Northern Ontario launches large-scale radiology network

By Jerry Zeidenberg

A new, computerized network for sharing medical images in Northern Ontario is expected to save many sick patients from car trips that are up to five hours long when they need to see radiologists at the region’s major hospital in Timmins, Ont.

Not only will the system eliminate uncomfortable and hazardous drives in harsh northern weather, but it will also result in faster medical diagnosis and treatments for patients, doctors say.

Nine medical centers are participating in the NORrad (Northern radiology) network, launched earlier this year, in an area of 150,000-square-kilometers that reaches as far as Moose Factory on James Bay. Other hospitals are located in Hearst, Kapuskasing, Kirkland Lake, Cochrane, Iroquois Falls, Matheson, and Smooth Rock Falls.

There are only two radiologists serving this territory, and both are based at the Timmins & District Hospital.

In the past, when patients turned up at a remote hospital emergency room with complicated ailments, the local ER physician was unable to obtain a diagnosis from a radiologist because there was no way to send high-quality images to Timmins.

As a result, doctors would often send patients directly to Timmins – by car or air ambulance. Patients would receive the attention of radiologists, but the process could take hours.

However, with this year’s installation of the NORrad Picture Archiving and Communications System (PACS) – said to be the largest medical imaging network in North America – images can be sent over high-speed telecommunications lines, while the patients remain in their hometowns.

Radiologists in Timmins can receive the pictures in seconds, make sense of them, and report back to doctors in Moose Factory, Cochrane and other centres – all at the touch of a few computer keys.

“This means we’re moving the patient’s information instead of the patient,” said Dr. Claude Vezina, director of diagnostic imaging for the nine hospitals making up the NORrad network. “It’s a huge benefit, because a family doctor in a small center suddenly has access to a radiologist 24 hours a day, 365 days a year.

“If something doesn’t look right with a patient, the physician can send images to us in Timmins,” said Dr. Vezina. “Actually, if we want, three or four physicians can view the images at the same time on computers, all in different places, to determine what’s wrong with the patient and to decide on the best course of treatment.

“In the end, it often means the patient can stay where he or she is,” said Dr. Vezina, which saves the patient a good deal of time, worry, and the expense of the trip. And as a result of the quick feedback from radiologists, treatment of the patient can also begin much sooner.

NORrad is the result of four years of planning and fund-raising. It’s a $10 million project, with money chipped in from the federal and provincial governments, along with hospital budgets.

The partners evaluated several systems, but decided on PACS technology from Agfa Inc., of Toronto. Interestingly, Agfa’s PACS software was developed by a company it owns in Waterloo, Ont. Sold worldwide, the Canadian-designed technology has made Agfa a leader in the fast-growing medical imaging marketplace.

Indeed, a study conducted by Toronto-based Canadian Healthcare Technology magazine in 2001 discovered that while only 15 percent of Canadian hospitals had a PACS network last year, 48 percent said they would have one by the end of 2002.

Sending computerized medical images over long distances – such as in Northern Ontario – is much easier when high-speed telephone lines are available. Dr. Vezina noted that Northern Telephone Ltd. recently upgraded its lines in the region to include high-capacity ATM capabilities, largely to accommodate the needs of the medical community and their plans for sending and receiving big diagnostic imaging files.

Without high-speed lines, a medical imaging system can sputter to a crawl when trying to process large picture files.

A layperson might wonder why specialized PACS software is needed for storing and transmitting medical images, when it seems a standard database might do the job.

Brian Fullan, informatics business manager for Agfa, explained that the software contains many features that make it easier for radiologists to conduct their work.

For example, when the radiologist in Timmins receives a patient file on his computer, the PACS network will automatically query a centralized image archive containing hundreds of thousands of pictures to retrieve the patient’s previous images – called studies – for comparison.

This way, the radiologist can compare current X-rays, ultrasounds or MRI scans with those taken three months ago or even a year ago. He or she can more easily determine if there have been changes in anatomical structures – such as improper healing or the emergence of tumours.
“This pre-fetching of images eliminates hours of searching on databases for the radiologist,” said Fullan.

