Hospital News April 2019 by Hospital News

Special Focus: e-Health Conference 2019 Inside: From the CEO’s Desk | Evidence Matters | Safe Medication | Ethics | Careers

April 2019 Edition

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Contents April 2019 Edition

IN THIS ISSUE:

Astronaut takes part in study of bone marrow health

8 ▲ Cover story: Virtual care

▲ Seamless and dynamic echocardiography

16 ▲ Precise and powerful bot CyberKnife robot

COLUMNS Guest editorial .................4

In brief .............................7 Evidence matters ...........20 From the CEO’s desk .....31 Long-term care ...............34 Ethics ............................ 44 Safe medication ............45

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▲ Virtual reality in long-term care

eHealth h supplementt

New Breast Screening Guidelines

Do Canadian women deserve recommendations based on outdated studies? By Jean Seely hanges to breast cancer screening guidelines have been big news since the release of the Canadian Task Force on Preventive Health Care’s (CTFPHC) updated guidelines in December. Women 50-74 years are now recommended to undergo screening mammography every two to three years, while women 40-49 are advised not to undergo screening and not to examine their breasts, regardless of breast tissue density. But patients must wade through the recommendations with caution – here’s why. Adoption of the new Breast Cancer Update are projected to result in over 400 Canadian lives lost each year. Incredibly, these new guidelines were issued without the involvement of an expert in breast diagnosis or treatment. Instead, the panel involved family doctors, nurses, a chiropractor, an occupational therapist and a nephrologist (kidney specialist).

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Why? The Task force claimed that including an expert in breast cancer diagnosis would bias the guideline development. The Task Force implied that because radiologists earn a living by diagnosing breast cancer they place financial gain above the welfare of patients. As a physician who lost a loved one to breast cancer, and as a mother, friend and colleague to many women affected by breast cancer, I find this particularly galling, and many of my colleagues in Canada agree. The Task Force demonstrated an ignorance of the extensive evidence supporting breast cancer screening. A recent study from Sweden published in the journal, Cancer showed that screening mammography resulted in 60 per cent fewer deaths from breast cancer over a 20-year time period. Another study published just this week in Cancer shows after 30 years, screening mammography and advances in treatment have averted nearly 615,000 deaths from breast cancer in the U.S. alone since 1989. Continued on page 47

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IN BRIEF

Clinical guidelines

from specialty societies often biased linical practice guidelines issued by specialty societies in North America often recommend health care services linked to their specialties, in contrast with European guidelines and those from independent organizations, argues a commentary published in CMAJ. “Regardless of country of origin, physicians often recommend procedures and treatments that they are trained to provide, a phenomenon known as ‘specialty bias,’” write Drs. Ismail Jatoi, University of Texas Health, San Antonio, Texas, and Sunita Sah, Cornell University, Ithaca, New York. “This may explain why medical specialty societies frequently issue guidelines calling for greater use of health care services linked to their specialties…, thereby exacerbating overdiagnosis, overtreatment and increasing health care costs.” For example, the National Comprehensive Cancer Network in the US

REGARDLESS OF COUNTRY OF ORIGIN, PHYSICIANS OFTEN RECOMMEND PROCEDURES AND TREATMENTS THAT THEY ARE TRAINED TO PROVIDE.

included 25 urologists on its 32-member guideline panel for prostate cancer and recommends prostate-specific antigen (PSA) screening for healthy men aged 45 and older. By contrast, the Canadian Task Force on Preventive Health Care, with no urologists on its nine-member panel, and the European Society for Medical Oncology, with one urologist on its 4-member panel, both recommend against PSA screening for men of all ages. The type of health care system, such as fee-for-service, can also affect the type of recommendations, with specialists in such a system recommend-

ing more intensive diagnostic and treatment guidelines. “Evidence-based clinical practice guidelines can improve health care delivery,” write the authors. “Yet specialty bias and fee-for-service conflicts of interest threaten their validity and may lead to unnecessary overuse of health care services. More is not necessarily better in medicine; if anything, patient outcomes may be worse the more “care” they receive. Every medical test, procedure and treatment adds risk against potential benefit, and some may lead to more harm than H good.” ■

Examining how virtual care can improve access and quality he Canadian Medical Association (CMA), the Royal College of Physicians and Surgeons of Canada (Royal College) and the College of Family Physicians of Canada (CFPC) are launching a task force to examine virtual care technology and how it can improve access and quality of care for patients from coast-to-coast-to-coast. The task force will identify what regulatory changes are required for physicians to deliver care to patients within and across provincial/territorial boundaries while also addressing its administrative challenges. In addition, the task force will explore how health information can be effectively captured and available to both physicians and patients.

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“It is time for our policies and regulations to evolve to today’s available technology. Removing barriers can lead to improved access to care for all Canadians,” says Dr. Gigi Osler, President of the CMA. “This is a timely opportunity to improve access and communication between patients and their doctors,” says Dr. M. Ian Bowmer, President of the Royal College. “Together, we’re laying the groundwork for an innovative approach to delivering care to patients.” “The CFPC is leading family medicine into adopting new ways of helping family doctors care for their patients in all communities across the country,” adds Dr. Paul Sawchuk, the CFPC’s President. “This physician-led taskforce

will support our members in continuing to provide quality, compassionate care through virtual interactions.” A 2018 Ipsos poll confirmed that seven in 10 Canadians say they would take advantage of virtual physician visits if they were available, and nine out of 10 physicians support either a national licensure regime or universal recognition of provincial/territorial licensure. The task force is expected to complete its work by the end of 2019, with recommendations put forth in early 2020. The task force will be comprised of representatives from regulatory bodies, medical and healthcare organizations, eHealth industry, among other H experts. ■

New tool better at predicting death after cardiac admission than current indexes new tool designed for patients with heart disease is better at predicting death after hospital admission than current tools, according to a study published in CMAJ (Canadian Medical Association Journal). “This cardiac-specific tool, or index, to predict death outperforms current general indexes used to predict death,” says Dr. Marc Jolicoeur, Montreal Heart Institute, Université de Montréal, Montréal, Quebec. “The other available tools are good for all patients, but we developed one that is better specifically for cardiac patients.” Current indexes already exist to help predict likelihood of death and are widely used in clinical settings, although these are not disease-specific, and accuracy for patients with cardiac issues has not been widely investigated. Researchers analyzed administrative data on cardiac patients admitted to the Montreal Heart Institute to create and test an index, the Cardiac-Specific Comorbidity Index, to help predict death both in-hospital and within one year in a group. They then tested the index in a group of almost 19,000 cardiac patients in Alberta. Their cardiac-specific comorbidity index outperformed both the Charlson–Deyo comorbidity index and the Elixhauser comorbidity index. “Estimating risk is important for patients and their families, as well as policy-makers, to help them monitor outcomes at various hospitals and guide decisions,” says Dr. Jolicoeur. “With this tool, patients at high risk can be flagged, and appropriate care can be taken to manage their condition,” he says. Most importantly, this tool was derived and validated in Canada and will therefore be suitable for use by Canadian researches, administrators and deciH sion-makers. ■

APRIL 2019 HOSPITAL NEWS 7

NEWS

Canadian astronaut takes part in study of bone marrow health in space By Amelia Buchanan anadian Space Agency (CSA) astronaut Dr. David Saint-Jacques is taking part in a made-in-Ottawa experiment on bone marrow health during his six-month mission on the International Space Station. The study, led by Dr. Guy Trudel, is called MARROW, and will provide world-first insights into how space travel affects the bone marrow, which produces blood cells. These findings will inform longer space missions, and may also help patients back on Earth who spend weeks in bed recovering from illness. “Aboard the International Space Station, I will be participating in hundreds of science experiments on behalf of researchers from around the world,” says Dr. Saint-Jacques. “I will conduct Canadian experiments which focus on health sciences, like MARROW. As a doctor, I have a strong interest for that type of research that has concrete impacts on the lives of Canadians.” Dr. Saint-Jacques is one of 14 astronauts who signed up to be part of the MARROW study. Breath and blood samples are taken over the course of their six-month mission in space and in the year after they return to Earth. The goal is to understand how living in space affects their bone marrow health and how it recovers upon their return. “What astronauts go through in space is similar to what I see in my own patients,” says Dr. Trudel, a researcher and rehabilitation physician at The Ottawa Hospital Rehabilitation Centre and professor at the University of Ottawa. “The low gravity in space weakens muscles and bones. The same happens to patients who spend a long time in bed in the intensive care unit.” Many researchers travel to the Johnston Space Center to pitch their projects, hoping for astronauts to say “yes.” Dr. Trudel’s team beat the odds, with 14 astronauts signing up for MARROW in just three years.

Photo credit: NASA

CSA astronaut Dr. David Saint-Jacques is one of 14 astronauts who agreed to take part in a world-first experiment to learn about bone marrow health in space.

THE STUDY, LED BY DR. GUY TRUDEL, IS CALLED MARROW, AND WILL PROVIDE WORLD-FIRST INSIGHTS INTO HOW SPACE TRAVEL AFFECTS THE BONE MARROW, WHICH PRODUCES BLOOD CELLS. “Very few astronauts we talked to said “no” to MARROW,” says Dr. Trudel. “Because they were so eager to sign up, everything is going much faster than I anticipated.” He expects all the data will be collected by 2020, and the results published soon after. Not only did Dr. Saint-Jacques agree to take part in the study, but he also visited Dr. Trudel’s lab to help the team adapt their experiment for space. “Dr. David Saint-Jacques has been a

very enthusiastic supporter of MARROW,” says Dr. Trudel. “As a doctor, he could see this was an experiment that needed to be done, not only to help astronauts in space, but for patients here on Earth.” Dr. David SaintJacques and Dr. Guy Trudel Dr. David Saint-Jacques (left) visited Dr. Guy Trudel’s lab to help the team adapt their bone marrow health experiment for space. Photo credit: University of Ottawa.

After recruiting all 14 astronauts, work is far from over for Dr. Trudel’s team. Every day they need to be aware of what is happening on the International Space Station so they can adapt the experiment or the delivery of supplies. Dr. Trudel says MARROW remains an exciting project, full of unknowns, including what the results will be. The project was funded by the Canadian Space Agency. “Having a Canadian astronaut aboard the space station is the most visible part of Canada’s contributions to space exploration,” says Dr. Trudel. “But Canada’s work in robotics, artificial intelligence and telemedicine are all essential to the space program and helping the next generation of astronauts achieve even longer H missions.” ■

Amelia Buchanan is a Senior Communication Specialist at the Ottawa Hospital Research Institute. 8 HOSPITAL NEWS APRIL 2019

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NATHALIE AND ÉMILE KNOW ABOUT “ACTIVE OFFER” OF FRENCH LANGUAGE SERVICES

DO YOU? It’s a parent’s worst nightmare: an emergency visit to the hospital in the middle of the night. “My child’s in danger,” screams your mind, sending alarm bells ringing. “Will he be okay?” That’s what happened to Nathalie when she took Émile to Emergency at a hospital in Toronto. Only, the thoughts going through Nathalie’s mind were in French because she and her child are French-speaking. Though Nathalie was able to interact with staff in English, the situation was stressful for both her and Émile since their primary language is French. By chance, one of the attending nurses spoke French. “Quelle différence,” says Nathalie. It made a world of difference since she could speak to the nurse in their common language and more importantly, little Émile could better grasp what was going on and be reassured in his mother tongue. This time, by chance, Nathalie and Émile were lucky. And because the hospital was able to provide linguistically and culturally appropriate service, there was a better outcome. Find out more here: refletsalveo.ca/active-offer-training

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“DON’T LEAVE IT TO CHANCE” Imagine a health system where on arrival, Nathalie and Émile would have known they could be served in French (through a clearly displayed sign), where they could have been identified as French speakers (through a simple question at intake) and where the hospital could have connected them to French-speaking staff (by identifying language skills and tracking them electronically.) “Quelle différence!”

That’s Active Offer. It makes a difference. It improves patient experience, reduces risks and leads to better health outcomes.

NEWS

Precise and powerful

CyberKnife robot

destroys inoperable tumours By Caitlin Renneson atients don’t need to have a metal halo screwed into their skull when they receive radiation treatment with CyberKnife. That was one of the appealing factors for neurosurgeon Dr. John Sinclair to bring the radiosurgery robot to The Ottawa Hospital. With previous radiosurgery, a patient with brain tumours had to have their head immobilized during treatment. A metal frame or ‘halo’ was screwed into their skull and then fastened to the table they’d lie on for treatment. However, a patient does not need to be rigidly immobilized when receiving CyberKnife radiosurgery. The robot uses X-rays and complex precision software to accurately track the tumour, and deliver a high dose of radiation to the precise location of the brain tumour while the patient lies on the table fitted with a custom-made plastic mask. “CyberKnife has an advantage over regular radiation because it is so much more accurate; precision is less than a millimetre,” says Dr. John Sinclair, Director of Cerebrovascular Surgery at The Ottawa Hospital. “You can give

very high doses of radiation right to the lesion and get almost no spill over to normal tissue. And as a result, we see much more improved responses to this type of treatment compared to traditional radiation.” Dr. Sinclair was first introduced to CyberKnife when he did a fellowship at Stanford Medical Center in California. CyberKnife was invented at Stanford, so the neurosurgeon was one of the first to see the benefits of this frameless radiosurgery treatment. When Dr. Sinclair was recruited to The Ottawa Hospital in 2005, he hoped to bring this novel technology to patients here. At the time, it was a technology that wasn’t approved by Health Canada. So, Dr. Sinclair and his team made a case for robotic radiosurgery, presenting scientific data that validated its success. The Ottawa Hospital was eventually one of two health research centres in Ontario allowed to test the CyberKnife. However, there was no government funding available to purchase the machine. The hospital appealed to the community, which pulled together and generously raised the entire $4 million to purchase it.

