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UHN and Mount Sinai become trailblazers in 64-slice CT scanningBy Jerry Zeidenberg TORONTO – The University Health Network (UHN) and Mount Sinai Hospital (MSH) are among the first medical centers in Canada to acquire 64-slice Computed Tomography (CT) scanners. According to diagnostic imaging experts, the 64-slice technology provides remarkable improvements in imaging speed and performance, resulting in significant benefits for radiologists and patients. The Department of Medical Imaging at UHN (made up of the Toronto General, Toronto Western and Princess Margaret hospitals), and working in conjunction with MSH, recently purchased four multi-slice Aquilion 64 scanners from Toshiba Canada. One of the machines, located at the Toronto Western Hospital site, is dedicated to neuro abdominal and orthopedic applications, while the systems at the Toronto General campus will be used primarily for cardiac imaging. The CT devices are capable of acquiring 64 images (or ‘slices’) every rotation (0.4 seconds), so that approximately 140 (512 x 512) full resolution pictures are acquired every second. As a result of the fast acquisition of images, exams can now be performed in a matter of seconds, rather than minutes or hours. “We can now image the head in five seconds,” commented Dr. Karel terBrugge, Chief of Neuroradiology at the Toronto Western Hospital. Commenting on how far CT scanning has progressed, he said, “When I first started using CT in the 1970s, there were three scanners in the world, one of them in Montreal. Back then, it took us 45 minutes to do a CT scan of the head.” Moreover, with Toshiba’s latest 64-slice system, special software automatically reconstructs the slices into 3D images of the brain, heart and other organs, and sends them on to radiologists – a major advance in workflow and a big time-saver. The speed of the latest system produces other major benefits: • Scanning is so fast that clear CT pictures can be taken of the beating heart – previously, blurring usually occurred when radiologists used CT to image the heart; • CT imaging of the arteries can be performed, instead of catheter angiography, resulting in less contamination of the blood vessels; • The shorter exams are better for children, since little or no sedation is required; • With faster studies, lower doses of X-rays are given to patients; • Automated 3D reconstruction software gives radiologists new and often better ways of looking for abnormalities in the human body than previous, 2D formats. • Quicker imaging means that physicians can start treatment sooner. This may have particular importance for trauma and stroke patients, where it’s important to start therapies as soon as possible. Dr. Patrice Bret, Chief Radiologist at the UHN and Mount Sinai Hospital, said the upgrade to 64-slice imaging results in qualitative improvements that amount to a turning-point in diagnostic imaging. It’s a change that goes far beyond what the numerical jump from 4 or 8 slices to 64 might signify. “This is a major leap,” said Dr. Bret. “It’s the first time you can do 3D in CT with real speed.” He explained that the shift to 3D imaging improves not only the pace but also the quality of the work performed by radiologists. Viewing data in three-dimensions enables radiologists to see structures from many angles and planes, both inside and outside, with the assistance of a variety of computerized tools. “With everything done so quickly, it means that viewing in 3D will now become what’s normal, not 2D,” said Dr. Bret. He noted that for some years, the thinking at UHN and MSH has been to convert to CT not just for sophisticated brain and heart scans, but for a number of indications of general radiography, which still account for about 70 percent of the imaging studies performed. General radiography includes common exams like chest X-rays and imaging of broken bones, and has traditionally used two-dimensional X-ray imaging. Dr. Bret asserted that it’s far better to look at images in three-dimensions, using low-dose CT for better views, and to glean more information, than to continue using flat X-ray images. As the power of CT continues to increase, he said, costs will plummet, making it viable to replace X-ray machines with CT scanners. Because of the three-dimensional capabilities, it appears that CT may be preferable to investments in direct radiography, a computerized upgrade for film-based X-ray scanners. Already, four-slice CT scanners can be obtained for $250,000 apiece – half the cost of the Digital Radiography machines. Asked about the role of Magnetic Resonance (MR) imaging in this scenario, Dr. Bret responded that magnetic resonance imaging will only grow in usage, as it’s a contrast resolution technique, while CT is best for spatial resolution. “MR has a huge future, especially, in functional imaging, where it can tell me if a lesion is active and functioning,” he said. While CT is valuable for pinpointing the location of structures and anatomical changes in the body, unlike MRI it’s not able to detect changes in function or metabolism. As such, both modalities will be needed in the future. Mr. Toshihiro Rifu, General Manager, CT Systems Division for Toshiba Medical Systems Corp., of Tokyo, attended an educational event at the UHN and commented that the Aquilions installed at the hospital are among 30 that the company has delivered worldwide. He forecasted that by the end of March, Toshiba will have shipped 130 units with 32 or 64-slice capabilities. Toshiba is already working on the next generation of its CT scanners, which will be able to acquire 256 slices in a single gantry rotation. Several test units are already in use in Tokyo. Mr. Rifu noted that the industry is producing new generations of equipment in two-year cycles, and that it won’t be long before Toshiba begins commercial shipments of the 256-slice machines. “Every two years, we’re stepping up to the next technology,” he said. As a result of the shift to 64-slice and higher performance machines, the benefits to radiologists and patients will only continue, said Behram Engineer, Vice President of the Medical Systems Group for Toshiba of Canada. “A major advantage will be the reduction of invasive procedures,” said Mr. Engineer. “You’ll also keep patients on the table for far less time, which is a big savings for hospitals.” BACK TO CONTENTS LISTING
