feature report: developments in medical imaging — … · joanne jubas [email protected]...

BY JERRY ZEIDENBERG

RICHMOND HILL, ONT. – MackenzieHealth is set to go live in July withits Epic Electronic Medical Records(EMR) implementation, an ad-

vanced, “end-to-end” installation that willbe used by clinicians and patients alike. Thenew EMR, for example, will not only enablesurgeons to schedule time in the OperatingRoom from their offices, but it will also al-low patients to book follow-up appoint-ments at times when the encounters aremost convenient.

And while the Epic system is one of thetop EMRs available, Mackenzie Health CEOAltaf Stationwala recognizes that “one ven-dor can’t solve all of our problems.” Indeed,the hospital has an ambitious plan to use

technology to dramatically improve the de-livery of healthcare, and it’s integrating ahost of solutions around the core Epic sys-tem to reduce bottlenecks and clear logjams.

Those solutions will first be deployed atthe existing Mackenzie Health site in Rich-

mond Hill; they will then be rolled out atthe new hospital that Stationwala and histeam are building in nearby Vaughan, a$1.6 billion investment that will open itsdoors in 2020.

“The number one complaint we’ve heardfrom clinicians is the amount of time it

takes to use passwords to log in and out ofdifferent systems,” said Stationwala. Whenclinicians want to check information in dif-ferent systems, it’s just too difficult andtime-consuming to leave one applicationand get into another.

For that reason, Mackenzie Health willmake use of Imprivata’s single sign-on solu-tion, including ‘tap-and-go’ technology, whenthe Epic system fires up in July. Not only willclinicians be able to access all applicationswith a single password and sign-on, but theywill be able to walk from one computer to an-other, tap their badges, and resume wherethey left off on the new computer.

That wireless app also recognizes the mo-bile nature of the work physicians andnurses are performing – they’re walking

Mackenzie Health devises new workflows for ‘smart’ hospital

CONTINUED ON PAGE 2

Computers can already recognize faces better than humans, and systems using Deep Learning and Artificial Intelligence are developing theability to spot diseases in diagnostic images and provide possible treatments. How long will it be before such systems are as good as radiolo-gists? The question intrigued DI experts at the recent Radiological Society of North America conference, in Chicago. SEE STORIES ON PAGES 4 and 17.

Will radiologists be needed in era of AI computers?

PHO

TO:

CO

URT

ESY

OF

THE

RSN

A

The hospital is using the Internetof Things to build intelligence intoclinician workflows.

INSIDE:

Cloud-based QAReal Time Medical is now provid-ing small and large hospitals witha subscription-based peer reviewservice. It is available for specialistssuch as radiologists, cardiologists,pathologists and ophthalmologists. Page 6

Appropriate orderingSt. Michael’s Hospital, in Toronto,is running a research project with80 physicians to analyze the DI or-dering habits of doctors. The sys-

tem will also advise family doctorsabout the most appropriate teststo order for patients. Page 6

Information governance?With the explosion of computer-ized and paper-based data inhealthcare organizations, it is moreimportant than ever to develop in-formation governance standards. A group in Canada has beenlaunched to do just that.3

Innovation showcaseDI vendors often wait until the endof the year to unveil their newesttechnologies at the RSNA confer-ence. The meeting in November

2016 offered a look at many newsolutions, including a self-compres-sion system for mammographyand a twin C-arm for angiography.Page 22

Pub

lication

s Mail A

greem

ent #

40018238

FEATURE REPORT: DEVELOPMENTS IN MEDICAL IMAGING — SEE PAGE 18

CANADA’S MAGAZINE FOR MANAGERS AND USERS OF INFORMATION SYSTEMS IN HEALTHCARE VOL. 22, NO. 1 FEBRUARY 2017

FOCUS REPORT:

EDUCATIONPAGE 14

1 2

TELEMETRY-INITIATED

CODE BLUE

from room to room in the hospital, andnot staying in any one place.

But the high-powered Epic system, andthe solutions that are being added to it,wouldn’t work well without a high-speednetwork.

That’s why Mackenzie Health is in-vesting in an incredibly fast Cisco net-work. “We need the fastest network pos-sible,” said Richard Tam, Executive VicePresident at the hospital. So MackenzieHealth is installing a 10 gigabit/secondwireless network, and a 100 gigabit/sec-ond wired system.

“They will be the fastest hospital net-works in Ontario,” said Tam.

Stationwala explained, “We could putEpic in without these steps, but it wouldrun as slow as molasses. A high-speed net-work, with zero lag time, is a must.”

These systems will be at the heart of the“smart hospital” that’s being invented atMackenzie Health.

The new, hospital of the future is be-ing created through strong partnerships– with the builder Plenary Health, andwith Philips Canada, which will handlethe procurement of all technology goinginto Mackenzie Health. (While much ofthe technology will be from Philips, agood deal will be from other vendors –it’s another facet of the best-of-breedphilosophy.)

Another key partnership was recentlysigned with Compugen, a systems integra-tor and IT solutions provider that happensto be locally based, in Richmond Hill.Compugen is one of the biggest systemsintegrators in the country, with 1,400 em-ployees across Canada; it will help the hos-pital get all of its systems up and runningsmoothly.

It has also been enlisted to helpMackenzie Health produce some of itsown technology – in particular, systemsthat will improve workflow. Most of these

solutions are so advanced, they’re notavailable from commercial vendors.

“Compugen will be co-developing 75smart workflows with us,” commentedStationwala.

For example, one of the workflows isbeing designed to help with Code Blues,the alerts given when a patient is having acardiac arrest or severe pulmonary prob-lems. There are typically three to four ofthese each week, and when they happen,loud alerts are sounded over the public ad-dress system, specialists drop everythingand rush to the scene, getting there as fastas humanly possible.

Using the new workflow, silent alerts willbe sent out to members of the Code Blueteam, via smartphones, so that patients andother clinicians are not disturbed.

As well, “the system will talk to the pa-tient’s infusion pump and stop the med-

ications that are being delivered,” said Sta-tionwala. That’s a safety precaution that’snormally not performed until the team hasarrived on the scene. With smart pumpsand intelligent networks, it can be doneahead of time.

Further, using the Internet of Health-care Things (IOHT) framework, elevatorsnearest the Code Blue team members canbe dedicated to those members only –smart location technology can do this,sensing where the team members are, andshutting off access to others.

Even the patient’s bed can automaticallyconvert to cardiac arrest mode, with analert from the smart Code Blue system.

“All of this saves precious seconds,” saidStationwala.

In future, Mackenzie Health may makeuse of the Code Blue scoring system con-tained in Epic, which automatically col-lects vital sign data from sensors and de-termines whether a patient’s cardiac healthis deteriorating.

“This can trigger the system to alert thecritical care resource team,” said Tam.

“They can descend on the patientbefore an incident occurs.” The smart alerting system can alsobe adapted for Code Pink, CodeWhite and other emergencies, Sta-tionwala said. “Once they are developed, the appli-cations will mushroom,” he said. Nursing workflows will also im-prove with Epic and the new systemsthat are being built. For example,Mackenzie Health is switching tocharting at the point of care close topatients, on wall mounted comput-ers. “No longer will nurses writedown notes on paper at the patientbedside, then re-enter the informa-tion on a Workstation on Wheels(WOW) in the hallway,” said Tam. They will be doing their charting inthe patient’s room, on 24-inch mon-itors that are wall-mounted. Nursesand doctors will also have comput-erized decision support on these sys-tems, right at the point of care. Various bedside monitors, more-over, will be integrated into the

EMR, to improve workflow. As an exam-ple, Tam noted that OB traces, typicallyprinted out on paper and then scannedinto the EMR, will electronically feed in-formation right into the system.

And a closed-loop medication manage-ment system will be introduced, to im-prove patient safety.

In all, it’s a huge task, but Stationwalaand Tam believe they will be successful –largely because they have the support ofclinicians.

The project is under the direction of themedical chief of staff, Dr. Steven Jackson,and all clinical department heads haveagreed with the choice of the Epic systemand the ‘smart hospital’ roadmap. “Everysingle chief has bought into the plan,” as-serted Stationwala, saying this will preventthe mishaps that have struck some otherlarge-system implementations in Canada.

Indeed, the choice of systems has beendriven by clinicians themselves, throughtests at Mackenzie Health and site visits toactual implementations of EMRs at otherhospitals in Canada and the United States.

Still, a great deal of training and changemanagement will go into the move to Epicand the new systems. Stationwala says thesolutions will be tested and perfected overthe next four years at Mackenzie Health’sRichmond Hill site before the new hospitalopens in Vaughan.

By that time, staff and physicians willbe well acquainted with the new systems.“They will only have to get used to thenew space, not to the clinical systems,”said Stationwala.

CONTINUED FROM PAGE 1

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 1 February 2017

Contributing EditorsDr. Sunny MalhotraTwitter: @drsunnymalhotra

Dianne [email protected]

Richard Irving, [email protected]

Rosie [email protected]

Andy [email protected]

Altaf Stationwala Richard Tam

In advance of the HIMSS 2017 confer-ence and trade show, scheduled for Or-lando February 19-23, HIMSS has re-

leased information about technology buy-ing trends.

Storage. According to HIMSS Analytics,healthcare organizations are strugglingwith a data explosion, and 39% are plan-ning storage investment. Of those storagebuyers, 14% are planning VNA, while 12%are planning cloud.

Pharmacy technology. 56% are plan-

ning investment in pharmacy technolo-gies. Nearly one-third of those buyers areinvesting in carousels or high-speed pack-agers, and more than one-third will investin multiple pharmacy technologies.

Security. 78% of U.S. hospitals planningIT security investments will be looking tobiometrics.

Auto ID. Auto identification technologywas one of HIMSS Analytics’s top techs towatch in 2017, with 22% planning to in-vest in RFID for the first time.

Technology buying trends in U.S. hospitals

Mackenzie Health’s Epic EMR implementation is set to go live in July

2 C A N A D I A N H E A L T H C A R E T E C H N O L O G Y F E B R U A R Y 2 0 1 7 h t t p : / / w w w . c a n h e a l t h . c o m

Building a healthy society Philips’ vision is to improve the lives of 3 billion people a year by 2025. As a proud partner of Mackenzie Health, we have made a commitment to building a healthier society in Canada by providing the latest in healthcare innovation. Philips delivers innovation that matters to you.

Discover Morewww.philips.ca

N E W S A N D T R E N D S

BY NEIL ZEIDENBERG

When a patient arrives for anappointment at a large hos-pital, they’re often in a hurryand may be unfamiliar with

the exact whereabouts of their doctor’s of-fice, the lab, or various clinics. There mayeven be more than one parking area, andadvance knowledge of this can be the dif-ference between arriving on time or not.What if you could engage with patientswhen they enter hospital and put the helpthey need right on their smartphones?

Telus Health has partnered with Aruba(www.arubanetworks.com), a Hewlett-Packard Enterprise company, to introduce amobile solution that provides patients withthis kind of information. Using the ArubaMeridian platform and free guest Wi-Fi(ClearPass Guest), visitors can quickly log-in to a hospital portal and locate points-of-interest like public washrooms; the giftshop, cafeteria, or admissions department.

“Guest access is very easy to deploy us-ing a single portal, and portals can be cus-tomized in one hour,” said Jason Fernyc,Consulting System Engineer, Aruba.“Aruba is compatible with everything inyour current network, so there’s no need toinstall or learn a new platform.”

Moreover, Aruba is already in use inmore than 1,300 healthcare organizationsaround the globe. A few of the latest Cana-dian facilities to sign on with Aruba in-clude Sunnybrook Hospital and The Scar-borough Hospital.

To help visitors find their bearings,

some hospitals offer wayfinding solu-tions (a kiosk) near a building’s entrance,but it can only guide visitors as far as aperson’s memory will take them. How-ever, Aruba takes it a step further by us-ing a real-time location system (RTLS) togive users turn-by-turn instructions totheir destinations – right on a person’smobile device.

When hospitals install Aruba BluetoothLow Energy (BLE) beacons throughout itscomplex, Meridian can identify personslogged-in to the hospital portal to pin-point their exact whereabouts. Thewayfinding app can also locate a doctor or

a specific piece of equipment. Doctors canuse it on their smartphones to determinethe exact room their patient is in, and toobtain access to their medical record (Ap-ple iOS, Samsung).

Once a person has connected to thehospital portal, an auto check-in mobileapp can be used to help manage their ap-pointments. Alerts can update patients onhow long they’ll wait before seeing theirdoctor. “This benefits the patient by givingthem the option of taking care of impor-tant tasks, visiting the washroom, cafeteriaor gift shop, prior to rushing to the waitingarea,” said Fernyc.

Once in the waiting room, connectedpatients can use various apps to keep theirminds off their appointments by playinggames, read about news and special events,and they may be encouraged to watchhealth videos such as proper hand-wash-ing techniques or a free flu shot clinic. Fur-ther apps may encourage visitors to partic-ipate in surveys or provide feedback abouttheir latest visit.

Fernyc mentioned the potential tohave code announcements in a hospitaldone more effectively – and far more qui-etly. “Code notifications can be madewithout disrupting patients and staffwho don’t need to hear the announce-ment, but rather alert only those in a po-sition to help.”

Visitors and staff can connect to the por-tal using a hospital’s own network or theAruba network. You can buy a subscriptionto the Aruba Meridian platform for use onyour own network, or you can pay for in-stallation of the Meridian platform usingthe Aruba network. For more info, visithttp://www.arubanetworks.com/support-services/

Once people are using the technology,analytics can help put it all into perspec-tive. IT administrators can use the data todetermine how many people used the appsand what apps were used most or least.They can also obtain patient feedback. Itall comes down to improving the patientexperience. A good mobile engagement so-lution, Fernyc noted, can help to lowerstress and anxiety and makes for a betteroverall patient experience.

How do radiologists remain relevant in an era of machine learning?

CHICAGO – With the rise ofenterprise viewers and high-powered networks, manydoctors are reading diagnos-tic images on their own, and

bypassing the radiologists. Moreover,machine learning is being applied to ra-diology, and threatens to automate muchof what radiologists now do.

So the question many radiology lead-ers are asking is, How does radiologystay relevant and important as a medicalspecialty?

“Radiologists were instrumental in thepast. How do we ensure this is the case inthe future,” asked Dr. Richard Baron, pres-ident of the Radiological Society of NorthAmerica during his address at the annualRSNA conference here in November.

Dr. Baron urged radiologists to havemore personal interaction with otherphysicians, so they can provide insightsto their colleagues on a formal and in-formal basis. They can also learn fromtheir fellow physicians, in this way, too.

Something has been lost, he noted,with the tendency of radiologists to iso-late themselves in reading rooms andsend off reports via computer networks.

“Technology has removed the needfor face-to-face encounters,” said Dr.Baron. “Today, radiologists can work ina vacuum.”

Ideally, radiologists should be workingin teams with other doctors, and in closeproximity, so there are easy interactions.

He pointed to hospitals at the Univer-sity of Colorado, the University ofChicago and Johns Hopkins as forwardthinkers. “They’ve moved their radiolo-gists nearer to the consulting physicians,to be closer for collaboration.”

