Hospital News 2016 June Edition

INSIDEFrom the CEO’s desk .........................10

Nursing Pulse .....................................14

Legal Update ......................................15

Evidence Matters ...............................20

Safe Medication .................................22

Careers ...............................................23

Using MRIs to predict kidney failure

Transforming shoulder care

6 8

FOCUS IN THIS ISSUEHEALTH CARE TRANSFORMATION/EHEALTH/MOBILE HEALTH/MEDICAL IMAGINGPrograms and initiatives that are transforming care and contributing to an effective, accountable and sustainable system. Innovations in electronic/digital process in healthcare, including mHealth (health applications on mobile devices). A look at medical imaging techniques for diagnosis, treatment and prevention of diseases.JUNE 2016 EDITION | VOLUME 29 | ISSUE 6

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Mobile health apps are changing healthcare. But are they effective? Private? Safe? Should we care?

There’s an

APPfor that:Story on page 16

HOSPITAL NEWS JUNE 2016 www.hospitalnews.com

2 Focus HEALTH CARE TRANSFORMATION/EHEALTH/MOBILE HEALTH/MEDICAL IMAGING

urns outs an auto manu-facturer has a thing or two to teach Canada’s largest teaching hospital.

That’s why Toronto’s University Health Network (UHN) is taking a lesson from Toyota and designing patient care using a Lean management system.

The approach provides employees with a systematic method for continuously im-proving the way an organization runs, by fi rst standardizing processes and then mak-ing small, incremental changes in order to reach important goals. Decisions are based on data, and both errors and waste are re-duced by making processes easy for staff to follow correctly.

When a problem occurs, the root cause is identifi ed before a solution is implemented.

“Toyota has one of the most advanced process improvement cultures in the world,” says Brenda Kenefi ck, Director, Lean Process Improvement, UHN. “While people often tell me that treating sick peo-ple is very different from manufacturing cars, we can learn a lot from Toyota about how to create a culture where we achieve specifi c goals by teaching every single staff member how to identify problems, and de-velop effective solutions.”

Such improvements are necessary for healthcare organizations to be able to meet the demands of an aging population while increasing the quality of care without sub-stantial additional funding.

The following examples from UHN show what can be achieved with a con-tinuous improvement culture – safety im-proves, wait times shrink and patients go home sooner.

Improving safetyIt was a moment three-and-a-half years

in the making.The team on a spinal unit at Toronto

Western Hospital (TWH) recently cel-ebrated 60 days without a single patient developing a pressure ulcer. It’s a fi rst for the team, and for UHN.

And it’s particularly impressive given the limited mobility of the spinal injury pa-tients the unit treats.

Pressure ulcers occur when the skin breaks down due to prolonged immobility.

They are painful and notoriously diffi cult to heal once they develop. They are also preventable.

“We work very hard to be preventa-tive and proactive,” Rosemary Ritchie, the former nurse manager, now retired, says in explaining how her team reached this milestone. “We discuss every patient that comes on to our unit during our daily huddles.

“If they are deemed at risk of develop-ing a pressure ulcer, a fall or a urinary tract infection, we fl ag them on our risk board and act immediately by involving other team members or employing the necessary equipment to prevent harm.”

The team also realized that to prevent pressure ulcers they needed to better edu-cate patients and families on what happens if they don’t turn, or move. Patients can be totally dependent on others for their move-ment, and may not always want to mobi-lize. Educating them on why it is important to roll over or move to a chair helps the team blend their comfort and safety.

Reducing wait timesSome patients at Toronto Rehab are

now getting in the door much earlier. And when it comes to rehabilitation, how soon a patient starts may affect their recovery.

You might think reducing wait times comes at a cost – more infrastructure, more staff, more hours. But it turns out the best way to solve big, complex problems like wait times is to work with the people doing the job to solve the small, simple problems.

By doing that, the Stroke Outpatient Rehab Clinic reduced its wait time from 15 days to six.

Clinic patients need to see up to three clinicians in one day, three days a week, for at least four weeks. It’s a scheduling

challenge that the team used to manage by meeting once a week to fi nd a way to fi t in all their new patients.

By fi nding a new way to schedule the team can now come up with appointments as soon as the referral is received.

“You have to be adaptable,” says George-ta Savu, manager, Stroke Rehab Outpa-tient Rehab Clinic, Toronto Rehab. “In or-der to make any changes work, you’ve got to be prepared to measure them, evaluate and make changes when necessary.

“Most importantly the team knows their goal, and came up with the solutions them-selves. It’s a signifi cant change and one that was achieved by the team.”

Streamlining dischargeThe longer a patient spends in a hos-

pital, the more time they spend at risk of a fall, a medication incident or acquiring an infection.

That’s why hospitals need to discharge people as soon as they are ready to go – getting them to the right place at the right time.

One unit at the Peter Munk Cardiac Centre (PMCC) has done just that.

“We’re not doing this to create more bed space,” says Jeanne Elgie-Watson, nurse manager, PMCC. “In our effort to become a high-reliability organization, we need to look at reducing length of stay as a fundamental part of improving patient safety.”

Patients on her cardiovascular surgery unit are heading home with or without support, on average, just over a full day earlier than they were three months prior.

That’s a 16 per cent reduction in length of stay, down to 6.1 days from 7.3 in just 12 weeks.

“We achieved that by smoothing out the barriers to timely discharge,” says Jeanne. “The work started with help from the Lean Process Improvement team in our Rapid Improvement Event and it’s continued every day since in our huddles.”

While the team made numerous minor changes to the discharge process, much of the improvement stems from three major changes:• Ensuring test results are ready in time to

discharge the patient.

• Continuous communication of an up-to-date discharge plan to the patient and their family.

• Daily huddles implemented by the clinical team to discuss process prob-lems and discharge rounds so as to identify patients who will be ready for discharge within 48 hours.“The medical team usually needs the

results from morning blood tests and echocardiograms before discharging any-one,” says Jeanne. “The night shift now draws blood by 6 a.m. for patients we’re planning to discharge that day.

“By starting the process earlier, we get results back in time to make decisions.”

After surgery most patients need fami-ly support to safely transition back home. The team communicates the estimated discharge date to the family two days in advance, giving them some time to make arrangements for transportation and home care.

The engine driving these improve-ments has two components. The first part is the team’s daily huddle where they address process problems, and the sec-ond part is their new discharge rounds. At 1:30 p.m. every day, the entire team gathers for 15 minutes to identify any pa-tients who will be ready for discharge in the next 48 hours and discuss their indi-vidual needs or outstanding tests.

The unit’s target length of stay is six days. When they beat it, they celebrate as a team. When they meet it, they re-cord it as a success on their performance board. When a patient is discharged on day seven or later, they find out why.

Often a delayed discharge is because the patient required more medical care. If the delay was due to a problem with the discharge process the team is reluc-tant to simplify; they dig into the root cause and address it.

“Everyone knows our goal, and we work together to achieve it,” says Helen Zhang, a Nurse Practitioner at PMCC. “Whenever a patient is ready to go home by day six after surgery, we cheer.” ■H

Michael Ronchka is a Communications Associate at University Health Network.

Lessons from the auto industryBy Michael Ronchka

T

It turns out the best way to solve big, complex problems like wait times is to work with the people doing the job to solve the small, simple problems.

Photo courtesy of the UHN

1 A unit team participating in daily discharge rounds, where the team identifi es patients leaving within 48 hours to make sure they are ready to go. 2 Georgeta Savu, nurse manager, University Health Network, works closely with her front line staff to reduce wait times for patients.

1 2

JUNE 2016 HOSPITAL NEWSwww.hospitalnews.com

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Last year in Ontario, 1,173 patients on the transplant wait list were given a sec-ond chance at life because of the generos-ity of organ donors and their families. For the second year in a row, Trillium Gift of Life Network reports a record number of deceased organ donors and patients who received a life-saving transplant.

Between April 1, 2015 and March 31, 2016, 296 deceased organ donors gave

the gift of life, an increase of nine per cent over last year (and a 61 per cent increase over 10 years). More than 2,200 tissue donors enhanced the lives of thousands through the gift of corneas, skin, bone and heart valves, up 16 per cent from 2014/15.

“Another record year in Ontario con-fi rms that improvements to the donation and transplant system are taking hold,

and translating to more lives saved,” says Ronnie Gavsie, President and CEO of Trillium Gift of Life Network. “We are making progress towards our goal: to en-sure that donation is an integral part of quality end-of-life care and that when donation is possible, every family is given the opportunity to save lives.”

Also, in 2015/16, over 340,000 On-tarians registered as donors, the highest number ever recorded in one year. By age of consent, 20-29 year olds continue to be most likely to register (22 per cent), com-pared to all other age groups.

“Ontario’s record donation and trans-plant results should give hope to the 1,600 people who wait for that second chance at life,” says Dr. Eric Hoskins, On-tario’s Minister of Health and Long Term Care. “All of us can help make a differ-ence. Register to be an organ donor at www.BeADonor.ca and talk to your fam-ily about your wishes. This act could one day save up to eight lives.”

Quick facts:• Today, Ontario’s registration rate is 29

per cent (or 3.5 million people) • Registration rates by community are

available at www.BeADonor.ca/score-board

• Everyone is a potential organ and tissue donor. To date, the oldest Canadian or-gan donor was 92 and the oldest tissue donor was over 100. ■H

Transplants:Canadians face wait times of about 449

days in order to get access to new, poten-tially lifesaving medicines in public drug plans, according to a new IMS Health Can-ada Inc. report commissioned by Innovative Medicines Canada.

The 2016 Access to New Medicines in Public Drug Plans: Canada and Compa-rable Countries analyzed reimbursement for new medicines in provincial drug plans comprising at least 80 per cent of the eli-gible national drug plan population. The report fi nds Canada’s public drug plans are seriously lagging compared to other simi-lar OECD nations. “Compared to similar countries, Canadian patients have access to fewer new medicines and also face long delays for the drugs that are covered under public drug plans,” says Brett Skinner, Exec-utive Director, Health and Economic Policy, Innovative Medicines Canada.

Canadians who rely on public drug plans are facing more than a year’s delay to ac-cess new, potentially lifesaving treatments. This report shines the light on why access to medicines in Canada needs to be improved – patients must come fi rst.• In Canada, 59 per cent of cancer medi-

cines were covered in public drug plans, ranking Canada in 17th place of 20 coun-tries.

• Canadian public drug plans placed reim-bursement conditions on 90 per cent of new medicines, ranking Canada 17th of 20 countries.

• In Canada, only 23 per cent of new bio-logic medicines were reimbursed in public drug plans, putting Canada in 19th place of 20 countries.Innovative Medicines Canada is the na-

tional voice of Canada’s innovative phar-maceutical industry. We advocate for poli-cies that enable the discovery, development and commercialization of innovative medi-cines and vaccines that improve the lives of all Canadians. We support our members’ commitment to being valued partners in the Canadian healthcare system. ■H

Canadians facing delayed access to

The Canadian Foundation for Health-care Improvement (CFHI) recently released dramatic results from a bold pan-Canadian initiative reducing the inap-propriate use of antipsychotic medication among seniors in long term care (LTC) – fewer falls, less aggressive behaviours and resistance to care, and an improved quality of life for residents and their families.

From 2014-2015, CFHI worked with 56 LTC homes that agreed to take senior resi-dents off any antipsychotics that weren’t appropriately prescribed.

“Antipsychotics are often used in pa-tients with dementia to curb resistance to care and other challenging behaviours,” says Stephen Samis, Vice President, Pro-grams, CFHI. “But they provide limited benefi t and can cause serious harm and complications from overuse – especially falls, which ultimately lead to unneces-sary visits to the emergency room. With this initiative to reduce use, LTC provid-ers report improved care for residents and a better culture at their facilities. Most important, family members say they now have their loved ones back.”

