NORrad Northern Radiology PACS Picture Archive Communication System

NORradNORradNorthern RadiologyNorthern Radiology

PACSPACSPicture Archive Communication SystemPicture Archive Communication System

Picture

Archiving

Communication

System



Removing Geography from Removing Geography from the Quality of Care the Quality of Care

Equation:Equation:

Diagnostic Imaging in North Eastern Ontario



NORrad PACSNORrad PACS((PPicture icture AArchiving and rchiving and CCommunications ommunications SSystem)ystem)

The Impact of the Digital Radiology Project

NORrad Partners

•Timmins

•Hearst

•Kapuskasing

•Smooth Rock Falls

•Cochrane

•Iroquois Falls

•Matheson

•Kirkland Lake

•Moose Factory





Overview of the NORrad Region

9 separately governed hospitalsTimmins to James Bay100,000 people130,000 Procedures/Year300,000 square milesResource-based economy: mining + forestry Population older than provincial average 2 Radiologists



Challenges in North Eastern Ontario

Distance WeatherAccessHealth Care Human ResourcesAvailability of Diagnostic ResourcesSparse Population Poor Health Status Personal Safety





Why a Made-in-the-North Solution?

Patient care improvements locally and regionally Practical solutions to meet real needs Enhancing the integration of care among hospitals Leveraging technology to overcome natural obstacles Leveraging technology to create medical/fiscal efficiencies Fiscally viable service Making better use of limited human resources



Scope of the NORrad Project

$10 million enterprise project – 80% funded by governmentImplementation completed at all sites in 6 monthsIncorporates latest technologies:

Voice Recognition Software for dictation of reportsWeb Browser Access for off-site physiciansConsultation workstations in all key clinical areasDiagnostic access on all nursing floorsEncryption and security softwareRegional Hospital Information System24/7 Radiologist Coverage in all hospitals



Project Background

Timmins District Hospital (TDH): the district referral centre Timmins provides all diagnostic services from x-ray to MRI Other hospitals provide x-ray/ultrasound/mammo/fluoro Patients typically travel long distances for diagnosis Sudbury: regional tertiary centre – cancer, neuro, cardiac Dx Images from Timmins carried by patients to Sudbury Recognition of need for a Made-in-the-North Solution



Project Background - Driving Forces

X-ray film is a 107 year old technology that has outlived its usefulness

Hospital restructuring acted as integration impetus for region’s hospitals

Scarcity of physician resources serving huge geography

Increased risk to patients and physicians traveling to receive and deliver care



Project Background - Driving Forces

Measurable differences in the quality of care:Increased patient travelDiagnostic report turnarounds from 3 days to 3 weeks,

depending on location (highway hospitals to Moose Factory)

Lack of immediate service to local physicians



Why PACS? Why Radiology?

Radiology is the largest IT application in health care

Radiology is the data & communication branch of medicine

50% of hospital IT technology + information resides in DI

$40 million of IT equipment/facilities

$60 million of IT patient care data

$8 million of new data annually



Why PACS? Why Radiology?

• Radiology has historically grown at a faster rate• X-ray film expenditures over next 10 years would exceed cost

of NORrad by 15-20%• PACS technology facilitates improved patient care and better

service to their referring physicians• Increased need and recognition to better manage this key

information resource• PACS is recognized as the foundation of a successful EHR



The Genesis of NORrad

A vision to improve patient care and access to radiology

6 years of planning, researching and preparing

Business case development

Funding submission preparation

Countless meetings with funding agencies/government



The Genesis of NORrad

PACS technology due diligence Use of DICOM & HL7 standards

RFP selected Agfa as PACS partner

Wide Area Network (WAN) design

WAN partner selection – Northern Telephone Ltd./BCE

Detailed implementation plan

Engagement of key technical resources



What is NORrad?