McGill hospitals select iCongo for e-supply chainBy Jerry Zeidenberg MONTREAL – When it comes to e-commerce applications such as electronic ordering and invoice handling, Quebec hospitals are poised to become the most advanced in the country. Major medical centres in Quebec are now implementing e-commerce solutions from providers such as GHX and iCongo. They’re converting transactions with medical supply companies from paper and telephone communication to more automated computerized systems – a much more efficient way of working. In January, the McGill University Hospital Centre, consisting of five teaching hospitals, signed an agreement to implement iCongo’s MediChain system as a pilot project, in conjunction with Source Medical, a large distributor of medical supplies. If all goes well with the test, 45 other suppliers will be encouraged to come on board in the following weeks, enabling purchasing managers and staff members to streamline the ordering, invoicing and reconciliation process for an estimated 80 percent of the organization’s annual purchasing. The MediChain solution will be offered to 75 other hospitals that make up the Association Quebecoise de la Logistique et de l’Approvisionnement du Sectueur de la Sante (AQLASS) – enabling a large group of hospital professionals across the province to computerize their supply chain processes. “Until now, almost all orders exchanged between Quebec hospitals and their suppliers have been paper-based,” said Carole Duhamel, Director of Materials Management Services for the McGill University hospitals. “All transactions have been manual – from printing out purchase orders, faxing them to suppliers and calling the companies to check on whether the documents have been received and entered in their systems. All of this is very time-consuming. And when the invoice doesn’t match the price on the original order, even if it’s out by just a penny, the whole process is rejected and must start over again. “We expect to see major savings when all of this is done electronically and automatically,” said Duhamel. Theoretically at least, all of the supply chain procedures she mentioned can be done at lightning speed through computerized routines. With fewer person-hours needed for the ordering and checking process, the participants expect to see major benefits. “We think the system will reduce their operating costs by 50 percent,” said iCongo president Irwin Kramer, citing statistics from successful implementations in other industries. For its part, iCongo (www.icongo.com) is a specialist in enterprise portals, catalog and e-procurement systems, on-line trading exchanges and other solutions. It counts among its large-scale installations such customers as Industry Canada, the Canadian Apparel Federation and the National Hockey League. Kramer said it takes $50 to $75 to process a purchase order manually, largely as a result of the staff hours needed for order entry, paper handling, checking and reconciliations. For its part, the MUHC puts through some 50,000 to 60,000 purchase orders each year. The annual cost is in the neighborhood of $3 million, using a figure of $60 for processing each P.O. If MediChain and iCongo can bring this down by half, as suggested, the McGill hospitals could be looking at a savings of $1.5 million yearly. Similar improvements are anticipated at other Quebec hospitals that intend to implement the system. “Quebec’s hospitals will save tens of millions of dollars a year,” said Kramer. Duhamel noted the McGill hospitals and AQLASS evaluated six different e-commerce solutions before choosing iCongo’s MediChain. “It was the best in terms of supplying us with a turnkey solution that would require little customization,” said Duhamel. “It also was the easiest to use. It has the ability to send any kind of document to any type of system. The others that we looked at weren’t as technologically advanced.” She explained that while Quebec hospitals considered e-commerce in the past, until now the systems seemed difficult to implement. As a result, “we’ve got close to zero electronic transactions between provincial hospitals and their suppliers.” She asserted that the situation will rapidly change this year as the MediChain technology fans out through the provincial hospitals. According to iCongo, its MediChain solution is a document exchange and e-procurement platform that makes use of middleware to connect the systems of hospitals and suppliers over the Internet. Steven Kramer, the company’s Director of Business Development, said the solution has two major components. First, it uses a document exchange server that delivers purchase orders to suppliers, sends back P.O. acknowledgements, advance shipping notices and invoices – all electronically. What’s more, the system is integrated right into the financial systems of the users. Secondly, MediChain includes a catalog system that’s constantly refreshed with updated product and pricing information. Duhamel said the catalog will be extremely