BY DIANNE DANIEL

Emergency physicians in Saskatoon, aswell as medical practitioners acrossthe province, are getting used to

speaking into microphones, and it’s chang-ing the way they work and care for patients.

As part of a province-wide rollout of anew, standardized dictation and transcrip-tion service, all three of Saskatoon’s emer-gency departments are using real-timespeech recognition software from M*ModalCanada. Instead of typing notes into theAllscripts Sunrise Clinical Manager elec-tronic patient record – a time-consumingprocess doctors often left to the end of theirshifts – they now dictate directly into patientrecords, reviewing, editing and signing theirnotes within minutes.

Each computer in the department isequipped with a microphone and doctorsusually document directly in the EHR afterseeing a patient.

“It’s just one example of how the move toa provincial service model for front-endspeech recognition and transcription ischanging the way people work,” said JulieJohnson, director, Provincial Dictation andTranscription Services at 3sHealth, the sharedservices organization supporting the newlyintegrated Saskatchewan Health Authority.

“It’s a revolutionary change within acutecare that we probably wouldn’t have been

able to predict five years ago,” said Johnson.“It’s transforming the way doctors are work-ing and reducing frustration with a signifi-cant benefit to patients.”

The move to a single provincial servicecoincides with Saskatchewan’s journey to-wards a unified health system. Starting in

December 2017, the province’s 12 separateregional health authorities began operatingas one integrated organization. When thebusiness case for a unified, speech-drivenclinical documentation strategy was madetwo years prior, each regional authority hadits own technology and process.

“It was all over the map, some were usingcassettes, others had made a technology in-vestment,” explained Kendell Arndt,3sHealth vice-president, Strategic Informa-tion & Corporate Services, noting that insome cases patient reports were backloggedfor weeks.

The new provincial service is supportedby M*Modal Fluency for Transcription.Some parts of the health authority are con-tinuing to use transcriptionists and back-end speech recognition; others, like Saska-toon’s three emergency departments, havetransitioned to front-end speech recogni-tion using M*Modal Fluency Direct and

New service transforms charting in Saskatchewan

CONTINUED ON PAGE 2

The new province-wide dictation and transcription service in Saskatchewan is transforming the way clinicians work, enabling them to cre-ate and finalize their documentation much faster than before. As well, the system has unified dictation solutions across the province. Picturedabove, family physician Dr. Mark Brown has found the system allows him to chart on the spot, instead of playing catch-up at night.

The innovative provincial serviceis supported by M*ModalFluency for Transcription.

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Evidence-based order setsA project to implement ‘best prac-tices’ through order sets in Ontariohas exceeded its target goals.Working with Think Research, 82hospitals, with 107 sites, have par-ticipated in the provincially fundedprogram.Page 6

High-powered analyticsThe Hospital for Sick Children, inToronto, has opened up its analyt-ics platform enterprise-wide, allow-

ing clinicians and staff to analyzeperformance and come up withnew solutions.Page 4

How to reduce SSIsSpeaking at a Health Quality On-tario conference, internationalquality expert Dr. Patch Dellingerinstructed surgeons on best prac-tices for reducing surgical site in-fections. They include keeping yourpatients warm, reducing bloodsugar, and using OR checklists. Page 6

Keep those cell phones cleanMackenzie Health, in RichmondHill, Ont., has placed an innovativemachine for quickly cleaningsmartphones in the lobby of the

hospital. It’s enabling clinicians,staff and visitors to disinfect theirphones, tablets and other items.Page 14

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FEATURE REPORT: DEVELOPMENTS IN SURGICAL SYSTEMS – PAGE 18

CANADA’S MAGAZINE FOR MANAGERS AND USERS OF INFORMATION SYSTEMS IN HEALTHCARE VOL. 23, NO. 2 MARCH 2018

FOCUS REPORT:

ANALYTICSPAGE 12

are dictating into desktop computers orsmartphones.

Either way, each clinician has a single,cloud-hosted voice profile which enablesthem to easily move between devices, loca-tions and workflows (mobile documenta-tion, front-end speech recognition and/ortranscription) as preferred.

Whether using front-end speech recog-nition or back-end transcription workflow,clinicians at the health system are sup-ported by top-ranking, market-validatedsolutions: 2017 #1 Best in KLAS, SpeechRecognition: Front-End EMR, M*ModalFluency Direct, and 2017 #1 KLAS Cate-gory Leader, Speech Recognition: Back-End, M*Modal Fluency for Transcription.

Since completing its 18-month M*Modalimplementation in November, 2016, theprovince has set a target of 24-hour turn-around for all reports. For those cliniciansusing front-end speech recognition to docu-ment directly into Sunrise Clinical Manager,reports are available immediately.

“The biggest change management piecewe’ve tried to focus on is readiness,” ex-

plained Johnson. “It’s about fully under-standing the current and desired workflowof the practitioner so that the technologysupports what they need to do to ensurepatient information is flowing.”

3sHealth recently hired two full-timeSystem Change and Adoption specialistswhose focus is to help clinicians transitionto the M*Modal solutions, including front-end speech recognition. The first step is un-derstanding the current workflow so thatthe technology can enhance the individualand preferred workflows of clinicians anddrive better quality clinical documentation.For those who want to self-report, the sup-port is there to help them.

Family medicine physician Dr. MarkBrown decided to move to front-endspeech recognition so that he could chartbetween patient visits. Not only does thenew way of working allow him to includemore meaningful information in his chart-ing, such as negative findings and conver-sations with patients, he also has moretime for his clinic now that he spends lesstime typing.

Additional time is saved using anM*Modal Fluency Direct feature that au-

tomatically inserts blocks of standard textusing key words.

“I used to stay late or take chartinghome with me,” said Dr. Brown. “Now Itake coffee breaks and lunch. I am home intime to have supper with my family and tobe ‘Dad taxi’ for my kids.”

Dr. Terry Zlipko, an ER physician inSaskatoon, echoes Dr. Brown’s enthusiasm.“I love this new system. I know for sure

that I’m now doing my charting in half thetime it used to take me. That gives memore time to spend at the bedside. Insteadof spending 23 minutes typing a report, Ican now do that same dictation, edit it andsend it on its way in about three or fourminutes tops. It’s been incredible.”

Clinicians who prefer real-time docu-mentation are further supported byM*Modal Fluency Direct’s Computer-As-sisted Physician Documentation (CAPD)functionality.

This real-time, fully-automated and AI-powered technology delivers high-valueclinical insights to physicians as they dic-tate or type the clinical note in the EHR.This closed-loop documentation solutionproactively suggests improvements in qual-ity, coding and compliance, and reports onphysician engagement with the system.

The system delivers physician feedbackon ICD-10 codes, gender and lateralitymismatch, gaps in documentation quality,variance in patient care, etc.

“Our mission is creating time to careand improving the patient-physician en-counter. To that end, our real-time artifi-cial intelligence (AI) and natural languageunderstanding (NLU) technology contin-ually analyzes the note, contextually un-derstands the physician narrative, and pro-vides in-workflow insights to physicians atthe point-of-care.

“Our solutions are designed to signifi-cantly improve the speed, ease, efficiencyand quality of clinical documentation sothat doctors can focus on patient care,” ex-plained Carey Silverstein, Vice-President,Operations, M*Modal Canada.

As of now, the only groups not usingthe provincial speech recognition andtranscription service are physicians oper-ating fee-based private clinics and medicalimaging.

All others, including laboratory, pathol-ogy and the provincial cancer agency, areon the M*Modal platform.

Carey Silverstein, VP Operations (l), and Paul Silverstein, VP Finance, lead M*Modal in Canada.

CONTINUED FROM PAGE 1

AI-Powered M*Modal solutions transform clinical documentation

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Publisher & EditorJerry Zeidenbergjerryz@canhealth.com

Office ManagerNeil Zeidenbergneilz@canhealth.com

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: info2@canhealth.com. Canadian Healthcare Technology will publish eight issues in 2018. 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. ©2018 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: jerryz@canhealth.com. ISSN 1486-7133.

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

Volume 23, Number 2 March 2018

Contributing EditorsDr. Sunny MalhotraTwitter: @drsunnymalhotra

Dianne Danieldianne.l.daniel@gmail.com

Richard Irving, PhDrirving@schulich.yorku.ca

Dianne Craigdcraigcreative@yahoo.ca

Friday, May 4th, 2018

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

BY JERRY ZEIDENBERG

TORONTO – Quality and safetycan be improved through theuse of tools like business in-telligence and analytics, butyou need to “democratize” the

data, so that everyone is on board acrossthe organization.

That’s the message delivered by theHospital for Sick Children’s CEO, Dr. MikeApkon, at a session on analytics that washeld last November during HealthAchieve,the Ontario Hospital Association’s annualconference.

“We want to be the safest children’shospital,” he said. “But 10,000 people haveto work toward it,” he added, referring tothe 10,000 clinicians and employees of theorganization.

As Dr. Apkon put it, “The key is trans-parency, so that someone who needs toknow about their performance has accessto the data.”

He reflected on his past experience witha U.S. hospital, where information was col-lected on the performance of staff andclinicians, but they didn’t have access tothe data.

When the hospital finally shared thedata, performance shot up. “And it hap-pened without a single conversation,” saidDr. Apkon, noting that people looked at thedata about their units or themselves andfrom that alone, were inspired to improve.

“It shows the power of giving people ac-cess to their own information,” he said.

David Grauer, senior vice president ofHealth Catalyst, and former CEO of Inter-mountain Medical Center, in Salt LakeCity, Utah, added, “Most people are intrin-sically motivated to do the right things, butthey don’t have the right information.”

Grauer was on stage engaging in a con-versation with Dr. Apkon about analytics,performance, quality and safety. Inter-mountain is itself a leader in the use of an-alytics and BI. Health Catalyst, a company

spun off from Intermountain, helps hospi-tals build data warehouses and improvetheir processes.

That being said, Dr. Apkon did notethat transparency of data can also motivatepeople in a different way.

“When people know that I can see theinformation each day, it improves theirperformance. It has an immediate effect.”

Indeed, with the democratization ofperformance data, everyone becomes moreresponsible for performance and quality.

Dr. Apkon commented that this kind ofcontinual observation and monitoring re-quires “data literacy” by the leadershipthroughout an organization.

Gone are the days when executiveswould wait for reports to be printed anddelivered to their desks. “You can’t just usea print-out,” said Dr. Apkon, explainingthat these boiler-plate printouts are oftenout-of-date by the time you see them, andoften enough, they don’t contain the infor-mation that’s needed.

By working with an analytics system,moreover, you can formulate your ownquestions and find your own answers.

Of course, implementing such tech-nologies is expensive, as is the training andeducation that goes along with it. But thechange that analytics and BI can bringabout is significant.

Dr. Apkon said the systems have been en-ablers of quality improvement at Sick Kids,where clinicians aren’t just given reports andtargets. They’re also able to dive into thedata for themselves, to check it and come upwith their own analyses and interpretations.

“We’ve given a lot of our physician lead-ers access to the data,” he said.

That’s been a big help when it comes toissues like length of stay, which the hospi-tal has been trying to optimize.

LOS can have many facets and questionssurrounding the figures and definitionsthat are used. “There are a million reasonswhy someone might question the numberwe have come up with,” said Dr. Apkon.

Indeed, physicians in particular mayquestion the official wisdom. “Tearingapart data is a sport for physicians. We’retrained to have a critical eye.”

But by letting doctors explore the data,Dr. Apkon said, engagement and utiliza-tion are fostered. So is understanding, asthe doctors can see how various numberswere arrived at.

Dr. Apkon said it’s important for theleadership to set goals and targets, but clin-icians and staff have to be free to developinitiatives, as well. After all, the problemsidentified at the front-lines can have animpact on workflow, safety and quality,too. And giving teams control over theiractivities also contributes to morale andjob satisfaction.

Linette Margallo, clinical director ofED at Sick Kids, commented that she hasseen “a huge evolution in data over thepast 10 years. “Having more data lets usreally dig in.” She and Kate Langrish, clin-ical director of paediatric medicine, gavereal-world examples of how analytics and

parsing the data have helped improve thedelivery of care at the hospital.

As one example, they described the in-cidence of supracondylar fractures inchildren. “Usually from falling from ajungle gym or tree,” commented Mar-gallo. Over a five-year period, they couldsee from the data that admissions wereincreasing, and so were wait times for ad-missions and treatment.

By further analyzing the data, theycould see that most of the arrivals were inthe afternoon – when orthopedic surgeonswere in the operating rooms. This meantthe surgeons weren’t available to admit thepatients from the ED to hospital.

The hospital then worked to change theadmitting process, enabling young patientswith fractures to get started sooner on painmanagement and other procedures. Andthe 10 to 12 hour wait time for admittingwas reduced to an average of eight hours –a significant improvement.