After only one year, early results from a sample of 416 residents from the facilities showed:

• 54 per cent of residents had antipsy-chotics discontinued or signifi cantly reduced (18 per cent reduced; 36 per cent complete eliminations).

•Among these residents:– Falls decreased by 20 per cent – Verbally abusive behaviour decreased by

33 per cent – Physically abusive behaviour decreased

by 28 per cent – Socially inappropriate behaviour de-

creased by 26 per cent – Resistance to care decreased by 22 per

cent “A major concern of removing the an-

tipsychotic medication was the potential of increasingly aggressive behaviour. Ag-gression is what typically triggers the use of antipsychotics in the fi rst place.

Our initiative not only showed a notable decrease, it took that issue off the table,” says Samis.

Recent studies show that more than one-in-four (27.5 per cent) seniors in Ca-nadian long term care facilities is on anti-psychotic medication without a diagnosis of psychosis.

If the results of the CFHI initiative were scaled up nationally, over the fi rst fi ve years an estimated:

• 35,000 LTC residents per year would have their antipsychotics reduced or dis-continued.

• 25 million antipsychotic prescriptions would be avoided altogether

• 91,000 falls would be prevented • 19,000 ER visits would be prevented (an

eight per cent decline) • 7000 hospitalizations would be prevent-

ed (an eight per cent decline) “CFHI projections also show $194 million saved in direct healthcare costs – even after the costs of implementing the program are taken into account,” says Samis.

CFHI is calling for:• Long term care homes and provincial-

territorial governments to step up efforts to change the culture of over-medicating seniors with dementia, and increase ac-cess to alternate behavioural support programs.

• Healthcare providers to take better pa-tient histories, conduct more regular medications reviews and work as care teams with family members.

• Frontline staff in LTCs to tailor servic-es – including music, pet or recreation therapy that replace strong medications – to support quality of care and quality of life for residents. ■H

Taking seniors off antipsychotics shows dramatic improvement in care

Three life-saving performed every dayinnovative medicines

www.hospitalnews.comHOSPITAL NEWS JUNE 2016

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UPCOMING DEADLINES

Guest Editorial

n a dramatic show of physician support for deep healthcare reform in the U.S, more than 2,200 physician leaders have

signed a “Physician’s Proposal” calling for sweeping change. The proposal, pub-lished May 5 2016 in the American Journal of Public Health, calls for the creation of a publicly-fi nanced, single-payer, national health program to cover all Americans for all medically necessary care.

If that sounds familiar, it should. These American doctors are calling for Canadi-an-style medicare. They want a decisive break from the expensive and ineffi cient private insurance industry at the heart of the U.S. healthcare system.

How ironic that at the same time U.S. physicians are calling for a single-payer health system like ours, Canada is in the midst of a legal battle threatening to pave the way for a multi-payer system resem-bling what has failed Americans.

What’s at stake? A trial about to begin in British Columbia threatens to make the Canada Health Act unenforceable.

The Canada Health Act is federal leg-islation that guides our healthcare system. It strongly discourages private payment for medically necessary hospital and phy-sician services covered under our publicly-funded medicare plans. This includes out-of-pocket payments in the form of extra billing or other user charges. Legislation in most provinces further prohibits private insurance that duplicates what is already covered under provincial plans.

If patients are billed for medically nec-essary hospital and physician care, the fed-eral government is mandated to withhold an equivalent amount from federal cash transfers to provinces or territories violat-ing the Act. At least that’s what supposed to happen.

Unfortunately, the last decade saw a proliferation of extra billing in several provinces, and few instances of govern-ment clawing back fi scal transfers. Per-haps, things will change. Minister Philpott recently stated that the government will

“absolutely uphold the Canada Health Act.”

In BC’s upcoming trial, the plaintiffs – including two for-profi t investor-owned facilities, Cambie Surgery Centre and the Specialist Referral Clinic – are attempting to have the court strike down limits on private payment. They support the cre-ation of a constitutionally protected right for physicians to bill patients, either out-of-pocket or through private insurance, for medically necessary care, while also billing the public plan.

In other words, the plaintiffs want to undo our elegantly simple single payer system for hospital and physician care, creating instead a multi-payer system like the U.S. If their constitutional challenge is successful, the door will swing wide open in BC – and across Canada – for insurers to sell what will amount to “private queue jumping insurance” for those who can af-ford it, potentially harming the rest of us who can’t.

The outcome of this trial could be that those who can pay for care would jump the queue, drawing doctors and other re-sources out of the public system. Those who can’t pay would likely wait longer. Rather than a solution for wait times, pri-vate payment in the Canadian context would make them worse.

Global evidence shows that private insurance does not reduce public system wait times. The Achilles’ heel of health care in several European countries, such as Sweden, has been long waiting times for diagnosis and treatment in several areas, despite some private insurance. After Aus-

tralia introduced private insurance to save the government money, those with private insurance have faster access to elective surgery than those without. Divisions in equitable access to care is one of the big-gest challenges now facing countries that have adopted multi-payer systems.

Multi-payer systems are administra-tively complex and expensive, explaining why the U.S. health insurance industry spends about 18 per cent of its health care dollars on billing and insurance-related administration for its many private plans, compared to just two per cent in Canada for our streamlined single payer insurance plans. Hospital administrative costs are lowest in Canada and Scotland – both single payer systems – and highest in the US, the Netherlands, and the UK – all multi-payer systems.

For all of its warts in how we deliver healthcare in Canada, the way in which we pay for care – a single public payer in each province or territory – avoids the high administrative costs of multi-payer systems.

Abundant evidence shows private in-surance is at the root of what ails the U.S. system. Dr. Marcia Angell, co-author of the Physicians’ Proposal, Harvard Medi-cal School faculty, and former editor-in-chief of the New England Journal of Medi-cine, sums it up: “We can no longer afford to waste the vast resources we do on the administrative costs, executive salaries, and profi teering of the private insurance system.” A Canadian-style single payer fi -nancing system would save the U.S. about $500 billion annually.

Meanwhile, in Canada, abandoning our single payer health care system for a U.S.-style multi-payer system would be the worst possible outcome for Canadians. Let’s hope the evidence convinces the judge. The trial begins September 2016. ■H

Karen Palmer is an advisor with EvidenceNetwork.ca, and Adjunct Professor in the Faculty of Health Sciences at Simon Fraser University.

Canadian-style medicareBy Karen Palmer

I

And how Canada risks losing the health advantage it has

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Why American doctors are calling for

The outcome of this trial could be that those who can pay for care would jump the queue, drawing doctors and other resources out of the public system.


5 HEALTH CARE TRANSFORMATION/EHEALTH/MOBILE HEALTH/MEDICAL IMAGING Focus

hen patients sit in front of a clinician, whether in a hos-pital Emergency Department (ED), an urgent care centre

or a community practice, they may al-ready have received care from dozens of other physicians, specialists and care pro-viders. To fully understand the patient’s medical condition and to offer the best and most timely care, that physician ide-ally wants to know what all of those other clinicians know. He or she needs the pa-tient’s medical information.

But patients rarely travel with their medical data, which means that the at-tending physician may have to spend time phoning around to other institutions, seeking the patient’s latest lab results or medical images, or even their medication history. Without this data, the physician may be forced to send the patient for du-plicate and potentially unnecessary tests, or unknowingly begin treatment that may confl ict with the patient’s current care.

More than just an inconvenience and burden to everyone involved, the lack of a patient’s medical data may signifi cantly compromise his or her care.

Recognizing this concern, Markham Stouffville Hospital (MSH) recently implemented an electronic health infor-mation sharing platform known as Con-necting GTA (cGTA). Part of eHealth Ontario’s larger Connecting Ontario initiative, cGTA integrates electronic health records through a centralized da-tabase.

“By seamlessly and securely linking through our hospital information system, our clinicians have ready access to a pro-vincial patient data repository,” explains MSH CIO Lewis Hooper. “Such access allows our clinicians to view information critical to our patients and their care.”

The system also limits the burden on patients who may already be over-whelmed by their current medical con-cern, particularly in an emergency situa-tion where the patient may not have had time to bring their records from home. Or in situations where patients may be experiencing cognitive impairments or language barriers that further complicate already challenging conversations.

MSH is part of the fi rst expansion wave of cGTA participants, the early-adopter phase linking 40 healthcare ser-vice organizations including 11 hospitals, which are already sharing patient data and populating the repository.

MSH was the fi rst hospital to link to cGTA with a new version of a prominent hospital information system, which pre-sented the organization a unique obsta-cle to overcome. This meant that MSH needed to work with the systems’ design-ers to create an entirely new way to link the two resources while maintaining im-portant features such as single-sign-on.

The one-click, or single-sign-on, sys-tem design allows clinicians to access the cGTA repository without having to open a second portal, further streamlining ac-cess to vital patient information. As well, the restriction to a single log-in improves

the system’s security, helping to ensure that personal medical information is only seen by those authorized to view it.

“We’re already seeing the benefi ts of the new system,” says General Internal Medicine Lead Dr. Allan Yee. “The rapid access to a patient’s previous care from connected organizations, and lab results from across the province gives us the information we need to support medi-cal decision-making. This is health data sharing at a level that provides us access when and where we need it the most.”

For example, ED physician Dr. Sonia Sabir lauds the ability to see clinical lab results from facilities throughout Ontar-io, thinking of one case where her next

treatment decision hinged on know-ing how well the patient’s kidneys were functioning. “The cGTA viewer allowed me to easily compare lab results from dif-ferent hospitals to see that there was no

worsening of the patient’s renal function over time,” she says. The MSH imple-mentation has also shown benefi ts from quite unexpected directions.

Kris Bayley, an ED nurse, recounted an incident involving a patient who was new to MSH and was presenting with suspi-cious behaviour. Checking cGTA for the patient’s medical history, she found more than 20 visits to various facilities in the region, all within the last few months.

Just by looking at the patient’s ADT (admission-discharge-transfer) informa-tion, the nurse realized that the numer-ous visits suggested drug-seeking behav-iour by the patient, and she was able to act accordingly.

As MSH was the fi rst hospital to link cGTA to the new version of the hospital information system, the design solution will be shared with other institutions us-ing the same vendor as cGTA rolls out across the province and with early adopt-er organizations as they upgrade to the same version.

As for MSH itself, the organization has begun the next phase of populating the cGTA repository with patient data. This completes the information loop and fur-ther strengthens cGTA and enhances the quality of patient care for all participat-ing organizations.

“We want to be sure we contribute in-formation quickly,” offers Hooper. “It’s great that we can view the data from cGTA, but it is just as important that we add whatever data we have to ensure op-timal care to all patients in Ontario.” ■H

Leela Holliman is a Project Manager at Markham Stouffville Hospital and led the implementation of ConnectingGTA.

Improving patient care by

By Leela Holliman

Dr. Lee accessing patient data from cGTA with a colleague to ensure they have the information they need to support the care plan.

connecting medical recordsW

More than just an inconvenience and burden to everyone involved, the lack of a patient’s medical data may signifi cantly compromise his or her care.



ne in every two patients diag-nosed with kidney failure will not be alive in three years.

“The major reason that kidneys fail is scarring,” says Dr. Darren Yuen, a nephrologist with St. Michael’s Hospital. “If we could fi gure out who has a lot of scarring, we could better predict which patients are most likely to develop kidney failure and treat these patients more aggressively.”

Scarring is irreversible and can cause ongoing kidney injury that eventu-ally leads to kidney failure. Regardless of whether a patient has diabetes, high blood pressure or another condition affecting the kidney, all these diseases can cause scarring, which ultimately can lead to organ failure.

Needle biopsy is the current “gold stan-dard” diagnostic test for assessing kidney scarring. A long needle is injected into the kidney and a sample – about the size of a mechanical pencil’s tip – is removed from the organ.