As well, radiologists should strive toadd more value to the reports they sendto referring physicians – helping withthe understanding of the patient and thepossible treatments. “We need to providemore value, and not just write descrip-tions of what we see.”

To ensure complete diagnoses and re-ports, he advised radiologists to makeuse of the RSNA’s template library.

But he also noted that to answer com-plex questions, radiologists will have todevelop expertise in additional areas,such as genomics. To do this, they mustbecome more proactive, making the ef-fort to constantly learn about new dis-eases, classifications and therapies.

“Radiologists must again become re-naissance physicians,” said Dr. Baron.

He called for continuing innovation,saying that innovation in radiology hasslowed recently, and that the position ofradiologists as leaders in medical inno-vation has been challenged by other spe-

cialties. He called for more research tobe done, especially large-scale, multi-centre trials.

Overall, he said that everythingshould be considered in the context ofpatient-centred care. “All decisionsshould be made on the basis of what isbest for the patient – not what is mostconvenient for the radiologist or what is

most lucrative.”When it comes topatient-centredcare, Dr. Baronmentioned a recentIsraeli study thatfound when a radi-ologist has a pic-ture of the patientin front of him orher, the accuracy ofthe work beingdone rises signifi-

cantly. That’s because the photo is apowerful reminder that the work is be-ing done for a real human being. In akeynote address on machine learning inmedicine, Dr. Keith Dreyer, vice chair ofradiology at Massachusetts General Hos-pital, observed that computers are nowable to identify photographic images,such as faces, better than people can.

At its booth at the RSNA conference,IBM demonstrated its progress in this

area. It showed how Watson could eval-uate images, and consider other clinicaldata such as the personal history of thepatient, and lab and medication reports,to make inferences and provide possiblediagnoses.

One such system, called Avicenna,provides the diagnosis and shows theclinician how it arrived at the finding.The clinician can then agree or disagreewith the diagnosis. In this way, the sys-tem becomes a radiologist’s assistant.

Some are asking whether Deep Learn-ing systems of this sort will ultimately re-place radiologists. Most expert observersagree that this is unlikely to happen.

“We see the technology as empower-ing a radiologist to see deeper, see morewhen solving puzzles,” said Dr. Eldad El-nekave, a radiologist and chief medicalofficer with Zebra Medical Vision, a TelAviv-based company that has producedcomputer systems that can diagnose CTscans and other images.

Dr. Elnekave says the process of read-ing images, combining the informationwith other data and arriving at a diagno-sis is more complex than it may appear.“I have been trained by radiologists whohave put together seemingly unrelatedinformation to arrive at a correct diag-nosis,” he said. “I can’t fathom a com-puter doing this.”

Aruba’s Jason Fernyc discussed the new wayfinding system at the top of Toronto’s CN Tower, in November.

New wayfinding app follows patient’s progress through the hospital

Dr. Richard Baron

h t t p : / / w w w . c a n h e a l t h . c o m4 C A N A D I A N H E A L T H C A R E T E C H N O L O G Y F E B R U A R Y 2 0 1 7

“...amazingly reliable and excellent at seamlessly integrating...” – Dr. John Bennett MDCM FRCPC

“...allows us to get prospective and timely feedback...”

– David Wormald MRT(R)(MR), BA, MBA Previous Assistant VP at

HHS and SJHH

“...provided us with consistent, reliable

service, with high quality reports in a

timely fashion.” – Dr. Scott Good

“The one-hour turnaround time or ER patients and inpatients’ results is phenomenal...”

– Shelly E. BottanDiagnostic Imaging Team Leader,Kemptville District Hospital

“major gains...in

work-sharing” – Dr. Dennis Janzen


BY KELLY O’BRIEN

TORONTO – St. Michael’s Hospitalplans to install a clinical decisionsupport system in the hospital’sfamily practice clinics to study

how to improve the appropriateness ofimaging tests ordered by physicians.

Healthcare providers across the countrysuspect a large number of MRIs and CTsordered and performed in hospitals are un-necessary.

As imaging technologies have advanced,more and more detail has become visible onthe scans they produce. This sometimesleads to additional scans for things thataren’t clinically relevant, driving up imag-ing costs on a per-patient basis.

“Unnecessary tests will also contributeto longer wait times and potentially de-crease access for patients who need thetests urgently,” said Kate MacGregor, theQuality Improvement and Radiation Pro-tection Manager in the Department ofMedical Imaging.

“Unnecessary tests can also potentiallyput patients’ health at risk,” she said. “Sometests use ionizing radiation, so from thatstandpoint it’s a public health problem.”

The clinical decision support systemwill service 80 family practice physiciansand 60,000 patients. The system will useOrderWise software, developed by theToronto-based company MedCurrent, togather additional information from familyphysicians to determine if the test theywant to order is appropriate.

“In imaging, sometimes the dilemma iswhen you think someone has a problem,what’s the best test to do?” said Dr. BruceGray, a radiologist at St. Michael’s and oneof the project leads. “When it’s decided

that an imaging test will be useful for themanagement of the patient, it raises thequestion: Is that really true? What is theevidence?”

The concept of the clinical decisionsupport system is relatively simple. Whenordering a test, clinicians will enter patientinformation into a computer, such assymptoms and relevant medical history.The software will then display whether thetest should be ordered, or whether a differ-ent test would be more appropriate. Theclinician will have the option to overridethe recommendation.

“We’ll then be able to identify how of-ten each clinician is overriding the system,and what types of cases they are overridingmost often,” said Dr. Gray. “When we seethey’ve been overriding, we can ask, why isthat? Maybe they have a legitimate reasonfor overriding it. We hope to make this apositive and engaging experience for thefamily practice physicians.”

The tool is designed to be combinedwith the patient’s electronic health records,said Dr. Gray, with only a few clicks neededto determine whether a test is appropriate.

A number of hospitals throughoutNorth America use OrderWise or similarsoftware to determine whether an imagingtest is appropriate. What’s different aboutthe St. Michael’s project, according to Dr.Gray, is that it will be the first site inCanada to use a clinical decision supporttool embedded with appropriateness rulestailored for the Canadian context.

The system will also improve the order-ing process for imaging tests for both pa-tients and clinicians. Currently, the order-ing of imaging tests is almost entirely pa-per-based and goes through a number ofpeople and departments before an ap-

pointment is scheduled. The clinical decision support system will

be added to the ordering process electroni-cally in order to give the patient an appoint-ment at the same time the test is ordered.

Dr. Gray said this increase in efficiencywill be a main selling point for familyphysicians to use the system.

But before the group leading the projectcan assess the effectiveness of the clinical de-cision support tool, they first have to deter-mine what the current ordering patterns are.

“One of the biggest problems in radiol-ogy is a lack of standardization with regardto how doctors order tests, typically theygive very vague reasons on the requestform, and then those request forms arescanned in, they’re not put into a databaseof any sort,” said MacGregor.

“Then when the radiologist dictates thereport, after reviewing the imaging tests,there’s no structure for that either, every-thing is free text. So there is no way to fullyunderstand what the current orderingpatterns are, and whether or not they’reappropriate.”

The team is using a natural languageprocessing tool called Montage to under-stand these baseline ordering patterns andbetter evaluate the effectiveness of the clin-ical decision support system when it’s in-stalled in the spring.

Using Montage, the team is finding pat-terns in the tests ordered by the familyhealth team and individual physicians.They hope to use this information to see ifpatterns change after the clinical decisionsupport system is installed in the spring.

Cloud-based peer-review, feedback available for medical specialists

TORONTO – Real Time Medicalhas announced the launch ofDiaShare, CloudQA: the firstCanadian peer review sub-scription service for specialists

such as radiologists, cardiologists, pathol-ogists and ophthalmologists.

Now experts across Canada can par-ticipate collaboratively and confiden-tially to review each other’s work by pro-viding their diagnostic feedback.

This means CloudQA helps physi-cians improve their skills while provid-ing quality assurance oversight to benefitpatients. Physicians with matching sub-specialty skills can review each other’swork anonymously, across large-scalepeer review networks. The cross-sectionof peers and level of objectivity usingCloudQA would not be possible within asingle hospital or clinic.

Hospitals and individual physiciangroups can avoid incurring the largecapital expense associated with acquir-ing individual solutions on their own,as CloudQA is accessed as a monthlysubscription.

Signup is reasonably priced and sub-scription costs are determined from vol-

ume, or on a per-user rate based onlength of subscription.

“Our affordable yet comprehensiveapproach to peer review benefits allCanadians by eliminating many of thebarriers and deficiencies found in tradi-tional approaches,” said Real Time Med-ical CEO, Ian Maynard.

Unlike traditional solutions that re-quire users to adopt system-wide sam-pling rates for all exam types, despite in-dividual needs, CloudQA sampling al-lows physicians to get feedback relativeto each subspecialty and exam type.

Some solutions even use an arbitraryone diagnostic case per day samplingrate regardless of the number of casesan individual generates. However,CloudQA uses statistically valid, ran-dom sampling providing participantswith more useful, individualized infor-mation as a basis for their continuousquality improvement programs.

“A valid approach to diagnostic qualityimprovement for physicians and patientsmust begin with statistically valid, indi-vidualized results”, says Maynard. “Resultsmust be valid if they are to be taken seri-ously, or provide value to participants.

“Non-statistically valid approachesfall far short of the benefits envisionedfor the implementation of quality assur-ance solutions.”

Maynard adds, “They can also create adangerously false impression of qualityassurance improvement for the partici-pants and the patients they serve.”

CloudQA enables physicians to signup as individuals, groups, hospitals or

groups of hospitals, enabling qualityoversight and peer review for even thesmallest operation. This is particularlyimportant for radiology given that 50percent to 60 percent of all exams inCanada are performed in small, privateclinic settings staffed by one or two radi-ologists, which is insufficient to establishobjective peer review and collaboration.

Establishing large-scale peer reviewfor both big and small diagnostic opera-

tions means affordable quality oversightfor the entire exam pool that Canadiansdepend on for diagnosis and treatment.

CloudQA is PHIPAA compliant. It ishoused on Canadian soil and runs out ofthe same highly secure data centre usedby large institutions, such as banks.

As with cloud-based peer review, RealTime Medical was also first to create anddeploy prospective peer review – an ap-proach that enables physicians to detectpotential diagnostic errors before theyoccur.

Early adopters of the first Canadiancloud-based diagnostic peer review willbenefit from incentive pricing with nolong-term commitments.

Real Time Medical is a diagnosticworkflow innovation company. It devel-ops vendor-neutral, context-aware work-flow management software solutions.These solutions organize diagnostic re-porting services across medical disci-plines.

Real Time Medical’s diagnostic shar-ing platform, DiaShare, improves thetimeliness, efficiency and quality of ser-vice delivery to patients. To find outmore, visit: www.realtimemedical.com

Dr. Bruce Gray is a radiologist at St. Mike’s, and one of the leaders of the appropriate image ordering project.

80 family physicians to participate in study of DI ordering patterns

Large-scale peer review isavailable for large and smallhealthcare organizations, atan affordable price.


Health information has the power to change the quality of our lives, and we’re working hard to improve healthcare across generations. When clinicians have access to complete patient information from the entire care continuum, everyone benefits. Enhanced analysis. Increased insight. Informed decisions. And that adds up to a better quality of life for everyone.

THIS IS THE MOMENT

THAT MATTERS.

SOLUTIONS FOR: Healthcare Integration | Population Health Management | Electronic Health Records

For more information, please visit us at HIMSS booth#5063 or e-mail [email protected]


BY DIANNE CRAIG

TORONTO – Two exciting infor-matics projects have beenlaunched in Toronto that areexpected to have fast and pos-sibly profound effects on brain

health. The Centre for Addiction andMental Health is developing a Neuroinfor-matics Platform to sift quickly through bigdata to facilitate research sharing and ac-celerate investigations.

As well, IBM is working with the OntarioBrain Institute and the University HealthNetwork (UHN) on systems that apply AIthrough machine learning to Parkinson’sresearch to accelerate drug development.

Neuroinformatics: CAMH is develop-ing an open source brain-research plat-form, scheduled for launch in summer,2017, that will enable investigators to eas-ily integrate and analyze large sets of re-search data from across the organization.

This will speed up research efforts,while also fostering collaboration with na-tional and international databases forgreater discovery and better patient care.

Ontario is well established as a leader inbrain science and neuroinformatics.“There’s a tremendous amount of effort atthe University of Toronto, and hospitals, interms of harnessing big data,” says Dr. Eti-enne Sibillle, Head of CAMH’s Neurobiol-ogy of Aging and Depression Laboratory.He is also the Campbell Family Chair inNeuroscience.

The new project will build on the recentrelease of new ‘big data’ secure storageservers at CAMH, supported by the Cana-dian Foundation for Innovation. “Thegeneral idea for developing a research plat-form was from a necessity in the field tobroaden this technology. There’s a hugeamount of data – a wealth of informationwe were not fully using,” says Dr. Sibille.

In the beginning, he says, CAMH man-

agement talked about the best way to de-velop the platform. “Do we set up a plat-form in our own organization or go to acompany to help?”

David Rotenberg, Manager, ScientificComputing, in the CAMH InformationManagement Group (IMG), determinedthe Ontario Brain Institute could help andhe reached out to the OBI two years agowith the intent of finding a consolidatedapproach for handling and harmonizingresearch data.

“Turned out they had the solutions wewere looking for, because they had de-signed it to contain data from provincialinstitutions, so we are able to adapt itspecifically for our hospital,” he says.

With the goal of enabling research toeasily integrate and analyze large sets ofdata from across CAMH, speeding up in-vestigations, the R&D platform and its fed-erated database will bring together all ofCAMH’s past/present/future ‘omics’ (tech-nologies used to explore molecules thatmake up the cells of an organism).

The platform will then enable re-searchers to interrogate those combineddatasets, and integrate them with multi-modal data from other CAMH researchers.

“The platform has user-friendly data-bases. Researchers can see the data andlearn everything about it,” says Rotenberg,explaining that the data types will includeimaging information, genetics informa-tion, and clinical information. “If you haveone researcher working on brain imagingon a molecular basis, (and) combine thatmolecular data with imaging data, themolecular data is going to inform analysisof the imaging data.”

The CAMH Neuroinformatics Platformis based on OBI’s Brain-CODE platform.“The Brain-CODE platform is sophisti-cated,” notes Rotenberg. “Typically re-searchers had to spend a lot of time look-ing for the data, instead of focusing on the

science,” he says, adding that the new plat-form should cut that time in half. “Re-searchers can write in a query, look for rel-evant data, look for a gene, etc. Before, theywould collect the data from disparatesources,” says Rotenberg.

“Other than the OBI, no one is success-fully combining all of these data types. Themain goal of our institution is to have alarger pool with thousands of partici-pants,” says Rotenberg. “We want to de-velop an Open Source platform that otherplaces in Ontario could access.”

“We hold a dedicated infrastructure forthis platform. A redundant infrastructurewith two servers for imaging, genetics, andclinical data,” he says. There is also a centraldatabase that links everything together.