“We used data to solve a problem andchange a process,” said Langrish.

Health Ecosphere holds showcase, demonstrates progress of innovators

TORONTO – “If innovationsaren’t being used, it’s really justresearch.” These words werespoken by Harvey Skinner, co-

chairman of the Health Ecosphere Inno-vation Pipeline, at the projects firstshowcase, earlier this month. Dr. Skin-ner, a psychologist, is a professor at YorkUniversity and was the Founding Deanof the school’s Faculty of Health.

The sentiment is the driving force be-hind the Health Ecosphere InnovationPipeline’s core goal – taking health tech-nologies from conception to commer-cialization. Since the project’s launch in2016, more than 40 health technologiesand enterprise solutions have receivedsupport in their development stages.

Earlier this year, in January, lead part-ners York University and Southlake Re-gional Health Services, along with Uni-versity Health Network, invited the pub-lic and stakeholders to learn exactly how

the project has benefited industry andresearch institutes to develop personal-ized health technologies, includinghealthcare apps, medical devices and bigdata platforms.

Held at Telus Tower in downtownToronto,12 of the 55 project partnershad the opportunity to showcase theirwork through a “speed-geeking” exercise,with five minutes to explain to attendeesexactly what their technology is and howthe Ecosphere project has contributed toits development.

Technologies featured in the showcaseincluded:

• DashMD, a mobile application de-signed to help patients track, manageand find the care they need after they’vebeen discharged from the hospital. Theapp will soon be tested in the EmergencyDepartment and Childbirth Centre ofMarkham Stouffville Hospital.

• ForaHealthyMe Inc. a solution that

delivers a virtual clinic without walls byblending clinical protocols for prehabili-tation and rehabilitation patient man-agement with real time analytics, motiontracking, 3D avatars, video and gesturerecognition technologies. The Fora-HealthyMe software and analytics engine

enables a provider to create custom careplans for patients. Using data related torange of motion and muscle strengthen-ing exercises, a provider can prescribespecific activities to patients prior to andafter a surgical procedure.

• Medly, a heart care system. Prescribedby clinicians, Medly enables patients liv-

ing with heart failure a platform torecord physiological measurements andsymptoms. A comprehensive algorithmuses these measurements to assess thepatient and in turn provides actionableself-care feedback. Simultaneously, theirclinician receives real time alerts in theevent of any significant changes to thepatient’s condition. The system is devel-oped by the eHealth Innovation team atUniversity Health Network and is cur-rently integrated into the standard ofcare for heart failure management at thePeter Munk Cardiac Centre.

The showcase event was clear evidencethat the Health Ecosphere InnovationPipeline is contributing to the vision oftransforming health through continuousinnovation and helping position Canadaas a global leader in digital health. Formore information on The Health Ecos-phere Pipeline project and the technolo-gies involved visit health-ecosphere.com.

Project partners had theopportunity to showcase theirwork through a “speed-geeking” exercise.

Analytics and data access lead to quality improvements at Sick Kids

Dr. Michael Apkon, CEO, (right), speaks with pediatric surgeons at Toronto’s Hospital for Sick Children.

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 M A R C H 2 0 1 8

Catch critical events before it’s too late

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

BY JERRY ZEIDENBERG

TORONTO – When Ontario’s Min-istry of Health and Long-TermCare asked St. Joseph’s Health Sys-tem (SJHS), Hamilton to lead the

Provincial Digital Quality Based Procedures(QBP) Order Sets Program, SJHS publiclyprocured Think Research to create and im-plement digital order sets for the program.

With a recruitment goal of 75 provincialhospitals, the program turned out to bemore successful than planned – to date, 82hospitals representing 107 sites have madeuse of the provincially funded program.

“We currently have 62 percent of allOntario eligible hospitals participating inthe program, which has exceeded our goalof 50 percent,” commented Donna Kline,Executive Lead, Project Management Of-fice at SJHS, who added that the programhas been extended for another year.

Order sets enable clinicians to quicklyand effectively implement the latest, evi-dence-based practices for a wide range ofdiseases and conditions. They have manybenefits, including producing better out-comes for patients, and reducing thevariability that’s found across the health-care system,

And although hospitals have been tin-kering with order sets for years, most ofthem have been working in isolation.

“Historically, hospitals using order setswould develop them on their own,” said Dr.Chris O’Connor, president and founder ofThink Research, who is also an ICU physi-cian. “They’re trying to re-invent the wheel.”

Others have tried to adapt Americanorder sets to the Canadian heathcare sys-tem. However, this can be expensive, in-volves customization work and does notconnect the hospital to the healthcare sys-tem it operates in, noted Dr. O’Connor.

“It is puzzling why hospitals would want

to use order sets developed for the high-cost, billing-driven, American healthcaresystem as a starting point for their own or-der set development in Canada,” he said.

“It’s much easier to be part of a group,to share knowledge through an order setsnetwork,” he said. “We connect hospitalswith experts and the rest of the healthcaresystem. There are companies that will sellyou order sets, like encyclopedia salesmen,but they won’t connect you to the Cana-dian healthcare system.”

Members of the network are able toshare best practices and influence the toolsthrough regular user meetings and clinicalworkshops, where various subject matter isdiscussed and refined. “We’ve just heldclinical review sessions on palliative care,thrombosis, diabetes, wound care, and de-mentia,” observed Kirsten Lewis, RN, VicePresident of Clinical R&D.

Dr. O’Connor said that medical knowl-

edge is growing at an ever-acceleratingpace, and the regular meetings help keepclinicians and administrators in touchwith the latest know-how. The peer-net-work, with support from Think Research,helps them incorporate the digitized ordersets into their own systems and workflows.

“Not only is medical knowledge in-creasing, the medical system is becomingmore complex as well. Care is now fre-quently delivered by large interprofes-sional teams across multiple institutions,”said Dr. O’Connor. “Our advanced clinicalsystems integrate Canadian content intohospital information systems, regardless ofwhat backend that might be.”

There are currently over 800 different ref-erence order sets for acute care hospitals inthe Think Research network, along withothers for long-term care. The most com-monly used order sets reflect the patterns ofcare in hospitals, with high demand for best

practices in COPD and coronary care, mus-culoskeletal surgeries, and normal deliveries.

Think Research is an active partner inthe network; it monitors the use of ordersets and receives feedback about them.“The data helps us to understand usabilityissues and clinical impact. We use thatfeedback to build better order sets,” com-mented Dr. O’Connor.

The system created by Think Researchhas evolved into an online platform thatcan be used for more than order sets. Workis under way in many new knowledge-based applications, including of e-referrals,virtual care, and med rec to name a few.

To support this, Think Research recentlyannounced a partnership with IBM Canadato make use of IBM’s cloud infrastructure.The plan is to migrate Canadian users ofThink Research order sets to the cloud, tomake implementation, utilization, and ana-lytics, even easier and more cost-effective.

“In terms of privacy and security, theIBM cloud infrastructure is light-yearsahead of others on the market,” com-mented Saurabh Mukhi, CTO. “It providesthe kind of scalable, 24/7 availability globalhealthcare facilities and systems demand.”

For its part, Think Research technologyis deployed in almost every provinceacross Canada. Moreover, it has expandedinto Ireland, implementing its solutions infive hospitals as part of a planned EU andUK expansion.

The company is also gearing up in theU.S. market, where it initially will be fo-cusing on the long-term care and smalleracute care hospital sector.

Overall, the company is quickly grow-ing, with about 200 employees and manynew projects on the horizon. “We’re usingthe most advanced technologies and creat-ing very exciting solutions for cliniciansacross the province and around the world,”said Dr. O’Connor.

How to reduce SSIs in your operating rooms? A global expert weighs inBY JERRY ZEIDENBERG

TORONTO – Surgeons who op-erate buck naked would likelyhave lower rates of patient in-fection, as without clothesrubbing their skin and shed-

ding cells, there would be less spread ofpossibly infectious matter in the OR.

Dr. Patch Dellinger, a general sur-geon and world authority on surgicalsite infections, made this light-heartedremark at Health Quality Ontario’s an-nual conference on surgical quality,held here last November.

The audience of some 300 surgeonsand OR staff thoroughly enjoyed this andmany other quips made by Dr. Dellingerduring his one-hour keynote address. ButDr. Dellinger, who works at the Univer-sity of Washington Medical Center, inSeattle, had a number of more seriousrecommendations on how to reduce sur-gical site infections (SSIs), and to im-prove quality, all of which were tied toevidence, studies and his own experience.

He had the following advice:• Keep your patients warm. ORs can be

cold places, especially in the early morn-ing. But it’s been found that warmer pa-tients have higher oxygen levels, which isimportant for discouraging infections insurgical sites. In a multicenter study inGermany and Austria, colorectal surgerypatients were randomly assigned to bekept warm or to be allowed to get cold. Itturned out the patients who were cold ex-perienced a much higher incidence ofSSIs. “Use a warming blanket prior to theoperation and when the patients are in theOR, to get them warm,” said Dr. Dellinger.

In addition to the improvement inclinical outcomes, there’s also higher pa-tient satisfaction. “What do patients hateabout surgery?” he asked. “Pain, nauseaand shivering in the OR. Warming thepatient can reduce the shivering, and im-prove patient-reported quality outcomes.”

• Use lots of antibiotics just prior tosurgery and during the operation, butstop right after. “When I was youngerand more foolish, I used to tell people

not to use prophylaxis for clean opera-tions [such as joints, as opposed to pro-cedures on internal organs, like the in-testines.) But in fact, there is consistentdata that no matter what your underly-ing infection risk is, you do reduce it

with prophylaxis.And it’s indepen-dent of the type ofoperation.”Dr. Dellinger saidhe is a strong sup-porter of antibi-otic and antimi-crobial steward-ship, and he isaware of the costsof drugs. But it’sclearly a case of

being safe rather than sorry. “If you’regoing to do a hernia operation on me,and stick mesh in there, even though theunderlying infection rate is low, I’d justas soon have one dose of prophylaxis.”

• Sugar levels in surgical patients were amajor topic of his discussion. He noted,

“There is a strong correlation betweenblood sugar and infection risk [in surgicalsites], and said it’s well-known that dia-betics have a higher risk of infections. Buthe stressed that non-diabetics with highblood glucose levels also experience muchhigher rates of surgical site infections.“Hyperglycemia doubles the risk of SSI.”

And while high blood glucose was atone time thought to be a risk only forcardiac surgeries, it has been establishedthat the risk is there for all types ofsurgery. “White cells bathed in glucose donot ingest and kill bacteria efficiently.And most white cells probably don’tknow if they’re in a laparotomy incisionor a vascular incision,” said Dr. Dellinger.

He cited a study of non-diabetics at theCleveland Clinic who were in for colec-tomies and had high blood sugar countsin the OR or post-op (above 125). “Theyhad increased mortality, increased sepsis,increased SSIs, increased re-operation. Itwas across the board in non-diabetics.”

That’s why it’s important to monitor

Think Research’s shareable order sets for best practices catching on

The Clinical R&D Team at Think Research are driving evidence-based innovation in the company’s order sets.

CONTINUED ON PAGE 23

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Dr. Patch Dellinger

SAGFA HEALTHCARE ENTERPRISE IMAGING S T E P S

S SATISFACTION

T TREATMENT/CLINICAL

h d l h h ' h l d l f l

E ELECTRONIC SECURE DATA

P PATIENT ENGAGEMENT & POPULATION MANAGEMENT

S SAVINGS

EDUCATIONAL SUPPLEMENT

Stepping It Up: HIMSS® Health IT Value STEPS™

Looked at through the eyes of the value optimization framework called HIMSS STEPS, healthcare systems can benefit from insights in: Satisfaction, treatment/clinical, electronic secure data, patient engagement and population management, and savings.

Patient satisfaction increases when physicians share images with patients and families. Research studies show that engaged and educated patients take better ownership of theircare. Care providers are more satisfied too, having easy access to information and tools to communicate and collaborate with peers. Administrators are more satisfied with bettercontinuity of care and reductions in cost.

When reviewing new imaging exams, clinicians can conveniently and quickly access a patient’s historical imaging record in a single, use-to-use user interface to enable informeddecision-making and swift initiation of treatment. Enterprise Imaging empowers care teams to collaborate and enhances continuity of care as transitions become smoother, moreinformed and purposeful. The hope is what follows are fewer hospital readmissions, fewer ED visits, increased patient safety and better chronic disease management.

With a complete EHR comes one means of electronic secure data storage. Format is no longer a foible, with Enterprise Imaging managing studies from any device or format,including DICOM, DICOM SR and non-DICOM images such as MPEG, AVI, WMV, MP3, JPEG, TIFF, BMP, CINE, WMA and PDF. Text files such as DOC and TXT are imported too. Images from mobile devices such as CR, point-of-care ultrasound or digital cameras can be added securely.