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THE CYBERKNIFE RADIOSURGERY ROBOT AT THE OTTAWA HOSPITAL IS MORE POWERFUL, MORE ACCURATE, AND MORE VERSATILE THAN REGULAR RADIATION, AND RESULTS IN LESS DISCOMFORT, FASTER RECOVERY AND BETTER OUTCOMES FOR PATIENTS.

Dr. John Sinclair is the Director of Cerebrovascular Surgery at The Ottawa Hospital.

CyberKnife began treating patients in September 2010. “Because it’s delivering a high dose, it’s considered similar to surgery without using a scalpel, so no blood loss, no pain, no ICU stay, or recovery time,” says radiation oncologist Dr. Vimoj Nair, one of the radiation oncologists trained to prescribe CyberKnife treatment. “So CyberKnife radiosurgery does provide an option where people can be treated with outpatient techniques,” says Dr. Nair. With conventional radiation, the daily doses were lower, and patients were required to come to the clinic for more radiation treatments overall. Conventional radiation treatment could range from five to six weeks. With CyberKnife, radiation is focused precisely to the tumour allowing for larger doses to be delivered daily and, therefore, the total treatment can be delivered in one to six days. The hospital’s CyberKnife has gained a reputation for improving treatment of various tumours. And Dr. Nair says because it is only one of three in Canada, patients occasionally are referred to The Ottawa Hospital for

treatment from British Columbia to the Maritimes. “At first, we would treat one tumour. Now, we treat five or six individual tumours at a time and spare the rest of the brain. We’re only delivering radiation to those metastatic tumours,” says Dr. Sinclair. “There is a proportion of patients who develop cognitive problems a few months after whole brain radiation. But with radiosurgery, because we only give the radiation – a higher dosage – to the actual tumours, patients have improved outcomes, and so quality of life is better.” Radiation therapist Julie Gratton says this has meant an increase in the number of patients having multiple tumours treated in the same session. “Treating several tumours at once helps keep the patient’s clinic visits to a minimum while targeting individual tumours rather than treating the whole organ helps spare healthy tissues and reduce side-effects,” says Julie who has worked on CyberKnife since it was installed at The Ottawa Hospital. Up until 2017, 1,825 patients had been treated on CyberKnife. In 2018, www.hospitalnews.com

NEWS

Sunnybrook mobile app helps clinicians easily add notes to patient chart By Laura Bristow magine being able to add a note about a patient’s progress to their chart from anywhere in the world with an iPhone. No physical chart or desktop computer required. That’s exactly what’s happening at Sunnybrook these days thanks to an app called SunnyCare Lite. SunnyCare Lite is a corporate iPhone mobile app that allows clinicians (e.g. physicians, nurse practitioners, residents) to dictate patient notes into the hospital’s SunnyCare system by using their phones. “It was developed in-house and Sunnybrook is the first hospital in Canada to implement this technology,” says Oliver Tsai, Director, Information Technology at Sunnybrook. “We’re seeing great results and getting good feedback from our users. It’s changing the way they work.” When the user logs in to the secure app, they are presented with their patient list. The user selects the patient they wish to dictate a note on and specifies the note type from a dropdown menu (e.g. consult note, follow-up note). Next they specify the Service or Clinic, based on whether the patient is an inpatient or outpatient. A Nuance Dragon-powered speech bar appears, and

359 patients have already received 1,824 CyberKnife treatments. Julie says that because more tumours are being treated at once in each patient, the number of treatments delivered per year has increased as expected. Although 90 per cent of CyberKnife treatments are for malignant or benign brain tumours, CyberKnife is also being used to treat tumours outside the head. As it doesn’t require a frame to

rigidly immobilize the area receiving radiation, CyberKnife’s image guidance system is used to treat organs that move constantly, such as the lungs, kidneys, liver, prostate gland and lymph nodes. CyberKnife can precisely align the radiation beam to the tumour even when it moves. The method of tracking tumours in organs and soft tissue has been improved by research H at The Ottawa Hospital. ■

Caitlin Renneson is the Communications Coordinator at The Ottawa Hospital.

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dictation can begin. Once finished, the note can either be saved as a draft or electronically signed-off. It is then immediately available in the patient’s chart in SunnyCare (the hospital’s integrated electronic clinical care system) where it can be reviewed or edited on a desktop computer. Signed notes are also immediately available in MyChart (the hospital’s patient portal system). The app launched at Sunnybrook on December 3, 2018, and since going live 2,153 notes have been created using SunnyCare Lite. It is also garnering rave reviews from clinicians. Dr. Todd Mainprize, Division Head of Neurosurgery, calls the app ‘transformative’. “It has been a major time-saver as it prevents me from having to track down either the physical patient chart or a computer to make a note,” says Dr. Mainprize. “It’s easy to use because it’s with you all the time, and it improves communication within the team, which is ultimately great for patient care.” Dr. Steve Shadowitz, Division Head of General Internal Medicine says, “SunnyCare Lite is a major timesaver, and so functional. I’m dictating notes everywhere, free from desktop or laptop from my H phone. It’s been tremendous.” ■

Laura Bristow Communications Advisor at Sunnybrook Health Sciences Centre.

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NEWS

Heart failure care:

How one new technology is paving the way for a new model of care By Jessica Fifield

eart failure is the most rapidly rising cardiovascular disease in Canada, currently affecting more than one million people nationally, and with more than 50,000 new diagnoses annually. A complex chronic condition, people living with heart failure face symptoms of shortness of breath, swelling in the lower limbs, and fatigue, as well as frequent flare-ups often leading to hospital admission. The journey that follows heart failure diagnosis is undeniably challenging and for many, life altering. Heart failure management requires patients to take an active role in their care by maintaining a low-sodium diet, restricting fluids and taking their medication as prescribed. Guideline directed care is a cornerstone of therapy. A major challenge in care is the lack of access to heart failure specialists. Currently, in Canada, clinics are facing high patient volumes that cannot be supported with traditional patient visits alone. Within the Heart Failure Clinic at University Health Network’s Peter Munk Cardiac Centre, one program is helping pave the way to transform how care is delivered for heart failure patients and reduce the burden on the health system, and most importantly the patients themselves. Medly, a heart failure management program,developed by the teams at UHN’s eHealth Innovation, Peter Munk Cardiac Centre and Ted Rogers Centre for Heart Research, is a first of its kind in Ontario and Canada. Medly is unlike traditional telemonitoring programs with its use of the Medly management algorithm, developed by heart failure clinicians to rapidly assess and triage patients, and the creation of a new role in the heart failure care delivery model: a Medly coordinator role.

Mary O’Sullivan, a registered nurse and the Medly coordinator at the Peter Munk Cardiac Centre, currently manages nearly 300 heart failure patients, a patient volume not typical of such a role. For Mary, her patient load is made possible and has the potential to grow with the support of the Medly Program. “I am able to connect and give nursing care to patients across the province each day,” Mary says. “ Medly provides a platform for such a unique nurse-patient relationship. It allows me to gain insight into how their heart failure management fits into their daily lives and enables me to interact with patients in their own environment and develop long-term relationships with them. This personal element enhances the way that I assess, triage and provide education for these patients.” The Medly Program allows Mary to assess, support, and provide education for her patients in real time from wherever they may be located. These patients use the Medly smart-

phone application to record their daily weight, blood pressure, heart rate and symptoms. These measurements are analyzed instantly via the Medly management algorithm. If the algorithm determines that a patient’s clinical status is deteriorating, an actionable feedback message is sent to the patient, and Mary is alerted through the Medly clinician dashboard. When alerts are received, Mary assesses the patient’s clinical need and can escalate to the patient’s cardiologist who then provides higher-level clinical expertise. Through this alert escalation process, more patients are able to access their heart failure specialist at the right time. For one of Medly’s clinical champions, cardiologist and Division Head, Cardiology, at PMCC Dr. Heather Ross, the addition of Mary’s role to the Peter Munk Cardiac Clinic has proved to be invaluable. “Mary has allowed us to realize the promise of Medly, specifically being able to scale a remote monitoring intervention to a large population at reasonable cost.”

In a perfect world, Mary’s role and technologies like Medly would already be infused and easily deployed across the healthcare system. Product Owner at eHealth Innovation, Mala Dorai believes the program is unparalleled to any other heart failure management solution she has come across. “The rapidly rising burden of heart failure requires us to think outside the box. We at eHealth Innovation are doing just that. We designed the Medly program with a team of engineers, researchers and human factors experts who understand the needs of heart failure patients, and consulting heart failure specialists with the practical clinical knowledge and processes of Canada’s leading cardiac care centre (PMCC). This is why I believe Medly is the kind of specialized yet scalable solution capable of addressing this critical need.” For more information on the team behind Medly and the program itself, H you can visit: Medly.ca/about ■

Jessica Fifield is the Marketing & Communications Coordinator, eHealth Innovation & Healthcare Human Factors, University Health Network 12 HOSPITAL NEWS APRIL 2019

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COVER

Virtual care:

The front door to patient-centred care By Dr. Ed Brown lizabeth, a 40-year-old from Moncton, NB, was diagnosed with a unique tumour that couldn’t be treated locally. Dr. Calvin Law, an oncology surgeon at Sunnybrook Health Sciences Centre in Toronto, was able to see her pre-op and post-op by videoconference. Elizabeth had to travel

14 HOSPITAL NEWS APRIL 2019

to Toronto only once – for her surgery. Franklin, a senior with congestive heart failure, uses a tablet with wireless blood pressure cuff, weigh scale and pulse oximeter at home. Andrea Portelance, RN, at the Toronto Central LHIN, monitors his vital signs at a distance and provides personalized health coaching by phone. He has

regained confidence in his self-management capability and has avoided having to go to the ER since he started the program. Dr. Nihal El Khouly, a family physician in Bolton, ON, responds to a secure message one of her patients sent from their smartphone. The patient gets a timely response and avoids the

need to arrange an office visit. These three real examples of virtual care in action demonstrate what patient-centred care can look like. And increasingly, providers and policy makers are paying attention. That’s because our healthcare systems across Canada are aiming to turn themselves upside down, moving from www.hospitalnews.com

COVER a predominantly provider-centric world to a patient-centric one. Providers and governments from coast to coast are talking to patients and looking to design new models of care delivery that improve the patient experience. The solutions generally involve strategies to integrate care delivery across the continuum while treating patients as partners in their own care, rather than just as... well... patients.

AS WE EMBARK ON THE INTEGRATED CARE JOURNEY, VIRTUAL CARE WILL EMERGE AS A MAINSTREAM CORNERSTONE OF THE RESTRUCTURING EFFORTS. These new care models come in many different flavours and names. In Ontario, we are calling these Integrated Care Delivery Systems “Ontario Health Teams”. But whatever one calls them, the goal is the same. It’s about value-based care that optimizes the outcomes that matter most to patients within the available budget. It’s long been recognized that digital health is central to integrating care in this way. Electronic health records need to be shared across the circle of care, including patients and caregivers. Data needs to be aggregated and analyzed to proactively apply preventive care and to examine progress against quality metrics. The electronic health record journey has been long – and expensive –

and we have made enormous strides over the last decade. However, there is a second type of digital care that has not received as much attention. While the electronic health record world focuses on sharing and collecting data, virtual care focuses on the use of technology to support patients in the community and to deliver care directly to them. Used well, it improves access to care and can greatly enhance the patient experience. The use of virtual care is growing rapidly. In 2018, there were over 960,000 clinical videoconferencing events in Ontario, similar to Dr. Law’s use above. More than 19,000 patients have participated in remote monitoring and coaching to empower patients with chronic disease in Ontario, as described above, since the program began. And in primary care, more than 30,000 patients and 275 primary care providers in Ontario are signed up for the project alongside Dr. El Khouly, enabling patients to securely message their own family doctor. As we embark on the integrated care journey, virtual care will emerge as a mainstream cornerstone of the restructuring efforts. To start with, virtual care will become the “front door” to care. It helps patients know who their provider teams are and to understand the resources available. It makes it easy to know where to go and how to connect for care. It adds convenience and will reduce hospital use. The ‘front door’ engages patients by easily linking them to “my care providers” and “my health services.” Moreover, virtual care also provides a whole new array of tools for providers that can be offered to patients in an integrated care model. There are many

Better care, lower cost

• Dr. Arsh Jain, a nephrologist specialist care in 2018 had at London Heath Sciences travelled instead, it could have Centre, uses virtual technology cost as much as $40 million in to help patients succeed at travel grants. home dialysis. The alternative • Some regions in Ontario that is hospital dialysis, which costs deliver the aforementioned about $30,000 more annually remote monitoring and coaching per patient. program for chronic disease • Patients who live in Northern report reductions in hospitalizaOntario are provided with travel tion of more than 50% for heart subsidies if they need to travel failure patients. to receive health care. If all of • It is estimated that more than the patients who used clinical $11 million in hospital admisvideoconferencing for their sions were avoided last year. areas that can be addressed but here are a few examples: • Palliative Care: The Champlain region engaged in a pilot program to support palliative care at home using remote monitoring for pain and symptom management, enabling people to spend more time at home with family during that very challenging period. • Specialist Access: Providers across Ontario did 56,000 video visits directly to people’s homes in 2018, providing a new level of convenience for patients and reducing pressure on hospitals. • Mental Health: Big White Wall, a free online peer community for people with mild to moderate depression or anxiety, was introduced in Ontario, starting this past fall, and some 16,000 people have signed up to use it. Virtual care solutions not only improve the patient experience but also tend to be relatively inexpensive to ac-

quire and can be used in ways that tend to reduce cost or improve efficiency. This is a “win win.” Better experience at lower cost. That’s why other industries like banking, travel and retail are already using online services.

HOW TO GET THERE At present, there is a prevalence of excellent virtual care solutions, apps and technologies available out there. That’s the easy part. The challenge on this front is deciding which are fit for purpose and how to deliver them as simply and coherently as possible to providers and patients. The harder part is creating the integrated care networks needed to deliver the care. That is a longer road that will need great leadership from our provider communities and our policy makers. What about the patients, you say? I think they are more than ready. All they have to do is pick up their smartH phones! ■

Dr. Edward M. Brown, MD, M.S.M., is founder and Chief Executive Officer of the Ontario Telemedicine Network (OTN).