“The problem with biopsy is that such a small sample means even after patients undergo this painful test, we still don’t know what most of the kidney looks like,” says Dr. Yuen, who is also a scientist in the hospital’s Keenan Research Centre for Biomedical Science. “The sample may show no scarring, but the rest of the organ may be severely scarred. We have no way

of knowing and so clinicians are hesitant to subject patients to a test that provides limited information and has risks such as internal bleeding.”

Dr. Yuen teamed up with Medical Im-aging specialists Dr. Anish Kirpalani and Dr. General Leung to apply and study a specifi c magnetic resonance imaging test – called an elastogram – and its ability to detect scarring in transplanted kidneys.

If their new MRI technique is able to quickly and clearly tell the difference be-tween mild and severe kidney scarring, it may prove particularly helpful for kidney transplant patients.

“In the fi rst year after surgery, patients with transplanted kidneys generally do very well,” says Dr. Yuen. “Their long-term prognosis, however, is unfortunately not as good.” Ten years after transplantation, up to 60 per cent of patient’s kidneys have some degree of scarring that can cause kidney failure.

“We’ve begun using MRI to measure a transplant kidney’s stiffness,” says Dr.

Kirpalani, a radiologist and director of St. Michael’s MRI Research Centre. “Stiffness is an early sign of scarring, and this has been shown with MRI in organs other than the kidney. Healthy tissue is more fl exible whereas scar tissue is more rigid.”

The team has begun studies to evaluate whether MRI can measure kidney scarring in patients more safely and accurately than biopsy. Unlike biopsy, the MRI test does not require needles or injections and MRI can analyze the whole organ for scarring, rather than just the small biopsy sample.

“We’ve already tested this technique in more kidney transplant patients than anywhere else in the world,” says Dr. Kirpalani. “If we’re able to detect scar-ring more safely and accurately than a needle biopsy, we may be able to bet-ter guide how kidney transplant patients are treated early on and improve their long-term outcomes.” ■H

Geoff Koehler works in communications at St. Michael’s Hospital.

Using MRIs to predict kidney failureBy Geoff Koehler

O Drs. Kirpalani and Yuen shared their translational research project with donors at the St. Michael’s Foundation’s Angels’ Den event. The pair was runner up and awarded $80,000 from the foundation’s Translational Innovation Fund.

Photo courtesy of Dr. Kirpalani and Dr. Leung, St. Michael’s MRI Research Centre

The top two images compare mild and severe scarring using conventional MRI technique. The bottom two images contrast mild and severe kidney scarring with the new MRI technique being tested in transplanted kidneys at St. Michael’s.

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he Princess Margaret Cancer Centre recently launched a free app which helps guide pa-tients and families throughout

the cancer treatment process, from diag-nosis through to after treatment.

Many people fi nd themselves feeling overwhelmed following a cancer diagnosis. The stress of not knowing what happens next, what questions to ask, or where to fi nd help can lead patients to feel out of control. The Princess Margaret Cancer Journey app was designed to give patients a place to start.

Since 2011, the Princess Margaret has provided patients with a comprehensive, patient-focused cancer guide in the form of the My Cancer Journey Personal Guide Book, a three-ring binder full of help-ful materials developed by the Patient & Family Education program in consultation with patients and clinicians. The My Can-

cer Journey Personal Guide Book aims to develop patients’ self-management skills and self-effi cacy through the provision of timely information, leading to improved clinical outcomes.

With the booming popularity of mobile apps, the Patient & Family Education pro-gram worked with Princess Margaret’s Web & Digital Innovation team to adapt the Guide Book into a downloadable app, giv-ing patients more choice for accessing this information. By adapting the trustworthy health information from the Guide Book and leveraging the strengths of mobile

technology, the Cancer Journey app pro-vides a convenient, portable complement to the binder.

Like the Guide Book, the Cancer Jour-ney app is organized by the different phases of the cancer experience, providing infor-mation such as articles on what patients can expect at each phase of the cancer journey, examples of questions they may want to ask their healthcare team, and de-scriptions of services available at the Prin-cess Margaret and in the community. The Cancer Journey app also allows patients to take notes, write down questions they’d

like to ask their healthcare team, and keep track of their doctor’s contact information.

The mobile adaptation enhances the Guide Book by providing additional fea-tures that benefi t patients. Patients with visual impairments or limited English profi ciency can use Apple’s VoiceOver or Google’s TalkBack text-to-speech tech-nologies to listen to information rather than read. Patients can view websites with more details or call services at the tap of a button. The app provides instantaneous access to the latest and most up-to-date brochures, physician and services details, and health information as Princess Marga-ret information databases are updated.

The Princess Margaret offers quality educational materials in multiple media formats to provide patients with options to learn the information they want and need in ways that meet their learning pref-erences. Helping patients become active participants in their care leads to improved feelings of control and ultimately increases their quality of life.

The app was made possible by the Zas and Stella Ruth Feitelson Patient Educa-tion Fund at The Princess Margaret Can-cer Foundation.

Download the free app by searching for “Princess Margaret Cancer Journey” in Google Play or the Apple App Store. ■H

Alaina Cyr & Matt Turczyn are members of the Princess Margaret Web & Digital Innovation Team.

Cancer support in the palm of your handBy Alaina Cyr & Matt Turczyn

T

The Princess Margaret Cancer Centre recently launched a free app which helps guide patients and families throughout the cancer treatment process, from diagnosis through to after treatment.



magine not being able to work or run your business, or that you are a grandparent who cannot push their grandchild

on a swing. Imagine not being able to sleep through

the night, or that you are a paramedic who cannot lift a stretcher.

Every year, over 30,000 people in the Central East Local Health Integration Network (Central East LHIN) visit their primary care provider (PCP) because of shoulder pain.

Shoulder pain is second only to low back pain in terms of disability and costs. Patients often experience 12 to 18 months of unresolved pain and discomfort before being referred on to an orthopaedic sur-geon. During this time, many patients remain without a concise diagnosis, while receiving unnecessary diagnostic tests, in-effective medication and physiotherapy, only to return to their PCP several times before being referred on to a specialist.

Remarkably, only one in twenty-fi ve shoulder complaints result in surgery. The majority of issues can be solved through non-surgical interventions that do not au-tomatically require a surgeon’s attention.

In Ontario, lengthy wait times to see an orthopaedic surgeon persist in many LHINs, and thus it is not surprising that about 40 per cent of the shoulder patients in the Central East LHIN receive their shoulder care outside of their region.

With this in mind, Rouge Valley Health System has developed a novel specialty care program.

Designed and led by Rouge Valley’s own shoulder surgeons, The Shoulder Centre is transforming the way shoulder pain is treated: redefi ning and shorten-ing the patient journey, increasing the ease and access to consistent and quality care, as well as addressing system inef-fi ciencies that challenge health service sustainability.

“For primary care providers, determin-ing the next course of action for a patient who comes to them with shoulder pain can be diffi cult and frustrating,” says Dr. Stephen Gallay, Division Head of Or-thopaedics at the Rouge Valley Ajax and Pickering hospital campus and one of the founders of The Shoulder Centre. “They often order diagnostic tests (including costly MRIs) and try multiple treatments, all in the effort to return the patient to a pain-free state. The patient is then referred to a shoulder surgeon – sometimes three to twelve months after their fi rst appoint-ment with their PCP – and often without having received a concise diagnosis.”

In contrast, The Shoulder Centre’s new model of care immediately connects the PCP and their patient with the right shoulder specialist.

To do this, the Centre developed a new intelligent e-referral tool to guide the PCP through a more succinct assessment of their patient’s shoulder pain at the time of the patient encounter.

The referral tool generates a report that is triaged to establish which member of the Centre’s multidisciplinary shoulder specialist team will take charge of the pa-tient’s care. Only then are evidence-based diagnostics used (if needed) to determine the appropriate and most effective treat-ments, which could mean anything from a cortisone injection performed by a physi-cian assistant or sports medicine physician,

to a customized exercise program crafted by a physiotherapist, to surgery booked with an orthopaedic surgeon. Relying on a team rather than on an individual to provide care means the patient is seen sooner. And that means the patient will be pain-free faster.

Just in its fi rst three months, The Shoul-der Centre’s team has shortened patients’ wait times to between two to three weeks, and demonstrated signifi cant cost savings to the healthcare system.

“We’re really excited that we’ve been able to add a physician assistant [PA] to our team. We’ve trained her to provide ex-emplary shoulder care to many of our non-surgical shoulder patients so they don’t have to wait to see one of the surgeons. From a system perspective, the PA is deliv-ering the same quality of care for a particu-lar problem within her scope of practice at a fraction (approximately 25 per cent) of the usual cost that would be charged to OHIP if one of the surgeons treated the patient,” explains Gallay. “We’ve also projected that with patients being referred directly to The Shoulder Centre, we can reduce the number of MRI tests by two-thirds… that also leads to signifi cant sys-tem savings especially when an MRI is priced at $500-$800 a test.”

The next step for the Centre is to em-power and educate local PCPs and other allied health providers with shoulder knowledge. Thus the Centre will no longer be just a physical space that patients must travel to, but rather the hub of a specialty care community comprising of information and expertise that can be found through-out the network. Patients can then stay close to home, but still be confi dent that they are receiving consistent and quality shoulder care.

“The goal of this model of care is for the patient to easily and quickly reach the right care at the right time, and to also make it effi cient and sustainable. We’re starting with transforming shoulder care,

but recognize that this model is transfer-able to other areas in health care,” con-cluded Gallay.

For more information about The Shoul-der Centre located at Rouge Valley Health System as well as to download the referral form, visit www.theshouldercentre.ca. ■H

Jennifer R. Collins is a Special Projects Offi cer at Rouge Valley Health System Foundation And Farah Nabi, is Interim Manager of Outpatient Orthopaedics, Rouge Valley Health System.

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Transforming shoulder care By Jennifer R. Collins and Farah Nabi

I

Every year, over 30,000 people in the Central East Local Health Integration Network (Central East LHIN) visit their primary care provider (PCP) because of shoulder pain.

Orthopedic surgeon Dr. Joel Lobo performs an assessment on Sharon Graves at Rouge Valley Ajax and Pickering hospital campus in Ajax. In just its fi rst three months, Dr. Lobo and The Shoulder Centre’s team have shortened patients’ wait times to between 2-3 weeks to see a shoulder specialist, and demonstrated signifi cant cost savings to the healthcare system.

Question & AnswerQ. How many patients in Ontario’s Central East LHIN go to their family doctor for shoulder complaints? A. Approximately 30,000 per year

Q. Has The Shoulder Centre reduced the average wait time for specialized services?A. Yes! Lengthy wait times have been shortened to 2-4 weeks.

Q. How many patients with a shoulder complaint require surgery?A. Only approximately 4-5 per cent

Q. What is the effect on the health care system of The Shoulder Centre reducing the number of unnecessary diagnostic tests being ordered?A. If the patient is managed by the new Shoulder Care Community, The Shoulder Centre is projecting that it can reduce the number of MRI tests ordered by two-thirds, consequently saving the health care system $500-$800 per test



t is not uncommon for cancer patients undergoing treatment to experience side effects or sometimes painful complica-

tions that need to be addressed in an ur-gent manner. The Regional Cancer Centre at Trillium Health Partners developed a new program to address this and improve patient care.

The REACT: Rapid Evaluation and As-sessment of Cancer Treatment clinic was designed as a patient-centred service offer-ing patients undergoing cancer treatment at Trillium Health Partners’ Credit Valley Hospital site a more timely option for as-sessing their urgent symptoms and side-effects from treatment within 30 days of their last treatment.

Ted Goodwin was in the midst of un-dergoing his fi rst round of chemotherapy treatments when he developed a severe pain in his back and began to feel unwell.

He knew something was wrong and that he needed immediate help with his symptoms. “It was like a two-by-four was shoved in my back,” described Ted, 54.

