BY JERRY ZEIDENBERG

TORONTO – Humber River Hospitalannounced the opening of its StarTrek-like Command Centre with an

auditorium full of visiting luminaries in at-tendance – including GE’s CEO John Flan-nery, two Ontario government cabinet min-isters, and doctors and administrators from13 U.S. hospitals who came to learn aboutthe AI-powered centre.

It’s the first Command Centre in a Cana-dian hospital, and only the second in NorthAmerica – the Johns Hopkins UniversityHospital opened one about 18 months ago,but the facility at Humber River builds onthe U.S. centre and extends the concept fur-ther into managing quality.

“Not only is Humber monitoring thephysiology of the patient, they’re also moni-toring the physiology of the whole hospital,”said Jeff Terry, managing principal of GEHealthcare, which partnered with HumberRiver to design and build the system.

He explained the system at Humber Rivergives doctors and administrators the infor-mation needed to spot delays and bottle-

necks across the site, so they can addressthese issues quickly and restore patient flowto the desired rates.

Using data feeds from a raft of IT systemsaround the hospital, including the MeditechEMR, Medworxx bed management systemand an Ascom communications system, in-formation is displayed on 16 GE Tiles, eachwith real-time analytics to synchronize, co-

ordinate and help ensure better outcomesand patient flow.

They include bed management to trackbottlenecks, ED admissions and waits, anearly warning system to detect patients indistress, and a pathways module that dis-plays what needs to be done to keep patientson track for timely discharge.

Not only is this expected to result in a moreefficient hospital, but it will also raise the qual-ity of care and enhance patient satisfaction.

While the technology is leading-edge, the

facility also deploys new forms of organiza-tion. The Command Centre brings togetherprofessionals from different parts of the hos-pital, so they’re working together in one room.

“We’ve already noticed an improvement incommunication,” said Carol Hatcher, a Hum-ber River VP. “Hospitals tend to be siloed intodepartments, and this breaks down the silos.”

And Dr. Susan Tory, command centremedical director, observed that staff mem-bers in the Command Centre have been spe-cially trained to monitor and solve the prob-lems and challenges that emerge. A new rolehas even been created, that of clinical expe-diter, to take on tasks that will speed upprocesses or eliminate problems.

For example, if it’s found that a patient issupposed to have a consult/assessment or di-agnostic test, and it is taking longer than itshould, the clinical expediter can get in-volved and help to make it happen faster.

Barb Collins, president and CEO, assertedat the launch event that the Command Cen-tre is aimed at creating the “high reliabilityhospital.”

She observed the idea for the technologi-

Humber River Hospital opens futuristic command centre

CONTINUED ON PAGE 2

Humber River Hospital hosted politicians, business leaders and visitors from Canadian and U.S. hospitals at the launch of its Command Cen-tre last November. Pictured (l to r): Jeff Terry, GM of GE Healthcare Partners; Board Chair Terry Leon; Laura Albanese, Ontario Minister of Citi-zenship; Reza Moridi, Minister of Research; Barbara Collins, Humber River’s CEO; John Flannery, CEO of GE Global; Peter Bak, Humber’s CIO.

At the Command Centre, aclinical expediter helps speed upprocesses and solve problems.

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Patient access to imagesSt. Michael’s Hospital, in Toronto,is making diagnostic images easierto access for patients. With partnerPocketHealth, the hospital putsthem into the cloud, where theycan be securely reached by pa-tients, at their convenience.Page 6

Ottawa’s VR labThe Ottawa Hospital, a leader in3D printing, has now launched avirtual reality laboratory where

physicists are working with clini-cians on a system that makes iteasier to visualize the anatomy ofpatients and to plan surgeries andradiation therapy.Page 4

Compassion and dataSpeaking recently in Toronto, U.S.quality guru Dr. Donald Berwickurged his audience to treat pa-tients with more compassion. Hecritiqued the current American sys-tem, which he said is too con-cerned with data and finances. Page 8

Learning with the HoloLensMontreal’s CAE Healthcare has re-leased the world’s first augmentedreality childbirth simulator. CAE Lu-

cinaAR uses Microsoft’s HoloLensto offer a simulator with inte-grated mother-baby physiology.Page 14

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FEATURE REPORT: DEVELOPMENTS IN MEDICAL IMAGING — SEE PAGE 18

CANADA’S MAGAZINE FOR MANAGERS AND USERS OF INFORMATION SYSTEMS IN HEALTHCARE VOL. 23, NO. 1 FEBRUARY 2018

FOCUS REPORT:

EDUCATIONPAGE 14

cally advanced centre emerged at HumberRiver 10 years ago, when management vis-ited a Dell Computer command centre.They were impressed at how efficiently thecompany could operate using the alertsthat were generated.

While flying back to Toronto, they real-ized the airline industry has been usingcommand systems for years to ensure pa-tient safety. “That’s why it’s safe to fly on anairplane,” said Collins. “We thought, that’swhat we ought to do with healthcare.”

Soon after, the team at Humber Riverstarted talking to GE Healthcare about cre-ating such a system at the hospital, whichwas planning a new site – now consideredNorth America’s first ‘digital hospital’.

CIO Peter Bak noted in a video producedfor the launch that Humber River’s digitalsystems have already produced a 20 percentincrease in efficiency. The Command Centreis expected to achieve another 20 percentproductivity gain, which will be like adding40 more beds without any new costs.

“That’s like adding a small hospitalwithin our hospital,” said Bak.

At a tour of the Command Centre,Andy Day, managing principal, Hospital ofthe Future at GE, noted that when the newHumber River Hospital opened in 2015,ED visits exploded from 97,000 per year toover 130,000.

That has put special pressure on Hum-ber to manage patient flow and outcomes,starting in the ED.

Day explained the different monitors –called tiles – in the Command Centre, allof which are graphically oriented andcolour-coded. These 16 analytic tiles mon-itor dozens of hospital processes in realtime, display visual alerts, and have differ-ent teams monitoring them.

The overall hospital bed managementsystem showed the occupied beds on themedical floor running at 104 percent –triggering a red alert. “We have a teamworking together to see what can be done,to accelerate discharges and balance thehouse,” said Day.

An ED tile uses feeds and analytics totrack visits, ‘door-to-doc’ time, and evenmultiple visits by patients. For example, itcan spot patients who have visited the ED10 times in a one-month period – the fre-

quent fliers who may be drug addicts, orhave other chronic problems. “We want todeal with it, and to find solutions forthem,” said Day.

Commenting on the pressure on theHumber River ED, he noted the hospital isexperiencing days where 350 to 400 pa-tients visit. “That’s bigger than Mass Gen-eral,” he said.

As such, paying attention to the ED is of

prime importance. The analytics systemfor the ED is using a 12-stage scale to mon-itor patient volumes, and has extensive ca-pabilities to spot problems. “It will showyou exceptions, too, that must be dealtwith,” he said, like patients who are waitingtoo long to see a doctor or have yet to re-ceive their X-ray or CT scan.

There is a ‘pathways’ tile that ensurespatients are receiving all of the care theyshould be, using various order sets. Thisensures quality care and appropriate dis-charge times.

As well, the Command Centre makes useof an early warning tile, which spots patientswith abnormal readings. “An abnormal car-diac enzyme for a non-cardiac patient, or awhite blood cell count spike in a post-surgery patient, are indicators that a clini-cian in the command center can investigateand act on,” said Day.

“By combining alerts from one systemwith event or patient state information fromanother system turns data into decision sup-port, allowing intervention before a patientbecomes critical.”

It’s been well-publicized that Ontariohas a problem with Alternate Level of Carepatients – those who are awaiting a place ina nursing home, and are occupying hospi-tal beds. Unfortunately, when nursinghome patients go into hospital for morethan 30 days, they lose their place in thehome and must re-apply.

The Command Centre system has a 30-day countdown, showing the days left forthese patients before they lose their place intheir nursing home. It’s a reminder to com-plete all of the care-related tasks needed fordischarge, in order to safely return the pa-tient to the long-term care centre.

Not only does the system spot bottle-necks and delays, it can also predict them.The system will use the data that’s com-piled each day to learn, for example, whento expect increased patient flow in the ED,the ICU or the operating rooms.

Electronic screens display information collected in real-time from a host of systems across the hospital.

CONTINUED FROM PAGE 1

‘Wall of analytics’ launched at the high-tech Humber River Hospital

Art DirectorWalter Caniparoliart@canhealth.com

Art AssistantJoanne Jubasjoanne@canhealth.com

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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 1 February 2018

Contributing EditorsDr. Sunny MalhotraTwitter: @drsunnymalhotra

Dianne Danieldianne.l.daniel@gmail.com

Richard Irving, PhDrirving@schulich.yorku.ca

Dianne Craigdcraigcreative@yahoo.ca

2 C A N A D I A N H E A L T H C A R E T E C H N O L O G Y F E B R U A R Y 2 0 1 8 h t t p : / / w w w . c a n h e a l t h . c o m

Delivering Integrated Healthcare Solutions

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

BY JERRY ZEIDENBERG

trio of bright and innovativemedical physicists at The Ot-tawa Hospital’s new realize-LAB, for virtual reality solu-tions, have created a VR plat-

form that enables surgeons and other clin-icians to don headsets and seemingly enterorgans like the colon for a better look atthe anatomy.

By manipulating handheld controllers,they can also slice and pull apart 3D ren-derings of the thorax and skull – compiledfrom CT and MRI scans of their patients –that appear to be floating in space in justfront of them.

Drs. Justin Sutherland, Dan La Russa,and Jason Belec put the system together,which is powered by their own softwareand off-the-shelf hardware. The Viveheadsets are made by HTC, and other ven-dors, and the team cobbled together anumber of other consumer technologies.

“It runs on a gaming computer,” saidDr. Sutherland. “All together, it cost lessthan $5,000 to put together.”

Amazing then, the enormity of capa-bilities the system has to offer for such alow cost.

“Our clinicians are very interested inthis because it saves time, money and pa-tient lives,” asserted Dr. Frank Rybicki,chair of the department of radiology at theOttawa Hospital, and mentor of the VRproject at the realizeLAB. He also heads the3D printing project at the hospital – one ofthe most advanced in the country.

Dr. Rybicki explained the VR systemenables surgeons, for example, to look atthe position of a brain tumour and its re-lationship to adjacent structures, beforegoing into the operating room to conductthe surgery.

Moreover, by manipulating the VRtools – two handsets that are like Wii con-trollers – you can turn the object, removeblood vessels or other tissue, and view thetumour from various angles.

Sutherland, La Russa and Rybickidemonstrated the new solution at the Ra-diological Society of North America(RSNA) conference in Chicago last No-vember. They gave visitors a chance to test-drive a demo version of the system, whilewearing the headset and using the hand-held controllers.

It’s a mind-altering experience, to besure, to wave your hand and see the bonesof a patient disappear before your eyes, re-vealing only the soft tissue organs.

And it all seems so easy, like playing avideo game. Put on the glasses, and anumber of semi-transparent orbs are cir-cling before your eyes. Simply grab onewith your handheld controller, and drag itinto a bigger circle, and you’ve activatedthat app – it may be the patient’s colon,skull or chest.

Wave again, and you remove bone orsoftware tissue, or you can zero in on areasof interest.

“It gives you an excellent understand-ing of the tumour before going into theOR, of the spatial relationships,” said Dr.Rybicki. “You’ll never get this on a 2Dmonitor.”

With 3D virtual reality, “You can see 20

different views,” said Dr. Rybicki. “You canvisualize things in this way with 3D print-ing, too, but you wouldn’t want to make 20different models.”

He explained that 3D printing is a bet-

ter option for procedures like stent grafts,where there are not so many options andvariables for the surgery, but you still needa good view of the anatomy. Sometimes, aswell, you want to be able to hold the

anatomy in your hands, which 3D printingallows you to do.

Dr. Dan La Russa noted that many ofthe data sets for VR come from the modelsgenerated by the 3D printing lab, whichmakes use of CT scans and other exams.“There’s a complementarity, and we canuse their data, and they can use ours.”

The realizeLAB, which has been up andrunning for about a year, has recently beenassisting radiation oncologists as they planprocedures like brachytherapy and the po-sitioning of radiactive seeds.

“They are the biggest users of VR, sofar,” said Dr. Rybicki. “But we’re now ex-plaining virtual reality to others.”

Other clinicians, including surgeons,cardiologists and orthopedic surgeonshave all expressed an interest in the plat-form, as it gives them a much better idea ofhow to plan the most effective surgery orprocedure.

The hospital’s 3D printing lab now haseight employees, and Dr. Rybicki is confi-dent that the VR lab, which now has threePhDs splitting part of their time there,will expand to five employees in the nextyear or two.

Dr. Sutherland commented that a lot ofdiscussions have been going on with sur-geons, radiologists and radiation oncolo-gists. “We’re working with them to developthe tools they’d like to see.

“It’s a new domain,” he added. “We ex-pect to be creating applications that wenever imagined.”

Indeed, the field of VR is brand new,and many concepts are just being devel-oped and rolled out as practical technolo-gies. “Anything you can coherently explain,we can build,” said Dr. Sutherland.

Having the realizeLAB right in thehospital is a definite advantage, as it putsresearchers like himself, La Russa andBelec in the midst of clinicians workingwith patients. Together, they can fine-tune solutions that solve real-worldproblems.

