feature report: wireless and mobile solutions – page 14 · an ai platform in the near future. she...

BY JERRY ZEIDENBERG

HAMILTON, ONT. – A ground-breaking project is underway atHamilton Health Sciences (HHS)to address a major medical short-

coming in Canada and around the world: toomany patients develop complications afterhaving cardiac and vascular surgery, andmany are re-admitted to hospital after they’redischarged home.

The SMArTVIEW remote-monitoringproject – which has attracted over $12 mil-lion in government and industry support –uses Philips wireless electronic devices tomonitor patients’ vital signs followingsurgery and alert healthcare providers of anyindications that the patient’s condition maybe declining. The system also enables hospi-tal-to-home virtual recovery support.

The project aims to monitor up to 600patients at HHS and in Liverpool, UK, at the

Liverpool Heart and Chest Hospital. Thesystem is unique in that it will monitor post-op cardiac and vascular patients, after theyare transferred to step-down units or surgi-cal wards in the hospitals, as well as at home,once they are discharged.

SMArTVIEW will continuously monitorthe post-op patients in hospital, 24/7, using

a variety of wireless electronic devices, to en-sure their vital signs are stable. If not, alertswill be generated and sent to nurses, whocan attend to the patients or escalate by con-tacting physicians or rapid-response teams.

Once they are discharged from hospital,usually after five or six days, patients willcontinue to be monitored, once a day, by

nurses using two-way video on tablet com-puters, and by devices capable of measuringvital signs, weight, and other metrics.

“There’s a real problem,” said Ted Scott,chief innovation officer at HHS. “After heartor vascular surgery, there’s a 6 percent to 8percent rate of complications, and NorthAmerican data show that up to 18 percent ofpatients can be re-admitted.”

As well, about 40 percent of these post-op patients experience unrelieved pain forup to three months. These are poor out-comes for patients, and they can lead tohuge costs for hospitals.

Scott compared the high rates of post-opcomplications with the low rates of problemsencountered inside the OR. “Complicationrates in the operating room are lower becausepatients are being closely monitored,” he said.

The idea of SMArTVIEW is to raise thelevel of monitoring once patients have left

SMArTVIEW project ready to go live this fall

CONTINUED ON PAGE 9

Ginni Rometty, CEO of IBM Corp., was the keynote speaker at the Healthcare Information and Management Systems Society conference inOrlando, in February. She focused on the importance of artificial intelligence, predicting that all healthcare organizations will need to choosean AI platform in the near future. She is pictured above in a post-keynote discussion with Stephen Lieber, CEO of HIMSS. SEE STORY ON PAGE 6.

AI takes centre-stage at HIMSS conference

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SMArTVIEW will monitor post-opcardiology patients in the hospitaland when they return home.

INSIDE:

NYGH continues to innovateNorth York General Hospital won aDavies Award earlier this year forits leadership in using IT to im-prove patient care. The hospitalhas an ambitious plan to continueinnovating and setting an examplefor others.Page 4

Excellence in stroke care Hospitals across Alberta have re-duced the time needed to diag-nose strokes and deliver potentially

life-saving tPA medication from anaverage of 70 minutes to just 36minutes – a startling reduction.They’ve done it partly by re-engi-neering workflow in hospitals. Page 4

Vaccine for cancer?Using high-powered computers inthe cloud and Deep Learning,NantHealth claims has created acancer vaccine that can be cus-tomized for individual patients.Testing starts this year.Page 6

Point-of-care scanningZebra Technologies has produceda new handheld barcode scannerand a mobile, ruggedized com-munication device that can be

readily disinfected. The two de-vices have a range of features de-signed to enhance patient care.8

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FEATURE REPORT: WIRELESS AND MOBILE SOLUTIONS – PAGE 14

CANADA’S MAGAZINE FOR MANAGERS AND USERS OF INFORMATION SYSTEMS IN HEALTHCARE VOL. 22, NO. 3 APRIL 2017

MEDICATIONMANAGEMENT

PAGE 10

BY ANDY SHAW

Feel trumped by political devel-opments south of the border?Concerned that what has al-ways been quick access to theworld’s largest medical device

market won’t be easy any longer? Wellthen, how about as an alternative, theglobe’s third largest medical market,Germany?

Ranked only below the USA and China,the Federal Republic of Germany is ready,willing, and able to help you sell to its 328billion euros-strong home market.

And so too are allied Canadian govern-ments, international trade organizations,and other agencies keen to help – speciallynow, since our North American free tradedeals may soon start to unravel with a newprotectionist President at the controls inWashington.

The urge to assist Canadian innovatorswith alternative market access was veryevident last fall in Toronto, when On-tario’s International Trade Branch, alongwith the federal government’s Trade Com-missioner Service, hosted a one-day semi-

nar detailing how and why you should en-ter the German healthcare sector.

What’s more, seminar attendees also gotinsiders’ tips on how best to enter thehome markets of all other EuropeanUnion (EU) countries.

Featured seminar presenter was Dr.Marcus Schmidt, head of healthcare forthe federally backed German Trade & In-vest (GTAI) agency, headquartered inBerlin, but with representatives in 14 citiesaround the world, including one inToronto – all at the ready to assist withGerman market entry.

For openers, Dr. Schmidt offered somequick facts about Germany’s healthcaremarket size and shape:

• Germany’s population, thanks in part torecent immigration, has risen to 82 millionpeople, making it Europe’s most populouscountry and biggest medical market.

• the value of serving all those “volks” isabout 11.3% of GDP, amounting to a mar-ket of 328 billion or about $465 billionCanadian. (This doesn’t account for whatGermans pay out of pocket for theirhealthcare, only insured care spending. Sothe market is actually bigger.)

• over the past 10 years, the market hasbeen growing annually at an average rateof about 3.5 percent.

• as with most other European countries,healthcare insurance is mandatory, so vir-tually all Germans are covered.

• about 9% of them, however, are pri-vately ensured at a higher cost, but withquicker access to care. Studies show that inGermany, as elsewhere, the use of privateinsurance increases with age.

• care is provided by just over 2,000 hos-pitals in Germany, but their number is de-clining as consolidation is merging smallerhospitals into larger ones.

• as in Canada, cost pressure on the health-care system is seeing more hospitals run pri-vately, accounting at present for 35% of allGerman hospitals and trending upwards.

• larger hospitals, including Berlin’s 3,000-bed Charité Hospital, the country’s largest,tend to be teaching hospitals that attract“influence leaders” to their staffs.

“We target 10 of the most influentialhospitals and so we help introduce would-be exporters to those ones in particular,”says Schmidt. “But we can also help makeintroductions to any other hospital in thecountry.”

Specifically, Schmidt points out, themedical devices market in Germany runsapproximately €33 billion, or close to $50billion.

As a net exporter of medical technol-ogy, German medical device companiessell roughly two-thirds of their productionto the rest of the world.

“So the medical device industry is a verysuccessful one for Germany,” says Schmidt.“But it’s important to note that over 90% ofthe companies in Germany doing most ofthe exporting are not giants like Siemens,but rather small to medium-sized compa-nies, most with 20 employees or less.”

That’s good news for potential Cana-dian exporters, since such smaller compa-nies are more open to joint ventures,shared research and development, andother forms of collaboration with like-sized and like-minded companies.

There’s also additional support avail-able, thanks to a history of mutually bene-ficial relationships between Canada andGermany. For over 20 years, for example,the Province of Ontario and the Germanstate of Baden-Württemberg (centredaround Stuttgart) have had a formal agree-ment in place that involves financial sup-port, co-operative research, even a studentexchange program.

The result is that more than 30 Ontariocompanies have set up businesses inBaden-Württemberg and a similar numberof German firms have done so in Ontario.

Though it is a major exporter, Ger-many nonetheless is a significant importerof medical technology. The value of theGerman import market for medical de-vices is about €10 billon or about $14 bil-lion. Of those imports, some 28% is fromNorth America.

In terms of German market demo-graphics, Germany has one of the globe’soldest populations, ranking behind onlyJapan. Schmidt reports that by 2035 al-most a third of Germany’s people will be65 years of age or older. So as elsewhere,demand for products and services con-nected with aging and consequentlychronic disease will grow steadily.

The annual MEDICA trade show, in Dusseldorf.

Help’s there for innovators seeking to expand into Germany and the EU

Art DirectorWalter [email protected]

Art AssistantJoanne [email protected]

CirculationMarla [email protected]

Publisher & EditorJerry [email protected]

Office ManagerNeil [email protected]

Address all correspondence to Canadian Healthcare Technology, 1118 Centre Street, Suite 207, Thornhill ON L4J 7R9 Canada. Telephone: (905) 709-2330.Fax: (905) 709-2258. Internet: www.canhealth.com. E-mail: [email protected]. Canadian Healthcare Technology will publish eight issues in 2017. Featureschedule and advertising kits available upon request. Canadian Healthcare Technology is sent free of charge to physicians and managers in hospitals, clinicsand nursing homes. All others: $67.80 per year ($60 + $7.80 HST). Registration number 899059430 RT. ©2017 by Canadian Healthcare Technology. Thecontent of Canadian Healthcare Technology is subject to copyright. Reproduction in whole or in part without prior written permission is strictly prohibited.Send all requests for permission to Jerry Zeidenberg, Publisher. Publications Mail Agreement No. 40018238. Return undeliverable Canadian addresses toCanadian Healthcare Technology, 1118 Centre Street, Suite 207, Thornhill ON L4J 7R9. E-mail: [email protected]. ISSN 1486-7133.

