samhandling i radiologi - ntnu · pdf filesubspecialty expertise. •may send images to the...
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Samhandling i radiologi
Frode Lærum
Akershus Universitetssykehus
Sept 2009
Behov for nasjonal samordning?
Kan radiologien samhandle på andre måter?
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Radiologisk samhandling
• Pasient
• Klinikere/henvisend
e lege
• Andre radiologer
• Andre radiologiske
avdelinger
• Andre HF
• Andre land
• Samfunnsoppdraget
• Primærhelsetjenesten
• Spesialisthelsetjeneste
n
• Innad i radiologi
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Samhandling
• Nye teknologiske premisser
– Digitalisering
– PACS
– Nettverksløsninger
• Teleradiologi– Kun et verktøy!
• Organisatoriske konsekvenser?
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Pasient/kliniker og radiologi
• Tilgjengelighet
– Ønsket modalitet
– Ventetider
• Gjennomføring av undersøkelsen
– Profesjonelt ivaretatt
• Resultat
– Riktig
– Raskt
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Samhandling mellom
radiologer
• Second-look
• Subspesialist-konsultasjoner
• Virtuelle nettverk
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Teleradiologi
• Tolkningssentre (Barcelona)
• Satelitter (Ski-Aker sh)
• Virtuelle nettverk
– Helse Vest
– Nordfjordeid
– Private røntgeninstitutter
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Sykdomsgrupper og radiologi
• Screening
– Mammografi
– TBC/lungelidelser (”Skjembilde”)
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Klinikeren og radiologi
• Primærlegekontor(satelitt) til radiologisk
avd (Vinje, Trysil)
• Spesialist (satelitt) til radiol avd
• Radiol avd til spesialist (f.eks.
ortoped)/UUS
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Teleradiology trends
• USA: Between 50 and 55 percent of institutions now use some form of off-hours teleradiology service..,
• ...while nighttime teleradiology coverage will likely reach a plateau, outsourcing studies to subspecialists may become much more common.
• William G. Bradley Jr., M.D., Ph.D., prof. & chair UCSD, founder NightHawk 2009
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QuickTime™ and a decompressor
are needed to see this picture.
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•
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Controversies
• "I am concerned that the improper use of technologies such as PACS and teleradiology ... will provide a mechanism by which radiologists will move from the desired role of consultants to the role of expert image interpreters..... referring physicians could cease to consult with radiologists before or during imaging examinations if radiologists are no longer physically present.”
• C. Douglas Maynard, M.D., prof. Winston-Salem, N.C., 2000 RSNA president,
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Teleradiology I
• Institutions get access to a greater number of radiologists
• Teleradiology is finding applications in off-hours coverage - particularly in access to subspecialty expertise.
• May send images to the most appropriate faculty, regardless of the location of the imaging study."
• N. Reed Dunnick, M.D., Prof and chair, University of Michigan
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Teleradiology II
• "We should use the technology to route the exam to a specific subspecialist 100 percent of the time, at least during the normal business day.”
• ”Radiologists must ensure the smooth operation of the imaging facility. We must remember that there is much more to radiology than interpreting the images.”
– N. Reed Dunnick, M.D., Prof and chair, University of Michigan
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QuickTime™ and a decompressor
are needed to see this picture.
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Samhandling primær-
/kommunehelsetjenesten
• Elektronisk henvisning/svartjeneste
• Mobil røntgentjeneste
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35-40 000 sykehjemsenger i Norge
Table 1 Age, PADL score and chronic diseases in 714 nursing-home residents
Main variable Specification Result
Age (years), n=714 Mean
Range
85 years
37-107 years
PADL score, n=4131 Mean (SD)
Range
19.7 (5.3) PADL score
7-30 PADL score
Chronic diseases per
resident, n=714
Mean (SD)
Range
3.1 (1.4)
0-9
Most common chronic
diseases, n (%)
Dementia/cognitive failure
Fracture sequelae
Musculoskeletal disease
Psychiatric disorder
Hearing impairment
Visual impairment
Cancer
Neurological disease
Abdominal disease
294 (64.9%)
169 (37.3%)
152 (33.6%)
152 (33.6%)
103(22.7%)
91 (20.2%)
83 (18.3%)
59 (13.0%)
46 (10.2%) 1Recorded for all events except death
Figure 1 presents a flow chart on health-related events (occurrenc e and fo llow-up) among the 714
residents; data are given on referr al to specialist services and transport needs.
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Røntgen hyppigste henvisningsårsak
– 28% (128/453) henvist spesialisthelsetjenesten
– 82% (78) trengte videre behandling.
– Halvpartene av disse henvisningene var til
røntgen,
– 3/4 til skjelettundersøkelser.