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APRIL 2019 HOSPITAL NEWS 15

MSH sonographers attain spectacular images in fetal, pediatric and adult echocardiography.

NEWS

Millions of Canadians visit the hospital each year: How much does it cost

Seamless and dynamic O echocardiography

By Julie Bortolotti

By Lynne Campkin arkham Stouffville Hospital (MSH) recently expanded its cardiology programs which have resulted in an increase in patients who require more complex care. In order to serve these patients, high quality images of the heart, blood flow and fine anatomic detail are needed by cardiologists to make confident and specific diagnoses from echocardiograms. Dr. Joseph, Minkowitz, Lead Cardiologist at MSH, recognized a gap in the current system that made it more difficult for care providers to access these high quality images. He advocated for an improved electronic platform to address this gap and better serve the current and future growth of cardiac programs at both the Markham and Uxbridge sites. The MSH diagnostic cardiology and information technology teams set out to find a software solution that would enable the ideal workflow from order entry to signed cardiologist consultative report and deliver high quality images maximizing both temporal and spatial resolution captured at the bedside. Echo equipment continually improves and MSH sonographers attain spectacular images in fetal, pediatric and adult echocardiography. When the imaging chain is extended through the use of software and networks to transmit images for interpretation it is

important to ensure excellent image quality at staff workstations in the hospital and at each cardiologist’s desktop in the various locations that they work from. In November 2018, MSH upgraded to the Siemens Syngo Dynamics electronic image management software to optimize integration with their GE and Philips echo equipment. This provided seamless workflow for each clinical team member and ultimately enhanced patient care, customer service and team productivity. With this implementation, there has been a significant improvement in the time to send images to cardiologists and in overall report turnaround time. “The Syngo Dynamics integration with Meditech and the echo equipment helped with standardizing an improved structured report for both internal and external referring clinicians and enhanced work flow for the sonographers and cardiologists,” says Dr. Shruti Tandon, MSH Cardiologist. “The whole care team is more productive which means we can provide more timely care to more patients.” Having the whole image-to-report process fully digital replaces the intense manual process of recording important information in patient studies. “My team finds the case specific notes section a valuable communication tool

that enables an exchange of relevant qualitative information for the interpreting cardiologist.” cardiologist ” says Jennifer Martin, Lead Echocardiographer at MSH. “I love the ability to easily recall any patient’s full dynamic echocardiogram at any Meditech workstation throughout the day without interrupting patient care on the echo machine.” Cardiologists often need to refer to previous patient studies; in the past this meant searching through CD records which did not have easy search functionality. “The new reporting system is fast, enables patient study retrieval in full resolution to support education rounds and most importantly, delivers high quality, dynamic images for review and interpretation” says Dr. Jonathan Lu, MSH Director Echocardiography Laboratory. Finally, the clinical and technical system administrators and department leaders are happy with the ease of implementation, vendor product knowledge, easy retrieval of archived patient studies, and cost per case analysis. The future sustainability of the health care system depends on improving quality while growing capacity and saving valuable dollars. This digital improvement project achieved all of these requirements; delivering hard wired systems supporting scalability, accuracy H and efficiency for a low cost per case. ■

ur health care system is a source of pride for many Canadians and has a positive reputation around the world for universal coverage. Governments fund hospitals within the respective jurisdictions, but Canadians do not receive a bill after their hospital visit, and many are unaware of how much care costs. This year, for the first time ever, the Canadian Institute for Health Information (CIHI) released infographics and data tables that break down where hospitals spend money. Canadian hospitals cost more than $51 billion in 2017-2018 (excluding Quebec and Nunavut), while overall hospital spending has grown at an average of four per cent since 2005. Employee compensation was the largest area of hospital spending at 64 per cent, followed by supplies (12%) and sundry (6%). Sundry are expenses such as lawyer and advertising fees that do not fall into other spending categories.

WHICH CONDITIONS ARE THE MOST EXPENSIVE? Chronic obstructive pulmonary disease, also know as COPD, cost Canadian hospitals over $753 million in 2016-2017. Heart failure, pneumonia, partial knee replacements, and dementia made up the remaining top five conditions by total hospital cost, respectively. 1. Chronic obstructive pulmonary disease, $753.3 million

Lynne Campkin is Director, Diagnostic and Laboratory Services at Markham Stouffville Hospital.

Continued on page 17

16 HOSPITAL NEWS APRIL 2019

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NEWS

Scaling up virtual care in Canada: Addressing the barriers to capitalize on the opportunities By Dr. Gigi Osler n the world of medicine, we are living in an incredibly exciting time. Remarkable innovations in everything from minimally invasive surgery to biologic treatments continue to improve health outcomes. Yet in Canada, we struggle to evolve our models of health care delivery - models that have essentially remained unchanged since the 1960s. Although the world we live in has changed a great deal, with technology at the centre of many daily transactions, health care delivery has changed very little. The time has come for new technologies which enable virtual care to be integrated into our health care system. A survey conducted last summer by the CMA confirmed that Canadians are ready: seven out of 10 would take advantage of virtual physicians’ visits, if it were available. In fact, 75 per cent of Canadians believe new technologies could help address issues related to access and wait times. At the same time, when we look at the early development of virtual care, it’s noteworthy that Canada was once a

pioneer in this area. In the 1970’s, the late Dr. Maxwell House of Memorial University of Newfoundland was using telephone technology to provide virtual consultations to remote communities throughout the province. In a province as vast as Newfoundland, the benefits of this innovation were obvious. Yet despite these early innovations in virtual care, today Canada still lags behind in its adoption. So what is holding us back? In a discussion paper published by the CMA last August, four barriers were identified: • Governance of compensation mechanism: Most provincial payment systems are based on face-to-face

encounters between the patient and the physician and compensation for e-consultation remains very limited. In contrast, private sector companies have been very active in this space, offering a pay-per-visit fee or membership model for anyone willing to pay out of pocket. • Regulatory barriers: This is perhaps one of the most complex challenges. Regulations and policies have not evolved to support the introduction of virtual care and new technologies. Simple tasks, such as electronic prescribing, still require an original signature, forcing many medical professionals to rely on the fax machine

How much does it cost? Continued from page 16 Which health conditions are the most expensive?

What are hospitals spending on?

How does Canada’s hospital spending compare internationally?

The continuing shift from inpatient to outpatient care

2. Heart failure without coronary angiogram, $575.2 million 3. Viral/unspecified pneumonia, $505.8 million 4. Unilateral knee replacement, $486.4 million 5. Dementia $404.0 million For more information about the average costs of hospital services based on specific conditions, visit CIHI’s Patient Cost Estimator tool.

HOSPITALS CONTINUE THEIR SHIFT TO OUTPATIENT CARE A growing number of people access outpatient care at Canadian hospitals. Since 2005, the number of outpatients has increased almost 1.5 times more than inpatients. However, the complexity of care for both inpa-

tient and outpatient cases also has increased.

HOW DOES CANADA COMPARE INTERNATIONALLY? Canada’s hospital spending is in line with the OECD average per capita in government funds, but slightly below the OECD household out-of-pocket average. We spend less government funds than United States, Australia, Sweden and the United Kingdom. Contrary to what some people may believe, health care in Canada is not free. CIHI’s hospital spending data provides a glimpse of where hospitals spend money so that health system decision-makers are equipped with the data they need to H make decisions and improve care. ■

– and so on. The other key issue is the delivery of care across provincial boundaries. In most jurisdictions, a physician cannot provide care to a patient in another province without a license from the patient’s provincial regulatory body. • Security of personal information: When we speak of electronic forms of communications, issues of privacy arise – and with good reason. More and more, we learn of privacy breaches with far reaching impacts. • Digital divide and access to technology: Consistent access to proper broadband technology is not guaranteed across the country. A 2014 survey found that only 85 per cent of Canadians living in rural communities have access to high speed internet. And this divide is even greater in many remote, northern, and Indigenous communities. For this reason, we were encouraged by the federal government’s commitment to high speed internet in rural and remote communities as part of its 2019 budget. The barriers to virtual care are not insurmountable, but they need to be reviewed and – most of all – addressed. This is why the CMA has joined forces with the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada to create a taskforce on virtual care. The physician-led group, composed of representatives from regulatory bodies, medical and healthcare organizations, eHealth industry, as well as patients, will identify the regulatory and administrative changes needed to support virtual care in Canada, and to allow physicians to deliver care to patients within and across provincial/territorial boundaries. I look forward to sharing the group’s report later this year. Virtual care offers unparalleled potential for efficiencies and improved access in our health care system. But the barriers are real and complex. For this reason, we need thoughtful, innovative thinking to ensure we are able to fulfill the vision of a better health care system H for all Canadians. ■

Julie Bortolotti is a Communications Specialist at The Canadian Institute for Health Information (CIHI).

Dr. Gigi Osler is President of the Canadian Medical Association.

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APRIL 2019 HOSPITAL NEWS 17

NEWS

Leading the integration of physical and mental health By Jasmine Sikand or years, mental and physical health were treated separately. For patients in the Inpatient Psychiatry Unit at Toronto General Hospital (TG), that meant having to move to another unit if they had a physical health condition needing attention. But that’s changing. For the past couple years, TG’s Inpatient Psychiatry Unit has been working on integrating mental and physical health, achieving some inspiring results that offer a snapshot of what the future of mental health care could look like. “Historically, we would only treat the mind, but patients don’t leave their other organs in the elevator when they come here,” says Aideen Carroll, Nurse Educator at UHN’s Centre for Mental Health. “We need to treat the whole person.” Aideen says the nursing staff in the Inpatient Psychiatry Unit realized patients needed physical interventions and care for the mind and body, as many of the patients have multiple conditions. About a decade ago, the Canadian Institute for Health Information found that Canadians reporting symptoms of depression also reported experiencing three times as many chronic physical conditions as the general population. Ultimately, Aideen says, the nursing team has learned the right patient needs to be at the right place at the right time. In December 2018, UHN’s Strategic Plan – “A Healthier World” – was released. One of its priorities speaks volumes to some of the goals UHN’s Centre for Mental Health (CMH) is working on: to “lead the integration of physical and mental health to establish new standards of care, as health and well-being require both.”

as patient demand for this type of care increases across the system. Lisa Crawley, Nurse Manager for the Inpatient Psychiatry Unit, says this change towards integrated care has evolved slowly as patient needs became more obvious and staff education and equipment were added to support it.

SOME CHALLENGES REMAIN Despite the interest from other hospitals, Lisa says there are still areas for improvement that would make this change more efficient and seamless. “Do you have a budget to bring in the equipment that you would now use?” Aideen says. “Are your staffing levels able to manage with these more complex patients that are going to come in?” Photo: Jasmine Sikand

Aideen Carroll, (L), Nurse Educator at UHN’s Centre for Mental Health, and Lisa Crawley, Nurse Manager for UHN’s Inpatient Psychiatry Unit

UHN IS ON THE THRESHOLD OF A HUGE CULTURAL SHIFT IN SEAMLESSLY BLENDING PHYSICAL AND MENTAL HEALTH, WHILE SIMULTANEOUSLY IDENTIFYING AND BREAKING DOWN THE BARRIERS BETWEEN THEM. The Inpatient Psychiatry Unit has been working on this integration by skilling up the nurses, who now routinely complete IV’s, blood work, blood transfusions, telemetry (the equipment used to track a patient’s heart rate, blood pressure, breathing and other vitals), complicated wound dressings, and more, based on the patient’s needs. This provides more integrated healthcare for patients within the unit. “If someone is in hospital for treatment for schizophrenia and also re-

quires telemetry, we can now provide telemetry without having to relocate the patient for the test and bring them back to the unit,” Aideen says.

OTHER HOSPITALS ARE TAKING NOTE Within the past year, staff from the Centre for Addiction and Mental Health (CAMH), St. Michael’s Hospital and Lakeridge Health have visited UHN’s Inpatient Psychiatry Unit to learn best practices in integrated care,

MOVING FORWARD Change requires a team effort, she says, adding that a first step is addressing barriers to providing excellent patient care. “I think it’s also about addressing our own stigma,” Aideen says. “I remember for years I would always hear you can’t have an IV pole in an inpatient psychiatric unit because it’s a potential weapon, but it may not be. “Instead, we now ask: ‘What does that individual patient need?’” Lisa says UHN is on the threshold of a huge cultural shift in seamlessly blending physical and mental health, while simultaneously identifying and breaking down the barriers between them. “No more are psychiatric patients going to be seen as being locked away in a unit somewhere; they’re going to a hospital for treatment of an illness,” Aideen says. “And maybe this will help with stigma as well, because it’s about crushing those barriers. These are illnesses like any other.” ■ H

Jasmine Sikand is the Program Development & Communications Coordinator at the Centre for Mental Health, University Health Network 18 HOSPITAL NEWS APRIL 2019

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EVIDENCE MATTERS

Monitoring tuberculosis treatment by video:

Might convenience increase compliance? By Barbara Greenwood Dufour n much of Canada, the risk of contracting tuberculosis (TB) is very low. However, the disease is still a significant concern among socioeconomically disadvantaged populations, immigrants, and Indigenous Peoples living in Canada. TB is an infectious disease that primarily affects the lungs but also the bones, joints, lymph nodes, or central nervous system. It’s very contagious, being spread through the air whenever an infected person coughs or sneezes. Effective treatment is, fortunately, available. Because treatment can require multiple medications over the course of several months, it’s recommended to have a health care provider watch patients take each dose to help ensure they’re adhering to treatment until they are cured. This is called directly observed therapy or DOT. Sticking with TB treatment until the end is important because incomplete treatment can lead to a drug-resistant form of TB that requires longer and more toxic treatment regimens. And people who aren’t effectively treated continue to be at risk of transmitting the disease to others. Completing the entire course of treatment, though, can be challenging for some people for a variety of reasons. For example, those living in remote northern communities, such as Nunavut, face challenges in accessing health care facilities due to severe winter weather and a lack of roads in addition to the shortage of health care staff to provide DOT. This coupled with the fact that in Inuit communities, according to the Public Health Agency of Canada, the rate of TB is almost 300 times higher than that of Canadian-born non-Indigenous populations makes the disease more difficult to eradicate.