With current and prior images available at the bedside at point of care, physician can engage patients with a clear understanding of their diagnoses and treatment course. Physicians alsocan engage each other or patients remotely using mobile devices. This helps to drive patient education, awareness and compliance, often supporting population management initiatives.

Savings is always top of mind in healthcare. Enterprise Imaging can lead to savings in time and costs. Consolidating images from a variety of specialties offers economies of scale in cost and improved accessibility. Integrated image access drives clinical best practices. Immediate and easy access to images and reports can mean faster and more productiveappointments and rounds throughout the hospital, improving workflows, increasing patient volume and enhancing the overall patient-provider experience. Ready access to imagescan help maximize revenue entitlements and avoid penalties, and maximize bonuses available under the government payer programs. Easy image access also eliminates the need for retakes and speeds timely patient discharge and thus reduces the amount of resources needed to address risk minimization efforts.

As we face the pandemic of issues with medical imaging and IT, we must build solutions to solve the fragmentation of care delivery, design security and data management, improvedelivery of patient care and efficiency, reduce waste, rein in lost revenue and reduce overall costs. We need to organize and present comprehensive patient information intuitively foreach caregiver. We need to evolve from being data-rich but actionable-poor to a knowledge-based/information-driven care delivery approach. To achieve value-based care, we needto maintain secure custody of medical images within the enterprise and leverage them as strategic assets of the entire organization. Clinical, operational and financial goals will allbe best-served with a patient-centered, longitudinal imaging record that completes the EHR strategy.

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

Renfrew Victoria Hospital – inRenfrew, Ont., about 90 km westof Ottawa – is the first hospital inCanada to install an innovative

solution to improve the safety of the med-ications being manufactured in the phar-macy department.

PharmacyKeeper Verification uses iPadsand a cloud-based software suite to ensureevery step in the preparation of chemother-apy and sterile products in pharmacy isdone correctly and is documented.

“We’re excited to be using this soft-ware,” says Andrew Wagner, Director ofPharmacy at RVH. “While hospital phar-macies have compounded medicationsand chemotherapy for years, and for themost part safely, when errors happen theconsequences for patients can be huge. Wewanted to ensure we were at the cuttingedge of technology used to improve pa-tient safety.”

Selection of the new PhamacyKeepersystem was made with input from the entireteam at RVH. “Our decision was based oncontributions from nursing staff and physi-cians, along with pharmacy,” says Wagner.

Several recent examples of major inci-dents in the United States and Canadahave created a paradigm shift in the over-sight of pharmacy compounding, andchanged the mandate of the Ontario Col-lege of Pharmacists increasing its oversightof hospital pharmacies.

What most of the public and even manywithin hospitals don’t realize is the exact-ing work that goes on in the pharmacy.Medications received from manufacturersare in sterile vials, but the pharmacy staffmust then use these sterile vials to prepare

patient-specific medications in a fashionthat is always accurate and maintains asterile product.

However, the process to do so hasn’t re-ally changed in the past 30 years, and is stillmostly paper-based tracking and visualdouble checks. Much more can be done toensure the safety of what is mixed in thepharmacy.

One such example is bar coding. “Mylocal Canadian Tire has been scanning barcodes since the early 1980s; the hospitalgift shop started doing it in the ‘90s. But inhospital pharmacies, despite having barcodes available on medications for years,barcode scanning technology has not re-

ally been adopted,” says Kevin McDonald,Director of Northwest Telepharmacy Solu-tions. “This is a high stakes business, mix-ing chemotherapy and other medications.Mistakes can have serious consequences,and we need to do everything possible aspharmacists to prevent errors.”

From a nurse’s and patient’s perspec-tive, in almost all cases, what comes out ofthe pharmacy is a clear bag with a clear liq-uid inside of it. Other than a label with thepatient name and what is “supposed” to bein the bag, it is a leap of faith that no errorshave occurred in the pharmacy and thatevery technique used followed a processthat ensured the product remained sterile.

Northwest Telepharmacy Solutions isalready the leader in providing remotepharmacist solutions and checking forhospitals. “When we saw the opportunityand improved safety that these IV work-flow solutions can bring to the pharmacy,we did a search for the best solution theworld has to offer,” says McDonald.

Of several workflow solutions on themarket, PharmacyKeeper is the fastestgrowing one in the United States and isKLAS rated as the top solution. The factthat it uses simple and available technol-ogy (iPads) significantly improves thevalue and portability of this solution.

As a technician prepares the product,bar codes are scanned to ensure the cor-rect products are being used, and expirydates with lot numbers allow traceabilityin the future.

Photographs are taken using an iPad,and these photos can then be used bypharmacists to check that the product wasprepared accurately. “What we like aboutthis software is that we can now easilytrack, review and audit every detail of thecompounding process for every patientwho has received a compounded product,including the specific lot number of amedication,” says Wagner. “Above all, we’redoing what we can to minimize the risk oferrors made during compounding and en-sure the safety of all our patients.”

Not only is the remote-checking abilityaccurate, it is also convenient. When atechnician was required to mix an emer-gency pain medication on Christmas Eve,Wagner appreciated checking the accuracyfrom home rather than making a specialtrip into the hospital.

Edmonton home to Canada’s first stroke ambulance program

Canada’s first mobile strokeunit is in Edmonton, oper-ating as part of a three-yearpilot project out of the Uni-versity of Alberta Hospital

and funded by the University HospitalFoundation. The unit can be dispatchedwithin a 250 kilometer radius of Ed-monton meeting regular ambulancescarrying patients with a suspected strokeen route.

CT scans and potentially other formsof treatment are conducted at the meet-ing point, with the goal of decreasing thetime to treatment from the onset ofstroke symptoms.

Around the world, stroke ambulanceprograms operate or are being evaluatedfor use in several US cities, as well as theUK, France, Belgium, Switzerland, andAustralia, among other countries.

What is it? Essentially a stroke unit onwheels, a mobile stroke unit is a modi-fied ambulance (or custom-built vehicleresembling a large ambulance) that isequipped with a CT scanner to provideimmediate imaging of patients with sus-pected stroke before they get to the hos-pital.

Aside from the CT scanner, other fea-tures can vary, but may include tele-

stroke equipment, point-of-care labora-tories, thrombolytic drugs, plus the stan-dard emergency response equipmentfound in a regular ambulance.

A key feature of the stroke ambu-lance is the staff on board. In additionto a paramedic or emergency medicaltechnician, the vehicle may also bestaffed by those specially trained for therapid diagnosis and treatment of stroke,including neurologists, nurses, radiol-ogy or CT technicians, or other healthprofessionals.

If telestroke equipment is installed,the vehicle allows staff to consult within-hospital specialists.

Given the potential for this vehicle toimpact stroke care, especially in rural andremote parts of Canada, Ottawa-basedCADTH examined the available evidenceas part of its efforts to scan the horizonfor promising new health technologies.

How much is it? A mobile stroke unitrepresents a significant investment forany health care organization.

The costs include the initial purchaseof the vehicle, plus the equipment, aswell as ongoing operating, maintenance,and staffing costs. The reported cost ofthe Edmonton vehicle is more than $1million.

What does the evidence say? Does theevidence show that faster treatment re-sults in better outcomes for patients?CADTH’s limited literature search foundtwo German randomized controlled trialsof mobile stroke units, as well as addi-tional observational studies, case studies,and cost studies from Europe and the US.

Much of the research about these vehi-cles evaluates the time it takes for a pa-tient to receive treatment, but the out-

come measured varies from study tostudy. In some cases, a primary end pointwas the time from when dispatchers acti-vated the stroke alarm to the time a treat-ment decision was made. In anotherstudy, the primary end point was the timefrom alarm to the time a thrombolytic(or “clot buster”) drug was administered.

The evidence suggests that mobilestroke units may reduce the time it takesfor patients to receive appropriate treat-ment, but it’s unclear if earlier treatment

in the unit improves long-term func-tional outcomes.

Researchers in Berlin compared theproportion of patients who had experi-enced acute ischemic stroke living with-out disability three months after beingtreated with pre-hospital intravenousthrombolysis in a mobile stroke unitwith patients who received standard hos-pital care.

No difference was found between thetwo groups. International research isnow underway to determine if strokeambulances can improve functional out-comes for patients. In terms of cost-ef-fectiveness, a German study found that,despite the initial and ongoing costs, theuse of these units may be cost-effectivecompared with conventional treatment.

Research that will help improve ourunderstanding of how a mobile strokeunit could benefit people with intracra-nial hemorrhage (hemorrhagic stroke)or triaging people with ischemic strokewho would benefit from mechanical clotretrieval (endovascular therapy) is inearly study.

To read the full CADTH article onthis device, visit https://cadth.ca/mo-bile-stroke-units-prehospital-care-is-chemic-stroke

Renfrew reduces compounding errors using IV workflow technology

PharmacyKeeper Verification uses iPads and cloud-based software to ensure high quality standards are met.

With a CT scanner on board,imaging of suspected strokepatients can take place beforethey arrive at the hospital.

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April 30 - May 1, 2018Metro Toronto Convention Centre South Building

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ocediscovery.comFor general information

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Discover Ontario’s state-of-the-art technologies Now in its 13th year, Discovery:

• Showcases leading-edge technologies, best practices and research across many sectors including Advanced Health, Greenhouse Gas Reduction, Transformative Technologies, Autonomous Vehicles, Fintech, Cleantech, Advanced Manufacturing, Aerospace, Digital Media and High-Performance Computing

• Brings together key players in the innovation community, including entrepreneurs, industry leaders, researchers, scientists, students, the investment community, international delegations and government to network and collaborate

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• Attracts over 3,600 attendees and more than 540 exhibitors

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our Advanced Health programs, including Health Technologies Fund and REACH,

administered by OCE on behalf of the Government of Ontario.

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

BY RODNEY BURNS

Ontario’s Community HealthCentres (CHCs) have beenusing data analysis to informevidenced-based planningfor over 25 years. Today, that

experience in simple data analytics is takingus into the sphere of advanced data analyt-ics where we can translate complex, diverseand timely information into better health-care decisions and healthier outcomes.

CHCs and partner members in the As-sociation of Ontario Health Centres(AOHC) are changing the Primary Carelandscape by using advanced analytics. Ourcutting-edge computational tools give par-ticipating centres a complete view into in-ter-professional care coordination, healthmanagement, and clinical services.

Get electronic: In 2008, 73 CHCs madea collective commitment to begin usingtheir clinical management system as a ro-bust electronic medical record (EMR). Us-ing the lessons learned by early adopters,the AOHC developed an EMR roadmapfor CHCs in Ontario.

By 2010 we achieved a significant mile-stone – almost 90 percent of CHCs wereusing their clinical management system asa full electronic medical record. A key fo-cus was to capture meaningful socio-de-mographic data to help determine ourstrategic priorities, which are identifyingand addressing barriers to achieving equi-table health outcomes for clients.

Share your data: But we did not stopthere. All our member centres were collect-ing key client data using a common en-

counter classification system – the Elec-tronic Nomenclature of Disorders and En-counters for Family Medicine (ENCODE-FM). It is a systematic and hierarchicalclinical terminology for family medicine.

ENCODE-FM simplifies comparabilitybecause it is mapped to all terms in the twowidely used classification systems, the In-ternational Statistical Classification of Dis-eases and Related Health Problems (ICD-10 and ICD9-CM) and the InternationalClassification of Primary Care (ICPC)code system. Working with our AboriginalHealth Access Centre members, we wereable to get key Indigenous identifiers andTraditional Healing Activities added to

ENCODE-FM, making it the only health-care classification system that we are awareof, with such identifiers.

Next, we focused on procuring a robustprovincially certified clinical managementsystem. This meant that we could align with,and integrate into, existing province-wideeHealth systems and datasets like the OntarioLaboratories Information System (OLIS)and the Health Report Manager (HRM).

Promote collaboration: To bring all ofthis together in a systematic and cohesiveway, we developed the Business Intelli-gence Reporting Tool (BIRT). It helps us tostandardize data and reporting amongst allparticipating member centres. It also gives

our members the power to share queriesand reports efficiently.

We consult members at every phase ofBIRT’s multi-year development to ensurethat the technology meets their evolvingneeds. BIRT consolidates and presents keydata from multiple EMRs, elegantly andsimply, with bilingualism, privacy and se-curity baked in by design.

Strategic planning decisions and qualityimprovement got a lot simpler. Today,BIRT is helping our member centres col-laborate – developing best practices, gain-ing efficiencies, and working together toprovide their clients timely access to theprograms and services that best meet theirneeds with the evidence to confirm thatthis is being achieved.

Improve health & well-being: Built onan Oracle platform and using IBM Cog-nos, BIRT gives our member centres thepower to view their operations across mul-tiple programs and services using near-realtime dashboards. We develop dashboardson the principles that visualized datashould be Strategic, Timely, Accessible,Relevant and Targeted (START).