Picture Archiving Communication System (PACS)The transition from a manual-based x-ray film environment toa full digital imaging solution that allows the movement ofpatients’ images rather than the movement of patients

Wide Area Network (WAN)Creation of a broadband telecommunications link betweeneach NORrad hospital dedicated to the bi-directional transferof diagnostic images, diagnoses and requisitions securelyand rapidly



• Picture Archiving Communication System (PACS) is a Digital Radiology Solution that will give us the ability to transfer Diagnostic Images, Physician Impressions and Final Reports around the NORrad Region and to the Outside Referral Centres to Improve Patient Care in all respects.



Picture X-ray Film

Computer Image

Archive Film Library

Electronic Storage

Communication Hand Delivered

Networked

System Inconsistent Structured



Electronic Radiology Managem ent System W AN Proposal

Timmins & District Hospital

Hop. Notre Dame, Hearst

Sensenbrener Hospital, Kapuskasing

Smooth Rock Falls HospitalLady M into Hospital, CochraneAnson General, Iroquois Falls

Bingham M emorial, M atheson

Kirkland & District Hospital

M oose Factory HC

High Speed DataNetw ork

E10

E10

E10

E10E10

E10

E10

E10

E10

5Mbps

T1T1

T1

256Kbps

256K

bps

256K

bps

256Kbps

256Kbps

Cisco 2610

Cisco 2610

Cisco 2610

Cisco 2610

Cisco 2610

Cisco 2610

Cisco 2610

Cisco 2610

Cisco 3620

T1 – 155Mbps Bandwidth



Benefits to the Network 13

Regional“Enterprise Wide”Electronic Imaging System

IntensiveCare Unit

Emergency

OperatingRoom(s)

Orthopaedics

HIS/RISInterface

At-Home-Teleradiography

WebServer

NursingStations

GPOffices

SpecialtyClinics

ConsultToronto

ConsultSick Kids

Consult fromJames Bay

REG IONAL

H. I.S.



EnterpriseEnterprise Network Network EnterpriseEnterprise Network Network

Virtual Electronic Patient Record

IntranetIntranet Internet InternetIntranetIntranet Internet Internet

ClinicsReferring

PhysiciansRemoteClinics

Physicians’ Office + Home

Rest of the enterpriseRest of the enterpriseRest of the enterpriseRest of the enterprise

Thin ClientsThin Clients

Web-basedWeb-basedDistributionDistributionWeb-basedWeb-basedDistributionDistribution

HospitalHospitalInformationInformation

SystemSystem

InterfaceInterfaceEngineEngine

EnterpriseEnterpriseMasterMasterPatient Patient IndexIndex

CDRCDRoror

MetadataMetadataRepositoryRepository

RadiologyRadiologyAny-ologyAny-ology

(Ie. Endoscopy,Ophthalmology)

PharmacyPharmacyLabsLabsPathologyPathologyCardiologyCardiology



The Digital ImageThe Digital Image

• CT, MR, Ultrasound, Nuclear Medicine and Digital Fluoroscopy will be stored in a digital format.

• General Radiology now will also be stored in a digital format through the evolution of Computed Radiology know as CR.



Patient Exam Images and reports can be pulled to multiple displays at any time

PACS Digital Image DistributionPACS Digital Image Distribution

Diagnostic Imaging

Emergency ICU O.R. Hospitalist Orthopedics

Multiple Web Clients



DICOM Network

Network

MRICT NM

Printers RadiologistRead Stations

View Stations

OracleServer

Archive ServerNetwork Gateway

LongTerm

ArchiveDR/CR

U/S DF/DSA

Timmins

Hearst, KapuskasingKirkland Lake

Cochrane, Iroquois Falls, Smooth Rock Falls, Matheson

Moose FactoryImageServer

Film Digitizer

Film Digitizer

Film Digitizer

ViewStation

CR/DR ReadStation

Printer

CR/DR



PACS: Diagnostic Image Management SystemPACS: Diagnostic Image Management System



Alliance WAN

Internet Access

Web Server Clients

Ultrasound

Preview/IDStation

ADCCCassettes

ADC CompactDigitizer

X-Ray

DICOM

DS3000 NTDisplay Station

Basix AS300Archive, Cache,

MS SQL dB, NWG, Broker Lite

Regional Database, Archive

& Web

Drystar3000

ATM 1

55HIS/RIS

Acquisition Archive & Verification

Display

HardcopyTeleradiology

BASIX Configuration

Sennsenbrenner Hospital, Kapuskasing

10/100 Mbps

DICOM

ToshibaPowervision

GE R&F

GE R&F

GE RAD

PS5000

Digitizerw/Doc

Scanner

QC Stn



• Method of getting conventional film radiology images into a digital format to effect the replacement of conventional screens and cassettes