beneficial to MUHC, easing the ordering process and enabling staff members to stay on top of changes. “We’ll quickly be able to order different products from vendors, and to accept, reject or re-negotiate changes.” On the technological side, the MediChain platform receives documents in a variety of file formats from suppliers and buyers, and sends them securely to their destinations in the required format. This is done using a series of web forms, which permit the online visualization of all transaction types (i.e., EDI 850, e-mail, XML and others.) When it comes to communications, the system supports HTTP, HTTPS, FTP, secured FTP, VPN, EDI-INT, AS2 and AS1. Data formats include XML (in different flavours, such as SOAP), EDI, text, Excel and any other file format. Real-time integrations are conducted, according to the company, using web services or direct ODBC or JDBC connections. “There’s no limitation on formats,” said Steven Kramer. “We can do any format to any other, and we can handle any type of communication protocol.” BACK TO CONTENTS LISTING
E-Learning improves computer application training at Toronto’s Mount SinaiBy Neil Zeidenberg TORONTO – New computer applications are introduced to hospital staff on a regular basis, usually leaving clinicians and staff members scrambling to master them. To speed-up the learning curve, a Toronto teaching hospital has initiated a two-step e-Learning program that lets doctors and nurses become familiar with new information on their own, before completing a learning module in a classroom setting. “Sinai e-Learning combines computer-based training with classroom education, and ensures everyone is at the same level of understanding when entering the class,” explained Marilyn Sanli, manager of information systems and education, Mount Sinai Hospital. Typically, new applications are learned in a traditional classroom environment with an instructor – a one-size-fits-all approach that doesn’t always work, since some clinicians learn very quickly and want to move on, while others require more time to understand the application. Sinai e-Learning is a big help to those who require more time to become familiar with new materials. It also allows clinicians and staff members to choose what they want to learn, and when. “The residents and interns love the flexibility of the program,” said Sanli. “The learning tutorial can be done at home, in the staff lounge, on the web or in the computer lab.” After completing the on-line tutorial, clinicians book a convenient time in the classroom with a qualified instructor. Classes are held between 8 am and noon, Monday through Friday. “Students come into the classroom with their peers and discuss the material with an instructor,” said Sanli. “There they discuss scenarios that apply to their specific rotations. For example, the use of computers in general medicine – the scenario is based on a day in the life of a resident on the general medicine floor.” The class ends with a competency test. Clinicians must score at least 80 percent in order to use the application on the hospital floor. This ensures that all clinicians with access to a computerized application have proven their ability to use it. Since January 2004, more than 840 clinicians have learned new applications via Sinai e-Learning – a tool created completely in-house without any technology partners. These applications include Results Review and Electronic Clinical Documentation, which went live in November 2004. “We’re also developing a similar program to Physician Order Entry, called Clinician Order Entry. That’s expected to go live in March 2005. And an application called MAR, a medication administration tool, is set to go live in April.” Because new clinical applications are expected to come into use on a regular basis, Mount Sinai has hired two full-time staff members to train people to use them. Sanli said that Sinai e-Learning has also made a big impact in school nursing programs. About 1,000 nursing students come through Mount Sinai’s doors every year, and training them to use computerized applications means a huge commitment of time and resources. Now all nursing students view the learning tutorial before entering the hospital and then book time in the computer lab for phase II. “We wanted them to be competent before they started using the system, and now we can incorporate that,” said Sanli. “Previously, we were forced to allow them to use the system without any training, or have someone else do it for them. “This allows clinicians to spend more time on the floor where it matters most, with patients.” BACK TO CONTENTS LISTINGNew and improved Open MRIs make headway in the clinic marketBy Andy Shaw Whether it runs under the Rockies, or chunnels its way to Paris, or performs magnetic resonance imaging (MRI) on our body parts, there’s something unnerving about entering a tunnel. If it weren’t so darn quick or so important to our health, many of us would rather get there by some other route. Especially trying is the experience of slowly passing through the 60-centimetre-narrow, thumpingly noisy tunnel of a traditional MRI scanner. But soon, patients won’t have to suffer that claustrophobia at the MYK Diagnostic Imaging clinic in Calgary. That’s where Dr. Deepak Kaura, a young but well-schooled paediatric radiologist, and his two partners are setting out to prove that today’s “open MR” systems are as good if not better than the regular closed-bore kind. “Lying on our new, open MR scanner, you’ll look to your left and look to your right, and all you will see are the walls of the clinic,” says Dr. Kaura. What’s more, when the MYK clinic installs its Hitachi Altaire 0.7 Tesla open MR scanner early