feature report: developments in telehealth – see … · eeg testing can accurately determine if...

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In-hospital tele-healthUHN, in Toronto, has developeda system that allows staff tomonitor at-risk patients from acentralized control room. It’sreducing the need for one-on-one sitters.Page 4

Patient input in ITResearchers have produced areport on how patients and theirfamilies may help improve thedesign of healthcare IT projects.It helps prepare staff andpatients for the exercise.Page 6

Mental telehealthThe use of video and text hasbeen taking off for the treatmentof mental health issues. Not onlydo these forms of telehealthprovide patients with a platformthey are familiar with, they arealso reducing wait times to seetherapists.8

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FEATURE REPORT: DEVELOPMENTS IN TELEHEALTH – SEE PAGE 18

CANADA’S MAGAZINE FOR MANAGERS AND USERS OF INFORMATION SYSTEMS IN HEALTHCARE VOL. 24, NO. 7 OCTOBER 2019

BY JERRY ZEIDENBERG

HAMILTON, ONT. – A McMaster Uni-versity spin-out company, calledVoxNeuro, has produced technol-ogy that allows clinicians to pre-

cisely gauge the level of brain activity in per-sons who have suffered head injuries – such asconcussions – or those who have experienceda cognitive decline, including the elderly.

Using EEG technology that’s coupledwith new proprietary algorithms for inter-preting the data, VoxNeuro allows patientsto be tested, non-invasively, in a matter of anhour, as opposed to the traditional form oftesting that can take three days.

Moreover, the testing accurately pin-points which functional areas of the brainare normal, and which are showing deficien-cies. These functional areas include workingmemory, automatic attention, reactive atten-tion, language comprehension and executive

function – all of which can affect a person’sday-to-day behaviour.

The EEG-based testing contrasts with cur-rent methods of assessing patients with braininjuries for cognitive functioning, where aclinician sits with the patient, asks questionsand subjectively scores the responses.

“Up to 43 percent of the patients whosebrain functioning is assessed after a head in-

jury walk out of the hospital with the wrongdiagnosis,” said Dr. John F. Connolly, co-founder of VoxNeuro and director of theCentre for Advanced Research in Experi-mental & Applied Linguistics (ARiEAL) atMcMaster University.

He is also co-director of the centre’s Lan-

guage, Memory & Brain Lab, and is the cre-ator of the patented assessment and much ofthe methodology that’s at the heart ofVoxNeuro’s approach.

By objectively assessing brain function,and by evaluating the activity in various re-gions of the brain, patients can be quicklydirected into more useful forms of rehabtherapy.

“Instead of trying eight forms of therapyto see what works, we can tell rehab clini-cians that, ‘These are the areas you need tofocus on’,” said James Connolly, co-founderand CEO of VoxNeuro. “Instead of guessingwhat might work, we can tell them what willaccelerate recovery.”

VoxNeuro brings scientific testing, diag-nosis and treatment planning to the exercise,instead of guesswork and trial-and-error.

He noted the information leads to betterpatient outcomes and reduced costs, as less

Innovative EEG system leads to more effective rehab

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The first-of-its kind VoxNeuro system tests the cognitive health of patients suffering concussions and other head injuries, and in the future,the declining mental health of the elderly. By pinpointing functional areas that are not performing well, clinicians can recommend rehabtherapies that produce faster results for patients and are more cost-effective for the healthcare system. SEE STORY BELOW.

The VoxNeuro system activelytests different parts of the brainto assess strengths and problems.

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time is needed for the patient to recoveror progress.

James Connolly is the son of Dr. John F.Connolly, and as a former corporate exec-utive with experience in business develop-ment in Canada and the United States,James is leading the commercialization ofthe technology along with COO and co-founder, Kimberly Elliott. He serves asCEO of VoxNeuro.

Also guiding the company is SamChebib, who serves as chairman and ChiefStrategist. Previously, Chebib was the CEOof Toronto-based Nightingale Informatix, aleading developer of electronic medicalrecords for physicians in Canada and theUnited States. The company was purchasedby Telus Health, which has been integratingthe technology into its own EMR system.

VoxNeuro was formally launched in 2017and makes use of 25-years worth of peer-re-viewed, globally funded research. Its flagshipassessment centre is located at McMasterUniversity, where VoxNeuro is currently ac-cepting patients, and has offices at the IBMInnovation Space in Hamilton, Ont.

It is also providing clinical servicesand conducting original research withinARiEAL, a research centre with multipleactive studies in concussion. For exam-ple, a research project in the centre is cur-rently assessing members of the McMas-ter University football team for signs ofcognitive damage that may have beensuffered in past concussions.

It intends to reassess football playerswho experience concussions during thecurrent season; it will also assess all theplayers after the season ends.

Dr. Connolly and his team are at theforefront of research into the effects of con-cussions on athletes – something that hasbeen gaining attention in recent years but isstill not fully understood. “Concussion iscomplicated,” said Dr. Rober Boshra, Di-rector of AI & Technology at VoxNeuro.

“Athletes who suffer concussions mayfeel okay after a few weeks, but sometimesthey’re really not,” he said. The functionalEEG testing can accurately determine ifthey’ve suffered damage to various areas ofbrain function.

Moreover, said Dr. Boshra, “If they gethit again, it can be a lot more traumatic.”

In addition to sports injuries, concus-sions can be suffered in car accidents, falls,and other incidents. A recent study by theToronto Rehab Institute estimates thereare 150,000 concussions a year in Ontarioalone. “That’s what people thought was thefigure for all of Canada,” said Dr. Connolly,noting the incidence of concussion hasbeen greatly underestimated.

Researchers are now starting to link ab-normal behaviour in some persons to con-cussions they have suffered – both recentlyand in their pasts. “Some people don’t fullyrecover,” said Dr. Connolly.

EEG is sometimes used in hospitals totest patients for brain function and activ-ity. However, the tests are largely per-formed while the patient is in a “restingstate”. That is, he or she isn’t performingany mental or intellectual tasks.

By contrast, VoxNeuro’s technologytakes the patient through a series of words,images and tasks and asks him or her to re-spond. By measuring the “active” responses,or lack of them, VoxNeuro can accuratelydetermine which areas of brain functionhave been injured or is malfunctioning.

The tests are done with electrodes at-tached to the patient’s head, using a cap.The leads pick up levels of electrical activ-ity in the brain while patients are looking ata computer screen and responding to im-ages and sounds. The data are collected andanalyzed by computer technology; reportscan be turned around and delivered to at-tending clinicians within 48 hours.

Already, VoxNeuro’s technology is beingused by St. Joseph’s Hospital, Hamilton.The Sports & Exercise Institute in Torontowill be launching a Toronto-based assess-ment centre later this year, and nationally,Bayshore Therapy & Rehab is using it tobuild out their concussion program.

In the near future, VoxNeuro will beadding cloud-based AI processing to theanalysis. As it collects more data, the com-pany will devise a system that can detectabnormalities with even greater degrees ofgranularity; it will be able to indicatewhich rehab activities will be more effec-tive in a particular patient, with a greateramount of precision. “We may even be ableto predict who is at risk of various prob-lems in the future, by analyzing the data,”said Dr. Boshra.

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Address all correspondence to Canadian Healthcare Technology, 1118 Centre Street, Suite 207, Thornhill ON L4J 7R9 Canada. Telephone: (905) 709-2330.Fax: (905) 709-2258. Internet: www.canhealth.com. E-mail: [email protected]. Canadian Healthcare Technology will publish eight issues in 2019. Featureschedule and advertising kits available upon request. Canadian Healthcare Technology is sent free of charge to physicians and managers in hospitals, clinicsand nursing homes. All others: $67.80 per year ($60 + $7.80 HST). Registration number 899059430 RT. ©2019 by Canadian Healthcare Technology. Thecontent of Canadian Healthcare Technology is subject to copyright. Reproduction in whole or in part without prior written permission is strictly prohibited.

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

Volume 24, Number 7 October 2019

Contributing EditorsDr. Sunny MalhotraTwitter: @drsunnymalhotra

Dianne [email protected]

Dianne [email protected]

Dave [email protected]

CONTINUED FROM PAGE 1

VoxNeuro’s leadership team includes Dr. Kyle Ruiter, Dr. John F. Connolly, and Dr. Rober Boshra.

EEG system allows clinicians to precisely gauge level of brain activity

2 C A N A D I A N H E A L T H C A R E T E C H N O L O G Y O C T O B E R 2 0 1 9 h t t p : / / w w w . c a n h e a l t h . c o m

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SUDBURY – In the Intensive CareUnit at Health Sciences North,you’ll find some of the sickest pa-tients in the hospital, with many

facing life threatening conditions. Butthese aren’t the only patients the staff arecaring for. On any given day, staff may helpsave the life of someone who could behundreds of kilometers away.

Just a few steps away from the ICUyou’ll find HSN’s Virtual Critical CareUnit, with its room full of computer mon-itors. There’s also a huge map on the wallof Northeastern Ontario, covered in dots,each marking a hospital that’s connectedto the system.

Every hour of every day, with the helpof a webcam and a specialized broadbandconnection, these hospitals can connect toan expert team when they are faced with apatient needing critical care.

Virtual Critical Care (VCC), relativelynew in Canada, was pioneered at HSN in2014. With the help of telehealth technolo-gies, patients requiring critical or lifesavingcare have immediate access to a team ofcritical care experts including physicianspecialists, critical care nurses, pharma-cists, and respiratory therapists.

With its vast geography and complexweather patterns, Northeastern Ontariopresents huge challenges to providingtimely, lifesaving medical care to a sparsepopulation.

Dr. Derek Manchuk, Chief of CriticalCare at HSN, and Medical Lead for VCC forthe NE LHIN, says as the tertiary care cen-tre for the region, Health Sciences North

has a responsibility to step up, as many ruralhospitals don’t have critical care teams andsee critically ill patients infrequently.

“We are the lifeline for the region. Dur-ing these calls we are able to collaborate andcoach teams through the situation, whichnot only helps the current patient, but mayalso help the next patient, as we are provid-ing real-time education during these calls.”

Dr. Stephen Saari, one of only threephysicians in the community of Chapleau,five hours northwest of Sudbury, says hecouldn’t imagine practicing medicinewithout VCC.

“We’re all family doctors, and don’t haveadditional training in critical care medicine.But by dialing into the VCC team, it gives us

the confidence to care for our patients. It’slike we have an entire team standing rightnext to us, giving us direction, checking onvitals, accessing lab results and imaging.”

HSN is now connected to 29 hospitalsacross the Northeast LHIN. This includesfour hospitals and two nursing stationsthat are part of the Weeneebayko HealthAuthority, along the James Bay Lowlands.

“It’s very important for us to be there andconnect with those communities and buildthose relationships,” says Melissa Bertrand,Manager of the VCC Program at Health Sci-ences North. “We’re able to build partner-ships and share our medical expertise to im-prove health outcomes for those patients,while also sharing our educational resources.”

VCC allows more people to receive carecloser to home, which benefits the patientand the healthcare system. Over the pastfive years, VCC has consulted in the casesof 1,504 patients and facilitated over 2,821virtual visits, allowing more than 620 pa-tients to remain in their home hospitalssurrounded by their local support systems.

Approximately 30 percent of these pa-tients avoid transport, resulting in annualsavings of over $10 million in transporta-tion costs.

HSN’s model for Virtual Critical Careis attracting attention from other health-care leaders across Canada and aroundthe world. Renee Fillier, a Virtual CriticalCare Nurse at Health Sciences North,says, “There was a pediatric virtual criticalcare started in Vancouver based on ourmodel. The Northwest LHIN now has aRegional Critical Care Response unitbased on our model. So do other LHIN’sin southern Ontario. There was also a del-egation from Barbados that came here tolearn from our approach. So it’s spreadingeverywhere.”