One radiation oncologist, for example,has asked for an app that allows him tostand inside the blood vessels runningthrough the brain, giving him a betterview of the anatomy of the issues he isdealing with.

Dr. Rybicki commented that not only isVR a big help to clinicians inside the Ot-tawa Hospital, but it could be used as atelehealth platform. Images could be takenof patients at a remote location, and ex-perts at the hospital could wear the VRgoggles to obtain a better look ataneurysms, tumors and other problems.

They could then advise local doctorson the best ways of treating the lesion orneoplasm. “You could do a consult withsomeone in Nunavut,” he said, effectivelyraising the level of care given to patients inremote regions.

Moreover, it’s a group activity. “You cancollaborate with clinicians in a remote lo-cation, and you’ll see others [in your fieldof vision] as avatars,” said Dr. La Russa.Your collaborators appear as heads on-screen, and you can interact simultane-ously with patient objects while conduct-ing an exam and consultation.

“It’s easy to have a discussion about theimages,” said La Russa.

Users of the system can manipulate the 3D patient images, which have been converted from CT and MR scans.

Dan La Russa, left, and Justin Sutherland, demonstrated the solution at the recent RSNA conference in Chicago.

Ottawa Hospital’s VR system used for surgical and radiation planning

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SAN FRANCISCO – The global augmentedreality and virtual reality markets inhealthcare are expected to reach (US)$5.1 billion by 2025, according to a newreport by Grand View Research, Inc. Themarket size was valued at (US) $568.7million in 2016 and is projected to growat a rate of 29.1 percent annually duringthe 10-year period.

The growing adoption of AugmentedReality (AR) and Virtual Reality (VR) inmedical field, increasing investments insuch emerging technologies, and con-stant developments in healthcare IT are

some of the key factors responsible forgrowth of this market.

The market is being driven by applica-tions in surgical simulations, diagnosticimaging, patient care management, reha-bilitation, and health management.

The Grand View Research reportnotes the application of AR and VR intraining medical professionals providesenhanced understanding of anatomyand physiology. It also assists in compli-cated surgeries that require precision,thus, resulting in reduced complicationsand lesser trauma.

Fast-growing market for AR and VR tech

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

BY JAMES WYSOTSKI

TORONTO – St. Michael’s Hospi-tal’s new image-sharing plat-form, PocketHealth, puts pa-tients first by making it easier toobtain and share medical images.

Created and run by the PocketHealthcompany, the online platform allows pa-tients to use mobile devices or desktopcomputers to access their medical imagesanywhere, including from their ownhomes.

Previously, the only option was to ordera CD-ROM with the images.

“The sharing of imaging records hashistorically been very challenging,” saidJennifer Meher, the manager of MedicalImaging operations.

Often, patients can wait while a CD isprepared, said Meher. But some facilitiesrequire 48 hours to process the request,causing patients to make a second trip tothe hospital. While the CD was free, pa-tients often incurred other costs such aspublic transit or parking. Frequently, italso meant taking a day off of work.

If patients needed to see a series of spe-cialists, Meher said the process becameeven more arduous. Patients would have toreturn to the hospital’s Film Library andrequest a free CD for each new physician.

“Sometimes patients would come in foran image only to find it wasn’t ready yet,and they’d have to come back anotherday,” said Cristhian Moran, a radiologysoftware administrator who helped inte-grate the new, PocketHealth platform withthe hospital’s systems. “Some patients livefar away, and it’s stressful for them to makethe journey here. By using PocketHealth,they no longer have to make the trip.”

While ordering CDs is still an option,Moran said patients can avoid the hassleand take control of their imaging recordsby using PocketHealth, which St. Michael’slaunched in August 2017.

“The new system is fabulous becausepatients can share images with many

physicians without incurring extracosts,” said Moran, “You have to pay only$5 for the images once, and then you’rein control.”

Instead of waiting at least 48 hours, pa-tients can get their images from the Pock-etHealth website in just a few minutes. Af-ter logging in and providing a credit cardto cover the $5 fee for each new set of im-ages, patients fill out an online version ofthe release of information form and thenenter the date of when their images weretaken. Moments after submitting the re-quest, they have full access to all images.

Moran said patients can store the im-ages indefinitely on PocketHealth’s servers,knowing they’re always available to bedownloaded or shared at no extra cost. Pa-tients can transfer the files to their com-puters or USB sticks, and they can evenburn their own CDs.

If patients had images taken elsewhere,and they’d like to keep them with theirother pictures in the PocketHealth server,there’s an upload function. And then, withjust two clicks of the mouse, they canshare the images with any number ofphysicians through the website’s easy-to-use interface.

Patient control over the images doesn’tstop there, said Moran, because theychoose how long doctors can access theimages on PocketHealth’s servers. Doctorsget an email, but no images or privatehealth information is attached.

Instead, there’s a password-protectedURL pointing to both the medical imagesand any accompanying reports. Patientscan deactivate the link at any point. Untilthen, doctors can view the images ordownload files in DICOM format foranalysis.

The next phase in integrating Pock-etHealth – ready in early 2018 – will allowpatients to access their images momentsafter a scan, said Moran. Removing thetime spent waiting for disks to be burnedmeans patients can see doctors sooner.They can even send access to the images in

advance of a visit, allowing doctors to pre-view images before a consultation.

Moran said another 2018 upgrade willprovide medical images to other facilitiesmaking after-hours requests when patientsare transferred. As long as the patient givesconsent, then images would be transferredinstantly via PocketHealth to that facilityinstead of having to wait until the next dayfor a CD.

PocketHealth protects personal healthinformation with 256-bit encryption, anindustry standard that Moran said is oneof the strongest formats available. Pock-etHealth is also compliant with the HealthInformation Protection Act and has built-in privacy features that include verifying apatient’s identity by OHIP number, date ofbirth and the St. Michael’s Hospital Med-ical Record Number.

Integrating PocketHealth has resultedin improved efficiency at the hospital, saidMeher. A 10 percent to 20 percent reduc-

tion in burning CDs, resulting fromroughly 200 PocketHealth requests eachmonth, has freed up staff resources to sup-port other Film Library activities.

“There is absolutely no reason whyeverything can’t be done electronically,”said Moran. “In time, we expect requestsfor physical CDs to virtually disappear.”

Moran said PocketHealth is proactiveabout collecting feedback and making im-provements. They created a feedback sur-vey for patients, and they also addressedissues reported to their toll-free patientsupport line and 24-7 support email.Moran said the feedback has been posi-tive, especially about how easy it is to usethe platform.

“At St. Michael’s, any process that fo-cuses on improving the patient experienceis one we strongly believe in,” said Meher.“PocketHealth is the future of health carewithin the imaging environment, and St.Michael’s is happy to be a part of it.”

PocketHealth eases image sharing for patients, clinicians and hospitals

PocketHealth is a company dedi-cated to making it easier forhospitals and medical imagingcentres to share imaging records

directly with their patients – instantlyand in full diagnostic quality. The com-pany was founded in 2016 by two broth-ers, Harsh Nayyar (a former Google en-gineer) and Rishi Nayyar (a former Citi-group investment banker), who felt thata flexible, patient-friendly platformcould replace the industry’s current re-liance on CD-burning.

“Historically, it’s been very difficultfor disconnected systems to electroni-cally exchange medical imaging infor-mation,” said Rishi Nayyar, Pock-etHealth’s CEO.

“That’s how CDs became the com-mon language between, for example, ahospital imaging department and a pa-tient’s surgeon. But CDs are slow, costly,

and demanded regular couriering by pa-tients, and we knew we could embed thatsame interoperability into a digital re-placement. What resulted was a platformthat can pull data from any RIS/PACSenvironment and send it to any authenti-cated patient, who can then share withany member of their circle of care.”

Unlike patient portals and govern-ment repositories that require physiciansto pre-register and leave their EMR envi-ronment, PocketHealth allows patientsto share directly into a physician’s EMRfor storage alongside the rest of theirrecords. This flexibility in sharing gavethe company crucial early traction withreferring physicians when it waslaunched in Summer 2016.

Since then, the cloud-based platformhas grown to over 100 installationsacross Canada. Their partners rangefrom rural community imaging clinics

to large, urban research centres like St.Michael’s Hospital in Toronto. Buildingon their Canadian success, the companyexpanded operations into the UnitedStates in December 2017.

Perhaps the most unique element oftheir model is that the platform is

funded solely by micropayments madeby patients (typically $5) in return forsecure storage and permanent access totheir requested records. Hospitals, clinicsand physicians can in the meantime de-ploy the system without cost – an un-common model in health IT. With tens

of thousands of registered patients, thisseems to be a model that has resonatedwith patients frustrated with travellingback to their hospital to pick up or dropoff a CD.

Their current progress aside, theToronto-based company has its sights ona much larger mission.

“Our long-term goal is to become thepipes – the underlying infrastructure –for the future of patient-centric datasharing,” says Harsh Nayyar, Pock-etHealth’s CTO. “We want to put pa-tients at the centre of every single ex-change involving their health data. Whena healthcare organization commits tothat goal, the results are clear: records gowhere they need to go, outcomes im-prove, and we resolve many inefficienciesin the healthcare system.”

You can learn more about PocketHealthby visiting www.mypockethealth.com.

The platform is funded by $5micropayments made bypatients in return for securestorage and access.

Accessing diagnostic images is easier for patients using PocketHealth

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Maggie Dubrawski, operations leader for general imaging, prepares an X-ray for upload to PocketHealth.

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Anjum M. Ahmed Global Director Imaging Information SystemsAGFA HealthCare

New imaging techniques are helping radiologists,cardiologists, oncologists, and other diagnosticianswith greater anatomical and clinical details,highlighting the need for fast access to imagingreports and results and collaborative workflows.Augmented Intelligence can ease the workload onhealth imaging experts and simultaneouslyimprove their performance. AGFA HealthCarereached out to senior radiologists, surgeons, andclinical leaders around the world, and have includedtheir responses in the following perspectives.

Task-based workflow optimization

AI will not replace radiologists or other physicians,but in fact enhance their workflow, helping them tomake collaborative and intelligent decisions.Enterprise Imaging, powered by AI, will help improveradiology even further with task-based workflowoptimization. Physicians will obtain faster access tocritical results, helping to reduce wait times andimprove referral services for cases that require andurgent patient care coordination.

In a recent survey, our respondents emphasized theneed for exploring capabilities of machine learning

and AI in addressing certain mistakes and errorsthat could alert radiographers and radiologists, andautomate certain non-essential tasks to easeworkload. “We should free our experts to undertakeexpert work by removing as many non-essential

tasks for them as possible,” noted Angie Craig,Assistant Director of Operations and Performance,Leeds Teaching Hospitals Trust, NHS, UK. “That’swhere artificial intelligence comes in.”

Disseminate DI intelligence with AI

As we breakdown silos of imaging workflows andenable multidisciplinary consolidation andcollaboration, the power of a consolidated platformresults in creation of a vast data lake, ready foranalysis by radiologists, diagnosticians,researchers and academics to help improve qualityof care by better understanding disease andpopulation health data.

This helps care organizations progress fromDescriptive to Predictive Analytics models to improveearly detection of diseases, and introduce care planmodels that help enforce and improve patientengagement and compliance. During discussionswith senior radiologists and diagnosticians, wewitnessed consensus regarding the clinicalapplication of AI to help address screeningchallenges associated with pressing healthcareproblems that include cancers, chronic chestdiseases, musculoskeletal conditions, neurologicaldisorders, cardiac conditions and detection ofvarious other clinical conditions. When it comes tooncology, our respondents discussed thesignificance of AI not only for initial diagnosis, butalso for follow up after the treatment in helpingtrack the potential recurrence.

“In my group, we’ve already demonstrated that anAI system for chest x-ray triaging and prioritizationcan lead to much faster reporting turnaround time,”said Giovanni Montana, Professor of Data Scienceat Warwick University, UK. “We’ve also shownpotential diagnostic benefits in early detection oflung cancer.”

Personalized medicine and smart applications

Care organizations and health authorities acrossthe globe are faced with pressing population healthchallenges. Whether it comes to detecting cancers,or chronic diseases, Machine Learning andAdvanced Analytics will help improve radiologists

and diagnosticians focus less on manual repetitivetasks, and more on improving care pathways.

“I think one of the biggest contributions deeplearning/artificial intelligence will realistically maketo me as a radiologist in the near future is notdirectly helping with image interpretation, but inbringing the relevant information out of theelectronic medical record (EMR) and presenting itto me in a meaningful way to better inform myclinical judgment,” said Dr. Bill Anderson,Edmonton Zone Medical Director, DiagnosticImaging, at Alberta Health Services. “Incorporatingthis directly into the report will be how we can reallyadd value as radiologists using Deep Learning. Itnot only will streamline my workflow, but will alsobe a major step towards more personalizedmedicine in radiology.”

Agfa HealthCare’s approach of building anecosystem of Augmented Intelligence powered byMachine Learning, Cognitive Reasoning and Task-based rules engine will help enable delivery ofinnovative solutions to enhance care delivery. AgfaHealthCare Enterprise Imaging platform isstandards-based, designed for interoperability andenables a leading-edge approach to seamlesslyembed machine learning algorithms.

