|
Inside the May 2005 print
edition of Canadian Healthcare Technology:
Feature Report: Developments in surgical
systems
 Chatham-Kent hospitals test on-line appointments
A new, online Patient Appointment Request Service
(PARS) is ensuring a hassle-free booking experience for patients of
the Chatham-Kent Health Alliance – a partnership of hospitals
located in southwestern Ontario.
Comprehensive portal
30,000 patients each month are using the web
portal at Boston-based CareGroup – a five-hospital organization – to
communicate online with doctors, make appointments, obtain referrals
to specialists and renew their prescriptions.
READ THE STORY
ONLINE
Stent revolution
High-tech manufacturers are now producing
drug-coated stents that disperse the medication over time, greatly
reducing the need for repeat surgeries in balloon angioplasty
patients.
Niagara region enhances care with 64-slice CT
Ontario’s Niagara Health System has acquired two
64-slice CT scanners, which use a high-powered technology that’s
expected to revolutionize the DI world.
READ THE STORY
ONLINE
Cash for information
In order to obtain the data needed to build
complete and accurate wait lists, Ontario has decided to pay
hospitals for additional surgical and diagnostic procedures only
after the centres have provided valuable information.
CCD-based DR
When evaluating a variety of direct radiology
systems, the Ottawa Heart Institute found that a CCD-based
technology came out best on image quality, ergonomics, ease of use
and price. It opted for the systems of Calgary-based IDC.
PLUS news stories, analysis, and features and more.
|
Chatham-Kent hospitals test on-line appointments
By Karen Gersohn
A new, online Patient Appointment Request Service
(PARS) is ensuring a hassle-free booking experience for patients of the
Chatham-Kent Health Alliance – a partnership of hospitals located in
southwestern Ontario. The service is enabling patients to book their own
non-urgent appointments, such as diagnostic tests and cardiac and
respiratory tests.
Previously, patients had to call a Patient Appointment Office or rely on
their doctor’s office to set up an appointment. And that meant battling
to get through their busy lines, or sitting on the phone waiting for
assistance, or calling back and forth trying to juggle schedules.
But now, says Marilyn Cadotte, project leader for the PARS application
and I.S. co-ordinator for Chatham-Kent Health Alliance (CKHA), patients
are able to input requests for procedures, tests and appointments
electronically 24 hours a day, seven days a week, from the comfort of
their own homes. “We are able to serve the patient when it is convenient
for them,” says Cadotte. “Office hours are not always convenient for the
workforce.”
The service has also made appointment-setting less cumbersome for
hospital workers.
Sharon Pfaff, chief information officer for Chatham-Kent Health Alliance
(CKHA), points out that in order to make this service possible, the
hospitals first needed to centralize their booking process. “We didn’t
want to have that person in the middle transferring information from one
system to another. Now, it’s possible to see the procedures that are
booked and the available spots in multiple sites,” she says.
According to Pfaff, the idea for the PARS project came about at a forum
where key individuals discussed the fact that hospitals were so far
behind in computerization.
“The rest of the world functions with electronic processes, but a simple
thing like booking a hospital appointment over the Internet was
impossible,” says Pfaff. “You can book your hotel room electronically
across the other side of the world, you can do all your banking online,
you can pay your bills, but you couldn’t even book a simple appointment
online for your procedure. Certainly, when there was a funding support
that covered online scheduling as a possibility, we decided to move
forward.”
PARS is funded in part by the Ministry of Economic Development and Trade
through a Connect Ontario grant. Concept Interactive Inc., the builder
of the Chatham-Kent community portal and the PARS application, also made
an in-kind contribution.
Pfaff stresses that the project was a joint undertaking with the
Municipality of Chatham-Kent. “We actually tapped into their system,
since we didn’t have the funds to build the system from the bottom up,”
she says.
The service, launched in January, is accessed via the Chatham-Kent
community portal (www.chatham-kent.ca).
Users first complete an online information form and are asked to enter
personal health information, including a health card number and the name
of a referring physician. The creation of a unique user ID and password
ensures that this information is protected.