HARNESSING MOBILE TECHNOLOGY TO PERFORM DIRECTLY OBSERVED THERAPY (DOT) FROM A DISTANCE — WHICH IS SOMETIMES CALLED VIDEO DOT OR VDOT — MAY OVERCOME THE TRAVEL AND ACCESS BARRIERS AND REDUCE THE INCONVENIENCE AND COST OF TRADITIONAL DOT. Harnessing mobile technology to perform DOT from a distance – which is sometimes called video DOT or VDOT – may overcome the travel and access barriers and reduce the inconvenience and cost of traditional DOT. CADTH recently included a summary of VDOT in its Health Technology Update newsletter. CADTH’s Horizon Scanning Service continually scans the horizon for emerging drugs, medical devices, and procedures that could have a significant impact on patient care and the health care system but are not yet widely available, in routine clinical use, or licensed for use in Canada.

VDOT allows patients to use a tablet, computer with a webcam, or smartphone so that their health care providers can see them taking their medications. It can be performed either synchronously – where patients transmit live video and health care providers see it in real time – or asynchronously – where patients record, save, and send videos to their health care providers. Common videoconferencing programs, such as Skype and FaceTime, can be used, although there have also been some specialized platforms developed. Does VDOT increase TB treatment adherence? It’s unclear. In researching this topic for Health Technology

Update, the CADTH Horizon Scanning Service looked for any available evidence on VDOT for managing TB, finding information on four observational studies and one randomized controlled trial. The conclusions of these studies are mixed – three (including the randomized controlled trial) reported that VDOT resulted in higher adherence (although only slightly in one study), and two found that the adherence rate with VDOT was similar to that of traditional DOT. It should be noted that CADTH only identified and did not critically appraise any of these studies, and so it has not assessed their quality. But a quick look at the conclusions of these studies gives us a sense that more evidence is needed. Since the CADTH Health Technology Update article was published, the results of a UK randomized controlled trial were published in The Lancet, which found that VDOT was more effective than DOT, less costly, and preferable for patients. For remote communities, VDOT might have the potential to address the significant geographic barriers to receiving TB treatment. Because VDOT requires high-bandwidth Internet access or smartphones with a data plan, it can’t be offered in many remote Canadian communities at the moment (note that about half of the communities in Nunavut currently don’t have cell phone service). But, a new satellite infrastructure expected to be put in place this year that could make the implementation of VDOT possible for these populations in the near future. If you would like to learn more about CADTH, visit cadth.ca, follow us on Twitter @CADTH_ACMTS, or speak to a Liaison Officer in your H region: cadth.ca/Liaison-Officers. ■

Barbara Greenwood Dufour is a Knowledge Mobilization Officer at CADTH. 20 HOSPITAL NEWS APRIL 2019

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14th Annual Hospital News

NURSING HERO AWARDS

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E-HEALTH

e-Health 2019:

A conference

re-imagined ith conference season around the corner, there are plenty of reasons to make the e-Health Conference and Tradeshow the ‘must attend’ event of the year. As the largest national digital health event, the conference brings together upwards of 1,500 passionate individuals from across the country to learn from leading digital health professionals and innovators from Canada and around the world. Along with all the great learning and networking opportunities that e-Health

Celebrate, Grow & Inspire Bold Action in Digital Health! 22 HOSPITAL NEWS APRIL 2019

always offers, this year the conference promises a new and modernized experience not to be missed. From a new location to the re-imagination of the conference program, there’s lots to look forward to at this year’s event. Taking place in Toronto, Ontario from May 26 to 29, at the newly renovated Beanfield Centre, the 19th annual event will continue to offer top-quality learning and no shortage of opportunities to Celebrate, Grow and Inspire Bold Action in Canada’s DigiH tal Health Community! ■ www.hospitalnews.com

E-HEALTH

Whatâ&#x20AC;&#x2122;s new at

e-Health 2019 e-Health 2019 is making big changes to its offerings to allow delegates to have a truly unique experience and make the most of their time at the conference. Here are some of the new features to look forward to: OPEN CONCEPT FLOORPLAN: e-Health is literally breaking down walls and moving toward a completely open concept space will provide delegates with the opportunity to move freely between the tradeshow floor, exhibits and plenary rooms, to ensure they do not miss a thing.

HEADSETS: The open-concept floor plan allows delegates to tune-into the speakers and sessions they are most interested in. To support this, all attendees will receive a headsets as part of their conference package. Not only will it give delegates control over which speakers they engage with, it will also mitigate any noise concerns.

WHITE SPACE: Delegates can take advantage of this new feature to create intentional free time. Need to check-in with the office, just relax, or a few minutes to create a viral tweet? This new feature is designed for delegates to create intentional free time between and during sessions to maximize learning and make the most out of their e-Health experience More features will be announced closer to the conference dates. Visit www.e-healthconference.com/conference-info/whats-new-at-e-health-2019 for updates.

CONNECTING MINDS: These brand new sessions offer delegates the chance to create their own brainstorming and meaningful networking opportunities in one of the educational areas set up on the show floor. Attendees are encouraged to step away from the hustle of the exhibit floor to share stories and insights of their daily issues in digital healthcare, either in a one-on-on setting, or with a group. Simply log into the e-Health 2019 mobile app (Available April 2019) and list topics you are interested in learning about or sharing knowledge on. The sessions will be held daily from 11:45-12:15 p.m. in H the dedicated areas. â&#x2013; www.hospitalnews.com

APRIL 2019 HOSPITAL NEWS 23

E-HEALTH

Sunday Workshop – Design Thinking with patients As a Patient Included accredited event, e-Health is also re-imagining its hallmark Sunday Workshop by inviting the team from Hacking Health to lead – PARTNERING TO DESIGN TOGETHER – An Innovative Workshop with Patients. This workshop will connect patients with digital health innovators to get their hands dirty and explore new techniques and resources through ‘design thinking’.

For those unfamiliar, design thinking approaches complex problems with the philosophy that solutions should be created with, and not just for, end-users. In this full day workshop, participants will adopt a design thinking mindset, as they identify problems, create innovative solutions and present ideas to the Hacking Health panel to be developed.

• Learn from and network with industry-leading experts, health enthusiasts and patients • Collaborate with colleagues from dif-

ferent disciplines to develop healthcare innovation • Increase knowledge and awareness of design thinking and patient-centred design • Develop and own a refined statement about a health innovation need and desired outcome for a specific patient The workshop will be an intense, collaborative, hands-on learning experience, that will enhance participants and spectators understanding of the design thinking process and definitely worth planning for an early arrival at the conference. Register today: www.e-healthH conference.com/register-now ■

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24 HOSPITAL NEWS APRIL 2019

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E-HEALTH

André Picard

Meet the Speakers espite the numerous change and upgrades promised at e-Health 2019, the conference will continue to deliver on its commitment to providing one-of-a-kind learning opportunities from some of the top leaders and minds of the digital health community from Canada and abroad. The conference has started to announce a stellar line-up of accomplished speakers that are not be missed.

OPENING KEYNOTE ADDRESS

Michael B. Decter

26 HOSPITAL NEWS APRIL 2019

Michael B. Decter President & Chief Executive Officer LDIC Inc. Michael B. Decter, a Harvard trained economist is the President and CEO of LDIC Inc. He served as Deputy Minister of Health for Ontario and Cabinet Secretary in Manitoba. Michael is a well-recognized expert on health care policy. He was the founding Chair of the Health Council of Canada. He continues to serve as the Chair of Medavie Inc. and Patients Canada. He is also a Trustee of Auto Sector Health Care Trust and Chair of its Finance, Audit and Investment Committee. He has authored Healing Medicare: Managing Health System Change – The Canadian Way

(1994). Four Strong Winds – Understanding the Growing Challenges to Health Care, (2000). and Navigating Canada’s Health Care, co-authored by Francesca Grosso, (2006). In 2004, Michael was awarded The Order of Canada

CLOSING KEYNOTE ADDRESS André Picard Award winning Health Columnist at The Globe and Mail André will be closing the Conference with the Lunch Closing Keynote Address, From Paper to Pixels – and Beyond. He is one of Canada’s top health and public policy observers and commentators, with a career spanning over three decades. He has received much acclaim for his writing, including the Michener Award for Meritorious Public Service Journalism and the Centennial Prize of the Pan-American Health Association, awarded to the top health journalist in the Americas. He is also an eight-time finalist for the National Newspaper Awards – Canada’s version of the H Pulitzer Prize. ■

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E-HEALTH

Conference Program With about 50 sessions and 250+ presenters spread out over the 4-day event, e-Health 2019 offers an abundance of learning opportunities on a range of topics, and opportunities for all attendees. Here is a selection of some of the planned sessions -- created from the hundreds of abstracts submitted from across Canada and internationally. MONDAY, MAY 27 10:30 A.M.–11:30 A.M. OS01 – It’s All About the Patient Outcomes • OS01.01 – Implementing a Patient Portal in a Paediatric World; Sarah Lee • OS01.02 – Virtual Emergency Support Service. “I’ve Got Eyes on the Patient”; Orpah Mackenzie • OS01.03 – Patient-Reported Outcomes for Hip and Knee Replacements in Ontario; Nicole De Guia • OS01.04 – Sex Workers’ Preferences for ICT Tools for Health and Safety OS04 – Cool Tools for Digital Health • OS04.01 – Streamlining communications for better patient outcomes #securemessagingworks; Mona Mattei • OS04.02 – Building an e-mental health toolbox: An implementation toolkit for clinicians; Danielle Impey

• OS04.03 – Usage of Kiosks to Improve Patient Registration Workflow; Dhara Hemant Desai • OS03.04 – Surviving big bang digital disruption: rapid problem solving and innovation; Bahdan Sadovy

MONDAY, MAY 27 12:30 P.M.–2:00 P.M. Plenary Session The Impact of Virtual Primary Care Visits on Continuity of Care, Friend or Foe? This panel will spotlight the increasingly active virtual primary care visit landscape both in Canada and internationally, and will discuss what we know about virtual primary care visits and their impact on continuity of care. This session will touch on the way in which provincial governments historically strived to ensure their populations were attached to a primary care physician for the sake of improved health outcomes and experience for patients, and how we can reconcile this approach with the inevitable technologies that change how primary care is delivered, by making available, physicians on demand.

TUESDAY, MAY 28 12:30 P.M.–2:00 P.M. Plenary Session Artificial Intelligence in Today’s Health System Artificial intelligence (AI) has become the buzzword bingo term in healthcare today. www.hospitalnews.com

Everywhere from health care conferences to organizational strategic plans tout the benefits of AI for addressing health outcomes, efficiencies, and cost barriers we face today in health systems. Exciting as it may be, how do we square this with the current state of health care in Canada? Do we have the quality and quantity of data required to optimize clinical care? Can we implement these tools into existing systems? What are some instances of AI being used today in Canada and what impact is it having? And importantly, where do our policy and regulatory frameworks stand in terms of readiness for AI tools in medical practice. Today’s panel hopes to spark a conversation about what’s required to make the most of AI, and be realistic about the practical approaches we need to take to implement these tools.

TUESDAY MAY 28 1:15 P.M.–2:15 P.M. OS18 – Increasing Digital Access for Patients • OS18.01 – Patient-facing Health Information Technology for Decision-making: Evidence/ Implications for Design; Selena Davis • OS18.02 – Patient Empowerment: A Review of Current and Emerging Approaches; Brian Lefebvre • OS18.03 – Engaged and Empowered: SK Citizen Health Portal; Lillian Ly • OS18.04 – Selling a No-Brainer; Stewart Cameron OS20 – Integrating Circle of Care • OS20.01 – Community Paramedics and Remote Monitoring in BCs Rural /Remote Communities; Jeff Kingdon • OS20.02 – Expanded ClinicalConnect Data Integrations Create a Powerful Patient Care Tool; Dale Anderson • OS20.03 – Increased patient engagement and team continuity in Community-based care; Jeff Mackay

• OS20.04 – Videoconferencing to Support Intraoperative Surgical Coaching: Are We Ready Yet?; Caterina Masino

WEDNESDAY, MAY 29 10:30 A.M.–12:00 P.M. OS29 – Virtual Care in Mental Health • OS29.01 – TELEPROM-Y: Mental Healthcare for Youth Through Virtual Models Of Care; Cheryl Forchuk • OS29.02 – Innovative Approaches to Leverage Technology to Build Mental Health Capacity; Anne Kirvan • OS29.03 – A Mobile Early Stimulation Program Supporting Children with Developmental Delays; Raquel Dias • OS29.04 – Embedding Virtual Care in the Delivery of Mental Health Services; Laura Prado • OS29.05 – Video-based Usability Testing for Healthcare IT: Making it Practical; Andre Kushniruk • OS29.06 – Gathering Perspectives: Strategy for emental Health Services in Atlantic Canada; Krista Balenko OS31 – Interoperability; When Will We Get There? • OS31.01 – An Innovative eOrdering Solution With Real-time Triage-based Scheduling; Danielle Porter • OS31.02 – Improving Information Flow to Support Continuity of Care: EMR Interoperability; Lillian Ly • OS31.03 – Impact Through Reach: Improving Follow-Up for Mental Health Patients; Elizabeth Keller • OS31.04 – Is e-Medication Reconciliation Capability a Missing Link to Improving Interoperability?; Gerald Elysee • OS31.05 – VIRTUES: Towards Interoperability in Arrhythmia Care Using Blockchain And FHIR; Dimitri Popolov • OS31.06 – Partnering our HIS for Better Outcomes for Kids in Ontario; Mari Teirelbaum, Sarah Muttitt APRIL 2019 HOSPITAL NEWS 27

E-HEALTH

Social events ne of the greatest perks of the e-Health experience is the opportunity to share a room with some of the biggest talent in the digital health business. With networking a major priority for many attendees, the conference is peppered with a number of events geared towards just that. The social events include the Welcome Reception, the e-Health Happy Hour, the Pre-Gala reception and Canadian Health Informatics Award (CHIA) Gala. Networking breaks are also weaved into the Conference program to make sure everyone has an opportunity to mingle with peers and make new connections.