Unbeknownst to him, his lungs were fi lling up with fl uid. Ted placed a call to his primary care nurse at Trillium Health Partners’ Carlo Fidani Regional Cancer Centre, who directed him to the REACT clinic. Upon his arrival, he was assessed by the REACT oncology nurse and treated a few hours later by a general practitioner specializing in oncology. “I felt so relieved,” says Ted. “I received great care and they took care of my immediate needs in an ef-fi cient and timely manner. It left me with peace of mind that I was in good hands.”

When a patient calls the REACT clinic they are immediately connected with an oncology nurse who will assess the pa-tient’s condition and recommend next steps, with help from a general practitioner specializing in oncology and the medical and radiation oncology team at Trillium Health Partners’ Carlo Fidani Regional Cancer Centre.

“Our patients undergoing cancer treat-ment can experience such side-effects as fever, nausea, vomiting and diarrhea. For support, many wait until their next sched-uled appointment or visit the emergency

department. We knew that we could pro-vide them with an option to better suit their specifi c needs,” says Dr. Katherine Enright, Medical Oncologist, Trillium Health Partners, and Regional Lead, Sys-temic Treatment Quality, Mississauga Hal-ton Central West Regional Cancer Pro-gram. “The REACT clinic revolves around the patient experience. It provides a quick response to our patient’s concerns, helps them to manage their urgent symptoms, and can help them avoid an emergency de-partment visit.”

In 2014-15, the bustling Carlo Fidani Regional Cancer Centre and Oncology Program at Trillium Health Partners wel-comed over 141,000 patient visits from across the Mississauga Halton and Cen-tral West regions. By offering the REACT clinic to its patients that currently receive cancer treatment at Credit Valley Hospi-

tal, Trillium Health Partners has provided faster and more convenient access to ser-vices that address their most urgent needs.

“With REACT, our patients receiving cancer treatment now have more timely access to high-quality specialized care for their urgent symptoms,” says Sarah Ban-bury, Program Director, Oncology Servic-es, Trillium Health Partners, and Regional Director, Mississauga Halton Central West Regional Cancer Program. “Ultimately, this can improve their quality of life and contribute to better outcomes in their care and treatment plan.”

For more information please visit www.trilliumhealthpartners.ca/patientservices/cancerservices ■H

Debbie Silva is a Communications Advisor at the Mississauga Halton Central West Regional Cancer Program.

cancer patients with urgent symptomsBy Debbie Silva

I

The REACT clinic revolves around the patient experience. It provides a quick response to our patient’s concerns...

REACT Oncology Nurse, Andrea Finlayson, in the REACT clinic.

New service offers faster assessment for

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10 From the CEO's Desk

his year Holland Bloorview Kids Rehabilitation Hospital is celebrating an important mile-stone in our 117 year history

– 10 years in our new state-of-the-art, ac-cessible, child-friendly facility recognized by the International Academy for Design and Health as “an inspirational building…which speaks to a child’s right to partici-pate in our society.”

We have come a long way since 1899 to become the largest rehabilitation hospital in Canada focused on improving the lives of kids and youth with disabilities. Over the generations, we’ve had many name chang-

es, locations and even amalgamated two organizations. Some of our former names you might recognize, others, however well-intentioned during their time, refl ect out-dated language: From the original facility called the Home for Incurable Children to the Ontario Crippled Children’s Centre, Bloorview Children’s Hospital, the Hugh MacMillan Medical Centre to our current facility, named following a generous dona-tion by the Holland Family.

Those name changes mark an evolution in the history of childhood disability and child health. Where we once saw “incur-able,” we now see possibility. Kids and youth and their families actively partner with their care teams at the hospital to set their own goals and plan their transition to home and community.

In addition to exceptional care, we are helping bridge the gap to adulthood with work experience programs like “Youth@Work” for the specifi c readiness skills needed for employment. We are constantly looking at new opportunities such as a recent robot building pilot program with FIRST Robotics Canada, which brings the inspiration of science, technology and teamwork to kids who may often require

technology for their activities of daily liv-ing. And supported by our generous do-nors, we have embarked on an ambitious three-year program to establish excellence in building the pathway to adulthood for kids and youth with disabilities.

Of course there is much further to go. The kids and youth we serve and their families with whom we co-create great care, have unlimited ambitions for recov-ery, capability, long-term health and inclu-sion in society. Research is a big part of the way they will achieve these aspirations.

Through our world-class research insti-tute we are expanding the reach of tech-nology to create a future when every child regardless of ability is able to communi-cate. Our team is advancing our under-standing and treatment of pain in children with cerebral palsy and helping to dissemi-nate that knowledge through download-able toolkits available to clinicians across the globe.

We are also making important strides in autism research in early intervention, clinician capacity building, technologies including anxiety monitoring, pharmaco-logical approaches, and understanding au-tism to help improve the lives of children with autism and other neurodevelopmen-tal conditions. And our work in participa-tion and inclusion is paving the way for a brighter future by identifying how to build resilience and improve service delivery for kids and youth and their families, as well as identifying barriers and the evidence to eradicate them.

Through novel programs such as ad-vanced simulation development, advo-cacy, and a “family as faculty” philosophy including a home visit program for medical and other health disciplines students, the Holland Bloorview Teaching and Learning Institute in partnership with our client and family integrated care team is giving the next generation of clinicians the tools they will need to help improve the quality of life for those we serve.

We have been engaging kids and youth and their families for years and developed a system-leading framework in 2011 through which we partner at all levels and for all major decisions in the organization. That’s why as important as 10 years in a building feels, we listen when our families remind us that they want health care excellence that isn’t confi ned within our bricks and mortar.

for children and familiesBy Julia Hanigsberg

T

Kids and youth and their families actively partner with their care teams at the hospital to set their own goals and plan their transition to home and community.

Continued on page 22

Julia Hanigsberg

Connecting2care



mergency contraception, also known as EC, is a woman’s last opportunity to prevent a pregnancy after unprotected

sex or a problem with contraception. Although there are three choices of EC available, most women only know about one – a pill that is available over the coun-ter, but is actually the least effective of the three methods.

That’s why a team of healthcare pro-viders and researchers led by Dr. Sheila Dunn, Women’s College Hospital (WCH) physician, recently launched whatsnext-forme.ca – a mobile-friendly guide to all emergency contraception options avail-able to women.

“After years of working in reproductive health and emergency contraception, I noticed how often women need back-up birth control and how many don’t know

what their options are. We developed whatsnextforme.ca to bridge this gap and provide women who need emergency contraception with information about all their options, so that they can make an in-formed choice that is right for them,” says Dr. Dunn, project lead and research direc-tor of the Family Practice Health Centre at WCH.

Whatsnextforme.ca was developed using the most up-to-date evidence

available, and designed based on feed-back from young women to provide user-friendly, easy-to-understand information. Although it’s primarily aimed at women between 18 and 30 years old, anyone who’s sexually active can benefi t from the information.

“Most women know about Plan B pill, which is actually the least effective espe-cially if there is a delay in getting emer-gency contraception or if a woman weighs

more than 75 kg. There are more choices out there that women don’t know about but may be better suited for them,” says Dr. Dunn.

One such option is the copper IUD. It’s the most effective EC method and can also be left in place to provide highly effective ongoing contraception. However, even if a woman wanted to get an IUD, she might have diffi culty getting one because few doctors or nurse practitioners insert them.

To help women fi gure out where they need to go to get emergency contracep-tion, including clinics that insert emer-gency IUDs, the website includes a handy clinic fi nder for local sexual health clinics that provide emergency contraception consultation services. The clinic fi nder is currently limited to Toronto, with the pos-sibility of expanding in the future.

The website was developed by a group of healthcare providers and researchers based at Women’s College Hospital includ-ing Dr. Sheila Dunn, Dr. Payal Agarwal, Dilzayn Panjwani, pharmacist researcher Lisa McCarthy and WCH’s Bay Centre for Birth Control team.Visit whatsnextforme.ca to learn more. ■H

Magdalena Stec is a Marketing and Communications Specialist Strategic Communications Women’s College Hospital.

Physician launches mobile-friendly guide to emergency contraception optionsBy Magdalena Stec

E

Whatsnextforme.ca was developed using the most up-to-date evidence available, and designed based on feedback from young women to provide user-friendly, easy-to-understand information.



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14 Nursing Pulse

he Registered Nurses’ Associa-tion of Ontario (RNAO) says government reforms that are expected to radically change

the way health services are delivered in the province won’t succeed unless they include a comprehensive health human resources (HHR) strategy.

To inform the conversation on how that strategy might look, representa-tives of RNAO were at Queen’s Park on May 9 – the fi rst day of National Nursing Week 2016 – to release a report that out-lines what must happen if Health Minis-ter Eric Hoskins wants to achieve his goal of putting patients fi rst – an initiative RNAO supports.

Mind the safety gap in health system transformation: Reclaiming the role of the RN takes an extensive look at recent trends in nursing employment and sheds light on how the minister’s priorities to improve the system are completely at odds with the reality of how nursing human re-sources are deployed today.

RNAO says developing a comprehensive and well-thought-out interprofessional HHR plan is a must for any major health system transformation, which is why it is the report’s fi rst recommendation.

“Given that nurses make up the larg-est share of regulated health profession-als in the province, we are advancing the HHR agenda by issuing this report,” says RNAO President Carol Timmings, adding that “nurses play a central role in deliver-ing health services, and statistical trends in nursing skill mix and organizational models of care delivery don’t bode well for patient safety and health outcomes.”

“How can we drive the important chang-es outlined in the health minister’s Patients First report without the fuel to make these changes happen?” asks Timmings. “It makes no sense that at a time when patient acuity is increasing in hospitals and in the community sector, RNs are being replaced by less qualifi ed personnel.”

RNAO is urging the minister of health and the Local Health Integration Networks (LHIN) to issue an immediate moratorium on the replacement of RNs, a trend associ-ated with increased morbidity and mortal-ity. “RNs are being replaced simply to cut costs, but this practice fl ies in the face of well-documented evidence that shows em-ploying more RNs actually costs less. This is because a higher proportion of RNs re-sults in lower complication rates, and fewer hospital re-admissions,” says Timmings.

And yet, data shows that between 2005 and 2010, the ratio of RNs to diploma-prepared registered practical nurses (RPN) was 3:1. By 2015, the ratio had shockingly dropped to 2.28:1. In fact, Ontario has the second-worst RN-to-population ratio in Canada.

RNAO CEO Doris Grinspun says “these statistics must trigger alarm bells, because if the government’s goal is to shorten lengths of stay in hospital and re-orient the system towards greater community care, a large infl ux of RNs is needed to respond to rising acuity levels, especially those of hospital patients deemed the sick-est of the sick.” That’s why RNAO is call-ing on the ministry to mandate an all-RN nursing workforce in acute care, teaching,

and cancer care hospitals within two years, and in large community hospitals within fi ve years.

Given that acuity will continue to in-crease in home care and long-term care, the report also includes recommendations for these sectors. For example, RNAO welcomes the health minister’s promise to move more care into the community. But as patients are discharged from hospital earlier and with more complex care needs, the report recommends every fi rst home care visit be conducted by an RN.

The association says the minister’s vi-sion of a more person- and family-centred system also needs to take full advantage of the expertise and authority of nurse practi-tioners (NP). To that end, RNAO’s report includes specifi c recommendations aimed at removing all barriers that handcuff NPs’ ability to fully care for Ontarians, including those who reside in long-term care homes.

Changes in nursing skill mix are not the only concern highlighted in RNAO’s re-port. The way nurses are increasingly being forced to deliver care is another troubling trend. Grinspun says more and more hos-

pitals are resorting to functional or team-based organizational models of nursing care delivery that result in fragmented care where no one is in charge of the compre-hensive care needs of the patient. These models, in which patient care is broken down into a series of tasks that are delegat-ed to various members of the nursing team, have huge implications in terms of quality of care and safety, says Grinspun. “Imagine being a patient or family member and not knowing who your nurse is.”