Going forward expanding telehealth andthe VCC service is a priority for the organi-zation. As part of the new 2019-2024 Strate-gic Plan, Health Sciences North is planningto work with community partners acrossNortheastern Ontario to expand virtualcare models and remote patient monitoringin mental health and addictions, pediatrics,and chronic disease programs, all with thegoal of reducing the need for patients totravel for quality healthcare.

Jason Turnbull is a Communication Special-ist with Health Sciences North.

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

Members of the Virtual Critical Care Unit at HSN use telehealth to assist hospitals across Northern Ontario.

BY MARIJANA ZUBRINIC

AND LUKE BRZOZOWSKI

TORONTO – A system that im-proves safety and saves moneyis a home run for a hospital,and University Health Net-work’s Patient Tele-Monitor-

ing Program has managed that feat. The system was developed to address

a rising expense: patient sitters. Thesepeople provide personal, around-the-clock observation, intervening and pre-venting patients from accidentally injur-ing themselves through falls, removinglines, or not following through theirtreatment plans.

To address the rising number of ad-verse post-surgery events in vulnerablepatients, UHN and other North Ameri-can hospitals have been increasing theuse of sitters in recent years. Althougheffective at reducing the number of ad-verse events, direct personal patient ob-servation is a rapidly growing financialburden on Canada’s healthcare. It callsfor a technology-backed alternative.

Working closely with the Sprott De-partment of Surgery, UHN’s Techna In-stitute designed, built and successfullyimplemented innovative technology to

provide 24/7 remote observation of pa-tients at risk for adverse events.

This first-in-Canada Patient Tele-Monitoring Program allows a two-waycommunication between a trained tele-monitor technician and up to six pa-tients at a time from outside their hospi-tal rooms.

Using off-the-shelf hardware for itsmobile camera units, speakers and mi-crophone, paired with an embeddedLinux system, the server can determinecamera names, IP addresses, and videoencoding formats.

The Tele-Monitoring application canconnect to the cameras, and the personobserving can set up a layout to monitormultiple patients simultaneously. Over-lays of the patient’s name, site, floor,room number, and call information todispatch help are displayed in an overlayfor each video source.

The remote observer can associateeach patient’s video feed in the softwarewith a nurse and dispatch number sothat a call can rapidly be placed, whenneeded, with a “touch-to-call” icon inthe application.

When a patient moves, the motiondetector sends notifications through acomputer to the technician, providing a

back-up to the human vigilance of theoperators.

The system allows the technician toverbally direct the patient to keep theirtreatments in place or stay in their bed ifgetting up by themselves is unsafe. Thetechnician can also rapidly make a dis-patch call through touch-based interac-

tion, with the patient room and eventdisplayed in the touched video feed.

Integrated within the UHN network,the program has been implementedacross the Toronto General and TorontoWestern Hospitals, as well as at thePrincess Margaret Cancer Centre, andhas received rave reviews from its users.

The efficiency of having one full-timetechnician over six sitters on an on-callbasis has saved hundreds of thousands

of dollars in operating expenses and hasalso improved the predictability of theexpense.

While UHN is targeting a 60:40 mix ofin-room and remote observation, someunits have already transitioned 80 percentof their cases to the new system, whilemaintaining a high level of patient safety.

Dr. Shaf Keshavjee, Surgeon-in-Chiefat UHN and the clinical lead and spon-sor of this project, said “the Telemoni-toring Program at UHN has not only de-veloped advanced and innovative tech-nology to improve patient safety, but hasalso led to savings in the cost of constantmonitoring of patients at risk.”

With the cost of bedside sitters con-stantly increasing, the Patient Tele-Mon-itoring Program has shown a significantreduction in sitter-associated healthcarespending, without compromising pa-tient safety. To help other hospitals withthis challenge, the Techna Institute isleading UHN’s activities to disseminatethe technology and clinical processes.

Marijana Zubrinic, RN, MScN, NP,Leads the UHN Telemonitoring Program;Luke Brzozowski PhD, is Senior Director,TECHNA Diagnostics and Technology In-novation.

Health Sciences North celebrates five years of virtual critical care

‘In-hospital’ patient tele-monitoring program devised at UHN

Staff monitoring at-risk patients at UHN.

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BY BLAIR MEDD

ST. JOHN’S, NL – The Newfoundlandand Labrador Centre for Health In-formation (NLCHI) is taking thenext evolutionary step for telehealth

services through its new Home-Based Tele-health initiative. Currently in its pilot phase,Home Based Telehealth will put a new andmodern spin on the age-old ‘house call’ byconnecting patients to physicians from thecomfort of their homes and offices.

The birth of Telehealth in Newfound-land and Labrador traces its roots to thepioneering work of the late Dr. MaxHouse, who in 1976 sought a more effec-tive way to treat his patients in the ruraland remote areas of the province.

Embracing the challenges associatedwith Newfoundland and Labrador’s vastgeography and dispersed population, tele-health has grown to become a significanttool within the provincial health systemfor keeping patients closer to home whenseeking medical care.

“Telehealth and other virtual care ser-vices are a natural fit for Newfoundland andLabrador’s healthcare system,” said CindyClarke, Director of eHealth Programs Com-munity & Virtual Care, NLCHI. “As peoplefurther embrace technology in their lives, wehave the opportunity to enhance healthcareaccess and delivery to all ages and regions.”

As the lead for the provincial Telehealthprogram, NLCHI has witnessed first-handthe significant growth of the service. In thepast seven years, Telehealth usage has in-creased by over 70 percent, with over

21,000 appointments using this technol-ogy this past year.

Recently, through an investment fromthe Atlantic Canada Opportunities Agency,NLCHI has been expanding and improvingprovincial telehealth technologies and ser-vices from standalone regional locationsinto new and innovative offerings.

As part of the expansion project, thetelehealth program has gone through sig-nificant technology upgrades to enhancethe quality of appointments. It has also im-plemented a provincial scheduling tool toimprove clinical workflows and has addedadditional regional sites – now numberingover 100 locations province-wide.

New clinical areas have been added toboth extend the reach of telehealth to ad-ditional patient groups and further reducethe need for patient travel. This includesadult and pediatric emergency servicesand long-term care, increased access tocommunity and public health services, andpathology appointments.

NLCHI is now leading the provincialtelehealth program into a new area outsideof the traditional acute care settings andinto patient homes and physician offices.

“Support for telehealth in central New-foundland has revolutionized the way I de-liver psychiatric care in just the past fewyears,” said Dr. Kris Luscombe, Regional

Chief of Psychiatry, Central Health and aHome-Based Telehealth pilot user.

“With a modern electronic medicalrecord system, improved technology andexpanded clinical and technical supportsystems, I now have a practice where themajority of my patient encounters are byTelehealth.”

Dr. Luscombe added, “This is a greatservice to my large remote population,providing better access and service equityto both rural and urban citizens. I see fur-ther opportunities to increase access as weexpand telehealth into homes, which canfurther improve monitoring and continu-ity of care.”

The Home-Based Telehealth programwill open new doors for patients and clin-icians to interact and connect, saving time,travel and expenses for patients, and im-proving the effectiveness of Newfoundlandand Labrador’s healthcare system.

What began with Dr. House’s vision ofgreater access to medical services in therural Baie Verte region has grown into aprovincial network of communicationstools and healthcare professionals. Theyare connecting with patients and col-leagues through technology, innovationand a desire to improve health outcomesand the healthcare experience.

For more information on NLCHI visit:www.nlchi.nl.ca or follow on Twitter@NLCHItweets

Blair Medd is Director of Communicationsat the Newfoundland and Labrador Centrefor Health Information.

Dr. Kris Luscombe, regional chief of psychiatry, sees the majority of his patients by using telehealth.

Newfoundland and Labrador extends telehealth into homes and offices

The need to innovate andmodernize healthcare deliv-ery is not new. Over the pasttwo decades, a broad rangeof technologies have been in-

troduced that interconnect healthcareproviders to enable integrated care oftheir patients.

With EMR penetration among pri-mary care physicians in Canada nowreaching 85% and streamlined commu-nications among healthcare professionalshelping to deliver enhanced continuityof care, important progress has beenmade to improve the provider-patientexperience and engage patients in theirown health management.

As encouraging as this progress is, thequestion facing providers, policy-makersand citizens alike is: how do we bringhealthcare delivery to the next level?

Today, 86% of Canadians own asmartphone and almost 100% of thoseunder the age of 45 access the Internetevery day. The impact of mobile deviceson individual lives and industries istransformative and is not slowing down.

The healthcare sector is not exemptfrom this disruption and the consumer-like expectations it has fostered with indi-viduals. While inherent factors are hin-dering the adoption of new technology inthe healthcare industry, the general con-

sensus is a desire for fundamental change.New findings from The Future of

Connected Healthcare report, releasedby the Canadian Medical Association,illustrate Canadians’ perspectives onhealthcare and the advance of technol-ogy. As the report highlights, a large pro-portion of Canadians believe that con-necting data, technology and innovationcan help cure their ailing healthcare sys-tem. According to the Ipsos poll of 2,005adults:

• 73% believe virtual care will improveaccess to healthcare services;

• 71% believe virtual care will lead tomore timely care; and

• 67% believe virtual care will lead tooverall better healthcare.

Introducing new technologies into ex-isting modes of operating comes withchallenges. However, other sectors havemet and overcome these trials and today,it is the turn of Canada’s healthcare sector.

In the US, consumer usage of virtualcare doubled between 2016 and 2017and about half of workers now have ac-cess to virtual healthcare. In the UnitedKingdom, an early adopter of virtualcare thanks to government-supportedtelemedicine and telehealth programs,penetration of tech-supported care isthe highest per capita in the over-65category of any global market.

Yet, when it comes to virtual care inCanada, a great divide exists betweencurrent demand (71%) and its currentrate of adoption (9%).

We are faced with a significant oppor-tunity for the Canadian healthcareecosystem. Virtual care is often discussedfrom the patient or consumer perspec-tive. And, indeed, many forms of virtualcare employ an important ‘patients first’approach.

However, physicians also want to beable to conduct virtual visits from withintheir EMRs in order to provide even bet-

ter care to their patients and have moreproductive practices. For example, lever-aging virtual care for certain follow-upvisits can reduce wait times for in-clinicconsultations for patients who need aface-to-face encounter.

Conducting virtual consultations withspecialists can cut the time required toaccurately assess a patient’s needs and getthe right form of care started. Efficienciessuch as these can be linked back to spe-

cific returns to the health system overall.The use of digital health technology

and mobile access to care can be gamechangers, not only for how care is deliv-ered and accessed, but in terms of ad-dressing lost productivity.

For its part, TELUS Health is proudto be at the vanguard of modernizinghealthcare delivery for citizens fromcoast to coast. In addition to offering so-lutions for physicians, pharmacists, in-surers and health authorities and theirpatients, TELUS Health is also a leadingenabler of virtual care in Canada.

Babylon by TELUS Health and Medisyson-Demand, powered by Akira, can pro-vide patients and employees with imme-diate access to clinical insight to assesstheir symptoms and guide them to the ap-propriate sources of care – a virtual physi-cian visit, an in-person consultation, or anemergency room.

The solution to addressing the majorchallenges barring the widespread adop-tion of virtual care to all Canadians willbe a collaborative effort requiring stead-fast political will, bold leadership and awillingness to collaborate in new waysacross sectors and throughout the health-care ecosystem. By adapting these ap-proaches, Canada can deliver a new stan-dard of care – one that ranks alongsidethe best healthcare systems in the world.

Shaping the future of healthcare delivery: the value of virtual visits

When it comes to virtual carein Canada, a great divideexists between demand (71%)and current adoption (9%).


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TORONTO – Increasingly, hospitalsand other healthcare organiza-tions are seeking the input of pa-tients and families when they

craft electronic health records, portals andother solutions. After all, the solutions areultimately for the benefit of patients, andit’s seen as prudent to get their feedbackand address their concerns from the get-go. However, knowing how best to do thistype of engagement in the healthcare ITcontext can be difficult.