Moreover, the PACS software contains dozens of specialized tools for viewing images on workstations, including the ability to display multiple images, to zoom-in and out on structures, and to adjust the contrast. As well, there are different tools for various types of exams – such as X-rays, MRI, ultrasound and CT.

Each of the nine participating hospitals will receive an Agfa IMPAX medical imaging system, as well as computed radiography technology for automatically converting X-ray images to digital format.

Other medical imaging scanners, such as ultrasound, CT and MRI, are all based on computerized technology and mesh well with PACS systems.

However, X-ray systems have traditionally used cameras and film. Agfa’s computed radiography system replaces the film, and converts the X-rays to digital format, making the images ready for storing and transmittal on computerized networks.

According to Agfa, the hospitals will also receive specialized workstations for viewing images. While any computer monitor can display the pictures, the workstations will offer much higher resolution and more tools for reviewing and analyzing medical images.

According to Dr. Vezina, the advantages of NORrad have attracted the attention of other hospitals in Northern Ontario, and plans are now being made to expand the network to include additional medical centres.

He stressed that the technology is helping to dramatically improve the quality of care for patients. “NORrad will reduce the barriers created by geography, so that the level of care will be closer to that provided in Ontario’s urban centres,” said Dr. Vezina.

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Hybrid technology helps diagnose patients earlier, more accurately

By Neil Zeidenberg

LONDON, ONT. – St. Joseph’s Health Care, a teaching hospital, and the Lawson Health Research Institute have together acquired Canada’s first machine that combines PET and CT technologies. By amalgamating the two systems, doctors can acquire scans that contain more information than before, enabling them to see and diagnose diseases much more accurately.

“We are very excited to be the first hospital in Canada to provide this type of diagnostic technology,” said Cliff Nordal, CEO of St. Joseph’s Health Care. While there are many CT scanners in Canada, there are only about a dozen PET machines scattered across the country, and no others that actually use the two technologies together to create a single picture.

By way of background, CT technology produces a type of X-ray image that shows physicians the structure of bones and tissue in the body. PET technology, on the other hand, shows metabolic differences in the body, and requires doctors to inject traces of radioactive isotopes into the bloodstream.

These isotopes are attached to sugar molecules, which are absorbed more quickly by fast-growing cancer tumours, for example, than by healthy tissue. As a result, the PET scanner will detect a burst of radioactivity at the site of the tumour, thereby allowing doctors to determine the location of the problem and a course of treatment.

Many radiologists believe that merging the two types of pictures – actually superimposing one on top of the other – provides a powerful tool for diagnosing and treating cancer, heart disease, and a host of other ailments.

Initially, the machine at St. Joseph’s Health Care will be used in research trials. These tests will involve oncology, cardiac and neurology patients, and will be used also to develop a reimbursement structure for doctors and the operating costs for the machine.

The PET/CT scanner, called the Discovery LS, was provided by GE Medical of Mississauga, Ont. The system incorporates GE’s LightSpeed CT Plus with its Advance NXi PET system.

The device captures a patient’s functional and anatomical information in a single examination. At sites in the United States which have both CT and PET scanners, this information typically requires multiple procedures, in separate machines, that are performed over days or sometimes weeks.

Using the new system, however, the patient first receives a CT scan, a procedure that takes roughly two minutes. Next, a PET scan is performed and completed in about 20 minutes. Finally, within five minutes, the two images are fused together to create a 3D image.

This all takes place with the patient housed in a single machine.

“We’ve cut the procedure times down from between one-to-two hours to about 25 minutes, a dramatic improvement,” said Tom Hook, general manager, functional imaging, at GE. “The result is less movement by the patient, hence better accuracy.”

In CT and PET scans, the less the patient moves, the less blurring in the image produced.

According to Hook, test results on patients have been excellent. The ability to pinpoint the exact location of tumors in the body has improved by 60 percent, and diagnosis of the type of lesion has improved by 40 percent. Moreover, hybrid scans can alter the course of treatment and management of cancer patients in one of three cases.