AUGMENTED INTELLIGENCETHE NEXT FRONTIER IN HEALTH IMAGINGUnlike Artificial Intelligence, which tries to replicate human intelligence,Augmented Intelligence works with and amplifies human intelligence.

AUGMENTED INTELLIGENCE SHOULDOPTIMIZE A TASK-BASED WORKFLOW

10%

90%

Fully Agree

Partially Agree

Neither Agree or Disagree

Partially Disagree

Fully Disagree

WHERE COULD AUGMENTED INTELLIGENCE HELP TO IMPROVECARE PATHWAYS?

35%

12%

23%12%

18%Contextual EHR History

Comparison with similar cases

Preliminary Reports

Incidental Findings

All of the above

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

BY JERRY ZEIDENBERG

Speaking in Toronto in October, Dr.Donald Berwick, co-founder of theUS Institute for Health Improve-ment, had a surprising message:

there’s too much measurement and analy-sis going on in medicine.

The guru of evidence-based medicineand the application of scientific methodsto healthcare had this advice. Bring morecompassion to medicine. “Cool the mea-surement,” said Berwick. “Measurementneeds to be a servant, not a master.”

Dr. Berwick was the keynote speaker atHealth Quality Ontario’s annual confab,where one speaker after another repeatedthe mantra of quality control. Namely, thebelief that you can’t manage what youhaven’t measured.

Nevertheless, Berwick argued convinc-ingly that the United States – and suggestedthe case was similar in Canada, too – haslost its way in recent years. That a spirit ofgreed and indifference has taken over.

“Today in my country, we’ve lost thetorch of compassion and embrace,” he said.

The problem is dire, he asserted.Berwick cited studies showing 50 percentof physicians today don’t recommend be-coming a doctor. “The workforce is de-moralized,” he said.

To be sure, there are onerous demandson physicians in terms of reporting, paper-work, and electronic forms. The result hasbeen burnout for many.

And the relentless pressure on perfor-mance has, ironically, put quality intojeopardy, Berwick said.

He spent a good deal of time recountingthe story of a patient he treated as a pedi-atrican. The boy of 11 was part of a familywith an abusive father. As a result, theyoungster became anxious and suicidal.

In response, Dr. Berwick worked withthe boy’s mother to establish a network ofcaregivers and supports for him. They in-cluded doctors, psychiatrists, social work-ers and other therapists.

Over a course of years, with ups anddowns, they restored the boy’s health; hebecame a high-ranking officer in theUnited States military, and served with ho-nour in Afghanistan.

Unfortunately, he died just a few yearsago of a brain tumour. But before passingaway, he personally thanked Dr. Berwickfor his work – saying it saved his life as ateenager, and that it gave him the opportu-nity to go onward.

Dr. Berwick asserted it was really the‘village’ of caregivers who took an activeinterest in the young man’s welfare, led byhis mother, who was tireless in advocatingfor her son. In short, it was compassionand teamwork that made a difference.Measurement and statistics had little to dowith it. “You can’t measure your way to ex-cellence,” said Berwick.

He followed the story with an anecdoteabout his own medical training, under theauspices of a wise teacher. Dr. Berwickstarted an exam with an elderly woman,Mrs. Goldberg, standing over her and ask-ing for history.

He suddenly felt a hand on his shoulder.The teacher counselled him to sit with thepatient, at eye level. Berwick sat and beganagain, asking his litany of medical ques-tions. All of a sudden, the teacher again in-terrupted: “Did you know that Mrs. Gold-berg has a brand new grandson?”

He had injected a human dimensioninto the encounter. Dr. Berwick said he im-

mediately got the message. “We need a newmission in medicine,” he said. “Not mea-surement and money, but joy and relation-ships.”

He lauded a nurse in Florida he recentlyencountered, who found joy in her work inthe maternity ward. Each time a baby wasborn, she held the child and wondered,“Could this be a future president?”

Berwick said more of this humanistic

approach is needed in medicine today,where the value of patients as people isrecognized. Patients, he emphasized, arealso parents, musicians, teachers and work-ers – all with families and loved ones. It’simportant not to lose sight of that.

When healthcare professionals do losetrack of this, it’s often because they are partof a system that values reams of statisticsand information – and profits.

Studies have shown, he said, that morethan 30 percent of the costs in the U.S.healthcare system can be attributed towaste, greed and fraud. Berwick showedhow the emergency room visit of a friendresulted in a $7,000 bill – with many of thecharges being unnecessary or verging onthe fraudulent.

It’s not that the young doctor conduct-ing the ER exam was corrupt, he said.Rather, he said, she was stuck in a systemthat imposed excessive testing and chargeson the encounters with patients.

“It’s all about the money,” he said. “Andit doesn’t feel good.” Berwick averred thatmedicine has lost its ‘noble intent’. He out-lined a number of ways for the professionto get back on the right track. First, he said,“Stop focusing on the money. The bestroute to financial success is to focus onwhat people need.” He also advised reduc-ing the amount of measurement that goeson. While some measurement is requiredin a modern medical system, it shouldn’tbe taken to extremes.

Dr. Don Berwick spoke at a recent HQO conference.

Quality guru Don Berwick calls for less data, more civility in medicine

BY DOUG DITTMER, MD

AND SHIRLEY FENTON, MA

WATERLOO, ONT. – Last Novem-ber, at the Waterloo MedTechconference, clinicians, industry,

academia and start-ups converged in theheart of Canada’s Toronto-Waterloo techcorridor. This second annual symposium,

supported by local government, incuba-tors, accelerators and industry, had over150 participants from across Ontario whogathered to look at the barriers that inno-vation faces in healthcare.

The conference opened with keynotespeaker, Hon. Kathryn McGarry, a provin-cial cabinet minister and a former nurserepresenting Cambridge, with the chal-lenges she faced as a nurse and howmedtech could have been a solution toproblems she encountered. Kevin Tuerspoke about Canada’s Open Data Ex-change and growth in data capabilities.

Dr. Alexander Wong, a Canada Re-search Chair in Medical Imaging Systemsat the University of Waterloo, spoke aboutdeep learning and the artificial intelligence(AI) revolution. Because AI can rememberorders of magnitude more cases than clin-icians, he noted we should not fear AI, butembrace it, to augment clinical intelligenceand improve the healthcare system.

Breanne Halyk, from JLABS Canada,talked about the entrepreneurial spirit in a129-year-old company. She explained howsmall companies can gain the benefits ofpartnering with a big company.

Simon Cheeseman, from BaycrestHealth Services, talked about their proto-type to procurement model, and theirjourney through the innovation ecosys-tem. They have invested over $38 millionin 67 projects, leading to the developmentof 84 new products, processes or services.

Fiona Fitzgerald, from GE Healthcare,discussed the barriers to innovation in alarge company. These include understand-

ing change, customer focus, organizationalstructure and connection to the ecosystem.

Dr. Matthew Bromwich, from the Chil-dren’s Hospital of Eastern Ontario, as-serted that you need vision, skills, re-sources, incentives, and an action plan tobe successful, otherwise you will run intofalse starts, frustration, resistance, anxietyand confusion.

Dan Sinai, from IBM, discussed IBMWatson Health in the continuum of careand the body as a source of big data. SarinaCheng from Sunnybrook Health Sciences

spoke about their 10-year journey with“MyChart” and the barriers and resistancefaced with placing such a novel idea into alarge hospital.

The keynote was Bill Charnetski, On-tario’s chief health innovation strategist,who spoke about value-based innovation.His office is focused on accelerating theadoption and diffusion of new health tech-nologies into Ontario’s health system. Thehope is to provide better care, closer tohome, by using virtual, mobile and digitalhealth technologies.

Dr. Doug Dittmer and Shirley Fenton, MAwere the Co-Chairs, Waterloo RegionMedTech Conference 2017.

MedTech conference brings together innovators and users

After the success of the 2017event, plans are now under wayfor a 2018 Waterloo MedTechconference.

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R E H A B I L I T A T I O N

TORONTO – An inter-professionalteam of Toronto-based scientists,including a biomedical engineerand music therapist, has been

recognized with one of Canada’s highesthonours – the Meritorious Service Cross(Civil Division), presented by the Gover-nor General of Canada. The decorationrecognizes Canadians for exceptionaldeeds that bring honour to the country.

The team, from Holland BloorviewKids Rehabilitation Hospital, started de-veloping the Virtual Music Instrument(VMI) software in 2003 to help individualswith complex disabilities express them-selves and experience the benefits of musictherapy – including an increased self-es-teem and sense of personal accomplish-ment. To date, the VMI has impacted thelives of kids and families in over sevencountries worldwide.

“We are deeply honoured by thisrecognition, and humbled that our workhas impacted the lives of people with dis-abilities across the world,” said Dr. TomChau, Holland Bloorview’s vice presidentof research. “Our work in driving researchdiscoveries into action means that tech-nologies such as the VMI are accessible tothe very people who would benefit mostfrom them.”

Dr. Chau, alongside Andrea Lamont,music therapist and educator; Pierre Duez,software engineer; and Eric Wan, engineer,began developing the VMI to create theopportunity for kids with disabilities toplay music – without having to hold ormanipulate an instrument.

“Whether it’s making music through

dance, finger movements, or even an eyeblink, the VMI gives a meaningful musicalexperience for children in recreation, edu-cation, and therapy settings,” said Lamont.

One of the VMI’s most unique featuresis that in contrast to current technologiesand apps, it adapts to a child’s abilities andphysical commands by acting as an exten-sion of their body. For children and theirfamilies, this is often a life-changing expe-rience. The VMI has been adopted by re-habilitation institutes worldwide with

kids, youth and adults both with and with-out a disability.

To use the VMI, a computer and webcamare required. The individual’s image getsprojected onto the screen with largecoloured shapes superimposed on the spacearound them; representing different notes,chords, and even bars of music. When achild moves a part of their body, the cameracaptures the movement over the shapes andtranslates it into musical sounds.

“What began as an exploration of the

potential of technology in music therapyhas become an instrument that has al-lowed kids with disabilities to engage morefully with music, even to the point of per-forming in concerts,” said Duez.

The VMI also has the potential to ad-dress goals in the physical, cognitive, com-munication, sensory, and social domains.It gives children and youth with disabilitiesaccess to a leisure activity, encourages ex-ploration, and offers a channel for emo-tional expression.

“It is incredibly rewarding to see thisinnovative technology have a positive im-pact on the lives of kids with disabilitiesand enable them to do what they haven’tpreviously been able to. It makes kids feelspecial and challenges the perceptions ofwhat a person with a disability can andcannot do. The Governor General’s recog-nition of our work is a triumph for Hol-land Bloorview and kids with communi-cation and mobility challenges across theworld,” said Wan.

The Meritorious Service Decorations(Civil Division) are an important part ofthe Canadian Honours System. They rec-ognize individuals who have performed anexceptional and often innovative deed oractivity that sets an example for others tofollow, or improves the quality of life in acommunity at a local, provincial, national,or international level.

Her Excellency the Right HonourableJulie Payette, Governor General of Canada,presented the decoration to the team dur-ing a ceremony on December 12 at RideauHall in Ottawa. To learn more visitwww.hollandbloorview.ca.

Holland Bloorview scientific team given award by Governor General

The team from Holland Bloorview received awards from the Governor General of Canada, Julie Payette.

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Virtual Care network launched to help patients with spinal cord injuries

TORONTO – Spinal Cord In-jury Ontario, in partnershipwith the Toronto Rehab In-stitute, ForaHealthyMe Inc.and the Centre for Family

Medicine, has started a pilot project thatenables patients with spinal cord injuriesto use a new, virtual care system.

The new platform delivers tools andapplications that enable communicationbetween clients and their communitysupport staff and physicians withouttravel. Instead, the computerized plat-form offers videoconferencing and theability to share medical records andother documents.

These ‘virtual visits’ will reduce theneed to make in-person appointmentswith a family doctor or specialist – whichcan often take weeks or months, and mayalso involve long and difficult trips.

“Accessing support is even more diffi-cult, the more remote you are,” com-mented Dr. Stuart Howe, CEO of SpinalCord Injury Ontario, which is partner-ing with Toronto Rehab – part of theUniversity Health Network – on the pro-ject. Other partners include technologycompany ForaHealthyMe Inc., which isproviding the technology platform, andthe Centre for Family Medicine, a familyhealth team with expertise in spinal in-

juries, based in Kitchener-Waterloo, Ont.The project, called the VIRTUAL Plat-

form for Spinal Cord Injury (ViP-4-SCI), has been funded with a grant of$424,638 from the Office of the ChiefHealth Innovation Strategist. Speaking atan event launching the project, BillCharnetski, the province’s chief healthinnovation strategist, noted that his of-fice is investing $5 million a year in lead-ing-edge projects for four years.

The project for patients with spinalcord injuries will start with a group of 50patients, located across the province. Theyand their families will be able to contactexperienced physicians, clinicians andproviders of social services online whenthey have medical or everyday issues.

The project will evaluate how SCIclients use a virtual care solution to ac-cess support and healthcare servicesfrom home. If the results indicate thatlarger groups of clients can benefit, thenmore clients will have access to servicesand support through the platform.

Dr. Cathy Craven, a physiatrist andclinician scientist at Toronto Rehab andone of the leaders of the project, notedthe network will act as a referral service,helping patients with spinal cord injuriesset up the appropriate appointments.