Recently, a group of researchers led by

Dr. Gillian Strudwick, an independent sci-entist at CAMH, studied the role of patientand family engagement in healthcare ITprojects by conducting a literature review,holding focus groups and organizing aday-long symposium. After learning moreabout some of the roadblocks to increasedpatient and family participation in theseprojects, Dr. Strudwick and her colleaguesidentified several recommendations.

For example, when committees areformed to design or develop an electronicsystem, patients or family members should

be involved. Financial compensation, as wellas holding meetings at times that are conve-nient to them – such as evenings, rather thanthe daytime, when they are at their own jobs– are other important factors to consider.

As a next step, Dr. Strudwick and hercolleagues hope to create a guide or set oftools to further help organizations whenworking with patients and families onhealthcare IT initiatives.

She said the project first emerged a fewyears ago. “We started to see a whole move-ment of patient and family engagement in

healthcare. We wondered why we weren’tengaging patients and families as fre-quently in this space (health informationtechnology) when it was seemingly beingused everywhere else.”

Dr. Strudwick noted that some organiza-tions were starting to include patients in thedesign and roll-out of apps. But there wasvery little involvement in the creation oflarge-scale systems, like enterprise EMRs,despite the fact that these systems centredon the patients themselves.

“We learned that those working inhealthcare organizations to implementhealth IT solutions needed tools andstrategies for greater patient involvement,”she said.

The researchers uncovered many usefulideas and issues. To ensure meetings forpatients and families are held at conve-nient times and places, it was suggestedthat videoconferencing be used more ex-tensively, so that more patients and familymembers could easily participate in meet-ings, or at least monitor them.

Follow-ups were also mentioned as animportant issue. In some cases, patientsparticipated in meetings, but received noword afterwards on whether ideas or sug-gestions were carried out.

As the report noted, “The beginning ofprojects often involves a meeting wherehigh-level ideas are shared and plans aremade. However, there often is no followthrough or updates afterwards. A patientwho attended the symposium said that,“Everybody walks away and then there’s noaccountability, no touch points.”

That being said, it’s important to com-municate regularly with committee mem-bers – something that shouldn’t be diffi-cult to do using e-mail and social media.

As cited in the report, “Communicat-ing with participants also provides themwith some transparency, letting themknow how their feedback or insight is be-ing incorporated. One family member ex-pressed that they would like an update:‘It’s been six months; this is what we’vedone so far, and this is how we’ve actuallyused your feedback.’”

At the symposium, one of the mostpressing topics for participants was therecognition of power dynamics in meet-ings. It’s difficult, in many cases, for pa-tients and family members to feel comfort-able sharing their perspectives in a roomdominated by doctors, nurses, IT profes-sionals and hospital executives. Havingseveral patients and family members pre-sent in meetings may be one way of shift-ing some of this power imbalance.

Training for meeting facilitators wassuggested, to ensure they can maintain anenvironment of mutual respect. As well, itwas suggested that IT training for patientsand family participants would help, as itwould give them more expertise. “Thetraining could even occur ahead of time,”said Dr. Strudwick, “so you don’t go in coldand are more comfortable with some of theterminology, concepts being discussed andbackground on the particular project.”

Finding the right mix of people for acommittee is always a challenge, too. It’simportant to have ethnic and gender di-versity. And of course, “you want peoplewho are committed and engaged.”


What to expect when you include patients and families in projects

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BY MICHAEL-JANE LEVITAN

Earlier this year, Toronto-basedThink Research extended itsvirtual care platform toBritish Columbia. The com-pany partnered with BC’s

Provincial Health Services Authority(PHSA) on a project to help test and ex-pand the delivery of Virtual Health de-livery across the province.

PHSA programs serve patientsthroughout B.C., which makes access achallenge for many people in remote andrural communities. Virtual Healthbridges that gap, bringing physicians,nurses, and allied health professionals topatients’ homes for services such as any-where-to-anywhere counselling sessions,pre- and post-surgical assessment, andfollow-up visits.

With stewardship from the PHSA’sOffice of Virtual Health (OVH), ThinkResearch integrated its VirtualCare plat-form to better serve several specialtyclinical areas, such as the BC Centre forDisease Control, BC Emergency HealthServices, Trans Care BC, and BCWomen’s Hospital & Health Centre.

“It is truly exciting to redefine theboundary of health care in the digital agein collaboration with our clinical part-

ners,” said Ying Jiang, the OVH projectmanager leading the initiative. “The bestpart is that our initiatives are always clini-cally led. We engage patients andproviders to ensure the solution addressescompelling clinical and patient needs.”

Patients enrolled in the project havecited numerous benefits, including con-venience, cost savings, reduced travel,and ease of use.

A user survey found 90 percent ofsurveyed patients used the platform tosave time and eliminate travel; 75 per-cent of clinicians found it very easy touse; and 100 percent of patients saidthey had no concerns with privacy orsafety while using the platform.

Comments from registered patientsreinforced the program’s success. “I did-n’t have the expense and time needed totravel to Vancouver, and I saved on hotelcosts. Big savings!” said one.

Another patient observed, “I lovednot having to deal with the weekendtraffic stress of BC Ferries.” Cliniciansand staff also noted that the tool fit intotheir workflows, “like any other appoint-ment I would have scheduled.”

Michele Fryer, director for the OVH,noted that, “PHSA policy requires thequality of virtual health visits must beequal to – or better than – the quality

of an in-person visit. Think Researchhas been working hard to ensure this isthe case.”

Many healthcare experts and mem-bers of the public are recommendingthat technology be used to reduce wait-time logjams in the delivery of health-care and to improve medical outcomes.However, it’s not always so easy – as thetechnological solutions offered don’t al-ways match the needs of patients andproviders. Testing, fine-tuning and col-

laboration are needed before systems canbe ramped up effectively.

“Health systems across Canada facesignificant challenges with new tech-nology adoption,” Dr. MohamedAlarakhia, Director of the eHealth Cen-tre of Excellence. “We’re often givennew solutions without being consultedon whether they’re the best way tosolve our most pressing challenges.Physicians want to focus on their pa-tients, not digital paperwork.”

“To make an impact in the market, weneed deep partner relationships with ourclinicians, not a vendor-client dynamic,”says Sachin Aggarwal, CEO of Think Re-search. “Engaging directly with frontlineusers early and often allows us to under-stand their pain points and tailor our prod-ucts to better meet their unique needs.”

Take for example, the eVisits PrimaryCare pilot program. Led by the OntarioTelemedicine Network (OTN) and con-sidered to be the largest of its kindwithin primary care in Canada, it waslaunched in 2017 in the Waterloo-Wellington Region through a partner-ship between Think Research and theeHealth Centre of Excellence.

Its design process integrated feedbackfrom physicians and patients, producinga virtual platform that makes it easy forpatients to interact with their primarycare provider. Appointments occur viathe safe and secure platform using chat,audio, or video for both mobile anddesktop devices.

Patient response to the new systemhas exceeded expectations, with approxi-mately 15,000 virtual visits completed by65 doctors. New doctors and patientscontinue to join.

“Beyond the positive patient impact,

Virtual care revs up in BC, using technologies from Think Research

PHSA policy requires thequality of virtual health to beequal to or better than thequality of an in-person visit.

BY ALEXIS DOBRANOWSKI

TORONTO – In August, members ofSunnybrook Health Sciences Cen-tre’s radiation team treated thefirst patient in Canada on its new

MR-Linac, the Elekta Unity. It’s the firstmachine in the world to combine radiationand high-resolution magnetic resonanceimaging (MRI), and will let doctors at theOdette Cancer Centre target tumours andmonitor their response to radiation withunprecedented precision – even as a tu-mour moves inside the body – thanks tothe machine’s real-time MRI guidance.

The team watched on MRI as a beam ofradiation hit a glioblastoma. Seeing the ra-diation hit the target means the team canensure exceptional precision, sparehealthy tissue, and adjust the radiationtarget if needed.

As a founding member of the ElektaMR-Linac consortium and the first Cana-dian centre to install an MR-Linac, Sunny-brook’s team made significant contribu-tions to the development and implementa-tion of this technology, beginning with animaging research study. It is now embark-ing on a clinical trial called MOMENTUM(The Multiple Outcome Evaluation of Ra-diotherapy Using the MR-Linac).

“We are so excited that our efforts cannow benefit patients,” said Dr. Arjun Sah-gal, radiation oncologist and head ofOdette Cancer Centre’s Cancer AblationTherapy Program. “The Elekta Unity willhelp us target tumours more precisely,sparing the healthy surrounding tissue.”

Dr. Brian Keller, medical physicist, has

been involved in the MR-Linac projectsince the beginning of 2013.

“The initial version of this machine wasa research version, which was eventuallyupgraded to a clinical version able to treatpatients,” he said. “Over the years, ourphysics group in the Odette Cancer Centrehas worked closely with Elekta to help val-idate this machine for clinical use, and tohelp produce a final product that is nowable to treat patients.

“Witnessing the evolution of this tech-nology from inception to clinical valida-tion to patient treatment is a unique expe-rience that exemplifies how basic scienceand teamwork can lead to real benefits forour cancer patients.”

As medical director of Odette CancerCentre Clinical Trials, Dr. Claire McCann hasbeen involved from the ethics and regulatory

perspectives helping to ensure the testing,evaluation, implementation and research useof this system from a clinical and researchperspective is conducted accordingly.

“I have also been involved as a clinicalmedical physicist, working in the clinicalimplementation of the system in terms ofcreating novel workflows to build this adap-tive radiation treatment paradigm thatleverages the unique capabilities of this sys-tem,” Dr. McCann said. “This has been atremendous multidisciplinary effort involv-ing physicians, therapists and physicists.”

Dr. McCann is a co-investigator of theMOMENTUM study, the next phase in theclinical implementation of the MR-Linac.The data collected through MOMENTUMwill help inform future novel treatmentapproaches on the machine.

Images will be taken on each day of a

patient’s treatment, and radiation deliverywill be adapted based on the image to tar-get the tumour, even as the tumour movesinside the body. This optimal radiationtreatment approach aims to improve pa-tients’ survival while also reducing damageto the surrounding healthy tissue.

Patients enrolled in MOMENTUM willbe asked if they are willing to share theirde-identified information about theirtreatment experience, including their MRimages and quality-of-life information.

At Sunnybrook, the team of radiationoncologists will identify patients to betreated on the MR-Linac, based on indica-tions that they believe are well-suited forthis technology. The MOMENTUM studywill focus initially on glioblastoma andprostate cancer, followed by pancreatic,head and neck, and cervical cancers.

Additional cancer sites will be rolledout in a controlled and systematic way, toensure the delivery of safe, effective treat-ments on this new device.

The implementation of the MR-Linactechnology and start of the MOMENTUMat Sunnybrook has been made possible bya large team of dedicated staff, includingradiation oncologists, medical physicists,radiation therapists, researchers, MRI sci-entists and more.

“Through MOMENTUM, we will col-lect and contribute to data that will helpresearchers and oncologists here andaround the world come up with the bestways of ablating tumours using this tech-nology,” said Dr. Sahgal. “This kind ofwork is so important for improving pa-tient outcomes and experience.”

First patient in Canada treated on Sunnybrook’s Elekta MR-Linac

Sunnybrook’s Elekta Unity is the first in the world to combine radiation and high-resolution MRI for therapy.

CONTINUED ON PAGE 22

h t t p : / / w w w . c a n h e a l t h . c o m1 0 C A N A D I A N H E A L T H C A R E T E C H N O L O G Y O C T O B E R 2 0 1 9

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E N T R E P R E N E U R S

BY JERRY ZEIDENBERG

TORONTO – Venture capitalistsand private investors offeredfree advice to medical tech en-trepreneurs who gathered atthe MaRS HealthKick confer-

ence in early April. The take-aways? • Be tenacious, because you may have to

knock on the door many times before youfind an investor who is willing to lay downsome cash.

