Sticking to standards, and vendor cooperation, keys to PACS network

By Andy Shaw

Ontario’s most sophisticated regional PACS network has expanded its borders and bridged a technical chasm in the process. The Southwest Ontario Digital Imaging Network now encompasses four more hospitals from the Huron Perth Health Care Alliance and brings to 13 the number of institutions that can share images, reports, and radiologists in real time.

With the help of a $481,456 contribution from Canada Health Infoway, Huron Perth’s hospitals in Clinton, St. Mary’s, Seaforth, and Stratford hooked up a new GE PACS system in April and connected it to the DI network used at nine other facilities. Those centres are anchored by London, Ontario’s two teaching hospitals, London Health Sciences Centre and St. Joseph’s Health Care.

“What makes this a particularly sophisticated PACS network is that the Huron Perth group is all Meditech (for hospital and radiology information systems), while our original London-area group is all Cerner,” said Diane Beattie whose full, formal title is Integrated VP and CIO of Information Management and Strategic Alliances for the two London teaching hospitals. But who, for short, has been the driving force of the Southwest Ontario Digital Imaging Network since it began as an Infoway-supported pilot project just three years ago.

“So now we have Cerner, Meditech, and GE, the PACS vendor for the network, all co-operating and exchanging with each other,” said Beattie. “I don’t think we have seen this kind of partnership between vendors in Ontario before and it is working extremely well.”

The result: all 13 hospitals on the PACS network can see, handle, and seamlessly pass around among themselves their patients’ exam images, from any imaging modality, generated by a variety of vendor imaging and reading equipment (GE, Philips, Siemens, Fuji, and HP among others) – pulling them out of and returning them to one central storage depository in London.

The new network is providing real benefits, for both patients and physicians. “We have radiology challenges as everyone does,” said Brenda Scott, program director of medical imaging. “Our one full-time radiologist is in Stratford (aided by a four-days-a-week part-timer), so in the past images from our other hospitals had to come in on film. Now, the imaging can be done at the other hospitals, and they come immediately into to an electronic work list for the Stratford radiologists to view and work through.

“Also, in the past, a lot of our patients had to go up to London for further consultation. But now they can have the imaging done here, stay here, and still have the consultation done with the imaging specialist in London.”

Referring physicians in Huron Perth can also tap in.

“Our information systems department developed a website that allows referring physicians to log in to our Meditech hospital information system, which gets them right into the PACS,” said Scott.

While Huron Perth and other groups are encouraged to develop whatever works for them internally, connecting with others in the larger PACS network is done strictly according to standards that determine how computers share information, said Beattie.

“Infoway is really pushing towards standards. So we’ve gone to the new IHE standards, which are a great thing. It means we are not going to use Hospital A’s or Hospital B’s approach. And that takes all the tension out of working together.”

Adhering to standards makes common how things are done. For example, Beattie explained, one IHE standard specifies how a user pulls the answer to a request out of the PACS network’s central database. “So adhering to that standard means each department in each hospital will set up workflows to match that procedure,” she said. “Consequently, the workflows in each radiology department will be very similar.”

That in turn translates to better patient care.

“Let’s suppose someone in a remote town, like Owen Sound, suffered a severe head injury in a snowmobile accident and the local hospital did a CT scan,” said Beattie. “In the past, that patient would have come into our trauma unit here in London, along with the CT scan recorded on a CD (compact disc). When they got here, if the imaging and information on the CD had not been put together in the same order as we normally did in London, the radiologist might well say, ‘This isn’t working for me’, and re-do the CT scan.

“Whereas today, if that happened, the radiologist in Owen Sound can call the specialist in London; both can have the same CT scan up on their screens at the same time, and because the workflows are also the same, immediately be able to decide what should be done next – before the patient even gets here.”

Eventually, reports Scott, this ability and the PACS network will branch out next north to the Grey Bruce area and then on to the cities and towns of Sarnia, Chatham, Windsor, Listowell, and Wingham, all within a year. That would effectively connect up all the hospitals in south-western Ontario’s two major health regions or LHINs (local health integration networks).

But that’s not all of what sets the Huron Perth initiative apart from others, suggests Scott. “What would be worth emulating elsewhere, I think, is how the project team put it together,” said Scott. “The key vendors, Cerner, Meditech, and the GE PACS people, all overcame any rivalries and worked together.”

Concluded Huron Perth Health Alliance CEO, Andrew Williams: “Our success ... was a direct result of exceptional teamwork at all phases of the project. Whether it was project planning, implementation, or, post-implementation follow-up, all aspects of the project succeeded because of the unwavering dedication and commitment exhibited by the entire team.”

