New centre aims to accelerate interventional radiology

By Jerry Zeidenberg

TORONTO – The Hospital for Sick Children has launched the Centre for Image Guided Therapy, a facility where interventional radiologists and other experts will have quick access to a variety of medical imaging modalities – all in the same room, without moving their patients.

The $20 million centre is expected to result in better treatment for children, who can be imaged and have certain types of minimally invasive surgeries performed all at once. This combination of imaging and surgery is a rapidly developing branch of medicine known as interventional radiology.

For example, a child with a suspected tumour could be wheeled into the centre to receive a diagnostic CT scan followed by a biopsy conducted under image guidance, either with ultrasound, CT fluoroscopy or through laparoscopic surgery. At the same time, a central venous line would be inserted using imaging techniques.

In one fell swoop, the patient gets three different procedures. He or she can then begin to receive treatment for the cancer earlier, instead of waiting for each procedure to be scheduled and performed separately.

It’s one-stop shopping,” commented Dr. Peter Chait, the pediatric interventional radiologist who heads the new centre. Dr. Chait explained that imaging and operating on a patient at the same time can significantly improve outcomes.

In particular, trauma patients who arrive in serious condition shouldn’t be moved much. At the Centre for Image Guided Therapy, they can receive several different diagnostic scans to determine the nature of their injuries.

Surgery can even be performed on the spot – using minimally invasive techniques or open procedures – since the centre has been built to meet operating room standards. This can all be done without moving the patient.

The Centre for Image Guided Therapy is the first facility of its kind in Canada – and perhaps the world – to bring so many imaging modalities to one room and to provide the opportunity for surgery at the same time. Dr. Chait notes that the Hospital for Sick Children has already been a world leader in interventional radiology and conducts some 3,000 to 4,000 procedures a year.

Moreover, he predicts the numbers will quickly increase.

To make it all happen, specialists from several disciplines within the hospital will work together. They include radiologists, surgeons, ‘endoscopists’ and anesthesiologists.

The centre consists of four rooms for imaging and surgery. Three of them will support multi-modality imaging.

A ceiling-mounted fluoroscopy machine, supplied by Toshiba of Canada Ltd., will be installed in each of the three rooms. The huge machines, with their dramatic C-arms, are traditionally floor-mounted. IGT has gone the ceiling-mounted route, however, to keep the floor clear for other equipment and medical staff.
What’s more, the Toshiba CT fluoroscopy machines are said to contain leading-edge features. They provide totally digital, real-time imaging – powered by charge-coupled device (CCD) technology. They’re also motorized, and ergonomically designed, commented Dr. Chait, making it easy for medical professionals to work around them.

State-of-the-art ultrasound machines will be incorporated into the imaging tables, instead of sitting alongside the patient – again freeing up floor space. “The ultrasound box will be built right into the table,” said Dr. Chait. “There will be no wires hanging out.” The special imaging tables are being designed and delivered by Toshiba.

What’s more, sub-second helical CT scanners – allowing rapid 3D reconstruction – will be rolled into the suites on rails. This means the patient doesn’t have to be shuttled out to a special CT suite – the work can be done right in the Centre for Image Guided Therapy.

A bank of four computer monitors will hang on each side of the patient table, enabling physicians to monitor images and to call up historical images from an archive. GE Medical is supplying a picture archiving and communication system (PACS).

A fourth room will contain a GE bi-plane angiography machine. The room will be dedicated to angiography and some interventional neuro procedures.

In the future, the centre plans to install interventional MRI scanners – enabling doctors to image their patients while conducting surgery. This can be useful in neurosurgery, for example, to determine the position of tumours and other lesions, and to ensure that as much as possible of an unwanted structure is removed.

Research will also play an important part at the centre. Doctors will test new interventional imaging therapies and measure the efficacy and economics of their solutions.

And because the Hospital for Sick Children is a teaching hospital with a mandate to spread its knowledge, the centre will use interactive video technologies to demonstrate the techniques that it is pioneering. This will include live video posted on the World Wide Web.

The Web site will enable children and their families to learn about the procedures. “This whole component involving children and their families is extremely important,” said Dr. Kevin Baskin, pediatric interventional radiology fellow at the hospital. “It makes them active in the process, instead of rendering them passive recipients of care.”