CANADA’S MAGAZINE FOR MANAGERS AND USERS OF INFORMATION TECHNOLOGY IN HEALTHCARE

Volume 22, Number 3 April 2017

Contributing EditorsDr. Sunny MalhotraTwitter: @drsunnymalhotra

Dianne [email protected]

Richard Irving, [email protected]

Rosie [email protected]

Andy [email protected]

Friday, April 28th, 2017 Doors open at 7:30am

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CALGARY – Alberta’s 17 stroke treat-ment centres are now among thefastest in the world in giving pa-tients the clot-busting drug tPA

(tissue Plasminogen Activator).Thanks to a year-long quality improve-

ment initiative, the average time it takesfrom a patient’s arrival at hospital to be-ing diagnosed with stroke and injectedwith tPA (known as door-to-needle time)has been halved from about 70 minutes to36 minutes.

An improvement of this degree andacross such a large geographical area hasnot yet been reported elsewhere in theworld. For example, a similar effort in theUnited States has seen average door-to-nee-dle times in participating hospitals drop 20percent, from 74 minutes to 59 minutes.

“For many years now, the acceptedbenchmark has been to treat patientswithin 60 minutes of their arrival at hospi-tal,” says Dr. Michael Hill, a Calgary-basedstroke neurologist and principal investiga-tor in a quality improvement and researchprogram, funded by Alberta Innovates,called QuICR (pronounced ‘quicker’),Quality Improvement & Clinical Research– Alberta Stroke Program.

“But we know that by doing better, wecan improve outcomes for patients by pre-venting or limiting long-term disabilities.And when we can give stroke patients bet-ter chances to fully recover, we also elimi-nate potential downstream costs to thehealth system,” says Dr. Hill, also a profes-sor in the Department of Clinical Neuro-sciences at the University of Calgary’sCumming School of Medicine and a mem-ber of the Hotchkiss Brain Institute.

During an ischemic stroke, in whichblood supply to the brain is blocked, abouttwo million brain cells die every minuteand about 12 kilometres of neural connec-tions are lost.

“One of the remarkable things that hashappened in Alberta in the past year is thatimprovements have been made by teamsin every stroke centre – not just the largehospitals in Edmonton and Calgary,” saysNoreen Kamal, project manager forQuICR.

“Staff in Fort McMurray, Westlock, RedDeer and smaller facilities like Grey Nunsin Edmonton have all rallied together andfigured out how to significantly reduce

their door-to-needle times – in some caseswith limited resources at their disposal.”

Covenant Health’s Grey Nuns Hospitalcurrently holds the provincial record forthe case with the fastest door-to-needletime, at six minutes.

“Successes like these have been drivenby staff on the front lines who worked to-ward a common goal,” says Dr. ThomasJeerakathil, an Edmonton-based strokeneurologist and QuICR co-lead for Qual-ity Improvement. “There are few other ar-eas in medicine where the concept of‘teamwork’ is more important.”

A patient who has had a stroke relies onthe efforts of a team, which includes para-

medics, emergency department nurses,registration clerks, diagnostic imagingtechnicians, stroke co-ordinators, emer-gency department physicians, radiologistsand neurologists. Behind-the-scenes sup-port from hospital administrators andmanagers in the emergency and diagnosticimaging departments is also critical.

Kamal, who brings a systems engineer-ing perspective to the task, says preciousminutes are saved when team memberswork in parallel rather than sequentially.

“A traditional clinical approach is tostep through necessary tasks one at a timeuntil a definitive diagnosis and treatmentrecommendation can be made,” she says.With QuICR, staff work concurrentlywhen possible. A lab technician mightdraw blood while the patient has a CTscan, while elsewhere a history is being col-lected from a family member and the tPAis being prepared.

“Improving the quality of stroke careprovince-wide has been made possible, inlarge part, through partnerships created andenhanced by AHS’ Cardiovascular Healthand Stroke Strategic Clinical Network,” saysDr. Kathryn Todd, Vice President, Research,Innovation and Analytics for AHS.

Laura Kilcrease, Alberta InnovatesCEO, congratulated the QuICR team forthe tremendous work they’re doing to im-prove outcomes for stroke patients.

“Alberta Innovates is proud to play anintegral role in supporting the QuICRteam. This type of innovative and outside-the-box thinking is critical and hasachieved meaningful results by improvingthe lives of stroke sufferers not only in Al-berta, but around the world.”

Innovative NYGH scoops up e-health award of excellence at HIMSSBY JERRY ZEIDENBERG

ORLANDO, FLA. – In Febru-ary, leaders of North YorkGeneral Hospital formallyaccepted a Nicholas E.Davies Award of Excel-

lence from HIMSS – the first-ever for aCanadian acute-care hospital. Only 50other hospitals around the world havewon a Davies Award, which is given toorganizations that have substantially im-proved patient outcomes using comput-erized healthcare systems.

NYGH was recognized for its multi-faceted eCare program – which amongother achievements, has prevented an es-timated 11,000 medication errors.

But the Toronto-based hospital isn’tabout to rest on its laurels.

Indeed, it’s on a multi-year drive forto further improve healthcare outcomesand enhance patient satisfaction. Thatincludes an investment in new systems.

“We’re looking at the next generationof applications, and continued refreshingof our infrastructure,” said NYGH’s chiefinformation officer, Sumon Acharjee.

Part of the plan is to upgrade fromthe hospital’s current Cerner CareMobilesystem to a modern, multi-use system

that can work with smarter and more in-tegrated devices. The goal is to improveaccess to information for cliniciansthrough the use of mobile solutions.

Acharjee was in Orlando, Florida withhis colleagues to receive the DaviesAward at the Healthcare InformationManagement and Systems Society(HIMSS) annual conference.

Not only does the team at NYGHplans to increase its HIMSS EMRAMstanding, in 2018, from Stage Six to Seven– the top tier. It also intends to reach ahigh standing in the HIMSS Continuityof Care Maturity Model (CCMM).

The Continuity of Care MaturityModel goes beyond Stage 7 of the Elec-tronic Medical Record Adoption Model(EMRAM). This newer model, whichalso has eight levels, addresses issues likeinteroperability, information exchange,care coordination, patient engagementand analytics.

It’s designed to improve communica-tions and interoperability both insidethe hospital and with care partners andpatients outside the walls of the facility.

To reach CCMM Stage 4, for example,you’ve got to have care coordinationthat’s based on a ‘semantic interoperablepatient record’. The requirements include:

• Shared care plans that track, update, taskcoordination with alerts and reminders.

• E-prescribing. Pandemic tracking andanalytics are in place.

• All care team members have access toall appropriate data.

• Semantic data drives actionable clini-cal decision support and analytics.

Stage 5 requires a community-widepatient record that includes patient en-gagement. Components include:

• Community-wide patient record withintegrated care plans and bio-surveillance.

• Patient data entry, personal targets,alerts are available.

• Patient data aggregated into a single co-hesive record. Mobile tech engages patients.

• Community wide identity management.

• Best clinical practices are derivedfrom care community healthcare dataand operationalized across the commu-nity (continuous quality improvementand adaptation).

NYGH is already a national leader inareas like order sets – it makes use of ev-idence and collaboration tools fromZynx to enable clinical adoption, but hascustomized them in accord with Cana-dian and regional practices. It is also aleader in Computerized Provider OrderEntry – 97 percent of physicians at thehospital currently use CPOE.

The hospital’s eCare system alsomakes use of closed-loop barcoding formedication reconciliation – somethingthat greatly reduces the chance of pa-tients receiving incorrect meds or doses.

The system offers point-of-care deci-sion support, and can transfer data frompatient monitors directly into the elec-tronic medical record.

Thanks to solutions such as these, theodds of dying at NYGH from commonconditions such as pneumonia orchronic obstructive pulmonary diseasehave dropped by as much as 53 percent.According to the hospital, this representsan estimated 120 lives saved from thesetwo health conditions alone.

Calgary neurologist Dr. Michael Hill talks with patient, Ian MacNeill, about the stroke treatment he received.

The NYGH team received a Davies Award at HIMSS.

Alberta’s stroke teams slash time taken to diagnose and treat patients

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BY JERRY ZEIDENBERG

ORLANDO, FLA. – IBM’s WatsonHealth is releasing its first com-mercial product, Watson Imag-ing Clinical Review, which uses

artificial intelligence and analytics to rec-oncile cardiology reports with electronicpatient records. In this initial offering,Watson Imaging Clinical Review will en-sure that diagnoses of aortic stenosis,when made by cardiologists, are also trans-ferred to the patient’s electronic healthrecord and problem list.

Aortic stenosis is a narrowing of the aor-tic valve, which can constrict blood flow andcause shortness of breath and chest pain; anestimated 1.5 million Americans currentlysuffer from this affliction.

By assuring that the finding is in the elec-tronic record, the system helps make thefinding known to all clinicians and reducesthe chance that the problem is overlooked oruntreated.

