Hospital News December 2018

Inside: From the CEO’s Desk | Evidence Matters | Special Focus: Radiology | Long Term Care

December 2018 Edition

www.hospitalnews.com

SPECIAL FOCUS: RADIOLOGY

Artificial

intelligence in radiology Page 20 BENEFITS THAT WORK FULL-TIME FOR THOSE WHO DON’T • Part-Time • Casual • Contract • Retirees Reach out to us today to learn more about our guaranteed coverage options for hospital employees!

1-866-768-1477 | www.heathcareproviders.ca

NOW AVAILABLE FROM COAST TO COAST

Would you trust your patients to write their own prescriptions?

It’s no different with medical cannabis.

We believe patients need doctors.

Now that recreational cannabis is legal, your patients will need your help more than ever.

Spectrum Cannabis is committed to improving the lives of your patients and supporting healthcare professionals.

Prescribe your expertise. www.MedicalSideofCannabis.com

Spectrum Cannabis 1 Hershey Drive, Smiths Falls, Ontario, K7A 0A8, Canada

Š 2018 Spectrum Cannabis. All rights reserved.

Contents December 2018 Edition

IN THIS ISSUE:

Measuring hospital harm

5 ▲ Cover story: Artificial intelligence in radiology

20

▲ Innovation in healthcare

8 Special Focus: Radiology

16

COLUMNS Editor’s Note ................... 4 In brief ............................ 7 Evidence matters .......... 10 Radiology ..................... 16 Long-term Care News ... 24 From the CEO’s desk ....30

▲ Cardiovascular Care

14 www.hospitalnews.com

Human-animal interaction in long-term care

24

610 Applewood Crescent, Suite 401 Vaughan Ontario L4K 0E3 TEL. 905.532.2600|FAX 1.888.546.6189

Why is

www.hospitalnews.com

clinician engagement

driving value-based healthcare?

I

editor@hospitalnews.com Advertising Representatives

Denise Hodgson

denise@hospitalnews.com Publisher

Stefan Dreesen

stefan@hospitalnews.com Accounting Inquiries

accountingteam@mediaclassified.ca Circulation Inquiries

info@hospitalnews.com

By Darren Gresch nnovation, Science and Economic Development Canada’s Health and Biosciences Economic Strategy Table recently proposed several recommendations for improving Canada’s health system. Its top recommendation focused on the importance of value-based procurement in achieving health system innovation and sustainability. If Canada and its provinces and territories are to develop the tools and processes necessary to support value-based procurement – and by extension, value-based healthcare – effective and efficient clinician engagement is needed.

Clinicians can provide vital insights into selecting products that benefit patients and taxpayers through improved health outcomes and health system efficiencies. Effective clinician engagement in the procurement process adds value through specialized knowledge, increased clinician buy-in and support, and improved organizational culture; these factors lead to better contracting strategies and care pathways. As such, efforts aimed at improving clinician engagement in the procurement process are in the best interest of patients, tax

Editor

Kristie Jones

payers, healthcare organizations and healthcare system sustainability.

Clinicians have many demands on their time, however, and limited availability to participate in innovative procurement methods. Therefore, to make their clinician engagement practices as effective and efficient as possible, organizations must balance the necessity of clinician involvement with the administrative burden of the process.

HOW ORGANIZATIONS SHOULD APPROACH CLINICIAN ENGAGEMENT The Conference Board of Canada’s recent report, Balancing Effectiveness and Efficiency, outlines considerations for how to strike the right balance between the necessity of clinician input into procurement and respect for their time. Depending on this balance, organizations may choose to pursue a combination of four broad engagement strategies: systemic, delegated, targeted, and exploratory.

Continued on page 13

ADVISORY BOARD Barb Mildon,

RN, PHD, CHE VP Professional Practice & Research & CNE, Ontario Shores Centre for Mental Health Sciences

Helen Reilly,

Publicist Health-Care Communications

Jane Adams,

President Brainstorm Communications & Creations

Bobbi Greenberg, Health care communications

Sarah Quadri Magnotta, Health care communications

Dr. Cory Ross, B.A., MS.C., DC, CSM (OXON), MBA, CHE Vice President, Academic George Brown College, Toronto, ON

ASSOCIATE PARTNERS:

UPCOMING DEADLINES JANUARY 2019 ISSUE

FEBRUARY 2019 ISSUE

EDITORIAL: Dec 7 ADVERTISING: Display – Dec 14 | Careers – Dec 18

EDITORIAL: Jan 15 ADVERTISING: Display – Jan 25 | Careers – Jan 29

Monthly Focus: Professional Development/Continuing Medical Education (CME)/ Human Resources: Continuing Medical Education (CME) for health care professionals. Human resource programs implemented to manage stress in the workplace and attract and retain health care staff. Health and safety issues for health care professionals. Quality work environment initiatives and outcomes.

Monthly Focus: Facilities Management And Design/Health Technology/Greening Healthcare/Infection Control: Innovative and efficient health care design, the greening of healthcare and facilities management. An update on the impact of information technology on health care delivery.

Advancements in infection control in hospital settings.

+ PROFESSIONAL DEVELOPMENT SUPPLEMENT

+ INFECTION CONTROL SUPPLEMENT

THANKS TO OUR ADVERTISERS Hospital News is provided at no cost in hospitals.

When you visit our advertisers, please mention you saw their ads in Hospital News.

4 HOSPITAL NEWS DECEMBER 2018

Hospital News is published for hospital health-care professionals, patients, visitors and students. It is available free of charge from distribution racks in hospitals in Ontario. Bulk subscriptions are available for hospitals outside Ontario.

The statements, opinions and viewpoints made or expressed by the writers do not necessarily represent the opinions and views of Hospital News, or the publishers.

Hospital News and Members of the Advisory Board assume no responsibility or liability for claims, statements, opinions or views, written or reported by its contributing writers, including product or service information that is advertised.

Changes of address, notices, subscriptions orders and undeliverable address notifications.

Subscription rate in Canada for single copies is $29.40 per year. Send enquiries to: subscriptions@ hospitalnews.com Canadian Publications mail sales product agreement number 42578518.

www.hospitalnews.com

Measuring hospital harm to improve patient care and optimize patient outcomes atients expect hospital care to be safe, and for most people it is. However, a recent study showed that patients experienced potentially preventable harm in more than 138,000 hospitalizations or about one in 18 hospitalizations (this does not include hospitalizations in Quebec).

Key findings from the Measuring Patient Harm in Canadian Hospitals report, which was released by the Canadian Institute for Health Information (CIHI) and the Canadian Patient Safety Institute (CPSI), showed that the five most common types of harm, making up 51 per cent of all harmful events, were electrolyte and fluid imbalance, urinary tract infections, delirium, anaemia-haemorrhage, and pneumonia.

It was estimated that patients who experienced harm spent a total of more than half a million additional days in hospital – that is more than 1,600 beds each day, or the equivalent of approximately four large hospitals occupied over a year. The associated hospital cost (excluding physician fees, follow-up care, and readmission) was about $685 million.

The Hospital Harm Measure identifies acute care hospitalizations with at least one occurrence of unintended harm (during the hospital stay) that could have potentially been prevented by implementing known evidence-informed practices. The measure is comprised of 31 clinical groups that fall under four categories.

The Hospital Harm measure complements other patient safety information available to hospitals, including patient safety incident reports, patient experience surveys, chart reviews or audits, infection control data, global trigger tools, and clinical quality improvement process measures. Combined, this information can inform and optimize improvement initiatives.

The Hospital Harm Improvement Resource was developed by the Canadian Patient Safety Institute to complement the CIHI Hospital Harm measure. It links measurement and improvement by providing evi-

P

dence-informed practices that support patient safety improvement efforts.

The online Improvement Resource is a compilation of evidence-informed practices linked to each of the 31 clinical groups within the Hospital Harm measure to help drive changes that will make care safer. Through extensive research and consultation with clinicians, experts and leaders in quality improvement (QI) and patient safety, the Improvement Resource is intended to make information on improving patient safety easily available, so teams spend less time researching and more time optimizing patient care.

The Improvement Resource includes a summary of evidence-informed practices that reduce the likelihood of harm, and suggested measures for outcomes and processes.

For example, evidence-informed practices for Delirium include: developing a standardized protocol for preventing or managing delirium, including identifying and treating underlying caus-

es; implementing non-drug strategies such as early mobility; implementing environmental strategies such as vis-

ible daylight; and reassessing sedation daily. For Medication events the evidence includes: conducting an organizational Medication Safety Self-Assessment; implementing medication reconciliation and high-alert medication safety processes; and improving core processes for ordering, dispensing and administering medications. Also included in the resource are patient stories, success stories, standards and required organizational practices associated with each clinical group.

The Improvement Resource is a dynamic tool that the Canadian Patient Safety Institute will continue to update as new tools and approaches are developed and more evidence-informed practices emerge.

The hospital harm project aims to provide health system leaders with better information on patient safety and support patient safety improvement efforts. Armed with evidence-informed practices compiled through continued research efforts and united through collaboration, clinicians, hospital staff and patients can all play a role in improving safety in Canadian hospitals. For more information, visit www.cihi.ca or www.patientsafetyinH stitute.ca ■

This article was contributed by the Canadian Institute for Health Information and the Canadian Patient Safety Institute.

EMERGENCY LOANS FOR HOMEOWNERS! WE REPRESENT OVER 400 LENDERS Manny provides 1st, 2nd and 3rd mortgages even with: • Horrible Credit • Bankruptcy • Unemployed • Power of Sale • Mortgage Arrears • Property Tax Arrears • Self-Employed • Pension & Disability

Does your bank offer payments THIS LOW? Mortgage Amount

Monthly Payment

Bi-Weekly Payment

$200,000 $220,000 $240,000 $260,000 $280,000 $300,000 $320,000 $340,000 $360,000 $380,000

$825.33 $907.86 $990.39 $1,072.92 $1,155.46 $1,237.99 $1,320.52 $1,403.05 $1,485.59 $1,568.12

$380.68 $418.75 $456.81 $494.88 $532.95 $571.02 $609.08 $647.15 $685.22 $723.29

$400,000

$1,650.65

$761.36

Licence # 12079 Mortgage Agent Manny Johar

Rates from

2.26%!

Amortization up to

30 Years!

As of January 2018, OAC – Based on 5 Year term & 30 Years Amortization

“My husband lost his job. We fell behind on our mortgage. The bank was seizing our home.

I still can’t believe that you gave us an emergency mortgage with no proof of income. You saved our home & gave us extra cash to get by until he finds another job. Thanks Expert Mortgage!” C.S.

Call Manny 7 DAYS A WEEK

1.888.646.7596 or www.MannyJohar.ca Ask him about COMMERCIAL – FARM – CONSTRUCTION loans!

Manny Johar is Ontario’s mortgage SUPERSTAR! www.hospitalnews.com

DECEMBER 2018 HOSPITAL NEWS 5

Thank you to the people who keep Ontarians safe and healthy during this holiday season.

844-677-3848 (OPSEU 4 U)

organizing@opseu.org

joinopseu.org

IN BRIEF

New data on cannabis use in Canada he old approach to cannabis did not work.

It let criminals and organized crime profit, while failing to keep cannabis out of the hands of Canadian youth.

In many cases, it has been easier for our kids to buy cannabis than cigarettes.

To address these issues, on October 17, the Government of Canada legalized and strictly regulated access to cannabis. To track Canadians’ knowledge, attitudes and behaviours towards cannabis, the Government of Canada is examining how usage changes from year to year. Standardized and comparable data are needed to evaluate the impact of the new cannabis legislation and to develop policy and program initiatives, including public education and awareness activities.