For this and multiple other issues that

may arise, it’s far better to contact a groupof physicians who are experienced withspinal cord injuries and can provide accu-rate assessments and fast, appropriate re-ferrals.

The family health team in Kitchener-Waterloo, led by Dr. James Milligan, willdo this, to start.

Dr. Craven said the goal is to expandacross Ontario, creating networks of pa-tients and expert providers of medicaland social services.

It is important to find the right caremethods for spinal cord injury patients,as it is difficult to get them to medicalappointments. The new network, us-ing ViP-4-SCI, can not only speed upaccess to appropriate care, it can alsoanswer questions that might other-wise have required a trip to aphysician.

Such trips aretime-consumingfor patient andtheir families,and they’re of-ten dangerous,too. Dr. Cravenobserved thatwheel-chair-

bound patients must be transferred tocars, and they can sometimes fall, break-ing limbs, resulting in the need for morecare – including nursing, physio, woundcare and even management of depres-sion.

There are huge benefits to the patient,in terms of health promotion, if suchtrips can be minimized.

As well, the overall cost to the patientcan be greatly reduced.

How easy is such a system to use for aspinal cord injury patient, some of

whom are paralyzed from theneck down?“You’d be surprised,” com-mented Dr. Brian Chan, apost-doc fellow at UHN.

“They have become very goodat using new technologies.”

Dr. Matheus Wiest, also apost-doc fellow at UHN,

explained: “There are now thingslike eye-motion detec-tors, and interfaces thatcan be controlled bysticks held in theirmouths. They get quitegood at this.”Of course, the families ofpatients can also assist.

h t t p : / / w w w . c a n h e a l t h . c o m1 0 C A N A D I A N H E A L T H C A R E T E C H N O L O G Y F E B R U A R Y 2 0 1 8

Dr. Cathy Craven

For more information, please visit us at e-Health booth#500 or e-mail CanadianSolutions@orionhealth.com

E D U C A T I O N A L S U P P L E M E N T

ith the advent of Electronic MedicalRecords (EMRs), clinicians are drowningin data, and they struggle to pull out

specif ics that help them make the right clinicaldecisions. They have become data rich, butinformation poor.

Frontline providers of patient care spend a greatdeal of time collecting data. Although onerous andtime consuming when done on paper, the digitalprocess can be even more burdensome. Cliniciansare forced to learn new systems and asked to makenotes they might not otherwise bother recording.As healthcare becomes more electronic, the dataworkload increases, unabated.

“The EMR has become the core system used inhospitals,” said Dr. Simon Kos, Chief Medical Off icerat Microsoft. “The paper record certainly had itslimitations, particularly for patients with chronicdisease, who might have multiple volumes ofpaperwork, but the EMR has turned into a dumpingground for any digital source of information. It’s theclinician’s job, the doctor especially, to knoweverything in the electronic medical record, and ifyou miss anything, well shame on you.”

An EMR may contain pages of narrative from socialworkers describing their interactions with patientsand their families. It may include lab results, EKGs,and medical imaging from multiple episodes.“Suddenly you have a document that probablyrequires hours to internalize,” observed Kos.“Clinicians are saying, ‘I don’t need this. I don’t wantit. Help me get my hands on what I need to providethe care I want to provide. I don’t want unnecessaryinformation, or worse, information that exposes meto medical or legal risk. Just what’s pertinent.’”

Making information actionable. According to IDC,the “Health Digital Universe” is growing 48 percentannually. “The problem isn’t lack of data,” said TomLawry, Director of Worldwide Health at Microsoft.“It’s getting easy access to it so you can turn it intosomething useful.” Historically, health data has beenstored in different places, or silos, usually in differentformats and under different ownership. Applicationsthat capture and store data, such as EMR apps,don’t integrate well with other systems. Even withina single organization, it’s diff icult to access the rightinformation at the right time to make decisions.

“If I have to rely on busy IT department analysts torun reports for me, I may have to wait days, weeks,

or months,” said Lawry. “By the time I get myreport, everything has changed.” Acting on old,incomplete, or fragmented information is like tryingto drive forward while staring in the rearviewmirror. “But what if all these constraints wentaway?” Lawry posits. “What if you could use everypiece of clinical data you have, no matter howmuch there is or where it is, and you had unlimitedresources to process and analyze that data—innear real time? What if you could not onlyunderstand what happened in the past and why,but predict what may happen in the future andtake prescribed action to prevent it? With cloud

analytics, we can do this—today. This is the newdata paradigm.”

Self-service, evidence-based analytics. The newdata paradigm uses self-service analytics tools,which provide research-on-demand withimmediate insight into data through dashboards,visualizations, and alerts. Staff can segment andcross-reference the most current data available,while analysts can focus on helping theminterpret results instead of programming complexdata queries.

As new data comes in and trends change, theresults update instantaneously, so healthorganizations can quickly formulate ways torespond. “The role for analytics going forward,” saidKos, “is to provide, at a minimum, that automatedsummary based on the needs of the clinician.Without it, there’s a sea of unstructured andunformatted notes to pore through.”

Clinical analytics can benef it hospital departmentheads, as well as frontline clinicians. “If all this data

is being collected,” Kos continued, “why not use itto gauge departmental performance? How can thedepartment improve the care it delivers? How is itdoing quarter to quarter? How does onedepartment compare with other departments inthe hospital? What is best practice? What are theareas for improvement?”

Aside from informing quality and performance,clinical analytics can lead to risk stratifyingpatients who are frequent attenders. It cansystematically answer questions like: Whichpatients are falling through the cracks? Who is

missing follow-up appointments?Who is trending poorly?

Predictive patterns. Hiddenpatterns and trends become visiblewhen health organizations applyanalytics to large amounts of datafrom sources such as EMRs, smartmedical devices, patient andpopulation demographics, and thepublic domain.

“When we tell health organizationsthat we can predict f ive years aheadof time whose congestive heart failurewill progress and how rapidly, theyhave trouble conceptualizing that,”

said Dr. T. Greg McKelvey Jr., head of clinical insightsat KenSci, a Seattle-based Microsoft partnerspecializing in health analytics.

Predictive analytics is a data-driven crystal balltaking analytics to the next level, beyonddescriptive or diagnostic methods that lookbackwards on what happened and why. You canlook at what happened, and what is happening inreal time, to not only predict what will happen, butto shape it using advanced methods known asprescriptive analytics.

Clinical analytics makes use of a steady stream ofdata to reveal trends applicable not just toindividual patients, but also to large patientpopulations. Continuous data feeds from smartdevices, along with scheduled interactions withchronically ill patients, help clinicians f ine-tunepersonalized care plans and intercede before crisisevents occur. This is particularly useful when thewindow of opportunity is in minutes, or evenseconds, and care teams need to make very quick,critical decisions that may save lives.

Download the full eBook for free at www.aka.ms/ClinicalAnalyticsEbook

Microsoft

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Making data actionableCloud-based systems produce useful EMR summaries

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

BY DIANNE CRAIG

Pediatric cardiac intensive carephysician Barbara-Jo Achuff,MD is acutely aware of the re-sponsibility that comes withleading her hospital’s sedation

stewardship committee.Not only is the 33-bed Cardiac Critical

Care department at Texas Children’s Hos-pital the largest of its kind in the UnitedStates, but U.S. News & World Report hasalso ranked the hospital as the best in thecountry for pediatric cardiology and heartsurgery.

“Being number one comes with respon-sibility,” she said.“We need to establish andfollow the quality metrics for best prac-tice.”

Speaking to attendees at Tableau Con-ference ‘17 in Las Vegas recently, Dr. Achuffsaid heart defects are the leading cause ofbirth defect-associated infant illness anddeath, and that one in 120 children areborn with a heart defect.

“Heart defects can be quite complex.We sometimes refer to it as ‘cardiovascularorigami’ – how some babies are born withquite jumbled hearts.”

And when patient recovery after correc-tive heart surgery is under way, there is noshortage of information to assess. “It’s likea ‘data hurricane’ – information is comingfrom all the life-giving machines in theroom, and from the baby. We have situa-tions where a decision has to be made veryfast,” she said.

The number one goal for all their pa-tients is comfort, said Dr. Achuff, notingthat children get “many, many doses” of

medications in order to achieve relief frompain and anxiety.

With a passion for ensuring the comfortand care of her young patients, Dr.Achuff ’s mission became sedation man-agement in pediatric critical care. At thesame time, she knew that comes with acost; some drugs can cause addiction,PTSD, and other issues.

“Sedative drugs can have effects on de-veloping brains. But, we can’t avoid them –we just have to know how to use themsafely. We wanted to assess the sedationpractice, make changes, and measure im-provement,” said Dr. Achuff.

At the time, there was some usage ofbusiness intelligence (BI) software at TCH,but not directly by care providers. Also,notes Dr. Achuff, requests to IT were longand arduous, since that department is in-credibly busy and sometimes overbur-dened.

The medical teams weren’t getting a re-sponse near real-time, when they neededit, and data architects were not really fa-miliar with the clinical relevance of theirrequests. Still motivated to find the righttool that could help them improve their se-dation practices, Dr. Achuff began lookingfor other options.

She had heard about Tableau businessintelligence software, and read about howit had been used, for example, by the TexasRangers Baseball Team to gain a full 360-degree view of operations and by banks totrack and follow dollars and profits.

“I needed a powerful, quick tool. Ithought, why can’t I use that resource formy patients?” said Dr. Achuff. Eager tomove forward quickly, she purchased a

desktop version of Tableau. She wonderedif Tableau’s Self-Service Visual Analyticscould give them the ability to look ateverything over the past five years in termsof medication dose and duration, by year,

month, day, hour, and provider – nurse orpractitioner.

They started working with the analyticsby looking at intravenous doses per patient– all medications given through IV asneeded, and then noted variations by hourof the day. The graph showed a trend ofspikes two to three times higher at 4 a.m.,7 a.m., and 7 p.m. It visually showed a dis-tinctive pattern with significant differencein day and night dosing totals.

The most frequently administeredmedication was Fentanyl, and the othertop drug was Midazolam. When the team

evaluated frequency spikes, and saw night-time dosing was much higher than day-time dosing, they wondered, is this follow-ing the rhythm of the patient or what thenurses felt was right, or another reason?

Their next move was to introduceS.T.A.R. activities, including: Staff Educa-tion, Fellow Education, Standardization,and Assessment Tools. As well, clinicalguidelines were established.

After the practice change and imple-mentation took hold, adjustments in seda-tion were evident. “We aimed to decreasedoses by 20 percent. Now Fentanyl dosingfrequency is down 12 percent and Midazo-lam frequency is down by 26 percent,” re-ports Dr. Achuff.

“All the while, the complexity of ourlittle patients is probably the highest inour history. And patient, parent, andnurse satisfaction have all skyrocketed.”

Dr. Achuff believes the benefits of vi-sualization are immense. “So far, we havebeen able to describe and provide insightinto previously unavailable data. Wehope to see outcomes change, includingreduced ICU length of stay, reduced totaldose exposure, translated into less pa-tients experiencing addiction and im-proved developmental outcomes.

“By using Tableau, and showing thedata, we’ve changed the culture,” sheadded. “We’re making practice changes,cultural changes, and writing publica-tions about sedation … and I will not goback to what we had before, now that Isee what we can do,” said Dr. Achuff,adding, self-service analytics puts thedata in front of the people who knowwhat to do with it.

Innovation Lab allows solution developers to create EHR prototypesBY CATHERINE KREVER

TORONTO – eHealth Ontario’sInnovation Lab is an onlinespace where healthcare devel-opers, individuals and startups

from around the country can learn howto write software that interacts with On-tario’s electronic health record (EHR).So how does the lab work and what doesit mean for healthcare in Ontario? Wespoke with Mike Krasnay, eHealth On-tario’s Director of Enterprise and Inte-gration Architecture, to find out.

What exactly is the Innovation Lab?

Mike Krasnay: The lab contains every-thing an innovator would need to writesoftware that can interact with theprovincial electronic health record (EHR).It contains descriptions of EHR services,interface specifications, sample code andmessages, a test harness for learning, testdata, and crucially, actual web servicesthat innovators can connect to.

Currently, the lab contains twoprovincial EHR repositories and two in-frastructure services. No personal orpersonal health information is con-tained. Participants use the lab to testhow their systems interact with an EHR

service to validate their planning, makeproduct adjustments, prove concepts,build and experiment with clinical pro-totypes, and better understand and esti-mate the cost and effort of conformingto EHR specifications.

Why did you build it?

Mike Krasnay: To create opportunityfor more companies and individuals toenter the digital health market. Wewanted to provide a place where allideas can be showcased, not just thosefrom large organizations, but also fromstartups, individual clinicians, studentsand professors.

The goal is promoting inno-vation that leads to engagingOntario clinicians and patientsin using technology for betterhealth.

By putting our systems on-line, innovators can learn howto write software prototypes thatinteract with Ontario’s EHRand create real production-grade software. Thishelps them garner

support, be it financial or clinical, be-cause they can now demonstrate thattheir idea is technically feasible, showhow it works, and display the benefits.

How does the Innovation Lab work?