Patients are able to book appointments online for the full range of
tests and procedures offered by the hospitals in Chatham and Wallaceburg,
including diagnostic imaging, nuclear medicine, cardiology tests,
respiratory tests and others. However appointments for CT scans still
have to be scheduled by physicians in collaboration with the
radiologists at the hospital.
But appointments that need to be scheduled within two weeks cannot be
booked on-line.
According to Cadotte the system is set up so that it automatically
defaults to two weeks in advance. “If there is anything urgent, we want
the patient to call. When they sign in, a message tells them that if the
appointment is of a critical nature, they need to call.”
Patients are able to choose a day and time-frame for their appointment,
and they can make more than one suggestion. The procedures on the paper
format of the doctor’s order form are duplicated in drop down boxes on
the electronic form. The patient must access the service again within
two days to receive an appointment verification. They can then accept
the proposed time or decline and suggest an alternate time.
Cancellations or changes can only be made by phone.
So far, the feedback from both patients and doctors has been positive.
“Things are working well, but our volumes are not high at this time,”
says Cadotte. “We are going to publicize it a bit more and we are in the
process of enhancing some of the features to make it easier for the
patients to use.”
Pfaff added that physicians’ offices seemed to be excited about this
opportunity. “We are going to be doing some more marketing as we move
forward, particularly honing in on physicians’ offices,” she says.
According to Cadotte, future plans include the possibility of
physicians’ offices being able to access the scheduling package
directly.
“We will also be setting up an evaluation form for the users to
complete, and we will base how we move forward on the feedback from
that.”
The PARS application is the only one of its kind in the Canadian
environment. According to Sean Bredin, vice president, Concept
Interactive Inc., two other municipalities are scheduled to follow
Chatham-Kent. “There has been quite a bit of buzz created from this
application,” said Bredin.
Boston’s CareGroup hospitals pioneer the
web-based patient portal
Canadian hospitals interested in building their own
patient portal would benefit from examining the PatientSite Project,
created by the Boston-based CareGroup Healthcare System, a
Harvard-associated, five hospital system of 12,000 employees, 2 million
patients, and 1,700 medical staff. Its flagship is the Beth Israel
Deaconess Medical Center (HMFP).
PatientSite (www.patientsite.org)
is a sophisticated web portal for patients and physicians that’s been up
and running since April 2000. Its features include requesting
appointments, obtaining prescription renewals, and requesting care
referrals.
The PatientSite project began in 1999, when I.T. and general medicine
staff first discussed the concept of “patient relationship management” –
the idea that patients should be able to view their medical records on
line and communicate electronically with their physicians.
In early 2000, PatientSite was piloted with a small number of highly
motivated, early adopter physicians and patients. By August 2000, over
1,000 patients were enrolled, along with 43 physicians in 10 practices.
Currently, over 30,000 patients, 200 primary care clinicians and 300
staff use Patientsite every month, commented Dr. John Halamka, CIO of
Harvard Medical School and Beth Israel Deaconess Medical Center.
The project achieved this degree of adoption by ensuring PatientSite is
compatible with all browsers, is easy to use and is highly customizable.
For example, physicians work with their patients to enable specific
features, such as how messages are routed to nurse practitioners,
prescription clerks and appointment clerks.
For security, PatientSite uses a Secure Sockets Layer with 128-bit
encryption. Users access it by logging in with a username and password.
All accesses are audited and all audit trails are available for review
by patients.
One of the features of PatientSite is secure messaging. Users (patients,
staff, and providers) have a mailbox on PatientSite that enables them to
send messages to other users on PatientSite. No clinical information
ever leaves the secure website: when a message arrives, recipients are
alerted via an unencrypted e-mail message sent through regular e-mail.
Recipients can then click on the PatientSite URL, their web browser will
open, and they can then log in to read their message.
The functions of the PatientSite mailbox are in many ways similar to
that of an ordinary e-mail program. Each message has a subject and a
body. Messages can be composed, read, sent, and forwarded to others.
Other features differ from e-mail. Each message has a classification,
such as “clinical,” “referral,” “prescription.” Because messages have a
classification, they can be automatically routed to those who can best
handle them (e.g., prescription requests to the prescription staff).