• Get ready to re-structure your start-up,because the people needed to create a com-pany aren’t necessarily the ones who canscale it up quickly. That means even you,the founder, might be out as the top gun.

• And finally, for Canadian start-ups, beprepared to step into the bigger U.S. or Eu-ropean waters quickly, as vencap investorsagree the home market is too small a pond.

“Canada doesn’t rate,” commentedKelly Holman, Managing Director ofGenesys Capital. At least it doesn’t, he ex-plained, when it comes to quickly buildinga business that can provide investors with10 to 20 times return on their capital.

The MaRS technology accelerator indowntown Toronto hosted five days of pre-sentations and meetings that aimed to en-lighten would-be medical-tech entrepre-neurs about becoming the next big thing,and offered introductions to financiers,consultants and potential partners.

It was all part of the city’s annual HealthInnovation Week.

A session on ‘Early Stage Digital Healthand Medical Device Investing’ was moder-ated by Sheryl Thingvold, Senior Advisorat MaRS Venture Services.

On the topic of fast expansions to theUnited States, the financial experts notedthat you’ve got to think differently. “In theU.S., it’s a complex payment system, withmany payors,” said Gerry Brunk, Manag-ing Director of Lumira Capital. “You haveto show them how you can drive downcosts and create savings. It’s not just about

clinical efficiency,” which might be the casein Canada.

Help is often at hand in the form ofpartnerships with larger companies. In-deed, multinational companies are oftenlooking to fast-track their own creativeprocess by partnering with innovative butfinancially shaky start-ups. “They’re des-perate to innovate and to grow, and they’vegot huge pools of capital,” said Brunk. Buthe warned entrepreneurs to “make sureyour IP is looked after.”

Holman observed that a partnership

with a multinational can give the fledglingcompany some stability, both financial andmanagerial. It can also provide an entréeinto new markets and into the meetingrooms of new customers.

At the same time, the financiers notedthat entrepreneurs must be wary of largecompanies and shouldn’t be too willing tosign away their intellectual property rights.If possible, don’t sign over exclusive rightsto the technology to one company, and ifpossible, have two large strategic partners.

“Get more than one, if you can,” saidHolman.

Another way to get into the U.S. marketis through an American accelerator.

On the panel at HealthKick Invest was

Bill Carpou, CEO of the Orange CountyTechnology Accelerator Network (OC-TANe), located outside of Los Angeles. Hetold the crowded room that each year, OC-TANe accepts 40 companies for coaching,training and assessments of their tech-nologies, and it’s welcoming Canadian in-novators into the fold.

“We see 350 to 400 a year, and we select40,” said Carpou, noting the companies thengo through a 16-week mentoring course.Since its inception in 2009, OCTANe hasworked with 571 companies. “And 86 per-

cent have been funded afterwards,” said Car-pou. “It’s kind of unheard of.”

Not only does OCTANe guide the com-panies, it also assesses their technologies,management and market readiness in 30areas and creates its own metrics. “Weneed the analytics to back up what we’resaying about these companies,” said Car-pou. “We give investors a set of analyticsthat compare the start-ups with successfulcompanies.”

To get in the door, however, a companymust have the backing of a clinician. “Alldeal flow comes through physicians,” saidCarpou. “We don’t look at you withoutphysician endorsement.”

OCTANe’s motivation is to bring more

medtech jobs and innovation to the South-ern California region. He says that Canadi-ans don’t necessarily have to leave Canada;instead, they can use Southern Californiaas a U.S. base.

And the organization has ties with themajor hospitals and schools in the area, in-cluding Cedars-Sinai Medical Center,UCLA, and USC.

Of course, companies can go throughdrastic changes when expanding from astart-up with an interesting technology toa mid-sized or large competitor with ma-jor contracts and sales volumes. Thatmeans the founder of the company mayhave to step aside and let executives withmarketing and management acumen takecharge.

“We start with the science, but usually,the scientist is not the CEO,” said panellistSam Ifergan, Managing Partner of iGanPartners. “Different skill sets are needed.”

That can be difficult for the founder –but if he or she really wants to grow thecompany, they must be willing to take on adifferent role.

Ifergan noted that it must always be anopen discussion about the managementstrategy. “It’s an unwritten rule that youdon’t surprise anyone.”

Still, he said, you need to discuss fromthe start who will be running the company,and whether the founder will be requiredto let go of the reins.

How do you even get through the doorsof a vencap company? “Call us,” said Lu-mira Ventures’ Gerry Brunk. He cautionedthat an initial meeting will likely not resultin an investment; indeed, it may takeyears. “We followed one company for 11years, and then invested.” Realistically, itnormally doesn’t take that long, if a com-pany has an impressive technology, clini-cal endorsements and a few small teststhat show promise. But it’s key to showtenacity and resilience.

Said Holman: “I wouldn’t dissuade youfrom cold calling until you get the no.”

Pictured left to right: Sheryl Thingvold, MaRS Venture Services; Gerry Brunk, Lumira Capital; Bill Carpou, Or-ange County Technology Accelerator Network; Kelly Holman, Genesys Capital; Sam Ifergan, iGan Partners.

Want to be a med-tech success story? Venture capitalists offer advice

BY JERRY ZEIDENBERG

TORONTO – Waiting in limbo tohear if a healthcare organiza-tion is going to buy your inno-vation can be deadly – if it

takes too long to reach a decision, astart-up company can run out of moneyor lose focus.

Nevertheless, the reality is that hospi-tals and other healthcare centres moveslowly. Most make decisions by commit-tee and require buy-in from numerousstakeholders.

“You need to have about a year’stimeline or horizon – it will take thatlong [to make your case to an organiza-tion and get a yes or no],” said JonathanTafler, a senior director at ShoppersDrug Mart. Tafler was on a panel dis-cussing the adoption of innovation atpublic and private healthcare institu-tions during the HealthKick conference.

“If you don’t have that much time,”he said, “don’t get into it.”

That being said, Tafler did emphasizethat Shoppers Drug Mart is activelylooking to innovate and welcomes out-side partners. But you’ll need to get thesupport of someone inside the company,and to do that will take time and energy.

“It has to start with a great storyabout how your innovation could helpour customers or our business,” he said.“Once you’ve got that story, don’t stoptelling it. You might have to tell it 10times before you get any traction.”

He noted that you might have to meetwith various groups within Shoppers, asit’s a very large company, and is nowowned by the Loblaw corporation.“Wouldn’t it be great if Loblaw, a200,000-person company, had one per-son to go to for innovation? But it does-n’t work that way,” cautioned Tafler.

Innovation happens in many different

places across the organization, so thereare many different points of contact.

At Southlake Regional Health Centre,a large community hospital in Newmar-ket, Ont., there is a central office for in-novation called CreateIT. Entrepreneurscan contact this office, or informally ap-proach physicians or administrators inthe hospital with a good idea.

However, Rob Bull, vice president offinance, technology and innovation ob-served that delays can easily happen,even after you’ve got the ear and interestof a person at the hospital. “It’s easy toget the innovation office interested – but

the end-users may not be interested,”said Bull. “Or funding may not be there.”

Unfortunately, said Bull, “you maynot find out for nine months,” whetheryour project is approved.

“That doesn’t mean the solution isn’tgood,” said Bull. “It means it just didn’tmake the list of priorities.”

Bull noted one success story that’sbeen adopted by the hospital. It’s a solu-tion created by Medchart, a Toronto-based start-up that collects the medicalrecords of patients – both electronic andpaper – and stores them in digital formin a portal.

It dramatically speeds up the processof collating the records and makes themquickly available to patients who needthem, or their representatives. “Some ofthe users are legal firms trying to getcomplete records for their clients,” saidBull. “Now, they can do it all online, andfaster than before.”

Entrepreneurs must tell a story, solve problems, and have staying power

“Once you’ve got that story,don’t stop telling it. You mighthave to tell it 10 times beforeyou get any traction.”


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And that can make all the difference.

BY ELISA BIRNBAUM

Valerie Perreault was diag-nosed with multiple sclero-sis 27 years ago. A couple ofyears ago, when day-to-daylife got a bit tougher for the

51-year-old author from Gatineau, Que-bec, her doctor suggested she try a newapp called Aby – and Perreault is gladshe did.

The free app provides resources andsupport to people living with MS, help-ing them navigate their disease. It offerscurated articles with tips, updated infor-mation and advice.

A journal feature allows patients torecord their symptoms and appoint-ments while keeping track of theirmoods. There are exercise videos too, de-veloped by practitioners with experienceworking with MS patients. And an inter-active feature allows users to connectwith nurses who provide answers totheir questions.

The daily journal is one of Perreault’sfavourite features. She uses it to track

her mood, sleep, energy level and mobil-ity. “It reminds me that I have good daysand that it’s okay to have bad days too,”she says. Perreault is also a fan of the fit-ness program and how it’s broken upinto 20-minute intervals, allowing for re-covery between sets.

Since Aby launched in Canada inMarch of this year, the app has amassedmore than 14,000 users nationwide. It isavailable for download on Google Playand on the App Store, which can also beaccessed via aby-app.ca.

Ardra Shephard is also pleased withAby. The award-winning blogger ofTripping on Air, which provides a frank,often-humorous look at her life withMS, Shephard is determined to changethe narrative of the disease while cham-pioning disability representation. Theblog helps reduce misperceptionsaround MS and promote a culture of ac-ceptance for mobility aids, she explains.“Rather than seeing them as limiting de-vices that make your world smaller; theyactually make your world bigger.”

Asked to try Aby in its beta test phase

and offer recommendations for im-provement, the Toronto resident was ho-noured to have had the opportunity tobring added value to an app that alreadyimpressed her so much.

“Aby is unique to the MS toolkit.There’s no other product like it,” she says.

Shephard is especially fond of the ar-ticles and patient stories, which can

prove invaluable for the newly diag-nosed. And for someone who’s been onthe MS journey a long time, being ableto track moods and symptoms and bereminded of appointments and medica-tions are the features that inspire Shep-pard to keep the app close by.

The information can be included in areport and e-mailed directly to one’s

doctor, an especially convenient featurethat many users appreciate.

It’s a feature that can prove particu-larly helpful for Janet Brown. A regis-tered nurse for 39 years, (13 as the mul-tiple sclerosis coordinator), Brown worksat the neurology clinic of the HSC-Gen-eral Hospital in St. John’s, Newfound-land and Labrador.

“As you can imagine, my time is in-creasingly in demand,” she says, addingthat many patients don’t even have ac-cess to a local chapter of the MS Societyor a general practitioner.

To fill some of those gaps – and forsupplementary care – Brown has beenpromoting Aby to all her patients. Andshe’s received positive feedback, espe-cially with regards to the content, exer-cise and tracker features.

“Technology has been a big advan-tage to my patients,” says Brown. WithMS symptoms so diverse, Aby “helpsthem live with their disease and havemore control,” she shares. “It doesn’ttake the place of face-to-face visits, butit helps.”

Support at your fingertips: Aby app helps people with multiple sclerosis

The information can beincluded in a report and e-mailed directly to one’sdoctor or nurse.

REBECCA IHILCHIK

We live in an app-ified world– and seniors’ care is no ex-ception. Among the manyseniors’ apps available on

the market, some digitize or simplify tasksfor a caregiver or health professional, whilesome allow older adults to access entirelynew activities that can inform, entertain,or enrich their lives.

For the elderly, apps can provide a senseof agency when it comes to managing theirhealthcare needs. And apps offer a way forthose who are homebound to more readilyaccess a helpful resource when they need it.