Mike Krasnay: There’s no cost to usingthe lab, but registration is required.Once registered, innovators have accessto all of the lab’s resources. These re-sources (specifications, samples, test har-ness, and forum) equip software devel-opers with the knowledge they need tointegrate with the EHR. With this

knowledge, innovators can writesoftware that interacts with the

EHR web services in the lab. There are two types of services:Lite, and now Full. Those newto healthcare integration canexperiment with our Lite Ser-vice: these are like the Full Ser-vice, but without cryptography,

authentication, and other secu-rity controls that can be complex

and intimidating to new-comers.

Lite Services helpparticipants learnand show thebenefit of inte-

grating with EHR information. Oncethey have mastered the basic exchange ofEHR information, they can proceed toFull Services; it’s essentially Lite Serviceswith the addition of privacy and securitycontrols.

What’s next?

Mike Krasnay: We are constantly addingnew services and data sets, and are con-tinually improving the experience in thelab by upgrading the test harness, mak-ing the data more clinically representa-tive, and adding a code sharing facility.Later this fiscal year, the province’sprovincial drug and immunizationrepositories will be available.

An open provincial EHR platformthat allows ehealth solutions to be testedin a virtual EHR environment, the Inno-vation Lab gives innovators a space toprototype new ideas.

The virtual environment allows usersto understand and experiment with ba-sic EHR services and connectivity. Forthose building custom applications orsolutions, it’s a place to validate plan-ning, make product adjustments, andprove concepts. It can be accessedthrough eHealth Ontario’s website –https://www.innovation-lab.ca/.

Dr. Barbara-Jo Achuff, Texas Children’s Hospital

Hospital transforms its sedation practice using analytics, dashboards

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Mike Krasnay,eHealth Ontario

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Save your brainpower for stent deployment

BY RICH EMRICH

The Internet provides an abundance ofresources for the public to make bet-ter-educated decisions about theirhealth, which has put the patient-doc-tor relationship on more equal foot-ing. Family doctors used to be the pri-

mary source of guidance for health issues, but pa-tients are now armed with a wealth of knowledge anda variety of tools to inform themselves.

Given that part of a patients’ medical knowledgecan be gathered without the assistance of a medicalprofessional, patients are increasingly looking for adifferent kind of doctor – one who is not onlyknowledgeable about medicine, but also personable,has strong communication skills, and is empathicwhen providing care.

In addition, research shows that weak “non-acad-emic” traits and professionalism issues are at the rootof almost all legal complaints against physicians.

Licensure exams are increasing the emphasis on as-sessing non-academic based attributes of graduatingstudents, probing for aptitude in public health, ethical,legal, cultural competence, and communication skills.Programs are also moving to assessing non-academictraits in the form of in-program assessments like peer-reviews and supervisor evaluations.

While admissions departments in medical schoolshave a collection of good tools to assess the academicand knowledge (or cognitive) attributes of appli-cants, historically very little reliable information ex-isted to support a more holistic screening process.

To address these concerns, Dr. Harold ReiterM.D., a radiology oncologist who past-served as theAdmissions Chair for the Michael G. DeGrooteSchool of Medicine, and Dr. Kelly Dore Ph.D., an as-

sociate professor and senior scientist the Program forEducational Research and Development at McMas-ter University, constructed the CASPer test as a cost-effective tool for medical programs to use in the ad-missions process to assess the personal and profes-sional competencies of their applicants.

The test is a form of situational judgement test(SJT) that involves viewing a series of videos depict-ing challenging ethical or conflict situations in every-day contexts, and answering questions about whatstudents would do and why. Unlike other standard-ized tests like the MCAT, CASPer is completed onlineand is remotely proctored to prevent cheating.

CASPer was first introduced at McMaster’sMichael G. DeGroote School of Medicine in 2010 af-ter research and pilot studies showed good reliability

and predictive powers of the test. In late 2014, AltusAssessments was formed, and assumed responsibilityfor the development and delivery of CASPer.

By the end of this year, well over 100,000 applicantswill have written CASPer since it was launched, in-cluding over 50 percent of all U.S. and Canadian Med-ical school applicants. It is also used in other health-care programs, including nursing, veterinary, optom-etry, pharmacy, and physician assistants, and used asfar away as teachers education programs in Australia.

One of the first schools to adopt CASPer in the USwas New York Medical College (NYMC). The associ-ate dean of admissions from NYMC, Dr. Fern Juster

M.D., a pediatrician, has conducted research show-ing that CASPer can help address some of the barri-ers for applicants with diverse backgrounds.

At the 2016 Canadian Conference on Medical Ed-ucation (CCME) in Montreal, she presented ananalysis showing that CASPer was less disadvanta-geous to underrepresented groups in medicine, suchas Black and Hispanic applicants, and those fromlow-income backgrounds than traditional cognitivemeasures such as GPA and MCAT.

The lack of representative diversity in medicaleducation has long been a problem, and despite re-cent initiatives aimed at increasing the representa-tion of under-presented minorities, little progresshas been made.

Black individuals make up less than 1 percent ofCanadian medical school students, despite account-ing for almost 4 percent of the Canadian populationaged 15 to 24. A lack of diversity in medical educa-tion translates to a lack of diversity in the healthcareprofession, which can negatively affect the quality ofhealthcare for underserved minorities.

While CASPer helps programs to get a more reli-able and holistic view of applicants in the initial ad-missions screening process, many schools have alsoembraced a more rigorous interview process by re-placing the standard panel interview with the morerigorous multiple mini interview (MMI).

Both changes are similarly driven by admissionsdepartments wanting to get a better view of the non-academic traits of applicants while moving towardstools that are evidence-based and effective. More di-verse and holistically stronger physicians is some-thing we should all be excited about.

Rich Emrich is CEO of Altus Assessments. For more in-formation, please see: https://takecasper.com/

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Patients are increasingly looking for doctors who are more than just knowledgeable about medicine.

Judgement test, in addition to scholasticability, is changing the face of education

Admissions departments want to get abetter view of the non-academic traitsof applicants, using tools that areevidence-based and effective.

Simulator uses augmented reality, offers mother-baby physiology

MONTREAL – CAE Health-care has announced the re-lease of CAE LucinaAR

with Microsoft HoloLens, theworld’s first augmented reality child-birth simulator with integratedmother-baby physiology.

For the first time, clinical teamsand learners will be able to practiceemergency labor and delivery ma-noeuvres on a high-fidelity patientmanikin while guided by 3D holo-grams of the baby as it progressesdown the birth canal. The first CAELucinaAR learning module will pro-vide immediate visual and physiologi-cal feedback on the effectiveness ofevidence-based clinical emergencymeasures to resolve shoulder dystocia.

“CAE LucinaAR delivers a break-through simulation training experi-ence that allows learners to see theanatomy inside the patient simula-tor,” said Dr. Robert Amyot, Presi-dent of CAE Healthcare. “We chose

Lucina as the first CAE patient simu-lator for integration with our aug-mented reality platform because webelieve it will have an immediate andpowerful impact on the managementof shoulder dystocia deliveries andon mother-baby safety.”

Shoulder dystocia is a specific

case of obstructed labour wherebyafter the delivery of the head, the an-terior shoulder of the infant cannotpass below, or requires significantmanipulation to pass below, the pu-bic symphysis. It is diagnosed whenthe shoulders fail to deliver shortlyafter the fetal head. Shoulder dysto-

cia is an obstetric emergency, and fe-tal demise can occur if the infant isnot delivered, due to compression ofthe umbilical cord within the birthcanal. It occurs in approximately0.3-1 percent of vaginal births.

Following the release of its CAEVimedixAR ultrasound simulatorwith Microsoft HoloLens in 2017, thefirst such solution for the healthcareindustry, CAE has realized another in-dustry first by integrating augmentedreality into its patient simulators withboth didactic and interactive content.

“We are delivering on our commit-ment to innovate with integrated sim-ulation technologies that will dramati-cally improve clinical learning envi-ronments,” said Dr. Robert Amyot.“Today’s generation of learners expectsimmersive, engaging and acceleratededucational experiences that will pre-pare them to meet the high demandswithin healthcare as they constantlyadapt to advancing technologies.”

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Leading high performance culture

Con

Helping you accomplish your goals in 2018

Joule.cma.ca/Learn

BY DR . SUNNY MALHOTRA

Irecently had the opportunity of speaking withDr. Darren Larsen. He is Chief Medical Infor-mation Officer with OntarioMD, and is a can-didate to become President Elect (Nominee)of the Canadian Medical Association. Dr.Larsen has leading-edge insights about the

state of medical care in Canada and the application oftechnologies that could solve current problems.

Dr. Malhotra: What are the biggest areas of opportu-nity for technology in healthcare today?

Dr. Larsen: I think that artificial intelligence and ma-chine learning are real opportunities. The embed-ding of evidence-based algorithms into our elec-tronic medical record systems and the introductionof clinical decision support tools will make our deci-sions stronger and less variable.

This will be a huge advance in the care of our pa-tients. We will need to learn how to trust these sys-tems, and the evidence-base around them.

As we do so, we will find our clinical quality andoutcomes can improve. These systems will allow usto involve patients in decision-making. When theyare presented with a list of choices with confidenceintervals around those choices, we allow them to beactive participants in the care being offered to them.

This will build trust, not erode it. Admittedly, thisis nascent work, but the technology in this domain isimproving quickly and dramatically. There will needto be a strong change management and educationalapproach around this work. I believe there is a rolefor the CMA in this, either through the Associationor its subsidiary, Joule.

Dr. Malhotra: Where does privacy fit into all of this?

Dr. Larsen: This Big Brotherish idea – of data mov-ing out of EMRs for analytics – scares some clini-cians. We will have to work with them closely to en-

sure they understand the benefits versus the risks. Aswell, privacy of personal health information must beguaranteed.

There is no room for data breaches or PHI to fallinto the wrong hands. This will require both robusttechnology and strong public policy.

Furthermore, education plays a huge role. Clini-cians will need to know exactly their role in main-taining privacy and security.

Dr. Malhotra: Virtual visits with doctors are juststarting in Canada, but they could have a big impact,on both patients and the healthcare system. Do youthink they will?

Dr. Larsen: Virtual care will become a standardway of caring for our patients in the near fu-ture, not for everything but for a lot. Virtualcare doesn’t only mean telemedicine visits.It also includes use of email, remote mon-itoring, and even patient portals.

Tele-homecare is one example of this,but we haven’t even begun to think about

the ways that virtualization could expand intobroader healthcare knowledge and use.

Even the vast volumes of data being collected byour wearable devices can be incorporated into anoverall health plan for patients. We must create aspace where technology companies and start-ups canproduce products that succeed, making adoption ofinnovation easier in Canada.

It is frankly easier for start-up companies to mar-ket and grow in the United States than Canada. Thebrain drain of Canadian talent is a real issue. I wouldlove to see this brain drain stopped.

Dr. Malhotra: Should patients be given more accessto their health records?

Dr. Larsen: I strongly believe that patients shouldhave full access to their complete healthcare data sets.Not only can they or should they be able to read andconsume the information, but they should also beable to contribute to it.

There are many studies now that show that opennotes have a strong positive impact on patient care

and better healthcare outcomes. We physiciansneed to understand how patients’ contribu-

tions to their data set will help us as well asthem. The data belongs to patients. We mustwork cooperatively as team players withour patients to ensure that their data is usedfor good. They can help us be better clini-cians by having full access to their records.

This is something I stand strongly behindand will work actively to promote if I’m

elected as CMA president. I am cur-rently doing that even now in my

role as CMIO at Ontario MD.Open access will be revolu-tionary for healthcare inCanada. And as a patient, orpotential patient, I can’timagine any other way.

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An interview with Dr. Darren Larsen, chief medical officer with OntarioMD.

What to expect inhealthcare technology for 2018

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

Dr. Larsen: Patients should have fullaccess to their complete healthcaredata sets ... and they should be able tocontribute to their health records.

Team approaches to implementing technology are keys to successBY ROSEMARY GRAY

Rather than a new eco-adven-ture, BCHIMPS is the BritishColumbia Health Information

Management Professionals’ Society.They’ve been bringing together BC’shealth informatics, IT, IM and clini-cal leaders for three decades to net-work, share experiences and partici-pate in professional developmentopportunities such as the recent FallSymposium, held in September atVancouver’s Sutton Place Hotel.

This was the biggest BCHIMPSevent to date, with a sold-out venueand more than 140 registrants in theroom. When I walked into the corri-dor to fill my coffee cup, and re-turned to the room, it was like Icrossed a force field that could barelycontain the wall of positive energy,

curiosity, and passion for makingthings better for the patients weserve in our health system.

The Triple Aim: The Institute forHealthcare Improvement’s (IHI’s)Triple Aim construct now has world-wide acceptance as an approach tooptimizing health system perfor-mance. Canada has definitely boughtin – the construct, even if not named,underpinned each speaker’s approach.

The Triple Aim refers to the si-multaneous pursuit of improving thepatient (and provider) experience ofcare, improving the health of popula-tions, and reducing the per capitacost of healthcare. Its power is that itis actually a single aim with three di-mensions – you can’t achieve andsustain quality outcomes for patientsand populations without working si-multaneously in all three areas.

Dr. Jeremy Theal, CMIO for NorthYork General Hospital, in Toronto, laidout the themes quite clearly. Patientsdeserve and demand better qualityand safety – for instance, preventabledeaths in hospital are inexcusable.