The ability to reconcile records for aor-tic stenosis is the first in a series of cardiol-ogy problems that Watson Imaging Clini-cal Review plans to release. There are nineothers in the works, including myocardialinfarctions (heart attacks), valve disorders,cardiomyopathy (disease of the heart mus-cle), and deep vein thrombosis.

Another product in the works at Wat-son Health is a clinical summary systemthat pulls information from a variety ofsources for radiologists and cardiologistswhen they’re conducting a study. For ex-ample, if a radiologist is checking for heartdamage, the system will automaticallysearch through the patient’s records formedications, lab reports and previous DIreports for relevant information. Thissaves the clinician a good deal of time.

Another work-in-progress – one of themost exciting ones – is a Deep Learningsystem that can analyze diagnostic imagesand collate the information with other in-formation, such as the patient history, labresults, medications, etc., to come up withits own diagnosis. IBM demonstrated aversion of this system at the Healthcare In-formation Management and Systems Soci-ety (HIMSS) conference in Orlando; whendiagnosing an aortic dissection, the systemused images and data to produce a diagno-sis with a 95 percent confidence level.

All of these system are designed to serveas intelligent assistants to radiologists, car-diologists and other clinicians. They canact as decision support tools and help-mates that source out information thatwould otherwise be time-consuming forthe clinicians to fetch.

In his opening remarks to the conference

attendees, Dr. Michael Zaroukian, HIMSSchairman and CMIO of the Sparrow HealthSystem in Michigan, said that clinicians to-day are in serious danger of burnout.“Much of it is due to the paperwork bur-den,” he said. “There is no joy in that.”

Tools like those being produced by Wat-son Health are capable of reducing the pa-perwork and low-level tasks that physi-cians are being required to perform today.

In a panel discussion on how WatsonHealth is being used at various hospitals,Dr. Tufia Haddad, an oncologist at theMayo Clinic, in Rochester, Minn., observedthat she and her colleagues are spending upto 50 percent of their time searching for in-formation. “We need to get the time back tospend with patients,” she said.

She noted that in screening patients forcancer trials, staff using Watson Health havereduced the process to eight minutes from

the 30 minutes it took previously. “We’rerunning 57 different clinical trials, and Ican’t remember all of the eligibility specs.”However, a system like Watson Health can,and it can apply the specifications to variouspatients and their particular requirements.

Dr. Haddad noted that in many cases,patients don’t enter trials because theydon’t know they’re available. A computer-ized system, like Watson, can easily matchpatients with appropriate clinical trials.“Some trials don’t launch because we don’tget good candidates,” said Dr. Haddad.

Chris Ross, the CIO of the Mayo Clinic,observed that during his tenure he has wit-nessed the amazing increase in the powerof computers.

But it’s not just the hardware that’s con-tributed. “They systems are something like43 million times faster than they were in2003. It’s not just Moore’s Law at work (theconstant improvement in computerchips). It’s more to do with smarter algo-rithms.”

In her keynote address at HIMSS, IBMCEO Ginni Rometty asserted that the ap-plication of AI to healthcare is the modernday equivalent of the 1960s moonshot.“We can transform medicine,” she said.“It’s within our power.”

Watson, she noted, is being used to findnew medications and to advance precisionmedicine and genomics. It is also being usedto screen patients for cancer in the develop-ing world.

“In India there is one oncologist for every16,000 patients,” she said. “So WatsonHealth is rolling out across India, China andother developing economies.”

Rometty observed that Watson Healthwill not replace physicians. Instead, it will“augment what humans do, it will aug-ment their intelligence.”

NantHealth says cloud and AI have enabled it to produce a cancer vaccine

ORLANDO, FLA. – While IBMand its Watson Health di-vision have been vocalabout their plans to trans-form healthcare through

Deep Learning, NantHealth has beenquietly assembling its own platform thatuses artificial intelligence to combat oneof mankind’s worst healthcare problems– the scourge of cancer.

At the February Health InformationManagement and Systems Society(HIMSS) conference in Orlando,NantHealth CEO Dr. Patrick Soon-Shiong– a billionaire through his developmentand sale of pharmaceuticals – gave a pre-sentation in which he detailed the com-pany’s creation of an AI processing en-gine, cloud systems, and high-speed fibreconnecting the platform to cancer centres.

The system is able, said Dr. Soon-Sh-iong, to collect the genomic and pro-teomic data of cancer patients in real-time. It can process the information usingits own database, said to be the largest ge-nomic database of cancer patients in theworld, and then prescribe therapies basedon the patient’s individual cancer.

The precision-medicine therapy sys-tem is called GPS, and NantHealth has re-cently launched it, said Dr. Soon-Shiong.

It has enabled the company to pro-duce a customized vaccine for cancer pa-tients, which is going to be made avail-able this year. “2017 is the year we willimplement the Nant cancer vaccine,”said Dr. Soon-Shiong.

According to the company, GPS Can-cer is a unique molecular profile per-formed in the labs of NantOmics. It inte-grates whole genome (DNA) sequencing,whole transcriptome (RNA) sequencing,and quantitative proteomics to provideoncologists with a comprehensive molec-ular profile of a patient’s cancer to in-form personalized treatment strategies.

Dr. Soon-Shiong acknowledged thereare plenty of skeptics questioning thecompany’s ability to deliver such a mira-cle drug. While Dr. Soon-Shiong played avideo in which doctors and patientslauded the GPS system and the medica-tions that have put their tumours into re-mission, critics have noted NantHealth’slack of peer-reviewed studies.

Nevertheless, Dr. Soon-Shiong said

the company will be going forward withits own plans. “This will change thecourse of cancer,” he asserted.

He said the company is working with170 oncologists in the United States, and

25 health plans. They are feeding patientdata into the NantHealth cloud.

NantHealth’s network, which in-cludes 390,000 miles of high-speed fi-bre, is capable of processing largeamounts of data in seconds. “There are14 million cancer patients in the UnitedStates, with 1.7 million newly diag-nosed. The number of patient data you

must process each day is enormous.”NantHealth’s AI platform, called the

Medical Reasoning Engine, looks at ge-nomics, proteomics and imaging data, in-cluding spectroscopy and pathology. “It’sa learning system,” said Dr. Soon-Shiong.

By discovering “what the tumour issaying”, NantHealth can develop theright cancer vaccine for the patient. Thevaccine triggers the body’s own immunesystem to fight the cancer.

Dr. Soon-Shiong said the humanbody is producing cancer cells each day,as a normal process. However, at thesame time, killer cells regularly fight anddispose of the cancer cells.

It’s when the cancer outwits the im-mune system that tumours arise. TheNantHealth vaccine essentially re-trainsthe immune system to fight and conquerthe cancer cells.

But the right vaccine must be used,one that suits the individual and his orher cancer. “Cancer is an informationwar, which means we need to gather andharness all of your information in orderto stop this dreaded disease,” said Dr.Soon-Shiong.

After her keynote address, IBM’s CEO, Ginni Rometty, chatted onstage with HIMSS CEO Stephen Lieber.

Dr. Patrick Soon Shiong, NantHealth’s CEO.

Care-givers can use artificial intelligence systems as smart assistants


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BY JERRY ZEIDENBERG

ORLANDO, FLA. – Dr. Rueben De-vlin, the former CEO of HumberRiver Hospital in Toronto, led the

drive to create what his team calls NorthAmerica’s first digital hospital. The gleam-

ing new building, which opened in 2015,makes use of the latest technologies – alldesigned to improve workflow and en-hance medical outcomes.

But Dr. Devlin, now a consultant, is thefirst to advise hospitals to think lean – youshould initially work out the best way of

getting tasks done, and then add the ap-propriate technologies. “The tendency inhospitals is to add processes and technolo-gies,” he said. “But you should really be try-ing to simplify things.”

That’s what will really improve work-flow and productivity, he said.

He added that technological planningshould go hand-in-hand with leanmethodologies. “Don’t just put technolo-gies in at the front end,” he said. Instead,determine the smartest way of gettingwork done, and if they’re needed, then im-plement the right technologies.

Dr. Devlin was a speaker at the recentHealthcare Information and ManagementSystems Society (HIMSS) in Orlando, Fla.

One example of the planning HumberRiver did before opening the new hospitalwas to look at the impact a bigger facilitywould have on nurses.

A study discovered that nurses werealready walking 5.4 kilometres in a 12-hour shift. The bigger building would re-quire them to walk 11.6 kilometres – overdouble the distance.

A solution was found in the use of au-tomated guided vehicles (AGVs), essen-tially motorized platforms with wheels andcomputerized brains, which could deliversupplies, navigate hallways and even openand close elevator doors.

The AGVs are able to deliver 75 percentof the supplies in the hospital, savingnurses a lot of steps.

The hospital found another smart solu-tion in the use of Ascom wireless smart-phones, which have simplified hospitalcommunications and have also enhancedpatient safety. Working with Toronto-based ThoughtWire, which provided anintelligent platform, Humber River Hospi-tal deployed the phones so that cliniciansget alerts and calls on the smart devices.

That has eliminated much of the noisypaging and alerting that used to go on inthe hospital, and makes it much faster andeasier to send messages to the appropriateclinician. “The phones have eliminatedoverhead paging, which is loud and dis-turbs the patients,” said Dr. Devlin.

Moreover, it is a more efficient way ofcontacting clinicians.

“What might have taken five or sixphone calls in the past can be done nowwith one message on the smartphone,”commented Holger Cordes, CEO of Ascom.