Using the BIRT Multi Sectoral Account-ability Agreement (MSAA) dashboard, amember centre was able take significantstrides towards improvement of theirscreening rates. Being able to identify thechallenges, make improvements and seethe results in near-real time, the centre in-creased its screening rates to above the av-erage values for Community Health Cen-tres provincially.

Rodney Burns is CIO of the AOHC.

Use of analytics in community health helps achieve better outcomes

Financing technology has clinical, business, and legal implicationsBY DENIS CHAMBERLAND

ust as managing healthcare tech-nology has become significantlymore complex, identifying the rightfunding model for the task at handhas also become more complicated.

I briefly examine below four fundingmodels, not to compare them to eachother but to highlight select strengthsand weaknesses.

The Traditional Capital-FundedModel: The traditional approach world-wide is the capital-funding acquisitionand revenue-funded support modelwhere the hospital directly procures thehealthcare technology. In Canada thehealthcare technology is generally ac-quired through a competitive process –typically through an RFP process – wherebidders compete against each other forthe business, encouraging each one to re-duce costs and offer more benefits.

Here, the healthcare technology is usu-ally purchased on a one-off basis, allowingfor flexibility in the management of thetechnology and facilitating annual reviewsand changes to be made if necessary.

For example, if the in-house or the ex-ternal technology support fails or is inad-equate, there is an opportunity to quicklyadjust the mix and find the arrangement

that will best support patient care. Despite its widespread use, some im-

portant concerns attach to this model:• There is a dependence on a guaranteed

funding stream, which may become un-available during periods of financial stress.

• Because the capacity to stretch thetechnology’s use during funding short-ages is limited, the quality of clinical carecan be compromised where unreliablehealthcare technology remains in use.

The Rental Model: Renting healthcaretechnology may make sense where it’snot sensible for the hospital to own thetechnology, which might otherwise re-main unused for extended periods oftime. For example, renting can makesense when managing fleets of deviceswhere the number needed varies overtime. It can also make sense during re-placements. For example, renting a mo-bile CT for several weeks during replace-ment of the hospital’s own CT scanner.

The Leasing Model: In a leasingmodel, the ownership of the healthcaretechnology remains with the leasingcompany and maintenance is oftenrolled into the deal and provided as partof the lease terms. Here the hospitalneeds to negotiate with both the leasingcompany for the funding stream, as wellas with the leasing company within the

context of a procurement competition.A positive aspect of leasing is that anytechnology deficiency is the responsibil-ity of the leasing company. The riskstays with the leasing company.

A key concern with leasing are themany loose ends which can easily beoverlooked. First, many leases includeprovisions obligating the hospital to

keep the technol-ogy ‘in good con-dition’ and to re-pair it if necessary,which means thehospital assumesan uncertain fi-nancial risk. Second, there isthe question ofwhich party as-sumes responsibil-ity for software

updates/upgrades and other technologyupgrades during the term of the lease.

The Managed Equipment ServicesModel: The managed equipment services(MES) model is a life cycle managementapproach that converts the acquisition ofthe technology into a services transaction.This is therefore not a capital acquisition.

In this model, the hospital holds aprocurement competition (again, usually

through an RFP process) to find a ser-vice provider that will take responsibilityto procure, install and maintain thetechnology to a standard of performancethat is usually much higher than anyother model of technology acquisitionor rental. In this model the hospitalspecifies the service standard rather thanfocusing on the equipment alone andpays an annualized fixed fee for the ser-vices. The competition also tends todrive the costs down when compared tothe traditional acquisition model.

The MES contract typically extends totwo cycles of the life expectancy of thespecific technology, putting the serviceprovider in the position of absorbingand managing the periodic technologyreinvestment required to meet the per-formance requirements stipulated in theMES contract. As such, the serviceprovider assumes the risk of providingfuture technology, including financingthe risk, and the model also helps thehospital’s financial planning with a pre-dictable cost profile.

Denis Chamberland is a commerciallawyer with extensive procurement, tech-nology and trade law experience in thehealthcare sector. He can be reached atdac@chamberlandlawcorp.com

Denis Chamberland

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© 2018 Cerner Corporation

Leverage big data to driveimproved health outcomes.Improving the health of populations is a commitment we all share.Our strategy is to create a connected community that empowers thehealth and care of a person.

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Connectingwhat matters

BY LORELLE LAPSTRA

rtificial intelligence (AI) in the field of radi-ology is expected to bring a myriad of ben-efits, including improved diagnosis, fastermore efficient patient care and improved

workflow. While the potential impact ofAI on the practice of radiology has

generated millions in investment, there are only pock-ets of implementation in clinical practices. Widespreaduse in clinical practice is still several years in the future,in large part because the algorithms at the core of anyAI-based radiology application need to be trained andperfected through access to large image data sets andvalidated and enhanced by human professionals.

“We are still quite far away in most applicationsbecause we don’t have access to the data we need totrain algorithms properly,” comments Nils Forkert,PhD, the Canada Research Chair in Medical ImageAnalysis and member of the faculty of medicine atthe University of Calgary.

Forkhert and his fellow researchers often workwith small databases with only 20 to 100 data sets,which he notes is not enough to capture all the vari-ants of any disease or syndrome. Algorithms trainedand perfected through small data sets are actually tooprecise because they only reflect one slice of the totalpatient population.

“Right now we are in the early steps, despite thehuge hype around AI. Google’s tools are so successfulat recognizing cats and dogs because they have accessto huge databases of images. This is the struggle thatwe have in healthcare. We just don’t have access tothe images we need,” continues Forkert.

A recent study by a Mayo Clinic and Arizona StateUniversity research team highlights the role that im-age data plays in developing AI-based, or machinelearning (ML) imaging applications.

As explained by techtarget.com, “The basic premiseof machine learning is to build algorithms that can re-ceive input data and use statistical analysis to predictan output value within an acceptable range.” Theteam’s research explored using ML to assess ultra-sound images of thyroid nodules and determine theneed for a fine-needle aspiration (FNA) biopsy.

The ultimate goal of this work was to reduce the

number of FNA biopsies and their costs; only 10 per-cent of patients selected to have a biopsy actuallyhave cancer.

“[T]here is a clinical need for a dramatic reduc-tion of these fine-needle aspiration biopsies,” saidZeynettin Akkus, PhD, who is with the Mayo Clinic.

Ultrasound thyroid images include features that candifferentiate benign from malignant nodules and iden-tifying those features can reduce the number of FNAbiopsies. Creating a ML algorithm to identify benignnodules could eliminate the need for nearly half ofFNA biopsies, while still providing high-quality care.The team had access to 100 benign cases and 50 malig-nant cases to develop their algorithm. This limitedtraining dataset required artifi-cial augmentation to train thealgorithm, which is not ideal.

Ultimately, the perfor-mance of the algorithm needsimprovement with moretraining data. “Hopefully wecan increase the [size of the]dataset to thousands of im-ages, and … we are going tohave better prediction power,”explained Akkus.

To put AI to use in radiol-ogy there is an “urgent need to find better ways tocollect, annotate, and reuse medical imaging data,”reports a paper published in the May 2017 issue ofthe Journal of Digital Imaging.

Healthcare generates 800 billion images annually,which means the data needed to train algorithms ex-ists. Gaining access to these images is technicallychallenging because they exist in silos throughouthospitals and health systems.

To find and view images stored on PACS, VNA orXDS repositories requires a high level of interoper-ability. To meet personal health information privacyrequirements and other ethical issues regarding theuse of patient data, the data must also be anonymized.

In addition, image data must be properly labeledand annotated to maximize an algorithm’s develop-ment. Metadata required for medical imaging algo-rithm development includes imaging modality, examcodes and annotations on an image’s content.

While DICOM offers a standard file format forimage metadata, optional fields are often left blankor filled with proprietary data from an individualimaging system.

High-quality image recognition and analysis notonly requires solid standards, but also annotateddatasets and labeling that must be input by humans,which is both costly and time-consuming.

Medical imaging domain experts, medical imageinformaticists, researchers and others, are working tostandardize, and potentially automate, the image la-beling process to ensure that image data sets have theattributes that AI systems require.

Like any medical resident, algorithms need con-tinuous training to deliver high-quality and accuratediagnosis and decisions support. Access to data, suchas edge cases, is critical to creating AI systems thatcan deliver on their promised benefits.

To create the large data sets that AI needs, in addi-tion to developing and adhering to metadata stan-dards, healthcare systems must address technical, le-gal and ethical issues. On the technical end, imagingstudies can differ significantly depending on the pa-rameters of individual imaging systems.

And to create algorithms that truly capture thedeep knowledge of radiologists, AI systems need tosupport integrated access. The right solution wouldput AI outputs, such as diagnoses, in front of radiol-ogists in an unobtrusive manner. The radiologistcould accept, decline or correct an algorithm’s find-ings and then send their validations back to AI sys-tem for further refining the algorithm.

This collaborative loop offers clinicians the abilityto interact with AI development before they put it touse, relieving the perceived “threat” that AI presentsto radiologists and their profession. A collaborativeprocess between machines and humans will also helpto eliminate the cultural resistance to the idea ma-chines will replace humans. While there is much de-bate among radiologists about this issue, AI in radi-ology is predicted to augment radiologists’ clinicalpractice and not replace it.

Lorelle Lapstra is the VP of Healthcare Products withCalgary Scientific and is responsible for the healthcareproduct portfolio.

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Widespread use in clinical practice is still several years in the future.

AI algorithms need access to imaging dataand human experts for training

Visual analytics enabling hospitals to achieve quick insightsBY DIANNE CRAIG

LAS VEGAS – Many hospitals areusing business intelligence (BI)software to drill down through

and gain valuable, quality metricsfrom the vast amounts of patientdata, operations data, and other in-formation they collect. While tradi-tional BI platforms were made fordata specialists, the visual analyticsplatform from Tableau software isdesigned to be more of a self-serviceapproach for achieving quick insightsand measurable results, and equallyimportant, for getting the right in-

formation to the right people.“It’s a data myth that a BI plat-

form takes away power and flexibil-ity from the people,” said chief prod-uct officer Francois Ajenstat, duringthe conference keynote at TableauSoftware’s fall TC17 conference inLas Vegas. “We want Tableau to be acreative canvas for creative thinkingand decision-making.”

At TC17, where more than 14,000attendees met, Tableau announcedthe beta release of Tableau 10.5 – thelatest version of its analytics plat-form, as well as several new innova-tions. One key innovation was Hy-

per, a new in-memory data enginethat will replace the current one forfaster extracts, with the ability to‘slice and dice half a billion rows of

data in sub-seconds’, as was demon-strated during the keynote. Anothernew introduction was the release ofa data prep product code-named

Project Maestro, which instantly ed-its and updates data rows.

At the TC17 sessions, clients froma wide range of industries talkedabout their experiences withTableau. Here is a look at some ofthe unique applications hospitalshave found for Tableau – includingdeveloping visual dashboards to im-prove everything from operationalefficiencies to patient care.

Alberta Health Services: AlbertaHealth Services, which has 9,700physicians and 650 facilities servingthe province, has developed a

A

Tableau announced thebeta release of its analyticsplatform, as well as theHyper data engine.

Lorelle Lapstra

CONTINUED ON PAGE 23

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

BY STEFANIE KREIBE

With the dramatic increase ofmobile devices such asphones and tablets used bypatients, families and

healthcare providers, hospitals are increas-ingly challenged to keep germs out of careenvironments,” says Heather Candon,Manager of Infection Prevention and Con-trol (IPAC) at Mackenzie Health in YorkRegion, Ontario. “Recent research hasshown these devices, can carry all sorts ofgerms. At Mackenzie Health we are alwayslooking for ways to stop infectious virusesfrom entering the hospital and avoidingtransmission between patients.”

In the spring of 2017, Mackenzie Healthidentified the need to find a way to sanitizea number of mobile devices, not only forhealthcare team members, but also for pa-tients, visitors and the general public.

With the organization’s recent imple-mentation of a new electronic medicalrecord, enabled by more mobile devicesthan ever, the need to find a safe andproven way to effectively and quickly cleandevices became urgent.

Enter Mackenzie Health’s partnership,with CleanSlateUV, a company that spe-cializes in Ultraviolet (UV) technology tosanitize a wide range of small, non-criticalmobile devices such as cell phones, tablets,ID badges, stethoscopes, watches and otherhard, non-porous items. Following a sur-face-clean to remove any visible dirt, thetechnology can sanitize these common de-vices in 30 seconds. UV technology is notused to sanitize equipment that breaks theskin of a patient.

“We’re encouraged by the results andare pleased that many people now cleantheir cell phone regularly, such as whenthey enter the lobby or while they are wait-ing in the coffee line,” adds Candon. “Thisis a good thing all year-round, but evenmore so during flu season.”