PatientSite allows physicians to dictate routing of these various
message types. By default, clinical messages would be handled directly
by the physician.
In addition to secure messaging, PatientSite allows patients to perform
convenience transactions online. This includes requesting appointments,
obtaining prescription renewals, requesting managed care referrals and
viewing their bills.
Patients wishing to have a non-urgent appointment may (if their
physician has permitted it) view the physicians schedule and fill out a
web-based form specifying when they would like the appointment.
The appointment request is sent and reviewed by whomever the physician
has designated as being responsible for managing these requests. The
patient is contacted either through secure messaging or by telephone to
complete the booking.
PatientSite similarly allows patients to request prescription renewals
using online forms. In this case, the patient specifies not only details
about the prescription, but also delivery instructions for the
prescription. Prescription information is automatically completed when
the patient uses the refill button next to a medication on their
medication list screen.
The prescription can be left for the patient to pick up, or the patient
can specify that the prescription should be called in or mailed to a
specific pharmacy. Each patient’s favorite pharmacy is the default, but
other pharmacy information may be entered, and a pharmacy lookup is
provided as a reference.
In addition, when patients need specialty referrals, online referral
forms enable them to request the referral from their primary care
physician.
Every patient’s “home page” on PatientSite contains customizable health
education links. These may be “prescribed” or suggested to a patient by
a physician through a message (often to support a response to the
patient) or they may be selected directly by the patient.
Discrete links may be added, but patients can also select predefined
collections of links, clustered by category. These collections are
managed by our patient education committee.
Patients may also view drug information monographs about each of their
drugs by clicking on the drug of interest that appears on their
medication list. In this way they can better understand their
medications, how to take them, and what adverse effects can result.
All patients registered on PatientSite have links to their patient
records that are established at the time of registration. Once this is
done, it is possible for patients to view their records online.
Patients may see most aspects of their record online, including
medication lists, problem lists, allergies, and all test results (except
for initial HIV test results). If the patient’s physician does not use
computerized patient records or does not have tests performed through
one of CareGroup’s affiliated medical centers, then these elements will
not be viewable.
Clinicians can view all messages sent through PatientSite through a
“Messages” section of the clinical information system. All PatientSite
messages are archived as long as the rest of CareGroup’s clinical
information.
Patients can maintain a health record on PatientSite. They can input
their own medications, problems, allergies, and notes. They can also
track and graph data over time, for example, blood glucose measurements,
weights, blood pressure, symptom scores, and any other quantitative
information. Finally, they can upload files, including images,
documents, and spreadsheets.
Since the implementation of PatientSite in April 2000, CareGroup has
monitored its use both by patients and providers. It only counted as
active users patients who logged on and signed the usage agreement after
they were enrolled.
The median age of PatientSite users is 43, with 4 percent over the age
of 70. Fifty-seven percent are female.
One of the things that concerns physicians about electronic
communication is that they will be flooded with e-mail. The PatientSite
data do not support this. Looking at the volume of clinical messages,
the number of messages handled by physicians is quite modest, on the
order of 20 to 40 messages per month per 100 patients. If we imagine a
busy practitioner who has 1,500 patients using PatientSite, the maximum
number of messages he can expect to handle from patients each day would
be 15.
Even as it has been well received by many patients and physicians,
PatientSite has raised controversial issues that are worthy of future
discussion:
• Should certain types of data be restricted?
• Is it necessary for physicians to review results before patients can
view them?
• How should information from the medical record be presented to
patients to enhance their understanding of their health without
needlessly alarming them?
• PatientSite has three major stakeholder groups, patients, physicians,
and practices. How can we best balance the needs and concerns of each
group to guide development?
• What should happen to patient-entered information in the personal
health record?
• Should physicians be able to view the patient’s personal health
record? Should they be required to do so?
• In a teaching environment, how should preceptors oversee their
trainees’ use of electronic messaging with patients?
• Should physicians be reimbursed for using PatientSite? If so, who
should pay? How much should they be reimbursed?
Online health consumers are increasingly prevalent, and are therefore
important to healthcare providers. Organizations must fulfill their
needs for communication, information, convenience, and access to their
health records.
