norrad northern radiology pacs picture archive communication system
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NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
Picture
Archiving
Communication
System
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
Removing Geography from Removing Geography from the Quality of Care the Quality of Care
Equation:Equation:
Diagnostic Imaging in North Eastern Ontario
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
Challenges in North Eastern Ontario
Distance WeatherAccessHealth Care Human ResourcesAvailability of Diagnostic ResourcesSparse Population Poor Health Status Personal Safety
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
• 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.
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
Picture X-ray Film
Computer Image
Archive Film Library
Electronic Storage
Communication Hand Delivered
Networked
System Inconsistent Structured
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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.
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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.
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
PACS: Diagnostic Image Management SystemPACS: Diagnostic Image Management System
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication 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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
• Method of getting conventional film radiology images into a digital format to effect the replacement of conventional screens and cassettes
Computed Radiography (CR)
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
Computed Radiography (CR)
General x-ray exams
Cassettes compatible to existing x-ray tables
No film in cassette
Storage phosphor plate
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
ADC COMPACT ADC SOLO
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
Image Processing FeaturesImage Processing Features
Mark key imagesAnnotate text, markersAnnotate measurements, regions of interestCalibrate video captured images for measurementSave above parameters with image
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
CS5000 CS5000 CLINICAL DISPLAY STATIONSCLINICAL DISPLAY STATIONS
• CS 5000 1X1K or 2X1K Color Landscape– Intended for ICU, O.R., ER, Hospitalist
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
OrthopodsOrthopods• Pre-surgery
planning now done softcopy
• New versions of familiar tools
• Digital templates incorporated from various vendors
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
WEB 1000WEB 1000
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
Best Practice E-Health Initiatives:
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
Best Practice E-Health Initiatives:
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
Best Practice E-Health Initiatives:
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
Best Practice E-Health Initiatives:
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
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
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
Critical Success Factors
3. In-house technical support and consulting expertise
4. Requires radiology and management leadership with strong working relationship with IT department
NORradNORradNorthern RadiologyNorthern Radiology
PACSPACSPicture Archive Communication SystemPicture Archive Communication System
THANK YOU !!