Quantitative measurement and re-porting: Increasingly, there’s an em-

phasis on accountability for eHealthinvestment that relies on a measure-ment and reporting framework thatsupports the Triple Aim. We are start-ing to assess the quantitative impactof change, by measuring improve-

ment (or lack of improvement) interms of lives saved, costs avoided,harms prevented, patient outcomesimproved, and provider experience ofthe change. These are the kinds ofmeasures that are meaningful toproviders, patients and other part-ners, and help us all to understandthe tangible impact of investment.

Evidence-informed clinical deci-sion making: There’s an increasingemphasis on the incorporation ofclinical decision support into the dayto day workflows of clinicians.Adoption of clinical standards isabout making the best path to fol-low, the path of least resistance – thelessons are to make the right way,the easy way, and “don’t impede clin-ical workflow”.

North York has had success with

You may achieve positiveor negative outcomes withthe same tools. It’s amatter of approach.

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V I E W P O I N T

BY DENIS CHAMBERLAND

Mackenzie Health, in Rich-mond Hill, Ont., recentlylaunched an innovation pro-curement to acquire artifi-

cial intelligence (AI). AI is simply software,but software that harnesses big data ana-lytics, which is the process of examininglarge and varied data sets (ie, a collectionof related sets of information) to uncoverhidden patterns, unknown correlations,market trends, individual preferences andother useful information that can help or-ganizations make better informed businessand clinical decisions.

The exponential growth in machineprocessing power in the last few years hasenabled the technique of machine learn-

ing, in which com-puters learn by ex-ample and teachthemselves to carryout pattern recog-nition tasks with-out being explicitlyprogrammed to doso. Healthcare isnow regarded as ahighly promisingsector for AI. Mackenzie Health’s

innovation procurement was initiated toaddress the province’s privacy and securityrequirements. As the province embracesuniversal Electronic Health Records for allOntarians, a significant challenge for hospi-tals relates to the handling of the ballooningvolume of personal health information.

The growing mass of information thatprivacy officers need to deal with is daunt-ing, particularly in the light of the guid-ance issued by the Information and Pri-vacy Commissioner of Ontario (IPC), di-recting hospitals to audit all accesses topersonal health information in electronicsystems. The IPC’s guidance was issued inthe aftermath of the launch of a $412 mil-lion class action lawsuit in 2014 after ahospital admitted to privacy breaches re-sulting from two employees selling patientinformation over a two-year period.

To ensure it has the capacity to complywith the IPC’s guidance, MackenzieHealth sought to procure a health recordprivacy solution that not only meets theIPC’s auditing requirements, but alsoproactively identifies trends and strategiesto prevent future unauthorized access,promotes real-time access to shared pa-tient records, and improves the cost-effi-ciency of care delivery.

By contrast, conventional technologysolutions focus on simple rules-based au-diting, which can result in a very largenumber of false-positives needing to bemanually reviewed, an impossible task toachieve in real-time.

With the objective of leveraging bigdata analytics and machine learning,Mackenzie Health tapped the market toprocure a solution capable of conductingaudits in real-time, of performing au-tonomous and/or semi-autonomous eventanalysis to maintain a low false positiverate (with a high accuracy rate), and pro-viding a range of tools to expedite the in-vestigative process. This, it is hoped, will

slow or reduce the growing cost of privacycompliance and transform privacy audit-ing from a reactive after-the-fact investiga-tion model to a pre-emptive, real-timeprotection model.

To procure its heath record privacy so-lution, Mackenzie Health’s project team

adeptly leveraged the Competitive Dia-logue, a highly effective type of innovationprocurement flagged by the Ontario Cen-tres of Excellence.

Although new to Canada, it has beenused in Europe, where the Dialogue’s pro-cedure allows a buyer to hold separate but

contemporaneous negotiations with qual-ified parties. Unlike the classic request forproposals (RFP) process, where only thesolution described in the RFP is consid-ered, the Dialogue produces a variety ofdifferent and more responsive solutions,

AI can involve new forms of procurement, along with new legal issues

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CONTINUED ON PAGE 23

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BY DIANNE DANIEL

Don’t be surprised if ‘3D Printing Lab’signs start popping up at Canadianhospitals. Early adopters of the tech-nology say it’s only a matter of timebefore 3D printing reaches even thesmallest community institution.

A little more than a year after launching its multi-departmental 3D printing program – one of the firsthospital-based programs in Canada – The OttawaHospital is printing every day, mainly for cardiology,oncology and orthopedics. Applications range frompersonalized, anatomically correct models that helpphysicians visualize surgeries, set complex fracturesand resect tumours, to advanced prosthetics and insome cases, equipment parts.

“Now we need to maintain the quality and thesafety of the program so that it can be portable to otherinstitutions in a safe, efficacious and cost-effectiveway,” said Dr. Frank Rybicki, Chief of Medical Imagingat The Ottawa Hospital and Chair of Radiology at theUniversity of Ottawa. “That really is a huge job.”

The lab has grown from one to two Stratasysprinters, including the original Objet500 Connex3PolyJet printer and a second fuse deposition model-ling (FDM) printer. It is primarily operated by Uni-versity of Ottawa engineering students and overseenby a first-of-his-kind 3D clinical fellow who is in thelab full-time. Vaughan, Ont.-based Proto3000 re-mains a strategic partner as the hospital continues toexplore possibilities, such as printing titanium boneimplants, organ implants and even skin in the future.

Based on early results, Dr. Rybicki is confidentthat “3D printing is poised to save enormousamounts of money” in healthcare. In one instance,the lab printed MRI replacement parts required tobiopsy breast lesions, saving close to $100,000. In an-other, surgeons saved an estimated four hours of ex-pensive OR time by rehearsing a complex procedureon a 3D printed model.

Now the hospital is working to develop a formal3D medical printing policy to ensure the longevity ofits program. “We’re working towards getting reim-bursement for 3D printing; we know in the caseswhere we appropriately use it, it will save time andmoney,” he said, noting that the goal is to manage 3Dmedical printers much like other medical devices.Cases where 3D printing is deemed not appropriateinclude routine lung or colon cancer surgeries, sim-ple fractures or appendicitis, he added.

Appropriate use is just one area under investiga-tion. Other topics include: How often do printersneed to be calibrated and serviced? What are thetraining standards for people working in the 3Dprinting lab? How will residents be trained? Does the3D design software, used to translate high resolutionscans to printable digital files, need to be approvedby Health Canada? Just as MRIs, CT scanners andsurgical robots are regulated healthcare devices, theentire 3D printing program “needs to be up to snufffor medical standards,” said Dr. Rybicki.

Reuben Menezes, Marketing Manager at Proto3000,believes a formal policy is necessary and will help tospur widespread adoption of 3D medical printing.“There needs to be a framework, there needs to bestandards, really a defined process of when, how andwhy to print,” he said.

Funding for the technology has to “catch up,” he

added. “One of the things holding it back in Canadais … that 3D printing is seen as a luxury item, a nice-to-have, but not a necessity that needs to be funded,”said Menezes. “As the government continues to havea deeper understanding and more studies show howit impacts the bottom line, we’ll see better adoption.”

Right now, 3D printing is primarily found in re-search hospitals and centres across Canada where themajority of printers are donated or purchased withdonated funds, and where young researchers andprofessionals are pushing the boundaries to evolvethe technology where it makes the most sense.Anatomically accurate models for pre-surgery plan-ning and education purposes are a clear early winnerbecause 3D printers can replicate 3D images afford-ably and with a high degree of accuracy.

Early adopters include the Institute for Recon-structive Sciences in Medicine, based at MisericordiaHospital in Edmonton, where 3D printing is improv-

ing treatments for patients with serious skull and fa-cial problems. The team uses sophisticated computermodelling and 3D printing to prepare detailed surgi-cal plans and templates, improving precision of re-construction surgery and reducing mean operatingtime by as much as 18 per cent.

Surgeons at The Hospital for Sick Children (Sick-Kids) in Toronto have partnered with Stratasys to 3Dprint pediatric heart models in-house, using a softermore realistic material that provides realistic hapticfeedback. Surgeons are excited about the new mater-ial and the ability to provide real physical models forsurgical practice, particularly for students.

Recently, Stratasys introduced its BioMimics Med-ical Service to provide similar realistic models for abroader range of clinical scenarios, including bones,hearts and blood vessels. According to the company,“different materials can be used together to producecomplex combination models, such as a spine withvertebras, discs and nerve roots.” The intent is to printand deliver models to hospitals as a service.

John Brown, Director of Additive Solutions atJavelin Technologies Inc., a Stratasys reseller head-quartered in Oakville, said lifelike 3D printed modelsare transformative because they are enabling surgicalteams to be more efficient with better outcomes, andgiving patients an unprecedented opportunity to

give more informed consent. Printing a heart modelmay cost anywhere from $500 to $2,000, but the po-tential savings related to fewer complications,quicker recovery and reduced lengths of stay arecloser to $20,000, he said.

Instead of trying to visualize the geometry of a pa-tient’s heart on a computer screen, surgeons are able tohold an accurate model in their hands. They can thendevise and attempt several plans before coming to a de-cision on the best way to attack a problem, and in somecases can print custom parts required for the surgery.Once they’ve settled on a plan that indicates a positiveoutcome is highly likely, they present it to the surgicalteam as well as to the patient or patient’s parent.

“This is about outcomes and economics,” saidBrown. “Patients are going to get better surgery, bet-ter informed consent and higher satisfaction;providers will be able to align complex surgicalteams, reduce waste and gain better reputations; and,

payers will avoid costs and complications and drivedown the costs of longer term healthcare.”

Another anticipated benefit is that lifelike modelswill enable a new, accelerated way to train doctors, headded, by allowing them to amass experiencethrough practice early on in their careers. “We wantto get them as good at 30 as they are at 60,” he said.

The process of 3D printing an anatomically cor-rect model typically starts with a high resolutionscan (DICOM image) that is segmented and con-verted to STL, a 3D printable format. In the case ofmedical 3D printing, the STL file enables the printerto distinguish skin, bone, muscle and open space, forexample. The printer selects appropriate digital ma-terials according to the data it receives and uses a lay-ering process to build the fully formed object, aprocess called additive manufacturing.

Jeff McIsaac, General Manager of Mohawk College’sAdditive Manufacturing Resource Centre in Hamilton,Ont., believes 3D printing has huge implications forthe medical space. The centre is working with a hand-ful of healthcare partners, including a Niagara regiondentist who is 3D printing custom dental implants.

“One of the most interesting things to me about ad-ditive manufacturing for healthcare applications is theidea of controlling the geometry of the part for masscustomization,” he said. An example would be hip and

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Additive technologies have led to reduced time in the OR, fewer complications and faster recoveries.

3D medical printing is producing better medical outcomes

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

knee replacements. Rather than selecting thebest fit from a catalogue of artificial joints, aknee could be 3D printed from a precisescan. “It wouldn’t be the closest you can getand hope it fits, it would be the exactanatomy you need,” he said.

What’s required, said McIsaac, is a newdesign paradigm, one that opens up an en-tirely different world where it’s possible tocreate weird curves and organic-lookingstructures instead of relying on square cor-ners and round holes. “We’re very earlydays in terms of people getting thatthought process through their heads. Oncethat starts to take over, people will be usingadditive manufacturing to make stuff wehaven’t even heard of yet,” he said.

One group of Mohawk students is al-ready thinking outside of the box. On theirown time, and without earning any credits,they formed the Mohawk 3D PrintingGroup with the aim of producing ex-tremely life-like medical models, known asphantoms, by applying advanced additivemanufacturing techniques to print syn-thetic flesh, bones and organs. They are anopen source, not-for-profit project withthe sole intention of advancing research.

Mechanical engineering student Addi-son Wood co-leads the group with LaurenStephen, a student studying software de-velopment. Wood said the main challengepresented by existing multiple extrusionsystems – 3D printers that can print inmore than one material – is that the typesof materials available are limited. “We’retrying to make multiple, very different ma-terials work together in one whole success-ful print,” he explained.

Ballistic gel, for example, is proving to bea good material to replicate synthetic flesh.The students are working to ensure it main-tains the right temperature during printingin order to obtain the necessary viscosity. Ifthe temperature rises too high, the materialcan bubble. They are also considering Nin-jaFlex, a flexible 3D printing filament, as aviable material to print organs.

“We haven’t quite figured out organ tis-sue, but we are going to do bone plasticand ballistic gel,” said Wood. “Incorporat-ing those two together is a huge step.”

“We’re in agreement that this is the fu-ture of medical phantom production,”added Stephen. “If we can nudge it for-ward and some other player takes some ofour research and perfects it, that’s also asuccess in our minds.”

As an academic centre, the MohawkAdditive Manufacturing ResourceCentre has the luxury of working

with new materials and taking risks thataren’t always available to industry. Failuresare as important as successes, said McIsaac.

“In the next 10 years, additive manufac-turing will affect every industry at somelevel,” he said. “Students who’ve been work-ing with us have had the opportunity to bein here working on real engineering prob-lems…and everyone is trying to explore andlearn. It’s a fantastic opportunity for them.”

As early adopters of 3D medical print-ing continue to push the technology for-ward, the Canadian government is alsoweighing in.