PatientSite, a Website developed and implemented at CareGroup Healthcare
System, is an excellent way to meet these needs. It has been vigorously
adopted by both patients and providers, and yet the demand on physician
time is modest. The system has introduced controversial and interesting
issues that CareGroup continues to work through. PatientSite is also a
useful platform for future projects, such as patient-computer
interviewing, disease management, healthcare quality, and patient
safety.
New developments in cardiac stents lead to
improved ‘keyhole’ surgeries
By Karen Gersohn
In one of the latest surgical technology revolutions,
cardiac stents are now being coated with drugs to produce dramatically
better outcomes for patients. The time-released medications are
preventing blockages from re-occurring in the arteries surrounding the
heart.
That will mean far fewer return visits to the catheterization lab or
operating room for cardiac patients – something that will be welcomed by
health-conscious patients and over-burdened hospitals alike.
For several years, stents – tiny mesh tubes made out of soft but sturdy
metals have been used in surgical procedures to prop open arteries after
the blood vessels have been cleared of blockages by balloon angioplasty.
As physicians can accurately insert stents into the body on the tips of
catheters, guided by real-time images from scanners, the small mesh
coils have become a leading-edge therapy in minimally invasive surgery.
Unfortunately, scar tissue often forms near the implanted stent and can
cause the artery to re-clog or restenose in approximately 10 to 40
percent of patients, depending on patient and vessel characteristics.
That has resulted in return visits to the catheterization lab or OR for
patients.
With drug-eluting stents, however, the rate of restenosis plummets.
“Drugs embedded in a polymer on the stent itself modify the healing
process, so that scar tissue does not build,” commented John Groetelaars,
vice president for Boston Scientific Canada, a leading developer of
drug-eluting stents. “The polymer has a time-release mechanism, so that
the drug can be dispensed or eluted into the tissue nearby. This has
dramatically reduced the rate of restenosis and repeat procedures to
just 3 or 6 percent.”
In the past, the traditional treatment for coronary disease has been
bypass surgery. In this procedure, the breastbone is cracked open, the
heart is stopped and the blood is sent through a heart-lung machine. An
artery is taken from the groin or arm of the patient, and grafted into
the cardiac artery, thereby circumventing the blockage.
The recovery period for this major procedure is four to six weeks, after
a hospital stay of about a week. And 20 to 30 percent of patients will
need a second procedure within 10 years.
Contrast that with the less-invasive angioplasty or stent placements – a
small slit in the groin or arm, an overnight stay in the hospital and
back to work within two days. And with the insertion of drug-eluting
stents, the prognosis is even better, as restenosis rates tumble.
Dr. Eric Cohen, director of cardiology at Sunnybrook and Women’s Health
Sciences Centre, in Toronto, says that more people with coronary disease
are now being treated with angioplasty and contemporary stenting than
with by-pass surgery.
“If you can avoid a surgery, have a quick recovery and a relatively low
risk of complications up front, it is more desirable, as long as the
need for a repeat procedure is relatively low,” he said.
And when it comes to drug-eluting stents, Dr. Cohen adds that, “The
response from doctors has been enthusiastic. The clinical trials have
been consistent and fairly dramatic.”
As the technology is still young, Dr. Cohen offers a caution: “There
have been some lingering concerns in the background about safety,
because we don’t know that much about the long term effect of putting
these drugs against the artery wall.”
But that’s quickly changing, he said. “Every year that we get additional
data or follow-up on earlier patients provides more reassurance.”
According to Ken Spears, business unit manager for cardiology at Boston
Scientific Canada, “there are an estimated 35,000 PCI’s (Percutaneous
Coronary Interventions) being done in Canada annually, and virtually all
of these patients receive coronary stents. In 2004, three-out-of-ten
Canadian patients and eight-out-of-ten U.S. patients received a
drug-eluting stent. The cost of each drug eluting stent is approximately
Cdn$2,000.
For its part, the Ministry of Health in Ontario has invested $12.5
million annually for the past two years to pay for drug-coated stents.
The only other drug-eluting stent on the market at this time is made by
Cordis Corp., a Johnson and Johnson company. As well, Medtronic is
poised to enter the market with a drug-coated stent.