Between May and July 2018, Health Canada asked almost 13,000 Canadians about their knowledge, attitudes and behaviours related to cannabis, including their cannabis use and driving behaviours after consuming cannabis. Results from the 2018 Canadian Cannabis Survey provide a snapshot of Canadians’ views and habits related to cannabis several months before the Cannabis Act came into force, including; How much and how often they used cannabis, where they got it from, what forms of cannabis they consumed, the extent to which they were accepting of cannabis use, what they thought about its potential to be habit forming, and whether they believed cannabis could affect someone’s ability to operate a motor vehicle.

The Canadian Cannabis Survey contributes to the foundation of information needed to measure and monitor the impacts of the Government’s cannabis legislation. It also complements previously collected For more information H visit: www.canada.ca ■

T

www.hospitalnews.com

Canada’s drug spending growth outpaces that for hospitals and doctors C

anada is expected to spend $33.7 billion on prescribed drugs in 2018, according to the Canadian Institute for Health Information (CIHI). This marks an estimated annual increase of 4.2 per cent for drugs, compared with 4.0 and 3.1 per cent for hospitals and doctors, respectively.

In 2018, $14.4 billion (42.7%) of prescribed drug spending is expected to be financed by the public sector, while the remainder will be financed by private insurance and individuals paying out of pocket. Drug spending is just part of the expected $253.5 billion in total health spending in Canada this year.

Biologics used to treat conditions like rheumatoid arthritis and Crohn’s disease will account for the highest proportion of public drug spending

(8.2%) for the sixth consecutive year, while antiviral drugs to treat hepatitis C will account for the second-highest proportion (5.0%).

Looking back to 2017 spending, about 1 in 4 Canadians received a benefit from a public drug program, with people living in low-income and rural/remote areas more likely to receive a benefit. In addition, people with high drug costs ($10,000 or more) represented only 2.3 per cent of beneficiaries but accounted for over one-third (36.6%) of public drug spending last year.

Other health spending highlights for 2018: • Total health expenditure is expected to rise by 4.2 per cent to reach $6,839 per person in 2018.

• Provincial per capita health expenditures will continue to vary, from $7,552 in Alberta and $7,443

in Newfoundland and Labrador to $6,597 in British Columbia and $6,584 in Ontario.

• Hospitals (28.3%), drugs (15.7%) and physician services (15.1%) are expected to continue to account for the largest shares of health dollars (close to 60% of total health spending). The remaining 41 per cent will be spent on other healthcare goods and services, including long-term care facilities and allied health professionals.

National Health Expenditure Trends, 1975 to 2018 provides an overview of how much is spent on healthcare annually, in what areas money is spent and on whom, and where the money comes from. It features comparative expenditure data at the provincial/ territorial and international levels, as well as health spending trends from H 1975 to 2018. ■

Trazadone associated with similar risk of falls and major fractures as antipsychotics s physicians attempt to decrease antipsychotic use in seniors with dementia, they need to be aware that trazadone, frequently used as an alternative, is associated with a similar risk of falls and major fractures as atypical antipsychotics, according to new research in CMAJ (Canadian Medical Association Journal)“As clinicians move to decrease antipsychotic use, we should not consider trazadone as a uniformly safer alternative to atypical antipsychotics, because trazadone use was associated with a comparable risk of falls and major osteoporotic fractures to atypical antipsychotics – drugs associated with these adverse outcomes in our patient population,” writes Dr. Jennifer Watt, St. Michael’s Hospital, Toronto, Ontario, with coauthors.

The rate of dementia in Canada

A

is seven per cent, but it approaches almost 25 per cent in people older than age 85. In long-term care facilities, 62 per cent of residents have dementia, and many exhibit aggressive behaviour. Although evidence is limited on efficacy, antipsychotics and trazadone, an antidepressant also used for sleep issues, are commonly prescribed for patients with dementia.

Using linked data from ICES, researchers looked at data on 6588 seniors newly dispensed trazadone and 2875 newly dispensed an atypical antipsychotic. They found that patients dispensed trazadone had a rate of falls and major fractures, including hip fractures, similar to that of the group receiving atypical antipsychotics. However, trazadone was associated with a lower risk of death in these patients.

“We hope this information can be used to inform conversations that patients and caregivers are having with clinicians about the benefits and risks of different treatment options,” says Dr. Watt.

“Watt and colleagues also underscore the importance of prioritizing nonpharmacological approaches for the management of behavioural and psychological symptoms of dementia,” writes Dr. Elia Abi-Jaoude, The Hospital for Sick Children (SickKids) and University Health Network, Toronto, Ontario, with coauthors in a related commentary “Nonpharmacological approaches comprise a variety of behavioural, environmental and caregiver-supportive interventions, and existing evidence suggests that these show greater effect than many psychotropic drug H therapies.” ■ DECEMBER 2018 HOSPITAL NEWS 7

NEWS

Innovation vital to the future of healthcare

By Sharon MacSween s communities grow, age and healthcare needs increase, many hospitals are turning towards innovation to help improve and enhance the patient experience.

Digital health solutions are one way that Mackenzie Health is transforming the patient experience as part of its commitment to delivering world-class and compassionate care. Mackenzie Health, which includes Mackenzie Richmond Hill Hospital and the future Mackenzie Vaughan Hospital alongside its community-based locations, serves one of the fastest growing communities in Canada. This community is expected to grow by 25 per cent between 2012-2027.

For many patients, visiting the hospital can be a stressful and unfamiliar time. Keeping track of ongoing appointments, procedures and medical treatments may also intensify feelings of anxiety. With a focus on improving the patient experience and care delivery, Mackenzie Health undertook a major healthcare clinical transformation with the introduction of its new Epic electronic medical record (EMR) in mid-2017. Last month, Mackenzie Health was recognized for these efforts as the first Canadian acute care hospital with an emergency department and intensive care unit to receive Healthcare Information and Management Systems Society (HIMSS) Electronic Medical Record Adoption Model (EMRAM) Stage 7 designation.

From prevention of medication administration errors to ensuring complete health records are available to all clinicians, the designation signifies that Mackenzie Health has implemented a paperless environment through its EMR. It also represents the highest level of user adoption of digital health solutions that benefit the patient experience and care delivery.

A

Mackenzie Health’s novel approach pairs the self-serve patient registration kiosks with staff and volunteers to encourage patient familiarity, efficiency and utilization of the kiosks.

The emergence of digital health technologies in partnership with healthcare staff, physicians and volunteers can make a meaningful impact to the patient experience. Patient safety is a key focus of Mackenzie Health which was recognized by Accreditation Canada in 2017 with its second consecutive award of Accreditation with Exemplary Standing.

“Patient feedback from the first year has been overwhelmingly positive,” says Diane Salois-Swallow, Chief Information Officer, Mackenzie Health.

“We’re inspired by the potential of smart technology to further enhance the care experience for all patients and families, from the moment they enter our door.”

As part of Mackenzie Health’s year in review, these technologies are al-

ready showing a transformative impact. Highlights include: • Improved patient safety and prevention of errors: Technology-enabled bedside product administration helps ensure the right product is given to the right patient (greater than or equal to 95 per cent barcode medication administration, breast milk scanning and blood scanning).

• Physician computerized ordering eliminates deciphering handwriting to help support clear, efficient ordering accuracy. Further, secure electronic documentation and viewing helps clinicians view all areas of a patient chart within 24 hours.

• Integrated voice recognition with electronic documentation in the hospital helps maximize speed and efficiency.

• Self-Serve Patient Registration Kiosks: Mackenzie Health’s new kiosks reduce registration time by more than 12 minutes, prevent the duplication of information entry and overall contribute to an improved and positive patient experience.

With a strong 90 per cent checkin rate at the kiosks, Mackenzie Health’s novel approach pairs the technology with staff and volunteers to encourage patient familiarity, efficiency and utilization of the kiosks. Now, registration takes just 40 seconds and allows patients to get to their appointments faster. It also helps ensure that patients receive this optimal level of efficiency even as health needs increase in Mackenzie Health’s growing community.

• Mackenzie Health MyChart: MyChart helps connect patients to their medical history and upcoming appointments to empower patients to manage their own care at their fingertips. More than 23,445 patients have signed up for MyChart since launching in 2017.

As Mackenzie Health looks to a ‘smart’ technology future both at its Richmond Hill hospital and the future Mackenzie Vaughan Hospital, it credits the success of its digital health innovation to partnerships between patients and families, staff, physicians and volunteers.

“We are proud of the positive impact that innovations have made on care delivery and the patient experience,” says Richard Tam, Executive Vice President and Chief Administrative Officer, Mackenzie Health. “Implementation of digital technologies in healthcare should always serve a greater purpose – such as supporting a world-class health experience, enhancing patient safety or increasing patient engagement in their own H health journey.” ■

Sharon MacSween is Director, Clinical Informatics Information, Communication and Automation Technology (ICAT) at Mackenzie Health.

8 HOSPITAL NEWS DECEMBER 2018

www.hospitalnews.com

Creating a Brighter Future of Health at Home

SE Health (Saint Elizabeth Health Care) Home Care

Family Caregivers

Providing high quality trusted home care, delivering more than 20,000 health care visits daily.

Providing caregiver self-care support and resources through Elizz and Elizz.com.

Seniors Living

Hospital Partnerships

Providing a wide range of personal support services in independent, assisted living and long-term care residences.

Working with hospitals to create innovative patient-focused programs.

Celebrating 110

Years of Impact

www.sehc.com/impact2018

2 018

EVIDENCE MATTERS

Gene therapy is here: Now what?

By Sarah Garland enes are the building blocks of life on earth, and genetic material provide the set of instructions that makes us who we are. However, abnormal genes can be the cause of disease and illness; and when we get sick, the thought that we can manipulate genetic material as a treatment for illness seems like the stuff of science fiction. Gene therapy can be defined as a set of strategies that change the behaviour of an individual’s genes, or repair abnormal genes. This can involve immunotherapies that modify an individual’s cells, or regenerative medicine that uses modified cells or tissues to treat an illness.

Gene therapy is an area of therapeutics – the field of medicine focused on the treatment of disease – with the goal of curing or significantly improving the management of diseases with few or no treatment options. These are typically treatments for people with severe, hard-to-treat illness. While gene therapy has been an active area of research for the past few decades, the approval of gene therapy products for marketing has been a recent development (e.g., 2015 for approval in the United States). A 2017 brief by the Massachusetts Institute of Technology’s New Drug Development Paradigms Initiative predicted that by the end of 2022, 40 new gene therapies would be approved for use, with the majority treating cancers and diseases that affect very few people (i.e., orphan diseases or extremely rare diseases).

One area of particular focus has been gene therapies for cancers that do not respond well to conventional treatment (e.g., chemotherapies and radiation). Cancers of the blood and lymphatic system show promise as some gene therapies involve manipulating immune cells outside of the body and transferring them back to the patient. Chimeric antigen receptor T-cell therapy – or CAR T-cell therapy – is a type of gene therapy that does just that. CAR T cells are engineered by removing T cells (immune cells) from the blood, modifying them in a

G

GENE THERAPY CAN BE DEFINED AS A SET OF STRATEGIES THAT CHANGE THE BEHAVIOUR OF AN INDIVIDUAL’S GENES, OR REPAIR ABNORMAL GENES. laboratory to recognize antigens (protein labels) commonly expressed on cancer cells, and reinjecting them into the patient, where they multiply and attack diseased cells.