The new databases will connect to theCAMH Compute Cluster. “It serves ourneeds now,” Rotenberg says, adding that theyare in the process of “building a Hadoop

cluster – we need to mine it effectively so wecan analyze the data in real time.”

Asked about the investigations, Dr.Sibille said, “the studies are quite complexand require handling large amounts ofdata. Just to get the data in shape – prepar-ing it, etc., takes weeks.”

One of the key areas of focus for Dr.Sibille is depression as it relates to agingand the molecular pathways that are in-volved. He wants to use that approach toidentify new targets for treatment or pre-vention of depression.

Asked if the new CAMH neuroinfor-matics platform would be applied to thispursuit, Dr. Sibille said “Yes, we’ll use it forpretty much everything. We might identifygenes that change with age.”

He indicated they will look at the geneticmakeup in those genes and “create compos-ite scores or genetic scores that could pre-

Heart-SIGN will help arrhythmia researchers find and share answers

TORONTO – Solving cardiac ar-rhythmia research queries, likemany other types of medical re-

search probes, can take years. The Car-diac Arrhythmia Network of Canada(CANet) has partnered with IBM on amission to change that with a newcloud-based research platform designedto speed query time from a matter ofyears to just minutes.

Called Heart-SIGN (System for Infor-mation Gathering and Networking), thenew analytics platform will manage,monitor, store, correlate and analyzedata from all CANet research projects.Most important, it will facilitate sharingof findings between researchers.

CANet, based at the University ofWestern Ontario in London, Ont., is amulti-disciplinary network that bringstogether families, government andleading hospitals and universities, in-cluding University Health Network,Hamilton Health Sciences, Sunny-brook, and others. They fund a number

of research initiatives across Canada.“The concept is that instead of doing

the research individually, they wanted aplatform for sharing of results,” saysNathalie LeProhon, Vice President,Healthcare, IBM Canada.

CANet is using IBM BigInsights, a setof cloud-based analytical tools that areopen source, explains LeProhon, plusIBM’s Watson Analytics to build an in-formatics platform to help spark newideas and share research related to heartrhythm disturbances.

This combination of IBM cloud tech-nology and the cognitive computingpower of Watson Analytics will enableresearchers and clinicians to quickly sortthrough data in a single interface andfind in minutes what previously wouldhave taken years.

The faster route from query to insightis a key benefit, but so is the idea of eas-ier sharing of information, which willlikely result in better, deeper insights.Findings will come from and be used by

CANet’s network of more than 100healthcare professionals, patients, acade-mia, government, and industry experts.As LeProhon notes, once you have 100healthcare professionals putting theirdata on the platform, you can do so

much more.Cardiac arrhyth-mia is a set of con-ditions that in-clude irregularheartbeats, or aheart beating toofast or too slow. Itdramatically af-fects productivityand quality of life,and can cause sud-den cardiac death.

In Canada, arrhythmia takes the lives ofapproximately 40,000 people per year.Other disorders, such as atrial fibrilla-tion, also stem from the condition andaffect 350,000 Canadians.

Over the next three years, CANet has

planned a strategic focus on three majorcardiovascular research challenges – di-agnosis, recognition, and treatment.

This cloud-based research platformwill integrate the research strengths ofCANet with the analytical strengths ofIBM to transform and accelerate the wayarrhythmia research is performed.

The sheer volume and continuousgrowth of complex, big data has beenoverwhelming for the healthcare indus-try. LeProhon has observed that thisplatform will mean “less time siftingthrough data, and more time gaining in-sights, and for delivery transformationwhere it’s needed the most.” The plat-form should help deliver faster, more co-hesive clinical outcomes.

Heart-SIGN is another example ofthe power of this type of technology tochange the future of healthcare. “This isnot about machine replacing man … it’sabout embracing, leveraging doctors’and researchers’ capabilities through thepower of machine,” says LeProhon.

CAMH is developing an open-source brain research platform that is scheduled for launch in summer, 2017.

R&D initiatives set to strengthen Canada as a leader in brain science

Nathalie LeProhon

CONTINUED ON PAGE 23


CPhA also publishes primary care therapeutic infor-mation in the Compendium of Therapeutic Choices(CTC) and the Compendium of Therapeutics for MinorAilments (CTMA). Authored by expert physicians andpharmacists, this content provides current, evidence-based therapeutic information to help health careproviders make the best possible therapeutic decisionsat the point of care.

“For over 10 years we have been providing our drugand therapeutic content online through e-CPS™,e-Therapeutics™, and now through our new platform,RxTx™,” says Lyndon McPhail, Senior Product

Manager at CPhA. “As the only fully Canadian solutionoffering bilingual, Health Canada–approved drugmonographs and therapeutic content, our content iscritical to clinicians treatingpatients, and thus, our online user-base continuesto grow.”

With a reportedreach of over 200,000healthcarepractitioners whoperform over 5 million

searches annually in RxTx, it is clear that this solutioncommands the respect and confidence of Canadianclinicians.

Although the content is readily available throughprint, online and mobile solutions, there is no doubtthat accessibility during patient encounters could beimproved. “There is incredible pressure on healthcarepractitioners to provide quick and efficient therapeuticdecisions while maintaining safe, quality care andoptimal health outcomes,” explains McPhail. “Withmultiple standalone clinical decision-support tools, theexpectation to assess, diagnose and determine the bestcourse of treatment, all within a 10-15 minuteappointment window, can sometimes make it achallenge to provide adequate information andcounselling at the point-of-care.”

The Canadian PharmacistsAssociation is working withthe healthcare community tointegrate their drug andtherapeutic content into

Clinical Management Systems (CMS). Forover 55 years, Canadian clinicians haverelied on the Compendium ofPharmaceuticals and Specialties (CPS) astheir trusted source for drug information.

CPhA ensures critical Canadian drug and therapeutic informationis available at the point-of-care

NEWS AND TRENDSEDUCATIONAL SUPPLEMENT

For over 10 years we have been providing ourdrug and therapeutic content online through e-CPS™, e-Therapeutics™, and now through our new platform, RxTx™

— Lyndon McPhail,Senior Product Manager at CPhA

CPhA reports that itsintegration solution will givehealthcare professionalsimmediate access to vital drug

and therapeutic content within theirEMR, EHR or pharmacy dispensingsystem without having to interrupttheir encounter or dispensing workflow.“Any field in the practitioners’ CMSthat captures or stores drug andtherapeutic data can incorporate theRxTx™ integration feature,” statesMcPhail. “By selecting the RxTx icon ormenu option, their CMS will make acall to RxTx and will return specificclinical information based on theinformation present in the field.”Imagine a physician, nurse practitioneror pharmacist needs to find out if thereis any risk to a patient continuing acurrent medication now that she ispregnant. This solution allows the userto select the integration button besidethe drug(s) listed in the patient record,immediately view the productmonograph and then click the“Warnings and Precautions” section to

view the Pregnancy and Breastfeedinginformation. “The desired informationis displayed in just two clicks with nosearches required,” explains McPhail.“Effortless access to critical informationis what clinicians can look forward to once this solution is installed intheir CMS.”

In addition to on-demand access tothe clinical information, the solutionwill automatically scan all drugsrecorded in the patient chart andidentify any Health Canada advisories,warnings or recalls associated with thatdrug, thus eliminating the need forclinics and pharmacies to establish ormaintain manual processes for internaldistribution and information retention.

So the obvious question is: Whenand how can I get this? CPhAexplained that the development work iscomplete and they are now reachingout to pharmacy and EMR vendors todiscuss the integration process anddetermine potential timelines withintheir development roadmaps. “CPhAhas done all the heavy lifting on

development for this integrationsolution. We knew that in order for 3rdparty vendors to get this into theirroadmaps in a timely fashion, it mustbe a quick development cycle. I believethat we have accomplished that,”asserts McPhail. “Vendors have many

competing priorities, and based onpersonal experience, developmentpriorities are often based on value anduser demand.”

Access to CPhA drug and

therapeutic content is subscription-based; however, a recent agreementwith Joule™, a Canadian MedicalAssociation (CMA) company, nowprovides a CPS drug contentsubscription to CMA members as anexclusive benefit.

The RxTx Integration Solution fullysupports the Canadian healthcaremarket’s transition from the adoption ofEMRs to ensuring meaningful use.“Adopting evidence-based medicine inpractice has a direct correlation tobetter health outcomes,” says McPhail.“With such high demands for patientvisits, it can be difficult for health carepractitioners to keep up with thecurrent therapeutic evidence andCanadian guidelines. Ensuring theseclinical decision-support tools areavailable directly at the point-of-care,without interruption of practiceworkflow, is critical for both thepractitioners and their patients.”

For more information on the RxTxIntegration Solution, visitwww.pharmacists.ca/rxtxhct.

Introducing the RxTx™ Integration Solution

As the only fully Canadiansolution offering bilingual,Health Canada–approved drugmonographs and therapeuticcontent, our content is criticalto clinicians treating patients,and thus, our online user-basecontinues to grow.


BY HUGH MACKENZIE

EDMONTON – Now in its second year, theAlberta Netcare eReferral program hasshown promising results. A notable featureis the addition of an “advice request” refer-ral rather than a full in-person referral.

“We were told that about 30 percent ofthe time for non-urgent patients, specialistsfeel that they could have given an opinionwithout seeing the patient,” says Dr. AllenAusford, a family physician and proponentof the eReferral solution.

“Adding a feature where care providers

could simply seek advice, rather than de-laying a patient’s care with an unnecessaryvisit, could fix a lot of the gaps in care andincrease in-person referral capacity to seemore urgent patients.”

Dr. Ausford is also an expert in clinicalinformation systems, and recently partici-

pated in an Orion Health webinar outlin-ing the Alberta experience with eReferral.Orion Health, a leading provider of popu-lation health and integration systems, haspartnered with the province in buildingthe Alberta Netcare eReferral solution.

Alberta aimed for an electronic systemwhich would be user-friendly, requiringonly three minutes for GPs to complete areferral, on average, along with the abilityto track a referral’s progress through thesystem.

They also wanted it to connect to theAlberta Netcare system, a healthcare net-work that reaches tens of thousands ofclinicians throughout Alberta. Moreover,the designers sought to include analyticscapabilities so they could identify work-flow and information bottlenecks.

The addition of the ‘advice request’ fea-ture, mentioned above, is an example ofhow workflow – and patient flow – hasbeen streamlined.

Another new feature involves blockingthe submission of a referral unless all theinformation a specialist needs has been in-cluded.

Traditionally,when doctors usedfaxes to communi-cate, up to 30 per-cent of referralswere incomplete.

“The main com-plaint we’ve heardwas that careproviders don’t re-ceive enough infor-mation. So theyhave to send the referral back to the pri-mary-care physician with questions,” com-mented Dr. Ausford.

This led to a lot of back and forth, re-sulting in longer waits for patients to seespecialists.

Some of Alberta’s hip and knee re-placement clinics have reported that anincomplete referral results in the patientwaiting an additional six weeks for an ap-pointment.

But by converting from faxes to com-puterized referrals, many of the delays canbe avoided and the risk of losing referralsis reduced.

Another feature of eReferral allowsusers to update an active referral as a pa-tient’s condition changes, so the patientcan be further moved up the waiting list.

Dr. Ausford recounted a story of one ofhis patients who was dealing with a sorehip for some time as a result of arthritis.A referral for a hip replacement was doneby eReferral.

The patient initially started as a low pri-ority for hip replacement, but when hispain increased to the point of needingdaily narcotics, his situation was updatedin the electronic system.

The referral’s status was changed to ahigher priority, resulting in a reduced waitfor consultation.

In Alberta, the eReferral system is beingsteadily accepted by GPs and specialistsacross the province. It is now servicing re-ferrals for medical/radiation oncology,(breast and lung cancer), hip and kneejoint replacement and nephrology (advicerequest only).

Evolving Alberta Netcare eReferral benefits patients and physicians

Dr. Allen Ausford

Need skilled IT or managerial staff?Try the CHT Job Board!If you’re seeking:• Project Managers & Team Leaders• IT Designers, Programmers & Analysts• Marketing & Sales StaffAdvertise your positions on the Job Board!

Our site is visited by 12,000 individuals each month. These visitors are healthcareprofessionals, with expertise in information technology.

We are also proactively marketing the Job Board with a dedicated, monthly HTMLblast to promote the site, along with ads in our publications – the e-Messenger andTechnology for Doctors Online.

Reach the people with the skills you need!

Modestly priced at $250/month

www.canhealth.com/jobs

h t t p : / / w w w . c a n h e a l t h . c o m1 0 C A N A D I A N H E A L T H C A R E T E C H N O L O G Y F E B R U A R Y 2 0 1 7

EAMINGExpand your technical capacity

and capability

OOLINGSpeed your development process

RAININGDigital health knowledge

and expertise

ESTINGEnsure product success

and compliance

135 Fennell Ave. West | Hamilton, ON | L9C 1E3

Funded by

The Technology Access Centre in Digital Health is part of Mohawk College's mHealth and eHealth Development and Innovation Centre, an internationally renowned applied research centre in digital health.

MEDIC, located in Hamilton, Ontario, Canada, helps companies, start-ups, not-for-profits, and government organizations develop and implement innovative digital health solutions to improve patient care.

Visit www.mohawkmedic.org to become an applied research client. Funding, grants and subsidies are available for eligible Canadian-owned small and medium-sized enterprises.


BY JERRY ZEIDENBERG

Electronic patient records in Ontarioare reaching a critical juncture. Foryears, eHealth Ontario has labored

to connect hospital systems, DI and labs.It’s pretty much accomplished this withthe three regional repositories.

Now, however, the focus is on movingto link the records of community physi-cians into the repositories.

“We started with hospital systems, butnow we’re shifting focus to physician sys-tems,” said Cynthia Morton, speaking inNovember at Infoway’s Partnership Con-ference in Toronto. “There are billions of

data points to take into account. “And thequality of the data will make or break thesystem.”

Morton noted that policy makers andsystem designers alike have recently startedpaying attention to data quality issues.Without high quality data, clinicians can-not make informed decisions.

Moreover, if the quality of the data islow, so is the value of the system – whichnevertheless may have been installed atgreat cost.

The potential value of the data that’sstored in the systems of GPs and specialistsis vast. “80 percent of the data in EMRs isat the community level,” said SarahHutchison, CEO of OntarioMD.

She noted that 13,000 Ontario physi-cians are now using EMRs, and 7,000 ofthem are now receiving hospital reportsand discharge summaries, along with e-notifications and alerts when their pa-tients are admitted to hospitals and whenthey leave.

She observed that when it comes toelectronic solutions, getting things rightand providing workable solutions is para-mount. “Physicians do not have a high tol-erance of risk,” she said.

Dr. David Daien put it succinctly:“When the technology fails, the physicianswill walk – and so will the patients.”

That means there is enormous pres-sure to ensure computerized systemswork the way they are supposed to. Aswell, clinicians must understand howthey work and what they’re supposed todeliver.

Dr. Daien asserted that experts used tosay the technology isn’t important, it’s the

business case that matters. But in fact, thetechnology is very important.

Often enough, systems are piloted inhospitals and clinics, but they don’t workthe same way when they’re rolled out to awider audience.