In October, 2017, the standing senatecommittee on Social Affairs, Science andTechnology released its report ChallengeAhead: Integrating Robotics, Artificial In-telligence and 3D Printing Technologies

into Canada’s Healthcare Systems. As partof their investigation, committee membersvisited the general campus of The OttawaHospital to examine a range of 3D printedobjects and watch a 3D heart model print.

The report states members were“amazed at the innovations … humbled bythe ingenuity on display and overwhelmedby the potential impact these disruptiveinnovations can have on the healthcare

system” and goes on to suggest that “in or-der to be successful in integrating robotics,AI and 3D printing into healthcare deliv-ery, Canada has to address the hurdles thatlie in the way.”

Some of those issues include trusting thetechnology, protecting patient privacy andaddressing ethical concerns, as well as mak-ing necessary adjustments to training andeducation, and changes to the regulatory

framework for medical devices. One of sev-eral recommendations made by the com-mittee is that Canada convene annual na-tional conferences attended by all key stake-holders to ensure that new challenges willbe identified and addressed as they emerge.

“These technologies are going to revo-lutionize the way Canadians live andspecifically the way healthcare is deliv-ered,” stated the report.

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

BY JERRY ZEIDENBERG

CHICAGO – There’s been a furor oflate over the role of artificial in-telligence and Deep Learning inradiology – with some observers

surmising that computers will somedaysupplant radiologists. That day, however,appears to be a long way off, says Dr. PaulChang, professor and vice chairman of ra-diological informatics at the University ofChicago.

“Replacing radiologists? That’s hard,”said Dr. Chang. “It’s going to take a longtime.”

He explained his skepticism in a stand-ing-room only session at the RSNA confer-ence. “There’s a hype cycle going on,” saidDr. Chang. “I’m an old guy, and I’ve beenthrough this before,” observing that PACS,EMRs and structured reporting all gener-ated waves of excitement that took a longtime to produce value to physicians, hospi-tals and patients.

He assured the audience that, “I am anadvocate of Deep Learning.” However, hesaid the claims made about artificial intel-ligence and its current capabilities are ex-aggerated. A good deal more work must bedone before it can deliver on its promise.

That may indeed happen, he said. Andif it does, it could be of great benefit to ra-diologists, who are becoming overloadedwith studies to read and reports to write.Smart systems could be a godsend thattakes some of the mundane tasks away.

“What we do as radiologists is unsus-tainable,” said Dr. Chang. “Our heads aregoing to explode.”

He said the image sets are getting big-ger, in both numbers and complexity. Inthis environment, with huge volumes ofscans, radiologists have only a few secondsto read an image.

At the same time, the analyses are ex-

pected to be more precise than ever before,with demands surging for “multidiscipli-nary synthesis and actionable informa-tion.” Rads are now expected to combinetheir verdicts on whether there is a mass orlesion with related data about its charac-teristics, along with suggested therapies.

So the need is there to become more ef-ficient. “But I know of no way of doing thiswithout I.T.,” said Dr. Chang. Computer-ized tools will be the way out of the morass.

He said that Deep Learning systems inradiology, at least so far, have only accom-plished simple tasks and are nowhere nearreplacing radiologists.

Examples include organ segmentation,lesion measurement, and even the identifi-cation of osteoporosis.

Harder tasks, like the identification andclassification of lung cancer lesions,haven’t been perfected – at least, not to anygreat extent.

According to Dr. Chang, that’s becauseDeep Learning requires huge data sets, andcomparatively speaking, lung cancer is rareand the images are hard to come by.

“The Deep Learning applications areboring,” said Dr. Chang. “It’s because theydon’t have a lot of studies available to them.”

And there’s a Catch-22 at work, henoted. Because the studies aren’t available,the more challenging applications haven’tbeen developed. And until more useful ap-plications appear, hospitals and universi-ties are hesitant to invest in the infrastruc-ture needed to produce and test DeepLearning systems.

Meanwhile, some have been caught upin the hype about Deep Learning in radiol-ogy. Some of that hype has been spawnedby the plethora of papers posted on arXiv,the free repository of academic papers.However, Dr. Chang warned the audienceto be extremely wary of these papers, asthey are not peer reviewed.

And while papers must be accepted bygroup moderators on arXiv, Dr. Changsaid the standards seem to have dippedlately when it comes to moderating.

Without the skeptical eyes of radiolo-gists reading the papers, some of themethodologies and results have been ques-tionable, he said.

“Early validation methodologies aresurprisingly lightweight and suspect.”

Nevertheless, the potential is there inDeep Learning for great gains to be made. Inparticular, the technology could be used tohelp solve the productivity conundrum thatradiologists currently face. Indeed, systemsthat automate mind-numbing or time-con-suming tasks would be greatly welcomed.

Initially, these solutions, rather thanrepresenting huge strides in AI or DeepLearning, will consist of “minimallyheuristic use case sweet spots.”

There is equal danger, he said, in miss-ing the boat in Deep Learning because ofdisappointment with the early systems.The radiology community, he said, shouldstart investing in the infrastructure thatwill enable Deep Learning, and get into itslowly.

“The stuff that needs to be done is notvery sexy – it just needs to be done.”

He observed that high capacity systemslike Hadoop should be investigated andprepared for, as they are capable of han-dling large data sets. As well, hospitalsshould start thinking about the processingpower they will need.

The hardware leader that has emergedin this area is NVidia, commented Dr.Chang. “Neural networks are not new.What’s new is the enabling technology –the drug dealer. Which in this case isNVidia,” he quipped.

Deep Learning – coming soon, to a radiology department near you!

CHICAGO – Dr. Paul Chang,radiologist at the Universityof Chicago and a respectedcommentator on digitalhealth systems, cautioned

his colleagues at the recent RSNA meet-ing to avoid the current hype about arti-ficial intelligence and machine learning.Not much has been accomplished yet,he warned, although he said to staytuned, as things are likely to happenfaster than expected.

“We are too early [as radiologists] toembrace the hype before it can help ourpatients,” said Dr. Chang at an overflow-ing session on Deep Learning. “But thenwe’re often late when it can help them.”

To be sure, radiology vendors areworking feverishly to bring “helpful”machine learning applications tofruition, and it’s good to keep an eye onthem. Several companies demonstratedsolutions that could have a huge impacton the way physicians conduct theirwork – though rest assured, none are go-ing to replace radiologists any time soon.

Instead, they will enable DI expertsto work more effectively, while simulta-neously improving the delivery of carefor patients.

Here are some cases in point:The team at IBM Watson Health

demonstrated a technology called Pa-tient Synopsis that digs into the hospi-tal’s EMR to find patient informationthat could be useful when a radiologist isconducting a study. The goal is to savetime and effort for the radiologist, whocould use the data in the EMR, but is al-ready hard-pressed to complete the read-ings on his or her worklist.

When a radiologist is conducting a CTliver exam, for exam, Watson can searchthe EMR for important data in patientencounters, vitals and other exams. “Wat-son can scan the whole record, includingunstructured data, to find what’s rele-vant,” said Alex Abed, AI Solution Expertwith IBM Watson Health. “For example,if there are notes about persistent nauseaand vomiting, and loose bowel move-ments. It also gives the radiologist the

name of the doctors who did the notes,in case they want to follow up.”

This kind of information gives the ra-diologist a much more complete pictureof the patient’s condition. And it does itautomatically, when the radiologistopens the patient’s studies in the work-list. Watson Imaging Patient Synopsis is

a work in progress, but a commercial re-lease is planned for 2018.

The system uses machine learning,and has been trained to watch what ra-diologists look for when searchingthrough EMRs so that it knows what todo on its own. Patient Synopsis is ex-pected to save time and increase qualityof readings for radiologists.

For its part, GE Healthcare is also

working on bringing more context andinformation to the radiologist, as he orshe works. At RSNA, the companydemonstrated Imaging Related ClinicalContext (IRCC) and enhanced readingworkflows, which were developed inpartnership with University of Pitts-burgh Medical Center (UPMC). IRCCwill deliver patient clinical content incontext, including EMR data such assurgical notes, pathology reports andclinical notes, directly to the radiologistas part of the existing workflow.

The new IRCC algorithm is expectedto be available in 2018. GE Healthcaresaid it learns directly from radiologiststhrough semantic feedback (the rele-vance of certain key words and sentencestructure) how to best select and presentrelevant clinical data when contemplat-ing a diagnosis.

Also on the AI front, GE Healthcareshowed a new X-ray quality applicationfeaturing Repeat/Reject Analytics (RRA).According to the company, hospitals are

Patient Synopsis is expectedto save time and increase thequality of readings forradiologists.

Deep Learning has a long way to go before it replaces radiologists

The University of Chicago’s Paul Chang led a well-attended session on Deep Learning in diagnostic imaging.

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

CHICAGO – The annual Radio-logical society of NorthAmerica (RSNA) meeting inChicago, held after the Amer-ican Thanksgiving in Novem-

ber, is always an eye-opener when it comesto innovative technologies. The latest ver-sion, held last fall, was no exception, withadvances in Deep Learning, virtual andaugmented reality, and new techniques forall imaging modalities being discussed ineducational sessions and demoed in threebig halls.

Siemens Healthineers showed off fournew CT scanners, two of them in the SO-MATOM.go family, and two more in thehigh-end line – the SOMATOM Edge Plus,a premium single-source system, and SO-MATOM Force, the new version of thedual-source CT, quipped with two X-raytubes and two detectors. Speaking of theForce, Eberhard ten Weges, VP of globalCT sales, said: “It’s the fastest in the mar-ket. It’s a beast.”

Ten Weges noted the new SOMATOMgo.All and SOMATOM go.Top scannersare especially useful if space in short sup-ply, as they can be configured as “one roomsolutions” using a shelter instead of a ded-icated control room. Moreover, the set-upcan be controlled using a tablet computer,meaning the technologist can remaincloser to the patient during the examprocess. The 64-slice SOMATOM go.Allcan cover scan ranges of up to 100 mm inone second, while the 128-slice go.Top canperform whole-body scans of up to 200

cm, with a scan speed of up to 175 mm persecond. These systems can be used inemergency medicine, interventional radi-ology and cardiology.

On the high-end side, the SOMATOMEdge Plus and SOMATOM Force allowclinical users to cover all CT applications,regardless of patient or clinical issues. Bothsystems also offer high-precision diagnos-tics, which is a prerequisite for individual-ized prevention and therapy. “More than200 scientific papers show what SO-MATOM Force is capable of,” said Andri

Hartung. “With this new version of ourtop-of-the-range system, we want to helpour customers take the next step on theirway to precision medicine.”

Such precise diagnostics come from theFAST applications that are integrated intothe premium systems. One application isthe FAST Integrated Workflow with the all-new FAST 3D Camera for automatic pa-tient positioning. In many CT examina-tions, incorrect patient positioning is an ob-stacle to achieving optimal results. TenWeges pointed out the camera uses infrared

sensing and Deep Learning to optimize pa-tient positioning for specific protocols.

“This technology enables institutions topotentially have fewer rescans, decrease thetime required for patients and staff, andtherefore benefit from precise diagnosticsat lower cost,” the company says.

Siemens Healthineers also announced aninnovation in the MRI area, specifically forknee imaging. A company spokesman notedthat knee imaging is the third most scannedregion, after MRIs of the brain and spine. Soit’s significant that the company has pro-duced GOKnee3D, an MRI application thatshortens the time required to perform com-prehensive diagnostic exams of the knee.Currently, a typical knee examination can beroughly 20 minutes. GOKnee3D enables apush-button, high-resolution diagnostic 3Dknee exam in just 10 minutes.

At the Hologic booth, the companyshowed the Affirm Prone Biopsy, the firstdedicated prone biopsy system that isupgradable to allow for 3D (tomosynthe-sis) imaging-guided breast biopsies. Both2D and 3D image guided biopsies can beperformed with this system. According toHologic, this marks the first significantstep forward in prone biopsy technologysince systems were first introduced morethan 20 years ago.

The product was showcased at RSNA2016 after receiving FDA clearance; HealthCanada approved the system in 2017.

Older breast biopsy systems are re-stricted to 2D imaging, which has a narrow

DI companies are devising new strategies for their IT businessesBY THOMAS HOUGH

t RSNA17 I was expecting to seesome new functionality and a lot

about Artificial Intelligence(AI); instead, I heard some-

thing entirely different. The real news wasthe condition of healthcare IT in Diag-nostic Imaging.

IT firms like Canada’s Intelerad are infull growth mode and prospering. In anumber of ways Intelerad is starting toact like a $100 million company withplenty of capacity for growth worldwide.Meanwhile, other firms like GE, Agfa,and Siemens are making organizationalchanges by segmenting their DI IT divi-sions as sub-sets of their DI businesses.

Word on the RSNA floor is that someof these firms are preparing to sell-off orspin-off their DI IT divisions. Example:McKesson spinning off DI IT intoChange Healthcare in order to recouptheir DI IT investment.

Why? We once thought DI IT was go-ing to be a billion dollar global marketand it likely is; however, Fortune 500 ven-dors are finding this market has a veryhigh cost for product development, mar-keting and sales and very slim margins.

There is not enough ROI to meetshareholder needs, and the low returnsalso make it difficult to sell off the divi-sion. Thinking about this, McKesson

was smart in their strategy to recouptheir investment.