A solution accelerator in the longevitysector, the Centre for Aging + Brain HealthInnovation (CABHI), powered by Bay-crest, helps Canadian and global innova-tors test, develop, and validate theirpromising products, practices, and ser-vices. Among more than 210 projects,CABHI supports a number of apps thatare impacting the lives of older adults andtheir care teams. Here are four of them –all developed and tested in Canada:

Health promotion for seniors: We tendto engage with healthcare reactively – bydiagnosing a problem or treating a symp-tom. Nova Scotia-based educational non-profit Fountain of Health is disrupting the‘disease model’ of healthcare by proactivelypromoting the ways seniors can embracehealth and wellness in their everyday lives.

The non-profit’s free Wellness Apphelps older adults adopt healthy habitsbased on five key actions: positive think-ing, social activity, physical activity, brainchallenge, and mental health. The app al-lows users to set goals and helps themachieve those aims by providing remindersand encouragement.

The app was developed by Dalhousie

psychiatry professor Dr. Keri-Leigh Cassidyand is based in current science on healthyaging and cognitive behaviour therapy.With CABHI support, Fountain of Healthis now scaling the app and other educa-tional materials to healthcare providersacross Canada. The Wellness App is avail-able at fountainofhealth.ca.

Helping to deprescribe: According to a2018 report by the Canadian Institute forHealth Information, two out of three Cana-dians over the age of 65 are taking at leastfive different prescription medications. Onein four of them take upwards of 10.

But in some cases, medications thatworked well in the past are not the bestchoice now. In those circumstances, an in-tensive drug regimen is at best not helpful;at worst, it’s downright dangerous. In re-sponse, many healthcare professionals areshifting toward deprescribing – re-evaluat-ing their patients’ medication intake and

reducing or stopping to prescribe particu-lar drugs.

Deprescribing guidelines are availableonline and in print, but not in a mannerconvenient for busy healthcare profession-als. With CABHI support, Dr. Barbara Far-rell, a scientist at Bruyère Research Insti-tute, led a team that developed an interac-tive smartphone app for use at patients’bedsides and in pharmacies. The app usesguidelines and algorithms to help health-care professionals decide when and how toreduce medications safely, and how tomonitor their effects. The app is availableat deprescribing.org.

Support for caregivers: Up to 90% ofpeople living with dementia will experi-ence behavioural and psychological symp-toms that will affect their caregivers – suchas physical or verbal aggression, wander-ing, agitation, or resistance to support, inaddition to others. These symptoms can

cause stress for caregivers that is itself as-sociated with early or frequent admissionto hospital and long-term care for the per-son living with dementia.

Dementia Talk App is a tool for care-givers to track behaviours and develop acare-plan to manage their loved ones’symptoms. The app’s six features – a behav-iour tracker, behaviour care plan, ‘my team’sharing feature, medication list, calendar,and ‘caregiver corner’ – act as a cohesiveone-stop shop for a caregiver’s needs.

The app was created with CABHI sup-port at Sinai Health System by Einat Danieli,a former occupational therapist who was in-spired by her own experiences working withcaregivers to create a technological solutionthat addressed their concerns.

Dementia Talk App is available on theApp Store and on Google Play.

Non-verbal communication assistance:One of the biggest life changes for thoseliving with advanced dementia can be theloss of ability to communicate verbally.The Linggo app, developed with CABHIsupport by Seneca College professor LingLy Tan, is an effective and affordable com-munication system for non-verbal individ-uals. Linggo uses intuitive visual represen-tations to allow the user to select phrasesor build sentences, which it then commu-nicates in words onscreen and out loud.

The app incorporates machine learningto adapt to the individual user by learningtheir daily needs and preferences, making ithighly customizable. Linggo not only helpsnon-verbal individuals to communicate,but also to maintain a sense of agency andindependence. Users can include not onlyolder adults living with dementia, but thosewho are non-verbal due to stroke or autism.

With support from CABHI, Linggo isbeing tested and will be made publiclyavailable in the future.

A P P S F O R H E A L T H C A R E

Pictured (L–R): Members of the deprescribing app team, Pam Howell, Dr. Barbara Farrell, and Rachel Grant.

Improving the quality of care for seniors? There’s an app for that!


Charting a new course for

healthcare.We are leveraging innovative technologies

to enhance health experiences for Canadians and their care teams.

Discover our digital health solutions at telushealth.com

BY DR . SUNNY MALHOTRA

rtificial intelligence has made a significantimpact on many modalities of healthcare. Ithas improved operational workflows, di-agnostics, and clinical care outcomes, but

has only scratched the surface in termsof frontline care implementation.

Ophthalmology and optometry are featured assome of the specialties that AI has potential applica-ble solutions. Artificial intelligence defines algorith-mic learning from data to create trained outputs bymirroring human thought processes and learningtechniques.

There are multiple fields of artificial intelligencethat are pertinent to frontline healthcare includingcomputer vision, natural language processing andaugmented reality while providing supportive deci-sion-making solutions.

Ophthalmology is enriched with big data that canbe utilized with convolutional neural networks topotentially interpret a multitude of topography andretinal studies.

There have been multiple studies where imageshave been labeled for supervised learning and usegradient descent via feed-forward neural networks toidentify the likely output, such as in the context ofdisease screening in high-risk patient populations.

For example, Verily has done extensive researchon thousands of retinal images to classify diabeticretinopathy.

Diabetic retinopathy (DR) is one of the mostcommon diagnoses for patients presenting to ocularhealthcare professionals. The use of Optical Coher-ence Tomography (OCT) and retinal imaging areused in screening and diagnosis of various ocularconditions, including DR.

Typically these scans and images are assessed by a

primary eye-care provider or ophthalmologist andthe diagnosis, stage of disease and treatment is deter-mined. AI can be integrated into this workflow byutilizing convolutional neural networks and analyz-ing supervised labeled datasets to flag the presence ofretinal disease on imaging sequences.

This can be extrapolated to other retinal diseasesusing the same framework. Using machine learning

and gradient descent, patterns in macular degenera-tion can be identified and treatment strategies can beoptimized based on therapy response.

This can represent a new form of precision medi-cine with improved treatment regimens basedon objective data. The implications of thiscould greatly reduce screening costs, in-crease patient access and ultimately im-prove patient outcomes.

Corneal topography is an imagingmodality whereby parameters aremapped out to profile the cornea as well

as to determine an initial ‘sizing’ for contact lenses.Contact lens fitting could greatly be streamlined

via machine learning. Automation can be used tobuild a patient profile prior to the patient’s arrivaland this information can be relayed to the op-tometrist using email automation and medicalrecord integration.

During the clinic visit, the patient’s corneal para-meters can be measured using the topographer andautomatically cross-referenced with contact lensmanufacturer fitting guidelines, offering an immedi-ate fitting recommendation.

Once the fit has been subjectively approved, thelens parameters are sent to the technicians throughautomated messaging. The inclusion of intelligentautomation can improve efficiency, yield accuratefirst fits in more difficult lens modalities and re-duce the turnaround time for patients to receivecontact lenses.

Artificial intelligence has improved patient careand efficiency in many fields including ophthal-

mology and optometry. These fields are par-ticularly suited to the strengths of AI as itcan comb through and analyze vast data-bases of images, scans and patient metricsin a relatively short amount of time. More importantly, it can use these data-bases to build its accuracy over time, mak-

ing it a highly effective tool in a diverserange of applications. AI has the ability to

identify ocular diseases, create treatmentstrategies, improve efficiency and cut

down wait times. This trend ofAI implementation in ourclinical workflows is a de-velopment toward the fu-ture of healthcare and willinevitably be embraced.

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This could greatly reduce screening costs, increase patient access and ultimately improve outcomes.

Boosting healthcare performance:A.I. converging with ophthalmology

Dr. Sunny Malhotra is a US trained sportscardiologist working in New York. He is anentrepreneur and health technologyinvestor. He is the winner of thenational Governor General’sCaring Canadian Award 2015,NY Superdoctors Rising Stars2018 and 2019. Twitter: @drsunnymalhotra

Artificial intelligence has the ability to identify ocular diseases, createtreatment strategies and cut down wait times for patients.

Artificial intelligence will be needed to alleviate hallway medicineBY DAVID STOLLER

By now it should come as nosurprise that Canada is facinga very difficult challenge: an

aging population that is going to re-quire economic, social, and infra-structure support which, as of today,is not properly in place.

As the population ages the eco-nomic pressure on the healthcare sys-tem will continue to mount, as morepeople will require healthcare sup-port either in home or in hospitals.This increase in volume will mostcertainly put pressure on the govern-ment to increase funding and ensureolder adults are properly cared for.

Moreover, the social implicationsare considerable, as family membersand friends will be called into therole of caregiver to support a lovedone through the aging process – arole many people are not formally

trained or prepared for. Finally, hospital beds and long-

term care vacancies will be at a pre-mium. This means that the Cana-dian infrastructure in place to sup-port this vulnerable population seg-ment will need to be upgradedquickly. Otherwise, people will beforced to deal with hallway medi-cine, long wait times at hospitals, orsimply age in place hoping to get thesupport they need at home.

As mentioned, this populationgrowth presents unique challengesfrom an economic, social, and infra-structure perspective. These chal-lenges need solutions, and the tech-nology community in Canada, andaround the world, are working fever-ishly to develop solutions that willconfront this challenge head on.While there are many new and innov-ative uses of technology out there,one of the most interesting and in-

triguing, not to mention fastest grow-ing, is artificial intelligence (AI).

AI has many definitions, but forthis article, it makes sense to use oneof the more general explanations: The

theory and de-velopment ofcomputer sys-tems able toperform tasksthat normallyrequire humanintelligence,such as visualperception,speech recog-nition, deci-sion-making,

and translation between languages.AI can support an aging popula-

tion, either directly or indirectly, byperforming tasks that are typicallydone by humans, but in less time andwith significantly reduced cost. To-

day, computers can perform tasksand calculations faster than ever be-fore. When that is combined with thevast amounts of data collected everyday, there is a massive opportunityfor this technology to help speed updiagnosis, improve efficiencies withinhospitals, and make significant im-provements to the healthcare sector.

In many cases, AI is not going todo anything humans can’t do them-selves. Rather, AI will simply dothings faster. For example, recentyears have seen a significant increasein the volume of data collected withina hospital, data that would take hu-mans days, if not weeks, to properlyanalyze and understand. With AI,data can be analyzed and evaluated toproduce actionable insights in a frac-tion of the time humans would need.

Consider the ability to predict aheart attack, identify overcrowding

David Stoller

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V I E W P O I N T

BY ARSLAN IDREES

In 2014, one in seven Canadians wasover the age of 65. By 2036, StatisticsCanada predicts that life expectancyfor women will be 86.2 years (84.2 to-

day), while for men it will be 82.9 years (80today). Much of this increase can be attrib-uted to advances in healthcare. Canadiansare living longer because we have betterhealth treatments and better access to care.

However, these demographic changespose unprecedented challenges for our al-ready strained health system. Wait-lists forlong-term care will continue to grow andhospitals will be even more overcrowded.Those are just two of the casualties on asystem that is fighting to keep up with theincreasing needs of patients as resourcesare stretched ever tighter.

This is not an easyproblem to solve,but it must be a pri-ority. It affects indi-vidual Canadians,their extended fami-lies, health serviceproviders, organiza-tions, policymakersand the health sys-tem as a whole. There is no one so-lution that can fix it

all, but just as technology has transformedmany other aspects of modern life, it doeshave the potential to do the same forhealthcare by increasing efficiency, conve-nience and quality.

With technology, new service modelscan be designed to enable healthcareproviders to do many of the things thathave been conventionally done in a hos-pital or clinic setting in an individual’shome.

We believe this “feeling of home when itcomes to care” is a growing desire amongolder-adult patients and their families.

SE Health has been a proponent of thismovement for more than 110 years andunderstands the critical role technologyplays in realizing it. Technologies supportnew care models in many ways, such as re-mote monitoring of biometrics with wear-ables, virtual care delivery, use of sensorsto monitor changes in daily activities,voice-enabled digital assistants to do well-ness checks or medication reminders, andshared care plans enabling personalizedand interactive care.