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Sun also rises, in British Columbia

By Jerry Zeidenberg

They say that British Columbia does things a bit differently than the rest of Canada, and it appears they’ve remained true to form in the construction of a province-wide, interoperable Electronic Health Record (iEHR) network.

In April, the B.C. government announced it had chosen Sun Microsystems of Canada Inc. to lead the $148 million effort. It’s the first time that Sun Micro has led a large-scale healthcare I.T. project in Canada.

What’s more, to supply the lab system that will constitute the iEHR’s first major application, Sun’s partner is MedPlus, of Cincinnati, Ohio, a subsidiary of Quest Diagnostics, which is based in Lyndhurst, N.J. These companies have scored successes in the United States and abroad, but are relative newcomers to the healthcare scene in Canada.

While it may appear risky to rely on contractors and technologies without a track record north of the 48th parallel, the winning corporations say they were chosen for the sake of security – they’re a safer bet to install robust systems, on time and on budget.

“We were selected because we’ve got lots of experience in building large-scale, cost-effective systems around the world,” said Andy Canham, president of Sun Microsystems of Canada.

He asserted that by using time-tested, ‘off-the-shelf’ software and hardware systems, along with proven project-management methodologies, British Columbia will avoid the delays and setbacks experienced by other provinces and health regions in Canada that have tried to develop their own eHealth applications.

Canham said the system will “present data in a single view, in a highly secure manner.” What’s more, it will operate in real-time, creating a ‘virtual patient record’ by pulling together the most up-to-date information from disparate sources, right at the moment when caregivers need it.

A good deal of provincial health data, including lab information, will be consolidated at a data centre in British Columbia, with a mirror site for back-up and disaster recovery in Calgary. The data centres will be operated by Telus, another partner in the Sun Micro consortium.

High-powered hardware will be supplied by Sun in the form of Sun Fire x64 and Sun Fire UltraSparc servers, running the Solaris 10 operating system. As well, the company will provide storage systems able to support 25 terabytes of data.

On the software front, Sun will use its Java Composite Application Platform Suite (Java CAPS), which is said to be easily installed at large and small sites alike.

The provincial laboratory information system (PLIS) will become the first large-scale application on the new B.C. network. Working hand-in-hand with Sun and other consortium partners (they include Telus, First Consulting and CGI), MedPlus is going to design, build and implement the lab solution, which will give authorized clinicians electronic access to tests and results from laboratories throughout the province.

To do this, MedPlus’ Care360 Physician Portal and health information exchange infrastructure will be used, allowing caregivers to access a central repository of lab orders and results.

Piloting of the lab results system will begin in the fourth quarter of 2007, with the orders system following in 2008, said Phil Present, chief operating officer for MedPlus. The company will design, build and implement the lab system with 15 to 20 MedPlus employees stationed in British Columbia.

“It will be the first installation of Care360 in Canada,” said Present, who noted there are some 8,000 to 10,000 physicians in British Columbia who will be able to access the portal.

Asked if creating a solution for an entire province poses any challenges for MedPlus, Present asserted that the company already has implemented systems for 80,000 doctors in the United States, and is adding 1,500 more each month. As such, he said the company has the experience to roll out the solution, quickly and securely, to a large physician population.

MedPlus is also the developer of ChartMaxx software, an electronic health record solution. The company claims it has more than 125,000 clinical and administrative users of the system at U.S. hospitals and physician practices. It is planning to market the system to hospitals in Canada, as well.

The first phase of British Columbia’s iEHR system will be constructed over the next 24 months. Canham said other applications will be added in subsequent phases. These may include pharmacy records and diagnostic imaging studies and reports.

First Consulting Group – another member of the consortium – will work with Sun to jointly design, build and implement the iEHR. First Consulting’s First Gateways Suite will be used to integrate information and securely present health records in the iEHR.

In addition to supplying the underlying hardware and software infrastructure for the iEHR, Sun Microsystems will design, build and implement the identity and access management solution for the system, based on the Sun Java Identity Management (IdM) Suite. Sun says this will ensure that all information is managed, protected, stored and shared according to role-based access control.

Role-based access means that healthcare professionals will be able to obtain only certain types of information, based on their need to know – for example, physicians may be granted access to a large portion of a patient’s record, while administrators may be allowed to see a smaller part.

CGI, the Canadian consulting firm, will be responsible for the iEHR’s operations and application management.