Dr. Baskin said the live video and Web site projects will also become valuable teaching tools for other hospitals and medical professionals: “They’ll allow other healthcare providers, either on-site or remotely, to learn about these developing procedures through real-time, collaborative interactions.”

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The Chatham-Kent Health Alliance: A model of innovation and cooperation

By Andy Shaw

Not every bankruptcy is a bad thing. One indeed helped launch what’s likely to be the country’s most advanced regional healthcare system. The thin-client based Chatham-Kent Health Alliance network will serve over 700 users and a wide-spread urban and rural population of 110,000 people in south-western Ontario. By spring of next year, the $12.9 million project will link up the Alliance’s two hospital campuses in Chatham, a 40-bed rural hospital, an outreach centre, a mental health clinic and a long-term care facility. It will also extend the network into patients’ homes through the Victorian Order of Nurses (VON). Next to come on line will be a pilot group of the area’s physicians.

But the project did not start out in such happy circumstances.

“We were on the verge of crisis in May of 1996 because the major systems vendor for two of our hospitals went bankrupt,” explains Jerome Quenneville, vice president of finance and corporate systems for the Alliance. “That left us with very little support. Just the few people we could take on from the vendor. We also knew that our systems were not going to be Year 2000 compliant. So we got the project under way then.”

Alliance CEO Bernie Blais, however, says the timing couldn’t have been worse: “We were and are capital poor and resource poor. So spending nearly $13 million on a hospital our size (about 250 beds all told) makes the project a very risky venture.”

Yet Blais’s experience told him it was worth the risk. His background includes years spent at senior levels with both British Columbia’s and Alberta’s ministry of health. There he took a direct hand in extending healthcare systems to serve far flung populations, despite cutbacks and other healthcare restructuring.

“As the healthcare system is restructured, the hospitals that will face up to its demands best are going to be the ones that are part of a regionally based, integrated system,” says Blais with conviction.

True to his view, Blais put the re-vamping of Chatham-Kent’s systems on hold when he first came East to take over the CEO reins in 1996. He had the project re-tendered to ensure that whatever was built could be plugged into from outside hospital walls. That ability to connect to others was fundamental, says Blais. “We didn’t want to get caught and realize later that we should have done it right from the outset.”

Now, adds Blais, all the region’s health agencies and providers can think about connecting to an information sharing system that was built for that very purpose. In the end, no matter what institution a patient is sent to in Kent County, he says, the system will be able to pass that patient’s data from one site to the other. Also, the project is aiming to develop high-speed, telemedicine links with its further flung referral centres in London, Ont. and elsewhere.

“That means we will be able to bring services into the community we don’t have now. We will improve the quality of life for people like our diabetics, or our cancer patients or our dialysis patients who now have to travel extensively to get follow-up care,” says Blais.

Such savvy has caught the eye and budgets of other officials. Ontario’s Ministry of Science and Technology gave the project a $1 million dollar boost through its TAP grants, specifically to integrate the VON’s home visits and the Copper Terrace long-term care facility. The Ontario Ministry of Health also selected Chatham as one of just five “primary care pilot project” sites in the province. The initiative’s aim is to wire-up the offices of general practitioners and other local doctors with regional systems.

Aside from Blais’s plug-in or perish dictum, the Alliance project team made two other clever decisions. They opted for thin-client hardware from Data General, a project partner, as well as for a regional software license from HBOC, another project partner. It all makes for an Alliance network that should be speedy, secure, economical, and readily expandable.

“The thin-client has a long list of advantages,” says Quenneville. “First of all it is very secure. There are no external disk drives on the terminals, for example, so there can’t be any unauthorized copying and downloading of confidential data. Also, because the data and the apps are stored centrally (on 12 fat Terminal Servers from Data General) the data is not really being transmitted to the terminal, just their images. So you can’t intercept the data either.”

Just as importantly, says Quenneville, stripped down thin terminals simplify use and speed authorized access. “A physician doesn’t need much computer knowledge at all to operate the terminal,” he says. “ And because it’s operating from the server, physicians can move from one terminal to another and no matter where they are, their screens will come up just how they’d left them at the last terminal.”