Following a successful pilot of the tech-nology at Mackenzie Richmond Hill Hos-pital by the Mackenzie Innovation Insti-tute (Mi2), the equipment is now availablein the main lobbies of the hospital for useby the care team and visitors.

Mi2 is a separate entity that acts onMackenzie Health’s applied innovation vi-sion and helps build the infrastructure

needed to create and propagate sustainablechange. By developing partnerships withindustry and academia, Mi2 has establishedan evaluative focus on implementation, us-ability, adoption and scalability of disrup-tive innovations, predominately in health-care technology, but also in evidence-basedpractice changes and alternative service de-livery and procurement models.

Partnerships are built on a common vi-sion of healthcare innovation and remaincritical to the success of early innovationinitiatives.

“Innovation is a key enabler in achievingour vision to create a world-class health ex-perience,” says Richard Tam, Executive Vice

President and Chief Administrative Officerfor Mackenzie Health.

“We believe that, through pioneeringprojects such as the partnership withCleanSlate, we can help demonstrate thevalue of mobile, ‘smart’, and secure commu-nications in a healthcare environment andare looking forward to the opportunity toexpand our findings for the benefit of thegeneral public.”

The Mi2 team in collaboration withMackenzie Health staff worked closelywith CleanSlate to optimize their technol-ogy and improve their design for usewithin a hospital. The feedback sharedhelped CleanSlate refine their equipmentand the hospital benefited from a solutionthat is fast, user-friendly and effective.

“Our collaboration with MackenzieHealth’s staff and the Mi2 team has beenfantastic,” says Manjunath Anand, ChiefTechnology Officer at CleanSlate UV.“Their feedback led to meaningful productdesign and user interface improvements,and they helped prove how valuable thetechnology can be to patients and visitors,not just to clinicians. This has created valuefor users and for hospitals seeking a one-stop solution for the problem of mobile de-vice sanitization and personal hygiene.”

CleanSlate’s technology was initially in-tended to be tested in a clinical setting. Af-ter a deeper review, the Mi2 team in con-sultation with Mackenzie Health staff,identified that the system would potentiallyreceive more foot traffic in a public settingand be of value to a broader audience.

Stefanie Kreibe is Senior CommunicationsConsultant with Mackenzie Health.

In future, more radiologists will be in therapeutic side of medicine

CHICAGO – With AI and machinelearning now appearing that canspot lesions and other problems,

where does this leave the radiologist – es-pecially five to 10 years from now, whenthese solutions will have matured? Will ra-diologists play second fiddle to machines?

This issue was on the minds of manyat the RSNA 2017 conference last No-vember. The president of the RSNA,Saskatchewan-born Dr. Richard Ehman,urged his colleagues to “Embrace dis-ruption. If we don’t, we will becomevictims.”

Dr. Ehman, a professor of radiology atthe Mayo Clinic, in Rochester, Minn., as-serted that radiology must evolve througha process of continuous innovation. “Ifwe continue to re-invent ourselves, wewill continue to serve our patients.”

His colleagues on the podium gavevivid examples of how radiology is al-ready changing. Dr. Roderick Pettigrew,former head of the National Institute ofBiomedical Imaging and Bioengineering,stressed that the radiologist must evolveinto a data scientist.

To do this, radiologists will need towork more closely with other experts incomputer science, along with other med-ical disciplines.

He used a video to demonstrate how aGI expert in London, UK, could deploytelehealth to work with a radiologist inMumbai and a computer scientist in At-lanta to diagnose a cancerous lesion in apatient undergoing a colonoscopy.

All three experts conducted their workon a single computer screen, where theywere represented as cartoon-like, ani-mated avatars. Meanwhile, 3D reconstruc-tions of the patients’ bowel and otherparts of the anatomy floated on-screen,where they could be turned, pulledapart and examined by the radiologist.

As this occurred, the radiologistgave his report and suggestions fortherapies.

“It’s mixed reality,” said Dr.Pettigrew. “You can bring yourfavorite expert into the team.”

He said in the future, the ra-diologist workstation will ap-pear more like that of a pilot’scockpit in a jetliner, but with3D images appearing on screensaround him or her, along withdashboards of physiologic data.

Dr. Elias Zerhouni, also akeynote speaker, agreed thatdata will play a bigger part inradiology – namely in the

form of big data science and genomics.Dr. Zerhouni, VP of research and de-

velopment with Sanofi, and a formerleader of the NIH in the United States,said radiologists will shift from inter-preting spatial and temporal informa-tion in images to connecting this datawith genomic and even environmentalinformation.

He claimed that a big gap in radiol-ogy exists in the ability to tell whether

prescribed therapies are actu-ally working. For example,whether cancer drugs are ac-tually making their expectedimpact.“We need to be able to tell if

therapies are working – no-body can do this today.”He said that new technolo-gies like PET/CT andPET/MR have the great-

est potential inthis area. Ofcourse, the ma-chines will alsoneed the right“software”. “Weneed to de-

velop biomarkers to do this,” he added.Dr. Zerhouni didn’t disparage the use

of AI in radiology; instead, he insisted itwould be very useful. He commentedthat there can be a huge variation in thequality of readings from one radiologycentre to another, and that AI could beused as a decision support tool toachieve greater consistency and higherquality outcomes. “It can improve ourperformance as a community, and re-duce error rates.”

With whole sets of studies in thecloud, and processing in the cloud, radi-ologists could compare their readingsagainst these models. Using these high-quality benchmarks, radiologists will beable to produce more accurate diagnoses.

He pointed out that in some areas,machines can do a better job of identify-ing and classifying diseases. For instance,in the area of textural analysis, comput-ers can be trained to be more accuratethan humans.

The challenge, he said, will be to pro-duce high-quality repositories of studiesin the cloud. Without top-notch data,you cannot produce good models.

The issue will become, he said, “whohas the best reference patients, and whohas the cleanest data.”

Mackenzie Health improves hand hygiene with ultraviolet technology

‘

Dr. Richard Ehman

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BY DR . SUNNY MALHOTRA

Blockchain technology – cryptographi-cally secured, distributed ledgers – hasexisted for almost 10 years and is begin-ning to emerge as a viable solution inhealthcare. Startups are addressing painpoints such as medical record interop-

erability, data security, reimbursement, and pharma-ceutical supply chain management. Blockchain is al-ready a powerful tool in the financial sector becausethe ledger cannot be altered or accessed without per-mission.

These principles make blockchain uniquelysuited to host healthcare transactions and patientinformation.

Blockchain is a public ledger of cryptocurrencytransactions which can disrupt data management,including data access for clinicians and family mem-bers or researchers, and healthcare supply chainmanagement and financial transactions.

Here are some major use-case scenarios ofblockchain technology in the ecosystem:

Electronic medical record interoperability: Pokit-Dok is an API developer for healthcare sectors suchas claims, pharmacy, and identity management. Pok-itDok has a blockchain solution called DokChainwhich is a network of financial and clinical datatransaction processors in the healthcare industry.

This provides a secure network for patient datafrom EMRs, medical devices and pharmaciesthrough a distributed blockchain network.

Identity protection: There have been attemptsto create an identity prototype based onblockchain technology that could provide a digital

identity to those without a formal ID includingrefugees who would benefit from education andhealthcare services.

Blockchain Health is a software company thatprovides healthcare organizations with HIPAA-com-pliant digital identity for people and allows them to

share health data with researchers using the inte-grated platform.

Pharmaceutical and biotech solutions: Block-pharma focuses on tracing drug sales online bydeveloping an application programming in-terface that can plug into pharmaceuticalcompanies’ information systems. This canalso be helpful for the illegal counterfeitdrug market.

Clinical solutions: Doc.AI’s Robo-Ge-nomics platform is a deep conversational

agent designed to provide decision-support based ongenetic data comprehension. The decision supportcan be provided for disease, pharmacogenomics andfamily planning.

Risk management: HealthCombix is a companywhich provides a token-based healthcare paymentand risk management network enabling payments,data asset monetization and risk adjustment. Theplatform preserves digital privacy and interoperabledata brokering. This empowers patients andproviders with control over the data. Consumers cancontrol data exchange for research, precision healthand disease intervention.

Reimbursement: Gem Healthcare Network devel-ops blockchain applications on the Ethereumblockchain. It enhances security via permissionedblockchains in which patients control access and a

shared ledger system in which every new changeis recorded. They are pursuing health claims

management by allowing patients,providers, and insurers to securely view apatient’s health timeline in real-time.The implementation of blockchain tech-nology and penetration into the healthcaremarket has provided solutions to multiple

barriers the sector is currently facing. Therise of cybersecurity concerns has made this

technology an important issue forpharma, insurance, and biotech

stakeholders. Many have startedto embrace these solutions,but they need to be inte-grated into large-scale ap-plications to become prac-tical solutions.

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Blockchain is already a powerful tool in the financial sector; healthcare may be next.

Blockchain solutions are starting to appear in the healthcare sector

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

The rise of cybersecurity concerns hasmade this technology an importantissue for healthcare providers, pharma,insurance and biotech stakeholders.

How to improve procurement in Canada’s healthcare sectorBY LYDIA LEE

What should a great health-care Request For Proposal(RFP) look like?

In its simplest form, the purposeof an RFP is to connect a specificproblem to the best and most innov-ative solution. The RFP should artic-ulate an organization’s challenge andoutline a creative, effective and effi-cient way in which the third partyfirm would provide assistance to ad-dress that challenge.

All too often, however, ill-pre-pared RFPs can attract the wrongvendors, exclude new innovators andincrease the cost of sales, ultimatelydiminishing the value that can be at-tained by both parties.

While RFP preparation is a bit ofan art, I do believe that most RFPshortcomings can be remedied at nocost for considerable benefit.

Why is this issue important? Overthe course of my career, I’ve been onboth sides of the RFP process in

healthcare, first, as a former hospitalCIO and now as a digital healthcareconsultant.

Based on the diverse perspectivesthat I have experienced over my ca-reer, I want to share what I havelearned about the process and howto improve RFPs overall, so that is-suing organizations can receive thequality of help they need.

I see three standout challengeswith public sector healthcare RFPsthat diminish value creation. Beloware some observations as well as easyfixes that every organization can im-plement to make the RFP processsimpler and more effective:

Unclear scope and conflicting re-quirements: RFPs issued by hospitalsare often unclear in scope becausethey fail to articulate the problemthe organization is experiencing.

The RFP may have too many re-quirements, which aren’t essential tosolving the problem. These “kitchensink” RFPs reflect to the marketplacethat there wasn’t enough attention

paid to the most important engage-ment elements.

Responders then risk focusing onthe wrong priorities, diluting the ul-timate benefit for the client. Or, RFPshave internal contradictions, such as

desiring inno-vative, flexibleapproaches,while the eval-uation criteriafocus on de-tailed minu-tiae that tiesthe vendor’shands, limit-ing the abilityof the vendorto actually cre-

ate an effective solution.“Kitchen sink” RFPs or contradic-

tory requirements, typically leavevendors cold because we can’t be surethat we can actually interpret andmeet an organization’s true needs.

Instead, RFPs should include clearproblem statements that articulate

the challenge being addressed andwhy. Organizations should have aclear image of what success lookslike and should seek qualified indi-viduals who are not part of the RFPcommittee to review the RFP forclarity before posting.

By checking that your evaluationcriteria reflects the experience andattributes needed to solve the prob-lem at hand, it will increase yourchance of a successful outcome. Besure to edit the requirements toeliminate non-essential ones. Themore freedom you can give to theresponders about how to approachyour request, the more likely youwill get better proposals.

Rigid submission templates: Hav-ing sat on many proposal evaluationpanels when I was on the buyingside, I understand that templated re-sponses are faster to review becausethey restrict proposal content. How-ever, a template that’s too rigid im-pairs responders’ ability to give a

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Lydia Lee

CONTINUED ON PAGE 23

V I E W P O I N T

BY MICHAEL BILLANTI

While the term ‘populationhealth’ is becoming com-monplace, it lacks an ac-cepted, industry-wide defi-

nition. As such, its potential to impactchange can be misunderstood or misrepre-sented. Population health is more thansimple information queries and analytics –to make a real difference, it must provideactionable outputs and clinical recom-mendations for proactive healthcare.

Population health is taking responsibil-ity for managing the overall health andwellbeing of a defined population and be-ing accountable for its health outcomes. Itencompasses the proactive application of

strategies and inter-ventions to definedgroups of individu-als (e.g., people withdiabetes, cancer pa-tients, those withmental health issues,or the elderly withmultiple comorbidi-ties) with the goal ofimproving the qual-ity of care and out-comes in an inte-

grated, caring and efficient way for citizens.A Canadian advantage? If we take the

view that population health is part of awider health and well-being strategy thatincludes wider determinants of health,such as housing, the environment and em-ployment, Canadians are at a clear advan-tage over other’s globally.