Dr. Devlin noted the system is capableof assembling teams when Code Blues areinitiated – the alarms that calls togethercare-givers in the event of severe cardiac orpulmonary incident. However, he notedthat most of the alerts in a hospital are of anon-urgent nature – such as lab or MRI re-sults. Still, he said, it is important to getthem to clinicians in a timely manner.

He observed that clinicians are verypleased with the new communication sys-tem. “Physician satisfaction is up,” he said.

Creating a digital hospital, of course, isno small task. Dr. Devlin estimated thereare some 17,000 devices at Humber Riverthat are being integrated.

But he emphasized that anyone creat-ing an intelligent hospital must first do alot of work at the beginning to smoothout and improve the workings of the fa-cility. “You don’t want to digitize badprocesses,” he said.

For its part, Ascom at HIMSS an-nounced Unite Context, an integratedcommunication and collaboration plat-form that enables hospitals to bridge theinformation gap between back-end sys-tems, EHRs, and the front-end workflow.

Think lean before loading up on IT to improve workflow in hospitals

A gateway to integrated careWith the Agfa HealthCare Portal, hospitals can offer care providers, referring physicians and patients “anywhere, anytime” access to the patient’s health information, even from different sources. Taking the knowledge and experience it has built up with proven solutions that share images and other data, Agfa HealthCare is now extending it beyond the hospital walls, to eventually integrate all players in healthcare delivery.

To nd out more, visit www.agfahealthcare.com.

IT’S ALL WITHIN YOUR REACH…


the OR through the use of wireless, elec-tronic equipment.

To accomplish the task, a team at HHSworked for the past two years on the de-sign of the system and gained buy-in fromclinicians. Through open procurement,the team also assembled a group of ven-dors who created unique solutions for in-hospital and remote, at-home monitoring.

The key vendors include Philips andThoughtWire, which are contributinghardware and software for vital signs mon-itoring; QoC of Toronto, which has pro-duced an interface that promotes patientself-care; and XAHIVE, which is consult-ing on cybersecurity.

The inpatient monitoring software so-lution, known as Philips IntelliVueGuardian, is designed to detect patient de-terioration, send clinician validated vitalsigns from the vital sign monitoring de-vices to the EMR at the point of care, andto automatically alert clinicians if there isa change in patient status.

ThoughtWire’s intelligent platform isbeing used to automatically relay the alertsto the appropriate clinicians and teams.

The inpatient hardware consists of the vi-tal sign monitors and wireless measurementdevices. The outpatient monitoring solutionwill use the Philips eTRAC solution. TheeTrAC ambulatory telehealth program en-

ables clinicians and patients to stay closelyconnected during the transition to ambula-tory care for chronic disease management.

Recently, the SMArTVIEW developmentteam has been fine-tuning the alerts andworkflows that are a key part of the system.Dr. Michael McGillion, assistant dean of re-search at the school of nursing, McMasterUniversity and SMArTVIEW project leadinvestigator, explained that nurses havebeen involved in the testing of the solutionat Hamilton Health Sciences and the Liver-pool Heart and Chest Hospital.

They have been involved in high-fi-delity simulations where trained actorsplay the role of patients, while they learn touse the technology, on the hospital ward.

“They then debrief with us on the expe-rience and this allows us to optimize theconfiguration of our systems, as well as theworkflow,” commented McGillion.

During the actual SMArTVIEW trial,which will start in the fall, McGillion notedthat it is expected that over 80 nurses willbe involved from both countries, alongwith surgeons and clinical staff.

While other vendors and healthcare sys-tems in Canada have launched remote mon-itoring projects, Scott believes SMArTVIEWdiffers in its combination of in-hospital andat-home monitoring. He explained that

most post-op patients are not closely moni-tored for the five to six days they are recu-perating from surgery in the hospital.

In contrast, SMArTVIEW will providecomprehensive electronic monitoring instep-down units and surgical wards. Oncethe patient returns home, the monitoringwill continue with daily, virtual visits by anurse, who the patient will see on his orher Samsung tablet computer.

The patient will be able to discuss hiscondition, transfer vital signs, and alsosend photos of wounds.

In all, the patients will be monitored fora total of 30 days. “After 30 days, most ofthe danger is over,” said Scott.

He pointed out that patients recover-ing at home will be monitored by atrained surgical nurse, based in the hos-pital, who is familiar with surgical issues

and potential problems. In contrast, mostpatients convalescing at home are tradi-tionally visited by home care nurses whoare not necessarily trained to deal withpost-op pain, wound care and othercomplications.

The SMArTVIEW project has part-nered with the Liverpool Heart andChest Hospital, in the UK, as it is a centre

P.J. Devereaux (left) and Michael McGillion, co-princi-pal investigators of the SMArTVIEW research project.


SMArTVIEWCONTINUED FROM PAGE 1

CONTINUED ON PAGE 18

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F O C U S O N M E D I C A T I O N M A N A G E M E N T

BY JERRY ZEIDENBERG

OAKVILLE, ONT. – Quick, safe andconvenient are watchwords inHalton Healthcare’s pharmacydepartment. It’s one of the first

in the country to install a Swisslog medica-tion robot, which packages the varioustablets and pills needed by patients intoenvelopes, barcodes them, and organizesthe envelopes on a plastic ring.

A ring may contain four or five or moremeds.

From there, they are transported to thefloors of the hospital – where they’restored in Omnicell medication cabinetsuntil needed by nurses.

As the meds are barcoded, the nursescan scan a patient’s wristband and en-velopes at the bedside to ensure they’re de-livering the right drug and dose to theright patient, at the correct time.

“We’ve noticed a decrease in medicationincidents already,” comments Sandy Saggar,Halton Healthcare’s CIO. “The system helpsnurses catch any mistakes before adminis-tering the wrong medication.” Saggar notedthe hospital is in the midst of a comprehen-sive survey to measure the efficacy of a num-ber of new, computerized systems, includingelectronic medication management.

The hospital doesn’t yet have comput-erized practitioner order entry (CPOE) onthe front end – but that project is in theplanning hopper.

“We didn’t want to introduce too muchchange all at once,” notes Helena Trabulsi,director of pharmacy, explaining that ittakes time to tweak the practices of phar-macists, technologists and nurses. “We’vebeen working on these projects [the roboticsystem and eMAR] for five years now.”

Something the Oakville-TrafalgarMemorial Hospital has pioneered at thefront-end, however, is an imaging system –connected to the pill packaging robot –that visually checks the medications beingpackaged.

“If something comes through that iswrong – like two of the same pills in apackage, or a broken capsule – it is rejectedright at the start,” says Boris Curcic, phar-macy manager.

He notes that a great deal of work wentinto setting up the system, as about 100images of each medication were taken tocreate a visual database.

“And we’ve got over 400 different med-ications in the database – they are the highvolume items that are most in demand.”

That’s a picture database of over 40,000images, and it’s checked against each med-ication as it rolls into the robot.

“It means we don’t need manual check-ing as the medications go into the robot,”says Michael Wood, senior pharmacy tech-nician. “That’s a cost saving.”

Trabulsi adds that instead of employingstaff at the front end, tediously checkingthe medications going into the packagingmachine, they can be used elsewhere in thepharmacy. “We’re better utilizing the timeand skills of our technicians,” she says.

It’s a thoughtful approach – one thatyou’ll find throughout the hospital. Notonly does it make better use of the skills ofstaff, but Halton Healthcare believes it willtranslate into better patient care, with im-proved medical outcomes.

Smart design and thinking has beenincorporated into many areas of the newhospital.

For example, the inpatient portion ofthe hospital has been designed so that it’s

separated to a great extent from outpatientclinics. “In-patients are constantly beingwheeled through the halls for tests, andthey don’t like other people seeing themon stretchers,” explains Melanie Maddock,DI manager. “They’re not looking theirbest, and it’s uncomfortable for them.”

By separating the inpatients and outpa-tients, there are fewer people walkingthrough the inpatient corridors, whichcreates a sense of privacy.

“It’s a different atmosphere than inmost hospitals,” says Maddock.

A special, patient-friendly feature of thehospital is the Emergency Department’sown Imaging Centre – called the ImagingCluster. Situated between the EmergencyDepartment and the Diagnostic Imagingdepartment, it gives priority to emergencypatients and enables them to be imagedand diagnosed faster than at the oldOakville hospital.

“It means quicker turnaround foremerg patients,” says Maddock.

The cluster benefits from two CT scan-ners – including a high-end, Siemens SO-MATOM Definition Flash, one of the firstto be installed in Canada. It ‘freezes’ car-diac motion so that even patients withhigh and irregular heart rates can now geta reliable diagnosis.

Strangely, the emergency Imaging Clus-ter appears to be quiet, even though emer-gency department throughput has increasedby 20 percent since the hospital opened lastNovember. Maddock chuckles as she ex-plains that visitors always wonder where thepatients are, and why the department isn’tnoisy and bustling, like the floors of manyother hospitals.

The answer is that the spacious ImagingCluster also has private consulting rooms,where emerg patients are brought beforetheir imaging exams.

How about an Amazon-like procurement model for Canadian hospitals?BY TIM WILSON

Healthcare’s spending crisishas been a prominentnews issue in 2017. In On-tario, we heard from the fi-nancial accountability of-

fice that the province must remove $2.8billion from health spending by 2019.