While there is a lot of excitement about gene therapy, there are also some considerations for their implementation into our health system. To help guide decisions about gene therapy, and specifically CAR T-cell therapy, decision-makers and the healthcare community turned to CADTH – an independent agency that finds, assesses, and summarizes the research on drugs, medical devices, tests, and procedures – to find out what the evidence says. CADTH undertook an environmental scan (Gene Therapy: International Regulatory and Health Technology Assessment (HTA) Activities and Reimbursement Status) and a horizon scan (Gene Therapy: An Overview of Approved and Pipeline Technologies).

The environmental scan and horizon scan reports paint a complex picture of gene therapies in Canada, and internationally. There is widespread variation in the definition of gene therapy used by regulatory bodies, and by reimbursement bodies. These reports also highlighted specific areas for consideration, including the adequacy of evidence for decision-making, the cost of treatment, and the health system requirements that need to be in place to provide gene therapies.

Since these technologies are so new, and are sometimes regulated through accelerated reviews, they may reach the market with limited evidence on how well they work and without long-term data on their safety and effectiveness. This uncertainty could mean that certain regions (i.e., provinces or countries) make contradictory decisions about the adoption of gene therapies until initial findings are confirmed. Additionally, gene therapies

tend to be quite expensive, with listed costs ranging from US$65,000 to greater than US$1 million. This makes decisions about insurance and reimbursement additionally complex, and could create a barrier for the provision of gene therapies. In terms of providing gene therapies, there may be special requirements for manufacturing facilities, care facilities, clinician training, and follow-up care for patients.

CADTH is also currently reviewing two CAR T-cell therapies: tisagenlecleucel and axicabtagene ciloleucel.

Tisagenlecleucel is a CAR T-cell therapy for the treatment of adults with relapsed or refractory diffuse large B-cell lymphoma (r/r DLBCL) and children and adolescents with relapsed or refractory acute lymphoblastic leukemia (r/r ALL). Axicabtagene ciloleucel is a treatment for adult patients with relapsed or refractory large B-cell lymphoma. This includes DLBCL, high grade B-cell lymphoma, and sub-types of DLBCL (e.g., primary mediastinal large B-cell lymphoma and DLBCL arising from follicular lymphoma).

For both tisagnelecleucel and axicabtagene ciloleucel, CADTH is undertaking Optimal Use projects to assess the clinical impact, cost-effectiveness, and implementation considerations including patient and caregiver perspectives and experiences, ethical considerations, and other considerations such as facilities for the administration of CAR T-cell therapy, therapy eligibility, travel requirements, and resource costs associated with the provision of these therapies in Canada.

The area of gene therapy is complex and ever changing. CADTH reviews are here to help healthcare decision-makers and provide much needed evidence.

To learn more about CAR T-cell reviews at CADTH, visit: https://cadth. ca/cart.

To learn more about CADTH, visit www.cadth.ca, follow us on Twitter: @CADTH_ACMTS, or talk to our Liaison Officer in your region: www.

H cadth.ca/contact-us/liaison-officers. ■

Sarah Garland is a Knowledge Mobilization Officer at CADTH. 10 HOSPITAL NEWS DECEMBER 2018

www.hospitalnews.com

Hospital and healthcare team leaders: Organizational and cultural issues can impact team morale, put patients at risk and be costly.

To help you, Saegis offers the Organizational Improvement Series: Strategies for Managing Unprofessional Behaviour Learn to understand and navigate challenging behaviour; Develop personal and institutional plans for your work environment

Programs are delivered on-site at your hospital or institution

Just Culture Certification

Find out more:

Establish a more open and fair culture that improves safety, efficiency and morale

1-833-435-9979

Communicating Unexpected Outcomes in Healthcare Improve communications with patients and families after unexpected clinical outcomes

info@saegis.solutions www.saegis.solutions

As a member of the CMPA family, Saegis is uniquely positioned to help you address some of the most difficult challenges you, your team and your hospital will face.

Saegis is a wholly owned subsidiary of the CMPA that offers professional development, safety programs and practice management solutions to physicians, healthcare professionals and teams, clinics and hospitals.

SAFE MEDICATION

Advice for cold and flu season

By Guylène Thériault and Wendy Levinson old and flu season for many Canadians means getting ready to have their lives and routines thrown off by painful and annoying symptoms. This can mean days off work or school dealing with sore throats, nasal congestion and fever. For parents, it can be challenging to try to comfort young kids with fever, coughing or ear pain.

As doctors, we know that both doctors and patients would love a quick fix – a magic bullet to deal with these symptoms. Patients want to get their lives back to normal as quickly as possible. Unfortunately, antibiotics are not usually the answer.

Antibiotics are commonly misused because people mistakenly believe they will treat the symptoms of colds and flus. In fact, fever, cough and ear pain are usually due to a virus – and viruses are not affected by antibiotics.

More than half of all antibiotic prescriptions in Canada are estimated to be unnecessary – and ineffective.

Common conditions that are usually viral in nature but that are often prescribed antibiotics unnecessarily include sinus infections, ear infections and chest colds (or bronchitis). Antibiotics do not typically help for any of these conditions and the symptoms will get better with simple rest and time.

C

It’s hard for us as physicians not to be able to offer a cure, and hard sometimes for our patients, to accept that there isn’t much to be done aside from managing their symptoms and waiting it out.

A good first step is for doctors and patients to have a conversation about the downsides of unnecessary antibiotics. What harm can taking unnecessary antibiotics do? Plenty.

When trying to treat symptoms which are caused by viral infections, antibiotics don’t help and can actually make patients feel worse. Antibiotics work by stopping illness-causing bacteria from growing and multiplying.

When diseases are viral in origin, not bacterial, antibiotics have no impact.

Using an antibiotic when not needed also promotes the growth of bacteria that are resistant to commonly-used antibiotics. This makes patients, especially the elderly, more vulnerable to antibiotic-resistant infections and undermines the good that antibiotics can do for us and others when they are truly needed.

There are also side effects to taking antibiotics; about one in four people who take antibiotics experience stomach upset, dizziness or skin rashes.

There’s a new tool that you may notice in your doctor’s office to help

have conversations about when antibiotics aren’t necessary – it’s called a “viral prescription pad.” This is a tear off sheet similar to what you might receive for a prescription, except it contains information about symptom-relieving strategies for fevers, aches and pains. It also explains the risks of unnecessary antibiotics and offers examples of when you should go back to see the doctor should your symptoms worsen.

Receiving no antibiotics for a cold or flu does not mean no treatment.

It just means a different approach.

One way to start the conversation about whether or not an antibiotic is really necessary is to use these three questions developed

by Choosing Wisely Canada when talking with your doctor: Do I really need antibiotics? What are the risks? Are there simpler safer opH tions? ■

Canada’s Leading Healthcare Architect 1 Valleybrook Drive Toronto, Canada M3B 2S7 Telephone: 416.467.8000 Fax: 416.467.8001 Email: info@parkin.ca

1737 West 3rd Avenue, Suite 220 Vancouver, Canada V6J 1K7 Telephone: 604.283.8054 Email: vancouver@parkin.ca

12 HOSPITAL NEWS DECEMBER 2018

20 James Street, Suite 200 Ottawa, Canada K2P 0T6 Telephone: 613.739.7700 Fax: 613.739.7780 Email: ottawa@parkin.ca

Dr. Guylène Thériault is a family Physician who practices family medicine in Gatineau, Québec. She is the Assistant Dean, Distributed Medical Education, Department of Family Medicine, McGill University. Dr. Wendy Levinson is the Chair of Choosing Wisely Canada, a Contributor with EvidenceNetwork.ca based at the University of Winnipeg and a Professor of Medicine at the University of Toronto. www.hospitalnews.com

INFECTION CONTROL 2018

Value-based healthcare

Continued from page 4

IF CANADA AND ITS PROVINCES AND TERRITORIES ARE TO DEVELOP THE TOOLS AND PROCESSES NECESSARY TO SUPPORT VALUE-BASED PROCUREMENT - AND

BY EXTENSION, VALUE-BASED HEALTHCARE - EFFECTIVE AND EFFICIENT CLINICIAN ENGAGEMENT IS NEEDED. A systemic engagement strategy is typically best suited when tenders involve large, complex, inter-organizational initiatives with diverse and numerous stakeholders, and multiple engagement activities (e.g., clinical supply chain teams, education initiatives). A delegated engagement strategy emphasizes the importance of end-users over stakeholders with deep expertise, and is best suited for reducing the workloads of specialists and key clinicians. Targeted engagement leverages networks and relationships to access influential and situationally appropriate stakeholders. This is an ideal strategy, provided the strength of the networks and relationships within and across organizations can support it. Lastly, an exploratory engagement strategy emphasizes the development and maintenance of those networks, and improves stakeholders’ understanding of how to best engage; it should be used proactively to increase an organization’s capacity for clinician engagement. Depending on a contract’s mix of clinical importance and administrative burden, organizations might use elements of each strategy to suit their needs.

These strategies are not mutually exclusive of one another and they are by no means a universal guide; however, they can help leaders think about how to effectively and efficiently engage clinicians in their organizations’ procurement processes.

HOW ORGANIZATIONS CAN IMPROVE THEIR CLINICIAN ENGAGEMENT PROCESSES Given the diversity of the stakeholders in the healthcare sector, there is no one-size-fits-all approach to cliwww.hospitalnews.com

nician engagement. However, there are several process considerations to help organizations improve their clinician engagement practices, including: involving end users, developing networks, engaging senior leadership, and ensuring that good relationship management, communication, education, and compensation practices are in place. A central focus of these process considerations is on people and their relationships with others.

Aside from specific process considerations, stakeholders need to engage clinicians early and often in conversations about potential product changes to facilitate the clinician engagement process and subsequent product conversions. This will help stakeholders identify and address potential challenges while driving value throughout the entire process.

Buy-in for clinician engagement at all levels of the organization is also important. Effectively engaging with clinicians requires that hospital leadership – executive and clinical – provide the necessary education and awareness to their procurement and clinical staff on the basics and importance of collaboration in the procurement process.

Lastly, criteria, such as clinical risk rating, frequency of use, and potential end-users, can all help to formalize the clinical engagement process, including the types of personnel and degree of involvement required. This does not mean that all engagement needs to be “formal,� but it should be structured in such a way that it manages the expectations of all stakeholders.

ONLY ONE PIECE OF THE PUZZLE

Clinical Engagement Strategy Framework Clinical Importance Targeted

Systematic

Administrative Burden Exploratory

Delegated

Source: The Conference Board of Canada

could get clinician engagement right, it would provide some of the momentum and alignment required to successfully transition to a truly valH ue-based health care system. â–

what is required in value-based health care. However, it is only one piece of the puzzle; many other governance, funding incentive, and culture changes need to occur. If organizations

Darren Gresch is a Research Associate, Innovation Policy, at The Conference Board of Canada.

UPCOMING PROGRAM DATES

March 8 - June 8, 2019 14 days over 3 months

Masters CertiďŹ cate in

Save $500 with code “GIFT18�

Healthcare Management Embrace health sector challenges to deliver better care and lead people more eectively.

Participants Will Learn to: Q Q

Q Q Q Q Q

Understand and respond to workplace issues to improve results.

Combine core business competencies with healthcare industry leadership skills and knowledge.

Promote a culture of accountability, innovation and collaboration.

Lead and manage in a fast-changing, multidisciplinary environment.

Gain useful tools, techniques, and checklists to take back and apply immediately.

Manage complexity and promote organizational success.

Build their professional healthcare network.

Request brochure at seec.online/12183 email: H[HFHGLQIR#VFKXOLFK \RUNX FD ä call: ä visit: seec.schulich.yorku.ca

Clinician engagement is a crucial component and a great example of DECEMBER 2018 HOSPITAL NEWS 13

NEWS Dr. Thomas Lindsay, the vascular surgeon at the PMCC who led Thomas York’s case shows a graft model.