“Production environments need to beidentical to test beds. And the rolloutsneed to be flawless.”

In the real world, however, things areseldom perfect. No wonder change man-agement services are so important, some-thing that was emphasized by Hutchison.

Nevertheless, non-technological fac-tors can also screw-up a technologicalimplementation. Dr. Daien observed thatin many cases, when a project was readyto go live, he has seen it pulled back bythe lawyers.

“Lawyers don’t like data sharing,” hesaid. “I’ve seen numerous instances of lastminute delays because the lawyers weren’tcomfortable.”

Dr. Daien sees that as a problem.When it comes to privacy and security,“we have to change the mantra. We haveto put the power back into the patients’hands.”

In particular, he noted that proper test-ing of systems has been a problem becausevendors and development teams often arenot permitted to use real-world patientdata in test systems. That means they don’tget a real sense of how the systems willwork in a production environment.

Unfortunately, the systems tend to hitunexpected glitches and roadblocks whenthey go live.

Technology and humans can delay the roll-out of large-scale clinical systems

A RECORD NUMBER OF DELEGATES fromacross Canada participated in the annualInfoway Partnership Conference, inToronto November 16 and 17, duringDigital Health Week.

Partnership 2016, A Conversationabout Digital Health, embodied thetheme in every sense. Not only did thesessions focus on patient-centered dig-ital health, digital health innovation,interoperability and medication man-agement, the discussions both on andoffline mirrored those sessions and re-flected collaborations that are just be-ginning or are ongoing across thecountry.

“It was both encouraging and inspir-ing to see patients, clinicians, vendors,government and other industry leaderschampioning the call for improved pa-tient and consumer access to healthcare,” said Dr. Keith Wilson, FamilyPhysician and Associate Professor, Fam-ily Medicine, Dalhousie University. “Pa-tients first by design resonated in thisconversation, as demonstrated in the keywords that were tweeted.”

Digital health leaders from the UnitedStates, the United Kingdom andthroughout Canada shared experiencesand best practices about clinical leader-ship, serving the needs of Canadians, in-ter-jurisdictional collaborations, opioidmisuse, patient safety and e-prescribing.

Shelagh Maloney, Vice President ofConsumer Health, Communications andEvaluations at Infoway, indicated a notablechange from past conferences was the ‘Pa-

tient Included’ designation. “We wanted todemonstrate a commitment to incorpo-rating the experience of patients as ex-perts”, she said. “Digital health innovationhelps drive better patient experiences andoutcomes; patient as well as clinician in-sights from real world experience are criti-cal as we work toward a more effectivehealth care system.” For more informa-tion on the Infoway Partnership Confer-ence, visit http://bit.ly/2fUstmX.

Insights from a patient-centred Infoway conference

A patient and caregiver panel shares consumer insights with delegates at the 2016 Infoway Partnership Con-ference. (Left to right) Shelagh Maloney, Vice President, Consumer Health, Communications and EvaluationServices, Canada Health Infoway, Jilliane Code, patient, Brian Penner, patient, and Sara Kearley, caregiver.


Eighty percent of the data inelectronic medical records is atthe community level, says SarahHutchison, CEO of OntarioMD.


BY ROSIE LOMBARDI

Everyone says healthcare informa-tion is as precious as financial in-formation – but is it actually pro-tected with the same bullet-proof

safeguards? This was one of many key is-sues discussed at the first-ever CanadianHealthcare Information Governance (IG)Summit held recently in Edmonton, Al-berta, under the auspices of the CanadianHealth Information Management Associa-tion (CHIMA).

Many emerging trends, from the Internetof Things to consumer demand for health-care information, are creating new risks be-cause healthcare information is spilling outof its previously protected domains, saidAndrea Bacqué, Director of Canadian Solu-tions at Iron Mountain, a global businessdedicated to storing, protecting and manag-ing information and assets.

Bacqué is co-chair of the IG Summit’sSteering Committee, along with KathleenAddison, Board Chair, CHIMA and Se-nior Provincial Director, Health Infor-mation Management at Alberta HealthServices (AHS).

“We don’t have or apply standards inconsistent ways for managing informationacross the healthcare ecosystem. Provincesare being driven to develop these them-selves, but each province has their ownview,” said Bacqué. “That might not be thebest scenario for a Canada-wide e-healthobjective.”

Addison noted that policies are frag-mented at the organizational level, too.“Many pockets within organizations man-age their healthcare assets properly, butthere’s very little formalized rigor and con-sistency in the way these assets are treatedacross organizations,” she said.

To help get everyone on the same page,many believed a conference where viewscould be exchanged would be a good idea.

“Information Governance is broaderthan Health Information Management,”said Addison. “We wanted to assemble athink tank of thought leaders around IGso we could collaborate and identifywhether Information Governance is anemerging discipline in the Canadianhealthcare context.”

Several healthcare information expertsand leaders from a number of Canadianorganizations attended the IG Summit, aswell as members from the AmericanHealth Information Management Associa-tion (AHIMA), which has made IG a pri-ority in recent years.

To be sure, said Bacqué, IG needs moreattention in Canada. “CHIMA, with thesupport of Iron Mountain, created a Steer-ing Committee and held the Summit be-cause we felt that this topic needed to beelevated across Canada.”

Proper IG is important as the use of sys-tems and devices expands and becomemore interconnected.

Agreed-upon rules and standards areneeded to ensure trust across the health-care sector as information flows in and outof disparate systems and organizations.

The current state of neglect is creatingproblems that will be difficult to addressin the future, Bacqué said. For example,one issue that Summit participants dis-

cussed was the application of data-map-ping standards when moving to the e-health record state.

“What are the data fields and relateddata mapping standards that we want toconsistently apply to the e-health record sothat when we’re searching for information

on a patient across a province or region, wecan expect to find similar patient informa-tion? At present, nobody is leading in de-veloping Canada-wide data mapping stan-dards. And each e-health system vendorwill have their own approach. This makes ita challenge when you’re trying to create

one record with multiple systems in play.”Some domains of IG are more mature

than others, said Addison. For example, anincorrect patient name in a hospital data-base holds risks – it can prevent searchesfor the right patient’s records, which in

CHIMA aims to boost awareness of Information Governance issues

© 2017 Cerner Corporation

Visit cerner.ca

At the center of everything we do stands our commitmentto improve health and care for the individual. We design our

technologies to be open, scalable and data-driven.And through our global relationships, we create healthier stories of improved care, lowered costs, increased safety,

aligned priorities, long-term value and changed lives – for the organization, the community and the individual.


h t t p : / / w w w . c a n h e a l t h . c o m F E B R U A R Y 2 0 1 7 C A N A D I A N H E A L T H C A R E T E C H N O L O G Y 1 3

BY ANDY SHAW

Radiology has long been lauded as anearly adopter of technology; and di-agnostic imaging departments areamong the most technologically ad-vanced in hospitals. Yet, in manycases, it’s the human touch that can

add value to radiology, and to medicine in general.Closer interaction with patients, and other health-care professionals, is resulting in better outcomes.

Moreover, spreading the word about best practicesand new ideas can also have a tremendous impact.

To that end, Paul Cornacchione, the senior direc-tor of imaging for the tri-hospital Joint Departmentof Medical Imaging (JDMI) in Toronto and others atJDMI have been developing a new program. It offerstechnologists at Sinai Health System, UniversityHealth Network, and Women’s College Hospital thebenefits of academic research, best practice educa-tion, and continuous improvement incentives.

The objective is to promulgate a ‘culture change’among technologists. It is a culture where the normis not just to capture excellent images, but to go fur-ther clinically using new-found knowledge andnewly acquired skills to help raise patient care to asafer, higher level.

To illustrate how that can work to the point ofeven saving lives, Cornacchione tells the story of a re-cent event at Women’s College Hospital, whichtouched him deeply.

“The imaging technologist there was performinga CT scan on a male patient’s brain,” recalls Cornac-chione. “In the past a technologist, as I once was,would have followed the basic routines to con-duct the scan.”

But this JDMI-educated and trainedtechnologist acted differently. To startwith, before the exam he took time tolook at the patient’s history carefully.That extra care with his work pointed to apossibly severe eventuality for the patient. Sothe first benefit was that technologist knew ex-actly what malady in the brain he was trying tofind and capture with his imaging.

“Then after the exam, instead of letting thepatient walk away, the technologist asked him tohold on, saying he thought he spotted somethingin the image that he should check out further,” saysCornacchione.

Sure enough, consultation with a radiologist con-firmed the technologist’s suspicions that the patienthad a potential “bleed” in his head. One that if he hadjust walked out, could have soon killed him.

“In the past and even now, the routine is for sometechnologists to pass the images on to radiologistswithout comment who, in turn, might take up to 24hours to report their findings. Then it’s another 24 to48 hours before the patient’s referring doctor gets theresults. So as many as three days or more might passbefore the patient finds out about his dangerous con-dition,” says Cornacchione. “And from what we nowknow of that particular case, the patient in the mean-time would very likely have died.”

Happily, the technologist’s intervention did notlet that happen. Nor did he let the patient leaveWomen’s College Hospital until he had ordered upan ambulance that sped the patient across-town toToronto Western Hospital’s neurological depart-

ment – where the patient immediately received suc-cessful aneurysm repair.

“What’s important to note, is that rather than justhanding the patient off to someone else, the technol-ogist actually took care of the patient,” says Cornac-chione. “Indeed, the technologist noticed the patientwasn’t doing well even in the waiting room andmight have soon died without really knowing any-thing was wrong with him because there is no painassociated with a potential bleed in the brain. Inshort, the technologist took ownership of that pa-tient, and as a result, saved his life.”

It’s just that kind of care that JDMI is striving to in-still, first of all in its own medical radiation technolo-gists. To that end, the organization conducts a regularlecture series featuring leading academics, researchers,and other figures to unlock the potential of imagingprofessionals and encourage them to go the extra mile.

Participants have included the Ottawa-basedCanadian Association of Medical Radiation Technol-ogists (CAMRT) and its CEO, François Couillard,who was the main attraction at a recent after-hours

JDMI lecture on the evolution of medical radiationtechnologist practices.

“It’s important to understand that medical radia-tion technologists are mostly of two breeds. We haveas CAMRT members both imaging technologists andradiation therapists who work very closely withphysicians, including radiologists, radiation-oncolo-gists and interventional-radiologists in their work.And we also have imaging technologists, who don’t.At least not so much anymore,” says Couillard.

“Back when we used film, the technologist and theradiologist had to get together to look at the film. Sothey did collaborate. But now, all the imaging tech-nologist has to do is acquire the image and pass it onto a radiologist who may be as far away as India.”

The CAMRT is also intent on returning imag-ing technologists to their former closer ties withphysicians.

“Our radiation therapist technologists, who makeup about 10 percent of our members, are much fur-ther down the road. As a group, they may well be the

best in the world when it comes to working closelywith physicians and medical physicists as a collabo-rative team to deliver better care,” says Couillard. “Soas an organization CAMRT is doing a lot to fosterthis type of inter-professional collaboration with ra-diologists as well.”

One way is by encouraging imaging technologiststo take advantage of their teaching hospital environ-ments and do publishable research in CAMRT’s ownScientific Journal or present at its annual conference.

“The year before, our JDMI people had nothingsubmitted to the annual CAMRT conference, but lastyear, in 2016, we had 16 abstracts submitted fromJDMI staff and 14 accepted for presentations. So weare thrilled with that,” said Catharine Wang, JDMI’sExecutive Director.

Wang addressed her remarks to the audience at-tending Couillard’s talk, a group that attended themeeting at the Toronto General Hospital from hos-pitals across the Greater Toronto Area.

Couillard also applauded the 16-abstracts accom-plishment, no doubt the result of Wang’s constant ef-forts at encouraging and facilitating more interactionbetween researchers and JDMI’s 600-member staff.

“What we are doing here may not be for everyone,”admits Wang. “We want technologists working atJDMI who really want to find constant improvementin their work and are willing to look for new ways ofdoing things that research has shown have provenmerit. But not all technologists, I know, are like that.

Those who are content to just producegood images and pass them on, may bechallenged by this direction.”Couillard agrees that the JDMI approachis not for all, but for different reasons. “A program like the one JDMI is devel-oping is something we at CAMRT cer-tainly applaud. And similar programswould be absolutely the thing for otherlarge teaching hospitals to model them-selves on,” says Couillard. “But forsmaller hospitals, or in rural areas, or insome other parts of the country, needsout there can be quite different. Nonetheless, Couillard and Wang areagreed that new imaging techniques, newapproaches to radiologist-technologistcollaboration, even new clinical proce-

dures that may see imaging technologists doing un-precedented tasks like inserting lines into patientscould well trickle out to healthcare institutions of allsizes across the land.

Certainly, future medical radiation technolo-gists of all stripes at all levels will have to be moremulti-skilled.

“One of the trends we see emerging is toward ‘hy-bridization’ as it’s called,” says Couillard “We knowabout this thanks to CAMRT’s Future AdvisoryCouncil, which we formed a few years ago.

The Council invites radiology equipment vendorsto meet with it one at a time behind closed doors andbrief the Council on future trends. Based on thosepredictions, CAMRT makes decisions about chang-ing its educational and other programs to meet ourmembers’ needs.

So once there was just CT, but now as Couillardpoints out, there is hybrid PET/CT, CT/Angiographyand SPECT/CT. Where there once was just MR, there

ED

UC

AT

IO

N

&

TR

AI

NI

NG

The objective is to promulgate a ‘culture change’ among technologists.

A new approach enriches the role of medical radiation technologists

ILLU

STRA

TIO

N:

LIN

DA

WEI

SS



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

BY DIANNE CRAIG

London Health Sciences and localpartner St. Joseph’s Health Careare among the most computerizedhospitals in the country. Indeed,

within a short timeline, LHSC and St. Joe’simplemented Computerized Physician Or-der Entry (CPOE), Closed Loop Medica-tion Administration (CLMA), electronicMedication Reconciliation, and also docu-mented Best Possible Medication Historiesto all of their facilities.

The implementations have gone well –indeed, in the past year, the organizationshave seen a 40 percent decrease in medica-tion adverse events.

Clinicians believe the addition ofCerner’s cloud-based, eCoach educationaltool has helped fill a gap in their learningsystem. The solution was installed about ayear ago, and has been re-named “Learn-Now” inside the two organizations.

LearnNow gives doctors, nurses, phar-macists, and other healthcare professionalsquick, one-stop access to every conceivabletype of EHR training resource. It has en-abled ‘just-in-time’ training and education,when and where the clinicians need it.

With the touch of a button, clinicianscan find out how to perform admissions,create care plans, order medications andexams, and many other procedures.

Prior to the launch of LearnNow, clini-cians were sometimes unsure of the correctplace to find the most up-to-date trainingtools for electronic solutions. It took timeto locate the right training resources – insome cases, clinicians just didn’t bother.

That all changed with the arrival ofLearnNow, which allows training and edu-cational assets to be searched without re-quiring a sign-in or connection to the or-ganization’s internal network.

“I wish this had been available sooner,”says Dr. Robin Walker, Integrated VicePresident, Medical Affairs and MedicalEducation.