“This could lead to some additional options in terms of the arteries
that the stent can be delivered into,” said Dr. Cohen. “It will also
lead to more competition, and hopefully, more price reductions.”
What’s next, in terms of stent technology? “On the horizon, I see
biodegradable and reloadable stents coming to the market,” said Dr.
Cohen.
Boston Scientific is currently working on gaining approval in Canada for
their second generation of stents, which should be available in the next
six to nine months. “In addition we are working on being able to reach
vessels that are at the bifurcation point,” said Groetelaars.
“Frequently, that juncture point is where there is disease.”
When it comes to neurosurgery, Boston Scientifics’ Neuroform stent is
now being used as a less-invasive alternative to neurosurgical clipping
for patients with wide-necked brain aneurysms. Used in combination with
platinum micro-coils, which are used to fill the aneurysm, the stent
isolates the aneurysm and reduces the risk of rupture.
According to Groetelaars, “the coils are used as the primary way to
treat the aneurysm, and the stent is put in place to essentially create
a backdrop for the coils to sit up against.”
‘The aneurysm is stuffed from the inside of the blood vessels with
coils, and that relieves the blood pressure of the sacs. But with a
wide-necked aneurysm, the coils could fall out without the stent to hold
them in place,” he said.
Dr. Karel TerBrugge, head of neuroradiology at the Toronto Western
Hospital, believes that coiling and stenting is a fast and effective
method of saving the lives of neuro patients.
“Coiling and stenting can usually be done within hours of the patient’s
arrival at the hospital,” he commented. “Surgery has to be booked and
negotiated. During the delay, patients can re-bleed and that can be
fatal. From the patient’s point of view, not having to have the head cut
open and the brain retracted and pushed around is obviously better
tolerated, and the wound is not an issue.”
The Neuroform stent was first used in Canada in May 2003. “Since then
approximately 200 procedures have been done with the stent. Usage is
predicted to rise to about 25 to 30 percent, representing about 200
procedures per year,” said Peter Aikins, Boston Scientifics’ business
unit manager for Interventional Neuroradiology.
“The U.S. adoption rate is already at about 25 percent, given that
funding is not a barrier,” he added.
The price of the stents, at approximately $4,000, is much more expensive
than surgical clips. But shorter hospital stays and recovery times
offset this cost. And the ability to perform procedures more quickly,
and saving more lives, is a monumental benefit.
Dr. TerBrugge predicts that in the future stents will be used alone to
treat aneurysms.
“Eventually, we will probably use a stent that has a tighter mesh and we
will not need coils anymore,” he said. “There is no doubt that
intracranial stenting is here to stay. It is clearly a good evolution
and is obviously working.”
The Neuroform stent is the only intracranial stent approved for use in
Canada. The Leo stent from Bolt is licensed for sale in Europe, South
America and Asia.
A third area of the body where stents are proving useful involves the
colon.
Colorectal cancer can cause complete or partial colonic obstruction due
to tumour growth. However, colonic stents can be implanted to open up
the stricture and allow waste to be cleared naturally. They are deployed
with a colonscope and catheter via the anus, and there is no need for
open surgery.
According to Dr. Laura Targownik, assistant professor of medicine,
Gastroenterology, University of Manitoba, “the advantage of doing a
stent procedure is that you save a lot of patients from having to have
an ostomy and having to undergo emergency surgery.”
When a patient presents at emergency with acute bowel obstruction, the
standard of care has been to do a Hartmann’s procedure (two-stage
surgery). The abdomen is opened and a stoma bag is attached for the
draining of stool. The patient then requires six to eight weeks of
recovery time before the next stage of surgery can be attempted.
“Stent insertion allows you to get rid of the obstruction, let the
patient settle down, and when the surgery is done to remove the tumor a
few days later, you can hook the two ends of the bowel together and
bypass the need for a bag,” Dr Targownik said.
She uses Boston Scientifics’ Wallstent. “It has a through-the-endoscope
delivery system, which means that you can deploy the stent under direct
visualization.”
Colonic stenting can also be used as a palliative measure where the
cancer is too far gone to make tumor removal feasible.
