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PACS
Picture Archive Communication System
NORrad
Northern Radiology
Picture
Archiving
Communication
System
PACS
Picture Archive Communication System
NORrad
Northern Radiology
Removing Geography from
the Quality of Care
Equation:
Diagnostic Imaging
in North Eastern Ontario
PACS
Picture Archive Communication System
NORrad
Northern Radiology
NORrad PACS
(Picture Archiving and Communications System)
The Impact of the Digital
Radiology Project
NORrad Partners
•Timmins
•Hearst
•Kapuskasing
•Smooth Rock Falls
•Cochrane
•Iroquois Falls
•Matheson
•Kirkland Lake
•Moose Factory
PACS
Picture Archive Communication System
NORrad
Northern Radiology
PACS
Picture Archive Communication System
NORrad
Northern Radiology
Overview of the NORrad Region
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9 separately governed hospitals
Timmins to James Bay
100,000 people
130,000 Procedures/Year
300,000 square miles
Resource-based economy: mining + forestry
Population older than provincial average
2 Radiologists
PACS
Picture Archive Communication System
NORrad
Northern Radiology
Challenges in North Eastern Ontario
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Distance
Weather
Access
Health Care Human Resources
Availability of Diagnostic Resources
Sparse Population
Poor Health Status
Personal Safety
PACS
Picture Archive Communication System
NORrad
Northern Radiology
PACS
Picture Archive Communication System
NORrad
Northern Radiology
Why a Made-in-the-North Solution?
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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
PACS
Picture Archive Communication System
NORrad
Northern Radiology
Scope of the NORrad Project
 $10 million enterprise project – 80% funded by government
 Implementation completed at all sites in 6 months
 Incorporates latest technologies:
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Voice Recognition Software for dictation of reports
Web Browser Access for off-site physicians
Consultation workstations in all key clinical areas
Diagnostic access on all nursing floors
Encryption and security software
Regional Hospital Information System
24/7 Radiologist Coverage in all hospitals
PACS
Picture Archive Communication System
NORrad
Northern Radiology
Project Background
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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
PACS
Picture Archive Communication System
NORrad
Northern Radiology
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
PACS
Picture Archive Communication System
NORrad
Northern Radiology
Project Background - Driving Forces
 Measurable differences in the quality of care:
 Increased patient travel
 Diagnostic report turnarounds from 3 days to 3 weeks,
depending on location (highway hospitals to Moose
Factory)
 Lack of immediate service to local physicians
PACS
Picture Archive Communication System
NORrad
Northern Radiology
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
PACS
Picture Archive Communication System
NORrad
Northern Radiology
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
PACS
Picture Archive Communication System
NORrad
Northern Radiology
The Genesis of NORrad
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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
PACS
Picture Archive Communication System
NORrad
Northern Radiology
The Genesis of NORrad
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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
PACS
Picture Archive Communication System
NORrad
Northern Radiology
What is NORrad?
Picture Archiving Communication System (PACS)
The transition from a manual-based x-ray film environment to
a full digital imaging solution that allows the movement of
patients’ images rather than the movement of patients
Wide Area Network (WAN)
Creation of a broadband telecommunications link between
each NORrad hospital dedicated to the bi-directional transfer
of diagnostic images, diagnoses and requisitions securely
and rapidly
PACS
Picture Archive Communication System
NORrad
Northern Radiology
• 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.
PACS
Picture Archive Communication System
Picture
Archive
Communication
System
NORrad
Northern Radiology
X-ray Film
Computer
Image
Film Library
Electronic
Storage
Hand
Delivered
Networked
Inconsistent
Structured
PACS
NORrad
Picture Archive Communication System
Northern Radiology
Electronic Radiology Management System WAN Proposal
Cisco 2610
Cisco 3620
E10
E10
Moose Factory HC
s
bp
5M
25
6K
bp
s
Timmins & District Hospital
Cisco 2610
Cisco 2610
E10
E10
T1
T1
High Speed Data
Network
Kirkland & District Hospital
Hop. Notre Dame, Hearst
ps
Kb
256
T1
Cisco 2610
Cisco 2610
E10
E10
25
6K
bp
s
256Kbps
Bingham Memorial, Matheson
s
bp
6K
25
Sensenbrener Hospital, Kapuskasing
Cisco 2610
Cisco 2610
Cisco 2610
E10
E10
E10
Anson General, Iroquois Falls
T1 – 155Mbps Bandwidth
Lady Minto Hospital, Cochrane
Smooth Rock Falls Hospital
PACS
NORrad
Picture Archive Communication System
Northern Radiology
Benefits to the Network 13
At-HomeTeleradiography
Intensive
Care Unit
Emergency
Operating
Room(s)
Regional
“Enterprise Wide”
Electronic Imaging
System
Web
Server
Orthopaedics
Nursing
Stations
GP
Offices
HIS/RIS
Interface
Specialty
Clinics
Consult
Sick Kids
Consult
Toronto
Consult from
James Bay
R
E
G
I
O
N
A
L
H.