When we use digital tools across thecontinuum of care, multi-disciplinedteams can share information and seam-lessly work together. Patients are truly atthe centre of their healthcare. This is at theheart of the ACCESS 2022 movement,Canada Health Infoway’s bold movementto promote a future where all Canadianshave access to their personal health infor-mation and to digitally enabled health ser-vices anytime, anywhere, from the deviceof their choice.

This access will empower patients, max-imize the use of scarce health human re-sources and improve health outcomes.

When it comes to technology anotherkey area is connecting different systems. AtSE Health, the concept we use is “friction-less integration.” It means reducing digital

friction by streamlining data access meth-ods and focusing on open-data solutionsthat make integration with partners easier,while retaining high levels of security.These aren’t new technologies per se, butthey have been refined to have the highlevel of humanity that patients need.

Another often overlooked advantage toincorporating more technology is its effecton the experience of care providers. Theycan be more efficient once we equip themwith the right information at the righttime to better support informed decisions,and ultimately provide better quality care

to patients. The key to success is to thinkholistically across the whole ecosystemand ultimately offer a streamlined experi-ence for patients, families and health ser-vice providers.

Not only is SE Health a user of tech-

In-home technological supports can reduce hospital over-crowding

Arslan Idrees

sehc.com

Hospital PartnershipsWorking with hospitals to create innovative patient

focused programs.

Home Care ExpertsProviding high-quality trusted home

care to patients and families in their homes and communities.

Elizz Family Caregiving A lifestyle destination for

daughters and sons to live well while caring for their aging parents.

Creating a Future of Health at Home

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h t t p : / / w w w . c a n h e a l t h . c o m O C T O B E R 2 0 1 9 C A N A D I A N H E A L T H C A R E T E C H N O L O G Y 1 7

BY DIANNE DANIEL

fter two decades of administering mentalhealth services, Toronto psychotherapistJennifer Heintzman is discovering a newway to listen, attend and respond to

clients – deepening her active listeningskills and challenging herself to

clearly communicate her empathy, understanding andconcern. At the same time she’s accessing more people,including a new generation of 20- and 30-somethings.

And it’s all due to her enthusiasm to embrace anew form of e-therapy for those struggling withmental health and substance abuse issues.

“I love what it’s given me as a therapist,” saidHeintzman, who joined Hasu Behavioural HealthInc.’s network of online therapists in 2017. “It’s re-quired me to grow in ways I didn’t even knowwere possible. It’s like learning a new languageand suddenly becoming proficient at it – real-izing this feels really good and that I neededthese words all along.”

Hasu eCounselling™ is a PHIPA- andPIPEDA-compliant online healthcare plat-form and mobile app that provides therapeu-tic services through secure video, phone andtext. Launched in 2015, the company startedout as a business-to-consumer (B2C) service.Recently, it is finding a new avenue of growthby providing a business-to-business (B2B)model for employers who are looking to in-clude mental health services as part of theiremployee benefit programs.

As a member of the Hasu team of onlinetherapists, Heintzman augments her face-to-face practice at a busy Toronto office – whereshe’s available three days a week for in-personcounselling sessions – by providing online ther-apy from the convenience of her own home.The majority of her online clients have beenwith her for more than a year. Many access herservices from different time zones across NorthAmerica and Asia; some travel a lot for work,some are housebound due to chronic illness andothers are pregnant mothers on bed rest. All ofthem are benefitting from the flexibility that theonline platform provides.

“I have clients who find an office at lunch time,shut the door and do therapy,” said Heintzman, whoprimarily works with people who are dealing with is-sues resulting from trauma, stress, anxiety, chronicillness or loneliness. “I’ve also worked with clients inremote areas where they don’t have access to theright services,” she added.

Most of Heintzman’s therapy is conversation-based. When she prescribes a cognitive behaviouraltherapy (CBT) exercise, she generally works through itwith the client during their scheduled online session,whether they choose video, phone or text. She alsoblocks time in her calendar for real-time texting. “Youmeet your clients where they’re at,” she said, notingthat when she makes herself available, they show up.

Over the last year, Hasu has been expanding itsreach by working with employers who want to addonline therapy to their existing employee assistanceprograms, or create new benefit programs to addressmental health. According to Hasu COO MarionAdams, a range of businesses are interested, includingfirst responder agencies where the need is obvious,

due to the nature of the work. Other employers at theforefront of addressing employee mental health issuesare newer, smaller start-ups led by millennials.

“If you want to be in the business of supportingpeople, you have to meet them on their terms andthat’s exactly why our text therapy business is ourlargest source of revenue at this point,” said Adams.“People who are using these services are already ontheir phone anyway, so it’s like texting a friend.”

Unlimited text therapy starts at $29 a week, plusHST. Video and phone counselling starts at $95 forone hour, plus HST. Hasu therapists are registeredand carefully vetted by Hasu CEO and founder GregRennie, who also serves as clinical director. To startthe intake process, clients can call a toll-free number,chat online or be referred by a physician. BecauseHasu therapists work in a tightly knit online com-

munity, they often refer clients among themselves aswell, depending on their areas of expertise.

“It’s common that there is an underlying issuethat can be discovered in the initial session,” saidRennie. “If there’s a need for additional work ortreatment, the therapist works on a referral or steersthem in the direction to seek additional help.”

Under the new B2B model, clients are enrolledthrough their employer and then use an employer-specific booking page to access services. Businessesare then invoiced monthly for services rendered byHasu e-therapists.

The technology supporting Hasu eCounselling issupplied by OnCall Health Inc. of Toronto, a com-pany founded by Nicholas Chepesiuk in 2016 tobring virtual healthcare services to Canada’s existinghealthcare system. Early on, the company found thatmental health was “arguably the best fit” for virtualcare and went on to engineer a platform from theground up that could deliver a high level of encryp-tion and security, yet require low bandwidth, he said.

“There are a lot of really big mental health clinics

and organizations across Canada that are doingamazing work and they have really thoughtful work-flow and treatment programs,” said Chepesiuk.“We’re not trying to replace those. We’re trying tohelp them bring their existing team and address theirexisting patient base in a more accessible, convenientway when appropriate.”

OnCall Health licenses its technology as a soft-ware-as-a-service to both clinics and clinicians whoare looking to augment in-person therapy with vir-tual appointments. Chepesiuk estimates there are1,000 mental health clinicians currently using theplatform across Canada, mostly for video and texting.

The technology is designed to automate day-to-day administrative tasks like scheduling, and can alsobe used by clinicians to track patient progress usingclinically validated assessments like the Patient

Health Questionnaire-9 (PHQ-9), aself-reported instrument that scoresnine criteria on a scale from “0” (notat all) to “3” (nearly every day).“Our system makes it really easy forclinicians to assign and digitize thoseforms, which are traditionally doneon paper, through a secure onlineportal,” he explained. “Patients fillthem out on their phone or com-puter, and we can score them andtrack their progress over time.”Chepesiuk claims there is evidence toshow that video counselling can be aseffective as in-person counselling, andin some cases more effective. Patientsoften feel more comfortable openingup about issues when they’re in thecomfort of their own home. There’salso a growing number of youngerpeople who prefer to communicateonline, he said.“It’s pretty cool knowing that rightnow in Canada about 15,000 patientsare doing video appointments on thissystem every month,” said Chepesiuk.“We like to think we’re helping to ac-celerate the adoption of virtualhealthcare in Canada.”The advancement of e-therapy in

Canada is also being fuelled by a growing need tomeet demand for mental health services. The Cana-dian Mental Health Association estimates that one infive people in Canada will personally experience amental health problem or illness in any given year,and that by age 40, about half of the population willhave or have had a mental illness.

At the same time, nearly one-half of those whofeel they’ve suffered from depression or anxiety havenever gone to see a doctor. Proponents of onlinetherapy believe the ability to connect with peopleover the Internet is starting to change that. At Hasu,for example, Adams said she is encouraged by thelarge percentage of men who are now signing on fore-therapy through the company’s new B2B model.

“It’s a fascinating and exciting finding for us be-cause typically men are much less likely to reachout,” she said.

Dr. Philip Klassen, VP Medical Services at the On-tario Shores Centre for Mental Health Services inWhitby, Ontario, said his organization has seen adoubling of requests for services in the last two years,

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A variety of illnesses can be treated this way, and wait-times for help can be dramatically shortened.

Online therapy is taking off, using virtual visits, email and texts

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resulting in long wait lists for treatment.Online therapy is seen as one way to effec-tively deal with that demand.

“The dual imperative is first, we need toimprove access to psychological therapiesand second, we need to improve access toevidence-based therapies, which means weneed to minimize variability and try tocontrol the product so that the product it-self has a strong evidence base,” said Dr.Klassen. “One of the possible solutions isInternet-based psychotherapy.”

In May of this year, Ontario Shores in-troduced SilverCloud, an evidence-basedplatform for delivering online mentalhealth services. Headquartered in the U.K.,SilverCloud is an industry leader in Inter-net-delivered CBT (e-CBT) solutions, aform of psychotherapy that Health QualityOntario recommended for public fundingin February. The company’s growing on-line library includes programs to treat anx-iety, depression, phobias, stress and OCDamong others.

Clinicians in Ontario Shore’s Anxietyand Mood Disorder Clinic are currentlyusing SilverCloud to treat outpatients, peo-ple living independently in their communi-ties who are suffering from a variety ofanxiety-related or depressive disorders. Af-ter an initial assessment to determine thate-CBT is an appropriate course of treat-ment, patients are scheduled for a brief in-take meeting to establish a baseline of theirsymptoms in person. After that, everythingrelated to their treatment happens online.

Patients are emailed an invitation to joinSilverCloud and establish a secure login toaccess their online program materials. TheAnxiety and Depression program, for exam-ple, has eight modules which patients workthrough at their own pace, typically com-pleting one per week, with each module es-timated to take 40 minutes. Online learningincorporates reading materials, audio andvideo clips, and a variety of tools such as anactivity scheduler, a mood tracker and a“thinking, feeling, behaving cycle tool” thatpromotes emotional awareness.

“As they move through the course, everytime they’re introduced to a new tool,there’s some opportunity within the mod-ule to do some practice with it right thenand there. There’s also an option to add it totheir home page so that the next time theylog in, it’s right there in front of them,” ex-plained Ontario Shores clinician KristenMoore, a registered nurse who works withinthe Anxiety and Mood Disorder Clinic. Oneof the advantages, she added, is that patientswho might be feeling overwhelmed withanxiety in a public place can quickly accessthe tools they need to work through theiranxiety right from their phone.

Patients who qualify for e-CBT arealso scheduled for a series of 10 30-minute meetings with a clinician

who serves as their personal coach. Themajority of meetings are conducted usingthe Ontario Telemedicine Network (OTN)videoconference platform, but in-personmeetings can also be scheduled if required.

As a coach, Moore logs in to SilverCloudto manage her e-CBT clients and monitortheir online activity. She sees how manypages they’ve read, what tools they’ve usedand any messages they’ve left for her. Clientsmay also choose to share entries from theironline journals. Once she’s reviewed theirweekly progress, she writes a response.

“We’re only interacting with clients andreviewing their work on the day they’rescheduled, so it needs to be a very focused30 minutes,” added Moore, noting that shetypically holds a video conversation forhalf of the allotted time and spends theother half on review. “Having that coachconnection is motivating, it holds them ac-countable each week.”

Moore estimates she is able to treat an

additional 10 to 12 patients over and aboveher normal workflow because of Silver-Cloud. The online platform is also helpingto reduce wait times since patients referredto e-CBT typically begin treatment within30 to 60 days whereas the wait time for in-dividual face-to-face therapy is typically ayear or longer.