Those terminals are also a lot cheaper than the level of PC needed in a fat-client, thin-server environment. Quenneville says terminals can be added on to the Alliance WAN for about $2,200 each, less than half the cost of an appropriately powerful PC.

Also, adding on another software seat doesn’t add to costs.

“We negotiated a regional license with HBOC for the software,” says Suzanne Flett, the project leader and consultant from Healthtech Inc. of Toronto, a healthcare systems implementer. “So that means we can go to physicians or potential community partners and entice them to get on the network by saying, ‘Here’s the software you need and there’s no charge for it no matter how many people use it.’”

Most users are sure to care less about the technicalities of the network (a switched 10/100 to the desktop network with a collapsed backbone hooked to a gigabit Ethernet switch) than what it can do for them. Doctors can log into the system remotely from their offices without making any changes to their PCs, other than adding the free software.

From their homes, VON nurses can download their case load for the day and then troop out to their patients, toting the system’s ruggedized notebooks. In the hospitals, cart-born, wireless point-of-care devices will instantly update the patient’s clinical information, which then is immediately available to their remote doctors. To make this happen, Data General is integrating the wireless technology with the hospitals’ local area networks and with a wide area network encompassing all Alliance members.

For other regions contemplating similar systems, there’s a unique point worth noting about the partnership arrangement sustaining Chatham-Kent’s network – especially if they too are resource poor and far from IT hotbeds. Flett, the project leader from Healthtech (and the president of the 15-year-old firm) is not only implementing the network but will continue to manage and develop the system as the de facto CIO of the Alliance.

“We’re not in a full outsourcing relationship, we have a hybrid arrangement which I think is unique and a win-win for both parties,” says Flett. “The Alliance had a very small IS department, so we went to the market jointing and looked for additional staff. So now we have a department of 10 full-time people. Healthtech supplies the two senior people (Flett and a systems administrator). But the rest of the staff can be seconded to Healthtech projects in the future.”

“What this means for me is that I have a staff I know well, that I have worked with before and that I can call on. For them, it provides professional variety in their work. For the Alliance, the arrangement enables it to retain good IS people after implementation,” says Flett.

But as much as Flett and Blais may be proud of such innovative approaches, they remain realists about how far along the road of modernization the healthcare community has come as a whole.

“Our information systems in healthcare are absolutely terrible,” says Blais. “We may have good systems in hospital by hospital stand-alones. But when you compare us to other sectors such as banking, the connections between our institutions, our hospitals and other healthcare providers are very poor.

“You can’t amalgamate or think of bringing hospital systems together, when they are all on disparate systems no matter how good their individual technology is,” says Blais. “You need to use technology to integrate them into a region. That’s what the vision should be.”

Blais acknowledges it’s easier to see how that can be done in urban/rural communities such as the city of Chatham and its surrounding Kent County farmlands. “We already have good co-operation with all our partners and stakeholders. We’re not battling each other for resources and we have all the players at the table as part of our steering group. That makes it easier for us to provide a seamless continuum of care.”

It will also make it easier, adds Blais, to ensure the Alliance’s future. “I think a regional system such as ours will be a draw to at least the young generation of physicians coming out. They will be looking for up-to-date information system tools and we will have them. Given that kind of information-to-the-desktop available to them and given the lifestyle in a community of our size, I think they will find it a very attractive place to work and live.”

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Endoscopies could be replaced by a computerized technique

By Jerry Zeidenberg

TORONTO – Doctors in Canada and the United States are experimenting with ‘virtual endoscopy’, a technique that may eliminate the need for traditional, fibre-optic-based endoscopy.

That could spell a great deal of relief for many patients, since old-style, endoscopic exams require a flexible tube equipped with a viewing scope to be pushed down the throat, or up the rectum and into the bowels.

While endoscopic exams can spot cancerous lesions early and save lives, most patients dread going through with the procedures. People gag during bronchoscopies, despite being sedated, and a colonoscopy can be a painful, sloppy affair.

By contrast, with virtual endoscopy there is no poking or prodding. Physicians can use the latest generation of computed tomography (CT) scanners to take hundreds of images of the chest, abdomen or other areas of the body – all in just a few seconds.