In particular, he noted the challenge ofworking in a high-stress environment andhaving to go outside the system to findlearning materials and related information.

“In areas where the pace is fast, you re-ally don’t have time to search for informa-tion, to call someone,” he says, citing theOR and critical care units as examples.

Clinical Informatics Instructor and RN,BSCN, Stephanie Aldridge agrees. “It’s niceto have everything in one spot.” Prior todeploying LearnNow, she explains, theyused to have the information in about sixdifferent places.

The system is itself ‘intelligent’, andhas the ability to perform contextualsearches specific to the user’s role in thehospital. For example, Aldridge says, ifthere were two quick guides relating toone topic – one on how to order, and oneon how to administer, the user would seeon screen only the guide that related tohis or her role.

“It’s very easy to access. The user justclicks on LearnNow, and will see videosand quick guides on what they’re workingon,” says Maureen MacPherson, Profes-sional Staff Relations Specialist at LHSC.“They can click on LearnNow and get theinformation they need, when they need

it,” she says, adding that often leads to ahuge sigh of relief.

There are multiple search options forfinding educational resources in theLearnNow library. Users can perform a fullsite search using key search words that ap-pear in document names or contents;

browse by role by clicking on the naviga-tion link that best describes their role inthe facility. The tool will also bring up re-cent searches, showing the last two areas auser was working on.

LearnNow can also be used to promotespecific content, or new initiatives. When

asked if the LHSC has been using that capa-bility, Aldridge said, “Yes. We can promotecontent. If there are consistent problems orissues – for example if something wasn’tdone properly, I can take an education doc-ument and put it on a ‘carousel’ that ap-pears as a spinning, clickable image.”

Cloud-based system gives clinicians fast access to EHR training assets

It’s the way we put it together that sets us apart!

Enterprise Imaging


BY DR . SUNNY MALHOTRA

Many doctors have excellentideas for apps and medical de-vices and are thinking aboutcreating products and compa-nies. Doing so, however, oftenrequires funding – many pro-

jects go beyond tinkering with software and hard-ware in the basement. You may need to hire pro-grammers, engineers, designers, business developersand marketers. This can be expensive.

Doctorpreneurs are not always familiar with thefundraising process. Some questions that need to beanswered first include: Why am I raising funds?When do I need to fundraise? What are the stages offundraising? Who are my potential sources offundraising? How much do I need to raise and inwhat form? Fundraising is a time limited process thatshould be started to reach milestones instead of sur-viving a time period or run rate.

Doctors who become entrepreneurs, who I call‘doctorpreneurs’, need to understand the fundamen-tal stages of fundraising. These stages include: familyand friends, government funding, seed round, seriesA, series B, etc.

The family and friends round is a way of collectingsmall amounts of capital to create a minimum viableproduct. This can often be blended into a seed roundwhere a minimum viable product is used to begin test-ing your startup hypothesis and create a business. Theserange from $25,000 to $250,000 depending on the run-rate (expenditure) of the company and costs incurredto find product-market fit or to achieve milestones.

Series A rounds are for companies that havereached a level where they have fine-tuned theirproduct and have found product-market fit. Thesecompanies are at a growth stage and are looking toexpand after optimizing their key performance met-

rics. This can be used for marketing, sales and hiringnew employees as an example.

Fundraising can be done via different measures.These include: equity investments, convertible notes, grants and venture debtfunding.

An equity investment is when money isinvested in a business by an entity forcommon stock which is not returned inthe normal course of the business. In-vestors recover it when they sell their

shareholdings to other investors or an asset is liqui-dated/exited.

Convertible notes are for seed investors investingin startups who wish to delay in establishing a valu-ation for that startup until a later round of funding,or a milestone is reached. These are often to offsetsituations where the value of a company is difficultto determine. When a milestone is reached or futureround has been established, the notes convert to eq-uity. There are often additional advantages such ascaps and discounts when a certain valuation hasbeen reached.

Grants can be obtained as government and non-government loans or full grants for companies thatare innovating and disrupting a certain area of needin healthcare.

Venture debt is a debt financing tool provided toback companies to find working capital or

capital expenditures. Venture debt is avail-able to startups and growth companies thatdo not have positive cash flow for signifi-cant assets for collateral purposes. The process of fundraising can be cumber-some and distracting to the operations of

any business. First, you must understand thequestions to be asked and then why you need

the funding. Once these questions are an-swered, you need to dedicate a block

of time to achieve your goals. It isimportant to focus the team

and provide deadlines andmilestones as the processcan become drawn out andyour business can suffer.

VI

EW

PO

IN

T

Fundraising can be done through a variety of measures.

Doctorpreneurs need to know aboutfinancing when they launch companies

Dr. Sunny Malhotra is a US trained cardiologistworking at AdvantageCare Physicians. He is anentrepreneur and health technologyinvestor. He is the winner of Bestin Healthcare - Notable YoungProfessional 2014 and thenational Governor General’sCaring Canadian Award 2015.Twitter: @drsunnymalhotra

Hiring programmers, engineers,developers and marketers can be costly.Doctors-turned entrepreneurs mustknow how to raise funds.

Healthcare needs to measure, prove and demonstrate valueBY SHIRLEY FENTON, SUZANNE

SCHELL, AND HÉLÈNE CLÉMENT

All types of performance im-provement projects have beenundertaken by healthcare or-

ganizations in Canada – and manyof them have failed to live up to ex-pectations. What is needed is a sys-tematic approach to improvinghealthcare, using a proven measure-ment and evaluation process thatgenerates viable outcomes.

Clearly, healthcare organizationswant value for their investments.While ‘showing the money’ is theultimate report of value, leadersrecognize that they must also show value as perceived by allstakeholders.

Organizations need a methodol-ogy that:

• Identifies where and how to im-prove programs

• helps improve investment decisions• identifies barriers and enablers of

success• measures the monetary value re-

ceived for investing in programs andprojects

• identifies intangible outcomes forpatients and stakeholders.

Many organizations all over theworld use the Phillips ROI Methodol-ogy, which is a straightforward step-by-step process to show the value thatgenerates a balanced set of data thatis believable, realistic and accurate –particularly from the perspective ofsponsors and key stakeholders.

The ROI Methodology is a com-prehensive measurement and evalua-tion process that collects, analyzesand reports data in a consistentmanner (see Figure 1).

Several types of measures are col-lected, including participant satisfac-tion with the program, changes inknowledge, skills, and attitudes re-lated to the program, changes in on-the-job behaviour or actions as theprogram, and changes in businessimpact variables.

The process also compares mon-etary benefits to the costs of theprogram, project or improvement

initiative (Return On Investment)and measures that are not convertedto monetary values (IntangibleMeasures).

This balanced approach to mea-surement includes a technique toisolate the effects of the program,project or solution.

Healthcare organizations, whichhave used ROI studies to evaluate

projects, have realized the benefits.In one study, a Health AuthorityPhysician Compensation Planningand Initiatives department wasformed in 2011 based on an InternalAudit recommendation.

After a few years, the staff be-lieved that the department had a sig-nificant financial and non-financialimpact on the organization but

wanted to undertake an evaluationto tangibly confirm this belief.

An ROI study was undertakenand confirmed that the PhysicianCompensation Planning & Initia-tives department had a significant fi-nancial impact, confirmed by anROI of 631 percent, which also pro-duced a number of intangible bene-fits for the organization and itsstakeholders.

As a result, recommendations in-cluded continued support of theteam’s mandate and dedicated pro-gram resources; expansion of theteam’s philosophy and collaborativeapproach to other program areas;and the creation of a similar team inother Health Authorities based onthe demonstrated results.

In another example, an organiza-tion undertook an initiative to pro-vide patients with a better experi-ence, including: reduced length ofstay, reduced chance of infection andincreased comfort.

ERACS Pathway (Enhanced Re-

Healthcare leadersrecognize they must showvalue as perceived by allstakeholders.



V I E W P O I N T

BY JERRY ZEIDENBERG

CHICAGO – In this new era of com-puters powered by Deep Learn-ing, many at the Radiology Soci-ety of North America meeting

last November were nervously joking aboutwhether the machines will replace physi-cians in the future. Most agreed that com-puters will remain assistants to radiologistsand other doctors, at least in the near term.

But already, computers are making di-agnoses. In November, Zebra Medical Vi-sion, based in Israel, launched a free ser-vice called Profound (http://profound.ze-bra-med.com) that enables patients to up-load diagnostic images to its cloud server,where an artificially intelligent system willmake a diagnosis.

It’s aimed at patients in Europe, Asia, thePacific Rim and Latin America. All youneed to do is upload CT scans or mammo-grams and the system will scan for prob-lems. It serves as a second opinion, and alsoas a way of identifying key issues that mayhave been overlooked by busy radiologists.

“It’s not that radiologists aren’t doingtheir jobs,” said Zebra’s chief medical offi-cer, Dr. Eldad Elnekave, an interventionalradiologist working in Israel. “The radiolo-

gist might be focused on appendicitis, andwill not be looking for other problems. Heidentifies appendicitis, and his job is done.”

However, the Profound system, usingDeep Learning, may spot any number ofother issues in the scans, including:

• Aortic aneurysms• Emphysema• Osteoporosis• Compression fractures• Fatty liver• Coronary calcium• Breast cancer (Zebra Medical has an-

nounced breakthrough algorithms forbreast cancer, and will be adding them infuture to the Profound system.)

Zebra Medical was started just twoyears ago, and has a team in Israel develop-ing algorithms for medical image analysis.For breast cancer alone, it is using ananonymized database of 344,000 images.The company is backed by venture invest-ments from computer industry titans likeMarc Benioff, the CEO of Salesforce, aswell as contributions from Khosla Ven-tures and the InterMountain HealthcareInnovation Fund.

Dr. Elnekave doesn’t believe that com-puters on their own can make accurate di-agnoses, each and every time. Instead, theycan act as screening tools and intelligentassistants for radiologists.

“We see the system as empowering a ra-diologist to see deeper, to see more and tosolve puzzles,” he said. “I’ve always beentrained by radiologists who have been ableto put together seemingly unrelated infor-mation to arrive at a diagnosis. I can’tfathom a computer doing this.”

However, he asserted that Deep Learning

systems allow radiologists to provide moreservices to growing populations. It could be-come a ‘killer app’, as demand for diagnosticimaging is expanding faster than the cohortof skilled physicians able to do readings.

Elnekave highlighted the ability to flagproblems that are often overlooked indaily practice. For example, in the UnitedStates, nearly 2 million osteoporotic bonefractures occur each year.

“After a hip fracture, 30 percent of pa-tients die within a year, and 50 percent areno longer independent,” said Dr. Elnekave.

Osteoporosis can be identified andtreated, but the bone density exams thatare required have a low compliance level.

Zebra Medical has devised an algorithmthat can spot osteoporosis in CT examswhen patients are being scanned for otherconditions; the radiologist is then alertedin the course of his or her reading. The al-gorithm is now being used in the UnitedStates by radiologists at USARad.com, atelemedicine company that provides DIreadings in 50 U.S. states and 10 countries.

Zebra Medical is providing its softwareand services to other organizations, aswell, that are using it for clinical decisionsupport and automated second opinions.

Deep Learning assistants can also be ofgreat help to radiologists who are over-loaded with readings: “A radiologist at 5pm is not the same as he was at 8 am,” ob-served Dr. Elnekave. The AI-powered com-puter can ensure that he’s spotting every-thing that he should.

Of course, at the RSNA meeting a greatdeal of the buzz about Deep Learning fo-cused on IBM’s Watson Health, which isconsidered the leader in applying artificialintelligence to medicine.

The team at Watson has been devisingradiology assistants and clinician assis-tants, both powered by the Watson super-computer and its artificial intelligence.Real products are scheduled to appear thisyear, in 2017.

Of note, is a peer review system for ra-diologists that could be used by radiolo-gists to scan and provide feedback on eachand every exam read by a radiologist,thereby providing continuous educationand support.

Most peer-review systems today useworking radiologists to assess the exams of

their colleagues, but only one study a daymight be checked. Computer-poweredWatson could do every exam, experts atIBM noted.

IBM recently acquired Merge Health-care, which gave it a collection of 35 billionimages to use for developing computerizedexpertise in analyzing images. The reposi-tory of images has been a boon to Watson,which uses Deep Learning to provide diag-noses and suggested therapies.

IBM demonstrated at the RSNA howthe system works – analyzing images andpatient records to produce diagnoses,which are also scored to show their likeli-hood of accuracy. A clinician can thenagree or disagree with the diagnosis.

Another titan that’s targeting DeepLearning in medicine is GE Healthcare.GE has launched its own healthcare cloud,and it is also devoting resources to artifi-cial intelligence.

One artificially intelligent system is pri-oritizing exams for radiologists on the ba-sis of urgency. GE Healthcare is workingon this now in research projects with

Boston Children’s Hospital and the Uni-versity of California at San Francisco.

“We know that 85 percent of lung ex-ams are normal,” said David Hale, presi-dent of Enterprise Imaging Care DeliveryManagement at GE Healthcare. “We areusing machine learning at UCSF to deter-mine which are urgent and which are not.”

In that way, radiologists can first con-centrate on the 15 percent of exams thatappear abnormal.

And at Boston Children’s, the project iscreating an expert system that can lend as-sistance to other hospitals – or countries –experiencing a shortage of expertise in pe-diatric brain imaging. “We’re also tyingthe diagnoses to outcomes, so we have abetter understanding of treatments thatare most effective,” said Hale.

For its part, Agfa HealthCare demon-strated a tight integration to IBM’s WatsonHealth that automatically culls a patient’selectronic health record and brings up rele-vant information when a radiologist – or acardiologist – is looking at images. It’s partof Agfa’s new partnership with IBM, and itdeploys Watson for this purpose.

“It’s very useful to see a patient sum-mary, but 90 percent of the time, radiolo-gists and cardiologists won’t go into theEHR,” said Brad Generoux, product man-ager, Enterprise Imaging, Clinical Analyt-ics at Agfa HealthCare. “It’s too muchtrouble to go into another system, andthey’re under time constraints.”

However, Agfa is now using Watson tobring that information into the work-flow. For example, if you’re a radiologistdoing a prostate study, Watson will besure to include a history of lab results inthe summary.

“Watson is looking at whether you’re aradiologist or a cardiologist, and bringsyou a one-page summary based on whatyou need,” said Generoux.

“And we’ve reduced the time it takes toone mouse-click,” commented JasonKnox, Solutions Manager, EnterpriseImaging, at Agfa HealthCare.

IBM’s Watson Health Imaging showed how it can diagnose medical images and suggest possible therapies.

Deep Learning and machine intelligence poised to take on radiology

turn can compromise patient safety andhave other adverse effects.

“There’s a lot of emphasis on theprivacy and security domain, but if youlook at data quality, there’s a hugeamount of work there.

Common data standards, with theappropriate metadata, are ultimatelyneeded to enable systems to interoper-ate.”

Three central questions were dis-cussed by participants of the IG Summit:

• Why is healthcare IG important inCanada and why do we need it now?

• What should be included in theCanadian IG definition and framework?