CHIA GALA Every year, the conference hosts the Canadian Health Informatics Awards (CHIA) Gala, where participants can dust off their fancy frocks for a special

evening dedicated to celebrating and rewarding excellence in the digital health community. These awards pay tribute to individuals, projects, teams and companies. Categories include: • Clinician Leadership • Corporate Citizenship • Emerging Leader in Health Informatics • Canadian Telehealth • Innovation in the Adoption of Health Informatics • Leadership in the Field of Health Informatics • Project Team: Implementation • Project Team: Innovation & Care Delivery • Project Team: Patient Care Innovation • Steven Huesing Scholarship Taking place on Monday, May 28 from 6:15 p.m. to 10:00 p.m., the evening will start with a reception followed by dinner and the awards H presentation ■ www.hospitalnews.com

E-HEALTH

www.hospitalnews.com

APRIL 2019 HOSPITAL NEWS 29

NEWS

Innovative approach dramatically improves wait times for cardiac patients Dr. Brendan Parfrey eart patients throughout Newfoundland and Labrador are benefiting from remarkable advances in cardiac care delivery that have been achieved in recent months through a special project focusing on improving capacity and reducing wait times. Eastern Health’s Health Sciences Centre in St. John’s has the only cardiac catheterization laboratory, or cath lab, in the province. Many patients have to travel long distances to get there, sometimes by road and air ambulance. Until recently, difficulties with scheduling and utilization in the cath lab often led to lengthy wait times for patients and the uncertainty of not knowing when they would have their procedures. “We had the expertise, the equipment and committed staff but lacked some of the processes to deliver the service that we know we could,” says Dr. Sean Connors, clinical chief of cardiology for Eastern Health’s Cardiac Surgery Program. “It was like having a Cadillac in the driveway with no gas to drive it.” Distressing as the delays were for patients and their families, they were also intensely frustrating for healthcare providers who were unable to deliver the care their patients needed when they needed it. The problems in

30 HOSPITAL NEWS APRIL 2019

the cath lab were felt across the province as patients waiting for catheterization took up beds in other hospitals. “Physicians often had to apologize for delays,” says Collette Smith, vice president of clinical services at Eastern Health. “Wait times weren’t meeting acceptable benchmarks and weren’t consistent. It was very stressful for our team because they couldn’t meet the needs of patients across the province. This made it hard to attract and retain the right physicians, nurses and other professionals.” All of that has changed over the past few months as a result of an innovative partnership between Eastern Health and Medtronic Integrated Health Solutions (Medtronic), to improve the cath lab’s performance. “The difference is dramatic,” Smith says. “Not only have we reduced wait times and made them more consistent, but we’ve created capacity to increase the likelihood that we can get patients into the cath lab right away when necessary, instead of waiting in a bed or in the ER. Now everyone is proud of what they can achieve with their patients. There’s very little turnover and our employee engagement scores are much higher.” The partnership with Medtronic began in December 2017. Eastern

Region

Fiscal 2017–2018

January 2019

Improvement

Eastern Health

4 days

1.95 days

51%

Central Health

8 days

3.27 days

59%

Western Health

10 days

2.8 days

72%

Labrador-Grenfell Health

11 days

6.2 days

44%

Table 1: Average Number of Inpatient Wait Days, 2019 vs. FY2017-2018 The following list shows the average number of inpatient wait days (from date of acceptance to date of procedure) for the province’s four health regions in January 2019, compared with fiscal year 2017–18 (April 1, 2017 to March 31, 2018). Health approached Medtronic because they already had a strong relationship and were impressed by the company’s approach to operational performance improvement, as well as their project management and data analytics expertise. Following Lean Six Sigma methodology, the project started by identifying issues, goals and key areas of focus. Collaborative teams facilitated by Medtronic subject matter experts worked to understand the root causes of the challenges. Solutions were proposed and initiated to address operational challenges and capacity issues. Metrics were identified and reviewed

to measure successes and shortfalls. Based on the outcome measures of the new strategies, either adjustments were made, or the new strategies were implemented across the program. “It was important for the entire team in the cath lab that we work together to implement positive changes to meet patient needs and, ultimately, to improve their overall health experience,” says Dr. Connors. “Delivering treatment sooner to some of our most critical patients can lead to improved long-term health outcomes. That’s the kind of patient-focused care that we strive to provide cardiac patients right across the province.” Continued on page 32 www.hospitalnews.com

FROM THE CEO’S DESK

Dispatches from the epicenter of hallway healthcare in Ontario By Arden Krystal n any given day (especially during the winter months) around 500 patients stay overnight at Southlake, either on an inpatient unit or waiting for a bed in the Emergency Department (we were built for around 425). Most of these 500 patients are acutely ill and require the care that a leading edge acute hospital provides. But a substantial number, anywhere from 60-100 depending on the day, have to stay at Southlake because there is nowhere else for them to go. These people do not need (or want) acute care. They do not need the significant infrastructure associated with operating an acute hospital. And the other patients waiting for a proper bed in a real room probably don’t find their stretcher in the ED or their temporary bed in a staff lounge to be a restful or healing environment. This scenario is playing out in large community hospitals across the province – this is “hallway healthcare.” These are more than just 60-100 patients. They are often seniors whose family members had to get to the hospital, pay for parking, and sit in a chair at their loved one’s bedside in order to see them. These are grandmothers and grandfathers. Imagine what their grandchildren must think about the system that we have created in Ontario when they visit their grandparent? These are wives and husbands, often separated from their spouse, in a place where they don’t want to be. These patients receive care from amazing team members at Southlake – but hallway healthcare takes a toll on staff too. Frustrated nurses and physicians understand the risks of hospital-acquired conditions for patients staying in hospital longer than necessary. Discouraged allied health pro-

STAFF SATISFACTION, THE FLIPSIDE OF THE PATIENT EXPERIENCE COIN, IS WAVERING AS WELL. CLINICIAN BURNOUT AND STAFF MORALE CHALLENGES IN ALL SECTORS ARE WELL DOCUMENTED. fessionals and personal support workers see patients deteriorating during extended unnecessary stays. Hospital administrators wrestle with the negative operational and financial impacts of overcrowding. The proposed changes announced by Minister Christine Elliott in late February represent a chance to change this. They are designed to reduce the layers of bureaucracy and management that have stood in the way of system improvement. rovement. At best, these layers havee added little value for patients. At worst, st, they have distracted clinicians from m spending time providing care and inhibited bited administrators from making decisions sions to improve patient experience, e, streamline operations, and forge better er partnerships. Evaluated valuated against the Quadruple Aim, m, many parts of Ontario’s current system em have room for improvement. Overhead rhead costs as a proportion of spend nd are higher than other provinces. Patient experience can suffer from uncoordinated oordinated transitions, a lack of integrated grated digital health solutions, and persistent istent silos. Staff satisfaction, the flipside ide of the patient experience coin, is wavering avering as well. Clinician burnout and staff morale challenges in all sectors are well documented. And clinical outcomes, comes, though excellent in some areas, s, aren’t measured as robustly as theyy should be. Too often the focus is on process measures.

For a clear and concise “problem statement” about the current system, see the initial report from Dr. Rueben Devlin and the Premier’s Council on Improving Healthcare and Ending Hallway Medicine. At Southlake, we believe the path forward is a “bundled community” approach, where care is connected and responds to evolving local needs. Forward-looking providers (be they community-based community based or hospitals) want

funding linked to outcomes and have the confidence to push for shared-risk models. We need to learn from the successes and failures in other jurisdictions to more rapidly improve our system. Yes, hospitals want the ability to partner directly with colleagues from other sectors, but we also welcome the shared accountability for outcomes, system-wide, in each element of the Quadruple Aim. As the saying often attributed to Deming goes, “every system is perfectly designed to get the results it gets.” By many indicators, the results our system is producing can be so much better. These new changes lay the groundwork for transformation. It’s now up to hospitals and our partners from across the system to H deliver.■

Arden Krystal is President and CEO, Southlake Regional Health Centre.

www.hospitalnews.com

APRIL 2019 HOSPITAL NEWS 31

NEWS Continued from page 30

cardiac patients Improving the cath lab’s processes “was a long journey and required a major culture shift,” says Smith. “Our team was wary because the problem had been going on for so long. But slowly trust developed in the process and the teams involved. The changes had to come from the front line, as people learned from their own experience and created their own solutions. There was permission to try new things. As we made progress, we found we could create capacity.” Based on this work, a new approach was launched on October 9, 2018. Staffing schedules are now created to make maximum use of clinic rooms, an on-call team has been created, and overtime has been reduced. The results speak for themselves. Over the next five months, the outpatient wait list shrank by 15 per cent while utilization of the cath lab grew by 37 per cent. Reductions in wait times have been even more impressive in January 2019 compared to fiscal year 2017–2018, ranging from a 44 per cent reduction at Labrador-Grenfell Health to a 72 per cent reduction at Western Health (see Table 1). Some additional costs were incurred, but the savings achieved are anticipated to balance them out. Meanwhile, in keeping with Lean Six Sigma principles, the process of continuous incremental improvement continues. “We have a huge board in the cath lab for suggestions,” Smith says. “People are really good about using it. We’re trying to move the boards into other areas, hoping the problem-solving approach will move as well. “To others facing challenges like we had, I would say it’s an approach you should try. Our solution can’t be transferred elsewhere – it was created by our team to address our specific needs – but the approach can be. For us, it wasn’t a quick fix but a long-term solution that has lasting benefits for H our patients across the province.” ■ Dr. Brendan Parfrey, is the Director of the Cardiac Cath. Lab at Eastern Health. 32 HOSPITAL NEWS APRIL 2019

Sunnybrook’s radiation and clinical trials teams recently took the first human images on the Odette Cancer Centre’s new MR-Linac – the Elekta Unity - as part of an imaging study. The images will help the team develop the protocols that will be used to treat patients on the MR-Linac once Health Canada approval is received.

Sunnybrook takes first human images taken on MR-Linac By Alexis Dobranowski unnybrook’s radiation and clinical trials teams took a huge leap forward in February when they took the first human images on the Odette Cancer Centre’s new MR-Linac – the Elekta Unity. The new technology is the first machine in the world to combine radiation and high-resolution magnetic resonance imaging (MRI), and will let doctors at the Odette Cancer Centre target tumours and monitor their response to radiation with unprecedented precision– even as a tumour moves inside the body– thanks to the machine’s real-time MRI guidance. As the first Canadian centre to install an MR-Linac, Sunnybrook’s team is leading the way and helping to set up and conduct clinical trials that will establish the best treatment protocols for this new machine. The first step is an imaging study that began in February. Study participants will have their imaging and treatment as usual, and then will undergo an extra MRI on this new machine. The imaging study aims to establish

the MR (magnetic resonance) scan protocols that will be used to treat patients on the MR-Linac, explains Dr. Claire McCann, medical physicist and lead of the imaging study. “We will use the images in our study to help us develop procedures to allow us to adapt a patient’s radiation treatment to changes in the tumour that may occur over time,” she says. Currently, a patient has a CT image taken before radiation. That image is used to plan the patient’s treatment, like where to aim the radiation beam. For some patients, we also get a single MR image, which helps us with this radiation planning. “With our new MR-Linac, we will be able to get MR images before every radiation treatment,” says radiation oncologist Dr. Arjun Sahgal, clinical director of the MR-Linac. “Those MR images will be used to help us ensure the most accurate treatment based on the tumours specific location each and every day. These images will also allow us to monitor how the tumour responds and determine the best way to adapt the treatment to those changes in real time.”