Dr. Klassen called online psychother-apy the “choice of the service future.” Sil-

verCloud embeds measurements like thePHQ-9 and Generalized Anxiety Disorder(GAD) seven-item scale directly into itsplatform. “One of the huge gaps in mentalhealthcare in many places is that it’s notmeasurement-based,” said Dr. Klassen.“But with SilverCloud, measurement isbuilt in, so clinicians can look both at in-dividual and group data to see what theiroutcomes are like.”


T E L E H E A L T H

Unlocking the Possibilities: Telehealth in CorrectionsLead presenter: Linda Bridges, Horizon Health Network, Saint John, NB

In 2010 the federal offender population inthe Atlantic region demonstrated a signifi-cant increase, resulting in a correspondingrise in the number of offenders visitingcommunity specialists at Horizon Healthfacilities. During an 11-month period, 880federal medical escorts were performed (anaverage of 80 escorts per month). Analysisof these escorts determined that as many asone third could have been completed usingtelehealth processes and technology.

That year, Horizon Health Network andCorrectional Service of Canada (CSC) en-tered into a Memorandum of Understand-ing (MOU), resulting in a TelecorrectionsPartnership Project. Telecorrections hasincreased both staff and patient safety byreducing or eliminating the need for in-mate transfers to receive specialty care.

Security costs and potential opportu-nity for elopement associated with escortshave been reduced. One tremendous ad-vantage has been the ongoing knowledgetransfer which occurs during these assess-ments for those CSC clinicians involved.Having these same clinicians present dur-ing sessions has been pivotal to maintainan open dialogue and general facilitation.

This initiative provided the confidenceand experience within Horizon to beginthe recent provision of services to provin-cial correctional facilities as well.

Telenephrology and the Elimination of Geography for Hemodialysis PatientsLead presenter: Krisan Palmer, Horizon Health Network, Saint John, NB

Telehealth promotes access to those scarceclinical resources most often located in moreurban settings to which patients must travellarge distances to receive treatment. Prior tothe establishment of Horizon Health Net-work’s first satellite hemodialysis unit, pa-tients requiring this life sustaining care hadto do just that – three times every week.

The goal in establishing satellite he-modialysis units is to ensure safe, compre-hensive and evidence-based local care forthis vulnerable patient population byeliminating the geographical barrier be-tween them and their nephrologists by us-ing telehealth processes and technology.

For a satellite unit to be established, thephysical, technical and clinical environ-

ment must be replicated to match those ofthe main dialysis center. The same clinicalstandards of care that are adhered to by theNephrology Program clinicians in themain dialysis unit must be operationalizedand maintained in the satellite unit.

This includes the weekly patient roundsconducted by the nephrologist in conjunc-tion with the nurses at the patient’s chair-side or treatment station while undergoingdialysis.

For this to occur at a distance, Telehealthmust be employed. The nephrologist at themain unit connects to the satellite unit viaa real-time interactive audio and video andis able to discuss the patient’s treatmentplan with both the patient and the nurse,just as it would occur if the patient was be-ing treated in person by the nephrologist.This is what has become known as te-lenephrology. Four satellite units currentlytreat 94 patients per week, eliminating 158round trips per patient per year.

Virtual Palliative Care: Supporting Patients in Their HomeLead presenter: Sandra Mierdel, Ontario Telemedicine Network

The Ontario Telemedicine Network (OTN)worked with partners in the ChamplainLHIN to co-design a virtual palliative caremodel that would enable a regional systemwith capacity for the delivery of in-homepalliative care. Patients responded to a se-ries of self-assessment surveys on tabletcomputers from their homes. Care

providers received real-time feedback onthe patients’ information, which triggeredspecific events and corrective actions.

A total of 118 patients with an averagePalliative Performance Scale score of 50%were enrolled in the project. In terms of pa-tient satisfaction, 87% were satisfied withthe experience; 85% were satisfied with thecoordination of resources, use of technol-ogy, and information received; 75% weresatisfied with the progress made towardscare goals including location of care prefer-ence; 74% would recommend the initiativeto others; and 73% agreed that virtual caresaved them time by not having to travel tosee their provider.

Patient feedback showed the potentialfor emergency department usage to de-crease from 68% to 27%. Family caregiversreported little to mild burden in caring forloved ones. Clinicians reported that thetechnology enhanced their ability to dotheir jobs, increased efficiency and allowedthem to monitor the health conditions oftheir patients over time.

Digital Health Enhances the Continuumof care for Oncology PatientsLead presenter: Krisan Palmer, Horizon Health Network, Saint John, NB

The overall driving factor for the provisionof teleoncology in New Brunswick is theconcentration of clinical oncology special-ists in the southeastern and southwestern re-gions of the province. Patients not in theselocales, with their families or caregivers,must travel to interact with their clinicians.The goal of teleoncology is to provide safe,evidence-based practice in the nearest com-munity to where the patient resides.

For this study, oncology referral pat-terns were analyzed and, in conjunctionwith the established satellite chemother-apy clinic locations, oncologists were ap-proached to explore the potential use oftelehealth for patient follow-up appoint-ments. It was determined during this exer-cise that teleoncology provides the abilityto deploy a wide range of services, includ-ing clinical consultation, diagnostic ser-vices, knowledge exchange in the form ofclinician and patient education, peer sup-port and professional development.

Teleoncology enables patients to be seenby an oncologist or a general practitionerin oncology (GPO) prior to each cycle ofchemotherapy – a national standard. Thismethod of care delivery has greatly dimin-ished the need for oncologists to visit out-lying areas on a rotating basis. As well, itprovides the opportunity for many patientsto become engaged in clinical trials,whereas prior to telehealth, distance andaccess eliminated them as recruitment can-didates. Currently, one group of oncolo-gists at one urban center in New Brunswickvisit over 30 sites virtually on a regular ba-sis to deliver patient care.

A Comprehensive Telestroke Solution for New BrunswickLead Presenter: Jennifer Sheils, Horizon Health Network, Saint John, NB

The goal of the provincial Telestroke pro-gram is to provide a solution that allowsevery New Brunswick citizen experiencingan acute stroke the potential to receiveleading-edge stroke care for this emergencyevent, as well as thrombolysis therapy,specifically a medication known as TPA.Telestroke NB, which is built upon NB’s ex-isting telehealth capacities, links every 24-hour emergency room with computed to-mography (CT) access to an on-demand

stroke specialist in real-time, regardless ofthe location of the patient or specialist.

Neurologists connect to the hospitalnetwork using a virtual private network(VPN) from their homes or offices to re-view the CT images within seconds of thescans being completed.

Telestroke NB was developed coopera-tively between two provincial health au-thorities (Horizon and Vitalite), Ambu-lance NB, and Heart and Stroke Founda-tion of NB with the support of the govern-ment of New Brunswick.

Each health authority supported the de-velopment of consistent guidelines andprocesses to ensure patients receive care inboth official languages. Emergency roomstaffs were integral to the program successas they developed ways to support the re-mote specialist with performing neededclinical assessments and dialogue with pa-tients and their families.

Telestroke NB is one step of a trulycomprehensive stroke system; moving to-wards using Telehealth for primary andsecondary stroke prevention.

Explaining Longitudinal Patient Adherence in a Heart Failure Telemonitoring ProgramLead Presenter: Patrick Ware, Toronto, ON

Telemonitoring can improve heart failureoutcomes by facilitating patient self-careand clinical decision support. However,

Telestroke NB links every 24-hour emergency room withCT access to an on-demandstroke specialist, in real-time.

TORONTO – Call it virtual care or virtual health, remote care ortelehealth – it’s a revolution in care delivery innovation and it’shappening across the country. One of the best places for awide-ranging overview of projects in regions across Canada isthe annual e-Health Conference and Tradeshow, presented by

Canadian Institute for Health Information (CIHI), Canada Health Infowayand Digital Health Canada.

Now in its 20th year, e-Health remains a vital epicenter of digital healthdiscussion and debate, with interactive panels, presentations, and postersfrom the top minds and talent from the Canadian digital health community.

Listed here are just some of the exciting telehealth projects discussed at e-Health 2019 in Toronto.

A look at innovations in care delivery at e-Health 2019 Conference



T E L E H E A L T H

BY ALEX GREEN

North America, in particular theUnited States, is advanced interms of telehealth implemen-tation, compared to other ma-

jor international markets. It is also filledwith vendors that have seen revenues rampup rapidly over the last five years.

Changes to reimbursement in the nexttwo years mean that many financial barri-ers for providers deploying telehealth willbe lifted, driving further demand.

To date, most telehealth IT vendors andservice providers have achieved success bytypically focusing on one specific segmentof the telehealth market and establishing aleadership position in that segment. How-ever, this is rapidly changing.

Point-solution leaders: For example,American Well, Teladoc Health, MDLiveand Doctor On Demand have establishedthemselves as clear leaders in the U.S.payer-focused, on-demand video consul-tation market. However, until recently theywere all very reliant on just this one mar-ket segment.

Conversely, companies such as InTouchHealth, Avizia (now part of AmericanWell), AMD Global Telemedicine andGlobalMed established leadership posi-tions in the inpatient/emergent provider-focused market (both commercial andgovernment), initially driven by sales ofhardware (e.g. telehealth carts) and morerecently, software and platforms.

However, most had little business out-side of these segments. Philips had alsoseen success in this vertical, specifically thecentralized tele-ICU sub-segment, a mar-ket it has largely made its own.

At the same time a plethora of special-ist, provider-focused telehealth companieshave also had success, again typically tar-geting one specific market segment. Exam-ples include SOC Telemed, providing neu-rology capacity/specialist support servicesto health systems, and Advanced ICUCare, providing tele-ICU monitoring ser-vices to hospitals and hospital networks.

However, the last 12-to-18 monthshave seen this landscape start to change;specialization in one segment is no longerenough. This change is forecast to accel-erate over the coming years, forcing sup-pliers to evolve. Two key factors are dri-ving this change of focus: Low marginsand high competition in the payer-fo-cused on-demand telehealth market; andthe demand for enterprise-scale tele-health platforms.

Low Margins in the payer market: Thepayer-focused, on-demand video consulta-tion market has proved fruitful for Ameri-can Well, Teladoc Health, MDLive andDoctor on Demand in terms of revenuegrowth.

For example, the market leader, TeladocHealth, has seen annual revenues increasefrom less than US$80 million in 2015 toover US$400 million in 2018, mostly dri-ven by its payer business.

However, there are many serviceproviders vying for a share of this markettoday, resulting in high levels of price com-petition and low margins or losses.

Using Teladoc Health again as an exam-ple, it had the highest volume of video

consultations in 2018 (more than 2.6 mil-lion globally, up from 1.5 million in 2017)but was still not profitable.

Price pressure has consequently forcedthe “big four” in this segment to look else-where to drive a more profitable businessmodel.

All have now decoupled their physiciansupport service business from their plat-form business. (Although some much laterthan others. For example, Doctor on De-mand only launched its provider-focusedsolution Synapse in early 2019).

This means they can now sell platform

solutions to healthcare providers, withoutforcing the provider to use the telehealthcompany’s physician support network.This was a key sticking point when target-ing this market historically. Success hasbeen relatively quick, with MDLive now

Analyst insight: Battle lines drawn in North American telehealth market



boasting more than 20 provider customersand American Well claiming more than160 health system partners.

However, the move has taken these suppli-ers out of their original niche, resulting inthem now competing with those vendors thathad traditionally served the provider market.

Via acquisition some have also startedto target higher-acuity market segmentswhere margins are higher.

Teladoc Health recently acquired sec-ond opinion service provider Best Doc-tors, whereas American Well acquired in-patient/emergent vendor Avizia.

International expansion has also beenanother strategy. Teladoc Health acquiredAdvance Medical in May 2018 andMédecinDirect in March 2019. It then fol-lowed this with the organic expansion ofits direct-to-consumer services to Canadaearlier this year. This has transformed thefirm from a U.S. only service provider to a

company with a global footprint in lessthan 24 months. American Well’s acquisi-tion of Avizia had a similar result in termsof its international expansion.