Akutte, helsemessige hendelser hos 714 sykehjemspasienter over
8 ukers periode (n=453):
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Digital røntgen i sykehjem
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Pasientene
undersøkes i sin
egen seng
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Mobile DR Outpatient emergency clinic
(Oslo legevakt)
Exposure deviation 0.12%
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I tjeneste hverdager 08.00- 15.30 (OuS/UuS)
• Start sept 2004; 6 sykehjem
April 2009:
• 2900 pasienter fra 55 sykehjem
• Ca 3500 undersøkelser
– 70 % kvinner – 30 % menn
– Gjennomsnittsalder 86 år
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Type undersøkelser
Første 1,5 år Totalt (2007)
Rtg thx 16.0 % 32%
Rtg abdomen 1.4 % 1%
Rtg columna 6.6 % 9%
Bekken/hofter 45.0 % 29%
Overekstremitet 15.0 % 13%
Underekstremitet 17.0 % 16%
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Funn diagnoser (%)
0,21,2 1,7
2,3 2,73,3
6,87,9
10,611,8
13,7 13,7
24,1
0,0
5,0
10,0
15,0
20,0
25,0
30,0
Ileus
"Con
stipation"
Metas
tasis / T
umou
r
Osteo
poro
sis
Prosthe
sis fa
ilure
Pneum
onia
Nor
mal
Hea
rt fa
ilure
No
hear
t failure
/ pn
eum
onia
Fractur
e (n
ew)
Prosthe
sis
Fractur
e (o
ld)
Deg
ener
ative
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Betydning –
mobil rtg i sykehjem (n=125/197)
• Konsekvenser
– for pasientbehandling 85% (n=106)
– for stell/pleie 71% (n=89)
• Tentativ diagnose
– Bekreftet 58% (n=72)
– Avkreftet 42% (n=52)
– (Usikker n=1)
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Alternativ til mobil røntgen:Ingen (for dårlige pas.) 10% (n=12)
Innleggelse 14% (n=18)
Poliklinikk. 72% (n=90)
Innlagt senere 8% (n=10)
Røntgen når bilen ”var der” 3% (n=4)
Spørreundersøkelse sykehjemsleger 125/197 observasjoner
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Involvert personell (pr rtg us)
• 2 ambulanse-transporter 4 personer
• 1 ansatt sykehjem
• 1-2 radiografer
• 1 radiograf
• (1 ansatt sykehjem)
Før: Mobil rtg:
Sparer samfunnet ca 3200 NOK pr undersøkelse
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Alternative transportation
(n=125/197)
Ambulance 54% (n=68)
Taxi 36% (n=45)
Missing information 10% (n=12)
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Økonomi/pasienttransport• Noen RHF får økte utgifter
• Kommunehelsetjenesten får gevinst
• Radiologiske avd får økte utgifter
• Ambulansetjenestene/pasienttransport får gevinst
• Relevante refusjonstakster finnes ikke
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Estimert nettoeffekt for
sykehuset• Unngåtte innleggelser: 98 (14 % av 700 u.s. Gjsn.liggetid: 5
dager/pasient. Gj.sn.døgnkostnad: 6.500 NOK) = 3.185.000 NOK
• Pasienter likevel innlagt: 56 (8 % av 700 pasientkontakter).
= 105.000 NOK
• Estimert merforbruk: 70 u.s. (10% - 70 x 1.886) = 133 000 NOK
• Utgift for helseforetaket: Avskrivning og driftskostnader for 1
rtg.bil/år =1 460 000 NOK
• Nettoeffekt 1 ”røntgenbil”, 700 u.s./år
= 1.487.000 NOK
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Avleggere i utlandet
• Mobirad
• Geneve, Basel
• Lunds Universitetsjukhus
Skåne
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Påtrykk fra myndighetene
• Ny helse- og omsorgsteknologi som mobile helsetjenester (mobil røntgen i sykehjem, mobile laboratorietjenester) vil inngå som en integrert del av helse- og omsorgstilbudet. (St. meld. nr. 7 (2008-2009)
Et nyskapende og bærekraftig Norge)
• Styringsdokumentet 2009 HOD/RHF SØ
• Samhandlingsreformen
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US og CT service
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Flytte utstyr – ikke pasienter
• Respons på den kommende geriatiske tsunami
• Ny teknologi gjør det mulig å øke utstyrets mobilitet –tilby mer fleksible helsetjenester
• Bedre beslutningsgrunnlag for pasienthåndtering/behandling utenfor sykehus
• Mindre belastning for pasientene
• Samfunnsøkonomisk lønnsomt i tett befolkede områder
• Redusere inntakspresset på sykehusene
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Tolkningssenter i offentlig regi
• Radiologene nærmere klinikken
• Volumproblemer
• Utdannelse
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Fjerntolkningssenter i off regi
Styrke radiologenes nærhet til
pasientrettet, klinisk arbeide i sykehus
Styrking av fagkompetanse, kvalitet og
utdanning i radiologi gjennom ny
organisering
Bedre radiologenes arbeidsforhold