“It’s very helpful to know exactly where that cancer is. You may have a sense of its location with a CT, though not all tumors are cancerous. And not all cancers are clearly positioned by PET alone,” said Nordal. “By having a clear and accurate picture, it should really help the surgeon determine how exactly they’re going to proceed during the operation.”

For the patient, it means potentially fewer invasive procedures and unnecessary surgeries, reduced anxiety, and shorter examination times. For the physician, the combined image can provide more information more quickly, leading to fast, accurate diagnosis, treatment planning and treatment monitoring.

Currently, patients in London must travel to Hamilton to receive PET scans and then return to London for their CT scans. The trouble here is that the radiologist or oncologist would then superimpose the images together in their minds, since they’re done at different times. As a result, the images may not be calibrated identically, which can lead to inaccuracies. However, the new, hybrid technology eliminates these problems.

“It’s an interesting technology,” Nordal said. “I think this is the area where scanning is moving forward for certain types of work. Certainly brain scans, cardiac and cancer will be the top three areas that this will be used.”

A cyclotron, which is needed to manufacture the radioactive isotopes necessary to perform PET scans, is currently located at McMaster University in Hamilton. However, London will eventually have its own cyclotron, thereby giving it rapid access to radioactive isotopes.

According to Nordal, cyclotrons are becoming much smaller and compact and don’t require nearly the space and resources that they did decades ago. “They are becoming instruments that are more affordable and will be required as PET/CT scanners are licensed in various academic centres across the country.”

Though exact numbers were not disclosed, the price of the Discovery LS is upwards of $5 million and includes some very powerful software to help operate the scanners. The software platform, called eNTEGRA, allows for preventive, predictive and corrective maintenance of the scanner online from a remote center.

At the time this story was written, 65 Discovery LS hybrid scanners had been installed throughout the globe, though 100 have been sold.

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Intranet-based e-Learning strategy developed at Atlantic Health Sciences

By Anne Kilfoil

In these times of reduced resources and increased demands, the Atlantic Health Sciences Corporation (AHSC), like most other Canadian healthcare institutions, has explored options to improve learning opportunities for its staff. The launch of the AHSC corporate Intranet in 2000 offered an opportunity to meet this challenge through the introduction of web-based learning.

The AHSC Intranet provides the infrastructure to effect internal business advantages, acting as a single entry point for access to existing legacy databases and systems and enabling business processes, knowledge sharing and access to just-in-time information. The e-learning strategy is an integral component of the AHSC Intranet’s overall goals and directions.

The AHSC e-learning strategy aims to provide:

• 24/7 access, especially relevant in a hospital environment

• equal access across AHSC’s multi-site, geographically widespread region

• just-in-time, on-demand learning for busy staff unable to attend scheduled classroom training

• a cultural shift in empowerment of users (i.e. ‘pull versus push’ )

• the ability to illustrate systems relationships by hyperlinking related resources, such as corporate policies and other business applications

A registration process is built into each learning program. Participants are prompted for online registration only after successful completion of the learning quizzes. This registration data is automatically submitted to a training database. Periodic reports are compiled and sent back to managers to facilitate monitoring of compliance with required learning programs.

E-learning initiatives are managed by the Department of Organizational Learning. To date, 20 programs have been developed, including blended clinical programs (advanced nursing competencies and delegated medical functions), management development and culture development (Ethics, Time Management, Presentation Skills), and required safety training (WHMIS, Codes Training).

Learning programs have been adapted to meet the requirements of individual programs – delivered as a 100 percent self-directed program, as a pre-requisite to classroom learning, or as a component of “blended” learning, which combines self-directed e-learning with a real-time or “virtual” classroom.

Getting Started: Following the positive feedback arising from a six-week Intranet pilot evaluation, an assessment of e-learning acceptance was initiated on two nursing units.

Conducted over a period of five weeks, this ‘Virtual Classroom’ pilot provided participants with a choice of five e-learning programs developed by a third party vendor. Surveyed on their interest in future e-learning opportunities at the conclusion of the pilot, 38 percent of participants said that they were very interested, 48 percent were highly interested, 13 percent were somewhat interested and 0 percent indicated no interest. Further assessment indicated that self-directed web based learning was preferred over classroom-based learning.