Computed Radiography (CR)



Computed Radiography (CR)

General x-ray exams

Cassettes compatible to existing x-ray tables

No film in cassette

Storage phosphor plate



ADC COMPACT ADC SOLO





Patient Patient scheduledscheduled

Patient Patient registered registered for D.I.for D.I.

Image Image TakenTaken

Develop Develop & print & print filmsfilms

Transport Transport & hang & hang filmsfilms

Radiologists Radiologists review & review & report report dictationdictation

Transport Transport tapes & type tapes & type reportsreports

Match Match report report with film with film & file & & file & invoiceinvoice

Medical Medical record to record to referring referring physicianphysician

Traditional Traditional Modality FocusModality Focus

The Productivity OpportunityThe Productivity OpportunityThe Productivity OpportunityThe Productivity Opportunity

InformationInformation ManagementManagement

FocusFocus

1-7 Days 45 Min. 15 Min. 45 Min. 2 Hours 3 Hours 4 Hours X Hours 1-2 Days

“Diagnostic Clinical” Process:

WorkstationWorkstationDominantDominantApproachApproach



Display FeaturesDisplay Features

Features are common to all workstationsUser Selectable Formats: 1 on 1, 2 on 1, etc.Split screen view: multiple series and studiesSimultaneous viewing of all modalitiesImage Manipulation: Zoom & Pan, Window and Level, Invert, Rotate, FlipScroll through entire study quicklyStack & Cine loop displayVary cine speed, stop frame



Image Processing FeaturesImage Processing Features

Mark key imagesAnnotate text, markersAnnotate measurements, regions of interestCalibrate video captured images for measurementSave above parameters with image



RadiologistsRadiologists• Workflow changes are

significant• Some adapt more than

others• Images instantly available,

no walking• No lost films• Tools that are not

available on film• Live consults • Remote consults

• Initial increase in reporting time

• Less time searching for previous

• Overall, increased capacity





CS5000 CS5000 CLINICAL DISPLAY STATIONSCLINICAL DISPLAY STATIONS

• CS 5000 1X1K or 2X1K Color Landscape– Intended for ICU, O.R., ER, Hospitalist





OrthopodsOrthopods• Pre-surgery

planning now done softcopy

• New versions of familiar tools

• Digital templates incorporated from various vendors



Web ServerWeb Server

Security and encryption meet regulations View images and reports over the Internet View grayscale & colour imagesStack images & view Cine loopsIdeal for remote viewing by radiologist, referring physicians and hospital departmentsWavelet compression to stream images over Internet

Internet

PACS Workstation



WEB 1000WEB 1000



Health Care Benefits Hospitals

Enhanced support for small hospital physiciansIncreased relevance of local and district hospitalsElimination of lost films, decreased x-ray film storage

and operating costsTransfer of diagnostic images to referral or teaching

hospitals to eliminate unnecessary patient travelAvoids duplication of exams and reduces radiation

exposure



Health Care Benefits Physicians/DI Techs

Leverages shortage of physicianReduces medical risk and professional isolationProvides a virtual consulting relationship between

radiologists + referring doctors irrespective of distanceFacilitates retention of existing physiciansIncreased hospitals’ attractiveness to new physiciansProvides high tech employment for northernersImproved working environmentPhysician access to images/reports in their officesSupports northern medical school innovation mandate



Health Care Benefits Patients

• Better patient care provided locally in distant communities• Improved access to local patient care• Better outcomes• Shorter lengths-of-stay & fewer admissions• Fewer emergency evacuations• Reduced travel to district & regional hospitals