Then the Ontario Chamber of Com-merce published a report arguing formore efficient procurement and supplychain processes. And now, the Instituteof Fiscal Studies and Democracy says thefederal government has to come up withmore cash.

Amidst this handwringing, there havebeen few specifics on how the system cansave money. But one Canadian technol-ogy company, ThoughtSpeed eCommerceLtd., has evolved its cloud-based offeringto position it as a major player, drivingadvanced capabilities from its experienceproviding a SaaS-based order manage-ment system for the Canadian Pharma-ceutical Distribution Network (CPDN).

CPDN is a group of 25-plus pharma-ceutical companies that supply theirproducts to over 800 hospitals in Canada

using integrated technology and distrib-ution services to lower drug costs.

“The innovation and efficiencies arerealized through our software’s ability toconsolidate orders with multiple suppli-ers and warehouses,” says Ken Will,ThoughtSpeed’s CEO.

“This creates significant cost savingsand moves beyond pharma and intomedical-surgical devices and consum-ables.”

The ThoughtSpeed technology couldtake the Canadian healthcare supplychain toward an Amazon-like model.However, despite the company’s abilityto ensure custom pricing in a multi-channel, multi-supplier environment,the healthcare sector has been slow to re-spond, with the mainstream news focus-ing on the problem and not the solution.

The report from the Ontario Cham-ber of Commerce, for example, devotesconsiderable space arguing for a frame-work for modern supply chain practices– but with few specifics on the technolo-gies that will drive this change.

“Right now, wholesale ordering inhealthcare is a black hole,” says MikeNeary, ThoughtSpeed’s VP Business De-

velopment. “But we’ve developed a systemthat supports one-stop shopping, with fullinventory, contract and pricing visibility,which drives operational efficiencies andreduces overall costs.

It’s the Amazon model for Canadianhealthcare, which allows any supplier toship directly.”

This shift toward a consolidated, nim-ble, and more consumer-oriented ap-

proach has been in the air for years, butthere has been little news of a technolog-ical solution because it was assumed thatCanada’s single-payer system, and itscentralized funding models, tended tosupport traditional B2B technologies.This is certainly true of Ontario’s SharedServices organizations (SSOs).

“We bought SAP, and we coordinateAriba for contract management,” saysDavid E. Yundt of Plexxus, an SSO that

represents 10 hospitals in Ontario. “SAPis used for supply chain and finance, andAriba is primarily run for contract man-agement.

“These are complex projects – therewas no way any of the hospitals couldhave hoped to have implemented thatsolution on their own,” notes Yundt. “Ittook us 3.5 years to get SAP running,and another year to get the data cleanedup. Only then can we leverage the ad-vantages.”

To date, Yundt says that Plexxus’scommon information technology plat-form, which the hospitals share for thesupply chain finance function, has savedthem upwards of $100 million.

That’s significant, and speaks to theadvantages of having shared services or-ganization manage a common IT systemon behalf of a group of hospitals. But itremains the tip of the iceberg in terms ofpotential savings.

“Our experience with CPDN is agood indication of where future savingscan be found,” says Will. “ThoughtSpeedcan handle a range of different products,from multiple manufacturers and thirdparty warehouses.”

The robotized medication system at Halton Healthcare includes an imaging solution that checks the meds.

Oakville hospital’s pharmacy automation enhances speed, accuracy

It’s possible to move towardan Amazon-like ordering anddelivery system formedications in Canada.

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BY KELLY O’BRIEN

If a radiologist wanted to know how manypatients at a hospital experienced claustro-phobia in an MRI, but who had written ona questionnaire that they weren’t claustro-phobic, it would be an extremely tediousprocess.

Radiologists do not use templates or follow a spe-cific structures when dictating reports. Because everyreport is different, software that works like a searchengine for a hospital’s radiology information systemmay not turn up everything if the search isn’t sophis-ticated enough.

“They’ll be able to find where the radiologist haddictated, ‘Exam cut off because of claustrophobia,’but because one doctor doesn’t use the word ‘claus-trophobia,’ and others do, they won’t have a completecohort because they hadn’t looked at other ways ofdictating claustrophobia,” said Kate MacGre-gor, the quality improvement and radiationprotection manager in the Medical Imag-ing Department at St. Michael’s Hospitalin Toronto.

To improve the quality of their searchesMacGregor and her colleagues are using nat-ural language processing, a branch of computerscience concerned with the interactions be-tween computers and human languages.

Natural language processing allows search

tools such as Montage, the software used at St.Michael’s, to understand human speech as it occursnaturally, both spoken and written, which allows formore accurate search results.

In the past, the type of information gathered us-ing natural language processing, combined with asearch tool such as Montage, could have been doneonly by chart review, said MacGregor.

Now, she said, radiologists have the tools to mineall the data available to them in electronic medicalrecords and the radiology information system, whichhouses all the reports. “If we wanted to do any of thiswithout Montage, we’d have to go into the electronic

medical record and look at each patient to see whichones have pre-conditions or something like that,” shesaid. “So it wasn’t possible to do this kind of stuff be-fore. It’s pretty amazing when you think about it.”

Tools such as Montage have the ability to do aword search using computer science techniques in-cluding Boolean logic and exclusion criteria, and fil-ter out what the radiologist wants to see, accordingto Dr. Bruce Gray, a radiologist in St. Michael’s Med-ical Imaging Department.

“Let’s say 1,000 reports have what you want, that’swhere the natural language processing piece comesin,” he said. “We want to create improved algorithmsto try and parse out the data, or parse out the text,and try and determine whether there’s information

or content there that is useful.”Before the radiologists can do anything with

the data they find useful, a statisticsanalysis software programmer must usethe patient history to validate the imagesto ensure the search didn’t pick up theterms from different parts of the reportand put them together illogically.“You can search ‘rule out appendicitis,’ butwe’re not 100 per cent it matches the un-derstanding of what ‘rule out appendicitis’is,” said MacGregor. “There might be some-thing that says, ‘previous appendicitis, rule

out gall bladder,’ so it would’ve combinedthose words and it wouldn’t have been a rule

out appendicitis, it would have been a ruleout gall bladder.”

VI

EW

PO

IN

T

Branch of computer science makes computerized search tools more effective.

St. Michael’s Hospital refines the use of natural language processing

Waste management in hospitals: best practices are evolvingBY DAVID HEEL

For all areas across the health-care sector, minimizing andeliminating cross-infection en-

sures a decreased workload in havingto treat unnecessary infections. Inaddition, staff themselves are health-ier and require fewer days off sick.For certain patients, such as the el-derly or immune-suppressed, effec-tive infection control can be life-sav-ing; it can also result in shorter hos-pital stays and reduce antibiotic use.

Minimizing the risk of health-care-acquired infections can there-fore directly reduce a healthcareprovider’s costs, as well as the avoid-ance of ward shutdowns when an in-fection cycle needs to be broken.

Selection of disinfection & dis-posal method: The selection of thedisinfection and disposal procedureto be used will always depend on theequipment to be disinfected, and thelevel of decontamination required(see Table 1 on page 18).

Table 2 shows the microbiocidalactivity of chemical disinfectants.There are inherent risks associated

with chemical disinfection, however.These include the toxicity of certainchemicals, the resistance of some or-ganisms to the chemicals, and ulti-mately the risk of instances of hu-man error, where items may not besufficiently decontaminated.

Due to the increasing number ofoutbreaks of infections caused byhigh-risk microorganisms such as C.difficile, and the inability of conven-tional methods to completely elimi-nate risk of cross-infection, manyglobal healthcare establishments arenow moving away from reusable hu-man waste containers.

These are instead being replacedwith single-use ‘pulp’ containers –which allow for subsequent macera-tion and disposal of the pulp bed-pans – as an alternative and ex-tremely reliable means of ‘total in-fection control’. Macerators willcompletely destroy both the pulpbedpan and urine bottle containerand contents, including ‘macerator-friendly’ wipes, tissues etc. Theseitems are pulverized into small par-ticles using carefully designed bladetechnology.

Furthermore, as well as eliminat-ing the potential contamination riskof reusable products, pulp macera-tors offer much faster cycle times,typically less than two minutes.Moreover, soiled utensils do notneed to be emptied or rinsed beforebeing put in to the macerator.

The machines can generally dis-pose of between two and four bed-pans, but, to prevent soiled bedpans

from accumulating, the cycle may bestarted at any time that a utensil isdeposited in the macerator. The mac-erator cycle includes the use of botha high pressure water spray, and cut-ting blades, which macerate the wasteinto a fine slurry, which is thenflushed into the drainage system.

A final spray then cleans and dis-infects the interior chamber of themacerator ready for the next use.

Innovative design, low mainte-nance: The macerator is much sim-pler in design compared with awasher disinfector, and requires lessperformance monitoring and main-tenance. Equally, macerators use lesswater and electricity than a washerdisinfector. Alongside offering afaster cycle time, they do not use hotwater, and are thus not prone toproblems associated with lime-scalebuild up, which is common in hardwater areas.

For its part, DDC Dolphin hasover 25 years of experience in sluiceroom solutions and continually seekfurther advice and guidance from allgoverning bodies, an approach thatwe believe enables us to better un-derstand our customers’ needs in allareas of the healthcare industry, in-cluding the key subject of humanwaste management.