In addition to readiness, technical competence was also assessed. An organizational computer-literacy assessment indicated that potential users possessed the required skills to move forward. Basic web skills training opportunities are ongoing.

The first program introduced to the corporation was the WHMIS training program. Because WHMIS training is an annual requirement for all AHSC staff, it offered the greatest cost-benefit potential. Other programs soon followed. In addition to the 20 programs available to date, a dozen more are currently in development or undergoing pre-launch user testing.

Resourcing: The Learning Facilitators, trained adult educators, developed competency in e-learning program design and management through self-directed reading and attendance at conferences. One facilitator, Barbara Mannette, received certification in web based training and acts as the e-learning facilitator.

There is a full time web developer dedicated to facilitating e-learning and a partnership with the New Brunswick Community College and other training institutes to provide ‘work experience’ opportunities to web design students.

Front Page is used as the development tool. Because most of the PCs in the organization are not equipped to accommodate multimedia, we are not incorporating streaming at this time.

Almost half of all e-learning programs are developed in partnership with a clinical or subject specialist ‘content owner’. The content owner is responsible for the currency and accuracy of the information presented. The e-learning facilitator develops the program, working with the web designer. In most cases, Organizational Learning staff also act as ‘content owners’.

While the department explored the option of purchasing web-based learning programs, it decided to develop its programs in house. This decision was reached following a cost-comparison analysis that indicated greater efficiencies could be realized at AHSC with in-house development.

It also allowed for customization of the programs with regards to integration of organizational policy, values and culture, and, hyperlinking with other Intranet resources such as policies. In-house development is not cost-efficient in every case, however. Economies of scale require minimum participant numbers to realize the cost benefit.

Evaluation: All e-learning programs are beta tested for content and navigation for six weeks by the e-learning facilitator, utilizing online feedback methods.

Some programs are also subjected to focus-group testing. Again, feedback is encouraging, as 91.5 percent of users rated navigation of the e-learning programs as ‘excellent’ or ‘good’.

Anne Kilfoil is Project Lead, AHSC Web Applications and Director, Organizational Learning.

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Researchers’ model for wireless medical computing offers many benefits

By Dianne Daniel

KINGSTON, ONT. – Researchers at Kingston General Hospital and Queen’s University have created a model for wireless, medical computing that not only saves time and money, but also improves charting timeliness, order tracking and prescribing, drug error and data collection.

“One pilot project shows we can collect 30 percent more data in a standardized format in a third less time, so that means technically, I can see more patients,” said Dr. Goldstein, medical director of the two-year-old Queen’s University Anesthesiology Informatics Laboratory (QUAIL) project.

Dr. Goldstein, an anesthesiologist and professor in the Departments of Anesthesiology and Surgery at Queen’s, said: “At a time when doctors have no time, no money, no beds and no resources, anything we can do to be more efficient is paramount.”

The QUAIL project originated as a peri-operative anesthesia acute pain study, with the aim to create a database of crucial patient information that can be accessed by nurses, pharmacists, anesthesiologists and physicians at various stages of a patient’s surgical treatment using a secure wireless infrastructure supported by various mobile devices.

Working closely with hospital staff, researchers have developed wireless point-of-care clinical applications in the areas of Patient Self-Assessment, Pre-Operative Consultation, Intra-Operative Monitoring and Post-Operative Care.

For example, patients participating in a QUAIL study were asked to fill out self-assessment questionnaires prior to surgery using either a PC in their surgeon’s office, a laptop, personal digital assistant or large tablet kiosk, creating electronic files that were stored in a central server at the hospital.

When those same patients arrived at the Consult Clinic days, weeks or months later, their personal information was automatically available via handheld devices to the clinic nurses and pharmacists who performed the pre-operative assessments using handhelds at the bedside to update the computerized files with the new information – all of which was later available to the anesthesiologist, simply by scanning a patient’s barcode bracelet or entering their hospital ID number on a PDA.