We are data rich, and live in a rela-tively integrated society where health,education, social services, labour and fi-nance ministries are all run by each ofthe provincial or territorial governments.We should be able to better leveragethese, although siloed, very maturesources of information.

The UK and other European countriesalso have an advantageous opportunity.Our socialized medicine systems areprovincially based, with integrated socialcare systems, and as such we can bring to-gether a full battery of healthcare, socialcare, community assets and the citizensthemselves in a truly integrated and holis-tic system of care.

For example, in England, there is a 12-year discrepancy in life expectancy acrossthe Wirral peninsula, a small area about 24km long and 11 km wide, with key oppor-tunities to improve outcomes for chronicdiseases such as diabetes, COPD, asthma,and depression.

The region has areas of both high andlow income, high rates of smoking and al-coholism, poor housing and low employ-ment rates. The health system realized thatthe population health opportunity is to es-tablish new care models that holisticallyaddress health, care and social determi-nants of wellbeing.

They have created a population healthmodel to solve these problems at theirsource to improve the wellbeing of thesecitizens and reduce the stress on thehealthcare system. As I discuss populationhealth with organizations across Canada,the stories that Health Canada, CIHI and

local public health publications tell arestrikingly similar and provide the verysame opportunities.

Informatics is the enabler: Populationhealth management informatics arerapidly evolving to step up to these op-portunities, but it is by no means clear

what a full set of informatics capabilitieswill be.

At the root of it we adopt concepts likeBig Data, which is great for enabling theinvestigation and discovery of issues.Most of the Canadian healthcare organi-zations we speak with already know the

issues they have, so the thought of an-other analytics solution or different wayof aggregating and organizing data seemsoff-putting.

But this is where we need a new way oflooking at the problem. It is key to how

Population health management: Will you rise to the challenges?

Michael Billanti

CONTINUED ON PAGE 23

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BY DIANNE DANIEL

The sooner you learn of a potential risk,the more likely you are to mitigate it.That’s the premise behind recentstrides to bring early warning systemsto hospital surgical wards, where thegoal is to reduce complications, emer-

gency room visits, hospital readmissions and mortal-ity rates after surgery by more closely monitoring pa-tients – even after discharge.

In January, Ontario’s Hamilton Health Sciences(HHS) started to enrol patients in its SMArTVIEWtrial, a ground-breaking project that aims to reducecomplications and improve outcomes in patients aged65 and older who undergo cardiac or vascular surgery.

While in hospital recovering from surgery, pa-tients are outfitted with wireless respiratory pods,blood pressure cuffs and oxygen saturation moni-tors, all of which are continuously monitored by thePhilips Guardian system. Radio frequency hot spottransmitters placed throughout the surgical ward al-low them to roam freely without losing connection.

If there is a change in their vital signsthat reaches a predefined threshold score,nurses are notified via a verbal message ontheir smartphones to “check vitals” and aregiven two minutes to respond. If they don’tanswer, they get a second verbal reminderwith an additional 30 seconds, and if theyfail to respond to that, an alert is sent to thecharge nurse.

This paging interface was built byThoughtWire, and was conceived by theteam to recognize that busy nurses need atimeframe to respond, and contingencybuilt in place, in case they can’t respondright away.

“Research from leaders in our grouphas shown that hypoxia, where your oxy-gen saturation is less than 90, can be re-lated to complications, such as having aheart attack post-op,” said Dr. MichaelMcGillion, a scientist at HHS’s PopulationHealth Research Institute and Principal in-vestigator for SMArTVIEW, along with HHS cardiol-ogist and co-lead Dr. PJ Devereaux.

“The idea is to call early attention back to bed-side,” he added.

In order to reduce alert fatigue, there is a delaybuilt into the system so that it doesn’t send notifica-tions with every little change in patient status, ex-plained Dr. McGillion, noting that some patients willnormalize on their own. When responding toSMArTVIEW notifications, nurses check patient vi-tals and input additional information required bythe system, such as temperature. The Guardian sys-tem provides an early warning score, and if war-ranted, clinicians intervene, engaging the rapid re-sponse team when necessary.

SMArTVIEW is considered a pioneering studybecause close patient monitoring continues for 30days after discharge – the period which is known tobe the likeliest for an adverse event to occur. Each pa-tient enrolled in the program goes home with atablet, plus Bluetooth-enabled vital signs equipment,such as a blood pressure monitor and weigh scale,oxygen saturation probe.

The SMArTVIEW trial provides a cellular data

bundle, so there’s no cost to patients. At the end of 30days, they simply box everything up and return theequipment via pre-paid courier.

Once at home, patients are asked to measure theirvital signs three times daily – morning, afternoonand evening – and results are automatically sent tothe tablet. The only measurement entered manuallyis temperature.

They then use their tablets to hold daily video vis-its with their SMArTVIEW nurse, a newly created rolefor the hospital. Appointments are scheduled, butnurses adapt to the patients’ schedules as required.

Because the management and collection of pa-tient data – including vital scores – is handled re-motely by the Philips eTrAC ambulatory telehealthprogram, SMArTVIEW nurses are able to monitortheir at-home patients using the Philips eCareCoor-dinator dashboard. Patients also use their tablets tophotograph their surgical wounds, which are eithersternal or leg incisions, enabling SMArTVIEWnurses to perform visual assessments and watch forsigns of infection.

“We’ve had a tremendous response from patients

who are saying, ‘This is wonderful. Now I get to takethe hospital home with me’,” said registered nurseFilomena Toito, one of four initial SMArTVIEWnurses. “Patients have expressed that sense of relief thatthey are still connected to the hospital team and thattheir care continues even beyond the hospital walls.”

SMArTVIEW nurses are a new addition to thehospital workflow, serving as a bridge between thenew monitoring technology, the patients, and thenursing staff to help resolve issues and coach peopleon how to use the devices. In addition to monitoringthe early warning scores, the SMArTVIEW nursesgauge their patients’ overall wellbeing, asking howthey’re eating and sleeping, for example.

“Patients feel so empowered that they’re using thisnew technology,” Toito said, “Having that connectionis so reassuring and it’s helping with best possiblecare as an outcome.”

Karen Barrett, Natalia Worek, and Carley Ouel-lette are also key members of the SMArTVIEW nurs-ing team.

“A key concept of the study is that when there’s atransition from hospital to home, there are gaps,”added Dr. McGillion. “The argument we are making

is that the SMArTVIEW nurse gets to know the pa-tient on the ward, know their story, know their issues,and then follows them for the first 30 days at home.”

Patients are also empowered to take part in theirown healing process. Researchers involved in theproject have developed SMArTVIEW Restore andRecover, a five-week education program developedin collaboration with QoC Health that includes in-teractive videos and podcasts. Patients learn how tocommunicate pain, what foods to eat to promote re-covery and how to transition back to physical activ-ity over time, for example. They also stay in contactwith a recovery coach stationed at the hospital.

SMArTVIEW is funded in part by Ontario’sHealth Technologies Fund, a fund administered byOntario Centres of Excellence on behalf of the Officeof the Chief Health Innovation Strategist. In additionto Philips Healthcare and ThoughtWire Corp., part-ners include QoC Health Inc., CloudDX, XAHIVEInc., Argyle Public Relations and the OntarioTelemedicine Network. McMaster University andHHS are also collaborating with Coventry Universityand Liverpool Heart and Chest Hospital in the U.K.,

where trials are under way this year.“They’ve kicked it up a notch, wherethey have international team mem-bers, trans-disciplinary teams, pa-tient advocates, sector experts andtop clinicians. It’s a pretty excitingteam,” said OCE Director, Innova-tion Procurement, Tania Massa.Massa said SMArTVIEW is ad-dressing a significant hospitalsymptom by taking an active ap-proach, as opposed to reactive,and by empowering patients toprevent adverse effects followingsurgery. At the end of thedemonstration project, which in-volves 600 patients who will bemonitored for a period of sixmonths, she expects to see astrong business case put forth forwider adoption of the program“We’re hoping to see reduced re-

admissions and improved patient satisfaction,”she said.

Rob MacLellan, Project Manager, ICT Initiatives atHHS, called early warning systems an emerging fieldin healthcare. His team devoted 900 hours towardsintegrating the system, working with the differentvendors to connect the various pieces. “We crunchedour brains as best we could to think of what could gowrong, and now we’re just waiting for the ‘Aha! Mo-ment’, as in, ‘Aha! we didn’t think of that one’,” he said.

He, McGillion, and Devereaux credit the hospi-tal’s clinical informatics, IT and biomedical technol-ogy team for working with Philips and ThoughtWireto bring the trial live. Because ThoughtWire was al-ready in place at HHS to support a separate earlywarning initiative, the alerts generated by the Philipssmart monitoring technology are integrated with theexisting ThoughtWire notification process.

“Patient information goes up into the Philipscloud. We don’t store anything on the hospital side,”explained MacLellan.

At Kaiser Permanente Northern California, anearly warning system called Advance Alert Monitor(AAM) has undergone testing since 2013. By the end

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Ground-breaking system aims to reduce complications and mortality after cardiac or vascular surgery.

SMArTVIEW tests early warning systemfor post-op patients

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S U R G I C A L S Y S T E M S

of this year, 21 sites will be using AAM toobserve all medical-surgical patients in or-der to predict and prevent crashes.

The idea for an early warning systemsprouted as early as the 1980s, when anumber of studies pointed out that out-comes for patients who suffered cardiacarrest on the hospital ward and were sub-sequently transferred to the intensive careunit were extremely poor.

“When I quantified the outcome of un-planned transfers to the ICU at our KaiserPermanente facilities in northern Califor-nia, it became clear to me that these pa-tients were really sick; they were 3 percentof hospitalized patients, but one of five ofthe deaths,” said Dr. Gabriel Escobar, Re-gional Director for Hospital OperationsResearch for The Permanente MedicalGroup (TPMG) at Kaiser PermanenteNorthern California.

He is also a Research Scientist at theKaiser Permanente Northern CaliforniaDivision of Research.

Dr. Escobar’s team realized early on thatvital sign data would be key to predictingwhich patients were at risk. Using data frommore than 650,000 patients, they worked todevelop a predictive model that forms thebasis for AAM. The system started out as aweb service, grabbing real-time data from ahospital’s Epic electronic medical record(EMR), applying advanced algorithms to ar-rive at an early warning score, and sendingan alert for those patients at greatest risk.

The score is based on more than 62 sep-arate factors, including multiple lab values;nursing assessment data such as vital signs,neurological status and pulse oximetry;and, patient demographics. It identifiesthose patients who are at risk for deteriora-tion within 12 hours. The first sites to pilotthe system were Kaiser Permanente’s SouthSan Francisco and Sacramento medicalcentres where AAM ran every six hours anddisplayed results directly in the EMR.

As Dr. Escobar described, alert fatiguewas a very real issue. “There’s a trade-off. Ifyou make the alert too sensitive, you’ll begenerating a lot of work for physicians andnurses for no yield,” he said. “If you make ittoo specific, you’ll miss too many patients.”

Based on that early experience, KaiserPermanente decided to move ahead with adifferent implementation plan, incorpo-rating an existing off-site command centercalled eHospital Safety Net to serve as anAAM hub.

The centre is staffed by eHospital nurseswho now receive the AAM alert notifica-tions, interpret them, and collaborate withthe larger clinical team to review and plannext steps, making changes where neces-sary to address early changes in a patient’sconditions.

The hub model means the scores canbe run more frequently, increasingthe likelihood of successfully inter-

vening to prevent a patient from crashing.It also gives frontline clinicians an oppor-tunity to understand how the scores arederived and how to apply them appropri-ately, noted Dr. Vivian Reyes, a Kaiser Per-manente emergency physician and TPMGRegional Director of Hospital Operations,

“I’m hoping over time this will become‘Oh, of course, the predictive model’ sowhen we roll out subsequent scores, peoplealready know how to use them and therewon’t be room for misinterpretation,” she

said. This spring, Kaiser PermanenteNorthern California will conduct an in-depth evaluation of the AAM system,looking at 1.2 million hospitalizationsfrom before the system went live, up toFebruary 2018. Preliminary data showsmortality rates have dropped, said Dr.Reyes. “We’ve also seen a decrease in theICU length of stay, which is huge,” sheadded. “It’s hard to pull patients back once

they’ve crashed and coded, but if you canprevent that from happening, they getback to their normal physiological statefaster and they don’t need the ICU.”

Moving forward, the Kaiser Perma-nente implementation team is planning toapply AAM to patients who are admittedto the hospital after a visit to Emergencybut are awaiting a bed, referred to as EDboarders – a high-risk group.

They are also working closely with Epicto integrate the AAM workflow directlyinto their electronic medical record, re-moving the need for using web services.

“The real challenge is not in developingthese predictive models,” noted Dr. Esco-bar. “The real challenge is in making sureyou integrate them seamlessly into theworkflow so that they really help clini-cians, not add to their burden.”