The key takeaway from the last twoyears is that these service providers haveambitions well beyond low-cost domesticvideo consultation services, meaningthey’re now encroaching on market seg-ments dominated by other players.

Enterprise scale telehealth: The de-mand for enterprise-scale telehealth is theproduct of the market maturing. Until re-cently, most healthcare providers were stillat the pilot, or early deployment stages interms of their use of telehealth.

Pilots and early deployments are smallscale, but they are also typically focused onone specific use-case, care setting, or ad-dress one specific problem.

For example, better triage of stroke vic-tims as they arrive in the ED, reducingreadmission rates for congestive heart fail-ure patients or addressing the primary care

needs of sufferers of musculoskeletal dis-orders (MSDs).

Early deployments were often limited toone department in terms of scale and the ITsolutions used were often point-solutionsdesigned to address a single use-case orproblem in question. This has been an idealenvironment for many of the specialistleaders mentioned earlier to win business.

However, as providers’ understanding oftelehealth has evolved, deployments have

started to be more connected and a morestrategic enterprise-wide vision developed.

This has resulted in demand shiftingfrom point solutions targeted at specificfunctions, to enterprise solutions that can beleveraged across organizations. It has alsoresulted in healthcare providers no longerlooking for just a telehealth IT vendor, orjust a telehealth physician support serviceprovider. Often, they want both from thesame supplier, or at least the flexibility toemploy either where and when they see fit.

Several trends in relation to the supplybase have resulted from this change:

• Telehealth IT providers have started tobring physician support services in house,usually via acquisition. For those that havenot made acquisitions, partnerships havebeen established.

• Physician support service providershave decoupled their platforms from theirphysician support services and expandedthe range of specialties serviced. For exam-ple, SOC Telemed decoupled its platformfrom its services earlier in 2019 and ac-quired behavioural health specialist JSAHealth in 2018, expanding the range ofspecialties it addresses.

• Vendors have made strategic acquisi-tions in order to fill gaps in their portfo-lios, particularly in relation to care set-tings served. For example, InTouchHealth recently launched its new plat-form Solo, the product of solution inte-gration from its legacy portfolio andthose of Reach Health and TruClinic,which it acquired in 2018. Solo supportstelehealth in both inpatient and virtualcare applications.

Alex Green is the Director and Principal An-alyst at Signify Research, a UK-based mar-ket research firm focusing on health IT, digi-tal health, and medical imaging. For furtherinformation on its new telehealth report,please contact Signify Research at [email protected].

the eVisits Primary Care pilot demon-strated that when we partner with clinicalpartners to adapt our technology to theirpractice, we can provide comparable work-flow, benefits, and experiences to a tradi-tional in-person appointment,” says Aggar-wal. “As the virtual care market in primarycare matures to enterprise levels, we envi-

sion running hundreds of workflowswithin the app while giving physicians andhealthcare providers customized technicalsupport lines and branding opportunities.”

Patient feedback confirms the pilot’ssuccess in mitigating the strain on otheraccess points for the health care system. Ina recent program review, 10 percent of the

patients who participated in a virtual visitsaid that if the service had not been avail-able, they would have sought care at awalk-in clinic. Four percent would havegone to an emergency room.

Aggarwal sees flexibility and clinicalpartnership as the keys to the VirtualCareplatform’s success. “Our experience build-ing networks across geographies and clini-cal settings has given us unique insightinto introducing, embedding and scalingtechnological solutions.

While the benefits are broadly applica-ble, our most successful deployments fea-ture virtual visits that complement, ratherthan replace, in-person visits; build onpre-existing patient-physician relation-ships; and occur regularly or with ad-vance notice.”

Michael-Jane Levitan is director of client ser-vices at Think Research. With special thanksto our project collaborators, the Office of Vir-tual Health at the Provincial Health ServicesAuthority, eHealth Centre of Excellence andOntario Telemedicine Network.

As providers’ understanding of telehealth has evolved,deployments have started tobecome more connected.

“We envision running hundredsof workflows within the appwhile giving physicianscustomized support lines.”



Virtual care revs up in British Columbia

nologies and methods that improve thedelivery of home care, it’s also an innova-tor. This year, SE Health and AMS Health-care announced their collaboration on afour-year project to implement an innova-tive model of home and community care.The Hope Initiative will create a LivingLab where the H.O.P.E. Model® andemerging technologies will be piloted withapproximately 1,000 clients, their familiesand neighbourhoods, and a team ofnurses. The H.O.P.E. Model® was createdby SE Health based on international bestpractices and more than a century of com-munity nursing expertise.

Inspired by the Netherland’s Buurtzorgneighbourhood care model, the H.O.P.E.Model® has been adapted for and pilottested within the Canadian healthcare sys-

tem, and is now poised to become a majortransformation and system change.

The H.O.P.E. Model® is aligned with aglobal movement that is transformingcommunity nursing from a transactionalmodel, to a more empowered, efficient andperson/family centered model. A numberof innovations and digital tools will helpcreate seamless communications and co-ordination across the circle of care forclients and their families. Over the nextfour years AMS and SE Health will partnerto further evaluate and refine the H.O.P.EModel® and position it for spread andscale in Ontario.

Our approach to healthcare must evolveto serve the rapidly changing Canadianpopulation. So much is possible when welook at solving problems with differentthinking and creative solutions instead ofmore and more of the same. Digital can bethe catalyst that ushers in a new age ofhealthcare for the aging population; let’s getstarted for a better future for Canadians.

Arslan Idrees is Digital Transformation Of-ficer at SE Health, a national social enter-prise bringing excellence and innovation tohome care, seniors’ lifestyle and family care-giving to forever impact how people live andage at home.


Reducing hospital over-crowding

in an emergency room before it hap-pens, or reach out to providers whenmedication is needed without the needof human interaction or responsibility.AI-based technology can not only tacklethese tasks, but it can also allow clini-cians and healthcare workers to focusattention where it is needed most – onthe people receiving treatment.

There are several examples of howAI is already making an impact onhealthcare today, and in this three-partseries we will look into several key lead-ers in the sector.

Consider Qventus, a California basedgroup that has developed technologythat leverages artificial intelligence andmachine learning to optimize patientflow within a hospital. This is an AI so-

lution that is currently empoweringteams to excel in real-time, and a goodexample of how AI is able to supportsome of the infrastructure challengesfacing hospitals today. According to theirwebsite, Qventus has worked with hospi-tals in Canada and the United States, in-cluding SickKids in Toronto.

So, what do they do exactly? Qventusidentifies operational challenges withina hospital before they present them-selves, and can recommend immediateaction and course corrections to helpmanage operational efficiency.

Focusing on key areas within the hos-

pital such as system operations, the emer-gency department, inpatient, and operat-ing rooms, this AI tech can react to real-time events to help hospitals avoid bottle-necks and improve overall patient flow.

Within the emergency department,Qventus can anticipate overcrowdingand help identify patients likely to leavequickly, while at the same time identifywhere beds for patients are likely to beneeded, notify doctors when assessmentsand diagnostics are complete, and ulti-mately help move patients towards dis-charge, or an inpatient transfer.

This AI driven tech is helping hospi-tals reduce costs and capital spending byreducing inefficiencies. Their “system ofaction” is optimizing patient flow bypredicting overcrowding and delayeddischarges – before they happen.

David Stoller is Managing Director, My-Sense Canada Ltd.

A.I will be neededCONTINUED FROM PAGE 16

With artificial intelligence,data can be analyzed andevaluated in a fraction of thetime humans would need.

The battle lines are drawn in the North American telehealth market

Care providers can be moreefficient once we equip themwith the right information atthe right time.


T E L E H E A L T H

these outcomes are only possible if patientstake the expected physiological readings.While the literature is rich with studies ex-ploring barriers and facilitators to patientuptake, few have studied longitudinal pa-tient adherence to telemonitoring programsexisting outside the context of clinical trials.

The objective of this study was to quan-tify and explain longitudinal patient ad-herence in a heart failure telemonitoringprogram offered as part of the standard ofcare in a Toronto-based specialty heartfunction clinic.

A mixed-method explanatory sequen-tial design was used to first quantify patientadherence rates over a 12-month periodand subsequently explain adherence usingsemi-structured interviews. As patients areinstructed to take readings daily beforenoon, monthly adherence rates were de-fined as the percentage of completedmorning readings (weight, blood pressure,and symptoms) over each 30-day period.

Characteristics of interviewed patients in-cluded a range of ages (22-83), sex (70%male), time since onboarding (0-12 months),and overall adherence rates (30-96%).

Key themes explaining patients’ moti-vation to adhere include: (1) perceivedbenefits of the program (self-managementsupport, peace of mind, and improvementin clinical care); (2) ease of use; (3) a posi-tive opinion of the program from familyand friends; and (4) supporting services(training and technical support).

Themes explaining low and imperfectadherence include: (1) technical issues thatperiodically prevented the transfer of read-ings and/or which led to patient frustra-tion; (2) life events or circumstances thatinterfered with the ability to take readings;and (3) the perception that the benefits ofthe program were suboptimal, due to thesystem’s inability to adequately capture ad-ditional context related to the readings.

Despite a 15% drop in adherence afterone year, an overall mean adherence of70% is considered high given our strict de-finition of adherence and because thepragmatic nature of this study meant thatwe could not account for periods when pa-tients were unable to take readings (e.g.,travelling, inpatient stay, etc.).

This limitation meant that true adher-ence was likely underestimated. This studyfound that longitudinal adherence is notso much predicted by patients’ demo-graphic or health characteristics but rathertheir perception of a telemonitoring pro-gram’s benefits, its ease of use, and thepresence of supportive individuals andsupporting program components.

Intra-institutional Teledermatology: Results of a mixed methods case studyLead presenter: Trevor Champagne,Women’s College Hospital, Toronto, ON

Historically, teledermatology’s benefitshave been mostly realized through im-proved access to rural or underserviced ar-eas. This study examines the benefits andthe overall impact of teledermatology inan urban, intra-institutional environment.A store-and-forward teledermatology ser-vice was created between family medicine

practitioners and a consultant dermatolo-gist in the same urban ambulatory intra-institutional hospital.

Mixed methods analysis was then ap-plied to chart reviews, electronic surveys toclinicians and patients, and semi-struc-tured interviews with referring providersand dermatologists within a frameworkdeveloped from the Canada Health In-foway Benefits Evaluation.

Survey questions were designed to as-sess benefits quantitatively and interviewswere subjected to qualitative thematicanalysis. 84.2% of the 76 consultations re-viewed over 18 months of service weremanageable solely with teledermatology.

Subgroup analysis revealed that skinlesions had a much lower success ratewith 40.9% requiring transition to an in-person consult, as opposed to skin

rashes, of which 94.3% were manageablethrough teledermatology. All patientsagreed they would use the service again.Cited benefits included savings in time,money, and missed work.

The e-Health 2020 Annual Conference andTradeshow takes place at the Parq Vancou-ver from Sunday, May 31 to Wednesday,June 3, 2020.

WORLD FORUM FOR MEDICINEBE PART OF THE NO. 1!

DÜSSELDORF, GERMANY 18–21 NOVEMBER 2019

Leading International Trade Fair

Member of www.medica.de

More IQ for medicine!Information and communication technology in hall 13

www.medica.de/inftech2

Canadian German Chamber of Industry and Commerce Inc.Your contact: Stefan Egge

480 University Avenue _ Suite 1500 _ Toronto _ Ontario _ M5G 1V2Tel.: (416) 598-1524 _ Fax: (416) 598-1840

E-mail: [email protected] Travel Information: LM Travel /Carlson Wagonlit

Tel: 1-888-371-6151 _ Fax: 1-866-880-1121E-mail: [email protected]


Conference overviewCONTINUED FROM PAGE 20

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