She says some hospitals are relying on these models to meet bottom line pres-sures. “Not only are they ineffective, there is no continuity of care. They are the fur-

thest thing from putting the patient fi rst,” says Grinspun. RNAO’s report recom-mends that hospitals use primary nursing as the most effective model, where one nurse is in charge and takes full respon-sibility for planning and delivering all of the care needs of a patient throughout their stay.

Grinspun says RNAO applauds Minister Hoskins for his desire to revamp the health system. “If we are going to shake up the sys-tem, we must make sure that it’s set up to succeed,” she says, adding the most impor-tant element in the delivery of health ser-vices is front line staff. “Those who provide care day-in and day-out are the ones who will help us deliver the necessary changes Ontarians have been waiting for, and we will do our part to ensure their experiences and health outcomes are the best.”

To read the report, and the full list of eight recommendations proposed by RNAO, visit RNAO.ca/mindthesafetyga ■H

Marion Zych is director of communications for the Registered Nurses’ Association of Ontario (RNAO)

Nurses release recommendations to ensure patients come fi rstBy Marion Zych

T

ommunity-based primary care providers often face chal-lenges accessing and navigat-ing hospital-based imaging for

their patients. The Medical Imaging Call Centre, a

partnership between Women’s College Hospital (WCH) and the Joint Depart-ment of Medical Imaging (JDMI), is a direct point of contact for primary care providers in the community to access medical imaging expertise. Staffed by a dedicated team of administrative profes-sionals and on-call radiologists, the call centre’s mission is to improve integration with primary care by providing naviga-tional and consultative support in real-time during patient visits.

While supporting Women’s College Family Practice Health Centre (FPHC), the Medical Imaging Call Centre is also part of WCH’s primary care strategy, aim-ing to make hospital services more acces-sible to community-based providers.

“The patients truly benefi t from such a tremendous service,” says Dr. Dominic Li, family physician in Toronto and frequent user of the call centre service for the last three years. “With direct access to such specialized imaging expertise, patients can be assured that they are receiving the appropriate information about their health without having to visit the emer-gency department.”

Established in 2008, this service was originally available to hospital clinicians at WCH, University Health Network and Mount Sinai Hospital.

In 2014, with the Ministry of Health

and Long-term Care’s support, the call centre was expanded as a pilot and en-hanced to support community physicians to evaluate the benefi ts to patients and referring physicians. Results showed a decline in emergency department visits, increased appropriateness of imaging by facilitating clinician-clinician conversa-tions between radiology and primary care.

“Creating an innovative, user-friendly call centre illustrates that primary care providers value conversations with medi-cal imaging specialists,” says Dr. Heidi Schmidt, medical imaging site director, WCH. “This initiative serves as an op-portunity to develop partnerships with primary care, elicit feedback, and tailor medical imaging services to their needs.”

Primary care feedback received through the call centre allows the JDMI and WCH to make improvements to the medical im-aging services they provide.

Designed to prevent unnecessary emer-gency department visits and improve the

appropriateness of ordered imaging tests, WCH and the call centre offer access to urgent imaging and expedited reports, real-time radiology consultations and navigational support. Prior to its expan-sion, community-based providers did not have a direct link to any of these services. Patients requiring urgent investigations were often sent to over-crowded emer-gency departments to expedite imaging.

The Medical Imaging Call Centre cur-rently provides its service to more than 120 family health practitioners in the GTA.

For more information please contact Corwin Burton, medical imaging man-ager, WCH at 416-323-6082 or [email protected]. ■H

Jamie Louie is Communications Coordinator, Joint Department of Medical Imaging, Mount Sinai Hospital, University Health Network, Women’s College Hospital.

A link to the community: Medical Imaging provides hotline to primary careBy Jamie Louie

C

The Medical Imaging Call Centre team.

“If we are going to shake up the system, we must make sure that it’s set up to succeed.”


15 Legal Update

he recent decision of the On-tario Divisional Court in Asa et al. v. University Health Net-work is an important reminder

to hospitals that their internal decisions may be subject to review by the courts, and that decision making processes by their committees must be fair and decisions themselves reasonable. This is well known in the context of medical staff who hold hospital privileges but Asa takes this mes-sage beyond that context.

In Asa, a number of renowned endo-crine oncology researchers applied to the Divisional Court for judicial review of a decision of the CEO of the University Health Network (the “Hospital”) to tem-porarily suspend the researchers’ activities as a result of fi ndings of research miscon-duct. The decision was made following an inquiry, investigation and internal appeal which were all carried out in accordance with the Hospital’s research policy, with the initial formal investigation having been carried out by an investigation committee. In their application for judicial review, the researchers asked the Court to void the de-cision and direct that it be reconsidered at an oral hearing.

In response, the Hospital argued that the decision of the Hospital’s CEO was not a decision which could be reviewed by the Court. The Hospital alternatively argued

that if judicial review of the decision was available, the decision was reasonable and it was made according to a fair process.

The Court determined that the decision could be judicially reviewed because it had a serious effect on public rights or interests. The following were key considerations for the Court in determining that the decision was reviewable:

• the decision concerned the researchers’ ability to continue to perform cancer re-search which affects the medical proto-cols used to treat cancer in Ontario;

• the decision concerned one of the Hos-pital’s core functions – the establishment and operation of research facilities and maintenance of programs for cancer re-search;

• the Hospital is a public hospital gov-erned by the Public Hospitals Act; and

• the research policy under which the de-cision was made was mandated by three government agencies. Having found that the decision was ap-

propriate for judicial review, the Court considered whether the decision itself was made fairly and was reasonable. The Court found that the process by which the deci-sion was made was fair and that an oral hearing was not required. Although there was no prescribed process for the inquiry, investigation and appeal, the Court noted the following in fi nding that the process that the Hospital had followed was fair:• the researchers were advised of the na-

ture and scope of the allegations;• the researchers were advised when the

allegations were expanded;• the researchers engaged the investiga-

tive committee and participated fully in the investigation, including by making oral and written submissions;

• the researchers were assisted by legal counsel;

• the researchers commented on the draft report; and

• the researchers were notifi ed of the fi nal report, appealed the Decision and made appeal submissions and reply submis-sions. The Court ultimately found that the De-

cision was reasonable in part: the CEO’s decision to uphold the investigative com-mittee’s fi nding of research misconduct in the form of material non-compliance with the research policy was reasonable. How-ever, the fi ndings of research misconduct

in the form of falsifi cation and fabrication were unreasonable because they were not supported by the evidence. The suspension of the researchers’ activities was remitted for reconsideration by the Hospital in light of the Court’s fi ndings.

When conducting internal investiga-tions and making decisions that affect medical staff and other hospital staff, hos-pitals should be aware that their internal investigative processes and decision mak-ing may be subject to the external scrutiny and review by a court even if the process and decision is not an exercise of a statu-tory power of decision. While the level of procedural fairness that a hospital should extend in the context of an investigation or decision will vary with the nature of the investigation and/or decision, hospitals should at a minimum provide parties who are subject to an investigation or potential decision with: (1) full disclosure of allega-tions; (2) an opportunity to participate in any investigation (including by being in-terviewed and making submissions); (3) an opportunity to be represented by legal counsel; and (4) notice of a decision with comprehensive reasons for the decision. ■H

Paula Trattner is a Partner and Aislinn Reid is an Associate in the Toronto offi ce of law fi rm Osler, Hoskin & Harcourt LLP.

Internal decisions may be subject to review by the courtsBy Paula Trattner and Aislinn Reid

T

Decisions of hospital committess must be fair and reasonable.



eady or not, hospitals, health-care providers and patients are seeing mobile health (mHealth) apps move into al-

most every aspect of care delivery. From operating room scheduling on your phone and patient information questionnaires on iPads to automatic medication re-minders for the chronically ill, wherever information needs to fl ow, apps are fi lling the system gaps.

Mom & Baby To Be app from Niagara Region Public Health offers interactive prenatal guides. The University Health Network’s (UHN) BANT app is down-loaded around the world by patients with diabetes to graph and trend blood glucose data. Albertans can use the province’s health services app to plan care and even check emergency department wait times in Edmonton, Calgary and Red Deer.

The effect it is having on care deliv-ery is encouraging and profound. And it marks a fundamental shift in how patients are engaging in their healthcare.

But not all apps are created equally. As the number of apps dedicated to health reaches over 165,000, questions arise over their effectiveness and safety, not to mention issues of privacy over apps gath-ering patient information.

Mobile ubiquityStill, the sheer ubiquity of mobile de-

vices (two thirds of Canadians own a smartphone and almost half own a tablet) is pushing the innovation agenda forward under a momentum of demand, driven as much by consumers as by health professionals.

Then there’s the push to digital health. A 2013 study commissioned by Canada Health Infoway found most Canadians recognized the importance of leverag-ing digital health tools and capabilities. Although the study didn’t ask specifi -cally about mHealth, 89 per cent said they felt it was important that they personally take full advantage of digital health capabilities.

There’s little data on how Canadi-ans are using mHealth apps, in part be-cause apps cross operating systems and geographic borders, but there are some trends on usage as reported by developers.

According to the Connecticut-based IMS Institute for Healthcare Informat-ics, of all the mHealth apps on the Apple iOS and Google platforms in 2015, two-thirds were wellness related apps like My-FitnessPal, serving to track exercise and count calories. These come mainly from app developers and their accuracy and effectiveness is ultimately judged by mar-ketplace reviewers. But there’s another 24 per cent that are focused on disease and treatment management, and only two per cent deemed specifi c to health care providers.

The chronically ill marketApps are collecting important amounts

of data from the chronically ill. IMS says an evidence base for mHealth app use is emerging from studies of type II diabetes, multiple sclerosis and Parkinson’s disease, cardiovascular health and obesity. It also found that in the last two years the num-ber of clinical trials using mHealth apps more than doubled. As might be expect-ed, the trials focused mostly on the treat-ment and prevention of disease in seniors.

A 2015 study from German fi rm re-search2guidance on mHealth app devel-oper economics explains that the focus on chronic diseases comes from the high cost of treating those patients and that if apps can help to change behaviours, they have the potential to reduce these costs.

“In most cases, this is still an unfulfi lled promise, as most of the apps are failing to retain their users for even a few weeks,” it reported.

From app to medical deviceIn Canada, mHealth apps are not spe-

cifi cally addressed in regulation but any smartphone or tablet enabled to function as a medical device is considered subject to the Medical Devices Regulations. What makes it a medical device depends on such things as its intended use. If it calculates a drug dosing regimen, for example, it’s a device. Apps that help with administrative functions like appointment scheduling, or with education, like a disease guide, are not likely to fall under the legislative defi -nition of medical device.

While the U.S. Food and Drug Adminis-tration also sees apps as a matter of medi-cal device versus not a medical device, it isn’t a simple determination. As a proac-tive measure, all the apps developed (six to date) at the University Health Net-work’s Centre for Global eHealth Innova-tion were submitted to Health Canada to determine whether they fell into medical device categories, notes Melanie Yeung, a manager with the Centre. “But there aren’t a lot of app developers that have even con-sidered submitting to regulators because many don’t know that this is a practice for medical device manufacturers,” she says.

Even if they aren’t considered medical devices, most hospital and health provider apps follow a process.

Apps and developmentIn Alberta, the requests for mobile app

development come from internal teams at Alberta Health Services (AHS) who want to share information rather than from external developers.

“These have been less frequently at the facility-level than at a team or project level,” says Kass Rafi h,

executive director for AHS’s web commu-nications. “While the AHS mobile app was developed by a third-party, it was started as an internal project to share emergency department wait times with Albertans in Calgary, Edmonton and Red Deer.”