After that, the patient is no longer involved. The physician can reconstruct the pictures as 3-D images on a computer screen, and ‘fly-through’ the organs to look for cancerous polyps and other problems – just as you might fly-through a computerized video game using a joystick.

In the last few months, Dr. Raziel Gershater, chief of diagnostic imaging at North York General Hospital, in Toronto, has been conducting virtual endoscopies on an experimental basis. He has peered into the bronchi, colons and arteries of patients, none of whom endured a conventional endoscopy.

Instead, Dr. Gershater collected CT images of the patients, and used new software from Algotec Systems Ltd. of Israel to transform the ‘slices’ into three-dimensional images.

The powerful Algotec software can ‘extract’ an organ – such as the colon – from the mass of structures captured in a CT scan. That means Dr. Gershater can separate the snake-like colon from the rest of the abdomen, and display it on the computer for close-up looks.

In some respects, says Dr. Gershater, a virtual endoscopy is technically better than the traditional technique. For one thing, an endoscopist with a conventional scope can only see in a forward direction – by pushing the flexible tube with its light and lens through an organ.

By contrast, a virtual endoscopist can go backwards and forwards, checking and re-checking structures, simply by ‘flying’ back and forth.

Moreover, it’s possible for a virtual endoscopist to examine tight narrowings in the bowel caused by various lesions – narrowings that sometimes prevent the conventional endoscopist from passing through.

“Conventional colonoscopy fails to examine the entire colon in 10 percent to 15 percent of cases, and it misses 10 percent of carcinomas in areas viewed,” said Dr. Gershater. “A safe, non-invasive method of detecting colon lesions, such as virtual endoscopy, is extremely attractive.”

And by using the computer, Dr. Gershater has a better idea of the exact location when he locates a lesion.

Flying through the bronchi of one patient – the thousands of tiny airways that line the lungs – Dr. Gershater commented: “A bronchoscopist might get lost in here.” On the computer screen, however, an arrow on a diagram of the lungs marked the spot he was currently viewing in the fly-through portion of the monitor.

Still, there are currently several limitations to virtual endoscopy. First, the resolution isn’t quite good enough to see very tiny polyps and lesions. Using CT scans, doctors have had good success in locating polyps – precancerous lesions – in the colon that are 1 cm or larger. There have been mixed results, so far, in spotting smaller polyps.

As a result, the technology will have to be further developed before physicians abandon fibre-optic endoscopy in favour of this electronic version.

“No one will do just a virtual endoscopy and nothing more,” commented Dr. Gershater. “We can’t see very small cancers or ulcers yet, but it seems probable that in the foreseeable future it will become a standard diagnostic test.”

Indeed, he’s confident that the resolution will improve. “I think it will get to the point where you can see everything.”

As well, when it comes to colonoscopies, the computerized image can’t yet tell the difference between a cancerous lesion and a small lump of feces that might have been left in the bowel. (Patients receiving a CT scan of the bowel must still drink a cathartic that clears the feces from the system, but the results are imperfect!)

Dr. Gershater stresses that virtual endoscopy is still in its infancy, and that a great deal of scientific testing must be done to compare the results with traditional endoscopy.

It appears likely that this work will be done, in the near future, given the potential benefits of virtual endoscopy.

Dr. Gary Glazer, chairman of the department of radiology at Stanford University in California, points out that colon cancer is a huge problem in the United States and Canada. Many deaths could be prevented, he said, if men and women had regular colon check-ups after the age of 50.

However, a colonoscopy is so uncomfortable that many people don’t bother going for an exam. “Compliance is poor,” said Dr. Glazer.

He believes that many more patients would comply if the exam were of the painless ‘virtual’ variety. Given that two-thirds of colonoscopies turn out to be normal, a virtual endoscopy could be used to screen out the normal patients. Those with abnormalities could go for a routine colonoscopy, so that doctors could get a better look at a potential lesion and take a biopsy.

Dr. Glazer noted that a group at Stanford – in a federally funded project – are researching virtual endoscopy. Several other groups at universities and hospitals – including the famed Mayo Clinic in Rochester, Minn. – are also investigating the technology.

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