UHN, GE to launch centre for digital pathology

By Jerry Zeidenberg

TORONTO – GE Healthcare will open its first global centre of excellence in digital pathology in Toronto, in conjunction with the University Health Network and HTX, a health technology commercialization agency that’s funded by the Ontario government.

“The centre in Toronto will play a central role in the transformation of the 125-year-old practice of pathologists using slides,” commented GE Healthcare’s Canadian general manager, Peter Robertson, speaking to a room full of partners, clinicians and dignitaries at the Toronto General Hospital.

He explained that pathologists, for the most part, still make their diagnoses using slides and microscopes – a slow and laborious process. The new centre will develop and test a new generation of digital slide scanners, workstations and workflow software that’s designed to improve the speed and quality of diagnosis, and to enhance patient safety.

GE Healthcare and its digital pathology joint venture, Omnyx of Pittsburgh, Penn., will invest $7.75 million, while the Ontario government-backed Health Technology Exchange (HTX) is kicking in a $2.25 million grant.

Robertson said discussions are under way with other partners who are expected to furnish another $7.2 million for a total of $17.2 million over the next three years.

In the last two to three years, experts have noted that digital pathology is verging on the brink of a revolution. Technological breakthroughs have been made – such as rapid and accurate scanning of slides – that are expected to change the nature of pathology in the way that PACS has already transformed the practice of radiology.

Where once radiologists relied on film and light-boxes, they now routinely make use of computerized workstations with instant access to images, digital tools for analyzing studies, and electronic sharing of pictures and data with colleagues. These benefits are expected to be disseminated throughout the discipline of pathology, where pathologists currently wait for slides to be delivered – often from hundreds of miles away – before manually slipping them under their microscope lenses and examining them.

Dr. Sylvia Asa, pathologist-in-chief at the University Health Network, observed that when using these traditional methods, pathologists must sometimes wait days for the slides to arrive – many rural hospitals don’t have pathologists or pathological sub-specialists on staff, and must send slides to the UHN or other large centres for diagnosis. This means that patients, in turn, must wait days for results and for their treatments to start.

To counter these delays, the UHN has been running a project with 21 hospitals across Ontario whereby the hospitals can digitize their slides and send them electronically to pathologists at the three hospital network – Toronto General, Toronto Western and Princess Margaret hospitals.

Moreover, the UHN is conducting a scientific study with the Timmins hospital, along with nine hospitals that surround it, to validate whether the results of digital slides and readings are on par with traditional techniques using glass slides and microscopes.

Dr. Andrew Evans, a pathologist at the UHN who was one of the first to advocate the use of digital technologies, pointed out that there has been some resistance by pathologists to make use of computerized methods. In the past, the scans of slides have not always been of the quality needed to make definitive diagnoses – and pathologists have balked at using them to make decisions that can have significant consequences, such as telling a patient that he or she has cancer. But in recent years, the technologies for scanning have vastly improved, as have the technologies for organizing and manipulating images on screen and collaborating with colleagues.

In particular, GE Healthcare and Omnyx have devised a two-camera system for taking fast, high-resolution scans of slides. The first camera scans the slide while the second is used to focus – ensuring that the image that is gathered is sharp, bright and clear.

Dr. Evans and Dr. Asa are confident the trials with Timmins will demonstrate that digital slides can be as good as standard slides. Once this is systematically demonstrated, pathologists are likely to switch to digital tools.

“Once they’re convinced that what they see on screen is the same as what they see on the slides, they’ll start using computers to make their diagnoses,” said Dr. Evans. He noted that they’ll want to see results from a large-scale study involving thousands of cases – and that’s what’s being conducted with Timmins and nine other hospitals.

Of course, numerous other technologies are involved, such as workflow tools that will link studies to patient records, call up previous slides from the same patient, help analyze the image that appears on screen, share digital slides with other pathologists and clinicians, and so forth.

In addition to GE Healthcare, other corporate leaders in the field include Philips and Siemens, along with a host of smaller, specialized companies.

What’s more, a variety of Canadian hospitals are developing expertise in digital pathology. In December, the federal government awarded funding of $13.3 million to the Centre for Imaging Technology commercialization and Research, a collaboration between Sunnybrook Research Institute, part of the Sunnybrook Health Sciences Centre, and the University of Western Ontario.