• What recommendations can bemade to the CHIMA board to helpthem champion and examine this do-main of practice?

The participants provided a great

deal of valuable input, said Bacqué.“What we plan to do next is to create apositioning paper on the insights gath-ered at the Summit that can be deliveredto various healthcare governing bodies.The IG Steering Committee,

CHIMA and Iron Mountain plan tofurther develop recommendationsbrought forward at the Summit, specificto championing an IG definition andframework.”

Various parties need to collectivelycome together at the federal, provincial,regional and local levels to help developIG, she adds.

“Ideally, there would be national sup-port on the creation and/or adoption ofthe standards that should be adhered toon how to govern and manage informa-tion across Canada. This isn’t anythingwe need to create from scratch, as thereare already international models wecould use as starting points.”


CHIMA aims to boost awareness


While Deep Learning machineswon’t replace radiologists in thenear term, they can serve aseffective screening systems.

BY DIANNE DANIEL

A56-year-old patient visits her familydoctor to discuss a recent decline inher short-term memory. She leavesthe appointment with a handwrittenrequisition for a CT scan. Delve be-neath the surface and you learn the

patient suffered a closed head injury in a motor ve-hicle accident 25 years earlier and remained in acoma for six days. The treating neurologist at thetime mentioned early onset of dementia as a possiblefuture outcome.

Review the best evidence and guidelines for or-dering imaging tests, including the latest researchconnecting dementia to traumatic brain injury, andyou find that perhaps a CT scan is not the most suit-able exam under the circumstances. When her resultscome back as “unremarkable,” you can’t help won-dering if she could have avoided the test – and its ac-companying radiation exposure – altogether.

In other words, was the right imaging test re-quested at the right time?

Appropriateness of diagnostic imaging is a com-plex issue that various Canadian medicalgroups are examining. Though no large-scalestudy exists, research suggests the number ofinappropriate imaging referrals carried out inthis country ranges from 2 percent to as high as30 percent, depending on the type of test andjurisdiction. Removing even a small percentageof those exams is expected to deliver cost sav-ings, improve patient safety and ensure thatlimited resources are put to the best use.

Appropriate Use Criteria (AUC) is a startingpoint and several organizations are currentlyinvolved in creating guidelines to promote ap-propriate use of diagnostic imaging exams.Compliance, however, remains a struggle.

“We’ve had referral guidelines out for manyyears. We’ve revised them but the reality is theysit on the shelf or they sit in a computer – theyjust don’t get used,” says Dr. William Miller, pres-ident of the Canadian Association of Radiolo-gists (CAR.)

CAR is hoping to change that. The associa-tion is currently in discussion with CanadaHealth Infoway and others, including peer as-sociations around the world, to discuss thepossibility of partnering to work on appropri-ate use solutions. One answer is to offer refer-ral guidelines in digital format at the point ofcare; this would be done by adding a decisionsupport component to the computerized physicianorder entry (CPOE) portion of electronic medicalrecords (EMRs).

In the scenario of the patient suffering short-termmemory issues more than two decades after her headinjury, a decision support tool would intervene at thepoint of care to alert her doctor to pursue a differentline of testing. The CT scan request would be placedelectronically instead of on paper and would be in-stantly vetted against a set of robust guidelines in thecontext of the patient history. The doctor would bepresented with an alternate recommendation basedon the best evidence.

“The idea is that this becomes the normal work-flow,” says Dr. Miller. “There’s obviously change man-agement that has to go on for people to learn and ac-

cept how to work in this system, but it’s being done inmany places in America now and it’s working.”

In the U.S., providers must meet requirements ofthe AUC program initially set forth in the 2014 Pro-tecting Access to Medicare Act (PAMA). By January1, 2018, they must consult a clinical decision supportsystem for advanced diagnostic imaging in order toreceive reimbursement.

Canadian providers aren’t faced with the samecompelling business case, but the consensus is thatmore appropriate use of diagnostic imaging will leadto better outcomes for patients while reducing un-necessary risk from radiation. It will also help to curbinstances of benign ‘incidentalomas’ – incidentalfindings that must be investigated once discovered,leading to further testing since clinicians face thechallenge of proving they are harmless.

Toronto-based MedCurrent Corp. is one decisionsupport software company working to deliver on-de-

mand evidence-based guid-ance to ordering physicians.The initial idea for its soft-

ware platform came from

founder and chief medical officer Dr. Stephen Her-man, a veteran thoracic radiologist who currentlyserves as associate professor at the University ofToronto Faculty of Medicine.

While reporting CT scans at The Princess Mar-garet Hospital in 2003, Dr. Herman noticed a signif-icant number “didn’t seem to be helpful for the pa-tient.” After enlisting the help of a colleague to con-duct a detailed study on a specific patient group, andfinding similar results, he identified an opportunityto present referral guidelines to ordering physiciansin a far more efficient manner, with the goal of en-suring the right test is ordered at the right time.

MedCurrent’s Orderwise platform is based onthree essential components: ordering, analytics andauthoring (customization). First and foremost, and

under the banner of ordering, the software is inte-grated with existing EMRs such as Cerner, Epic andGE Centricity, so that a screen pops up within theEMR at the time a request for an imaging test is made.

At a high level, integration means the screen is al-ready populated with relevant patient informationgleaned from existing health records and that anynew information collected throughout the process ofconducting the exam is passed back to the EMR tobecome part of the patient’s permanent record.

From the start, MedCurrent developers workeddiligently to structure existing referral guidelines in amanner that makes them more accessible to physi-cians, including limiting the number of questionsasked to determine the most appropriate test for apatient. “We virtually never ask more than two ques-tions in order to get to the recommendation,” ex-plains Dr. Herman. “It’s often one, sometimes two,but never more than two steps. That was a big effortto structure the knowledge in that way.”

The platform also provides a brief explanation tooutline why one imaging test is preferred over an-other. Physicians can click on the explanation to view

the underlying reference information appliedto the guideline. “It’s very important for the ordering physiciansto understand why the system may be askingthem to change from what they thought wasthe best test to what is the best test,” says Dr.Herman. Because of that feature, the softwareis approved for Continuing Medical Educationcredits by the Royal College of Physicians andSurgeons of Canada, he adds.The two other primary features of Orderwise –analytics and authoring – refer to the system’sability to capture and analyze information re-lated to system utilization, and its ability to al-low for local customization by authorizedusers. “There’s often some grey to these guide-lines; they’re not absolutely black and white,”he says, noting that one group of physiciansmay prefer ultrasound to investigate a partic-ular indication while another group may pre-fer MRI or a CT scan. “If you find a lot of peo-ple are disagreeing with a particular guideline,or a lot of doctors are ordering tests that thereare no guidelines for, you might want to adjustthe guidelines or write new ones,” he adds.Medicalis Corp. is another company workingto tackle appropriate use challenges related toimaging. Headquartered in San Francisco witha Canadian office in Kitchener-Waterloo, Ont.,it offers imaging workflow, decision support

and referral management solutions designed to auto-mate and manage the process of getting the rightimaging test referred for the right patient at the righttime. Medicalis chief medical officer Dr. JonathanDarer agrees that physician engagement is imperative.

“One of the big dangers for decision support imple-mentations is when everybody views this as a simple ITproject and they hand the keys over to a bunch of ITpeople and say ‘It’s perfect, just put it in,’” says Dr. Darer.

Part of the problem boils down to semantics. Ratherthan using words like decision support, Dr. Darer sug-gests focusing on quality improvement, referring toimplementations as “low back pain quality improve-ment projects” or “headache improvement projects,”for example. “It’s about clinical care, and we’re going tofocus our attention on making sure we all have the

FE

AT

UR

E

RE

PO

RT

Addressing inappropriate imaging could improve patient outcomes, save money and speed up wait times.

Canada trails US and other countries indecision support for diagnostic imaging

ILLU

STRA

TIO

N:

LIN

DA

WEI

SS


right information needed to assess the pa-tient’s status and whether or not imaging isappropriate,” he says.

Similar to MedCurrent, Medicalis fo-cuses a great deal of effort on both devel-oping and interpreting evidence-basedguidelines, and building the logic to trans-late that information into clinical recom-mendations. The company’s imaginglearning network meets weekly to discusscurrent best evidence and how it impactsclinical activity.

“A neurosurgeon who is seeing a patientwith a headache is a very different clinicaltask than a primary care doctor seeing a pa-tient with a headache,” explains Dr. Darer.“You want to be able to adjust your workflowto both the provider and the patient need.”

Medicalis places a priority on integra-tion, using existing data assets from EMRsand other sources to automatically popu-late its decision support tool with relevantinformation, which in turn helps with indi-cation capture. “When we get into interact-ing with the physician, we don’t want to doit as a static process based on guidelines, wewant to do it as a dynamic process based onwho that doctor is and who that patient is,”says Dr. Darer. “There’s nothing more de-moralizing for a provider than to see that apatient is a smoker in their chart and beforced to answer that question in a decisionsupport tool. It should know that already.”

In 2016, neither Medicalis nor MedCur-rent reported a Canadian customer, butboth companies indicated a high degree ofinterest from Canadian hospitals in theirproduct offerings. One reason for sloweradoption rates in Canada compared to theU.S. is the lack of a clear business case,since Canadian healthcare organizationsdo not face the same deadline as set out byPAMA, says Dr. Herman.

“One, healthcare is extremely slow inadopting technology as an industry. Two, Idon’t think people have appreciated thesize of the problem. And three, it’s not aclear business case here just because of theway healthcare is funded,” he says.

Even if the instance of inappropriateordering of imaging tests is as low as2 percent on average, significant sav-

ings are available if the issue can be ad-dressed through decision support, he adds.The Los Angeles County Department ofHealth Services is using MedCurrent tech-nology in its hospitals, for example, andrecently reported a savings of US$900,000in one year solely by applying decisionsupport to help guide MRI requests relatedto the investigation of lumbar spine pain.

“The use of a system like this is good forclinical reasons, for financial reasons, forpolitical reasons,” says Dr. Herman. “If thegovernment says we’re making a cut topayment for healthcare, people will get upin arms. But if it says we’re not paying forservices that don’t help the patient, it’shard to argue about that.”

Dr. Miller believes one developmentthat may prove to kick-start decision sup-port implementations in Canada related toimaging workflow is the sheer penetrationof EMRs. Canada Health Infoway reportsthat electronic health record data is nowavailable for 93.8 percent of Canadians,with 77 percent of primary care doctorsusing EMRs to record patient encounters.

“We’ve been talking to Canada HealthInfoway and we could partner with them

in the process because they’re interested inthe same outcome: to have the most ap-propriate request coming forward and tomake clinical decision support available tothe largest share of family physicians aspossible,” he says. “We think they may havethe reach, the network and the ability tohelp us get this out across Canada.”

CAR has also been invited to collabo-rate with other associations to develop a

robust and thorough set of guidelines, in-cluding the American College of Radiol-ogy and European Society of Radiology.

“The process is resource intensive andfor everybody around the world to be do-ing it separately doesn’t make sense any-more,” says Dr. Miller.

Both MedCurrent and Medicalis allowfor the use of multiple guidelines, accord-ing to user preference. MedCurrent ex-

tends beyond radiology to include cardiol-ogy and cancer care rules, and is currentlytalking with a partner regarding rules forlaboratory tests as well.

“If you’re a hospital that wants to put itin for radiology, before you buy a systemmake sure you get one that can be ex-tended because we believe the odds aregood that doctors are going to want that,”says Dr. Herman.

M E D I C A L I M A G I N G

As our market transforms, new challenges bring new opportunities.

Introducing Siemens Healthineers – combining deep engineering know-how with a pioneering spirit that boldly embraces the future.

In addition to ground-breaking technologies in medical imaging, laboratory diagnostics, and clinical IT, we offer an expanding portfolio of advanced therapies and molecular diagnostics, as well as new enterprise services. All to help healthcare providers improve patient outcomes while reducing cost.

Along with our new name comes a renewed commitment. We will do all we can to enable our partners’ success, because that is what partnership is all about.

Learn more at siemens.ca/healthineers.

© Siemens Healthcare Limited, 2017.

Engineers solve problems. Pioneers break new ground.

Siemens Healthineers does both.



BY THOMAS HOUGH

Iattended the annual RadiologicalSociety of North American confer-ence in Chicago last November. Tobe succinct, in my opinion, it was

neither a boom nor a bust. However,from the perspective of healthcare IT indiagnostic imaging, there were a numberof hits and fumbles. Here is one person’sobservations.

Hits this year include:• Karos Health, from Waterloo, Ont., and

Vital Images joining forces in a buyout tooffer a solution with advanced functional-ity. In my opinion, the system surpassesmany other vendors in the VNA and zerofootprint web-viewer market;

• TeraRecon is now offering 3-D printingdirect from their server-based zero-foot-print apps, which is changing the diagnos-tic and surgical planning process signifi-cantly. It will have huge patient outcomebenefits going forward for years;

• McKesson has Conserus to image-en-able the EMR and provide optimizedimaging workflows and clinical effective-ness. This is one of the better image/reportdistribution web-viewers (zero-footprint)available on the market today;

• Intelerad continues to offer one of themost cost-effective VNA and image view-ing solutions, and it attracts many radiolo-gists to Intelerad once they see the applica-

tion. The net result? It is worth your timeto call them for a look at the benefits of su-perior workflow, diagnostic applications,and low capital and operational costs onthis Canadian built solution.

• Lexmark continues with content man-agement and one of the most well-devel-oped VNAs in the marketplace. Neverthe-less, Canadian institutions appear to beslow to adopt this approach, even thoughit a proven technology with overall costreductions.

• Carestream has added a check-in kiosk toimprove staff productivity and workflow,resulting in less time spent by patients;

• Visage Imaging, with their enterprise-wide imaging and advanced imaging ap-plications, are now starting to make sometraction in Canadian hospitals. It is a hit tosee Canadian institutions seeking out andembracing vendors with different ap-proaches to solving long-standing prob-lems, and Visage has new solutions.

Interesting!• The best-executed strategy seen at

RSNA 16 is from IBM and the partneringthey have done with a large number ofOEM vendors. They are providing Watsonacross a wide variety of DI applications,thus not forcing clients into buying from asingle vendor in order to get access to Wat-son and the different applications andfunctionality it can be configured to offer.

• And excitement is building at Siemens

about the Healthineers spinoff. The com-pany will be able to do its own thing as anindependent, and says it will have fasterproduct launches and more innovations.We’ll see what the future holds.

Fumbles?• Fuji – In 2015, the company demon-

strated a compelling shift in their technologywith server-side, web-enabled rendering ofall applications for RIS, PACS, Advanced Vi-sualization and VNA, thanks to their acqui-

sition of Teramedica.At RSNA 16, whenvisiting their booth,their messaging wasconfusing, resultingin a missed opportu-nity. Fuji didn’t evenconfirm if the RSNA2015 apps were deliv-ered by RSNA 2016.Oops!• Philips – For me, itwas a surprising dis-

appointment. It appeared to be a great jobof re-packaging what they have had for thepast couple of years under new names andwith a different message. Some might ask,“Where’s the beef?”, to use an old advertis-ing phrase.