All DDC Dolphin Pulpmaticmacerators have patented hands-freetechnology, offering operation bymeans of a foot cup at the base ofthe machine and an optical hands-free sensor to close and start the

Using low-temperaturesteam has become a keymethod of sterilizingreusable items.

Dr. Bruce Gray, a radiologist at St. Michael’s Hospital in Toronto.

CONTINUED ON PAGE 18


V I E W P O I N T

BY LYNN M. NAGLE AND PEGGY WHITE

As a healthcare system, we con-tinue to count stuff – procedures,providers, case volumes, andoutcomes such as cost, lengths of

stay, alternate level of care days, deaths, in-fection rates. We do not, however, usuallyturn our gaze to the impact of the effortsand activities of the largest clinician com-munity in the healthcare system, nurses.

There is a lack of awareness amonghealthcare leaders of the potential value ofother standardized clinical data for thepurposes of aggregation and comparativeanalyses within and between care settings.

Nursing is the largest constituency ofhealth providers in Canada. This commu-nity includes 293,000 Registered Nurses,4,400 Nurse Practitioners, 5,800 RegisteredPractical Nurses, and 11,300 LicensedPractical Nurses.

Nurses are also the predominant usersof clinical data and contributors to elec-tronic health records. Recognizing the op-portunity to leverage EHR investmentsand continue realizing the possibilities forimproving healthcare delivery throughtheir use, Canadian nurses have begun todevelop a national strategy focused on theadoption of data standards.

In April 2016, an invitational sympo-sium was held at the University of Torontoand attended by 60 nurse leaders fromacross Canada. Sponsored by the CanadianNurses Association, the Canadian Institutefor Health Information and CanadaHealth Infoway, the symposium focusedon the development of clinical practice,administration, education, research, andpolicy strategies.

The meeting was also supported and at-tended by a select number of representa-tives from the vendor community, includ-ing Cerner, Orion Health, IBM, Becton-Dickinson, Healthtech, Gevity and HI Next.

Specific actions arising from the sym-posium included the advancement of aresolution to the Canadian Nurses Associ-ation endorsing the adoption of specificdata standards in nursing.

It was resolved that the CanadianNurses Association advocate for the adop-tion of two standardized, clinical referenceterminologies, specifically ICNP® andSNOMED-CT, as well as a standardizedapproach to nursing documentation in allclinical practice settings across Canada,specifically C-HOBIC and LOINC Nurs-ing Physiologic Assessment Panel.

This resolution was ratified by the CNABoard of Directors in November 2016.Other strategies addressing the adoptionof nursing data standards are being opera-tionalized and will be vetted at the nextsymposium in April 2017.

In particular, tools are being developedto support the integration of data stan-dards into EHR documentation systemsand the subsequent use of standardizedclinical data to inform practice and ad-ministrative decision-making.

Additional details of the 2016 sympo-sium deliberations and recommendednext steps can be found in the proceedings,available for download at: https://cna-aiic.ca/on-the-issues/best-nursing/nurs-ing-informatics.

The 2nd national symposium is slatedfor April 6-8, 2017 and this year an invita-tion has been extended to more than 100nursing and health system leaders fromevery Canadian jurisdiction. Within orga-nizations currently implementing elec-tronic clinical documentation and those

replacing legacy systems, there is an emer-gent energy and interest in continuing toadvance the adoption of clinical data stan-dards across the country. This importantdialogue will continue to unfold with aclear recognition that there are many ben-efits to be derived that will inform the fu-

ture of Canadian nursing and healthcare.

Lynn M. Nagle, PhD, RN, is an assistantprofessor at the University of Toronto. PeggyWhite, RN, MN, is Project Director, Cana-dian Health Outcomes for Better Informa-tion and Care.

Nurses call for standardized clinical terminology and documentation

© 2017 Cerner Corporation

Visit cerner.ca

North York General Hospital wins the HIMSS Nicholas E. Davies Award of Excellence. HIMSS awards it to organizations that have substantially improved patient outcomes using computerized health care systems.

Recognized for its multi-faceted eCare program, NYGH joins only 50 other hospitals around the world to have won a Davies Award. And it’s the first-ever acute care hospital in Canada to earn one.

Not one to rest on its laurels, NYGH plans to increase its HIMSS Electronic Medical Record Adoption Model from Stage 6 to Stage 7 in 2018.

Congratulations to NYGH for winning the Davies Award and for your commitment to providing the best in health care for your community.

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BY DIANNE DANIEL

The virtual doctor is not only in, but isalso delivering high quality, affordableand convenient care. That’s the consen-sus of early adopters of mobile on-de-mand services in Ontario that are con-necting primary-care physicians, fam-

ily health teams and mental-health therapists to pa-tients, providing an experience many say is ‘Uber-like.’

“To an extent this is ‘Press a button, get health-care,’” says Dustin Walper, CEO of Akira, a privatelyrun mobile telehealth service that provides online ac-cess to a team of clinicians to treat low-acuity care is-sues for a low monthly fee of $10. “But where we tryto go in a different direction is we very heavily vet thepeople we work with ... so it’s a much more curatedexperience than an Uber would be,” says Walper.

One of the first providers in Canada to offer asmartphone app than enables consumers to accessdoctors for ailments such as a rash, the flu or anxietyand depression, Akira has been featured three timesin the Apple App Store and reported 25,000 down-loads as of February 2017.

Walper says the app’s user base is growing at a rateof 30 percent a month and the company is currentlyinvesting heavily in Akira for Business, a model de-signed to entice employers to cover its cost for em-ployees. It is also working to leverage the structureddata it collects pertaining to each encounter in itssystem to better inform clinical decisions, as well asto advance research.

The service emulates a family health-team model,employing nurses, nurse practitioners, physician as-sistants as well as doctors. It recently added licensedpsychotherapists and plans to include pediatricians,dermatologists and dieticians soon.

Patients can renew prescriptions, get sick notes,receive specialist referrals or get lab requisitions. Sur-prisingly, the majority (70 percent) of patient inter-actions are conducted via text chats with no videoconsult required.

“There’s a lot of obsession about video in medi-cine as being the be-all and end-all,” says Walper. “Thereality is, people don’t like video that much and oftenfind it inconvenient. So, wherever possible and whereit makes sense, we often provide services via text.”

For a population accustomed to in-person, face-to-face consultations with family doctors, the moveto virtual healthcare is transformative.

A 2015 Canada Health Infoway survey of patientsand physicians in B.C. who used the Medeo virtualcare platform, found that 98 percent of respondentsdescribed the experience as convenient, time-savingand easy to use, with 95 percent indicating confi-dence in the privacy and security of their personalinformation.

A relatively small number – 33 percent – said theyfelt their visit was limited by not being able to receivea physical exam.

Ontario emergency room physician Dr. BrettBelchetz, CEO of Maple, a 24/7 virtual doctor’s officethat launched in Ontario in February, says as many as70 percent of visits to clinical providers for medicalissues don’t require a hands-on examination.

“It (a virtual visit) is never going to replace yourfamily doctor or hospital ER, but when we look atwhat percentage of cases really require a swab, whatpercentage really require a lab test, and what are the

cases that need a physical diagnosis, that’s onlyabout 30 to 40 percent of cases that walk in thedoor,” he says.

Maple differs from Akira in that patients connectwith physicians only. Users can sign up for the serviceon a smartphone but consultations take place from adesktop or laptop, primarily because mobile webbrowsers do not adequately support the modern webvideo and security technologies built into Maple’splatform. A native smartphone app is currently beingdeveloped and is planned for future release.

“The quality of the patient encounter and thequality of the medicine was the number one priority

for us,” says Belchetz. “... It made a lotmore sense to think about doing this as adesktop app because there are so manymore features we can build into it to make it a muchricher experience.”

Similar to the ‘schedule a ride’ button in the Uberride-sharing app, Maple provides a ‘see the doctornow’ button. Patients describe their symptoms, sharerelevant history and click to submit the information.

Requests are routed directly to physicians fortriage, eliminating the need for a middle person, andresponse time is typically four minutes. “Even if theonly advice you’re going to get is that you need to seeyour family doctor, you’re getting a physician review-ing your request and letting you know,” he says.

When a consultation is required, users are put ina virtual consultation room that supports audio, textand video. Custom built by Maple, the platform in-

cludes an electronic medical record system, digitalprescribing and note generation.

The service operates on a pay-per-visit basispriced at $49 per visit on weekdays and $79 pervisit on weekends. A $99 per visit fee is charged forafter-hours appointments, from midnight to 7:59a.m., and annual memberships providing unlim-ited visits are priced at $359 for individuals and$579 for families.

“The best way to think about our technology is it’sreally like Uber for doctors and patients,” says Belchetz.“It’s very much an on-demand staffing model.”

Dr. Eric Fonberg is a family and emergency physi-cian who is among the first group of subscribedproviders to ‘see’ patients on Maple. When a consultcomes in, he is alerted on his cell phone and if he isthe first physician to respond, he proceeds to set up aconsult on his Apple Macbook.

“It’s like an Uber model in that the closest Uber isthe person who gets the ride and in this case, thephysician who is most available picks up the call,” ex-plains Fonberg.