“So when I ask my questions, I don’t ask the first questions anymore,” notes Dr. Goldstein. “In other words I wouldn’t ask ‘Do you have high blood pressure’, because the patient would answer that themselves on a Web-based device. And I wouldn’t ask ‘Is your pressure well controlled or what medications are you on’, because that would be asked by the nurse and the pharmacist. What I would ask is ‘Have you ever had any problems with high blood pressure resulting in stroke or heart attack?’”

Then, during surgery, the same pre-operative assessment information automatically populates software called the Automatic Record Keeper, alleviating anesthesiologists of the pain-staking task of recording such information by hand. The Automatic Record Keeper is also linked to the anesthetic machine, so that physiological variables like heart rate, blood pressure and temperature are automatically downloaded to the patient record as well, which is integrated to the hospital’s main network including lab, pharmacy, imaging and operating room booking software.

According to Dr. Goldstein, quicker access to more accurate information not only helps anesthesiologists develop better strategies related to which anesthetic to use on which patient – ultimately leading to pain-free recoveries with little or no side effects – but will also help to create best practice, evidence-based approaches to peri-operative pain management in the future.

The intent is to create a wireless model that can potentially be used by any hospital, with the hope of creating one large database QUAIL refers to as the Portable Health Intelligence Network. While the goal is to remain technology-independent so that QUAIL-developed applications will work on any device under any operating system, the model currently in place at Kingston General uses wireless access points from Avaya Corp., Compaq iPAQ Pocket PCs from Hewlett-Packard Co. and the Windows CE operating system from Microsoft Corp.

“The informatics laboratory is a research-based group that’s looking at possibilities for introducing wireless technology into healthcare settings through the use of PDAs,” says Dr. Goldstein. “What we’ve shown is a model that’s tested for use by the acute pain service at the Kingston General where patients can benefit from the use of PDAS in a wireless environment.”

Other areas currently being investigated by QUAIL include using wireless information to improve the treatment of stroke patients, as well as to create better communication channels between palliative care doctors and community workers like the Victorian Order of Nurses.

The hope of the researchers is that other hospitals will begin to take note of the work being done, and will begin to investigate handheld technology for their own purposes.

For its part, Mount Sinai Hospital, in Toronto, is one facility conducting several different studies, primarily in the areas of critical care and respirology, in an effort to find out what information doctors find useful on a handheld computer and what format is most effective for delivery of that information.

“There are a lot of people out there (in healthcare) using handhelds,” says Dr. Stephen Lapinsky, associate director of the intensive care unit (ICU) at Mount Sinai Hospital in Toronto, who estimates somewhere between 30 and 50 per cent of physicians currently carry some type of PDA. “We believe it does help them, but it would be nice to have the data to prove it.”

One study, co-sponsored by the Ontario Hospital Association Change Foundation and Bayer Pharmaceutical Co., involves the intensive care units of four Toronto hospitals in an effort to ascertain whether or not mobile access to reference information actually improves patient care. Under the study, critical-care doctors at the four sites are being supplied with handheld units and given access to a critical-care database created and maintained by Mount Sinai.

As Dr. Lapinsky explains, the intent is for doctors to connect to the Internet before beginning critical-care rounds in order to download the latest information from the database, including up-to-date information on unusual diseases and management guidelines. Mount Sinai researchers will then run case scenarios in a simulated environment to determine whether access to the information ultimately impacts patient care. While the premise is the handheld computers will ultimately lead to better care, Dr. Lapinsky is quick to point out that isn’t always the case.

“It all sounds very good and there’s a lot of hype out there that this is the way to go, but we have found some challenges,” he says. “Not everyone finds this is optimal for them.”

According to Steve Goldberg, a management consultant with INET International Inc. of Thornhill, Ont., one of the significant challenges as hospitals move forward with efforts to implement handheld technology is getting collaboration from all interested parties, including physicians, research centres, government associations, IT management and IT manufacturers, so that any new handheld implementation will complement existing mobile strategies.

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