Cardiovascular care:

A year in review

he Peter Munk Cardiac Centre is the leading cardiovascular centre in Ontario, with clinicians and physicians ready to care for people with the most challenging and complex health issues.

The team meets compelling people daily, and performs cutting-edge surgeries and procedures to help keep patients healthy.

Read on to discover two very different stories from 2018 that illustrate PMCC’s exceptional drive and talent – and incredible people.

T

BEATING THE ODDS It was a normal Friday for Amir Bacchus. Until the heartburn started. Or, at least that’s what it felt like to the 28-year-old car salesperson. “I just felt weird,” he recalls.

By Sunday, Amir’s symptoms had worsened to include back pain and a fever. After some coaxing from his wife, Sue, Amir went to a walk-in clinic, where the nurse took his blood pressure and heart rate.

A normal heart thumps anywhere between 60 and 100 times per minute.

Amir’s was 186.

He was rushed to a hospital where three shocks to his heart accomplished nothing. He was then transferred to the Peter Munk Cardiac Centre (PMCC) at around 4 a.m. acutely ill.

It was Monday, two full days since Amir had originally experienced symptoms. Now, he needed life-sustaining therapy – ECMO – to help support his rapidly failing heart.

He was urgently assessed in the coronary care unit with the assistance of many, including Dr. Patrick Lawler, Dr. Vivek Rao, Dr. Juglans Alvarez, Dr. Carolina Alba and Dr. Phyllis Billia.

It was clear the team needed to make a decision, and fast. Making judgements on the turn of a dime that can fundamentally impact the course of a patient’s life is something the team at PMCC is used to doing. But this case was unique. Amir was young and was inching closer to death as the clock continued to tick. Time was on

14 HOSPITAL NEWS DECEMBER 2018

no one’s side, and many from different areas needed to drop their work, come together and brainstorm a series of solutions that would ultimately save Amir’s life.

“Our big, overarching question we asked ourselves was ‘how do we get him out of this?’” recalls Dr. Billia, who co-ordinated Amir’s initial care.

The team transferred Amir to the

medical surgical intensive care unit, where he was cared for with the help of physicians, nursing, perfusionists, surgeons and respiratory therapists, to name a few.

However, within 24 hours, Amir’s heart had become distended – a consequence of his left ventricle not pumping strongly enough to empty the chamber.

www.hospitalnews.com

NEWS

Again, the team needed to act quickly. They transported Amir to the cath lab, where they would map the arrhythmia and attempt to get rid of it by burning it with a tool. And they needed to put a hole in Amir’s heart to place a tube in order to shrink the left side.

With the incredible teamwork of Drs. Nanthakumar, Chauhan and Krishnan from the electrophysiology team, catheters were placed in Amir’s groin and then blindly through the diaphragm, under the heart. Eventually, the team was able to map and mark the arrhythmia.

But, they couldn’t get rid of it.

Meanwhile, Drs Horlick and Osten were waiting in the cath lab, ready to act. Their job was to place a separate tube to help reduce some of the pressure in Amir’s left ventricle by making a hole in the upper chambers of Amir’s heart.

Except the team was forced to abandon this plan when blood started pouring out of Amir’s diaphragm. The team struggled to find the source.

With no time to spare once again, the team worked quickly to take Amir to the OR where his chest was opened.

Here, Dr. Yau was able to confirm a small hole had been made in the heart.

He did this by placing the catheters through the diaphragm.

www.hospitalnews.com

The hole needed a stich to stop the bleeding. As surgery continued, Dr. Yau lifted up Amir’s heart, found the markings made previously and applied a cryoablation tool that freezes the area of the heart where the arrhythmias originate.

Sure enough, the first application of the tool settled Amir’s abnormal rhythm.

Everyone in the operating room was astounded.

“We had tried everything else, this was really our last resort,” says Dr. Billia.

This is the first time staff and clinicians at PMCC had performed an ablation in a critical ill patient supported with an ECMO machine.

“This story is an example of the “pit crew” approach to patient care: clinicians across disciplines and programs pulling together to help this young patient,” says Dr. John Granton, who was involved in Amir’s care. “It was extraordinary.”

In a few days following his life-saving procedure, the catheters that were previously inserted to help rest and support Amir’s heart were removed.

His recovery took weeks. Throughout all of this, his wife, Sue, has been Amir’s rock, his advocate, his partner and his lifeline. “Every day, I woke up wondering ‘what is this nightmare?’” she says.

For now, his family remains focused on his recovery at home. And, since he’s likely had an arrhythmia since he was quite young, Amir and Sue are intent on having their one-year-old screened for heart disease in order to prevent him from enduring Amir’s challenging journey.

“Dr. Billia is a godsend, our angel,” says Sue. “She made him a priority, and we are so grateful Meliodas [our son] can see his Daddy – it’s a gift.”

DISARMING THE “BOMB” IN HIS CHEST Thomas York points at the tiny scar on his left shoulder. The cut of less than one centimetre made way for a sophisticated procedure that restored his peace of mind.

“I was walking around with a bomb in my chest that could blow up at any time,” he says.

At age 71, Thomas lived the past five years with an aortic aneurysm. Repairing it is one of the most complex and delicate procedures in vascular care. And, in Thomas’ case, it was also a remarkable achievement of minimally invasive technique in Canada.

A silent and often fatal disease, an aortic aneurysm is an enlargement of the major artery that carries blood from the heart to the rest of the body. An aneurysm usually causes no symptoms, but it weakens the wall of the aorta, which can lead to a sudden rupture and massive internal bleeding.

Thomas’ “bomb” was disarmed by a surgery called endovascular thoraco-abdominal aneurysm repair.

Surgeons from the Peter Munk Cardiac Centre (PMCC) inserted a custom made graft that has branches for his bowel and kidney arteries in his aorta.

This graft is a flexible synthetic tube that basically works as a new aorta in the area that is enlarged. The branches are then attached to the four bowel and kidney arteries with short bridging grafts inserted from above an artery under the collar bone.

His surgery is believed to be the first totally percutaneous aneurysm repair in Canada for this specific type of aneurysm. Thomas had a thoraco-abdominal aneurysm, which stretches from the chest all the way down to the lower abdomen.

“I woke up with this tiny cut and it’s just like magic,” says Thomas. “I could hardly believe the surgery was done. It really blew my mind that they could do something with this level of precision like this.”

Dr. Thomas Lindsay, the vascular surgeon at the PMCC who led Thomas York’s case, says the recent advances don’t impress only the patients.

After witnessing the evolution of vascular repair from open surgery to a state-of-the art minimally invasive procedure like this over the last two decades, Dr. Lindsay says he can barely believe how far medicine has come.

“My generation, we were trained to do repairs for this type of aneurysm in open surgery,” says Dr. Lindsay.

“Something like this was a pipe dream H when I was training.” ■

National nursing job board Find the right fit for you

Post jobs and find skilled candidates fast NursingCareersCanada.ca

DECEMBER 2018 HOSPITAL NEWS 15

SPECIAL FOCUS: RADIOLOGY

Understanding the role and importance of radiologists in Canada

By Dr. Emil Lee adiologists are physicians who work with medical imaging to diagnose illnesses. These imaging procedures include MRI, CT, ultrasound and X-ray. Radiologists monitor patient treatment and screen for conditions including cancer, heart disease, and other conditions. Radiology is an essential component of healthcare in Canada.

A recent Nanos poll revealed that 97 per cent of Canadians support and understand the value of radiology.

Over 80 per cent of Canadians also support more research into the use of artificial intelligence in the field.

Patients from every demographic rely on medical imaging to diagnose and treat conditions. Radiologists interpret medical images, advise other physicians on medical imaging results in clinical workups, use imaging to identify or rule out a disease and recommend other imaging follow-up, if necessary.

There are various types of medical imaging in Canada. Below is a list of the various technologies and a brief description of how they work:

R

CT • Computed tomography (CT) uses X-rays and sophisticated computer imaging technology • Produces a series of 2D or 3D images of a part of the body • CT scans can be used to check for brain injuries, appendicitis and other abdominal indications

MRI • Magnetic resonance imaging (MRI) uses a powerful magnetic field to produce detailed images of organs, soft tissues, bones and other internal body parts • MRI is especially useful in detecting nervous system, musculoskeletal, cardiac and cancer-related diseases or injuries

Dr. Emil Lee.

X-RAY • X-ray imaging uses a form of electromagnetic radiation that passes through the body to create 2D images of a region of the body • These images are primarily used to detect muscle or bone problems

ULTRASOUND • Ultrasound imaging uses high-frequency sound waves interpreted by a computer to generate real-time images of the body • Ultrasound is also known as sonography and is used in obstetric and mammographic imaging A growing area in this field is interventional radiology (IR). IR has allowed complicated surgical procedures to become less invasive and more effective through guided imaging. Over the past two decades, this subspecialty has vastly expanded to treat a variety of diseases affecting every organ in the body. For example, IR has been used for cancer biopsies and stroke treatments, playing an important role in ensuring treatment efficiency by restoring blood flow quickly and safely.

IR has also contributed to significant efficiency gains in healthcare.

In Canada, radiologists have 13+ years of training in healthcare. They are licensed through the Royal College of Physicians and Surgeons of Canada.

Radiologists work closely with frontline physicians in helping to provide information which will assist in the assessment and treatment of patients.

Although in some instances there is no direct patient access, radiologists are working behind the screens to help identify illness and contribute to treatment plans.

In my practice I have had the opportunity to work first hand with many general practitioners and emergency physicians. The feedback I often receive is that the role of radiology is essential to diagnosis. By providing information to support or supplement their initial assessment diagnosis or to reveal a different diagnosis or any number of underlying conditions, the information that I can provide allows for them to care for their patients much more effectively.

problem solving, reasoning, understanding and recognition. The combination of computer science and medicine will help radiologists make more precise diagnoses and offer the correct treatments for patients.

Canada is a global leader in AI research. Canadian research groups are aiming to design computers that are better at identifying patterns and calculating better predictions with their algorithms.

The Canadian Association of Radiologists (CAR) has published a White Paper on AI in Radiology to guide and inform the implementation of AI tools in radiology, which includes information on all matters of AI in relation to medical imaging, including practice, policy, patient care and ethics.

It is CAR’s vision is to create a pan-Canadian AI research network for medical imaging. Collaborating with interdisciplinary stakeholders will help foster the development of best practices for implementation of AI in radiology.

RADIOLOGISTS PLAY AN IMPORTANT ROLE IN THE HEALTHCARE CONTINUUM. WORKING BEHIND THE SCENES AND DIRECTLY WITH PATIENTS, RADIOLOGISTS HELP DIAGNOSE AND TREAT ILLNESSES USING MEDICAL IMAGING TECHNOLOGY, THUS IMPROVING THE OVERALL HEALTH OF CANADIANS. Over the years the radiology profession has evolved and continues to change through innovation in technology. This has made a tremendous impact in how radiologists’ practice and has vastly improved patient care and outcomes.

Artificial intelligence (AI) is the next great leap forward in medical imaging technology. AI is the science of reproducing human cognitive function through computers, which includes

CAR focuses on ensuring that the radiology profession is understood and continues to flourish while improving the health of Canadians.

Through innovation in medicine and the implementation of new technologies there will be an evolution in the way radiologists conduct their practice. This will improve patient outcomes and help radiologists’ practice to their full scope with the larger H healthcare team. ■

Dr. Emil Lee is the President, Canadian Association of Radiologists (CAR), the national voice that advocates for the advancement of radiology in Canada. For more information about radiologists please visit car.ca 16 HOSPITAL NEWS DECEMBER 2018

www.hospitalnews.com

SPECIAL FOCUS: RADIOLOGY

Artificial intelligence

is advancing radiology in Canada A

rtificial intelligence (AI) is rapidly gaining momentum within Canadian healthcare, specifically in the field of radiology. Although much of the work is still research-oriented and experimental, AI tools for radiology are of growing interest to the medical community and to patients across the country.