Maple doctors can safely and accurately diagnosethe majority of common illnesses, ranging fromabrasions, body aches and cough, to ear ache, itchyeyes and skin infection. “I got a call about a little boywho had an unusual cough,” describes Dr. Fonberg.“The mom sat the little boy on her lap and I watchedhis breathing, heard him cough, and I was able to tellher without actually listening to his chest – whichwasn’t really required – what kind of treatmentwould be needed.”

In its first month, Maple signed on just over 50doctors and was adding five per week. The virtualcare platform is built to scale, relying on the IBM

SoftLayer cloud infrastructure to ensure highavailability, required to handle a high volumeof requests and multiple simultaneous consul-tations as the service grows.

TranQool is another Toronto-based start-uppoised for growth. Focused on delivering on-demand mental health services – primarily toyoung professionals and university students –the company is on a mission to make mental

health services accessible and affordable, elimi-nating current bottlenecks and making it easier

for patients to navigate Canada’s mental healthresources. “When it comes to ‘Ubering’ of our healthcare

system ... it doesn’t necessarily mean that if I need totalk to someone I should take my phone out of mypocket and get immediate access,” says co-founderand CEO Chakameh Shafii, a mechanical engineerwho was inspired to launch TranQool following herown experience with anxiety as a student.

“The challenge we had to solve was how to createthat feeling of your therapist is going to be at yourfingertips, but at the same time give the sense thatthis is a legitimate platform with legitimate researchbehind why video therapy works.”

Similar to Maple, TranQool delivered a web-baseddesktop application first, with a smartphone app ex-pected to be available this year. Android phone userscan sign in using the latest release of Google Chromeor Firefox for Android.

One of the company’s core strengths is its match-ing system which makes clinician recommendationsbased on information provided by patients. Afterviewing the profiles of their ‘matches,’ patients select

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Consumer demand for one of the first services, Akira, is growing by 30 percent each month.

Virtual healthcare services, using text and video, are growing steadily in Ontario

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the clinician they feel most comfortablewith and proceed to book and pay for anappointment, according to the availabilityshown in that clinician’s schedule. “Whenit’s time for your session, you log back inand click on start session,” explains Shafii.

The secure, one-to-one online videocounselling sessions are hosted in a redun-dant server environment to ensure thesoftware’s availability. TranQool develop-ers made privacy and security a top prior-ity, working with privacy-by-design advi-sors to comply with Canada’s stringentprivacy legislation. Sessions are held withaccredited counsellors who are trained incognitive behavioural therapy, an evi-dence-based approach to treating a widervariety of mental disorders that is shownto be equally as helpful as medications.

“These are psychologists and socialworkers who are working for less than halfof what they make for an in-person ses-sion,” stresses Shafii, noting that TranQoolfees are $120 for a 45-minute session witha psychologist or $80 for a social worker.“We’ve just enabled them to increase thenumber of people they can help.”

Gita Canaran is a London, Ont.-basedclinical psychologist using TranQool in herprivate practice to treat six to eight pa-tients per week from her Windows laptop.She says patients are quite relaxed speakingwith her via video and the 45-minute ses-sions are extremely productive. The serviceis particularly effective for one clients whoexperience high anxiety who can now re-ceive therapy from the comfort of home,and has the added overall benefit of reduc-ing social anxiety longer term.

“When you’re doing cognitive behav-ioural therapy in an office, that office be-comes a safe place for you, a place youlook forward to going to,” explains Shafii.“When you’re doing this at home or atyour office or in a library at school, thenwhat ends up happening is everydayplaces you live in become those safe placesfor you.”

The more that consumer-based, vir-tual services like Akira, Maple andTranQool catch on, the more they

are debated. Some critics claim fee-basedservices enable patients who can afford itto “jump the waiting line,” while othersworry that virtual visits aren’t attached to apatient’s primary caregiver and couldtherefore disrupt continuity of care.

Then there’s the question of physicianreimbursement and whether or not there’sroom for virtual care services to be sup-ported in a publicly funded system.

Maple’s Belchetz says a large percentageof early Maple users are hourly wage earn-ers who don’t have benefits and prefer pay-ing an affordable fee to see a doctor fromthe convenience of home versus takingtime off work or paying to travel or park.Many visits are for follow-up information,prescription renewal or basic diagnoses,cases he says can easily be brought into thecommunity, alleviating some of the bur-den on hospitals and walk-in clinics.

“The idea is never to replace the health-care system but to add to it,” he says.

Maple and Akira have expended a greatdeal of effort to include a digital medicalrecord as part of the service they provideand maintain that patients should be thecustodians of that information. BothBelchetz and Walper envision a future

where virtual care becomes part of thepublicly funded system, including in-prac-tice use by primary caregivers. This sum-mer, the Ontario Telemedicine Network(OTN) is planning to launch a pilot pro-ject to demonstrate how it might work.

OTN chief executive officer Ed Brownsays technology is the least of the prob-lems. “The technology (to support on-de-mand services) is so available and so sim-

ple,” he says. “The hard part is the work-flow to provide holistic care.”

The goal of the pilot, which issued anopen request for proposal to all virtualcare platform providers, is to enable pa-tients to send online requests and receivesame day clinical advice as a starting point,providing video consults with a primarycaregiver as needed. Brown says there’s agreat willingness among primary care-

givers to move forward with virtual care asan opportunity to deliver good healthcareconveniently.

“This is the new standard,” adds Maple’sBelchetz. “Every time I treat a patient onMaple, I think ‘Wow! This is a patient whodidn’t sit in a waiting room, who didn’ttake up a space in a walk-in clinic.’ Rightnow, these are dollars the government did-n’t have to spend.”



BY MARTIN TRÉPANIER

Quebec is an early adopter of Re-mote Patient Monitoring, havingused remote personalized care for

almost 15 years. In 2015, theprovince chose Orion Health’s RPM plat-

form for widespread use. In the first year,more than 1,500 patients were managedon the program and preliminary resultsare excellent.

Patient satisfaction is at 90 percent,which reflects the readiness of the patientto use such tools. When patients adopt a

prescribed treatment plan, these empow-ered patients take part in care decision-making, which results in better and moresustainable patient outcomes.

For patients living with a chronic condi-tion, every day can be a challenge. As thosewith chronic diseases or conditions under-

stand, treatment is less about curing a dis-ease and more about learning to live with it– a feat that can be challenging without sac-rificing an independent and fulfilling life.

Fortunately, solutions like Remote Pa-tient Management (RPM) have eased thelifestyle shifts that chronic diseases can en-cumber. In one case, a Quebec patient puton an RPM program last year was able toget back into running multiple times a week– despite the fact he had stopped physicalexercise for many years due to his illness.

This patient wasnot cured by theprogram. However,he learned how tolive with his chroniccondition more eas-ily. While not all pa-tients will end upwith such an extra-ordinary outcome,the empowermentand sense of securitythat comes from anRPM program can improve a patient’shealth status and quality of life.

RPM is the personal health assistant, el-evating patients and family-caregivers’ ex-pertise effortlessly through interactivedaily health activities. It fosters empower-ment and improves a user’s sense of secu-rity about their condition.

This is because they can manage theirhealth independently, reacting quickly tosymptoms and thereby avoiding unneces-sary ED visits. Simultaneously, patientshave direct access to care providers shouldthe need arise.

Furthermore, although patients withchronic conditions are often primary tar-gets, services delivered through RPM areexpanding. Value services such as pre- andpost-surgery monitoring, high-risk preg-nancy, oncology, etc., are generating excel-lent outcomes for patients and value forhealthcare administrators.

At this point, it’s hard to doubt the ben-efits of RPM, so the real question is: “Canhealthcare organizations integrate this toolwidely in conventional care processes?”

The first consideration must be the solu-tion’s ability to exchange information withexternal systems. Interoperability is impor-tant considering most patients targeted byRPM programs have complex chronic dis-eases with information in several systems.

As well, self on-boarding processes andsimplicity of use is important so that pa-tients can become familiar with RPM attheir own pace, on their own time. In short,simplification of logistics and reduced costssurrounding patient support, facilitatesmainstream deployment and improves ROI.

As the Certified Professional in Health-care Information & Management Systems(CPHIMS) handbook states, “Sustainability(of our healthcare system) is most likely tobe achieved by effectively engaging patientsas active participants in managing their ownhealth,” which is precisely what RPM does.

RPM is a solution that balances betterpatient outcomes while significantly low-ering the costs of complex chronic pa-tients. And patients are now demanding it.

Martin Trépanier, is Director, Québec, forOrion Health.

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t VON Canada, 6,400 staff and 6,200volunteers bring a wide range of

nursing, personal support, andcommunity services to more

than 10,000 people every day in Ontarioand Nova Scotia.

Delivering exceptional patient care isparamount to the organization, and VONCanada needed a more effective and effi-cient way to coordinate home care and en-sure secure communication in the field.

If field staff couldn’t get real-time an-swers to patient care questions or didn’tfeel tightly connected with the centralplanning team, care quality could be im-pacted and service levels could be missed.

Adding to these challenges was the needto address ever-changing regulations andfunding requirements.

Sharon Goodwin, Senior Vice Presidentof Home and Community Care, said, “Ourmanual field processes were no longerworking for us and were resulting in ser-vice issues. We needed to automate someof the work to improve delivery of care.”