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S U R G I C A L S Y S T E M S

BY DAVE WEBB

David Wyand’s introduction tobringing lifelike, immersive re-ality to the medical field camethrough a chance meeting.

In the fall of 2016, at a virtual realitymeetup, the lead-developer with Toronto-based Quantum Capture encountered Dr.Clyde Matava and Dr. Fahad Alam, twoToronto-based anesthesiologists. The twohad co-founded the Collaborative HumanImmersive Interaction Laboratory (CHISIL),a community of medical professionalsfrom across Canada devising VR systemsto simulate patient experiences and train-ing scenarios.

The veteran of game engine design withnow-defunct Garage Games became oneof the first developers to work on a CHISILproject. It was new territory for Wyand,and for Quantum.

Quantum is known as the virtual peo-ple people, providing hyper-realistic, 3D,full-body scans for VR and augmented re-ality content developers, largely gamingcompanies. “None of us had ever done amedical simulation before,” Wyand says.“It ended up being more complicatedthan some.”

Quantum worked with CHISIL to de-velop an immersive simulation of a fibre-optic bronchoscopy procedure. Thetrainee selects appropriate monitors andequipment while operating the broncho-scope handle, scoping the throat of animaginary patient with tracheal damage.

Meanwhile, there’s a virtual collar tobe removed, chatter and instructionsfrom other doctors to be processed, and,at the end of the day, a score reflectingperformance.

Dr. Matava, an assistant professor ofanesthesiology at the University ofToronto and staff member at Sick KidsHospital, and Dr. Alam, a staff anesthesiol-ogist at Sunnybrook Health Sciences Cen-tre in Toronto and director of research atthe Sunnybrook Simulation Centre,founded CHISIL in 2014.

CHISIL has been lauded for its

ChildLife Virtual Reality application, a 3Dheadset that simulates the preoperative ex-perience in a 360-degree interactive envi-ronment. More than 200 patients—mostlychildren at Sick Kids and adults with anxi-ety issues—have used the headset, findingit prepares them better and calms theirnerves more than a PowerPoint presenta-tion or drawings.

Anxiety can affect all stages of surgery,requiring more anesthetic and extendinghospital stays. (The application is availablefor download by Apple users on iTunes.)

“We’re at the forefront of bringing vir-tual reality to healthcare,” says Dr. Alam.The mission of CHISIL is to develop VR forpatient and medical education, as well asclinical applications: assessing, diagnosingand treating patients. It’s a community of“the right people in the right places,” withcommon interests for common outcomes,that can move the technology from concep-tion through validation, Dr. Matava says.

There is some resistance in the field. Clin-icians are very wary of consumer technol-ogy, according to Matava. “Virtual reality issomething that stays at home,” he says.CHISIL is trying to move VR from a gamingexperience to something of clinical value.

There’s a learning curve attached.They’ve had to learn about the technologiesand the many skill sets involved in creatingan immersive experience: not just graphicdesign, game design and coding, but direct-ing, set design, acting and scripting.

“It really does take a village to build vir-tual reality,” says Dr. Matava.

Quantum photographed Sunnybrook’strauma bay, modeled a patient’s mouthand trachea, and replicated every device—what it looked like, what it sounded like.The game development process calls for agame document, which details player op-tions and consequences; the team workedwith Dr. Alam and Dr. Matava on a flowchart for the procedure.

It wasn’t easy creating all of this, as thedoctors were conducting their day-to-dayclinical duties and were pressed for time.The need for close collaboration, combinedwith the doctors’ busy schedules, demanded

flexibility from the Quantum team.“We had to make sure when they were

available, we were available,” Wyand says.That meant lots of nights and weekends.

And it was necessary to add differentlevels of sophistication and difficulty. Forexample, Drs. Alam and Matava breezedthrough the simulation in early iterations,so it was necessary to toughen it up formore experienced users.

In the end, the project was a success – itresulted in a useful immersive reality train-ing tool for clinicians.

Meanwhile, another member ofCHISIL is working on how to use virtualreality to explore the connections betweenanesthetic use and cognitive deficits.

Dr. Sinziana Avramescu is the senior in-vestigator for virtual reality and cognition

with CHISIL. She is working on how im-mersive reality can help predict, diagnose,and eventually treat post-operative delir-ium (POD).

POD is often associated with generalanesthetic use, and is a persistent threat. Itsincidence varies from nine to 87 percentdepending on the age of the patient andthe severity of the surgery, according to a2011 paper from the Washington Univer-sity School of Medicine in St. Louis. PODis associated with increased length of hos-pital stay and a cost of $164 billion a yearto the healthcare system in the U.S. alone.More frightening is the 10-20 percent in-crease in mortality for every 48 hours ofdelirium, and a 10-fold increase in the riskof dementia.

“That’s quite scary,” says Dr. Avramescu.“Having surgery, most of the time, isn’t op-tional.” Dr. Avramescu, a clinician investiga-tor and assistant professor at the Universityof Toronto, says rapid diagnosis is key toameliorating the negative outcomes of POD.

Identifying patients likely to experiencePOD could help. While much is unknownabout the risk factors, a previous history ofcognitive problems appears to predisposepatients, according to a New England Jour-nal of Medicine article by Dr. Sharon In-ouye. Patients with mild cognitive impair-ment can often disguise symptoms in or-der to function in the community, Dr.Avramescu says; they can’t hide spatial im-pairment from a 3D simulation.

By engaging the patient in a fully im-mersive experience to test spatial cogni-tion—a maze, in this case—early signs ofdementia can be detected without the needfor an expert interviewer and patientsscreened for more in-depth investigation.

Dr. Avramescu’s mission is ongoing.The team is at the storyboarding stage ofthe spatial awareness project. After initialdevelopment comes a screening test onhealthy volunteers. Further down the road,she hopes the technology can be used fortreating POD, not just diagnosing it.“That’s a huge thing to do, to help them getbetter, not just telling them they have aproblem,” she says.

Demand for medical robots growing quickly, especially in Asia

The medical robots market is pro-jected to reach US $12.8 billionby 2021, up dramatically from

$4.9 billion in 2016, and growing at arate of 21.1 percent annually during theforecast period. The estimate was madeby tech research company Markets andMarkets, which authored the report,Medical Robots Market, Global Forecastto 2021.

According to the company, the high-est growth rate will occur in the Asia-Pa-cific region. The fast expansion in the re-gion can be attributed to the growth inthe number of approvals of robots formedical use in Japan, rising prevalenceof cancers in China, growing roboticprocedures backed by rising number ofhospital beds in India, rising adoption ofmedical robots in Asia, funding collabo-

rations across the Asian region, andtraining programs in Australia.

On the basis of product, the market issegmented into instruments and acces-sories and medical robot systems. Themedical robot systems segment is furtherfragmented into surgical robots, rehabil-itation robots, non-invasive radiosurgeryrobotic systems, hospital and pharmacyrobots, and other medical robotic sys-tems (capsule robots and robots foremergency medicine).

In 2016, the surgical robots segmentcommanded the largest share of med-ical robot systems. However, the reha-bilitation robot systems are likely togrow at the highest rate during the fore-cast period.

On the basis of application, the med-ical robots market is segmented into la-

paroscopy, orthopedics, neurology, spe-cial education, and other applications(gynecology, urology, cardiology, andnanomedicine). Of these applications,the neurology segment is expected togrow at the highest rate during the fore-

cast period. However, the laparoscopysegment is estimated to command thelargest share of the market, by applica-tion, in 2016.

In 2016, North America accountedfor the largest share of the global med-

ical robotics market. North America’sleadership in the market can be attrib-uted to favorable reimbursement sce-nario in the U.S., funding by the U.S.Department of Defense, grants fromNSF for research activities in the U.S,rising venture capital investments in theU.S., government support in Canada,and increasing medical robot purchasesbacked by rising preference for mini-mally invasive surgeries.

Key players in the global medical ro-bots market include Intuitive Surgical,Inc. (U.S.), Stryker Corporation (U.S.),Mazor Robotics Ltd. (Israel), HocomaAG (Switzerland), Hansen Medical Inc.(U.S.), Accuray Incorporated (U.S.),Omnicell, Inc. (U.S.), Ekso BionicsHoldings, Inc. (U.S.), ARxIUM (U.S.),and Kirby Lester LLC (U.S.).

Rehabilitation robot systemsare expected to develop andgrow quickly during theforecasted period.

Physicians partner with game developers to create VR for healthcare

CHISIL has developed a VR broncoscopy simulation.

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Dr. Fahad Alam Dr. Clyde Matava

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

VANCOUVER – In the first study ofits kind, Vancouver General Hos-pital Surgeon Dr. Andrea Mac-Neill analyzed the carbon foot-

print of surgical suites at three hospitals inCanada (VGH), the United States (Univer-sity of Minnesota Medical Centre), and theUnited Kingdom (John Radcliffe Hospital,Oxford).

Dr. MacNeill found the choice of anaes-thetic gases used in surgery can be a majorcontributor to greenhouse gas emissionsfrom operating rooms.

The study, published in The LancetPlanetary Health journal, found that it’spossible to reduce emissions in healthcaresettings and reduce costs. Researchersmeasured the direct emissions (gases), in-direct emissions (electricity), and otheremissions (surgical waste) according to theGreenhouse Gas Protocol. The data wascollected and evaluated in 2011.

According to the study:• Operating theatres are a resource-in-

tensive subsector of healthcare, with highenergy demands, consumable through-put, and waste volumes. The environ-mental impacts of these activities aregenerally accepted as necessary for theprovision of quality care, but have notbeen examined in detail. In this study, weestimate the carbon footprint of operat-

ing theatres in hospitals in three healthsystems.

• The annual carbon footprint of thestudied surgical suites ranged from ap-proximately 3218 tonnes of CO2 equiva-lents to 5187 tonnes of CO2e. While therewere differences in the size and case loadamong all three surgical suites, there werealso variations in the major contributorsto greenhouse emissions. For instance, atVancouver and Minnesota, anaesthetic

gases were responsible for 63 percent and51 percent of the total surgical emissions,compared to only 4 percent at Oxford.

• Operating Theatres were found to bethree to six times more energy-intensethan the hospital as a whole, primarily dueto heating, ventilation, and air condition-ing requirements. Overall, the carbon foot-print of surgery in the three countriesstudied is estimated to be 9·7 milliontonnes of CO2e per year.

• According to Dr. MacNeill, it means thatsurgeries are approximately equal to 2 mil-lion cars on the road every year.

• The Lancet Commission on Climateand Health has called for the healthcarecommunity to take a leadership role in ad-vocating for emissions reductions, and tocritically examine its own activities withrespect to their effects on human and envi-ronmental health. This study is the first toestimate the considerable climate impactsof surgical services.

How VGH is reducing its carbon foot-print: VGH is already making changesbased on the findings. When the study wasdone in 2011, the default was desflurane,one of the primary contributors to globalanaesthetic gas emissions and one of themost expensive anaesthetic gases. Desflu-rane is still used, but it’s no-longer the “goto” gas at VGH.

“It wasn’t difficult to switch,” saidanaesthesiologist Dr. Mitch Giffin.“There wasn’t a significant differencefrom a patient perspective.” Additionally,an anaesthetic gas capture system will bebuilt into the new operating room pro-ject at VGH.

“The 16 new operating rooms afford usan opportunity to do what’s right for theenvironment and our patients,” said ShellyFleck, OR Operations Director, VCH.

Innovative procurement simplifies access to surgical pathway solutions

When Sinai Health Sys-tem in Torontowanted to see whatbenefits patient moni-toring technology

could offer elderly patients at theirMount Sinai Hospital and BridgepointActive Healthcare campuses, they issuedan RFP to find vendors who could pro-vide solutions.

The exercise followed the traditionalapproach to procuring a product, ac-cording to Lily Yang, Senior Director ofQuality and Patient Experience, SinaiHealth System: identifying a solution toa problem, scouring the marketplace andvetting the vendors.

A different take that’s caught Yang’sattention, however, is innovative pro-curement, an approach used by the On-tario Telemedicine Network (OTN) toqualify vendors to provincial Vendor ofRecord (VOR) arrangements.

The first VOR OTN has recentlymade available – via its Innovation Cen-tre at https://otn.ca/innovationcentre/ –features three surgical vendors: InTouchHealth, SeamlessMD, and Vivify Health.Each offers mature and market-testedpatient engagement technologies thatstandardize surgical pathways and im-prove health outcomes.

“This open innovative thinking willaccelerate the process for sure,” saysYang. “Vendors are knocking on doors,hoping for data sets and proofs of con-cept. It’s nice to have OTN cut throughit. Many hospitals would be challengedby the expertise and resources needed to

evaluate the many existing technologyvendors emerging. This approach ismore about the future.”