Images taken during the imaging study will help the team develop the clinical workflows – procedures and processes for how they manage any tumour changes, to ensure the most effective way to adapt the patient’s treatment. Anatomical imaging lets the team see the tumour’s anatomy. Functional imaging looks at biological changes, for example changes in tumour blood flow as a result of radiation treatment. “As our experience with this technology develops, we will add functional imaging to supplement the anatomical imaging, which will allow us to adapt radiation treatment not only to changes in tumour size, shape and location but based on biological response to the radiation as well,” Dr. McCann says. Once the combined MR-Linac system receives full Health Canada approval, clinical trials will begin where patients will be treated with this technology using the imaging parameters and workflow developed as part of this imaging study for MR-guided adaptive H radiotherapy. ■

Alexis Dobranowski is a Communications Advisor at Sunnybrook Health Sciences Centre. www.hospitalnews.com

NEWS

Healthcare Innovation:

Barriers and opportunities By Tim Wilson ntellijoint Surgical is a great Canadian success story. It all started when co-founder, Armen Bakirtzian, came up with an idea for a product to make hip replacement surgeries more accurate while he was an engineering student at the University of Waterloo. “This was in response to a medical problem highlighted by my father, who is an orthopedic surgeon,” says Bakirtzian. “I teamed up with two colleagues, Richard Fanson and Andre Hladio, and pitched the idea at Ontario’s Next Top Young Entrepreneur Start-Up Pitch Competition in 2010. We ended up winning.” For the pitch competition, Bakirtzian and his colleagues put together a straightforward problem statement: surgeons make mistakes, which is both detrimental to patients and costly to the health care system, and there’s a need for technology that makes surgeons more accurate. This idea formed the basis for Intellijoint Surgical’s flagship product, Intellijoint HIP, which has since received rave reviews from orthopedic surgeons and patients. But there’s a hitch. Despite Intellijoint HIP’s proven efficacy in enhancing joint replacement accuracy, and strong uptake in foreign markets, you’d be hard-pressed to find the technology being used in a Canadian hospital. “We only conduct about three per cent of our surgeries in Canada,” says Bakirtzian. “There are two hospitals in Canada using Intellijoint HIP, but that’s because the federal government bought the product for them.” The issue isn’t that doctors don’t want to use the product. Instead, the challenge is that Intellijoint HIP raises the cost of surgery. It’s a challenge for hospitals to pay for the added expense, even for those innovative technologies that might improve outcomes for patients, and save the health care system

significant sums over time. “Administrators might truly want the best for patients, but there is a misalignment of financial incentives that doesn’t support that behaviour,” says Bakirtzian. Intellijoint HIP has a low fee-peruse purchase model, and ensures accuracy for both replacements and revisions. Intellijoint HIP provides quantifiable measurements that enable the proper angle at which the artificial cup (one component of the hip implant) is positioned within the pelvis, equalization of leg lengths and offset, and identifiable hip centre-of-rotation. This removes the need for surgeons to use bones as landmarks, or to simply eyeball and guess. This is a big deal, given that up to 62 per cent of cups are not placed within a predetermined target range using manual techniques, and that instability and dislocation are the leading causes of revision surgery, which can be a direct result of implants not being positioned properly. According to the Canadian Joint Replacement Registry 2017 Annual Report, acute care costs for revision total hip replacement are over C$13,700, which is 56 per cent more than a hip replacement, and does not include physician fees or other services like rehabilitation required during a standard 90-day episode of care. Because revision procedures are costlier than the initial surgeries, and add additional risk and inconvenience for patients, there should be an incentive to invest in a technology that improves accuracy and reduces readmissions. Unfortunately, Canada’s health system silos and reimbursement structures don’t currently incentivize investments that address issues such as this, despite the broader system savings and improved patient care it would provide. “Everyone responds well and predictably to financial cues and incentives, and if we get those financial

Armen Bakirtzian with Intellijoint. incentives right, we can really affect meaningful change,” says Ken Spears, Boston Scientific’s Canadian country director and regional vice-president. The potential benefits to the health care system of Intellijoint HIP are significant. The technology not only makes redos themselves safer and more accurate, but can also reduce the need for revisions in the first place. Sadly, hospital readmission costs – and the personal distress caused by hip instability or dislocation, implant loosening, leg length inequality, and premature implant wear – aren’t taken into consideration at the time of purchase. “There are a number of examples in Canada similar to Intellijoint’s,” says Spears. “Hospitals and procurement groups are operating within the same system as are technology firms. We all need the system to change in order to bring innovative new solutions to patients. That means creating new funding mechanisms that cut across silos and tie the cost of care to meaningful patient outcomes. Until that happens, purchasers and hospitals are limited in how much innovation they can facilitate access to.” In Canada, Intellijoint is making progress with the Waterloo Wellington Local Health Integration Network, in part because they had an innovation department. “They’re considering purchasing our technology because we have real-world evidence in surgery in other countries,” says Bakirtzian. “It’s a little backwards. You need to be successful outside of Canada to prove to Canada that you’re successful.”

Despite the lack of success in getting its technology adopted in Canada, all of Intellijoint Surgical’s research and development is still done here, and every piece of an Intellijoint product flows through its head office in Waterloo. “If we don’t champion this in our own country, then who’s going to do it?” says Bakirtzian. “We have a passion for Canada. We’re trying to create an environment that supports the adoption of innovative medical solutions, and we feel strongly that our offerings and technologies significantly benefit patients and the health care system.” The risk for Canada is that many innovative healthcare technology companies will be tempted to take the easy way out, and move to where they can be closer to their customers. Part of the difficulty lies with the fact that Canada has always seen health care as a cost area, eating into budgets, and not as an economic driver. But it isn’t all bad news – some positive change appears to be on the way. “We’re making headway in Ontario,” says Spears. “Ontario’s bundled care pathway for orthopedics is a great example of a program that will probably bring about positive change. For the first time ever, funding for hip and knee replacement surgeries cover 90 days post-discharge and take patient-reported outcomes into consideration. By getting hospital and community-based care providers under the same financial umbrella and coordinating their efforts, we might even create the kinds of incentives that lead to adoption of technologies like H Intellijoint’s.” ■

Tim Wilson is a freelance writer who wrote this piece on behalf of MEDEC – the association representing Canada’s Medical Technology Companies. www.hospitalnews.com

APRIL 2019 HOSPITAL NEWS 33

LONG-TERM CARE NEWS

Osteoporosis and bone health in long-term care By Dale Mayerson and Karen Thompson here is a great loss of freedom and a reduction in quality of life when an older person is relegated to a wheelchair due to a fragility fracture of the hip. Osteoporosis Canada quotes a recent study, which shows that 17 per cent of people who have a hip fracture move into long-term care (LTC). Elderly LTC residents are approximately 1.5-2.0 times as likely as similarly-aged persons living in the community to suffer a fragility fracture of the hip.

BACKGROUND ON BONES The adult human skeleton is made up of 206 bones. Although bone seems stable and unchanging, bone is dynamic tissue and is constantly being remodelled – built up by cells called osteoblasts, and broken down by osteoclasts – throughout life. Bone is made of protein, with layers of minerals that crystallize around the protein framework as added structure and support. As adults, bone growth and bone breakdown are in an equilibrium state, so that bone strength and density are maintained. During the aging process, bone breakdown is more active. This results in a gradual loss of bone strength and density. Bone strength depends on good nutrition and weight bearing exercise. Bone is also negatively affected by alcohol overuse and by smoking. The minerals in bone are calcium, phosphorus, magnesium and fluoride. Copper, iron, potassium and zinc also play important roles in bone health. Vitamin D plays a critical role in bone health by helping calcium to be absorbed

34 HOSPITAL NEWS APRIL 2019

by the body. Vitamins A, B12, C and K also are key for bone health.

DISEASES OF BONE The small amount of calcium that is not used for bone has other functions in the body and is actually the body’s first priority. Calcium is involved in muscle contractions, transmission of nerve impulses, as cofactor for many enzymes, helps blood to clot and has other important functions. To carry out all these important activities, the body will remove calcium from the bone if it does not receive enough calcium from the diet. This can lead to calcium deficiencies. This is especially important for vegans, pregnant women and post-menopausal women. Osteopenia is the loss of smaller amounts of bone, while osteoporosis is related to significant bone loss. People with osteoporosis have a greater risk of a fragility fracture due to bone

Normal

SEVENTEEN PER CENT OF PEOPLE WHO HAVE A HIP FRACTURE MOVE INTO LONG-TERM CARE. becoming thin and more porous. For older people who have osteoporosis, falls with resulting fractures are a risk. Bones at the hip, wrist and spine are most affected by bone loss and are most likely to fracture due to a fall.

DIAGNOSIS OF OSTEOPOROSIS For seniors, a change in measured height could be a sign of bone loss in the spine and potential for osteoporosis. It is well known that women may start to lose bone mass shortly after menopause but men also gradually lose bone as they age. To accurately measure changes in bone density, a densitometry scan uses a machine that is easy and painless.

This test is recommended for everyone over the age of 65 and for younger people if they have a family history of osteoporosis or other risk factors such as smoking, low body weight, use of certain medications and other factors that could contribute to bone loss.

TREATMENTS FOR OSTEOPOROSIS Treatments include increasing daily calcium and vitamin D intake. Vitamin D is essential in helping with calcium absorption from the small intestine, and is needed for calcium balance in the body and bone mineralization. Vitamin D supplementation is recommended for all adults over the age of 50 to help maintain calcium in the body. Natural sunlight assists in maintaining vitamin D status in the body, however this is very limited in Canada for the majority of the year. Drug treatments support bone health by binding to the surfaces of the bones and slowing bone breakdown. Women also have the option of using hormone replacement therapy to maintain bone mass Exercise treatments include daily posture awareness and balancing exercises, weight bearing exercises, along with strength training and general aerobic exercises.

DIETARY CONSIDERATIONS Dietary patterns that negatively affect bone health can include: low intake of dairy foods, lactose intolerance, high intake of

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LONG-TERM CARE NEWS sodium, little vitamin D, diet poor in magnesium, vitamin K, zinc and other minerals that have an impact on bone strength. Inadequate caloric and/or protein intake also negatively affects bone health Dairy products such as milk, yogurt and cheese are most well known for supplying calcium in the diet. Other foods high in calcium are soybeans, tofu and leafy green vegetables. Calcium fortified orange juice and milk alternatives, made from soy, rice and almonds are other options. Vitamin D is provided as a supplement because there are few food sources. Liquid milk does contain added vitamin D. In the LTC setting, each resident undergoes a comprehensive nutrition assessment by a registered Dietitian upon admission and is reviewed at a minimum each quarter. An individualized plan is developed in collaboration with the resident and their family or Power of Attorney as appropriate.

This plan will include individualized strategies that address all of a resident’s nutrition needs including bone health. In LTC, the focus is on preventing fragility fractures. All care team members play a role in keeping residents safe with their functional movement, and help residents to participate in their own care as much as possible. This provides an integrated approach to individualized care and treatment decisions. Osteoporosis Canada offers a set of short videos that focus on the roles of staff in LTC, specifically personal support workers, physiotherapists and restorative care teams. Osteoporosis Canada will be releasing updated Osteoporosis Management Clinical H Guidelines in the fall of 2019. ■

Osteoporosis

Dale Mayerson, BSc, RD, CDE, and Karen Thompson, BA Sc, RD are Registered Dietitians with extensive experience in Long-term care. They are co-authors of “Menu Planning in Long Term Care and Retirement Homes: A Comprehensive Guide” and have participated for many years on the Ontario Long Term Care Action Group, an advocacy group of Dietitians in Canada.

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LONG-TERM CARE NEWS

Virtual reality in long-term care By Nikki Jhutti magine starting your day off at a café in Rome, spending your afternoon snorkeling along the Great Barrier Reef and taking a quick trip to Paris to see the Eiffel Tower at night, all in the same day. Sounds impossible right? Not for Providence Manor residents. The long-term care home’s recreation department recently invested in virtual reality, to give residents the chance to see the world and all it has to offer. “We’re the first long-term care home in Kingston to offer virtual reality,” explains Danielle Preston, program coordinator. “Residents can experience something new and different that takes them outside the four walls of the home. We offer as much as we can in terms of recreation, but for someone who may be in a wheelchair who used to travel, this allows them to do that again, which improves their quality of life. Families are excited about it and staff are excited about it.” With 243-beds Providence Manor is Kingston’s largest long-term care home. It provides care to residents who have stable medical conditions, but who also require 24-hour nursing care. Preston and her small but mighty recreation department run a minimum of seven activities a day, including evening programming. Every month there’s hundreds of fun activities and games for residents to take part in, but finding something everyone likes can be a challenge. “No two people are going to like all the same things. There’s no cookie cutter here, so we have to offer a variety of programs and a variety of experiences throughout the day. We’re consistently reevaluating what we offer and looking at levels of engagement, because ultimately it’s the resident’s decision if they want to participate.” Providence Manor also has a younger demographic. There are quite a few people under the age of 65, who have had strokes or

The Interact Project helped set up the virtual reality system at Providence Manor and trained staff on how to use it. live with multiple sclerosis, who now call Providence Manor home. “Your stereotypical long-term care home programs aren’t what those residents want,” explains Preston. “They want the Superbowl Sunday party and pub nights, so we have to keep adapting and altering our programming to make sure there’s something for everyone.” That’s why Preston wanted to bring in virtual reality or VR for short. The interactive computer generated system uses a headset and sensors, and creates a highly immersive, 360 degree artificial environment for users, who download games and experiences. With endless possibilities, there’s something for everyone; from hitting the fairways at some of the top PGA Tour Courses, to hiking up Machu Picchu in Peru. And those adventures are just a click away. “You can literally download any type of experience or game. You can meditate in a field, or hop on roller-

coasters at different amusement parks. You can go on Google Earth and look up your childhood home, or the school your kids went to, or a neighbourhood park,” adds Preston. She admits she isn’t the most tech savvy person, that’s why she enlisted the help of The Interact Project to set things up. The nonprofit has volunteers who bring VR systems to long-term care homes and rehabilitation centres for a few hours a day, for free. Founders George Cao and David Zheng created The Interact Project while volunteering at a long-term care home in Ottawa. “One of the most popular activities was bingo on Saturday afternoons. We would talk to residents after and they told us they weren’t really interested in bingo, they were just passing the time,” says Cao. Both had recently tried VR and thought it could be a great fit in longterm care homes. “When we first tried it, we were surprised at how realistic it was. We

thought it was too good not to share,” says Zheng. “Sometimes when you’re in a longterm care home you don’t really get the opportunity to go outside as much, so this is a nice escape.” The pair added most homes end up purchasing their own VR systems once they see the benefits and how much residents enjoy it, which is what Preston did with Providence Manor. “It’s been shown to decrease depression, and increase quality of life and social engagement. Residents feel happy and they get to control where they want to go, or what they want to do, and I think giving them the control, can be life changing,” explains Preston. “We want residents to have fun with it, to laugh and play, to try something new that takes them out of their comfort zone and experience something that brings them pure joy.” And with the world at their fingertips, there’s no limit to what sorts of adventures Providence Manor resiH dents will have. ■

Nikki Jhutti is a Communications Officer at Providence Care in Ottawa. 36 HOSPITAL NEWS APRIL 2019

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Making life better

for long-term care residents with dementia By Annie Atkinson atricia Laurin says her 92-year-old mother Shirrill Crawford has been “totally lost” for several years due to Alzheimer’s disease. “She doesn’t know me. Her memory is really compromised.” Yet the day ABBY – a wall-mounted personalized activity technology – was installed at Crawford’s Midland, Ontario long-term care home, she became “totally engaged for 90 minutes. It blew me away when she named my grandmother and my brother in pictures displayed on the screen”, says Laurin. “My mother manipulated the board and got a meaningful response from it. It stirred a lot of memories and she was fascinated by the music and pictures. It was amazing to see her so engaged, relaxed and enjoying herself.”