The venture is aimed at helping researchers and small companies commercialize medical imaging and digital pathology innovations in Canada.

The UHN centre is the first project to be supported by HTX under the Ontario Flagship Program, which is designed to attract multinationals to establish advanced R&D facilities in the province.

John Soloninka, president and CEO of HTX, noted that GE Healthcare and Omnyx could have established a digital pathology centre of excellence anywhere in the world, but chose Ontario because of its high level of medical imaging expertise.

As a means of leveraging the province’s human capital in medical technologies and creating companies that will generate jobs and products to sell around the world, HTX and the government of Ontario have identified two missing pieces. “The first is increased financing for early-stage companies, and the second is multinational companies that will invest in R&D in Ontario,” said Soloninka. “This collaboration will address both.” Commented Soloninka: “The new centre will create an outstanding platform to generate new companies.”

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New generation of wireless devices suit the workflow of healthcare professionals

By Andy Shaw

Is wireless, that favourite subject of small pilot projects in healthcare for the last decade or so, finally ready for the big leagues? Well, some of the biggest players in the mobile health game certainly think so. “What we have seen recently is an explosion of wireless and hand-held applications,” said Gord Stein, the business segment vice-president at Rogers Communications Inc., as he helped open the annual eHealthAchieve conference organized by the Ontario Hospital Association (OHA) late last year in Toronto. “And they have exploded first of all in response to the drive towards more personalized medicine for the patients, but also to the enormous pressure there is now in the healthcare system to both improve service and provide greater efficiencies.”

Mobile applications have also ‘exploded’ because the duds have disappeared.

“We have the wireless technology we need for mobile health here right now. And it works,” said Bruce Ross, the president of IBM Canada Ltd. Ross was one of three heavyweights on an opening morning eHealthAchieve panel that included Don Morrison, the chief operating officer for Research in Motion (RIM) and Rob Devitt, the president and CEO of Toronto East General Hospital.

Morrison cited some International Data Corporation (IDC) statistics supporting the notion that better clinical collaboration is a vision of caregivers all connected to each other with cell phones, pagers, nurse alerts and wireless tablets. As he put up another IDC-based slide, COO Morrison commented on a critical component of digital collaboration: “It’s showing that 80 percent of doctors in Canada will be using some form of mobile technology by 2012.”

And that’s because even traditionally skeptical MDs see the logic of mobile healthcare’s greatest benefit: In hand, they’ll have what they need to know when they need to know it, unlike ever before.

“Doctors and other caregivers will be on the receiving end of a system that aggregates data from all sorts of systems and then renders the data in a way that allows them to do their jobs faster and better,” said Morrison. “Ten years ago I might have been giving a presentation like this and saying, ‘This is what the future holds’ – but that future is now. Whether you are talking (wireless) software or hardware today we have what it takes. It is just a matter of putting them together, and that is what IBM is so good at doing.”

And what earlier adopter Toronto East General hospital, with IBM’s help, has been so good at implementing.

“What we did first, and I strongly advise others to do the same, is to start small –but think big,” said hospital CEO Devitt. “We started with a small wireless device, the Vocera communicator, that simply hangs around your neck on a lanyard.”

Devitt went on to say that because of the sophisticated and rock-solid, secure, wireless technology the little Vocera offers, Toronto East General went on to implement wireless in a big way.

“We knew that if you gave employees something less sophisticated like a single purpose alarm, they would carry it for about two months and then it would end up in their lockers,” said Devitt. “But the Vocera has so many other functions that we soon saw the greater quality of care and safety, as well as the financial returns it brings, so we went big with it.”

IBM started the project by installing 300 wireless access points that provide hospital-wide coverage, despite what Devitt described as a “clunker of an old building full of nooks and crannies.” But he proudly points out that Toronto East General now has wireless coverage even in its stairwells and elevators.

“We stepped back at that point when we saw the bigger possibilities and decided to go hospital-wide with it, and not just in one department,” said Devitt. “And even with that, what was to be an 18-month project came in two months early and was on budget.”

What that budget bought were 1,500 Vocera communicators for 3,000 users who immediately began experiencing a slew of benefits.

“A nurse, for instance, can just double click the Vocera, and a ‘Code White’ goes out to the whole building. So every security officer in the place is instantly alerted and because of the device’s tracking capability, they know exactly where the nurse is,” said Devitt.