In Toronto, UHN’s Centre for Global eHealth Innovation works closely with clinical teams developing apps using in-put from specifi c stakeholders. The group started developing apps for ‘dumb’ Nokia phones almost 15 years ago and uses a traditional academic approach to vet the work.

Its products are put through randomized control trials (RCTs) similar to what is re-quired for new drugs, explains Yeung. It is peer reviewed and the UHN’s IT gover-nance committee and medical engineering evaluate the app, examining the develop-ment team’s quality management process before the fi nal product can be posted to an app store.

“RCTs are the academic gold standard, but it takes years to do. We’re looking at how we can evaluate health apps differ-ently, the way Google and others in the consumer space test product,” says Yeung.

There’s an app for that

By Yvan Marston

R

There are more than 165,000 mobile health apps and they are changing how patients and hospitals engage with the health system. But are they effective? Private? Safe? And who cares?

Cover story

How do you know a particular process or task is right for an app? Alberta Health Services asks submissions for mobile health apps to consider a number of things, among them:• What is the size and specifi city of the intended audience of the

app? • Does an app actually improve the end-user experience? • Does this need to be an app or would some other medium be

better suited? • Would anyone actually use this? There should be a

demonstrable purpose for it to be an app, and the audience should be broad enough (or specifi c enough) that the resources dedicated to building it are justifi ed.

“But these are just the start of a conversation with the various stakeholders,” says Kass Rafi h, executive director of web communications for Alberta Health Services. “We don’t maintain a rigid list of requirements before an app is considered.”

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A 2013 study commissioned by Canada Health Infoway found most Canadians recognized the importance of leveraging digital health tools and capabilities.



hile the digital age has en-abled many to take charge of their health, it has also put their privacy in an increasingly

precarious situation leaving many practi-tioners and patients to wonder just how vulnerable private medical histories have become with the increasing digitization of records, also known as Electronic Medical Records (EMR).

Technology offers a wide range of possi-bilities for improving healthcare, including streamlined monitoring of patient prog-ress, easy access to healthcare profession-als, and hospital effi ciency. If you’re one of the thousands of healthcare organiza-tions on the verge of making the transition from paper to pixel, there are many factors to consider.

The driving force behind the digitization of the healthcare industry

We all want information faster and with as little effort as possible. As technology progresses, so do the expectations of us-ers. This is driving innovation in access to digital health records, and along with this is a continued concern over privacy and security.

If technology makes information easier for users to access, does that make them more exposed compared to their paper pre-decessors?

We tend to believe that paper records are “secure” due to the fact that they are physically hard to access. But, in reality, paper records are far from secure; there are no passwords or audit trails, and no way to know if something was seen, copied, or removed. These shortcomings are the very reason records are being digitized.

EMRs can easily be stored behind fi re-walls with password-protected access. All logins are tracked, including audit trails of what was seen, changed, or deleted. The capabilities of EMR systems are not the core issue, as they can be used in a very secure way. Not all of these systems are used properly, which is primarily where the exposure comes into play.

What healthcare practitioners need to know

As the adoption of digitized health care becomes more widespread, action will need to be implemented by doctors, hospi-tals, and ultimately the legislators who cre-ate and approve health care policies. Here are some things to consider for your EMR:

1. Have your data professionally host-ed – locking a server in the offi ce is a tem-porary solution, but offers nowhere near the security that a professionally managed data centre has, with manned front en-trances 24/7, redundant power, Internet, and backups.

2. Check your audit logs – on a daily or weekly basis, scan through summary level audit reports looking for anomalies. Things like users who are accessing more records than normal, or have experienced too many failed login attempts can raise red fl ags.

3. Backups are essential – if you already have your vendor host your system, then this is likely already done for you. If not, ensure that the data backed up is encrypt-ed and that the device you back up on to

has all the information you currently hold, and that it is securely handled.

4. Elect a system administrator – every organization should have a System Ad-ministrator, who has the responsibility to ensure the best possible security measures are taken with respect to the set-up, audit, back up, confi guration and user training.

5. Ensure all staff sign an agreement – create an Information Managers agree-ment that outlines every user’s responsi-bility to only access the data they need to perform their obligations. Avoid sharing

passwords, always lock screens and moni-tor and review all employee activity. It’s important to communicate that actions will be tracked through audit logs and re-viewed regularly.

What your patients need to know

Digitization represents an important change for patients. With digital tools, patients can take a more active, participa-tory role in their healthcare and wellness decision-making. Digitized consumers are

more engaged, and can more effectively take part in their health destiny.

Patients should always be made cog-nizant of the risks associated with online medical records and virtual care, but they should welcome technology advance-ments. Digital healthcare is improving access to health treatments and provid-ers, and improving the effi ciency of the patient-doctor relationship. ■H

Michael Checkley is President and CEO of QHR Technologies Inc.

Medical privacy and securityBy Michael Checkley

W

There is hope for a better tomorrow.

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emptville District Hospital (KDH) has launched an inno-vative campaign to help transi-tion from providing patient-fo-

cused care to partnering with patients for Patient and Family Centred Care.

Dubbed “The Patient Experience Starts Here”, the campaign is generating excite-ment in the Eastern Ontario hospital and surrounding communities as well as other healthcare organizations. It was designed to encourage all KDH staff, physicians, and volunteers to internalize the principle that each one makes a vital contribution to the patient experience.

“I’m proud of the team here at KDH that took a new and creative approach to what I believe is a mission critical initiative for all healthcare organizations,” says the hos-pital’s CEO, Frank Vassallo. “The Patient Experience Starts Here” campaign is a key component of KDH’s patient and fam-ily engagement strategy, which was devel-oped as a roadmap to achieve Patient and Family Centred Care in its fullest form.”

Patient and Family Centred Care is a model of service delivery that is trans-forming healthcare both nationally and internationally. It shifts providers from do-ing something for or to a patient to part-nering with the patient, both in the care setting and in the planning, design, de-livery, evaluation and improvement of health services.

The benefi ts of Patient and Family Cen-tred Care are well documented: increased quality of care, enhanced patient safety, higher patient satisfaction, and a welcome spinoff – higher staff satisfaction.

In addition to providing these benefi ts, Patient and Family Centred Care is now mandated by the provincial government and our federal accreditation body: For 2016 surveys, Accreditation Canada has

added more than 350 new criteria that set out best practices for the delivery of Pa-tient and Family Centred Care.

With its next Accreditation scheduled for November 2016, KDH set ambitious goals in the fall of 2015 for implement-ing the Patient and Family Centred Care model: high levels of engagement with pa-tients and families, both during episodes of care and at decision making tables, starting immediately.

In February 2016, the hospital’s Board of Directors embraced the patient and family engagement strategy developed jointly by

KDH’s Quality and Patient Relations de-partments, and identifi ed Patient and Fam-ily Centred Care as a guiding principle for the organization.

As outlined in the strategy, “The Pa-tient Experience Starts Here” campaign addresses the challenge of encouraging frontline staff to make the shift from the patient-focused care that KDH is known for to partnering with patients in the care setting.

Lana LeClair, KDH’s VP Corporate Af-fairs, explains: “Although we knew that in many instances our healthcare provid-ers were already taking a partnership ap-proach, we needed all staff to be more de-liberate about partnering with patients to ensure the approach was consistent across the organization. In fact, we recognized that it would require a cultural shift to make Patient and Family Centred Care a daily reality at KDH.”

The delivery of Patient and Family Cen-tred Care in its fullest form results in an exceptional experience for every patient. LeClair’s team realized that to achieve the cultural shift, each KDH staff mem-ber, physician and volunteer would need to internalize the fact that she or he makes an important contribution to the patient experience.

The team came up with the slogan, “The Patient Experience Starts Here”, and de-veloped promotional materials to launch the campaign: eye-catching buttons for each staff member to wear and an Own-er’s Guide explaining the campaign, along with posters of a variety of staff, physicians and volunteers performing their individual roles in the hospital.

The Owner’s Guide pays homage to the great work KDH is already doing, describes the rationale for Patient and Family Cen-tred Care, and contains key messages for

staff as well as a workbook section where individuals can make a personal attesta-tion of how they contribute to the patient experience. The guide’s most important message is that delivering an exemplary patient experience is not the work of front-line staff alone. “Everybody who works, volunteers, or provides services here has the opportunity and responsibility to make Patient and Family Centred Care a reality at KDH,” the guide declares.

The campaign slogan and its accompa-nying materials were unveiled at a well-attended kickoff event held at the hospital in early March. The event featured guest presenters associated with Kingston Gen-eral Hospital (KGH), a national leader in Patient and Family Centred Care: Eleanor Rivoire and Marla Rosen. Rivoire is the former Executive Vice President and Chief Nurse Executive at KGH and a thought leader in the area of Patient and Family Centred Care. She is also an Accredita-tion Canada surveyor/educator and on the Faculty of the Canadian Foundation for Healthcare Improvement. Marla Rosen is a patient experience advisor at KGH who has been actively involved with the patient and family advisory council there, as well as with the KGH Oncology Program and Regional Oncology Council.

Rivoire and Rosen shared their experi-ences with Patient and Family Centred Care and provided inspiration as to how transformative the model can be.

Following the kickoff, Rivoire shared her impressions of the event: “It was won-derful to participate in the launch of the KDH “The Patient Experience Starts Here” campaign, and to experience the engagement, enthusiasm, and energy of all who were present – including the patient advisors.

Transitioning to family and patient–centred careBy Jenny Read

K

Kelli Cumming works in Kemptville District Hospital’s Health Records department.




The KDH team is clearly resolved to partner with patients in providing Patient and Family Centred Care, with confi dence that this will lead to even better patient outcomes, an improved work environ-ment for staff and better organizational performance. It is going to be exciting, over the months to come, to see and hear how this commitment builds on their al-ready strong commitment to excellence in patient care.”

Feedback from staff on the campaign has been very positive as well. “I found the posters of staff really resonated with me,” says one staff member. “They made me realize that whatever we do at KDH – whether we care for patients, keep the building at a comfortable temperature, or prepare healthy meals – we all do some-thing important.”

Other staff have reported that their “The Patient Experience Starts Here” but-tons are conversation-starters out in the community. “The clerk at the cash was admiring my button and asked me what it

was all about,” a staff member said. “After I explained, she responded that it sounded like a great campaign and we must be ex-cited about it. She added how rare that is and wished us the best.”

Following the successful launch of the campaign, notes LeClair, work continues on the implementation of the patient and family engagement strategy. Ongoing ef-

forts include education for staff on involv-ing patients and families as equal partners in their care. On the organizational side, the hospital is currently working with a small group of patient and family advi-sors and preparing to recruit more, with the ultimate goal of having the patient voice at every table where a decision is be-ing made that will materially impact the

patient experience. “We are so excited to start seeing the benefi ts – to patients, staff, and the organization as a whole – of our commitment to Patient and Family Cen-tred Care,” said LeClair. ■H

Jenny Read is a Communications/Patient Relations Offi cer at Kemptville District Hospital.

The benefi ts of Patient and Family Centred Care are well documented: increased quality of care, enhanced patient safety, higher patient satisfaction, and a welcome spinoff – higher staff satisfaction.

Ensuring patient safetyAt issue, of course, is the fear that

an app may compromise patient safety. In 2013, the University of Pittsburgh studied four apps designed to diagnose skin lesions using a smartphone’s camera. It found three of the apps incorrectly clas-sifi ed 30 per cent or more of melanomas as “unconcerning.”

Much of what is moderating the prolif-eration of apps in hospital administration and in disease treatment and manage-ment categories is the scientifi c rigour and governance applied by health providers and medical device manufacturers behind them. But clinical trials and peer reviews take time.

“By then, consumers have moved on,” says Dr. Puneet Seth, a Toronto-based hospitalist and CMO of InputHealth, whose software is used on iPads in over two dozen hospitals and providers across Canada to collect and analyze patient-centered data.