Meanwhile, GE and Agfa kept theirannual tales current with incrementalimprovements and changes in the realmof healthcare IT. An evolutionary strat-

egy rather than revolutionary – so no bigsurprises;

RSNA officials chose not to provide dailyattendance updates, but instead providedonly an advance-registration number:48,888 for total advance registration and23,656 for the professional advance registra-tion sub-segment. These numbers likely in-creased slightly by the end of the conference.

2015 and 2016 were similar in atten-dance volumes but lower than 2014 atten-dance. However, there may have been dif-ferences in how the numbers were aggre-gated since 2014, so it is difficult to make atrue comparison.

What is of real interest this years andshows the health of the industry is thegrowing number of exhibitors at RSNA2016: 691 companies. And 105 of the com-panies were first-time exhibitors. Thiscompares with 656 vendors at RSNA 2015,of which there were 94 first-timers. It sug-gests the start-up innovator companies areincreasing; to be sure, some new entriesinto the market can only be a good thing.

My prediction for RSNA 2017? Kazan –constant and never ending improvementon all fronts.

Thomas Hough is President of True NorthConsulting & Associates, a Diagnostic Imag-ing consulting company based in Missis-sauga, Ont. For more information, see:http://truenorthconsult.com

New tools will assist radiologists in an era of increased pressures BY DR . DAVID KOFF

PACS: the final frontier. TheImaging Enterprise mission isto explore new functionalities,to improve life and to boldlygo where no radiologist has

gone before. Does it sound familiar?With the fantastic new capacities of ourenterprise imaging solutions, we are nowreaching the edge of the galaxy, incorpo-rating new functionalities which willcontribute to improving the patientimaging journey.

The leading theme at RSNA 2016,held last November in Chicago, was“Beyond Imaging: The Future ofHealthcare Delivery”. Much of the buzzwas about Watson and the amazing de-velopments in Machine Learning andArtificial Intelligence.

A Watson demonstration on the showfloor invited radiologists to competewith the machine to see how effective acomputer could be at processing textualand non-textual information whenreaching a diagnosis.

Will the radiologist ultimately be re-placed by a machine? That was thetheme of an overcrowded debate, andeven if some are worried about losingtheir jobs, the overall impression is thatmachine learning will help and not re-place the radiologist.

Less spectacular but more practical isa breakthrough development, focused onimplementation, which has helped

greatly in reaching the new frontier:FHIR, which stands for Fast HealthcareInteroperability Resources.

FHIR is a next-generation standardcreated by HL7 for exchanging health-care information electronically, in orderto make Electronic Health Records easilyavailable. FHIR combines the best fea-tures of HL7 v2, v3 and CDA, whileleveraging the latest web standards.

FHIR is constituted of Resources,which combined, address most of thecommon use cases. FHIR can be used fora wide array of applications: mobilephone applications, cloud communica-tion, Electronic Health Records datasharing, etc. (For more information, seeFHIR: https://www.hl7.org/fhir/sum-mary.html)

Easier and faster access to and ex-change of information are making newapplications part of the patient journey,improving efficiency and efficacy before,during and after imaging.

Before imaging:• e-Scheduling: why can we book a

flight easily on-line and not a radiologyappointment? More radiology clinics andhospital departments are offering thistype of service and this will certainly ex-pand quickly, even if complex procedureswill still require interaction with a book-ing clerk. More importantly, in a countrywhere wait times for CT and MR are solong, in the absence of private sector al-ternatives, e-Scheduling will help to book

the first available appointment in the re-gion by giving access to multipleproviders.

• e-Referral: tied to Clinical DecisionSupport, and integrated within the EMR,e-Referral solutions allow healthcare pro-fessionals to order the right test at theright time for the right patient, in thelarger context of personalized medicine.e-Referral is tied to other applicationswhich will bring the relevant informa-tion required to the physician and radiol-ogist, such as creatinine levels, eGFR, etc.

Clinical DecisionSupport has beenin the works formany years, butnew developmentsand country-wideinitiatives willmake it real. • e-Protocolling: Akey improvementto quality and ap-propriate exam re-ferrals is proto-

colling, which is tied to e-Scheduling ande-Referral. This tool allows radiologistsor technologists to protocol studies ac-cording to the level of priority (urgencyas well as WTIS Priority) and the type ofimaging protocol required to make surethat the right test is performed with theappropriate imaging protocols. This re-duces the need to call patients back foradditional exams or contrast-enhancedstudies. It also ensures that the right per-

sonnel are available to perform the examand that the appropriate time has beenscheduled, which helps with efficient useof costly imaging equipment, such as MRand CT.

• Workflow Management: with increas-ing pressure on radiologists, from in-creasing volumes to faster turn-aroundtime expectations, intelligent load bal-ancing is becoming a requirement to im-prove efficiency in busy radiology de-partments, leveraging on available capac-ity to complete the work.

During imaging:• EHR integration: with a considerable

step forward in HL7 communication,data aggregation is now much easier anda number of applications can now ap-pear in the front end, providing the ra-diologist with clinical information anddata from multiple sources, such asEHR, EMR, RIS, PACS, LIS, etc. Filterscan be applied to ensure relevance, im-proving efficiency for the radiologist,who doesn’t have to go through multipleinterfaces anymore.

• Foreign Exam Management (FEM):seamless integration of exams performedat other institutions in the reporting ra-diologist workflow is a must to performside-by-side comparisons and assess dis-ease progression. All aspects of FEMmust be taken into consideration, such aspre-fetching, patient reconciliation andpurging from the local database.

• Peer-Learning (or Peer-Feedback,

RSNA 2016: Some hits, a few fumbles and squandered opportunities

Dr. David Koff


Thomas Hough


BY JERRY ZEIDENBERG

TORONTO – The Joint Depart-ment of Medical Imaging,which manages DiagnosticImaging and InterventionalServices for three downtownToronto hospitals, has not

only developed its own peer review soft-ware system for radiologists, it has also ex-panded the system to embrace technolo-gists, as well.

That’s expected to expand the level ofexpertise among the JDMI’s DI profes-sionals, who are already considered amongthe most advanced in radiology in Canadaand around the world.

“All imaging activities need to havesome form of quality control,” says Cather-ine Wang, the Executive Director of theJDMI, which includes the UniversityHealth Network, Sinai Health System, andWomen’s College Hospital. “This is deter-mined by the image quality from technol-ogists and the accuracy of the image inter-pretation by the radiologists. Our peer re-view program, called Coral Review, sup-ports multidisciplinary continuous learn-ing for technologists and radiologists inquality improvement.”

Not only will the system be used toidentify misses and near misses made byradiologists and technologists, but it is alsoan effective way of spotting best-practices

and spreading the word among imagingprofessionals.

That’s because reviewers will see thehighest-quality exams, too, said Wang, andthey can learn how the images were cap-tured at the regular Quality Rounds. These

results can be discussed by Quality Leadsand shared amongst technologists.

Paul Cornacchione, Senior Director ofImaging Operations for the JDMI, ob-served that reviews of the work of radiolo-gists and technologists are now being doneeach day.

As the reviews of technologists are new,having just started in 2016, the system onlylooks at X-ray technologists. However, itwill soon be expanded to embrace othermodalities, as well.

And another innovation being pio-neered at the JDMI is an alliance with theMichener Institute, an educational centre,to teach technologists how to review theirpeers effectively.

“The idea is not to be punitive, but tofoster improvement,” said Cornacchione.He noted the work with the Michener In-stitute, which was folded into the Univer-sity Health Network last year, will includeworkshops and simulations, where QualityLeads can learn useful methods of review-ing their fellow technologists.

Cornacchione said that issues for tech-nologists often include the proper posi-tioning of patients, optimal or sub-opti-mal imaging, and studies that are missingimages.

The reviews are also a form of clinicalquality control – when images are found tobe missing from a study, they can betracked down and appended to the file.

Cornacchione commented that UHN,through the expanded peer review pro-gram, is acknowledging the importance oftechnologists in diagnostic imaging. “Notonly does the quality of imaging dependon the techs, they are doing more andmore,” he said.

Technologists are giving clinical feed-back to radiologists, in some cases, wherethey spot unusual things in images. Aswell, techs are being trained to do a widerrange of procedures, such as inserting vas-cular lines and performing biopsies.

They’re highly trained to begin with –often they are graduates of four-year-long educational programs. And by con-

ducting more procedures, they are takingthe pressure off overloaded physiciansand nurses.

“There’s an enormous amount oftraining involved for technologists,” saidWang. “And they’re providing a criticalfunction.”

But as with all clinical processes, theJDMI believes the continuous oversightand improvement will help all involved –technologists, radiologists and patients.

The JDMI developed Coral Review inthe same way it created its own worksta-tion for diagnostic imaging – it was dissat-isfied with the systems that were availablein the commercial marketplace.

So a team led by Leon Goonaratne, Se-nior Director of Informatics, JDMI, pro-duced its own solutions. These systemshave proved so useful that other hospitalsare now deploying them.

Trillium Health, in Toronto, is now us-ing Coral Review, as is the Niagara HealthSystem. Moreover, North York GeneralHospital and St. Michael’s Hospital alsoadopted the solution in 2016.

Wang noted that the Ontario govern-ment is eager to see quality controls imple-mented in radiology and other hospitaldepartments across the province, andCoral Review may help.

The plans include more than diagnosticimaging, too. Goonaratne says there havebeen discussions to expand the use ofCoral Review to include pathology andcardiology.

The peer review system can be cus-tomized to suit various ‘ologies’, as well asto the needs of various hospitals andhealth regions.

“The software lets you do reviews basedon rules,” observed Goonaratne, and those

rules can be modified to suit the needs ofthe users – in various regions and for dif-ferent clinical purposes. As well, a data an-alytics system can be attached, to captureknowledge about how clinicians and tech-nologists are functioning as individualsand as a group.

Coral Review appeals to other hospitalson a financial basis, as the JDMI isn’t run-ning the effort as a profit-making busi-ness. Instead, is geared toward system-wide improvement.

“We don’t charge for the software, butusers do pay for the costs of implementa-tion,” said Goonaratne. “We’re chargingjust enough to have a little to put back intodevelopment.”

He said that all users are given softwareupdates and improvements, which comeout on a continuous basis. As well, the de-velopment team at the JDMI accepts re-quests for new features from the new users,which helps with the overall quality andusefulness of Coral Review.

“We could charge more, but our aim is-n’t to make profits,” says Wang. “It’s to im-prove the quality of care and patient safetythroughout the province.”

formerly Peer-Review): Peer-Learningis a preferred term, as it outlines theneed for the process to be educationaland non-punitive. It is not designed tosingle out poor performers but insteadto make the radiology community ben-efit from common errors and makesure that they don’t get repeated. Thisis a requisite for Quality Improvementand even if we are still waiting for for-mal provincial recommendations, moreand more sites are implementing PeerLearning in their radiology workflow.The ideal electronic Peer Learning so-lution must be prospective or timedretrospective, distributed, andanonymized.

After imaging:• Communication of critical test re-

sults: this is a major priority for health-care providers. Communication of ur-gent critical test results is usually notsuch an issue, as radiologists communi-cate directly with the Main ResponsiblePhysician (MRP) following a processwhich ensures that the communicationhas been appropriately delivered and ac-knowledged. However, it becomes muchmore difficult when it comes to commu-nication of non-urgent critical test re-sults, such as the incidental finding of alung nodule on a test performed for an-other reason. We need to ensure that theinformation is delivered to the right per-son, acknowledged in a timely fashionand acted upon with appropriate treat-ment and/or follow-up.

• Region-wide access to images: oncethe imaging studies are reported and

stored, they now have to be made avail-able to the healthcare community, in-cluding the report. Regional reposito-ries and Vendor Neutral Archives mustnow provide zero footprint viewersthat are easy to use and can be accessedwidely.

• Multispecialty and cross domaincommunication: diagnostic imagingdoes not function in isolation anymore,and multiple specialties share the sameneed to communicate and share infor-mation. New solutions must ensure thatall relevant information is made avail-able seamlessly, and again this is a prior-ity for the patient-centric medicine ofthe future. Cross-domain collaborationis a new trend and a welcome opportu-nity for IHE (Integrating the HealthcareEnterprise).

• Patient portals: last but not least, in aworld where patients are more educatedand empowered, it is necessary to givethem access to their medical informa-tion, as ultimately they may have tomake informed decisions. Patient portalswill certainly keep growing, which maychange the way patients communicatewith their doctors.

In conclusion, technology is progress-ing very fast and it is likely that the waywe practice in healthcare will changemore in the coming 10 years than in thepast 100 years. Is the next frontier be-yond the galaxy?

Dr. David Koff is Chief of DiagnosticImaging, Hamilton Health Sciences, andChair, Department of Radiology, McMas-ter University.

Leon Goonaratne, Catherine Wang and Paul Cornacchione are leaders of the Joint Dept. of Medical Imaging.

JDMI’s peer review system gaining traction at hospitals across the province


The Coral Review system isbeing used to enhance theexpertise and abilities oftechnologists, along with rads.


CHICAGO – At the RSNA con-ference last November,which attracted some 50,000attendees, Toshiba intro-duced new products in fourdifferent modalities – an-

giography, CT, MR and ultrasound. The an-giography announcement attracted a gooddeal of attention – the Infinix I Sky+, a ceil-ing-mounted system that features a doublesliding C-arm. It’s the first of its kind in themarket, and enables clinicians to increasetheir coverage, speed and patient access. Thenew C-arm has 210 degrees of anatomicalcoverage on both sides of the patient and ahigh-speed 3D rotation of 80 degrees persecond. (When you see the C-arm move,you realize it’s very fast!)

John Morra, a senior clinical consultantat Toshiba Canada Medical Systems, notedthe Infinix I Sky+ provides near CT reso-lution, in 3D, while clinicians are workingin the operating room or radiology suite –meaning the patient doesn’t have to bemoved for a CT exam, or given a CT studylater to check on the quality of the proce-dure. It can all be done while the patient ishaving the procedure performed.

In keeping with the move towardsdose reduction and ‘imaging wisely’, theInfinix I Sky+ has automated and user-selectable dose management tools de-signed to minimize X-ray exposure to pa-tients and clinicians.

With its new Vantage Galan 3T MR,Toshiba is offering an immersive in-boreMR Theater option. As the images dis-played appear to be much farther away thanthe actual bore, the MR Theater provides amore comfortable experience, encouragingpatients to relax and stay still during theMR exam. (This writer, placed inside themachine, found the experience to be inter-esting and relaxing – and a real change frombeing inside a typical MRI bore.)

The 71-cm bore is wider than mostMRIs, and Toshiba’s Pianissimo technol-

ogy reduces noise levels significantly – ac-cording to the company, noise levels arejust above ambient rooms levels. Tradi-tionally, MRI noise has been a complaintof patients and staff working with thetechnology. Toshiba says image quality hasalso been improved in the Vantage Galan3T, and the system offers non-contrastblood vessel imaging from head to toe.

In CT, the company announced theAquilion ONE GENESIS Edition, its pre-mium offering. The new system is aimed atresearch centres and acquires 640 slices withevery gantry rotation – the rotation speed is.275 seconds. The bore is very wide, at 78cm, and the bed is able to accommodate pa-tients weighing up to 694 lbs.