Large global commercial conglomerates as well as Canadian start-up companies are ahead of the curve and are working to implement these new technologies into medical imaging workflows. Radiology is among the first medical specialties to investigate and integrate AI into its clinical practice, because of the recent breakthroughs in applying machine learning and deep learning algorithms to pattern recogni-

A RECENT POLL CONDUCTED BY NANOS RESEARCH REVEALED THAT AN OVERWHELMING 83 PER CENT OF CANADIANS SUPPORT RESEARCH IN THE USE OF AI IN RADIOLOGY IN CANADA

tion in images. AI algorithms may pick up on subtle patterns that are beyond the threshold of human detection, enabling the detection of entirely new information. AI can better inform clinical decision referrals through computer-assisted/augmenting radiologist reporting which decreases unnecessary variation in reports. This technology complements the work of radiologists by enhancing their productivity and managing workflow while improving

patient outcomes. Radiology is at the cutting-edge of these technologies, which will enhance patient care into the future.

A recent poll conducted by Nanos Research revealed that an overwhelming 83 per cent of Canadians support research in the use of AI in radiology in Canada. Working in collaboration with a panel of experts, the Canadian Association of Radiologists (CAR) is taking a leadership position in AI and

• • • • • • • • • •

has published a White Paper, which describes ways in which this technology can be used to improve the delivery of patient care and population health.

Our experts have confirmed that harnessing AI in radiology enables radiologists to find patterns in complex data in medical images.

Dr. An Tang, Associate Professor at Université de Montréal and Chair of CAR Artificial Intelligence Advisory Group, believes that over the next decade, AI in radiology will significantly improve the quality, value and depth of radiology’s contribution to patient care and population health. “The radiological community should prepare for automation of certain image interpretation tasks that will transform patient care in a positive way,” says Dr. Tang.

Continued on page 21

Lead Lined Cabinets Radiation Barriers Modular Booths/Walls Lead Curtains Lead Bricks & Sheet Lead Borated Polyethylene Leaded Glass & Acrylic Lead Lined Storage Containers Tungsten Vial and Syringe Shields Laboratory L- Blocks & Caves

www.MarShield.com ISO 9001:2015, CAN/CSA Z299.2-85 CERTIFIED QUALITY MANAGEMENT SYSTEM

www.hospitalnews.com

DECEMBER 2018 HOSPITAL NEWS 17

A group meets in Toronto to discuss Clinical Decision Support Systems.

Clinical Decision Support Systems:

Breaking ground for imaging referral guidelines in Canada

By Dr. Martin Reed he Canadian Association of Radiologists (CAR) is advocating for the implementation of Diagnostic Imaging (DI) Clinical Decision Support (CDS) Systems in Canada. Access to updated medical imaging referral guidelines is crucial to ensuring the appropriateness of diagnostic imaging tests and quality patient care. The best way forward for appropriate imaging requires

T

a multi-tiered stakeholder approach to implement DI CDS across Canada.

CDS systems are software platforms that are installed at the point of physician order entry – at the level of the electronic health record or patient digital medical record. CDS systems integrate current, evidence-based guidelines for imaging of various health conditions and symptoms into the regular workflow of a referring physician.

CAR is steadfast in its position that the right test should be given to the right patient, at the right time. Ensuring that all medical imaging examinations are the most appropriate for every patient will not mean less care. It will mean that health system resources used for DI are used as efficiently and effectively as possible to enable optimal outcomes. Enhanced appropriateness of imaging referrals will also mean more timely access to care in some cases, which can contribute to decreased wait times for Canadians.

We are collaborating with several national stakeholder organizations on the issue of medical imaging referral guidelines, including the College of Family Physicians of Canada, the Canadian Association of Emergency Physicians and Choosing Wisely Canada.

Bringing together experts from these organizations has facilitated the sharing of information and insight about how best to ensure the appropriateness of medical imaging referrals while fostering access to referral guidelines for front-line physicians and healthcare workers. CAR has also held consultations with various provincial health authorities. These discussions have underscored the desire to establish one centralized, national system of DI referral guidelines and associated CDS systems.

The CAR has approached the federal government and has asked that they take a leadership role in the implementation of a CDS System in Canada.

To date CAR has been at the helm of facilitating stakeholder consultations

and would like to continue to be an active participant in this space: however, this initiative should be led by an independent collaborative body that can bring together affected groups.

In establishing a national set of DI referral guidelines, we improve the patient experience and save the healthcare system valuable time and money. A move to implementation of DI CDS systems nationally will help ensure better access for those who require medical imaging by appropriately meeting the needs of the patient and reducing the backlog.

CAR has hosted two stakeholder consultation meetings in 2018. The main objective was to receive expert guidance on integrating referral guidelines into CDS. Discussions focused on making clinical referral guidelines more accessible to front-line physicians: general practitioners and emergency physicians and integrating these guidelines into the Canadian health care landscape in a seamless and efficient manner. During that stakeholder consultation process participants reviewed examples from other jurisdictions and established recommendations for next steps.

It is our desire to continue in a guidance capacity in facilitating implementation of diagnostic imaging CDS systems in Canada. There will be challenges in introducing these into the Canadian healthcare market.However, with all the stakeholders on board and the federal government taking a leadership role on a strategy for CDS H integration is viable. â–

Dr. Martin Reed is Chair, Referral Guidelines Working Group, CAR. 18 HOSPITAL NEWS DECEMBER 2018

www.hospitalnews.com

SPECIAL FOCUS: RADIOLOGY

Use of simulated medical images improves accuracy of computers with AI

By James Wysotski adiologists in the Medical Imaging Department might get a new assistant in the coming years that never sleeps or leaves the hospital.

In April 2016, Drs. Tim Dowdell, Joe Barfett and Errol Colak – all radiologists – created the Machine Intelligence in Medicine Lab (MIMLab) to teach computers with artificial intelligence (AI) how to interpret medical images.

Computing systems with AI have been trained to think and learn like human brains. These systems progressively improve their performance on tasks by creating associations between data. The bigger the datasets, the better they learn. Once they’ve learned enough to demonstrate cognitive-like functions such as problem solving, they’re deemed to have AI. Embracing AI could help radiologists improve quality and reduce errors, notes Barfett. While medical mistakes are not frequent, they happen. Cancers occasionally get missed.

“With these AI tools, it’s very realistic to think that in the next five years no one will ever have a lung nodule accidentally missed on a chest X-ray,” says Dr. Barfett. “AI can make such instances go from rare to exceedingly rare.”

At present, he said there are limitations to what AI can do. For example, it can’t problem-solve to the degree that a human can. After flagging a potential lung nodule on an X-ray, it cannot ask why it’s there and start looking for the cause of the problem. That’s where a radiologist is needed.

However, adopting AI has other advantages. “I suspect that AI can detect cancers that a human cannot because of how well it can sense subtleties on X-rays,” says Dr. Barfett.

Plus, everything gets interpreted in real time, thereby speeding up workflows and reducing wait times for patients. Having computers flag potentially abnormal cases would also be a

R

Artificial intelligence expert Hojjat Salehinejad compares real medical images with simulations created by computers with AI. (Photo by Yuri Markarov) huge savings to the healthcare system since it would allow radiologists to spend their time on more complicated, patient-care oriented problems.

Soon after forming the MIMLab, the three radiologists recruited AI expert Hojjat Salehinejad, a PHD student in the Electrical and Computer Engineering Department of the University of Toronto, who Dr. Barfett said is now the driving force of their research.

Together they have overcome some early stumbling blocks – the team discovered it could not sufficiently train AI algorithms to interpret X-rays using just hospital databases because the datasets were imbalanced. While the

databases had numerous examples of common ailments, there were too few of the rarer conditions that also tended to be more life-threatening.

A unique solution was put in place and instead of relying solely on real medical images, the team augmented its database by programming AI algorithms to create computer-generated chest X-rays. Enough images of rare conditions were created, that when combined with the real ones it gave the team exactly what it needed to teach a machine how to spot conditions on a very broad spectrum – including those rare cases that could mean the difference between life and death for a patient.

“By including the computer-generated images, the computers’ ability to accurately interpret X-rays of common diseases improved by 20 per cent. For rarer conditions such as pneumothorax (a collapsed lung), the improvement was about 40 per cent,” says Dr. Barfett.

With each step forward in its AI research the MIMLab helps determine the future of radiology.

“We’re trying to channel our efforts into things that have immediate impact,” explains Dr. Barfett.

“We can direct the scientific discourse toward clinical questions that we know could lead to significant H improvements. ■

James Wysotski is a Communications Advisor at Providence, St. Joseph’s and St. Michaels.

20 HOSPITAL NEWS DECEMBER 2018

www.hospitalnews.com

SPECIAL FOCUS: RADIOLOGY

Pilot study to test

innovative lung screening x-ray

By Kara Weiler rand River Hospital (GRH) is partnering with KA Imaging to conduct a pilot study on the use of a high-resolution multi-energy digital x-ray imager for patients with lung nodules. This new technology is faster and less expensive, with the potential to detect lung cancer earlier with better image quality and lower levels of radiation than a traditional CT scan.

A startup out of the University of Waterloo, KA Imaging specializes in the development of low-cost portable multi-energy x-ray detectors like the one being piloted at GRH. A multi-energy detector is similar to previous dual energy detectors traditionally used to detect bone density. However, KA’s

G

detector is portable, requires only one exposure, enables conventional X-ray images at up to 30 per cent less radiation to the patient, and captures multiple energies enabling soft tissue and bone separation.

The study aims to compare the quality of images between a standard CT scan and the KA Imaging developed multi-energy digital x-ray imager.

Up to 30 patients with existing lung nodules who are already undergoing CT scans will be recruited to the study.

Patients will receive an x-ray on a KA Imaging prototype panel the same day as their scheduled CT scan. The prototype panels, which send images to nearby computers, are installed on one of GRH’s existing x-ray machines,

making their potential adoption easy and inexpensive. So far, four patients have joined the study.

“We are excited to partner with KA Imaging to trial this innovative technology at Grand River Hospital,” says Tina Mah, vice president of research and innovation at GRH. “Our mandate is to advance exceptional care and we continue to be leaders in our community by trialing new technologies, like this multi-energy x-ray, in partnership with our patients.”

KA Imaging founder Karim S. Karim, an electrical and computer engineering professor at University of Waterloo, believes that capability could pave the way for widespread screening programs to help save lives

Artificial intelligence Continued from page 17 Some of the key recommendations that came from the AI White Paper focus on the implementation of AI applications. AI applications should: – Integrate and be interoperable with existing workflows – Clearly define according to their role and type, and use clinical cases in their workflow – Prioritize the development of applications that provide information that is not achievable to human vision – Focus on the development of applications that provide knowledge that is not widely available in the Canadian radiology workforce “As additional research is conducted on AI and we move into the implementation phase, there will be a stronger focus on health informatics and computer science in radiology curriculums,” says CAR President, Dr. Emil Lee.

CAR’s White Paper identifies three considerations for implementation of AI into radiology: availability of data training sets, interoperable frameworks and collaboration between different stakeholders to ensure ethical, responsible and clinically useful applications.

Collaboration among stakeholders is the most important part of implementation. There needs to be an understanding of the role of AI in radiology and how the use of AI applications will improve patient outcomes to enhance the health of Canadians.