He further explained that the Vocera has also been hooked into the hospital’s nurse call system.

“How many at this conference have seen the situation where a patient pushes the button and the light flashes at the nursing station, but the nurse is not there?” asked Devitt. “So you have an angry patient and a frustrated staff member who missed the call. Now the patient pushes the button and the nurse gets the call no matter where the nurse is.”

Not a surprise then when the results of Toronto East General patient surveys came in showing their satisfaction with the hospital’s care have gone way up.

“We’ve had a number of other metrics on the Vocera. Our average time for a porter to respond successfully to a call has dropped from 45 minutes to 19 minutes,” said Devitt. ‘We’ve also applied wireless to our electrocardiograms and made the results available on an electronic chart. So our turnaround time for an interpretation has dropped from four days in our days of the paper chart – to one day today. And we estimate that we’ve saved $20,000 a year as a result of that one function alone.”

Those impressive wireless results also caused Devitt and the hospital’s powers-that-be to rethink their electronic medical record (EMR) strategy in a big way.

“We originally thought our EMR system would be a wired one, but now we’ve decided to make it completely wireless,” said Devitt.

As a result, Devitt and the hospital are working with IBM, RIM and their EMR provider to integrate all their mobile devices and wirelessly access their Cerner clinical systems.

“To have our nurses be able to both read and enter vital signs on the same device – that is our immediate goal,” said Devitt. “It’s another example of thinking big but starting small.”

Meanwhile across town, Mount Sinai Hospital has gone big having started small with Apple’s iPhone. As reported in the June/July 2010 issue of this magazine, Mount Sinai’s innovative VitalHub system is putting virtually all the hospital’s clinical applications and many of its administrative ones on the iPhone. That means that doctors, for example, can get up to speed on all their patients’ status before conducting morning rounds.

“Typically, when a physician sees it, they love it, and want it,” says Neil Closner, a Mount Sinai vice president who is now also CEO of the hospital’s VitalHub spinoff company.

“But some may already be on some sort of BlackBerry plan, so they might wait until their contract for that runs out.”

That delayed demand is a bit of a blessing in disguise, as it turns out.

“We’ve deployed over 200 iPhones, but one of our challenges has been a shortage of iPhones because of their sheer popularity,” says Closner.

Nonetheless, the clinically equipped VitalHub iPhones have made their way into two major departments at Mount Sinai: General Internal Medicine and Surgery. As well, there are a number of beta deployments in selected nursing departments.

Nor has the iPhone shortage deterred the now very entrepreneurial VitalHub from selling its system to others.

“We have preliminary agreements to roll out VitalHub at three other Canadian hospitals and we are having talks with a number of U.S. providers,” says CEO Closner.

That iPhone shortage, coupled with the explosion of new wireless gear mentioned at the outset, also have Closner and VitalHub thinking about other devices.

“The device manufacturers have really stepped up their game, in terms of making more and more devices available that are applicable to medicine,” says Closner. “We started out with a focus on Apple and we still have that focus, but we are also very optimistic about some others. RIM’s newer devices like the Playbook have certainly come a long way.

And we are also keeping our eye on Android to see how it plays out. So we are evaluating what our next platform will be.”

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Microsoft targets chronic conditions to improve health worldwide

Dr. Bill Crounse is a medical doctor and senior director of worldwide health for Microsoft Corp. But he didn’t start out in the direction of Bill Gates at all, even though they lived in the same neck of the woods. Bill Crounse first came to public attention as a television news anchor in Seattle – before making a dramatic career switch via medical school in Ohio to a family practitioner and later to hospital administrator work in Seattle. Since joining Microsoft a decade ago, Dr. Crounse has globe-trotted to more countries than he can remember – and has come back convinced that chronic disease is the healthcare world’s number-one challenge. Canadian Healthcare Technology’s Andy Shaw recently spoke with Dr. Crounse.

CHT: Dr. Crounse, you speak of “chronic condition management” rather than chronic disease management. Why is that?

Dr. Crounse: Well, it’s because there are a lot of risk factors related to chronic disease that you want to manage, but which are not really diseases. As a family doctor, for example, I might want to help you manage your fitness level, or your diet, or your weight problem. It’s also an important indication of how Microsoft and others have broadened their view of chronic disease management. It’s a view that instead of focusing only on patients and diseases, embraces people. When we think of chronic disease we think of patients. When we think of chronic conditions we think more about the needs of people, all people.