I am not saying this is what is goingto happen for every firm. However, let’sconsider a DI IT world where the largeplayers are out of the DI IT game andmid-sized to small firms dominate themarket. What are the advantages to this?Firms like Intelerad, Visage, and VitalImages, to name a few, leverage signifi-cant advantages over Fortune 500 firms.

First, they can incorporate new tech-nology, functions and interoperabilitymuch faster than large firms. Second,this size of firm has lower overheads, re-sulting in products development at lesscapital cost and more importantly, lesscostly long-term service agreements.

Third, these firms can grow to be$100 million to $300 million firms, per-haps the most efficient size to serve themarketplace. Fourth, they can focus onDI IT, resulting in a less costly R&D,while enjoying fewer distractions thanFortune 500 companies with their manyinternal agendas and constant need tosatisfy the shareholders.

So, what does this say? Perhaps mar-ket consolidation is not always the bestfor the industry as a whole. Perhapsmid-sized firms are best suited to be ag-ile, cost effective and customer focused.

So, where does this leave firms likeIBM Watson Health? It does not happen

very often, but once in a while a disrup-tive technology comes into a market thatcan have a huge effect on the industry –Watson Health may be one of these.

However, IBM with all its resourcesand abilities, is a massive company and itwill have trouble providing viable work-ing solutions that meet FDA and other

regulatory require-ments in a shorttime to market. Perhaps it recog-nizes this issue,and has forged anew path. It ispartnering with awide range ofsmall to mid-sizecompanies, and itis letting them in-tegrate Watson

into their products to create interoper-ability, resulting in the workflows andcost benefits the industry needs.

Remember, IBM is doing this for notonly healthcare, but in every other in-dustry that is data rich and insight poor.There are a lot of industries where Wat-son can play huge roles to make themmore efficient; the last time somethingso disruptive came along was when PCcomputers were introduced.

This strategy limits the amount of in-vestment IBM needs to make in any one

industry and produces a revenue streamlong before it could develop solutionsand get regulatory approvals on its own.This suggests there is still space in the DIIT market for large Fortune 500 firms.

So, let’s go back to the Fortune 500firms mentioned before. What happensto them and why do they want to sell offthe market share they fought so hard togain 10 years ago?

By selling DI IT, these firms will focuson their core competencies, such asMRI, CT, PET, US and Digital Radiologytechnologies. The DI IT business will nolonger cost them bottom line money.

Effectively, they can connect with allthe IT solutions in the hospitals via DI-COM, HL7 and FHIR. Firms like Philipshave stated, they will not develop a HISas they know they do not have expertiseto do this cost effectively for the clientor themselves.

Case in point – Siemens, with acquisi-tion of the SMS HIS firm 10 years ago.Simply, healthcare IT needs a full timefocus to be successful. Should this not bethe firm’s focus, experience shows it willcost money to participate in this market.

Thomas Hough is President of True NorthConsulting & Associates, a DiagnosticImaging consulting company based inMississauga, Ont. For more information,see: http://truenorthconsult.com

RSNA serves as showcase for new diagnostic imaging technologies

By using a tablet computer to control set-ups, technologists can spend more time closer to their patients.

Thomas Hough

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though it requires a good knowledge of thelegal procedural fairness duties.

Here the buying hospital and each bid-der collaborate in real time to devise a so-lution that truly meets the needs of thehospital. “We had a common problem thatrequired an innovative solution and theDialogue provided the flexibility weneeded to achieve our goal”, said RichardTam, executive vice president and chief ad-ministrative officer, Mackenzie Health.

The legal aspects of procuring AI raisesubstantial challenges for law and policymakers, as the law struggles to catch up.Procuring AI is more complicated thanprocuring a physical product or off-theshelve software.

What is being procured specificallyshould come from an interchange with themarket, which an RFP does not easily ac-commodate. The Competitive Dialogueprocess is well suited for defining complexneeds in the healthcare sector and is onethat hospitals should embrace.

But attention will need to focus on howthe Dialogue works with the procurementrequirements set out in the newly-promul-gated trade agreements that apply to hos-pitals across Canada (see the CanadianFree Trade Agreement, which came intoforce on July 1, 2017, and the Canada-Eu-ropean Union Comprehensive Economicand Trade Agreement, on September 21,2017). In Ontario, the rules set out in theBroader Public Sector Procurement Direc-tive apply to provincial procurements.

Any contract for the purchase of AI al-most inevitably requires a ‘bedding-in’ pe-riod to allow for deep learning, the processin which large datasets are fed into the AIsoftware to accurately recognize patternsfrom the input data. Once trained, the soft-ware’s decreasing error rates gradually al-lows it to make more accurate predictions.

If the AI software fails to reach the tar-geted level of predictive analysis during thebedding-in period, a contractual exit rampshould be available to the hospital. The le-gal consequences of such an exit need to beaccounted for.

There is also data law, which is at theheart of AI. Data privacy and security are

now prominent in the business world, butof equal importance are the legal rightsand duties around data licensing (whichparty to the contract has the necessary per-missions to do what they are aiming to dowith the data?) and data ownership (whichparty owns the data that is produced fromthe AI software?). And with AI software,there is the question of whether the soft-ware is regulated as a medical device underthe federal Food and Drugs Act.

For now, AI is so new that the focus is

still on getting the basic details of the deeplearning phase right, such as agreeing on re-alistic expectations in the statement ofwork.

Denis Chamberland is a commercial lawyerwith extensive procurement, technology andtrade law experience in the healthcare sectorin Canada and Europe. He worked withMackenzie Health in the above-described AIinnovation procurement. He can be reachedat dac@chamberlandlawcorp.com

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New forms of procurement with AI can bring legal issues

full adoption of several clinical bestpractice workflows by working withtheir clinicians to embrace many of theconstructs of world-class health sys-tems such as Sweden’s JonskopingCounty and InterMountain Healthcarein Utah. Clinicians review their indi-vidual practice patterns and preferencesand come to agreement as a group toco-design an acceptable workflow tosupport best practice and eliminate un-warranted variation.

Ownership: In the words of ourworld-class facilitator, Yoel Robens-Par-adise, “What’s the Secret Sauce?”. Thesame answer echoed through the day –building local user ownership of thechange is critical to success. It isn’trocket science, but it continues to be elusive.

Local clinicians and informaticiansmust work together to co-design solu-tions to improve patient care, and work-flows must support the improvement re-sult you’re seeking – careful review anddesign by the users impacted by theworkflows is essential.

As Dr. Jeremy Theal said, we must re-member that it’s possible to achieve

both positive and negative outcomeswith the same tools, and the same ven-dors – the difference is in the team andthe approach. The Island Health teamfrom Nanaimo echoed the same senti-ment – understand the user communityand engage with them early to identify

and develop solutions that the end usersperceive will add value, and the solu-tions will be more likely to result inadded value once implemented.

Island Health’s experience “pausing”the CPOE initiative, gave all theproviders a chance to learn the manytranscription and re-transcription stepsof the manual paper processes, anddeeply understand the risk to patients(and the wasted clinician and staff ef-fort) introduced by so many opportuni-ties for transcription error that can leadto patient harm.

Once providers saw the alternative,the value of automating became clear.In the words of Dr. Ben Williams, Is-land Health’s Executive Lead for Strat-egy and Engagement, “Keep going! It’sbetter for patients. Make improve-ments, but keep going.”

Rosemary Gray is a member of theBCHIMPS Board.

Team approachesCONTINUED FROM PAGE 16

Local clinicians andinformaticians must worktogether to co-designsolutions to improve care.

challenged to get the best possible imagewhile keeping patient radiation exposure toa minimum. Rejected images often are a sig-nificant barrier to achieving this goal, withsome U.S. healthcare providers seeing X-rayreject rates of up to 25 percent. The U.S. rec-ommended target reject rate is 5-8 percent.

Repeat images lead to unnecessary pa-tient radiation dose and inefficiencies suchas decreased throughput and wasted staff re-sources and time. RRA is a software applica-

tion that helps automatically identify andanalyze the root causes of rejected X-ray im-ages for quick and easy review, so healthcareproviders can take action with staff training.

Another hot area is the use of imageanalysis to spot potential problems in di-agnostic images, such as CT scans. Thesescans can be flagged and pushed to the topof the worklist of radiologists, so a patientwho may have an aneurysm or brain bleedisn’t left waiting.

Carestream demonstrated this capabil-ity at its booth; the solution works with theCarestream radiology system, prioritizingexams for radiologists. Carestream doesmuch of its software development in Is-

rael, and it has also partnered with ZebraMedical, an Israeli company that’s becomea global leader in Deep Learning for thehealthcare sector.

Fujifilm, too, demonstrated this yearhow it leverages its expertise in image pro-cessing and pattern recognition andshowed how AI can be immediately ap-plied to create a ‘smart’ worklist, by flag-ging studies with abnormalities, bringingthem to the attention of the radiologist be-fore the exam is even opened. Christie In-nomed has represented Fujifilm in Canadasince 1964.

Another Israel-based company that’squickly gaining traction in Deep Learningfor the healthcare sector is Aidoc; itdemonstrated its technology and approachat RSNA 2017. “We’re not focused on spe-cific use cases or diseases,” commentedTom Valent, VP of business development.“Our focus is on trauma, where time is ofthe essence.”

Valent explained that Aidoc’s algorithmdoes image analysis on the head and neck– a wide area of coverage – and quickly de-termines if patients should be moved tothe front of the queue for a closer look.

He said the system is primed to look for15 different pathologies, including epiduralhemorrhage and mass effect – the move-ment of the brain inside the skull. It’s con-ditions like these, he noted, that require fastattention. “A brain bleed or a fracture of thespine is time-sensitive,” said Valent. Thesystem is designed to flag problems for ra-diologists, not to replace them.

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New app encourages patient engagement

window for targeting lesions. Multiple X-ray exposures are required to find and posi-tion the suspect tumor for the biopsy nee-dle. The Affirm prone table allows you tomake fewer exposures (lowering the radia-tion dose compared with a traditional 2Dbiopsy); and because the table uses 3D tech-nology, you use fewer steps to target andgetting biopsies (faster, more comfortable).The Affirm Prone Biopsy system is availablein Canada from Christie Innomed.

For its part, GE Healthcare showcasedthe Senographe Pristina Dueta, an indus-try-first patient-assisted mammographydevice that puts women in control of theirown mammograms. Designed by womenfor women, an innovative wireless remotecontrol allows patients to manage their owncompression, under the supervision of atechnologist, during the exam performedon GE Healthcare’s newest mammographysystem, Senographe Pristina.

After the breast is properly positionedby the technologist, the patient has the op-tion to adjust her compression usingPristina Dueta. Studies in Europe showfour out of five patients using PristinaDueta said it made the exam more com-fortable, and more than half said the de-vice led to less anxiety.

Clinical evidence used in the FDA evalu-ation and clearance of Pristina Dueta showsuse of the device does not compromise im-age quality or increase exam time. Forwomen with dense breast tissue, supple-mental screening may be recommended.

The Invenia ABUS (Automated BreastUltrasound System) is proven to increaseinvasive cancer detection by 55 percentand is the only FDA-approved ultrasoundsystem for dense breast tissue screeningwhen used in addition to mammography.

SenoBright HD is a next-generationContrast Enhanced Spectral Mammogra-phy (CESM) diagnostic exam intended forpatients who have just had an inconclusivemammogram or ultrasound, or are at highrisk of breast cancer. SenoBright HD ex-ams are performed at the same time, samelocation, and with the same mammogra-phy equipment – Senographe Pristina –enabling the entire exam to take less thanseven minutes.

As compared to the first generationCESM, SenoBright HD delivers clearer im-ages and improves acquisition time by 40percent in women with large breasts.CESM provides high specificity to reducefalse-positives and helps prevent unneces-sary exams. Images are immediately avail-able for review following the exam.

Meanwhile, Toshiba Medical, which isnow a Canon Group company, premieredthe Aquilion Precision (pending regula-tory approvals). According to Toshiba, it isthe world’s first Ultra-High Resolution CT(UHR CT), and it’s capable of resolvinganatomy as small as 150 microns, provid-ing CT image quality with resolution typi-cally seen only in cath labs.

The UHR detector is newly designed toprovide more than twice the resolutionwhen compared with today’s CT technol-ogy, representing a breakthrough in CTimaging with an all-new detector, tube,gantry and reconstruction technologies.This new system required a complete re-engineering of the detector manufacturingprocess, said Dominic Smith, senior direc-tor, CT, PET/CT, and MR Business Units.

RSNA showcaseCONTINUED FROM PAGE 22

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Aidoc’s algorithm does imageanalysis on the head and neckand determines if patients shouldbe at the top of the queue.

The potential for MR is now even more astonishing. Introducing the SIGNA™ Architect 3.0T, a state-of-the-art imaging solution that combines the advancements in MR technology with GE Healthcare’s intuitive engineering. Fueled by our new SIGNA™Works productivity platform, the SIGNA™ Architect is a harmonious design of form and function. And the SIGNA™ Architect’s cutting-edge platform makes it the most versatile, adaptable, and powerful system available from GE to date, so you can make the unimaginable the expected.

©2017 General Electric Company. All rights reserved. GE Healthcare, a division of General Electric Company.

GE and GE monogram are trademarks of General Electric Company.

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