The organization needed a technologysolution that would facilitate communica-tion, increase efficiency, and improve doc-umentation accuracy and workflow au-tomation.

If it could do all that and reduce ad-ministrative costs, all the better.

VON Canada started by bringing infrontline personnel to identify all of theorganization’s operational processes, in or-der to identify opportunities to better con-nect management, staff, and patients.

Mapping these processes brought im-portant insights to light: from the mo-ment a client referral came in, it took 169distinct steps to get field staff to thatclient’s home.

It became clear that automationwould need to play a key role in any solu-tion. Additionally, the solution wouldneed to integrate with their back-officesoftware system.

CellTrak’s Care Delivery Managementsolution provided everything VONCanada needed.

It would allow the organization to bet-ter manage frontline staff; connect staffwith patients; and automate processes toimprove compliance, communication,care, and cost.

And it is integrated with their existingsoftware, providing seamless back-officeoperations.

But that didn’t mean execution wouldbe easy. As often happens when imple-menting new software, several complex in-tegration and change management issuesarose that required expert attention.

CellTrak and VON worked closely toaddress and overcome those issues andleverage the Care Delivery Managementsolution to help VON improve client care.

Using CellTrak is part of the solutionthat has allowed VON Canada to increaseproductivity by 25 percent and reducemileage expenses by up to 15 percent. Bystrengthening their service strategy, VONCanada is now fully equipped to imple-ment a metrics-based approach to manag-ing its staff and resolving problems beforethey become missed opportunities.

Combining automated workflows withan improved service chain has redesigned

the way work is done and has helped staffconnect with each other.

They’re communicating better, faster,more securely, and more often – and theycan update documentation in real-time in-stead of calling in.

“Using the CellTrak solution has made

connecting field staff with patients easier.We gained a new understanding of wherepeople are and what they’re doing. Thishas helped us provide the right care at theright time,” Goodwin said.

Moreover, the steps involved in servicingnew clients have decreased dramatically.

“Since connecting people in the ser-vice chain and automating some of ourprocesses with CellTrak, we reduced thatnumber to around 50,” noted Goodwin.As a result, each staff member now hasthe time to see one additional client perday.

VON Canada’s mobile solution has increased productivity by 25 percent

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machine. They also have the latest antimi-crobial materials in their lid constructionand offer automatic disinfection of the in-ternal chamber post maceration, all fea-tures which help to greatly reduce the riskof cross contamination.

The efficient operation of Pulpmaticmacerators translates into significant sav-ings in terms of staff time, water and elec-trical consumption.

Bedpan washer disinfecters: Using lowtemperature steam has become a keymethodology for decontaminatingreusable items within sluice rooms. Washerdisinfecters that use thermal disinfectionare now an essential element for emptying,washing, and disinfecting metal or plasticreusable human waste containers, such asbedpans, commode pots, and urine bottles.

The washer disinfector cycle firstflushes waste from the container placed ina racking system within the chamber to re-move visible contents, with a steam gener-ator heating to a minimum of 80°C for atleast one minute to ensure that all proteinsare denatured. The heat acts to completelydisinfect the container, as well as the ma-chine chamber.

It should be noted, however, that suchsteam disinfection is not sufficient to de-stroy C. difficile spores.

Advances in washer disinfectortechnology: DDC Dolphin offerswasher disinfecters which are de-signed to clean and disinfect urinals,reusable plastic and stainless steelbedpans and other accessories. Agreat advance in sluice room technol-ogy, they are designed to automate theentire process, and to eliminate theneed to empty the bedpan contentsbefore loading.

The new generation of washer dis-infecters are both reliable and afford-able, with the more recent models in-corporating antimicrobial materialsand hands-free technology to open,close, and operate the machineswhich ensure the highest standards ofhygiene and efficiency, greatly reduc-ing the risk of cross-contamination.

Thermal disinfection systems, asused in washer disinfecters, provideheat using steam to a fixed temperaturefor a specified time to deactivate the in-fectious elements. This is achieved us-ing the application of moist heat,(steam) at ambient pressure to an Ao of60, equating to 60 seconds at 80°C. Thecontinuous monitoring and recordingof the temperature and time are criticalto ensure that the required temperaturelevel is achieved.

Government standard testing and vali-dation procedures should be carried outon a regular basis weekly, quarterly, or an-

nually, depending on the checks required. Scale and disinfectants: The steam gener-

ator in a bedpan washer generates tempera-tures that may produce heavy scale deposits;thus in areas where hard water is not treated,the scale build-up may hinder its operation.

Most machines come with an inherentde-scaler system, but although this helps, itis recommended that in hard water areas adetergent with additional de-scaler is usedto maintain machine performance. Somedetergents can pose a threat to the widerenvironment, but modern disinfectants

such as DDC Dolphin’s EcoWash+and EcoWash+ Ultimate for hard wa-ter areas contain some caustic alkali,which is neutralized by other ingredi-ents in the effluent water. They do not contain DDAC (a car-cinogen), and the surfactants are allbiodegradable to EEC guidelines. Me-chanically the washer disinfector is acomplex machine, so a service andmaintenance plan should be consid-ered to avoid unnecessary costly ma-chine failures.Conclusion: Whether you chose amacerator or washer disinfector, thereare certain key features of DDC Dol-phin machines considered desirablefor increased contamination controland ease of use. For example, hands-free operation,and the incorporation of antibacterialmaterials in contact areas to create a‘microbe-safe’ surface, are highly rec-ommended to help reduce cross-cont-amination. Reduced water consump-tion is also advantageous for conser-vation of water, particularly in areaswhere water is a valuable commodity,and of course reduced power use bothhelps the environment and keeps coststo a minimum. Inadequate decontamination and dis-

posal of human waste can result in thetransfer of infection to patients andhealthcare workers.

The choice of equipment involves manyconsiderations: regulations, the number ofpatients, size of room, equipment, and bud-gets, but it is an important and essential con-sideration for all healthcare environments.

David Heel is Business Development Direc-tor for DDC Dolphin Canada, specialists insluice room and dirty utility room designand manufacture.

Waste ManagementCONTINUED FROM PAGE 12

that specializes in cardiac and vascularsurgeries and sees a high volume of pa-tients. It is also associated with CoventryUniversity, where researchers have de-vised tools for support patient self-man-agement during recovery. This expertiseis being incorporated into theSMArTVIEW software.

“It was a natural fit to work with them,”said Scott.

Overall, the home monitoring systemwill track many data-points. It will giveclinicians a clear idea of the patients whoare at greatest risk of developing complica-tions, such as infections.

“We can then increase the monitoringor make the appropriate intervention,”said Scott.

Patients will be trained in self-care, too,so they can take better care of themselvesand improve outcomes. The SMArTVIEWsystem includes an easy-to-use interfaceon that tablet for self-care, including goalsfor the patient.

Social media is another component ofthe project; it will enable patients to chatwith each other and learn from theirshared experiences. “We believe there is animportant role for peer-to-peer learning,”said Scott.

Some patients, he expects, will become‘champions’ who take an active role inteaching others about self-care and the useof the technology.

SMArTVIEW is a large project – the de-velopment team includes more than 100scientists and clinicians working at Hamil-ton Health Sciences, Liverpool Heart andChest Hospital, McMaster University,Coventry University, Mohawk College, theUniversity of Toronto and York University.

As well, the Institute for Clinical Evalu-ation Sciences (ICES) will be determininghow effective the project turns out to be,measuring the expected drop in re-admis-sions and its effect of hospital costs.

CONTINUED FROM PAGE 9

SMArTVIEW project ready to go live

HOLTSVILLE, N.Y. – ZebraTechnologies Corporation,a global leader in providingsolutions that give enter-

prises real-time visibility into their op-erations, announced two new mobilehandheld devices that will improveclinical mobility workflows and patient care.

The DS8100-HC series scanners andthe durable TC51-HC mobile computercan foster clinical collaboration forstaffers and drive better operational effi-ciencies, while also supporting the fiverights of medication administration tohelp increase patient safety.

The DS8100-HC imager series, whichcomes in both corded (DS8108-HC) andcordless (DS8178-HC) versions, feature apurpose-built housing using special plas-tics to help prevent the spread of bacteriaand allow for safe wipe-downs with awide selection of disinfectants used inhospitals.

The DS8100-HC series features user-selectable feedback modes to instantlynotify healthcare workers that a barcodewas properly captured without disturb-ing patients. In addition to standardLED, vibrate and beeper feedback, userscan individually or in any combinationeasily adjust beeper volume, frequency

and illumination intensity to improvethe patient experience.

Both the DS8100-HC series and theTC51-HC mobile computer can capturevirtually any barcode in any conditionand scan the most problematic barcodesfound in pharmacies, labs, and at thepoint of care to help improve productiv-ity and efficiency.

Healthcare providers can rely on theTC51-HC mobile computer with An-droid to replace multiple devices needed

to perform tasks such as calling/textingco-workers, receiving calls via PBX, ac-cessing patient records, scanning bar-codes and increasing medication admin-istration accuracy.

An ultra-high resolution rear-facingcamera and a front-facing camera en-able healthcare professionals using theTC51-HC to provide an intricate ac-count of their patients’ conditions andto offer remote consultations forquicker service.

Zebra Technologies offers new smartphone and scanner


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