Software available with the system uti-lizes forward projection iterations to deliverhigh-quality images with up to 85.3 percentdose reduction, compared with previousCT exams. A full volumetric reconstruction(320 images) for routine clinical use can beobtained as fast as three minutes.

Toshiba also launched new ultrasoundmachines at RSNA, the Aplio i-series 700and 800. The systems offer new technologi-cal advances and ergonomic improvements.

For its part, GE Healthcare announcedthe industry’s first self-compressionsolution for mammography. The

Senographe Pristina system has been de-signed in France with the help of clinicians,technologists and patients; it helps reducethe pain, discomfort and anxiety thatwomen experience when undergoing mam-mograms by enabling them to control thecompression of the machine against theirbreasts. The patient uses a remote control toadjust the amount of pressure, with thehelp of a technologist, so she can set whatfeels right for her.

Claire Goodliffe, global marketing di-rector for women’s health at GE Health-care noted that better images have beenobtained when women control the com-

pression – they are actually compressingmore than technologists, resulting inhigher resolution pictures.

It’s believed that compliance withmammography exams will go up, too, asthere is less anxiety about the exams whenwomen feel they have more control overthe procedure.

Other ergonomic features have beenadded to the system, too. The gentle,rounded corners of the bucky, where thebreasts are positioned, were designed tohelp reduce discomfort. Instead of womentensing pectoral muscles while grabbing theconventional handgrips, which can make ithard to acquire good images, they can leancomfortably on armrests, relaxing the mus-cles to simplify positioning, compressionand image acquisition. GE Healthcarenoted the system is undergoing FDA reviewin the U.S. and is not yet for sale; Canadiansales are also awaiting regulatory approvals.

At the RSNA meeting, GE Healthcareunveiled Freelium, a magnet technologydesigned to use one percent of the liquidhelium typically used by conventionalMRI magnets. Instead of the average 2,000liters of precious liquid helium, Freelium isdesigned to use only about 20 liters.

MRI uses superconducting magnetscooled to -452 degrees F in order to takehigh-definition pictures of a patient’sbrain, vital organs, or soft tissue. The onlyway to keep MRI magnets currently inclinical use that cold is by using thousandsof liters of liquid helium mined from be-low the earth’s crust.

Helium has gone through two shortagecrises, impacting hospitals and patientsaround the globe. The helium supply ap-pears to be finite and demand has been ris-ing over the past decades.

Magnets with Freelium technology aredesigned to be less dependent on helium,much easier to site, and eco-friendly. Thanksto Freelium technology, hospitals would nolonger need extensive venting that often ne-cessitates siting a magnet in a separate build-ing or newly constructed room.

“Venting pipes for helium can some-times be more expensive than the magnet,”commented Ioannis Panagiotelis, chiefmarketing officer, global MR business, atGE Healthcare.

Additionally, a Freelium magnet would

not need any refilling during transportationnor throughout its lifetime. Therefore, whenthe Freelium technology is integrated into acommercialized product in the future, itcould make MRI more accessible and lessexpensive to site and operate. This is partic-ularly important in developing regions thatlack necessary infrastructure, and in major

metropolitan cities where siting a magnetcan cost more than the magnet itself.

GE Healthcare notes that Freelium is notyet a commercialized product, but rather atechnology that is still under development.

“It’s a revolutionary advance for the in-dustry and we look forward to integratingFreelium technology into MRI systems soclinicians and their patients can benefitfrom it in the near future,” said StuartFeltham, magnet engineering leader of GEHealthcare MR. “There is still more than 70percent of world’s population with no accessto MRI. Our vision is to leverage this low-helium technology to increase world-wideaccessibility of MRI so that more people canbenefit from its diagnostic capabilities.”

GE Healthcare has been building it cloudand Deep Learning capabilities, and haslaunched partnerships with the Universityof California at San Francisco and at BostonChildren’s Hospital. The systems beingtested are designed to lend expert advice toradiologists – for lung screening at UCSFand pediatric brain imaging in Boston.

These systems may prove to be of enor-mous help in future, with growing de-mand for diagnoses but a severe shortageof radiologists, especially sub-specialists,commented David Hale, president andCEO of enterprise imaging care andhealthcare IT at GE Healthcare.

Deep Learning systems can screen theexams for radiologists, enabling them toconcentrate on the most urgent cases first.They can also help radiologists spot prob-lems in the exams, thereby boosting thequality of their readings.

Overall, GE Healthcare will be accenting

Vendors showcase innovations at the RSNA conference in Chicago

GE Healthcare has devised a self-compression mammography system, said to be an industry-first.

Toshiba demonstrated the Infinix I Sky+, an innovative angiography machine with a double C-arm.


Siemens is spinning off itshealth technology division asSiemens Healthineers, giving theunit more independence.

is now hybrid PET/MR and on the hori-zon, MR-Linac.

“So what does all that hybridizationmean?” Couillard asked his attentiveToronto audience. “Well, likely most of youwere trained in just one discipline, butfrom now on you’ll need to be flexible.You’ll need to learn and you’ll need to dothings differently. Or you might need tobecome an ‘uber specialist’ in one narrowdiscipline like PET/MR.”

Those multi-skill or narrow prospectsmay be upsetting to some, but the goodnews, predicts Couillard, is imaging tech-nologists won’t lack for work in future.

He asked his lecture audience whatthey thought the percentage was of imag-ing equipment buyers that are not imag-ing departments.

No audience guesses came close. “I have it from a senior sales executive

from one of the big three imaging vendorsin the world who spoke candidly to ourFuture Advisory Council, that today about75 percent of all new imaging equipmentis sold outside of radiology departments.They are selling the great majority of theirimaging equipment these days to neurol-ogy, to cardiology, to orthopedic surgeons,and the like. But those guys know nothingabout how to operate that equipment. Sothey are going to need you, the imagingtechnologist, and you will have to figureout a way to work with them.”

Figuring out how imaging technologistscan work better with an ever-wideningrange of users to achieve a higher level ofcare across the board is squarely within thewheelhouse of the JDMI.

And its importance is something that isburned deep into the consciousness ofJDMI’s senior director, Paul Cornac-chione, as he reflects candidly on thatimaging technologist who saved a life atWomen’s College Hospital and who didn’tjust acquire an image and pass it off to theradiologist. “I admit that back 20 years agoin my time as an imaging technologist, Iwould have known basically what task Ihad to perform. I would have welcomed

the patient, maybe asked him a few ques-tions, but then I’d have taken the images,thanked the patient, and likely escortedhim out, without further thought.”

Cornacchione, Wang, and Couillard aretaking steps to ensure that technologistsare going beyond image acquisition;

they’re encouraging a closer working rela-tionship with patients and physicians. Andthey’re fostering the spread of best prac-tices and technologist-based research andpublishing. It’s an innovative approach,and one that’s aimed at the goal of betterpatient outcomes.


A new approach enriches the role of radiation technologists

dict the level of function of those genes.” As Dr. Sibille and his team work on

identifying the cellular and molecular ba-sis of depression, they want to shift the waydisease is diagnosed, so it is “more in-formed by biological data and symptoms.The future is to have an integration of bi-ology into the diagnosis that will help withthe delivery of care.”

The new CAMH Neuroinformatics Plat-form, with its ability to quickly sort throughbig data will be a huge advantage. Rotenberg

says his pet peeve is “wasting data” – havingpools of data that are not managed. “This isa model we think all hospitals should adopt.We hope it sets a precedent.”

Watson and Parkinson’s Disease: Fiveyears ago, Jonathan Rezek, an executive onIBM Canada’s National Innovation Team,had a life-changing diagnosis after a fallwhen cycling. “I had a bad fall, broke myarm badly, and I had shaking in my armwhen I started riding my bike again. Hand-writing diminished. Visited a neurologistand was diagnosed with early-onsetParkinson’s,” says Rezek.

“It’s a very slow-progressing disease –and that makes it tricky to do researchon,” says Rezek, noting that symptomscan include stiffness, cramps, shaking,

and depression.As a member of the Innovation Team

he knew he was in a good position to en-gage IBM Watson to discover new drugs tohelp combat Parkinson’s. Cloud-basedIBM Watson, a supercomputer that makesuse of analytics and artificial intelligence,could make a huge difference in theprocess of drug development, for example.

Now IBM’s Watson Health, the OntarioBrain Institute (OBI), and the MovementDisorders Clinic (MDC) of the UniversityHealth Network (UHN) have announcedIBM Watson Drug Discovery for Parkin-son’s. This research project, a first inCanada, will harness Watson’s cognitivecomputing power to uncover previouslyhidden data and find faster paths to in-sights, breakthroughs, and treatments.Since the process of drug discovery hastraditionally been long and costly, the po-tential to significantly accelerate it coulddeliver significant benefits.

Asked how he helped bring IBM andUHN and OBI together, Rezek said, “Ireached out to data scientists at IBM Re-search, and asked for presentations to bemade to MDC about what we’re doingwith Watson,” says Rezek. “Watson can dothings on a massive scale,” he said, explain-ing that Watson can look at 26 millionmedical tests and find relationships.

“One of my colleagues is closely affili-ated with the Ontario Brain Institute,” hesays. “They’ve developed a platform calledBrainCode.” They thought BrainCodecould work well with Watson.

IBM Watson Drug Discovery for Parkin-son’s is set to transform how researchersdiscover new drugs, and which ones couldbe repurposed in the fight against the dis-ease, far faster than traditional methods.The team put together a project where theylook at the potential of repurposing certaindrugs, for blood pressure, for example. Oneof the advantages of focusing on repurpos-ing drugs for Parkinsons, notes Rezek, isthat those drugs already have been ap-proved for use in humans.

The platform is just launching now, saysNathalie LeProhon, IBM’s Vice President,Healthcare, adding that UHN’s MDC willfeed the queries. “There are three main ar-eas of focus: diagnosis, recognition andtreatment,” she says.

IBM Watson Drug Discovery uses ma-chine learning to find answers with un-precedented speed. When queries aremade, and Watson provides answers, ex-perts can determine which answers aregood, and the system bases future answerson knowledge gained from those learningexperiences. “You have to train it,” saysRezek, of the machine-learning aspect ofWatson. “Watson will be tremendous forParkinson’s disease.”

“It’s fast computing power that canmake connections humans cannot make,”adds LeProhon.


R&D set to strengthen Canada as leader

Watson Health will be used inCanada for discovering newdrugs and therapies forParkinson’s Disease.

covery After Colorectal Surgery) wasimplemented. Based on data collectedon 16 patients that have been throughcolorectal surgery using the ERACSPathway, it was shown there was notonly a monetary impact and ROI, butthere were also several intangible im-pact measures at the hospital level.They included an increase in staff en-gagement and common understandingfrom staff from all areas.

As a result, there was less chance ofinfections, and patients were happierand more comfortable followingsurgery. ERACS showed a positive ROIof 118 percent, including developmentand documentation costs.

Healthcare represents one of thelargest expenditures in our economy inCanada. Healthcare organizations andexecutives are constantly seeking meth-ods, programs and processes that allow

them to continue to deliver high qual-ity patient care while keeping costs un-der control. The investment in im-provement initiatives is growing andthe investment is focused on enhancingthe patient experience and care whilereducing or controlling costs.

Adopting ROI methodology will en-able healthcare organizations to gener-

ate data to help with decision makingon how to allocate funds to programs,projects and improvement initiativesthat deliver the highest value.

Shirley Fenton is VP, National Institutesof Health informatics; Suzanne Schell isCEO, ROI Institute Canada; Hélène Clé-ment is an eHealth Consultant.

Healthcare valueCONTINUED FROM PAGE 16

Healthcare executives areseeking methods that allowthem to continuously deliverhigh-quality patient care.

the role of smart systems and analytics as away of enhancing patient care around theworld. In Canada, new projects are on thego, including leading-edge work at Toronto’snew, high-tech Humber River Hospital,called North America’s first “digital hospital”.

And as Heather Chalmers, generalmanager of GE Healthcare Canada notes,“so much healthcare is happening outsidethe walls of hospitals, in long-term careand home care, that it is important to beconnected to it.” For that reason, Chalmerslikes to use the term “intelligent health-care” as the mission going forward.

At RSNA 2016, Siemens Healthineersannounced its robot-supported AR-TIS pheno angiography system,

which was developed for use in interven-tional radiology, minimally invasivesurgery, and interventional cardiology. Be-cause it can scan up to 15 percent faster inthe body area than prior Siemens Healthi-neers systems, the system’s syngo DynaCTclinical software application can produce3D images that use less contrast media, thusdecreasing the load on the patient’s kidneys.

The ARTIS pheno’s C-arm is 5 incheswider than its predecessor system, the Ar-tis zeego, and has a free inner diameter of37.6 inches, which offers more space forhandling adipose patients and enables useof longer instruments. The system’s multi-tilt table is designed to accommodate pa-tients up to 617 pounds.

The end of the table can tilt up anddown to stabilize patient blood pressure orfacilitate breathing, for example. And likethe Artis zeego, the ARTIS pheno’s roboticconstruction provides a flexible isocenter,so it can follow all table positions whilerepresenting the patient’s target area fromvirtually any angle.

Surgeons must be able to work easilywhile standing so they can perform lengthyoperations without fatigue. They also mustmaintain optimum access within the oper-ating area. Recognizing these needs,Siemens Healthineers designed the easy-float tabletop of the ARTIS pheno multi-tilt table to be easily moveable, regardless ofthe tabletop’s tilt or the patient‘s weight.

The ARTIS pheno recognizes the table-top’s position at all times and automati-cally aligns to the tabletop. The memorypositions allow the system to move the C-arm out of the operating area quickly andmove it back to the same position for fur-ther imaging, so surgeons can check resultsdirectly during the operation.

Optional application packages can beused with the ARTIS pheno to accommo-date requirements in complex cases, in-cluding spinal fusion procedures. Up to 10vertebrae can be visualized in 3D imagingusing syngo DynaCT Large Volume.

Syngo Needle Guidance then allows theuser to plan extensive procedures usingscrews or needles.

Clinicians can precisely plan screwpaths, and the Automatic Path Alignmentfunction automatically aligns the C-arm tofollow those paths. The laser integratedwith the system’s image detector displaysthe planned surgical path, helping to im-prove accuracy and speed in the OR.

At Chicago’s McCormick Place, theseparately managed healthcare businessof Siemens presented itself for the firsttime under its new brand name, SiemensHealthineers. According to the company,the new name underlines the company’spioneering spirit and its engineering ex-pertise in the healthcare industry.


”I love treating my patients, but not the paperwork.“

2017 Fujitsu Canada, Inc. All rights reserved. Fujitsu and the Fujitsu logo are registered trademarks of Fujitsu Ltd. All other trademarks are the property of their respective owners.17.0111.0114

ScanSnap: Versatile scanners for all needs in healthcare.

ScanSnap iX100 ScanSnap S1300i ScanSnap iX500 ScanSnap SV600

www.scansnap.ca

feature report: developments in medical imaging — … · joanne jubas [email protected]...

Documents