Dr. Targownik participated in a theoretical study in which a computer
program simulated a patient who had a colonic obstruction. “The study
found that not only is putting a stent in cheaper, but it also lowers
hospital stays, prevents additional surgeries and prevents patients from
needing an osotomy,” she said.
According to Stephane Taillefer, business unit manager for endoscopy at
Boston Scientific, colonic stents were first used about three years ago.
Approximately 300 procedures were done in 2004.
“However, the response has been slow in Canada, especially in Ontario,
as compared to the United States or Europe.”
Dr. Targownik added that the use of colonic stents by Canadian doctors
is patchy.
“Generally, patients with obstructions are referred to surgeons. Because
there is already a standard of practice of doing surgery, it is hard to
convince surgeons not to do surgery, especially if they are not trained
to put in stents.
“For the future, we have to encourage the visibility or the knowledge
that stents are available, encourage people to learn how to use them and
encourage referring physicians that they are out there and that this is
something that can make the lives of their patients easier,” she said.
CT technology enhances patient care at the
Niagara Health System
NIAGARA FALLS, ONT. – The acquisition of two 64-slice
Computed Tomography (CT) scanners by the Niagara Health System (NHS) is
dramatically extending diagnostic imaging capabilities and enhancing
services for patients.
Diagnostic imaging experts at the St. Catharines General Site of the NHS
say the benefits of the new 64-slice CT scanner – the first in Canada –
have been numerous since the unit went into full use in November 2004,
and include faster diagnosis of patients, earlier treatments and
discharges, improved image resolution and increased scanning speed.
A second 64-slice CT scanner went into operation at the NHS’s Greater
Niagara General site, in Niagara Falls, in March 2005, and it is
anticipated that wait times and throughput will also improve. The
Greater Niagara General site is the fifth healthcare facility in Canada
to acquire a 64-slice CT scanner.
“The tremendous speed of acquisition has made a difference in imaging
the sickest patients. For example, respiratory motion is no longer a
significant issue,” said Dr. Amit Mehta, acting chief of diagnostic
imaging at the St. Catharines General Site. “The improved throughput has
allowed for the faster diagnosis of both inpatients and ER patients,
thus allowing for earlier discharges or treatments.”
CT is a versatile modality which provides important clinical information
on a wide range of medical problems. In a general hospital setting, it
is used for cancer diagnosis, monitoring of cancer response to treatment
(surgery, radiotherapy, chemotherapy), imaging of traumatic injuries,
imaging of inflammatory or infectious diseases, vascular disorders, and
neurological disorders. The new scanners will continue to provide
information in the above conditions, but will do so faster and with
greater precision.
“Images obtained with the new scanners will contain more detailed
information because of improvements in image quality, “said Dr. Tom Li,
chief of diagnostic imaging at the Greater Niagara General site of the
NHS. “The new CT’s powerful computers also allow further manipulation of
the raw information into newer methods of displaying the information,
such as 3-dimensional reconstructions. The newer methods of image
display will not only improve the radiologist’s ability to correctly
diagnose conditions, but will allow other specialists to easily
recognize and understand conditions that they have referred their
patients for.”
Faster scanning speed not only increases throughput, but also addresses
problems encountered with patients who cannot remain still for long
periods of time, moving body parts such as a beating heart, and the
challenges of scanning the rapid movement of injected intravenous
contrast material through blood vessels and organs.
The increased versatility and image quality of the new scanners will
lead to improvements in patient care by improving the diagnostic
certainty of tests and expanding applications into new areas not
possible with older technology.
The CT scanners, from Siemens, are used to provide diagnosis for a broad
spectrum of disorders covering the entire body. Routine studies include
the head, lumbar spine, chest, abdomen and pelvis. Musculoskeletal CT,
CT angiograms (of the carotids, Circle of Willis, chest, abdomen and
limbs) are also routinely performed.
This permits radiologists and technologists to avoid traditional
invasive diagnostic angiograms in a significant number of patients. The
unit is also used to perform CT-guided intervention, including biopsies
and percutaneous drainages with the use of the CT fluoro package.
BACK TO
CONTENTS LISTING
|