As the voice of radiologists in Canada, CAR maintains that it is paramount to involve patients, radiologists, physicians, imaging technologists, hospital administrators, regulatory bodies as well as industry and academic partners in the implementation of AI in radiology.

Through the work of the AI Advi-

This article was submitted by The Canadian Association of Radiologists. www.hospitalnews.com

sory Group, CAR is facilitating these discussions.

CAR is encouraging the Federal Government to take an active role in setting ethical standards for AI while addressing regulatory and legal issues that accompany the use of AI in medicine. “A modest investment from government in AI research will have a significant gain in improving patient outcomes and ultimately make medical imaging more accessible for Canadians,” says Dr. Lee. While AI will benefit radiology workflows and promote quality improvement, the goal is to ensure Canadians have access to the best care possible. CAR AI Advisory Group will be publishing another White Paper in the spring of 2019 on ethical and legal considerations for the implementation of AI in radiology. Stay tuned for its release in the Canadian Association of H Radiologists Journal. ■

The new portable mulit-energy imager. as this technology may be used in the future to detect lung cancer earlier. “If a cancer lesion is located in the apex of a lung and bone obscures it, it can’t hide anymore,” explains Professor Karim. “If an abnormality is hiding behind the heart, we can now see it nice and clearly.”

Unlike CT scans, which are typically used only for high-risk patients because of radiation concerns, low radiation levels mean retrofitted x-ray machines could be used providing superior image quality at a lower dose of radiation on equipment that is a fraction of the cost of CT scan. Karim says nothing like this exists now.

Dr. Vikram Venkatesh is a radiologist at GRH and is leading the study at the hospital. He is excited to see the study progress and the potential impact an x-ray like this could have on improving patient care.

“The human side of this work is so important,” says Dr. Venkatesh. “We cannot make advancements in patient care without first working with them to trial new technologies.”

The initial prototype developed

by KA Imaging was made possible through funding from Grand Challenges Canada (GCC), FACIT, and the Ontario Centres of Excellence (OCE).

KA Imaging recently received Health Canada approval to extend the trial to include patients suspected of having lung cancer in addition to patients with existing cancer. After the study is completed, KA Imaging will launch the commercial version of the H technology in mid-2019. ■ Kara Weiler is the Community Engagement Specialist, Office of Research & Innovation at Grand River Hospital.

DECEMBER 2018 HOSPITAL NEWS 21

SPECIAL FOCUS: RADIOLOGY

A new model for primary care s Interim Radiologist-inChief for the Joint Department of Medical Imaging (JDMI), Dr. Heidi Schmidt is accustomed to the informal consultations that take place daily between colleagues. And she’s equally aware that family doctors don’t have the same kind of access to that expertise.

“They’re lacking the hallway conversations that happen in the hospital,” says Dr. Schmidt, “where you can ask someone, ‘Hey, by the way, what do you think I should do here?’”

Catherine Wang, VP of Clinical Operations and Diagnostic Partnerships at the University Health Network (UHN), and administrative lead for JDMI, which encompasses medical imaging across UHN, Women’s College Hospital and Sinai Health System, elaborates. “Tertiary and quaternary care hospitals are built for the specialist world. But if you think about it, patients seldom, if ever, see a specialist. They mostly go to their family doctor. So it’s not good enough that we’re only understanding what the specialist needs.”

Once they’d identified an opportunity to do better, Catherine and her team went to work.

“The radiologist isn’t the first person who springs to mind when you’re thinking of specialists,” she says. “But the radiologist is incredibly important to ensure an accurate diagnosis and determine appropriate treatment options. We have a huge role to play in changing the system if we really want to improve access for all patients in the community and hospitals.”

To start, they asked themselves some basic questions: How can we create a better relationship between the radiologist and the family doctor? How can we help primary-care physicians order the most appropri¬ate test and schedule it in the appropriate timeframe? How might we streamline the system so that patients don’t unnecessarily turn to Emergency departments (ED) due to limited imaging access in the community?

A

The answers became an innovative JDMI call centre program to give family doctors point-of-care radiology advice and faster access to imaging services for their patients.

Dr. Schmidt, who along with JDMI’s Office of Strategy Management and Operational leaders, founded the program, says, “In many cases the ED is the only way a family physician can access urgent imaging. By offering a direct pathway to our diagnostic services and radiologist consultation, a significant number of imaging related ED visits can be avoided.”

Additionally, with JDMI’s guidance, an initial request for magnetic resonance imaging (MRI) might be updated to a more appropriate and more readily available computed tomography (CT) scan, giving family physicians and their patients quicker access to the right test, and helping reduce wait times for other imaging studies in high demand.

And the benefits extend beyond this initial consultation, says Catherine. “We can design a report to meet the needs of the primary care physician, a report that’s not the same as the one that gets sent to a cardiologist, for example. We can also play a navigator role. Rather than simply sending the report and leaving it for the family doctor to figure out, we can aid in the interpretation of the report and suggest the next course of action, all because we now have a relationship with the doctor that we didn’t have before.”

Plans are underway to make the program even more useful and accessible. “If we can figure out a provincial strategy to allow electronic referrals, then we can really get going,” Catherine explains. “Right now, it’s all done manually, which is cumbersome. With an electronic platform, every family physician can have access to the right specialist, including radiology. We can also build in clinical decision support, like data related to referral practices. We can say to a family physician, ‘here’s your order in practice, and here’s what your order looks like in the

22 HOSPITAL NEWS DECEMBER 2018

Catherine Wang and Dr. Heidi Schmidt (l-r), clinical and administrative leads for Toronto’s Joint Department of Medical Imaging look for new opportunities to bring primary care physicians and hospital based specialists closer together. Photo credit: J.R. Clubb Photography

THE FAMILY DOCTOR IS THE GATEKEEPER TO THE WHOLE SYSTEM. THE LIFETIME HEALTH OF MOST PATIENTS IS PROBABLY MANAGED BY A FAMILY DOCTOR. SPECIALISTS MAY COME AND GO, BUT THE PRIMARY CARE PHYSICIAN IS GOING TO BE WITH THAT PATIENT FOR THE DURATION. context of all your peers ordering the same test. Are you an outlier? Are you not?’ We can offer real-time feedback and meaningful support.”

The call centre program is now built into a cross-organization, quality improvement collaborative, branded as SCOPE (Seamless Care Optimizing the Patient Experience) and the team at JDMI has provided guidance to other Toronto health providers to implement their own call centres following the same model.

This emphasis on primary care is mirrored in provincial policy, and to Catherine, that policy makes perfect sense. “The family doctor is the

gatekeeper to the whole system. The lifetime health of most patients is probably managed by a family doctor.

Specialists may come and go, but the primary care physician is going to be with that patient for the duration.”

“Some family doctors know exactly what they want to do, and we want to be respectful of that,” she adds. “But, innovations pioneered here at JDMI have led to real, tangible improvements in support for primary care practitioners. Going forward, we can play an even greater navigation role, and try to do away with the Snakes and Ladders game that patients sometimes H go through.” ■ www.hospitalnews.com

50 YEARS OF MEANINGFUL INNOVATION IN CANADA

Earl Bakken &R IRXQGHU

In 1949, Medtronic was founded. In 1957, Earl Bakken, inspired by Canadian research, invented WKH ƬUVW ZHDUDEOH EDWWHU\ SRZHUHG SDFHPDNHU 6LQFH WKHQ 0HGWURQLF KDV EHHQ D JOREDO OHDGHU LQ GHYHORSLQJ PHGLFDO GHYLFHV WKDW DOOHYLDWH SDLQ UHVWRUH KHDOWK DQG H[WHQG OLIH ,Q 0HGWURQLF RSHQHG WKH ƬUVW VXEVLGLDU\ RXWVLGH WKH 8 6 LQ 9DQFRXYHU ,Q 0HGWURQLF SURXGO\ FHOHEUDWHV LWV WK DQQLYHUVDU\ LQ &DQDGD KLJKOLJKWLQJ VRPH RI LWV PRVW PHDQLQJIXO LQQRYDWLRQV

THE WORLD’S SMALLEST HEART MONITOR

A MINIMALLY INVASIVE TECHNOLOGY THAT VISUALIZES THE ENTIRE *$6752Ç¢,17(67,1$/ 75$&7

Reveal LINQâ„¢ Insertable Cardiac Monitor

The PillCamâ„¢ Video Capsule Endoscopy

HELPING PATIENTS BREATHE MORE NATURALLY

THE WORLD’S FIRST $33Ǣ%$6(' 60$573+21( FRIENDLY HEART MONITOR

Puritan Bennettâ„¢ 980 Ventillator Series

MyCareLink Smartâ„¢ Monitor

7+( ),567 (9(5 6(/) $'-867,1* ,168/,1 3803

THE WORLD’S SMALLEST PACEMAKER

MiniMedâ„¢ 670G Hybrid Closed Loop System

Micraâ„¢ Transcatheter Pacing System

6RPH XVHU LQWHUDFWLRQ UHTXLUHG LQGLFDWHG IRU 7\SH \HDUV RI DJH RU XS

A GPS 7+$7 &$1 $,' ,1 7+( EARLY ',$*126,6 2) /81* ',6($6( SuperDimensionâ„¢ Navigation System

New Invention

A DEVICE THAT CAN HELP REDUCE STROKE RELATED DISABILITY

TECHNOLOGY FOR CARDIAC ARRHYTHMIA MANAGEMENT

+285 7+(5$3< )25 3$5.,1621p6

Solitaireâ&#x201E;¢ Platinum Revascularization Device

Arctic Frontâ&#x201E;¢ Advance Cardiac Cryoblation Catheter

Activaâ&#x201E;¢ Deep Brain Stimulation System

Designed, developed, and/or manufactured in Canada

Inspired/supported by Canadian research

LONG-TERM CARE NEWS

Animal assisted therapy

in long-term care

By Steve Crawford emember visiting a farm or zoo as a child? Think of the sounds, smells, sights and feel of the experience – being fascinated at watching the animals and perhaps being lucky enough to get a nickel from your mom or dad to buy some pellets from the modified bubble gum machine to feed your furry friends.

Whether you grew up on a farm or just enjoyed seeing the animals at your local petting zoo, most of us have some deep-rooted memories of that experience. Julie Casey, a social worker and animal-assisted therapy specialist, tapped into that memory by researching the fundamental reactions to animals in people with dementia in the hopes of better managing agitated behaviours.

“Animals offer us a deeply rooted connection,” says Julie. “They awaken

R

in us some profound emotions, memories and social connectedness that transcend any limits imposed by mental challenges.”

The study was conducted in partnership with King’s University College, renowned for the excellence of its academic program in social work, and McCormick Dementia Research, a newly founded division of the McCormick Care Group that is committed to engaging in research activity that enhances quality of life for people living with dementia.

In her work, Julie has frequently seen generally unresponsive people reach out to connect with her animals.

One 90-year-old lady, who rarely communicates and usually sits passively in her chair, began chatting away once she started cradling Delilah the visiting chicken. Another experience saw a generally catatonic man reach out to

feel the wool of Sweet Pea the sheep as she passed by. “While these are not outright miracles, I do tend to see a lot of cases where the animals generate some surprising reactions in otherwise unresponsive people,” says Julie.

“Human-animal interaction can produce a range of positive outcomes,” says Dr. Rick Csiernik, project supervisor and professor at King’s University College. “On the biological level there is the release of oxytocin, which is a hormone that is associated with positive affect.”

A total of 15 residents at McCormick Home, a long-term care home in London, Ontario, participated in the data-collection phase of the project.

In addition to interacting with Delilah and Sweet Pea, participants had the opportunity to bond with Barley the bunny, Blossom the goat, and Daisy, Delilah’s counterpart.

