P icture

2. Picture Archiving Communication System

3. Removing Geography from the Quality of Care Equation: Diagnostic Imaging in North Eastern Ontario

4. NORrad PACS(Picture Archiving and Communications System) The Impact of the Digital Radiology Project

5. NORrad Partners • Timmins • Hearst • Kapuskasing • Smooth Rock Falls • Cochrane • Iroquois Falls • Matheson • Kirkland Lake • Moose Factory

7. Overview of the NORrad Region  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

8. Challenges in North Eastern Ontario  Distance • Weather  Access  Health Care Human Resources  Availability of Diagnostic Resources  Sparse Population • Poor Health Status • Personal Safety

10. 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

11. Scope of the NORrad Project • $10 million enterprise project – 80% funded by government  Implementation completed at all sites in 6 months  Incorporates latest technologies:  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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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.

22. T1 – 155Mbps Bandwidth

23. Benefits to the Network 13 At-Home- Teleradiography Intensive Care Unit R E G I O N A L H. I. S. Emergency Regional “Enterprise Wide” Electronic Imaging System Operating Room(s) HIS/RIS Interface Web Server Orthopaedics Consult Toronto Nursing Stations GPOffices Specialty Clinics Consult Sick Kids Consult from James Bay

24. Physicians’ Office + Home Remote Clinics Referring Physicians Clinics Thin Clients Rest of the enterprise Intranet Internet Hospital Information System CDR or Metadata Repository Enterprise Master Patient Index Interface Engine Radiology Cardiology Pathology Labs Pharmacy Any-ology (Ie. Endoscopy, Ophthalmology) Virtual Electronic Patient Record Web-based Distribution Enterprise Network

25. 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.

26. PACS Digital Image Distribution Multiple Web Clients Patient Exam Images and reports can be pulled to multiple displays at any time Emergency ICU O.R. Hospitalist Orthopedics Diagnostic Imaging

27. Film Digitizer CR/DR Read Station CR/DR Film Digitizer Cochrane, Iroquois Falls, Smooth Rock Falls, Matheson Moose Factory Image Server View Station Printer Hearst, Kapuskasing Kirkland Lake Timmins DICOM Network Film Digitizer Archive Server Network Gateway Network Printers Radiologist Read Stations View Stations Oracle Server Long Term Archive MRI NM U/S DF/DSA CT DR/CR

28. PACS: Diagnostic Image Management System

29. Sennsenbrenner Hospital, Kapuskasing BASIX Configuration Acquisition Archive & Verification Teleradiology Hardcopy Regional Database, Archive & Web Ultrasound Toshiba Powervision HIS/RIS DICOM ATM 155 QC Stn Display Drystar 3000 X-Ray DS3000 NT Display Station ADCC Cassettes Preview/ID Station GE R&F 10/100 Mbps GE R&F Basix AS300 Archive, Cache, MS SQL dB, NWG, Broker Lite GE RAD Alliance WAN ADC Compact Digitizer Digitizer w/Doc Scanner Internet Access PS5000 DICOM Web Server Clients

30. Computed Radiography (CR) • Method of getting conventional film radiology images into a digital format to effect the replacement of conventional screens and cassettes

31. Computed Radiography (CR) General x-ray exams Cassettes compatible to existing x-ray tables No film in cassette Storage phosphor plate

32. ADC COMPACT ADC SOLO

34. Information Management Focus The Productivity Opportunity “Diagnostic Clinical” Process: Match report with film & file & invoice Radiologists review & report dictation Medical record to referring physician Patient registered for D.I. Develop & print films Transport & hang films Transport tapes & type reports Patient scheduled Image Taken 1-7 Days 45 Min. 15 Min. 45 Min. 2 Hours 3 Hours 4 Hours X Hours 1-2 Days Workstation Dominant Approach Traditional Modality Focus

35. 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

36. 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

37. 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 Radiologists

39. CS5000 CLINICAL DISPLAY STATIONS • CS 5000 1X1K or 2X1K Color Landscape • Intended for ICU, O.R., ER, Hospitalist

41. Pre-surgery planning now done softcopy New versions of familiar tools Digital templates incorporated from various vendors Orthopods

42. 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

43. WEB 1000

44. Health Care Benefits 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

45. Health Care Benefits 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

46. Health Care BenefitsPatients • 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

47. 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

48. 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

49. 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

50. 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