The ABBY system integrates touchscreen monitors, video, music and familiar tactile activities such as turning a wheel or petting a cat to create engaging experiences for long-term care residents with dementia. What’s more, if the resident is wearing a Bluetooth beacon, it signals to the unit to pull up personalized content including family photographs, a resident’s favourite music or TV show. ABBY, which uses a Montessori approach, was developed by industry partner Ambient Activity Technologies in collaboration with a Toronto-based research team and with support from AGE-WELL, Canada’s Technology and Aging Network. “We knew there was a problem with keeping people engaged in meaningful activities, so we wanted to physically

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Dr. Andrea Wilkinson engaging with a resident and the ABBY ambient technology. Courtesy: AGE-WELL. activate people. You have to approach the ABBY unit, physically engage with it, and then in response you get this content that is meaningful,” says project co-lead Dr. Andrea Wilkinson, a postdoctoral research fellow at the University of Toronto, AGE-WELL trainee and founder of Brain Shape Inc. Results are impressive. A 2017 study using ABBY at six long-term care homes showed a decrease in agitation, aggression, anxieties and paranoid delusions among residents living with dementia, along with improved quality of life. Staff experienced reduced burnout and for family members, outcomes included visitor satisfaction. “There is still so much left in people with dementia. If we can help them access these long-term memories that still exist so they can have meaningful conversations with their loved ones, this can bring such joy to the individual and to the family members,” says Dr. Wilkinson. Using content from their own lives draws the attention of residents to ABBY. “There is a genuine problem with triggering activity among people living with dementia. Familiar actions like petting a cat or turning a wheel use implicit knowledge that remains after a lifetime of use. Once the activity board reacts to their input, people become engaged and no further

triggering is required,” explains Dr. Mark Chignell, who is project co-lead, a psychologist and a professor in the Department of Mechanical and Industrial Engineering at the University of Toronto. “People are spending hours with ABBY. What I like about this project is the potential impact it could have for the almost 50 million people worldwide who live with dementia.” In Canada, approximately 62 per cent of residents in long-term care homes have dementia and nearly half exhibit aggressive or agitated behaviour. Boredom and lack of meaningful, engaging activities may be associated with increases in responsive behaviours, such as screaming and wandering. ABBY could prove to be an important part of a strategy to engage people living with dementia in longterm care. Marc Kanik, managing director of Ambient Activity Technologies, is travelling the country to introduce ABBY to long-term care homes. Orders are coming in. About two dozen units already have been installed in Ontario homes. “Everybody in our company feels good about working on something that has this kind of impact in bettering H people’s lives,” says Kanik. ■

Annie Atkinson is a freelance writer. AGE-WELL is a federally-funded Network of Centres of Excellence. The pan-Canadian network brings together researchers, older adults, caregivers, partner organizations and future leaders to accelerate the delivery of technology-based solutions for healthy aging. For more information, visit http://agewell-nce.ca/ www.hospitalnews.com

LONG-TERM CARE NEWS

Can virtual reality make longterm care residents happier? One CABHI project investigates By Rebecca Ihilchik

n one Fredericton longterm care home, older adults are donning headsets and entering alternate

worlds. Virtual reality (VR) is one of the most exciting technologies in seniors’ care innovation today. Based at York Care Centre, researcher Sherry Law is introducing VR to long-term care residents and testing whether VR sessions can improve their well-being. She’s also investigating how the technology might be used as a mental health treatment. The project is funded by the Centre for Aging + Brain Health Innovation (CABHI), powered by Baycrest, and the New Brunswick Health Research Foundation (NBHRF).

Sherry joined us for a Q&A about her work.

as a way to improve my grandmother’s situation.

WHAT INTERESTED YOU IN EXPLORING VIRTUAL REALITY IN LONG-TERM CARE?

HOW MIGHT VR AFFECT RESIDENTS’ LIVES?

The idea for my project came in 2013 when my own grandmother was nearing her end of life. She lived in Hong Kong, in an environment similar to that of long-term care. I wanted desperately to assist her, but being separated by distance I could only turn to technology to help in any significant way. That was also around when I first began hearing about VR prototypes being developed and made available, so naturally I considered it

VR can be an accessible and affordable means for leisure activities in long-term care. It can put users in calming or enjoyable settings, like a room full of puppies, or help them experience things they may not otherwise be able to do, like riding a roller coaster. VR can also take users to a different part of the world – for example, they can ‘sightsee’ at Big Ben in London, England. This way they can safely take a mini-vacation when they feel like it. All of this could have a positive effect on their mental health.

Researcher Sherry Law. Rebecca Ihilchik, Marketing & Communications Specialist Centre for Aging + Brain Health Innovation

WHAT’S THE FEEDBACK BEEN FROM PARTICIPATING RESIDENTS? Residents have expressed joy and amazement at some of the virtual worlds that we have travelled to. Often when the participant chooses to travel in VR, they begin recounting their past travels or telling stories about where they grew up. Continued on page 42

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LONG-TERM CARE NEWS

eConsult Program improving access to specialist care By AJ Adams oor access to specialist care remains a serious issue in Canada, causing frustration for patients and providers alike. Too often, patients wait months or even years for a specialist appointment, only to learn that all they needed was a new prescription or another test. In the meantime, they likely faced the frustration and anxiety of waiting, coupled in some cases with worsening health outcomes. Delays in care become even more concerning as patients age. A recent report from the Canadian Institute for Health Information noted that 25 per cent of elderly Canadian patients waited over two months for specialist care, and 37 per cent went to hospital emergency departments for treatments their primary care provider could have provided. These figures place Canada last among the 11 countries surveyed. Residents of long-term care facilities – many of whom are elderly – face additional barriers to accessing care, as a growing number suffer from Alzheimer’s disease or other dementias, complex health issues, behavioral challenges, and physical frailty. These conditions increase the need for specialist care and, at the same time, reduce residents’ ability to travel to a specialist appointment.

AN INTEGRATED SOLUTION The Ontario eConsult service is a secure web-based tool that lets primary care providers across Ontario send questions to specialists concerning a patient’s care. No matter where in Ontario they practice, providers can use eConsult to connect with specialists from over 80 specialties and receive a response in a timely manner – two days on average. In two-thirds of cases, the provider can go on to treat the patient themselves, without the patient needing

an in-person specialist visit. Neither the provider nor the patient has to pay for this service. Since 2018, the Ontario eConsult Program has collaborated with the Ontario Centre for Learning, Research and Innovation in Long-Term Care (CLRI) at Bruyère to offer eConsult to providers working in long-term care homes. Guided by a multi-institutional advisory committee with strong representation from caregiver partners, this collaboration strives to improve integration of care, patient safety, and quality of life for long-term care residents. In the first year of this exciting collaboration, providers working in 26 long-term care homes have joined the eConsult service. Data from the first 99 cases submitted by providers working in LTC in the Champlain region showed: • 60 per cent of eConsults provided LTC providers with advice for a new or additional course of action • 73 per cent of cases were resolved without the need for a face-to-face specialist visit • Providers accessed a wide range of specialty groups, with the most com-

mon being dermatology, infectious diseases and cardiology Feedback from users has been very positive. Some providers noted that using the advice received through eConsult, they were “able to avoid an ER visit and instead connect [their] patient directly to proper specialist care.” Others valued the “extraordinary attention to detail” and not having to “[make] important decisions in isolation.” In turn, caregivers recognized that “eConsult would provide an extremely valuable service [to their loved ones living in a long-term care home] by helping to connect their primary care providers with specialists.” In its 2017 assessment of eConsult, the Canadian Medical Protective Association indicated that “[eConsult] provides an opportunity to improve efficiency, enhance patient care, expand access to specialists and provides a clear audit trail of the specialist’s advice given to the provider for the suggested care of the patient.” As such, the Ontario eConsult Program is a valuable part of our increasingly integrated Ontario healthcare system. For residents of long-term care homes, eConsult offers a way to tran-

scend the typical barriers in accessing specialist advice and ensure these patients get the care they need in a prompt and safe manner. The program is led by the Ontario eConsult Centre of Excellence (eConsult COE), housed at The Ottawa Hospital in partnership with the Bruyère Research Institute. Regional partners include Champlain BASE™ (Building Access to Specialists through eConsultation) and the South East Academic Medical Organization (SEAMO). Delivery partners are the Ontario Telemedicine Network (OTN), OntarioMD, and eHealth Ontario, with the support of the Ministry of Health and Long-Term Care. The work in expanding eConsult to the long-term care sector is supported in part with funding from the Government of Ontario through the Ontario Centre for Learning, Research and Innovation in Long-Term Care hosted at Bruyère. The views expressed herein do not necessarily reflect the views of the Province. For more information about eConsult visit www.champlainbaseeconsult. com and about the Ontario CLRI visit H www.clri-ltc.ca ■

AJ Adams is the Communications & Events Coordinator at the Ontario Centre for Learning, Research and Innovation in Long-Term Care at Bruyère. 40 HOSPITAL NEWS APRIL 2019

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LONG-TERM CARE NEWS

Electronic tool has potential to improve asthma care By Ana Gajic new electronic decision support tool for managing asthma has the potential to improve the quality of asthma care in primary care settings, suggests a study led by St. Michael’s Hospital in Toronto, Canada. The research, published in the European Respiratory Journal, aimed to determine whether the Electronic Asthma Management System (eAMS) could help close existing gaps in asthma care. The system is a first-of-itskind evidence-based computerized decision support tool. “We have excellent therapies for this disease, yet most patients do not receive the best care, and as a result, are poorly controlled,” says Dr. Samir Gupta, an associate scientist at the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, who led this study. “There are many barriers facing busy primary care physicians in providing the best care, including lack of time, knowledge, training, and local resources. We sought to try to overcome these barriers by leveraging the power of technology.”

Dr. Gupta and his team followed 23 physicians for two years across three large family health teams, assessing care provided to 1,272 unique patients with asthma. The study analyzed baseline care for one year, then integrated the eAMS into the practices and monitored care for another year to identify changes in the quality of care. The evaluation of an electronic tool builds on recent research led by Dr. Gupta that found that significant gaps persist in asthma care in these areas across the province. With the eAMS, asthma control assessment increased from 14 per cent to 59 per cent of patients. The tool also increased the proportion of patients who received an asthma action plan from zero to 18 per cent. This is a self-management tool that lets patients know how to adjust their medications in case their asthma flares up. Asthma control assessment and action plans have been key recommendations in asthma care guidelines for more than 20 years. “Our research demonstrates that a carefully designed eHealth tool can

effectively be used in busy primary care settings, and can improve asthma care,” says Courtney Price, who was a summer student at the Li Ka Shing Knowledge Institute while the analysis was completed. “This is especially important as asthma affects 339 million people globally, is one of the most common chronic diseases in Canada, and is continuing to increase in both prevalence and cost.” The decision support tool consists of: 1. An electronic questionnaire which patients typically complete on a tablet device in the physician waiting room (providing information about their asthma); 2. An automated, computerized decision support system which then processes these data to instantly produce a set of asthma care recommendations and presents these to the clinician upon opening the patient’s electronic chart; and 3. A printable asthma action plan that is auto-populated by the eAMS and given to patients by the clinician (an evidence-based tool which provides

Dr. Samir Gupta, an associate scientist at the Li Ka Shing Knowledge Institute of St. Michael’s Hospital Hospital. guidance on what patients should do if their asthma flares up). Dr. Gupta and his team hope to provide access to the eAMS to all family physicians in Canada. Next steps will include integrating the system across the different electronic medical record systems in use across Canada, further studies to show its impact on patient health, and adding additional features to the tool. “In the future, we also hope to use the valuable lessons learned in this study to design similar tools for other H chronic diseases,” he says. ■

Ana Gajic works in communications at Unity Health; Providence Healthcare, St. Joseph’s Health Centre and St. Michael’s Hospital.

Continued from page 39

Virtual reality Some are younger residents who feel left out of being able to participate in technological advancements like computers or smartphones, so being part of the CABHI project helps them feel like they’re catching up. One of the participating residents used to be a teacher and lamented the fact that VR hadn’t been available as an educational tool when she was teaching. She believed the technology could do great things for residents. Another always reserves time in our sessions to ride some roller coasters,

which she’d never been able to do because of physical limitations. Sometimes she swears by accident because of the thrill! It’s a joy.

WHAT LONG-TERM IMPACT WILL THE CABHI PROJECT RESULTS HAVE? If the data indicates that VR can improve residents’ moods, the technology could be implemented in York Care Centre and other longterm care centres in Canada as a supplementary tool to alleviate mood

or mental health concerns in the population. The benefits of improving mood in long-term care residents are multi-faceted. An improved mood could boost participation in rehabilitation or medical intervention, improve cooperation between the resident and staff, decrease aggressive incidents, and potentially increase overall health by reducing stress. These advantages could be translated into financial benefits as well.