CHT: So in your global travels what have you seen out there in terms of technology that’s helping advance this broader chronic condition management approach?

Dr. Crounse: First of all, it’s probably worth talking about what the technology is attempting to do or improve. Certainly everything we are trying to do with healthcare technology at Microsoft, and other innovations in health and healthcare is to answer: How do we improve the quality of care, while at the same time drive down costs, and also make health information and care services more accessible?

And the starting gate for the answer is the electronic record, be it an EMR or an EHR or a consumer’s own personal health record (PHR), and their related technologies. So, on electronic record usage, what I see out there is that generally both in Canada and here in the U.S. we are lagging behind most of Europe and the likes of some Asian countries. I’m also seeing very good work around eHealth solutions in New Zealand, and especially Australia. And in the United States, if you look at the large managed care organizations, there’s no question that some of the best practices in terms of use of electronic records and eHealth initiatives are groups such as Kaiser Permanente and GroupHealth here in Seattle. They are virtually paperless.

CHT: How have they managed to excel?

Dr. Crounse: It’s because the business model for organizations like Kaiser in the United States is perfectly aligned to support eHealth initiatives. The physicians are employed by the organization which serves as the provider as well as the payer or insurer of care. It is the best milieu for technologies to play out to everyone’s advantage. GroupHealth here, for instance, has about 75 percent of its population online and they’ve been able to move about 30 percent of the usual demand for primary care services that it was experiencing in its actual clinics and move it online, so patients and consumers don’t even have to leave home in order to interact with health professionals. People can go online, and access their complete medical record, manage their prescriptions as well as their benefits, make appointments, participate in web conferences, email their doctors, and expect to get a timely reply to their email questions. It’s a great way to get the information and certain kinds of medical services that consumers are seeking to manage a lot of their minor ailments and chronic condition concerns.

In the United States, that model works fabulously well within the managed care system, but it quickly falls apart when you take it outside of those organizations because you lose that wonderful alignment of business incentives. Canada is very different from the U.S. but shares some commonalities, and there are things we can learn and apply from organizations like GroupHealth and Kaiser. For example, at the macro level, provinces both govern the provision of care and act as the insurer, therefore it is in the province’s financial interest to move care into more cost-effective paradigms, reduce duplication and improve quality. Helping people prevent illness and stay healthy has a positive impact on the health of citizens, improves productivity as a nation, and helps control spending. The Canadian model is not misaligned from a business model perspective, but more can be done to manage health like a system and align incentives across the various stakeholders.

CHT: And yet you say a country like Australia has managed somehow to get to the forefront of chronic condition management. How did the Aussies do it?

Dr. Crounse: Australia has done fabulous work which I can tell you a bit about in a moment. But at the outset they recognized that even when you get the electronic-record-in-place, the game is not over. The electronic record by itself won’t get you where you want to go. It’s what you do next that really addresses the big healthcare issues of quality, costs, and access. It’s how well you apply the digital information in your electronic records, how well you search or mine that data, and how well you use contemporary information/communication technology to improve lines of communication and collaboration among care teams and the people they care for, in the clinic, hospital or even the patient’s own home – these are the real measures of success.

I recently spent a few weeks in Australia and we did a big campaign going city to city talking about a new paradigm in chronic care and technologies that link patients and consumers with clinical care teams via technology. You can look up what’s been done down under on our Microsoft Australia site (http://www.microsoft.com/australia/health/chronic-care). It’s full of case studies on solutions for chronic care, such as prevention and self-management, coordinating and integrating care, care decision support and enabling care team collaboration and communication that are built on such products as SharePoint, Microsoft CRM for patient relationship management, SQL server, BizTalk server, and key performance indicator technologies. Many of the solutions are available in Canada.

CHT: So what could that all do for better chronic condition or disease management in Canada?

Dr. Crounse: First off, you can arm your community-care health workers with mobile technology, be it smartphones like the new Windows Phone 7 that I just picked up, or with tablet devices. They allow nurses and other clinicians to visit clientele in their own homes and immediately connect back to their caregiver agencies so that everyone is on the same page. Australia, some home-care initiatives in Europe, and the Ontario Association of Community Care are early adopters of our unified communications or what we now call Microsoft Lync technologies. We also have worked with the National Health Service and the Torbay Care Trust [in the south of England] to arm community matrons who go out and care for the elderly in their homes.