OTN’s competitive process focusedon qualifying solutions that improve thepatient experience, decrease length ofstay, reduce readmissions, and decreasesurgical cancellations. The VOR,https://otn.ca/innovationcentre/surgical,is supported by all 14 of Ontario’s LocalHealth Integration Networks (LHINs),that can be readily utilized by BroaderPublic Sector organizations.

“By leveraging this VOR, Ontariohealthcare organizations will be able tomore quickly gain access to qualified so-lutions,” says Dr. Ed Brown, CEO, OTN.

The solutions on the VOR supportpre-operative optimization, enhancedrecovery after surgery protocols, remotemonitoring, patient education, patient-reported outcome (PRO) collection, se-cure messaging, and analytics, accordingto Matthew Nelson, Director, Solutionsand Venture Development, OTN.

“The VOR can be a useful resourcefor hospitals seeking solutions to helpstandardize protocols for before, duringand after surgical care, in order to getpatients back on their feet more quicklywhile maintaining quality of care deliv-ery,” says Nelson.

InTouch Surgical is a patient-centrichealthcare app that allows doctors andsurgery patients to stay connectedthroughout the care journey. Amongother things it provides the patient withprocedure-specific content to prepare forbefore and after surgery; verifies con-

sents and confirms identity, procedure,and surgical site; identifies factors thatmay delay or even cancel surgery; andprovides alerts when symptoms requireintervention.

Studies of the solution have shownimproved outcomes through patient in-volvement and by incorporating safetyprotocols and remote monitoring. Theseinclude, specifically:

• Decreased readmission rates by 60.8%• Decreased deep vein thrombosis

by 56%• Decreased surgical site infections

by 75%

• High patient satisfaction with a NetPromoter Score of 77

SeamlessMD enables health systemsto elevate the patient experience, im-prove health outcomes and lower coststhrough innovative patient technology.Accessible via smartphone, tablet orcomputer, the SeamlessMD platformkeeps patients on track from preparationthrough recovery with reminders, video-based education, progress tracking andPRO data collection. Providers monitorpatients remotely and can access real-time dashboards to measure complianceand outcomes, intervene sooner for pa-tients at-risk and drive up quality.

SeamlessMD’s patient engagementand quality improvement platform isfrequently used by health systems to de-liver value-based models of care, includ-ing Enhanced Recovery After Surgery,Perioperative Surgical Home, prehabili-tation, readmissions prevention, bundledpayments and PRO data collection.

Research completed by academicmedical centres has shown SeamlessMDto reduce readmissions (67% 30-dayreadmission reduction with Sinai HealthSystem), hospital length of stay (1.5-dayreduction with Saint Peter’s HealthcareSystem) and phone calls (80% of Sunny-brook-Holland Centre patients reportedavoiding at least one phone call).

Vivify Go enables physicians to usemobile devices to improve patient man-agement, engagement, and education, aswell as adherence outside of the clinicalenvironment. For patients preparing foror recovering from surgery, it maintainsa better connection with the care teamto improve outcomes and support self-management.

“With customizable engagement in-tervals and levels, clinicians can monitorbiometrics and survey responses, pro-vide educational content and reminders,and conduct live video virtual visits us-ing the patient’s smartphone, tablet, orlaptop,” says Bill Paschall, VP, BusinessDevelopment, Vivify Health.

“All of the data is transmitted securelyto Vivify’s cloud-based platform. Thereare also opportunities to integrate withelectronic medical records for better pa-tient record workflows.”

BC surgeon first to study the carbon footprint of operating rooms

Dr. Andrea MacNeill studied the carbon footprint in operating rooms in Canada, the U.S. and the U.K.

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Using the Vendor of Recordarrangements, Ontariohospitals can quickly obtainand implement solutions.

sustainable in-house surveillance dash-board infrastructure using Tableau. Some100,000 employees have access to TableauServer, where over 300 publishers haveproduced over 1,400 clinical dashboards.

AHS executive director, public healthand surveillance structure, Dr. HusseinUshman, says there are two ways AHS usesTableau: for patient experience and out-comes, and for public health surveillance.Public health surveillance involves an on-going, systematic collection, analysis andinterpretation of data.

AHS consultant, analytics, Kyle Kemp,says traditional surveillance had cost andtime issues, and there was the issue that peo-ple from the business side didn’t speak thesame language, as well as other limitations.

“With so much manual work, and sim-ply reporting and creating information wasnot sufficient…the ability to find informa-tion when you need it is equally important.For effective utilization the informationneeds to be a click away, up-to-date, and in-teractive,” says Kemp. When they decidedto build an intelligent, in-house, analytical

infrastructure using Tableau, “the gamechanged for us,” he adds. “It has simplifiedthings for us and the user.”

Every dashboard produced has a land-ing page so people can access them easilywith one link. Some of the public healthsurveillance dashboards they use are Al-berta Opioid Surveillance; Know YourCommunity; Risk Factors at the ProvincialLevel; and Cancer-Related Risk Factors.

The one for Cancer-Related Risk factorsshows cancer risk factors at a glance, as wellas risk factors by community ranking, whichshowed rural communities had lower risks.

Through charts on the dashboard theycan compare communities in five zones byone indicator at a time.

Cleveland Clinic: In a presentation ti-tled Powering clinical and operational ex-cellence with EPIC and Tableau, speakerand Cleveland Clinic lead systems analyst,enterprise intelligence, Joan Thompson,described the hospital’s challenge of get-ting the right analytics to the right person.

The Cleveland Clinic has over 3,000physicians, and 7.1 million patient visitsannually to its 150+ locations. Thompsonsaid the overarching goal of the organiza-tion’s various Care Paths, such as SpineCare, is to make it easier to treat patients,but they were having problems having theright report reach the right person.

When they switched to visual analyticsthey realized a measurable improvement.“As users needed more information, wewould use the power of Tableau to dig intothe reports at different levels. They couldchoose institutions, physicians, caretrends, etc.,” says Thompson.

They created a Summary Dashboard totry to decrease ‘no shows’ for appoint-ments by 1 percent. Considering they have7.1 million patient visits per year, andabout 10 percent typically are recorded as‘no shows’, even a 1 percent reductionwould be very significant.

After creating a summary dashboardwith trend graphs around factors like age,ethnicity, time of the week, etc., by zipcode for different hospital locations, theyfound transportation issues were responsi-ble for 38 percent of ‘no shows’ and thatmost ‘no shows’ lived within just 10 milesof each hospital location. This discoveryled the Cleveland Clinic to partner with aride share company.

Mayo Clinic: When the Mayo Clinicwas challenged to enable its supply chainanalysts with relevant, right-time insightsto be able to assess vendor (supplier) per-formance, they developed a vendor score-

card. TC17 speaker Brian Pringle, a sys-tems analyst in supply chain managementat the Mayo Clinic, indicated the score-cards were intended to help them findways to improve their vendor relationshipsand to save time and costs involved inmanaging those relationships.

At first, these scorecards were producedas an Excel spreadsheet. Seven different peo-ple that had access to different databaseswere responsible for making the scorecard,and Pringle had to compile the information.

For the next version of the VendorScorecards, he took the compiled informa-tion and put it into Tableau visual analyt-

ics. It enabled them to look at total pur-chase orders, purchase order (P.O.) lines,and invoices.

One thing they found was that only 30percent of invoices came in through EDIwhile the rest came in through snail mail –even when the vendor was set up for EDI.It was causing them more work, saidPringle, because the vendors using EDI of-ten still also mailed invoices, so they had tocheck for duplicates.

They were dealing with 1.9 million P.Olines and 6,000 active vendors. One oftheir primary goals was to reduce effort in-volved with invoices as well as costs.

nuanced explanation of why their ap-proach is worthy. This can make it harderfor evaluators because they don’t haveenough information.

A suggestion here is to look at the tem-plate from the responder’s perspective. Ex-cel is great for formulas, however can makewriting difficult. If you decide to set a pagelimit, be reasonable.

The evaluators’ job will be easier if theycan ascertain the uniqueness, creativityand fit with their organization from eachvendor’s submission. This heralds higherquality engagements that drive more suc-cessful outcomes for the client.

In the spirit of value for money, I haveone more piece of advice: some RFPs stillrequire hard copies and USB keys to becouriered, even though all of the pro-curement websites provide for electronicsubmission.

Given that I work in the area of digital

healthcare, I find this requirement some-what ironic. As healthcare organizationsare transferring all of their records to dig-ital form, isn’t it time for us to make thetransition in procurement, too? It is timeto let responders submit their applica-tions electronically and save on the print-

ing and courier costs. In doing so, thisprocess will be a simpler, more efficientand eco-friendly.

Standardized terms and conditions:Public sector RFPs include legal termsand conditions (T&Cs) that the respon-der must review as part of the submis-sion. For hospitals in a group purchasingorganization (GPO), these T&Cs are sup-

posed to be consistent for hospitals in thesame GPO.

However, many hospitals use outdatedT&Cs with substantive legal differencesbetween them. This forces extra legal re-view and potentially more risk for theGPO given that its members are using dif-ferent T&Cs for contracts. GPOs shouldensure that their boilerplate RFP form in-cludes current T&Cs and that their mem-bers’ procurement departments use thecorrect version.

Win-win for all: Each of these sugges-tions is aimed at improving RFPs to get thebest responses from the marketplace to ad-dress clients’ needs. In the spirit of contin-uous improvement for all, I hope theseideas and recommendations can lead tomore efficient procurement processes, bet-ter engagements and more successful pro-ject outcomes.

Lydia Lee is a Partner and the National Dig-ital Health Leader for KPMG Canada.

they will deal with and scale to meet thehealth and care needs of their popula-tions. It is critical to how they will inte-grate with other social systems, and tohow they will make the data actionable atthose intersections where citizens inter-act with anything that may impact theirhealth.

We have the opportunity to providenear real-time operational approaches thatare both predictive and proactive. This isthe transformative opportunity that mod-ern informatics offers.

It will only work with whole systemchange: Although informatics is an impor-tant enabler, and it is necessary and ur-gently needed, it is certainly not sufficientin isolation.

Informatics has complexity and diffi-culties, no doubt, but sophisticated solu-tions now exist. I believe the harder chal-lenges lie in maturing the other key capa-bilities required.

To name a few: leadership with a clearvision and set of agreed priorities; part-nership, legal forms and governance, newcare models and system redesign, organi-zational redesign with new and evolvingstaff roles, payment reform and incen-tives, citizen engagement strategies, infor-mation governance, and above all else,cultural change.

Canada is rapidly falling behind its in-ternational peers, and the test for ourhealthcare system will be to advance thesecapabilities in parallel with world leaders,else risk getting stuck with the status quo.Consider this a call to action. We shouldchallenge each of the 13 Canadian health

ministries to establish a population healthmaturity strategy and model. Populationhealth requires a whole-system change, solet’s rise to it!

Michael Billanti is Director and GeneralManager, Population Health, Cerner Canada.

CONTINUED FROM PAGE 17

Population health management: Rise to the challenges?

CONTINUED FROM PAGE 16

blood glucose and to use insulin ther-apy to combat high levels. “If we have ablood sugar level of 140 in any patientin our operating room, they get startedon an insulin infusion program,” saidDr. Dellinger. While the best levels ofglucose control are not universallyagreed upon, “there are excellent algo-rithms available,” he said.

• Also of great importance is team-work and the use of checklists. “Howwell the team communicates and inter-acts in the OR really influences the rateof complications,” he said. “It’s not likethe old days, when there was one bossin the OR and everyone else shut thehell up.” In today’s more democratizedenvironment, all clinicians should havethe opportunity to be heard and con-tribute to the work being done. If not,problems can occur.

Checklists are way to ensure that teammembers get to voice their concerns, aswell as monitoring whether all of theright steps have been taken. Dr. Dellingersaid he was involved in the World HealthOrganization’s creation of OR checklists,and his hospital was one of eight aroundthe world to first use them. Overall, theeight hospitals had a “50 percent reduc-tion in SSIs, and improvements in reop-eration and mortality rates.”

He cited several other studies of hos-pitals using surgical checklists withgreat success. He also talked about aTexas hospital group that used ORchecklists, claimed 100 percent compli-ance, but experienced no gains. Skepticsin management sent a “quiet observer”into the ORs. When it came to team in-troductions, concerns expressed, poten-tial for blood loss, and other checklistcategories, “it was discovered they weredoing a terrible job.” So, while theteams were checking all the boxes, theyweren’t actually carrying out the steps.

Reduce SSIsCONTINUED FROM PAGE 6

Analytics enabled the MayoClinic to see that vendorswere still using mailedinvoices, along with EDI.

Some RFPs require hard copiesand USB keys to be couriered,even when their websites allowdigital submissions.

How to improve procurement in Canada’s healthcare sector

Visual analyticsCONTINUED FROM PAGE 12

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