British Columbia’s iEHR was announced in April by provincial Health Minister George Abbott. At the launch, he said: “Electronic health records are fundamental to modernizing the healthcare system and improving access and outcomes of Canadians.

“Technology has revolutionized the way people do business and communicate, and the way public services, including healthcare, are delivered,” he continued. “B.C. is starting to realize the full potential of this technology to give caregivers better access to patient records and improve services to patients.”  

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Ontario’s clinical labs are expected to modernize as hospitals expand

By Jerry Zeidenberg

TORONTO – Hospital laboratories in Ontario are set to embark on a new wave of automation in the next decade, thanks to the building boom that’s going in the province’s hospital sector.

While many hospitals have installed modern analyzers – devices that actually test samples – most labs haven’t taken advantage of the new ‘front-end’ automation that gets specimens ready for testing.

It’s the front-end or pre-analytical preparation that’s the labour-intensive part of lab work, and the one that can lead to perhaps the most dramatic improvements.

It consists of repetitive uncapping of samples, centrifuging to divide samples into their component parts, and aliquoting them (breaking them into smaller quantities so that a variety of tests can be conducted.)

Automating these steps appears to be just over the horizon, as dozens of Ontario hospitals get ready to build new wings or whole new sites.

“This is the next big piece in lab automation,” says Kathryn Snell, clinical lab director for Halton Healthcare Services, in Oakville, Ont. She has responsibility for three hospital labs – in Oakville, Milton and Georgetown – and is president of the Trillium Chapter of the Clinical Laboratory Management Association.

Ms. Snell points out that the slowness to automate the front-end procedures hasn’t always stemmed from a lack of funding – although lab budgets are as constrained as the other departments in hospitals (and some observers say that labs have been the poor, under-funded cousins to the more glamorous diagnostic imaging departments.)

From time to time, she notes, cash has appeared, but it hasn’t been allocated to front-end lab automation. As an example, Ontario pumped millions of dollars into labs and radiology departments in 2004 through its special funding of diagnostic labs and imaging departments. But it wasn’t used for front-end lab automation.

What held things up, observes Ms. Snell, was a lack of space.

“These are large machines were talking about, and you need a big, open space to fit them,” she says. “Most hospital labs are small.

She adds that in some cases, the pre-analytical systems- which resemble miniature assembly lines that move racks of specimen tubes down a line – require compressors and other equipment that must be installed in yet another room, or even on another floor. Older hospitals, starved for space to begin with, couldn’t accommodate such systems.

But new buildings can be constructed with front-end lab automation in mind.

Ms. Snell’s own hospital is a case in point. She notes that Halton Healthcare is about to begin construction of a new hospital, located northwest of Oakville. It’s scheduled to open its doors in 2013. “Front-end automation is definitely going into the lab at the new hospital,” she says.

Ms. Snell noted that other hospitals have also planned for such heavy-duty automation in their new or expanded sites. William Osler Health Centre, in nearby Brampton, Ont., will open its 600-bed Civic Hospital this fall, and pre-analytical automation equipment will be a key part of the lab.

There are terrific benefits to this type of automation. As you reduce human intervention throughout the testing process, you also cut the rate or errors – a boon to patient care and safety. It also leads to faster test results.

And as Ms. Snell points out, staff safety is improved. “You reduce the need for staff to physically open and handle samples,” she says, noting the contents of the tubes can be extremely hazardous. “You hear a lot about patient safety, but worker safety is also an important issue.”

Last but certainly not least, automation helps relieve staff shortages. “Our resources in labs are stretched as tightly as those for doctors and nurses,” says Ms. Snell. With greater automation, “your people can spend their time analyzing results, and making judgment calls, instead of capping and uncapping samples and centrifuging them.”

A sparkling example is the lab at Toronto’s Mount Sinai Hospital – one of Canada’s early adopters of laboratory automation and the first site to implement the Roche automated system. A large and busy lab, it’s capable of conducting 1,800 different types of tests and processes 2.7 million reportable tests annually.

As lab director Vince D’Mello points out, about 70 percent of those tests consist of biochemistry work, the heart and soul of most labs. But getting the samples ready for testing was a slow and laborious task.

“All of this used to be done by manual labour,” says D’Mello. Human intervention meant there were often “delays, errors and bottlenecks, when people were not able to keep up with the repetitive tasks and peak volumes.”

In September 2005, Mount Sinai’s lab took an innovative leap – it implemented a new piece of equipment from Roche Diagnostics Canada that automates not just the front-end processing of biochemistry samples, but also the second and third steps – called analytical and post-analytical processing.