CHT: Speaking of results, no doubt what you and Microsoft are developing is being influenced by President Obama’s healthcare reform drive, which includes supporting the spread of technologies and equipment that can demonstrate “meaningful use.”

Dr. Crounse: I am sure you’ll agree that not much could be more meaningful in “meaningful use” than enabling patients or consumers and their doctors or other caregivers to share information. That is what our HealthVault solution is about, which puts in consumers’ hands a vehicle for sharing health information securely with their providers, or anyone else they want to share it with. HealthVault is also now available in Germany where it is known as Assignio, and also in the United Kingdom. Of course, we are working hard with our Canadian partner, Telus, to bring their version of the solution to Canadians – Telus health space, powered by Microsoft HealthVault.

In my opinion, services such as HealthVault are part of a beautiful new model of health information – one that is patient or consumer driven, not healthcare system driven. But it is going to take businesses that can scale services to global levels with a rich system of partners who can look at the long haul and invest for years and years to really help transform the healthcare industry. That’s where Microsoft comes in. We have a pretty good track record of transforming industries, I think.

CHT: Well, now that we are talking about the future, what have you got in the Microsoft top hat that could be transformational?

Dr. Crounse: They are not just ours, of course, but cloud-based services hold enormous potential. We can see, for instance, that large public hospital systems that have already invested heavily in their own data centres might create a “community cloud” service to offer highly scalable, more manageable and less expensive ICT solutions for use by other hospitals, clinics, and doctors offices, as well as by local social service agencies.

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Assessing the impact of electronic systems in healthcare

By Richard Irving, PhD

As a follow up to my last column on Electronic Health Record adoption in Ontario, I will comment on a recent article in the Archives of Internal Medicine, Jan 24, 2011, by Romano and Stafford, entitled Electronic Health Records and Clinical Decision Support Systems.

Romano and Stafford analyzed physician survey data on over 250,000 ambulatory patient visits and found that only 1 of 20 quality-of-care indicators showed quality was greater in EHR versus non-EHR visits. For clinical decision support systems, again only 1 in 20 indicators showed better performance. For the rest of the indicators there were no other significant quality differences.

What can we conclude from this? Certainly some may conclude that EHRs are a waste of time and money if they can show no improvement in quality of care. I believe that conclusion is likely to be premature on a number of fronts.

First, I might raise the issue of whether or not the quality-of-care indicators used actually measure those aspects of care likely to be impacted by an EHR or CDS? In other words are the quality of care indicators too narrow? For example, would all medication errors appear in this data? Or would time saved by clinical care givers be recorded?

Second, I wonder if an analogy can be drawn between EHR adoption in healthcare and computerization in industry generally. In the early 1990s, Paul Strassmann, a senior IT executive and consultant, demonstrated that there was no relation overall between the amount invested in computers and productivity gains across industries or even within them.

However, detailed analysis showed that organizations which were well-managed tended to show positive gains from IT investment and those which were poorly managed tended to show losses from investments in IT. Overall, their IT investments tended to cancel each other out! One wonders if the same might be happening here. In other words, are some clinical organizations adopting EHRs but not changing their behaviors to take advantage of them?

A third quibble is that the conclusions are based on survey data and do not include any direct observation of EHR use. While survey data is valuable, direct observation can provide a level of depth and context that is not available with a survey. It would be helpful if a study of 20-50 sites could be done using direct observation. If these studies could be conducted over a period of several months or perhaps even a year or two so much the better.

Finally, the focus on quality-of-care indicators may be misplaced. If there are few or no differences in quality-of-care, at least these systems are doing no harm. But what about efficiency and effectiveness? Quality-of-care is an important aspect of healthcare but it is only one aspect. Are scarce clinical resources being used more effectively? Is the time taken to manage not only patients, but also the paperwork overhead reduced? Is coordination between caregivers better? Can the level of administrative staffing be reduced?

Before one can reach any general conclusions about the usefulness of EHRs, the preceding questions must be answered in some fashion.

Richard Irving, PhD, is an associate professor of management science at the Schulich School of Business, York University, Toronto.

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