I.
S.
PACS
NORrad
Picture Archive Communication System
Northern Radiology
Virtual Electronic Patient Record
Clinics
Referring
Physicians
Thin Clients
Physicians’ Office
+ Home
Remote
Clinics
Rest of the enterprise
Intranet
Hospital
Information
System
CDR
or
Metadata
Repository
Internet
Web-based
Distribution
Enterprise
Master
Patient
Index
Interface
Engine
Enterprise Network
Any-ology
Radiology
Cardiology
Pathology
Labs
Pharmacy
(Ie. Endoscopy,
Ophthalmology)
PACS
Picture Archive Communication System
NORrad
Northern Radiology
The 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.
PACS
NORrad
Picture Archive Communication System
Northern Radiology
PACS Digital Image Distribution
Multiple Web Clients
Patient Exam Images and reports can be
pulled to multiple displays at any time
Diagnostic
Imaging
Emergency
ICU
O.R.
Hospitalist
Orthopedics
PACS
NORrad
Picture Archive Communication System
Film CR/DR
Digitizer
Read
Station
CR/DR
Cochrane, Iroquois Falls,
Smooth Rock Falls, Matheson
Moose Factory
Image
Server
Printer
Northern Radiology
Film
Digitizer
View
Station
Hearst, Kapuskasing
Kirkland Lake
Timmins
DICOM Network
Film
Digitizer
Archive Server
Network Gateway
Network
MRI
CT
NM
Printers
U/S
DF/DSA
Radiologist
Read Stations
View
Stations
Oracle
Server
Long
Term
Archive
DR/CR
PACS
Picture Archive Communication System
NORrad
Northern Radiology
PACS: Diagnostic Image Management System
PACS
NORrad
Picture Archive Communication System
Northern Radiology
Sennsenbrenner Hospital, Kapuskasing
BASIX Configuration
Acquisition
Archive & Verification
Teleradiology
Hardcopy
Regional
Database, Archive
& Web
Ultrasound
Toshiba
Powervision
HIS/RIS
DICOM
QC Stn
X-Ray
GE R&F
ADCC
Cassettes
Display
DS3000 NT
Display Station
Preview/ID
Station
10/100 Mbps
GE R&F
Basix AS300
Archive, Cache,
MS SQL dB,
NWG, Broker Lite
GE RAD
Alliance WAN
ADC Compact
Digitizer
PS5000
Digitizer
w/Doc
Scanner
DICOM
Internet Access
Web Server Clients
Drystar
3000
PACS
Picture Archive Communication System
NORrad
Northern Radiology
Computed Radiography (CR)
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Method of getting conventional film
radiology images into a digital format to
effect the replacement of conventional
screens and cassettes
PACS
Picture Archive Communication System
Computed Radiography (CR)
General x-ray exams
Cassettes compatible to existing
x-ray tables
No film in cassette
Storage phosphor plate
NORrad
Northern Radiology
PACS
Picture Archive Communication System
ADC COMPACT
NORrad
Northern Radiology
ADC SOLO
PACS
Picture Archive Communication System
NORrad
Northern Radiology
PACS
NORrad
Picture Archive Communication System
Northern Radiology
The Productivity Opportunity
“Diagnostic
Patient
scheduled
1-7 Days
Patient
registered
for D.I.
45 Min.
Clinical” Process:
Develop
& print
films
Image
Taken
15 Min.
45 Min.
Traditional
Modality Focus
Radiologists
Transport
review &
tapes & type
report
reports
dictation
Transport
& hang
films
2 Hours
3 Hours
Workstation
Dominant
Approach
Information
Management
Focus
4 Hours
Match
report
with film
& file &
invoice
X Hours
Medical
record to
referring
physician
1-2 Days
PACS
Picture Archive Communication System
NORrad
Northern Radiology
Display Features
Features are common to all workstations
User Selectable Formats: 1 on 1, 2 on 1, etc.