The second, or analytical step, is made up of the actual biochemistry tests, and the Roche machine can conduct a battery of them – including cardiac functions, tumour markers, thyroid function, glucose, cholesterol, therapeutic drug monitoring, and many others. It also performs the final step, the post-analytical work that consists of reporting and auto-validating the results.

Auto-validation is an important feature, because if staff were required to check all the results manually, they’d quickly become fatigued and prone to making errors. This way, technologists can concentrate on abnormal results and verify whether they make sense or not.

All in all, the results have been impressive. Speed and reliability of testing has improved remarkably. “We’re now processing 90 percent of our biochemistry samples in 60 minutes or less, 24 x 7 x 365,” says D’Mello. “Before we installed the Roche system, we were only processing 60 percent of the samples in 60 minutes or less.”

D’Mello will be presenting these and other results of Mount Sinai’s lab automation experience later this month, at the American Association of Clinical Chemistry conference in San Diego. It’s the world’s largest annual medical lab conference, and D’Mello is a featured speaker.

He emphasizes that accuracy and speed are high priorities in lab work, especially when supporting a busy Emergency Department. “Doctors want their results yesterday,” asserts D’Mello. “The sooner they get results, the sooner they can start therapy.” And he notes that an extra hour or two, waiting for test outcomes, can seem like an eternity to both physicians and patients.

The new, automated system also means that high-priced lab professionals are no longer required to manually prepare or find samples for tests. Instead, they’ve been re-deployed to higher value-level tasks, such as quality control, validating results and evaluating new advances in technology.

An important feature in the Roche system is that it integrates all three phases of the biochem testing cycle – pre-analytical, analytical and post-analytical. While most Ontario labs have automated the last two, unless their systems are all tied together, staff members are still forced to distribute samples from one area of the lab to another. “It’s called a sneaker network,” quips D’Mello.

This can cause delays – when staff don’t pick up and deliver samples as soon as they’re ready. Moreover, errors and mishaps can occur when people are handling the samples. And the materials – blood samples – are potentially dangerous; better a machine handles them than people.

The integrated Roche machine, in contrast, ‘hands-off’ samples to the next stage of the cycle without delays, keeps potentially hazardous blood components isolated, and never loses track of a tube.

“Everything is automatically bar-coded,” says D’Mello. “The samples are much easier to track and find.” He points out a cold storage room where thousands of different samples are kept, in temporary storage, and asks, “How would you like to find one in here, at 2 in the morning, if it wasn’t bar-coded?”

Without barcodes and scanners, it would be like finding the proverbial needle in the haystack. A very cold haystack.

D’Mello points out that the rising pressure on labs will make the case for automation even more urgent in the future. “The population is aging, and there is increasing demand for lab tests,” he says, noting that Mount Sinai Hospital’s lab test volume is growing by about 10 percent annually.

“There are new tests being developed all the time, like molecular genetics, which is one of the fastest growing areas,” says D’Mello. “There’s an emphasis on early detection of disease, and on tailoring therapies to the genetic make-up of patients.”

At the same time, “there’s a shortage of trained technologists and lab physicians,” says D’Mello. “So there’s a strong case for automation. We’ll need it to make labs more responsive to rapidly changing clinical demands.

Jason Tutty, marketing manager for Roche Diagnostics Canada, observes that across Canada, skilled lab workers are getting harder to find. “It makes sense to automate the front-end processing,” says Tutty, “so your staff can do high-value work in other parts of the lab.”

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Good news: Canada’s medical expertise. Bad news: Putting up with wait times.

A conversation with Dr. Patrice Bret, chief of medical imaging, University Health Network

Dr. Patrice Bret is chief of medical imaging at the multi-hospital University Health Network (UHN), in Toronto, as well as professor of radiology at the University of Toronto. Born and educated in Lyon, France, Dr. Bret first came to Canada in 1985 and rose to chief radiologist and departmental chair at the Montreal General Hospital. In 1997 he crossed linguistic and healthcare boundaries to join UHN, where he furthered his research and interests in multi-modal imaging of abdominal diseases and the application of information technology to radiology. As such, he is one of Canada’s most highly regarded radiologists.

But Dr. Bret, who is equally engaging and eloquent in lightly accented English or French, keeps his connections with Europe alive with regular nurturing visits to southern France, where he maintains a second home in Provence.

CHT: Dr Bret, given your international credentials why do you still choose to work in Canada?