Outcomes of the study included a decrease in verbally aggressive behaviour and depression, and less resistance to care. In addition, those who attended more sessions exhibited a significant decrease in exit-seeking behaviour than whose who attended fewer sessions.

“While there were not significant improvements in all areas given the progressive nature of dementia, preserving function and quality of life can in and of itself be considered a success,” says Julie. “Overall, the study demonstrated that the farm animals did contribute to enhanced wellbeing and did not create any negative outcomes. Even minimal contact was found to produce some positive results in the participants.”

While a major limitation of the study was the small sample size, the outcomes were sufficient to warrant a

LONG-TERM CARE NEWS larger-scale investigation working with farm animals and this population.

“There’s been some animal therapy research done in the past, but not as much as you might think,” says Catherine Blake, research associate with McCormick Dementia Research. “We hope that the results of this study will help inspire additional studies that more formally establish a therapeutic connection between animals and those challenged by dementia.”

MORE PAWSITIVE IMPACTS The animal therapy research study at McCormick Home yielded a second phase that reviewed the impacts of the animal visits on staff morale and the work environment.

Results indicate that morale increased and stress levels decreased when the animals were present.

“It did make our jobs easier on the floor,” says one participant. The structured activity of the regular animal

McCormick Home residents interact with a rabbit as part of the two-phased animal-assisted therapy research project at McCormick Home. visits helped residents to stay calm and engaged, and enabled staff to provide more quality programming for the non-participating residents.

The presence of the animals also

enhanced positive, spontaneous conversation among not only staff on the floor but also among other staff members who came to see the animals just for fun. Overall, the benefits of ani-

mal contact on people with dementia extended even further than originally anticipated, resulting in residual positive outcomes for those who provide H their care. ■

Steve Crawford is CEO, McCormick Care Group scrawford@mccormickcare.ca.

Personalized home care services

Support is just a phone call away.

Personal Care Caregiver Relief Nursing Companionship Meal Preparation Medication Reminders Light Housekeeping Palliative / End of Life Care Physio & Occupational Therapy Hospital Bedside Care

www.bayshore.ca

1.877.289.3997 clientservice@bayshore.ca www.hospitalnews.com

DECEMBER 2018 HOSPITAL NEWS 25

LONG-TERM CARE NEWS

Home is where the health is

By Dr. Zayna Khayat any years ago, when you asked someone what image comes to mind when they think of healthcare, they might have said ‘hospital’, ‘H logo’, ‘red cross’ or ‘stethoscope’. Today, there is a shift towards associating health(care) with the home. This is a return to how healthcare was designed over 100 years ago with midwives and doctors doing house calls.

Innovation scholar Clay Christensen elegantly and accurately predicted this phenomenon in his book, The Innovator’s Prescription. Although the book was published a decade ago, his theory of disruption and decentralization stands the test of time, and we are seeing many of his predictions becoming reality for healthcare in this coming decade.

As Christensen predicted, heath systems around the world, including here in Canada, are shifting focus to

M

the home and community. The home is seen as a care setting that is well positioned to address the significant unmet needs of people, families and healthcare providers, while maximizing precious public resources. A great recent example of this shift was shared

by Dutch public servant Erik Gerritsen at Singularity University’s 2018 Exponential Medicine conference. He said, “We are moving care from waiting rooms to living rooms”. This vision statement has been backed by major policy reform where the Netherlands removed €2B from the ‘cure’ (hospital) budget and reallocated €1.5B to home, community and primary care.

THE FUTURE OF HEALTHCARE IS THE HOME This year SE Health marks 110 years of bringing care to people in their homes across Canada. As we work to-

wards our next century of impact, we are systematically sensing and mining the signals and trends reshaping healthcare to help drive our mission of Spreading Hope and Happiness to people wherever they live.

In early 2018, I was recruited by SE Health to establish a Futures team to guide the organization, our clients and the health system towards creating a brighter future of health at home.

With the appropriate title of ‘Future Strategist’, I spend a lot of time watching, digesting and translating what is happening around the world. I am looking at the changing preferences of people as they age, emerging technologies, decentralization of services from institutions into homes, and new business models to unlock value for individuals, families and the health system.

The home setting offers a greenfield of opportunity to challenge old assumptions about how people want to – and can – receive health services, and self-manage with their families and communities in the face of health challenges. Accelerating the shift to the home means letting go of deeply-held beliefs and constraints about what people are able to do in the home – for example, beliefs around privacy, tech savviness, quality of home care services, and constraints of time, distance and space.

EXCITING CHANGES COMING IN 2019 & BEYOND

Helping people live with independence, dignity and in comfort since 1925.

• Nursing • Physio and other therapies • Personal care and support • Homemaking

Also specializing in:

• Palliative support needs • Dementia care • Respite • Wound care

26 HOSPITAL NEWS DECEMBER 2018

www.vha.ca 1.888.314.6622

Within this context, here is a roundup of emerging and exciting ways that the boundaries between traditional formal institutional care settings and the home are blurring in 2019.

Hospital-to-Home programs: In the US and Canada, bundled care models in areas like hip and knee or cardiac surgery are allowing earlier discharge of patients to the home, supported by proactive home care and virtual supports. The INSPIRED hospital-to-home model for patients with COPD supported by the Canadian Foundation for Healthcare Improvement is a great example that has been scaling across Canada.

The hospital without beds: A growing cohort of hospitals like Bellevue Medical Centre in Washington and Women’s College Hospital in Toronto, are shifting their operating model to exclusively offer outpatient care – even surgery – to thousands of patients a day, with no overnight stays. These models greatly rely on robust virtual care and remote monitoring capabilities, as well as strong partnerships with service providers in the community.

The hospital without patients: The next step up from the hospital without beds, is the hospital without patients!

Mercy Virtual hospital in St. Louis has been the hallmark case study for this rebasing of the hospital model: fully decentralized locations where patients are cared for either in hyper-localized satellite sites or directly in their homes.

The home-spital: The quality and variety of care services available in the home is approximating (and even surpassing) that of many hospitals when they were first built more than a century ago. Although services such as chemotherapy, infusion, dialysis, phlebotomy, palliative care, clinical trials and rehab therapy have been ‘available’ in the home setting, they are still largely accessed in physical clinics or institutions today. With emerging availability of supports in the home coupled with technologies for remote monitoring (sensors), self-management tools, and new business models, patients will increasingly see the home setting as a viable alternative or adjuvant for these services. LifeLabs, a major community lab provider, is now piloting an inhome lab collection service in Canada.

Science 37, an upstart in the US, has pioneered a fully decentralized clinical trial model in the home setting, with significantly better rates of recruitment and retention rates compared to legacy institutionally-based models.

From hospital to health village: Many hospitals are reinventing their operating and business models to shift from a focus on ‘sick care’ to a more mission-aligned focus on ‘creating health’. This is manifesting in a few interesting ways. Some hospitals like Bruyere in Ottawa have been acquiring nearby real estate to create new home www.hospitalnews.com

LONG-TERM CARE NEWS

“THE HOME SETTING AND HEALTH SERVICES WILL BECOME SO SYNONYMOUS THAT THEY MAY NOT BE CALLED HOME CARE; RATHER, THEY WILL JUST BE MODERN HEALTH CARE,” STEVEN LANDERS, MD, MPH, CEO – VISITING NURSE ASSOCIATION HEALTH GROUP and community models such as affordable seniors’ living. Others are partnering in creative ways with community agencies to create and deliver new value propositions well upstream of sick care, tackling issues such as transportation, employment and housing.

Neighbourhood models of care: New models of home care are evolving to support people with complex medical and social issues in ways that traditional fee-for-visit transactional home care cannot. The Dutch Buurtzorg model of neighbourhood care is getting traction globally, with more than 20 countries now replicating aspects of the model. The key is a ‘management-free’ organizing model wherein

self-empowered nursing teams form and work autonomously with community supports in a given neighbourhood to holistically meet the patient and family’s needs.

The future of healthcare will continue to form around shifting client preferences and expectations, fiscal pressures and opportunities presented by budding new technologies. These changes are narrowing the gap between institutional and home care, and we are seeing new and innovative partnerships emerge to meet patient needs and alleviate pressures. It is an exciting time to be in healthcare as we watch the signals and future trends emerging H in Canada and around the world. ■

Dr. Zayna Khayat is the future strategist at SE Health.

>OLU `V\ 5LLK 8\HSPÄ LK *HYL

WE WILL BE THERE! Nurses PSWs - Alzheimers HCA - Sick Kids Massage Therapy Homemakers Companions

Sitters Foot Care Nurses Drivers Live in Caregivers Denture Services at home Palliative Care

>HP[PUN MVY `V\Y UL_[ JHSS Royal Canadian Health Care Services Inc.

905.669.5453 Serving all of Ontario including HAMILTON • TORONTO • OTTAWA

24 HOURS 7 DAYS A WEEK www.hospitalnews.com

info@rchcs.com www.rchcs.com DECEMBER 2018 HOSPITAL NEWS 27

NEWS

The future is here: Artificial Intelligence in healthcare helping predict and direct patient care

By Selma Al-Samarrai rtificial intelligence is everywhere. It exists in Amazon’s virtual assistant Alexa, and in Tesla’s self-driving cars. At St. Michael’s Hospital, it also exists in our hospital.

Artificial intelligence (AI) in health care is designed to make patient care more efficient, timelier and more enhanced.

“Healthcare is so data-rich and there is often too much to process for the average human mind,” explains Dr. Muhammad Mamdani, Director of the Li Ka Shing Centre for Healthcare Analytics Research and Training (LKS-CHART) – the team developing three new artificial intelligence tools at St. Michael’s.

“Artificial intelligence can make meaning out of complex data relationships, which we would then use to guide clinical practice and policy-making in healthcare.”

The first AI tool, called the Forecasting Tool, is already being used at St. Michael’s in the Emergency Department (ED) to predict patient volumes.

It not only provides Ray Howald, clinical leader manager in the ED with expected volumes over the next three days in six-hour intervals to assist in short-term staffing decisions that manages patient capacity efficiently and safely, but it also forecasts for the next three months to help with longer-term planning.

“Having the ability to forecast the volume of potential patients that may be arriving to the ED and their acuity is a valuable tool to ensure we have the correct staffing in place to deal with such demands. This tool allows me as a manager to make accurate and informed operational decisions which has a positive impact on patient care in the Emergency Department,” explains Howald.

The tool is automatically updated daily with the latest patient volumes

A

Dr. Muhammad Mamdani, director of the team developing artificial intelligence tools at St. Michael’s Hospital, is pictured here using the Forecasting Tool with the Emergency Department’s Clinical Leader Manager, Ray Howald. data as well as weather patterns, and has a prediction accuracy of well over 90 per cent. Ultimately, this tool is expected to help improve staffing levels in the ED, lower wait times, and enable the team to provide better patient care. By early 2019 the plan is to look at using this tool at St. Joseph’s Health Centre, which is part of the newly integrated hospital network that includes Providence Healthcare and St. Michael’s Hospital.

Another advanced artificial intelligence tool under development is called the Machine Learning Tool, which is expected to predict patient outcomes in General Internal Medicine inpatients, and subsequently help lower mortality rates.

“According to Miller’s law, the human brain can only process seven pieces of information at a time,” explains Dr. Mamdani.

“But when you’re an internal medicine healthcare practitioner dealing with multiple pieces of information on a patient that are changing constantly throughout the day, you might need a little help in processing all of that in-

formation to identify patients who may not do so well 12 or 24 hours from now.

This ‘prediction’ of a bad outcome well in advance will give the practitioner enough time to implement life-saving interventions.”