this spring, it will be: • the first its kind and strength in the country; • joining four low-power open MR systems in Montreal and Toronto; • the opening sale in what Hitachi Canada Ltd. hopes will be a shift in Canadian MRI buying patterns; • a litmus test of public-private healthcare. More about all this later, but first some background. In November last year, Hitachi Canada announced it was entering the Canadian MRI market with two new machines that had already proven a hit south of the border and elsewhere: the Altaire “high field performance” Open MR system and the “advanced mid-field” .3 Tesla AIRIS Elite. They are the latest in open MRI machines that have helped Hitachi gain an estimated 60 percent share of the U.S. open MRI market. In all, the company has sold over 1,350 open systems to American buyers and more than 3,000 worldwide. But none in Canada until now. “In the U.S., it was the private clinics that first started open MR sales going,” explains Doug Ragan, general manager of medical solutions for Hitachi Canada. “They were far cheaper than closed systems, but could do the basic head and spine examinations well.” As their use grew, so did their popularity with patients. In a traditional MRI encounter, the patient must lie dead-still for up to 30 minutes or more. Examinations are limited to body parts that can be put at the centre of the focus of the magnet and to patients who fit through the donut-hole opening. Fidgety children under six years of age usually have to be sedated beforehand. But an open MRI has far fewer physical restrictions: • injuries to shoulders, or knees, or feet or other awkward parts can be targeted simply by shifting the patient; • large and obese patients weighing up to 500 pounds can be accommodated; • parents can lie alongside their children to provide comfort during the examination. “It was patients asking for open MRI exams that gave the next boost to sales,” says Ragan. Then came a 1995 U.S. study that further heightened demand – and quieted the doubting Thomases in the American radiology community. “The knock against open MRI systems has always been their comparatively low field strength,” explains Ragan. “But a group of doctors and physicists did a double-blind study of field strength using two closed systems, a 1.5 Tesla system (the power of today’s standard closed models) and a .5 Tesla. “They concluded that even though there was a difference in image quality, it had no real impact on the ability of physicians to make an accurate diagnosis,” says Ragan. “And even 0.3 Tesla open systems are fine for most imaging tasks.” This is no marketing hype from Hitachi. Ragan knows of what he speaks, holding a Ph.D. from the University of Western Ontario in medical imaging. Still, Ragan admits, the stigma of being low field, low cost, and therefore second-class equipment has stuck with open systems, especially in Canada. “Also, radiologists in Canadian hospitals have had no real incentive to buy an open system,” says Ragan. “They knew that with a closed system they would have no trouble filling up their schedule. Also, there were no private clinics for a long time, so the profit motive wasn’t there either.” That is until the likes of Quebec, British Columbia, and Alberta came along to challenge dictums against private imaging clinics and their supposed threat to universal healthcare. And especially after one freshly minted radiologist from the University of Manitoba and the Alberta Children’s Hospital did specialist training at Thomas Jefferson University in Philadelphia. There Dr. Kaura saw first-hand the patient advantages, especially for children, of open MRI. And when he first saw the image quality and what the .7 Tesla Altaire could do he says, “I nearly fell off my chair. They’ve optimized the magnet’s sub-systems to make a .7 Tesla give you the same image quality as a 1.5. It is very impressive.” Hitachi’s VOSI (vo-sigh) sub-system technology improves on the holy trinity of image quality: Signal-to-noise ratio – distinguishing better between detected and random signals. Hitachi has made the vertical field magnet of an open system as effective in reducing unwanted image clutter as the conventional horizontal magnet of a closed system – by means of coil, receiver bandwidth, and pre-amplifier innovations. Spatial resolution – discerning more clearly the small distances between separate details in the image. The key piece here is the scanner’s gradient sub-system and its “slew rate”. In effect, Hitachi has strengthened the gradient and sped the slew rate up to unprecedented levels for an open system. Contrast resolution – making sharper the contrasts between different tissue types. Of note here is Hitachi’s unique FatSep pulse sequencing which effectively helps make obscuring fat disappear from the image. “The .7 Altaire can do the same as a closed 1.5 Tesla with the exception of functional MRI imaging and spectroscopy,” says Ragan. Dr. Kaura also thinks sophisticated cardiac imaging should be left to the closed systems. Despite these minor limitations, Ragan and Dr. Kaura think open MRs are now set to revolutionize diagnostic imaging in Canada – if and when the word gets out. Though his Calgary clinic and its equipment is privately owned, the service it renders to patients will still be billed to Alberta’s public health system. A formula the rest of the country – caught up in the private versus public debate about imaging clinics – should be watching with interest. What will make the MYK clinic profitable, Dr. Kaura firmly believes, will be patient demand and referring physician awareness.
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64-slice CT revolutionizes diagnostic imaging