Dr. Bret: Andy, Canada is one of the best places to work. I know because I have worked on three continents now. When you work in Europe, it has 2,000 years of history. So every time you have an idea, you will hear people say: Well, if it’s a good idea, someone must have already done it. Whereas if you come to a country like this – that 40 years ago was in the medical Middle Ages but which has been playing very good catch-up ever since – then you can have an idea and most people here will be interested in hearing about it. And if you have something behind the idea, you can build on it.

CHT: So in the time that you’ve been working here, what’s been the good news and the bad news?

Dr. Bret: Certainly the development of medical technology here has been encouraging. And Canada has pretty much caught up with the rest of the world. The bad news here is the wait time. And I put the responsibility for that not so much on the government but on Canadians themselves. Wherever they go they seem to accept waiting. They wait in line in stores. When they go to Emergency, they wait. It is natural to them. But if such wait times happened in Europe, governments I know of in France, in Germany, and in Italy, would be thrown out within two weeks.

Governments do respond to what they think the people want; so Canadians should be in the streets protesting wait times. I see these patients who know they have cancer, but have to wait for weeks or even months before they can get effective treatment. There is zero tolerance for drunk driving here. So there should be zero tolerance for wait lists too.

CHT: And yet you and your family stay here.

Dr. Bret: That’s because Canadians are among the most decent people in the world. There is no discrimination here. There are more than 20 different ‘nationalities’ within our department, for example. And nobody really speaks English properly and yet they all seem to understand each other. So that is cool. And the academic atmosphere in North America is better than it is in Europe, particularly in Canada. So that is why we are here.

CHT: When it comes to imaging and radiology, where would you say Canada stands in the world?

Dr. Bret: We supposedly have a universal healthcare system like those in Europe, but here it is not really universal. If you go to Quebec, for instance, there is no reimbursement for ultrasound outside of a hospital; but yet there is for PET (Positron emission tomography), while in Ontario there is no PET. In Quebec, you can have access to private MR (magnetic resonance) imaging, and in Ontario you can’t. If our healthcare is supposed to all be universal, how come it is so different from one province to the other?

The other thing that is very peculiar here is that with my simple MD degree from France, I can work in more than 20 European countries. Here, I could only work in one province to start with. If I want to move to another, then I have to start the whole credentials procedure again. So we need to remove these restrictions on professional immigrants if Canada is going to address its shortages.

CHT: So how have you found the radiologists you need?

Dr. Bret: To me it is better to hire the best radiologists we can get from Europe, India, and Asia than to ship my work to these areas. And then once they get here, they should be able to cross borders within the country, just as scientists can. Now I must say in the last five years, associations like the Royal College of Physicians and Surgeons and the College of Physicians of Ontario have made major efforts to allow the elite of the medical world to come and work here. So at UHN we’ve been able to hire 17 radiologists from across the world. They were not trained in Canada, but they are on a par with our best students. And that’s important to us because every radiologist who graduates from a Canadian university probably gets three job offers – very often for more money than we as an academic institution can pay. So we were faced with the choice of either shrinking our radiology research or globalizing it, which is what we have done. And I think it’s been quite successful.

CHT: So what gets you up in the morning? What is it that excites you about coming to work?

Dr. Bret: Well, first I like people. Our radiologists come from all over the world, so they enrich my life. And I like caring for people – even if there are a lot issues and headaches that go with doing that in a hospital.

I have found that most patients suffer from being lonely. They don’t have anyone to talk to. And it is amazing what you can do for them just by talking or listening to them. So there is a pretty good emotional satisfaction I get from the job.

On the professional side, either to be on the leading edge or to be contributing to discoveries or transformational research, that’s what’s exciting. That’s the intellectual satisfaction.

And then, too, I’m working with 70 radiologists here that I am connected to and responsible for. It is like a big family. And that is both challenging and rewarding.

CHT: So where do you think that family and radiology, in general, is heading in Canada? Are we heading, as some suggest, for convergence of the wide range of technologies that radiologists now use?

Dr. Bret: I don’t think it is going to converge on a single piece of technology. What we need to stop doing though is adding new technologies as they come along on top of the other ones. We do need to consolidate in order to get best bang for our imaging buck. If we have new technologies like PET that we want to get funded, then at some point it has to be at the expense of older technologies.

And we also have to move much more towards evidence-based medicine. But people are usually resistant to change, and physicians in particular can be the most stubborn. Just because the evidence is there that a new imaging technology can do the job better, doesn’t necessarily mean they are going to change.

The other challenge is that evidence coming out of imaging is not the same everywhere. In Quebec, a PET scan can be part of your evidence algorithm for treatment of lung cancer or lymphoma, say, but not so in Ontario. 

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