Split screen view: multiple series and studies
Simultaneous viewing of all modalities
Image Manipulation: Zoom & Pan, Window and Level,
Invert, Rotate, Flip
Scroll through entire study quickly
Stack & Cine loop display
Vary cine speed, stop frame
PACS
Picture Archive Communication System
NORrad
Northern Radiology
Image Processing Features
Mark key images
Annotate text, markers
Annotate measurements, regions of interest
Calibrate video captured images for measurement
Save above parameters with image
PACS
Picture Archive Communication System
Radiologists
• 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
NORrad
Northern Radiology
• Initial increase in reporting
time
• Less time searching for
previous
• Overall, increased
capacity
PACS
Picture Archive Communication System
NORrad
Northern Radiology
PACS
Picture Archive Communication System
NORrad
Northern Radiology
CS5000
CLINICAL DISPLAY STATIONS
• CS 5000 1X1K or 2X1K Color Landscape
– Intended for ICU, O.R., ER, Hospitalist
PACS
Picture Archive Communication System
NORrad
Northern Radiology
PACS
Picture Archive Communication System
Orthopods
• Pre-surgery
planning now
done softcopy
• New versions of
familiar tools
• Digital templates
incorporated from
various vendors
NORrad
Northern Radiology
PACS
Picture Archive Communication System
NORrad
Northern Radiology
Web Server
Security and encryption meet regulations
View images and reports over the Internet
View grayscale & colour images
Stack images & view Cine loops
Ideal for remote viewing by radiologist, referring
physicians and hospital departments
Wavelet compression to stream images over Internet
PACS
Picture Archive Communication System
WEB 1000
NORrad
Northern Radiology
PACS
Picture Archive Communication System
Health Care Benefits
NORrad
Northern Radiology
Hospitals
 Enhanced support for small hospital physicians
 Increased relevance of local and district hospitals
 Elimination of lost films, decreased x-ray film storage
and operating costs
 Transfer of diagnostic images to referral or teaching
hospitals to eliminate unnecessary patient travel
 Avoids duplication of exams and reduces radiation
exposure
PACS
NORrad
Picture Archive Communication System
Health Care Benefits
Northern Radiology
Physicians/DI Techs
 Leverages shortage of physician
 Reduces medical risk and professional isolation
 Provides a virtual consulting relationship between
radiologists + referring doctors irrespective of distance
 Facilitates retention of existing physicians
 Increased hospitals’ attractiveness to new physicians
 Provides high tech employment for northerners
 Improved working environment
 Physician access to images/reports in their offices
 Supports northern medical school innovation mandate
PACS
Picture Archive Communication System
Health Care Benefits
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NORrad
Northern Radiology
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
PACS
Picture Archive Communication System
NORrad
Northern Radiology
Clinical Example of PACS:
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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
PACS
Picture Archive Communication System
NORrad
Northern Radiology
e-Health Significance of NORrad
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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
PACS
Picture Archive Communication System
NORrad
Northern Radiology
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
PACS
Picture Archive Communication System
NORrad
Northern Radiology
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
PACS
Picture Archive Communication System
NORrad
Northern Radiology
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 centres
 Cost-sharing on an equitable cost-recoverable basis
 Long-term collaborative agreement
 Technology refreshment & replacement funding
 Anticipation to accommodate project expansion
 Flexibility to add new telehealth applications
PACS
Picture Archive Communication System
NORrad
Northern Radiology
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
PACS
Picture Archive Communication System
NORrad
Northern Radiology
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
PACS
Picture Archive Communication System
NORrad
Northern Radiology
Best Practice E-Health Initiatives:
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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
PACS
Picture Archive Communication System
NORrad
Northern Radiology
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, realign responsibilities, and seek cost avoidance opportunities
PACS
Picture Archive Communication System
NORrad
Northern Radiology
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
PACS
Picture Archive Communication System
NORrad
Northern Radiology
Lessons Learned
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World class solutions and proven technology partners
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Provide training in 2 phases: introductory and follow-up
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Plan for change management & process re-design after
first year
PACS
Picture Archive Communication System
NORrad
Northern Radiology
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
PACS
Picture Archive Communication System
NORrad
Northern Radiology
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
PACS
Picture Archive Communication System
NORrad
Northern Radiology
Critical Success Factors
3. In-house technical support and consulting expertise
4. Requires radiology and management leadership with
strong working relationship with IT department
PACS
Picture Archive Communication System
NORrad
Northern Radiology
THANK YOU !!