HOW’S YOUR EXPERIENCE BEEN WORKING WITH CABHI? Everyone on CABHI staff has

been gracious with their time, helpful with answering questions, and reassuring when I felt discouraged. They’ve offered many supportive services to help me not only complete my project, but also expand it and scale it up. I would also say that CABHI’s holistic approach to supporting their innovators’ development as businesspeople and leaders is an amazing value add to the Canadian market. They empower entrepreneurs and provide them with the tools needed to succeed. It’s a very special thing. To learn more about CABHI, visit H www.cabhi.com. ■

Rebecca Ihilchik is the Marketing & Communications Specialist at the Centre for Aging + Brain Health Innovation (CABHI). 42 HOSPITAL NEWS APRIL 2019

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ETHICS

Equality vs. equity

in a publicly funded healthcare system By Andria Bianchi

iving in a publicly funded healthcare system may lead some providers and/ or organizations to strive to achieve a system of complete equality when it comes to the implementation of services. The idea that we ought to treat all people in the same way irrespective of other factors that may be relevant to their identity (e.g. race, gender, ethnicity, sex, sexual orientation, culture, language, religion, disability, socioeconomic status, age, etc.) is prevalent; this is primarily what it means to treat people equally. Using equality as a guiding principle is, in many ways, commendable and helpful. It is commendable in that it suggests that all individuals ought to have equal access to receive the same care in the same kind of way, which means that a citizen who is poorer than others should not be denied necessary care on that basis alone in a publicly funded context. A goal of equality can also be helpful in that it may guide organizations and/or clinicians to develop policies and processes to help mitigate factors which may unintentionally and unfairly influence the provision of care (e.g. being influenced by implicit biases that favour or neglect certain kinds of people). If multiple people require a particular resource that is widely available, then a principle of equality would suggest that (all things being equal) the individuals ought to be treated in the same way when it comes to receiving it. Interestingly, one of the most significant challenges with using equality as a primary principle in healthcare, especially when it comes to developing specific processes and protocols, is the same thing that is also seen as a benefit; namely, that a principle of equality suggests that all people ought to be treated in the same way. Why

IF EVERY PATIENT IS TREATED EQUALLY, THEN SOME ETHICALLY RELEVANT INFORMATION MAY NOT BE CONSIDERED. might this pose a challenge from an ethics perspective? The reason was mentioned in the previous Hospital News ethics column, which said that it is often the case that equity is what matters when it comes to determining the most ethically defensible course of action – not equality. Equity suggests that a person’s individual vulnerabilities and life circumstances are relevant to determining the most ethically defensible act. For example, suppose two patients, Jamie and Jordan, are admitted to the same hospital to receive the same type of cancer treatment by the same clinician. Jamie and Jordan share many similarities. They are both 65 years of age, they live in a large urban city, they speak fluent English, and they have lots of family support. Now, suppose that by virtue of their cancer diagnoses, Jamie and Jordan

are eligible to enroll in a clinical trial for research purposes. Additionally, suppose that the clinical trial team always reserves 25 minutes to explain research-related information to eligible patients and to answer questions; they provide the same information in the same manner to all people in order to ensure that they are treated equally (i.e., a principle of equality is prioritized). While using a principle of equality to guide a research consent process in general may be apt, it may also pose challenges under certain circumstances. If, for instance, Jordan or Jamie is a Black male who lived during the time of the Tuskegee syphilis experiment, a person of indigenous descent who lived during the time of residential schools and “Indian hospitals” in Canada, a transgender person who has encountered significant discrimination and disre-

spect by healthcare providers, etc., then these experiences, backgrounds, and potential vulnerabilities will need to be taken into account during the consent process. Consequently, the consent process may take more time and resources. To take another example, suppose a hospital unit has a strict policy to discharge patients as soon as they are clinically ready; no other considerations are ever taken into account. The justification for this policy is to ensure that all patients are treated equally. While this policy may be legally permissible and appropriate for many patients, a person’s vulnerabilities and backgrounds may also be relevant when it comes to contemplating what is ethically permissible and/ or preferable for discharge planning purposes. Sometimes, a longer length of stay may be ethically defensible even if a person is clinically stable. For instance, if a patient with paraplegia lives in a non-accessible shelter system in a rural location with no family support, then it may be ethically permissible to prolong their stay until adequate supports can be put in place. If every patient is treated equally, then some ethically relevant information may not be considered. Equality implies that all people should be treated as though they have the same backgrounds, life circumstances, and vulnerabilities, which is certainly not the case. Instead of prioritizing equality, treating people equitably may be more defensible from an ethics perspective. Equity requires altering our typical approaches to care in light of relevant patient information; this may involve taking more time to speak with someone, prolonging a person’s hospital stay, exploring alternative clinical options, etc. Ultimately, equity allows for different cases to be treated differently; equality H does not. ■

Andria Bianchi, PhD is a Bioethicist at University Health Network. 44 HOSPITAL NEWS APRIL 2019

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SAFE MEDICATION

Medication incidents involving smoking cessation therapy:

A multi-incident analysis By Phillip Yang, Jim Kong, and Certina Ho very year, thousands of Canadians attempt to quit smoking with the help of nicotine replacement therapy or other non-nicotine medications. However, statistics show that as recently as 2017, 16 per cent of the Canadian population still continues to smoke despite the multitude of public and private campaigns that highlight the health related concerns associated with smoking. Studies have shown that an average smoker will experience five to seven unsuccessful attempts at smoking cessation before maintaining complete remission. Pharmacists, being one of the most accessible healthcare professionals in the community, can embrace their role to bring about positive changes in a smoker’s health and well-being with communication and patient education on smoking cessation. Currently, there are different interventions available to help patients quit smoking, which include medications and non-drug therapy (e.g. behavioural therapy). We conducted a multi-incident analysis on the use of selected drug therapy for smoking cessation in order to analyze the underlying causes that might have led to medication incidents and/or, ultimately, a potential failure in smoking cessation. Incident data were gathered from the ISMP Canada’s Community Pharmacy Incident Reporting (CPhIR) (https:// www.cphir.ca) Program between 2010 and 2014. Inclusion criteria included

STUDIES HAVE SHOWN THAT AN AVERAGE SMOKER WILL EXPERIENCE FIVE TO SEVEN UNSUCCESSFUL ATTEMPTS AT SMOKING CESSATION BEFORE MAINTAINING COMPLETE REMISSION. any voluntary incident reports pertaining to non-nicotine medication therapy for smoking cessation, such as Varenicline and Bupropion, including their generic equivalents. Although a search for medication incidents related to nicotine replacement therapy (NRT) was also conducted, there was insufficient data for incident analysis. As a result, NRT medications were excluded from this analysis. A total of 360 incident reports were included in this multi-incident analysis, with 39 per cent (n = 140) involving Varenicline and 61 per cent (n = 220) associated with Bupropion. The typical dosing schedule of Varenicline requires a one-week titration schedule with 0.5 mg once daily to be taken orally for the first three days, followed by 0.5 mg twice daily for the next four days; and this is included in the initial dosing pack (or starter pack) of Varenicline. The remaining 11 weeks of therapy (for a usual 12week course of Varenicline) can be dosed as either 0.5 mg twice daily or 1 mg twice daily. Our incident analysis has shown that instructions for the initial dosing pack (or starter pack) and subsequent refills of Varenicline

were often mixed up and patients have been either overdosed or underdosed, depending on their smoking cessation therapy status or progress. A potential recommendation to prevent this mix-up would be to apply highlighted labels (e.g. in bold characters) to reflect and help patients identify the different dosing schedule. In addition, the pharmacy practice management system or dispensing software, perhaps, can be set up to prevent filling of subsequent refills until the initial dosing pack (or starter pack) has been completed based on the number of days’ supply of the smoking cessation therapy. Utilizing a pre-printed order set that specifies the dosing pack type (e.g. an initial dosing pack (or starter pack) versus a subsequent refill prescription), the duration of use, number of days’ supply, and the number of prescription refills, etc., would be helpful for both prescribing and dispensing of Varenicline. Independent double checks within the pharmacy workflow or through patient counselling can always serve as a final or additional verification to help prevent unintentional misuse of Varenicline.

Bupropion, in the form of sustained-release tablets, is another non-nicotine drug therapy commonly used for smoking cessation. From our multi-incident analysis, we found that the various commercially available formulations of Bupropion (i.e. sustained-release tablets and extended-release tablets) often confused healthcare professionals, resulting in incorrect formulations being prescribed or dispensed for smoking cessation, followed by potential therapy failure. A possible recommendation to prevent this mixup would be to set up alerts in clinical decision support systems or prescribing and dispensing software applications to flag for a double check or verification during prescribing and order entry of the extended-release formulations of Bupropion, which is usually indicated for depression (instead of smoking cessation). In addition, auto-completion of drug names (a function that is usually available in dispensing software applications) with multiple commercially available formulations should also be discouraged during order entry at the pharmacy. Finally, similar to what was mentioned earlier, independent double checks within the pharmacy workflow or through patient counselling are always recommended as safe medication practices. Learning from medication incidents is a fundamental step to continuous quality improvement. It is hoped that our incident analysis findings will support safe prescribing and use of smokH ing cessation therapy. ■

Phillip Yang is a pharmacist and he completed a PharmD rotation at the Institute for Safe Medication Practices Canada (ISMP Canada) in 2014; Jim Kong is a Program Development Manager at ISMP Canada; and Certina Ho is a Project Lead at ISMP Canada. www.hospitalnews.com

APRIL 2019 HOSPITAL NEWS 45

NEWS

Runnymede Healthcare Centre is working to increase system capacity by enhancing its focus on rehabilitation and building a 200-bed LTC facility on its premises

Reducing hallway medicine through innovation and growth By Michael Oreskovich he issue of overcrowding in Ontario hospitals is worsening as the population ages, warns an alarming January 2019 report from the Premierâ&#x20AC;&#x2122;s Council on Improving Healthcare and Ending Hallway Medicine. Fortunately, Runnymede Healthcare Centre has kept a watchful eye on the healthcare system and is addressing these challenges head-on by taking innovative action

to increase system capacity. By launching a new inpatient rehabilitation program and moving ahead with plans to construct a long-term care (LTC) facility, the hospital is removing obstacles to patient flow that can result in hallway medicine. According to the Premierâ&#x20AC;&#x2122;s Council report, an average of 1,000 Ontarians received hallway medicine every day in 2018. One of the contributing factors is

patients occupying hospital beds when they no longer need the level of care provided by that healthcare organization. These patients are referred to as alternate level of care (ALC), and they are usually unable to move to a more suitable location due to long waiting lists for inpatient rehab, long-term care or community supports. Ultimately, this results in serious backlogs and capacity issues.

Runnymede is helping to help relieve these healthcare system pressure points by improving the flow of patients through the system. Its new active rehabilitation program, called High Tolerance Short Duration Rehab, was launched in February 2019 to provide care for patients who need intensive, short-term rehabilitation after illness, injury or surgery. Continued on page 47

Michael Oreskovich is a Communications Specialist at Runnymede Healthcare Centre. 46 HOSPITAL NEWS APRIL 2019

www.hospitalnews.com

NEWS

New Breast Screening Guidelines Continued from page 4

Continued from page 46 The new program makes it possible for Runnymede to accommodate more rehab patients than before, which reduces wait times for treatment. By providing active rehab beds at Runnymede, patients can transition out of acute care hospitals sooner, freeing up much needed beds and helping to lower ALC rates in the healthcare system. “Our new active rehab program improves flow and access for patients within the healthcare system while establishing Runnymede as a leading comprehensive rehabilitation hospital,” says Raj Sewda, Runnymede’s VP, Clinical Operations & Quality, Chief Nursing Executive & Chief Privacy Officer. Runnymede is also working to increase system capacity by building a 200-bed LTC facility on its premises. Currently, demand for LTC beds far outstrips supply – according to Health Quality Ontario, the median wait time for a LTC bed in Toronto in 2017/18 was over 150 days, which can leave seniors stuck in acute care for extended periods in ALC status as they wait for a LTC bed to become available. The new LTC facility at Runnymede will address this identified patient need, increase seniors’ access to comprehensive care in their community and in turn reduce capacity pressures in acute care hospitals. “Runnymede is evolving to fulfill the growing demand for high-quality care,” says Sewda. “Our new facility paired with our enhanced focus on rehabilitation helps to eliminate hallway medicine while ensuring our patients get the right care in the right place at the right H time.” ■

A Canadian study of over two million women screened for breast cancer over 20 years showed that women 50-70 had a 40 per cent reduction in breast cancer mortality, and women 4049 had a 44 per cent lower rate of dying from breast cancer when they participated in screening mammography. The CTFPHC issued its 2018 guidelines without including these important studies and focused instead on a 30-year-old Canadian National Breast Screening (CNBSS) study that had been previously discounted in 2002 by the World Health Organization due to poor quality mammography and poor study design. A breast cancer expert on the panel would have avoided this error. The Task Force focused on harms of screening. They cited an estimate of overdiagnosis of 41 per cent of breast cancers. No credible expert in screening correctly estimates overdiagnosis to be more than 10 per cent, a number that has been substantiated by the Swedish screening trials. The 41 per cent is based on the outdated and discredited CNBSS study. A breast cancer expert on the panel would have been able to point this out. The Task Force also focused on the harms of false positives from screening mammography. They estimated the rate of false positives to be 30 per cent. Wrong again. Canadian database statistics available online for free demonstrate the annual abnormal recall rates for each province and territory for screening mammography. The numbers are consistent – less than 10 per cent. A breast cancer expert on the panel would have been able to point out the error of this calculation.

And the Task Force did not consider one of the most significant harms of screening – the harm of a missed diagnosis or false negative. Several studies show that women who are not screened or detected at an early stage have a much higher rate of dying from breast cancer. Women with dense breast tissue have a much higher chance of being detected late with breast cancer, often after it has spread to the lymph nodes, because the cancer may be masked by their dense breast tissue. The Task Force ignored this evidence and did not consider the added risk of dense breast tissue in their guidelines. A

breast cancer expert on the panel would have been aware of this harm. Now, over 44,000 Canadians have signed a petition asking for these flawed guidelines to be opposed. What needs to happen now? The Federal Health Minister should reject the Task Force guidelines. A new Task Force should be convened that includes experts of breast cancer screening mammography. And the Canadian Task Force should update the breast cancer screening guidelines to include evidence from recent observational trials and actual Canadian data on screening mammography. To do less than this would be to H fail Canadian women and their families. ■

Dr. Jean Seely is the Head of Breast Imaging at The Ottawa Hospital and Professor of Radiology at the University of Ottawa. She is President of the Canadian Society of Breast Imaging.

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