This artificial intelligence tool has already ‘learned’ complex patterns that lead to a bad patient outcome by ‘studying’ over 20,000 internal medicine patients at St. Michael’s Hospital.

The Machine Learning Tool is being ‘trained’ to pull patient data on an hourly basis to predict Intensive Care Unit transfers or patient deaths 12-24 hours in advance.

“The hope is that, with this tool constantly monitoring our patients’ health, we have enough time to act on our patients and can subsequently reduce mortality significantly,” says Mamdani, whose team will be implementing this tool for pilot evaluation in the new year.

The third tool Mamdani’s team is testing is called the Natural Language Processing (NLP) tool. A lot of valuable clinical information is entered in a patient’s digital chart or health record,

but it is difficult to access quickly; a manual review typically takes between a few weeks to a few months, depending on the volume of information.

The NLP tool is designed to mimic human language models and make the process of reading the patient’s chart faster, more efficient and more accurate. There are codes entered into the tool to teach it to ‘read’ through these notes and extract specific patient information.

“For example, our vascular surgery group needs to identify specific subgroups of patients at St. Michael’s who may be at higher risk for poor outcomes to monitor the quality of care provided to them and identify areas for improvement. For the team to do this, they would have to manually read through detailed clinical notes to identify the relevant patients. That’s where this tool comes in,” explains Dr. Mamdani.

This tool is currently being employed for the Vascular Quality Improvement Dashboard which is being led by Dr. Charles de Mestral, staff physician in Vascular Surgery at St. Michael’s.

“The Vascular Quality Improvement Dashboard relies on the Natural Language Processing tool to identify St. Michael’s vascular patients and important quality measures. It’s an exciting new way to track and improve the quality of care of our patients,” explains Dr. de Mestral.

“We’re seeing a lot of interest in the area of artificial intelligence. I hope we’re able to develop infrastructure, foster highly-trained data scientists, and create a culture that welcomes these promising approaches, in an effort to improve the quality of care of our patients as well as hospital efficiency,” explains Dr. Mamdani.

“Good clinical data means good patient care: if we don’t know enough about our patient’s health, we can’t act H in the best way possible.” ■

Selma Al-Samarrai is a Communications Associate at Providence, St. Joseph’s and St. Michaels.

28 HOSPITAL NEWS DECEMBER 2018

www.hospitalnews.com

The future of health care tech in Canada is bright

Meet the 2018 Joule Innovation grant recipients at

joulecma.ca/grants

FROM THE CEO’S DESK

Championing virtual care to empower patients and build system capacity

By Dr. Brendan Carr s healthcare leaders, we’re challenged every year to find tangible, sustainable approaches to healthcare that are patient-focused, cost effective and in keeping with evidence-based best practice. Despite its many proven benefits, I believe one of the most overlooked opportunities in healthcare today is virtual patient-clinician care.

It’s hard to pinpoint exactly why we have been so slow in Canada to embrace virtual care as a viable way to build capacity within an overwhelmed system. While the technology and expertise exist, particularly here in Ontario, there are few examples across the country where virtual patient-clinician services have moved beyond the pilot stage to successful implementation.

Yet in a recent Ipsos survey commissioned by the Canadian Medical Association, seven in 10 respondents said they would take advantage of virtual physician visits, with many believing it would lead to more timely, more convenient and ultimately, better overall healthcare.

Digital technology has already transformed the way people bank, shop, and communicate. So why not the way people receive care?

At Osler, our own experience has convinced us that virtual care has a significant role to play in reducing the demand on emergency departments, building capacity in the system, and empowering patients to actively manage their own healthcare journey. It’s among the many reasons why virtual approaches to care are among the priorities outlined in our new 201924 Strategic Plan, Going Beyond for Healthier Communities.

Osler is no stranger to virtual care having partnered with the Ontario Telemedicine Network (OTN) on its highly successful Telehomecare program in 2012. More recently, our work has focused on introducing virtual patient-clinician care in our palliative

A

DIGITAL TECHNOLOGY HAS ALREADY TRANSFORMED THE WAY PEOPLE BANK, SHOP, AND COMMUNICATE. SO WHY NOT THE WAY PEOPLE RECEIVE CARE?

Dr. Brendan Carr care program at Brampton Civic Hospital. While our multi-faceted program includes an inpatient care unit, inpatient consultation services, an outpatient clinic and physician home visiting, like many others we face growing wait times for outpatient consults and follow-up outpatient visits, with demand often exceeding capacity.

Our palliative care team was eager to increase access to the program while also empowering patients to self-report symptoms as a way to prevent unnecessary visits to the hospital in between appointments. This led them to pilot two virtual care initiatives: conducting virtual home visits using a secure online app on the patient’s computer,

tablet or mobile phone, and introducing a mobile health app that enables patients to remotely self-report symptoms to their palliative care physician and clinical team to allow for more timely interventions.

Partnering with OTN, the team initiated virtual home visits with a select group of patients who were impacted by current wait times, lived more than a 30-minute drive away from Osler’s Brampton Civic Hospital site, and were experiencing urgent pain or symptoms issues. By conducting home visits virtually, palliative care physicians were able to double their outreach from four to up to eight home visits in a single day.

Among our key learnings, we discovered that virtual patient-clinician care: • Offers a platform for patient equity as it effectively removes barriers to accessing care like geographic location and financial issues (transportation, parking expenses); • Helps lessen the burden on informal caregivers by minimizing the need for transportation to and from clinic appointments, and by reducing unnecessary visits to the emergency department; • Provides for greater efficiencies through the timely digital submission of home care orders, consults and medication changes; and Continued on page 31

30 HOSPITAL NEWS DECEMBER 2018

www.hospitalnews.com

NEWS

Medtronic Canada

celebrates 50 years of innovation

By Neil Fraser

• Facilitates out-of-town family involvement in family meetings about goals of care and care updates.

Patients and informal caregivers alike were surprised at how much care could be managed virtually without the need for an in-person physical exam.

Patients also appeared to be more open and at ease discussing their pain and symptom issues from the comfort of their homes, leading to more informed decision-making about their care.

Osler also partnered with uCarenet and the Centre for Aging and Brain Health Innovation to design, develop and study a mobile browser-based e-health app (RELIEF) that empowers palliative care patients to self-report their pain, symptoms and distress to their clinical team on a daily basis from the comfort of their own homes.

The app provides nurses and physicians with real-time data of patient self-reported symptoms and alerts them when there is a change to a patient’s status, thus allowing for timely intervention and treatment when required. This helps reduce patient and family distress, prevent unnecessary hospitalizations and visits to the ED, and ensures that palliative care patients remain in their homes as independently and as safely as possible, for as long as possible.

While we’re only beginning to scratch the surface when it comes to leveraging virtual technologies, this two-pronged approach to virtual care has yielded promising results that hold exciting possibilities for hospitals, Health Links, and other sectors including long-term and hospice care.

Let us not lose sight of these opportunities to empower patients and build the much-needed capacity we need to H sustain our health system. ■

alf a century after it first established roots in this country, Medtronic capped a milestone year by doing what we have done consistently over five decades – launching a series of innovative medical devices that will help to improve the lives of thousands of Canadians.

In the fall, Health Canada licenced the world’s first self-adjusting insulin pump – the Medtronic MiniMed™ 670G system for use by people with Type 1 diabetes seven years of age and older in Canada. The game-changing technology promises to give people with diabetes and their caregivers more freedom from constant worry, daily insulin injections, and an improved quality of life that has been out of reach until now.

Bringing the new pump to market here, along with a series of other technologies for chronic pain, neurosurgery, and ear, nose, and throat procedures, is a fitting way for Medtronic to put an exclamation mark on 50 years of innovation and commitment to patient care in Canada.

We are proud of our long-running history here and our many Canadian connections.

While Medtronic currently has operations in more than 160 countries, its growth beyond its home base in the United States began in Canada.

Our late co-founder Earl Bakken, who died on Oct. 21, 2018 at the age of 94, opened Medtronic’s first subsidiary outside the U.S. in Canada in 1968. Since then, over one million Canadians have benefitted from a Medtronic technology or service.

Bakken, an electrical engineer who began the company in his Minnesota garage as a medical equipment repair service, had long followed the work of Canadian medical researchers. He was inspired by the research of pioneers such as Dr. Frederick Banting and Dr. Charles Best, whose discov-

Dr. Brendan Carr is President and CEO, William Osler Health System.

Neil Fraser is the president of Medtronic Canada, a member of the Health and Biosciences Economic Strategy Table, and a contributor to the book “A Canadian Health Innovation Agenda” published by McGill-Queen’s University Press.

Continued from page 30

www.hospitalnews.com

H

DEVELOPING THE MODERN PACEMAKER WAS ONLY THE BEGINNING OF A LONG TRADITION OF MEDTRONIC COLLABORATING WITH CANADIAN SCIENTISTS, MEDICAL RESEARCHERS, PATIENTS AND PARTNERS TO DELIVER BETTER PATIENT OUTCOMES. ery of insulin led to today’s sophisticated insulin pumps.

He was also captivated by research carried out by Dr. Wilfred Bigelow, Dr. John Callaghan and electrical engineer Jack Hopps, known as the Toronto Group, who are credited with coming up with the world’s first alternating current (AC)-powered pacemaker in the late 1940s.

Bakken built on the research and ingenuity of these Canadians by developing the first wearable, battery-powered pacemaker, paving the way for long-term pacing for cardiac patients around the world and leading to the development of the world’s smallest pacemaker. Interestingly, both pioneering engineers – Jack Hopps and Earl Bakken – had their own lives extended by the very technology they helped create.

Developing the modern pacemaker was only the beginning of a long tradition of Medtronic collaborating with Canadian scientists, medical researchers, patients and partners to deliver better patient outcomes.

For example, Dr. George Klein at University of Western Ontario and Medtronic Canada jointly developed Reveal,™ an insertable cardiac monitor that offers continuous monitoring to help determine the cause of unexplained fainting or stroke.

Dr. Marc Dubuc at the Montreal Heart Institute developed Medtronic’s Arctic Front Cryoablation system to treat patients with paroxysmal atrial fibrillation (AF), or irregular heartbeats in the heart’s upper chambers.

The technology is novel because it ablates or blocks the conduction of AF in cardiac tissue through the use of a coolant, rather than heat. It is proudly manufactured in Canada and more than 180,000 patients in more than 1,300 centres worldwide have been treated with the cryoballoon.

In all, Medtronic holds more than 80 patents for therapeutic technologies and devices involving Canadians and has done over 100 clinical trials in Canada.

I’ve been with Medtronic Canada for over 34 years and I’ve discovered that to achieve the mission Earl Bakken penned almost 60 years ago – to alleviate pain, restore health, and extend life – launching innovative products that improve patient outcomes is not enough. That’s why we’ve been collaborating with hospitals to reduce wait times through our Integrated Health Solutions service. And its why we’ve been educating the government and the health system about the importance of moving towards value-based procurement and payment models that consider the total cost of care and outcomes that matter most to patients.

As our 50th anniversary year in Canada draws to a close, we look back with pride on what we’ve accomplished with our Canadian partners to help people overcome pain and disability and to live longer lives. We look forward to further collaborating with Canadian patients, doctors, and health system leaders for decades H more to come. ■

DECEMBER 2018 HOSPITAL NEWS 31

KEEPING HOSPITALS SAFE. FIGHTING CANCER. Cobalt-60 from Bruce Power’s reactors helps sterilize 40% of the world’s single-use medical devices, and powers the Gamma Knife, which helps cure brain cancer.

BrucePowerNGS

brucepower4you

@Bruce_Power

@brucepowerngs

LEARN MORE AT WWW.CLEANNUCLEARPOWERSAFEHOSPITALS.COM