modality, private clinics will probably be established here, offering the technology on a user-pay basis.

Laberge said the CAR has been meeting with senior officials at Health Canada and has received positive signs that a task force may soon be established. For its part, the CAR would like to see the organization set up by October. If it takes longer than that, said Laberge, the delay would indicate a lack of seriousness on the part of the federal government.

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Government’s e-health records company to act like venture capital firm

TORONTO – Canada’s Health Infoway Inc. will act more like a venture capitalist or a mergers-and-acquisitions company than a traditional government agency, says William Pascal, director general, Office of Health and the Information Highway, based in Ottawa.

“The corporation’s job is not to manage a project,” said Pascal. “It’s to bring people together with competencies, and set out some deadlines.”

Speaking at the recent e-Health 2001 conference that was sponsored by COACH and CIHI, Pascal provided the latest news about Canada’s Health Infoway. The company was established to dish out $500 million for the creation of electronic health records across Canada. Prime Minister Jean Chretien announced the funding last fall, just before he called the October election.

Pascal observed that investing in electronic health records and telehealth isn’t a short-term undertaking – nor will the $500 million be enough to do the job.

“It’s more like a ten-year journey that will likely cost $3 billion to $4 billion,” said Pascal. “But $500 million from the corporation is a good start.”

One of the main thrusts of the company is to ensure the emergence of standards and interoperability. That way, systems created in one part of the country will be able to converse with those used in another part of Canada.

The corporation intends to plow money into projects that show good potential, so they have enough funding to prove the worth of a good concept. “There are people doing creative stuff in this country, but they don’t have enough funding,” said Pascal. “We can help them by investing, and then blow the (technology) out across the country.”

Pascal said this probably can’t be done in every jurisdiction. But if standards are engineered in the pilot projects, then the technology could be made portable and adopted anywhere.

He said that Canada’s Health Infoway wants to collaborate with both the public and private sectors. He asserted that many healthcare providers “do a lousy job of reaching out to the vendors.

“Vendors can tell us, in some instances, that we’re being far too conservative in our solutions,” observed Pascal.

Not only does the corporation want to build ties among providers and vendors, it’s seeking to create linkages with other programs. These include the primary care investment fund, an $800 million program, the $80 million Canada Health Infostructure Partnerships Program (CHIPP) investments, and the National Broadband Task force, which seeks to have broadband installed in every Canadian community by 2004.

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Palm encounters a crisis, opening up market opportunity to other players

By Issie Rabinovitch, PhD

In December of last year, I attended PalmSource 2000 in Santa Clara, California. Although organized by Palm, Inc., the conference is designed for everyone involved in the “Palm Economy”. That includes Palm licensees (and competitors) such as Handspring, Sony, and IBM, dozens of large software companies developing on the Palm platform, and some of the over 100,000 independent developers.

The mood at PalmSource was extremely upbeat, but almost overnight that conference’s optimism has been wiped out by the slowing economy and other factors. No one has been affected more than Palm itself.

Throughout much of last year, Palm was unable to keep up with the surging demand for its handheld computers. Early in 2001, Palm signed long-term deals with component suppliers to ensure that such a situation would not be repeated in 2001. The market for handhelds crumbled before the ink had dried. January was a good month, but by the end of February Palm was struggling with growing inventory levels.

By May, things had deteriorated to the point where Palm was reconsidering its business model. It had already cancelled plans to build a new headquarters, in order to preserve cash. It was forced to back out of a deal to acquire Extended Systems, a developer of enterprise software for the handheld platform. Palm will survive, but in the process will become a different, less ambitious company.

Palm’s new generation of handhelds, the monochrome m500 and the 16-bit colour m505, were announced in March and current models stopped selling. When the m500s began to ship in limited quantities in May, Palm was sitting on several hundred million dollars of unsold inventory.

The m500s represent a significant step forward. They are virtually identical, with the exception of colour. Both resemble the popular Vx in size, have 8 megabytes of memory, an upgrade slot supporting the SD standard, and run on the newest version of the Palm OS, v4.0.

There’s a speedier processor, a USB cradle for faster HotSync operations, silent alarms (vibration and/or flashing lights), better security, and more. The bundled CD has some very valuable new software, allowing users to view photographs, view and edit documents and spreadsheets, and read books.

In addition to memory modules, a new generation of scanners, cameras, GPS and Bluetooth modules, modems, telephones, and MP3 players will connect to the SD slot.

The number 2 producer of Palm-compatible handhelds isn’t Sony, as might be expected, but Handspring. In May, Handspring announced the opening of its new Canadian headquarters in Toronto. Handspring licenses the Palm OS from Palm, and ships a line of handhelds called Visors. Handspring’s market share in the United States is around 25 percent and growing. Visors have been selling well in Canada since last year. Now that Handspring has a marketing presence in Canada, the situation can only improve. Handspring has also been affected by the market downturn, but it seems to have managed better than Palm.

All Visors have a proprietary upgrade slot, called Springboard. Third party support has been excellent. The choice of modules available today includes memory, telephones, dictionaries and specialized reference materials, 56K and wireless modems, digital still cameras, MP3 players, GPS navigational devices, digital voice recorders, and game and entertainment packs.

Before year’s end, I expect Handspring to be on a more equal footing with Palm, and to be more influential in determining the direction of the platform. The handheld space consists of more than just the licensees of Palm, Inc. The number two platform is the Pocket PC, which consists of a scaled-down version of Microsoft Windows running on handhelds from Casio, Compaq, and Hewlett-Packard. Compaq’s iPAQ has emerged as the sales leader, and rightfully so. It has a brilliant colour screen, multiple upgrade options, and better compatibility with Windows than anything on the Palm platform.

It is slightly larger than the m505, more powerful, but harder to use. If the next version of the Pocket PC operating system, due in late 2001 or early 2002, delivers the anticipated improvements, Microsoft and its hardware partners could well be in a position to pass Palm.

On the other hand, this may never happen. Palm and its partners still enjoy a huge lead. If Palm is able to quickly solve its financial and inventory problems, and many exciting SD cards reach the market without delay, Palm has a chance of maintaining its position. Although it wasn’t able to acquire Extended Systems, it needs to work with them and others to enhance its ability to offer corporate and enterprise solutions. It can’t afford any more stumbles in this area, since it has a natural disadvantage relative to the likes of Microsoft, HP, and Compaq.

Handhelds continue to grow in importance, despite the gloomy aspects of some of the preceding discussion. I feel safe in predicting that, by the end of the year, handhelds will have edged ever closer to the centre of gravity of the computing world.

Issie Rabinovitch, PhD, is a Toronto-based computer consultant, writer and speaker.

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