“Clinical utility is a big piece. That’s where a lot of these apps fail,” says Dr. Seth. He’s beginning to see a demand for clinical research to re-examine the process for digital health. One that maintains the depth and precision of these studies while enabling a faster workfl ow.

Regulation and peer reviewed develop-ment is one thing, but with over 1,100 apps for diabetes alone, for example, the number of mHealth choices providers and patients face is a problem in itself.

Prescribing appsThe Canadian Medical Association re-

leased guiding principles on apps last year, and many hospitals offer guidelines to choosing an app, as well, some third-party platforms have appeared that evaluate and rate mHealth apps for health providers. But determining the suitability of an app for a particular patient comes down to be-ing a shared responsibility between doctor and patient.

Seth sees a strong parallel between pre-scribing an app and prescribing over-the-counter medication.

“You don’t prescribe a specifi c brand of cold medication. Instead you give them an idea of what might work for them, who is making the medication, what is it used for and then going back and reviewing how it is being used by the patient,” he explains.

It may also be helpful to think of it as another shift in the information revolu-tion. Google has yielded a more informed class of patient: many have come to un-derstand what a trusted source looks like from among the thousands of hits a disease search can yield. Apps fall into a similar eco-system where a great number of choices yield only a handful of trust-worthy contenders. Until a more robust means of rating mHealth is developed, providers and patients will have to share the responsibility. ■H

Yvan Marston is a freelance writer in Toronto.

Continued from page 16There’s an app for that

Continued from page 18Family and centred care


20 Evidence Matters

ne of the things that makes hospitals stand out is that many of them are home to im-pressive medical imaging scan-

ners. If you visit a Canadian hospital, you might fi nd a computed tomography (CT) machine, a magnetic resonance imaging (MRI) machine, or a single-photon emis-sion tomography (SPECT) machine. In some places you might even fi nd advanced machines that combine imaging modali-ties, such as hybrid positron emission to-mography (PET) and CT (called PET-CT for short).

These medical imaging technologies can be used for diagnosing and monitoring a range of diseases and conditions, from cancer to internal injuries. They can also be used to guide surgeries and other treat-ments. As the technology advances, so too do the uses.

But taking a step back, how does medi-cal imaging look in Canada as a whole? Are the technologies available where they are needed?

We recently conducted a large inventory – the Canadian Medical Imaging Inventory – to fi nd out where medical imaging equip-ment is located and how it’s being used. The inventory revealed that most imaging machines are located in hospitals in major urban areas, where the population is high-est. The regions with the greatest number of machines were Ontario, Quebec, Brit-ish Columbia, and Alberta. The less popu-lated provinces and territories have fewer machines, with the lowest numbers in the Northwest Territories, Yukon, Nunavut, and Prince Edward Island (PEI). The other east coast provinces – Nova Scotia, New Brunswick, and Newfoundland and Labra-dor – as well as Manitoba and Saskatch-ewan, were in the middle with a relatively moderate number of machines.

Interestingly, when counting the number of imaging machines per population, some of the less populated regions actually have a greater number of CT and MRI scanners per number of people, but the population is geographically dispersed so the machines may still be diffi cult for patients to access.

We created the inventory using a survey that captured information on six imaging modalities (CT, MRI, SPECT, PET-CT, PET-MRI, SPECT-CT); it did not look at

technologies such as ultrasound and x-ray. It includes results from a total of 374 fa-cilities in Canada; however, not all medical imaging facilities responded to the survey. Although the information is not entirely complete, the inventory provides us with the best and most current view of the land-scape of medical imaging in Canada. It’s an important foundational piece – a key start-ing point for making decisions about how these technologies are used and managed.

Most (90%) of the facilities that re-sponded are publicly funded. Most were hospitals, but tertiary care centres, free-standing facilities, and community hospi-tals also participated. Not all of their ma-chines are stationary – some of the MRI machines identifi ed by the inventory are mobile, meaning they move from one facil-ity to the next based on agreements.

All medical imaging equipment even-tually needs to be replaced as a result of wear and tear, technological progress, and changes in clinical practice and population needs. The inventory provides a “lay of the

land” and it can be used as a resource to guide decisions on purchasing new ma-chines, decommissioning old ones, and managing how they are used and shared. For example, in the territories and in PEI, where some modalities are absent, patients might need to travel to another province to obtain the type of imaging scan they need. Partnerships across provinces and territories could make the patients’ experi-ence easier.

CADTH is also exploring other issues in medical imaging. We recently published an Environmental Scan report that looks at the criteria and processes used across Canada to identify, prioritize, and fund the replacement or upgrade of medical imaging equipment. The report found that most provinces have processes in place, they use mechanisms to minimize costs (e.g., by working with purchasing groups), and they have contingency funds set aside for unexpected needs. Many of the deci-sions – about prioritization and funding – are made at the regional or local level. In Alberta, Manitoba, Nova Scotia, Quebec, and PEI, funding decisions are made at the provincial level.

CADTH has also conducted several re-views of the evidence for specifi c medical imaging uses, including a recent review of low-dose CT for lung cancer screen-ing, and a recent review of the safety and guidelines related to ionizing radiation in pregnant women.

What’s next? Based on feedback we’re hearing from clinicians, radiology groups, and other stakeholders, it’s clear there is a need for evidence to inform decisions on optimal use of medical imaging. This will be a key area for CADTH project work, now and in the coming years. Medical im-aging is a complex fi eld, and there is much to be studied and done to help achieve a sustainable medical system where all Ca-nadians, no matter where they live, have access to appropriate, safe, quality medical imaging services.

To read more about the fi ndings of the inventory and other related CADTH re-ports, visit our medical imaging evidence bundle: www.cadth.ca/imaging.

Kasia Kaluzny is a Knowledge Mobilization Offi cer at CADTH.

Medical imaging in CanadaBy Kasia Kaluzny

omen’s College Hospital’s (WCH) Centre for Ambula-tory Care Education (CACE) is thrilled to announce the

launch of CACE Homecare Curriculum – a fi rst of its kind evidence-informed online curriculum designed to support a variety of homecare workers in providing care to se-niors experiencing delirium, dementia, or depression.

Launched in March of this year, cace-home.ca is a free, mobile-friendly website featuring a virtual home-based homecare curriculum that uses teaching and learn-ing tools based within three different pa-tient cases set in representative Canadian households. It’s primarily aimed at person-al support workers, nurses and rehabilita-tion professionals but is also relevant to all healthcare disciplines.

The CACE Homecare Curriculum fea-tures realistic situations which address many of the nuances that are important when visiting a client’s home, such as as-sessing risks in the client’s environment, and respecting the client’s wishes.

Some of the features include:• Assessments and teaching tools designed

to improve learning• Learning objectives relevant to members

of different professions• Individual or team-based learning

modes, allowing team members to work together or individually

• Learners who fi nish all three modules in the curriculum are given a certifi cate of completionThe curriculum, which has been re-

viewed by a team of experienced homec-are workers and healthcare professionals including personal support workers, places an emphasis on interdisciplinary care for a client, and highlights the roles and respon-sibilities of allied healthcare professionals.

This project was created by CACE at WCH and the University of Toronto, in collaboration with multiple partner agen-cies, including St. Michael’s Hospital, VHA Home Healthcare, Ryerson Uni-versity, Fanshawe and George Brown Col-leges, and through the support of the Min-istry of Health and Long-Term Care, and SIM-one.

For more information visit cacehome.ca or contact Nicole Woods, CACE director, at [email protected] or [email protected]. ■H

Magdalena Stec is a Marketing and Communications Specialist | Strategic Communications Women’s College Hospital

By Magdalena Stec

Online curriculum

O

• Overall, Canada has seen a growth over the last three years in the number of medical imaging machines installed and operated.

• Most medical imaging scanners are used for clinical purposes; a small portion of the time they are used for research.

• CT is the most widespread imaging modality in Canada, with the highest number of machines (538 total) followed closely by MRI (340 total) and then the nuclear imaging modalities.

• The least common modality is PET-MRI (2 total; research use only), but it is also the newest specialty imaging modality and its clinical use is expected to grow.

• Hybrid modalities such as PET-CT have replaced single modality PET scanners.

Snapshot of fi ndings from the Canadian Medical Imaging Inventory

W

designed to support homecare workers in providing care to seniors



taff in today’s hospitals are fortunate to have a wide range of medical imaging platforms available to them. Of these,

ultrasound is the most portable, cost-ef-fective and safe imaging solution. How-ever, clinical ultrasound to date, operates at frequencies that have been too low to produce good image quality for visualizing small anatomy.

To overcome this challenge, FUJIF-ILM VisualSonics, based in Toronto, ON, recently introduced the new Vevo MD (FDA cleared, Health Canada pending). The new Vevo MD is the world’s fi rst Ul-tra High Frequency Ultrasound Imaging System available for the clinical market. FUJIFILM VisualSonics specializes in de-veloping ultrasound technology that has been scaled to much higher frequencies, up to 70 MHz in fact, which results in in-credible, high resolution images within the fi rst three cm of the body.

The Vevo MD was designed specifi cally to play a role in a range of clinical appli-cations where greater image resolution is highly desired. For example, when an an-esthesiologist needs to place a line to prep small children for surgery, she may have a tough time placing a line. Often times, the line is almost as large as the vein itself in young children and infants. There are of-ten multiple missed attempts that result in great discomfort for patients and families before the line is placed properly. Imaging the area, using the Vevo MD in this case, could greatly improve accuracy in line placement saving a lot of time and distress for everyone involved. FUJIFILM Visual-Sonics sees great potential for their new Vevo MD product across a wide range of clinical applications including neonatolo-gy, vascular, musculoskeletal, dermatology and other small parts that are within the fi rst few centimetres of the body.

The launch of this new product is an exciting development for an organization

that was once a start-up launched out of Sunnybrook Health Sciences Centre in Toronto. VisualSonics was founded in 1999 by medical physicist Dr. Stuart Fos-ter, a Senior Scientist at Sunnybrook Re-search Institute, who had been involved in the development of high-frequency ultrasonic systems since 1983. The com-pany’s intellectual property was based on research supported by the Canadian Insti-tutes of Health Research (CIHR), Ontario Research and Development Challenge Fund (ORDCF), the Terry Fox Founda-tion, and venture capital investment, with infrastructure support from the Canada Foundation for Innovation and Ontario Research Fund.

Originally, Dr. Stuart Foster and his team started using this technology in pre-clinical research, in small animal models of human disease (e.g. mice or rat models of cancer and cardiovascular disease). By using high frequency ultrasound, research-ers were able to study their live animals in real-time, longitudinally, and with no issues of safety or side effects. “From the inception of the company, we always en-visioned that the technology would even-tually fi nd a home in human clinical ap-plications and it is exciting that that day has fi nally arrived,” says Dr. Foster. In June of 2010, VisualSonics was acquired by SonoSite, Inc. (based in Bothell, US), a leader in hand-carried and mountable ultrasound, and impedance cardiography equipment. Sonosite, Inc., was then sub-sequently acquired by Fujifi lm Holdings in December of 2011.

Today, after 15 years of success in pre-clinical research, FUJIFILM VisualSon-ics is bringing the innovative Ultra High Frequency Ultrasound to the clinical mar-ket. “We are confi dent that Vevo MD is the kind of progressive tool that health care providers around the world will fi nd to be of value for a wide array of applica-tions as well as still unexplored areas.” says Andrew Needles, director of marketing at FUJIFILM VisualSonics. “The challenge is getting the word out that this new prod-uct exists and to try and get it into the hands of those that can really expand on its uses.”

For more information visit: www.vevomd.com ■HAruna Adhya is the Marketing Manager at FUJIFILM VisualSonics, Inc

S

VisualSonics was founded in 1999 by medical physicist Dr. Stuart Foster, a Senior Scientist at Sunnybrook Research Institute

World’s fi rst ultra-high frequency ultrasoundBy Aruna Adhya

Educational & Industry Events

To list your event, send information to “[email protected]”.