Clinical Example of PACS:• Moose Factory patient with bowel obstruction• Patient x-rayed at Moose Factory hospital• Local surgeon calls Timmins radiologist for diagnosis• Diagnosis made• Clinical consultation between radiologist and surgeon• Decision made to treat locally• Successful operative outcome• Enhanced local physician support• Unnecessary $5K emergency evacuation avoided• Better care provided locally



e-Health Significance of NORrad

NORrad: first multi-hospital integration project in the North

First major multi-governance project in existence in Ontario

First digital radiology application in Northern Ontario

Has re-engineered the delivery of radiology services

Fostered several best practice initiatives

Serves as the foundation for regional EHR



e-Health Significance of NORrad

PACS is an Information + Communications Technology Created critical mass for other telehealth initiatives

Complements regional telemedicine and regional HIS networks

Provoked interest in similar solutions for other remote areas

NORrad about to be emulated across the North



Since PACS Implementation January 2003:• Major reduction of unnecessary patient & physician travel• Establishing a PACS link with Sudbury regional caner centre &

Toronto Sick Kids is well under way• PACS implementation occurred without a hitch• Staff and referring physician reception - overwhelmingly positive• Increased level of interest by hospitals outside of NORrad• NORrad influenced PACS decision in Kenora & S. Ont. Hospitals• Radiologists’ productivity increased by ~25%• Diagnostic report turnaround within 24 hours for all hospitals



Best Practice E-Health Initiatives:

Inter-Hospital Agreement

Management structure to govern the project as a single enterprise while recognizing separate governance

Pooling of large hospital savings to offset shortfall in small centresCost-sharing on an equitable cost-recoverable basisLong-term collaborative agreementTechnology refreshment & replacement fundingAnticipation to accommodate project expansionFlexibility to add new telehealth applications




Security Audit & Patient Confidentiality

Engagement of external security auditor to review all hospital information systems, the PACS, the WAN at each location to assess and correct any infringement of existing systems

Development of security and system measures to provide ongoing coverage and monitoring

Inclusion of ongoing training to hospital personnel & physicians about security protocols and patient confidentiality




Security Audit & Patient Confidentiality

Development of policy and procedures governing technical, operational and management aspects of system security

Observance of HIPPA-level patient confidentiality in all electronic systems

Development of risk management and patient consent/awareness protocols

Operational security of PACS with tiered levels of access and passwords




Post-Implementation Audit• Requirement of CHIPP - Health Canada: • extremely valuable critical third party assessment• Engagement of Sierra Systems to conduct an independent review

of the implementation, training and operations of the PACS• Assessing NORrad against original project criteria• Measuring effectiveness of training, productivity, diagnostic report

turnaround, acceptance of new technologies, projected cost savings, privacy/patient confidentiality, physician/technologist recruitment




Change Management Analysis

Project to be initiated at end of year one to reassess and re-design workflow once personnel are comfortable with the PACS technology

Objective will be to investigate means to respond to increased demand, productivity improvement techniques, lower costs, re-align responsibilities, and seek cost avoidance opportunities



Lessons Learned

Must have a vision rooted in improving patient care Extensive planning required on a technical, medical,

regional basis Government support and leadership Local leadership to drive success Persistence and patience



Lessons Learned

• World class solutions and proven technology partners

• Provide training in 2 phases: introductory and follow-up

• Plan for change management & process re-design after first year



Lessons Learned

Managing referring physician expectations Report turnaround Some have an unrealistic on-call expectation

More PACS exposure and site visits for technical staff prior to implementation



Critical Success Factors

1. Government Funding, Vision and Support

• Northern Ontario Heritage Fund, MOH

• CHIPP - Health Canada, FedNor, NeoNet

2. PACS solution must extend to the key clinical users



Critical Success Factors

3. In-house technical support and consulting expertise

4. Requires radiology and management leadership with strong working relationship with IT department



THANK YOU !!

Documents

NORrad Northern Radiology PACS Picture Archive Communication System