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Regionalt fjerntolkningssenter
• Koblet til spesialistutdannelse,
fagutvikling og kvalitetssikring
• Effektivisere og strømlinjeforme
tolknings- og tilbakemeldingprosessene
for bildediagnostikk (”LEAN”, six-sigma)
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Mål og visjoner• Bedre pasientbehandling gjennom økt kvalitet og
tilgjengelighet på bildediagnostikk
• Redusere kapasitetsbegrensninger og bedre arbeidsforholdene for radiologer
• Styrke radiologenes nærhet til pasientrettet, klinisk arbeide
• Styrking av fagkompetanse, kvalitet og utdanning i radiologi gjennom ny organisering
• Gi bedre og mer stabil radiologisk kompetansetilgang for et større geografisk område gjennom virtuelle løsninger
• Kompetansemodulering mellom helseforetakene: Pasienter kan i større grad utredes lokalt
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Tolkningssenter i off. regi
• Ressurs for alle HF i regionen (evt. interregionalt), plassert der det er størst radiologtetthet og optimal mulighet for pendling fra flest mulig sykehus
• Rotasjon av alle HF-ansatte radiologer 2 dager i uka.
• Hver radiolog ”tar med seg” mer enn tilsvarende tolkningsvolum de ellers ville hatt i moderavdeling.
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Organ-orienterte
subspesialist-hierarkier
• Basert på nåværende ekspertise i hele det
regionale fagmiljøet, robust subspesialist-
tilgang
• Spesialistutdannelse og videre-/etterutdanning:
Eksponering for store undersøkelsesvolum,
kvalifisert veiledning
• Kontinuerlig kollegial/faglig feed-back
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Rotasjonsordning også for
spesialiskandidatene
• Inngår i det vanlige tolkningsarbeidet
som i HF i dag
• Hospiteringsordninger for eksterne
radiologer
• Samlokaliserte kurs- og
undervisningsopplegg
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Korte kommunikasjonslinjer
• Store tolkningslandskap
• Nærhet mellom radiologene
• Lett tilgjengelige subspesialister
• Bredt faglig nettverk
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Kvalitetssikring og effektivisering
• Egen enhet for fortløpende
virksomhetsovervåkning
• Assistenter for postprosessering og
tilrettelegging
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Volumgevinst
• Pendlerområdet Drammen/Oslo/Akershus/Moss 2
dager pr uke
• 2/5 av180 radiologer vil gi 72 radiolog-årsverk
• Ved uttak av full reservekapasitet for tolkning (150%)
– hver radiolog 1.2 radiologs tolkningskapasitet
– potensiell kapasitetsøkning på inntil 36 årsverk
– dvs 108 årsverk fra de 72 som settes inn
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Gevinstrealisering
• Må deles mellom -
– fagutvikling/spesialistutdanning
– incentiver for deltakende radiologer (lønns- og
arbeidsforhold)
– økt kapasitet for deltakende helseforetak/regionen
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Fysisk organisering• Bør bygges opp sentralt med gode
kommunikasjons-/pendlermuligheter (”Oslo sentralbanestasjon”), men utenfor eksisterende HF.
• Senteret må fullt utbygget ha – plass for rundt 70 PACS arbeidsstasjoner
– god og velorganisert IT-service og kontorstøtte
– undervisningsrom
– ”call-senter”.
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Organisasjonskart
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Servicenivå
Nivå 1: Enkle rutineundersøkelser
Nivå 2: Mer spesialiserte undersøkelser/klinikerkontakt/bruk av høyere kompetanse i de subspesialiserte faghierarkiene
Nivå 3: (Tolkningsassistenten) On-line fjernveiledning av avanserte pasientundersøkelse, protokolltilpassingEvt virtuelle kliniske vurderinger (slagpasienter,
multitraumer)
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Tolkningsassistenten RH
• On-line PACS og multikanal
videokonferanse
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Tolkningsassistenten RH
QuickTime™ and a decompressor
are needed to see this picture.
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Regional fellesvakt
• Fellesvaktordninger for deltakende HF
vil kunne organiseres innenfor rammene
av et offentlig tolkningssenter, bl.a. med
virtuelle løsninger (multikanal
videokonferanse og on-line PACS, jfr.
Tolkningsassistent-prosjektet)
• Bedre subspesialisttilgang
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QuickTime™ and a decompressor
are needed to see this picture.