We try to list all events and information but due to space constraints and demand, we cannot guarantee it. To promote your event in a larger, customized format please send enquiries to “[email protected]”

To see even more healthcare industry events, please visit our website

www.hospitalnews.com/events

June 2, 2016 Diagnosis – Strategies & Decisions A Diagnosis of the Digital health Agenda in Canada Webinar Website: http://www.nihi.ca

June 5–8, 2016 eHealth Conference Vancouver, BC Website: www.e-healthconference.com

June 5–7, 2016 Annual OACCAC Conference Westin Harbour Castle Hotel, Toronto Website: www.oaccac.com

June 6–7, 2016 National Health Leadership Conference Westin Ottawa, Ottawa Website: www.nhlc-cnls.ca

June 8-9, 2016 Association of Ontario Health Centres – Conference 2016 Sheraton parkway Toronto North, Richmond Hill Website: http://www.aohc.org

June 15-17, 2016 Canadian Association of Neuroscience Nurses (CANN)

Double Tree Hilton, London Website: http://cann.ca

July 7 -8, 2016 eLearning Alliance of Canadian Hospitals Toronto, Ontario Website: www.eachconference.ca

July 7-8, 2016 World Conference on Disaster Management International Centre, Toronto Website: www.wcdm.org

September 20-21, 2016 Patient Experience Summit Toronto, Ontario Website: www.patientexperiencesummit.com

September 28, 29 & 30, 2016 Mental Health For All Conference Hilton, Toronto Website: www.conference.cmha.ca

October 16, 2016 Sustainable Compassion Training Workshop Emmanuel College, University of Toronto Website: https://bit.ly/ECABSI

October 30-November2, 2016Critical Care Canada Forum

Toronto, Ontario Website: www.criticalcarecanada.com

November 7-9, 2016 HealthAchieve Toronto, Ontario Website: www.healthachieve.com

www.hospitalnews.comHOSPITAL NEWS JUNE 2016

22 Safe Medication

From the CEO’s deskContinued from page 10

ystems-based vulnerabilities are refl ected in the volume and type of medication er-rors, and anonymous reporting

demonstrates a commitment to an open culture of sharing and quality improve-ment by healthcare professionals. For a patient, a medication error can range from a near-miss to patient death, with varying degrees of severity in between. The pre-scribing stage represents the patient’s fi rst contact within the medication-use process and is an important milestone in helping to guide patients to positive outcomes and better health. Thus, to be able to de-fi nitively address medication incidents and prevent patient harm, ISMP Canada con-ducted a multi-incident analysis focusing on the prescribing stage of the medication-use process to highlight potential areas for improvement.

Incidents were retrieved from ISMP Canada’s Community Pharmacy Incident Reporting (CPhIR) program from the period between January 2010 and April 2015. Inclusion criteria included all levels

of harm to patients with the exception of “No Error”. The decision to exclude data from hospital reporting programs allowed ISMP Canada to gain an understanding of the more broad prescribing landscape of the community setting, which expands our exposure to medication errors in a non-for-mulary-limited prescribing environment. A total of two main themes and seven subthemes were identifi ed by this analysis.

Therapeutic Plan ErrorTherapeutic plan error refers to medi-

cation incidents that occurred during the prescribing stage as a result of any thera-peutic oversight of a patient’s pharmaco-therapy plan. The four subthemes that fall under this category include Incorrect Dose, Medication Discrepancy, Allergy, and Drug-Drug Interactions. A prescrib-er’s intentions are not always clearly out-lined, and there is a lack of a standardized format for prescribers to confi rm recom-mendations or aspects regarding dose appropriateness. These issues highlight the need for a readily-available, compre-

hensive medical information platform for healthcare professionals to refer to when prescribing medications. Any gap in pa-tient medication history knowledge lends itself to mistakes being made at all stages of the medication-use process, with the pre-scribing stage acting as the initial onset for this cascading effect. Recommendations based on the hierarchy of effectiveness and best medication practices are outlined in Table 1.

Therapeutic Plan Execution Error

The second main theme of this multi-in-cident analysis was therapeutic medication plan execution error which refers to me-diation incidents that occurred due to the technical aspects of the prescribing stage. This includes subthemes such as Incom-plete Prescription, Illegible Writing, and Wrong Patient. With the multitude of drug products on the current market, there is an increased need for vigilance when pro-viding prescriptions to patients. Although the technical aspects of a prescription are

often overlooked as minor issues, occur-rences still have the potential to cause severe patient harm. The implementa-tion of computerized physician order entry (CPOE) systems remains a powerful tool to help prescribers prevent medication errors. Recommendations based on the hierarchy of effectiveness and best medication prac-tices are outlined in Table 2.

Prescribers currently have more point-of-care tools or resources at their disposal than ever before and the opportunities to mitigate patient harm are vast. The proper use of clinical decision support systems and order entry sets can help overcome the therapeutic and technical limita-tions of prescribing, helping prescribers achieve their desired and optimal patient outcome ■HJim Kong is a Consultant Pharmacist at the Institute for Safe Medication Practices Canada (ISMP Canada); Kacy Park is a PharmD Student at the School of Pharmacy, University of Waterloo; and Certina Ho is a Project Lead at ISMP Canada.

Medication incidents that could have been prevented at the prescribing stageBy Jim Kong, Kacy Park, and Certina Ho

S

Subtheme Contributing Factors Recommendations

Incorrect Dose Lack of process to confi rm recommendations or therapy appropriateness

Use standardized order setsIncrease access to therapeutic information resourcesPatient education on signs and symptoms of over/under-dosing of medications

Medication Discrepancy Implement user-friendly clinical decision support systemCheck-point barriers for high-risk alertsUtilize mandatory data entry fi elds when gathering information from patientsConduct Best Possible Mediation History (BPMH) during initial interaction with patientsInvolvement of patients and caregivers to ensure compliance of medication therapy

Lack of appropriate clinical decision support systemAlert fatigueLack of relevant patient information

Allergy

Drug-Drug Interactions

Table 1. Recommendations to prevent Therapeutic Plan Errors

Subtheme Contributing Factors Recommendations

Incomplete Prescription Lack of forcing functions/reminders for data entry fi elds

Utilize CPOE systems with mandatory prescription fi elds*Utilize pre-printed order setsIndependent double checksStaff education regarding mandatory prescription data entry fi elds

Illegible Writing Utilize CPOE systems*Incorporate process for ensuring prescription legibility before providing prescription to patientAlerts for similar patient profi lesUtilize two separate patient identifi ers at each stage of the medication-use process

Lack of process to ensure prescription legibilityLack of process to confi rm patient identity

Wrong Patient

Table 2. Recommendations to prevent Therapeutic Plan Execution Errors

*CPOE systems may introduce other safety challenges in the medication use process. Therefore, always assess the risks versus benefi ts of using a new system in the workplace/workfl ow before widespread implementation.

That’s why we implemented, in part-nership with Canada Health Infoway and kids and their families, our connect2care portal that brings health records (as well as appointments and secure messaging with clinicians) to mobile devices and laptops.

Physical space still matters: Our building isn’t meant to feel like a hospi-tal. Thirty-three art pieces around the building create interest and inspiration. ScreenPlay, an interactive waiting room activity for kids of all abilities created by our research institute, turns waiting for

a clinic appointment into anxiety reduc-tion, physical activity and intellectual stimulation…oh and fun!

With a storied history behind us, Hol-land Bloorview is continuing a journey of healthcare transformation as we partner and lead to advance the most integrated, high-quality care for children and youth with disability and rehabilitation needs and their families. ■H

Julia Hanigsberg is President and CEO of Holland Bloorview Kids Rehabilitation Hospital.

After 117 years, Holland Bloorview Kids Rehabilitation Hospital is continuing a journey of health care transformation as we partner and lead to advance the most integrated, high-quality care for children and youth with disability and rehabilitation needs and their families.



WORK-FROM-HOME REGISTERED NURSES

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orking in the Emergency De-partment (ED) at Brantford General Hospital during the 1990s meant trying to track

patients throughout their visit using paper charts that ended up being piled up on the corner of the nursing desk. At that time, we did not have defi ned triage. Those who were sickest were seen fi rst and the rest… simply waited. We did not collect data on wait times and, as a result, we generally had no idea of the length of time some patients were waiting to be seen. Charts were sometimes lost or misplaced. Patients waited longer than necessary and were very frustrated. Our ability to try to plan for change was hampered by our lack of data or any effective way to monitor what was happening.

As healthcare progressed and technol-ogy evolved, we realized that the pile of charts sitting on a desk could lead to pa-tients being missed or worse – forgotten. It was commonplace for an Emergency Physician (EP) to leave a shift and not pass along information about a patient still being worked on simply because the chart was out of sight. As our department became busier, we realized the need for a far more organized approach. This led us to develop a card system with a wood cardholder. Each patient would have a 3” x 5” card made out with their individual patient sticker applied. The cards were then placed in a wooden holder which had a specifi c spot for each patient’s bed or stretcher. The EP would use a colour mark-er and check off those that they had seen. We were able to keep track of charts in a more organized manner, as well as track patients using the cards more effi ciently. Unfortunately, with triage becoming part of our world, cards for new incoming pa-tients were placed ahead of others due to a variety of reasons. Ultimately, we ended up with a cluster of cards with cards overfl ow-ing from the top and bottom of the holder. Patients continued to be “lost” within our department at times and often seen well out of sequence. Patients remained frus-trated. Planning change proved to be very diffi cult as we still did not have effective means of collecting any useful data regard-ing how the patient fl ow worked within our department beyond manually checking for times. Manual checks were too time-intensive and never happened.

ED patient trackers – electronic tracking boards – started to become more popular around 2005. We were a few years behind the wave of change, but we did eventually catch up. We examined a variety of differ-ent tracking boards and decided on Picis ED PulseCheck as it worked well and was available immediately.

The technology has made an amazing difference in how we are able to work. The tracker organized all patients within the department by room, physician, or Cana-dian Triage Acuity Scale (CTAS). It tallies data for all of our wait times and allows us to see the patient times in a live format. Also – and just as important – it allows us to see when investigations are complete. It enables nurses to send messages to the EPs without wasting time to come fi nd us. It has allowed us to create different work areas for different providers maximizing the effi ciencies of those staff without con-stantly having to go to one central area to ask “who should be seen next?”

Our ED has grown from approximately 105 patients per day to over 145 per day in just fi ve years’ time. We have gone from length of stay for lower acuity patients of over six hours to under four and for the sickest patients from over eight hours to under seven for their encounter to be fi nished. Wait times to be seen have gone from over 4.5 hours (90th percentile) to 3.5, even with the signifi cant increase in volume. Most of this change is, to a large degree, because we can now simply look at any screen within the department and im-mediately identify who is next to be seen, who’s tests are fi nished, notes from the nurses to come reassess, and best of all, we are able to narrow the scope of view of the list to those that we are involved with. We can focus on our individual work without getting lost in the overall picture of the de-partment. We no longer have to look at a board covered with 3” x 5” cards and won-der if some are lost. We no longer have to walk to one central area to check all that needs to be checked. We are able to reduce the waste of walking and focus on patients.

Although wait times certainly are not the only way to measure a department, they certainly do lead to patient satisfac-tion. ■H

Dr. Eric Irvine is Episodic Care Value Stream Medical Lead and Chief of Emergency Department at Brant Community Healthcare System.

Evolving from a paper-only systemBy Dr. Eric Irvine

W

As healthcare progressed and technology evolved, we realized that the pile of charts sitting on a desk could lead to patients being missed or worse – forgotten.

Careers DEADLINE FOR JULY 2016 ISSUE: JUNE 28, 2016

VIEW CAREER ADS AT: www.hospitalnews.com

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Hospital News 2016 June Edition

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