The Central BC & Yukon - Telemedicine Initiative

1.0 Introduction

The Central BC & Yukon - Telemedicine Initiative project is now complete. This project was to develop a network and tele - imaging system to enable Specialists centred in Kamloops at Royal Inland Hospital to view and report promptly on digital imaging originating from the following areas:

• Royal Inland Hospital (RIH), Kamloops, British Columbia.
• North Shore Radiology, Kamloops, British Columbia.
• Chase Health Centre, Chase, British Columbia.
• Dr. Helmcken Memorial Hospital, Clearwater, British Columbia.
• Barriere Health Centre, Barriere, British Columbia.
• Nicola Valley General Hospital, Merritt, British Columbia.
• Ashcroft & District General Hospital, Ashcroft, British Columbia.
• Lillooet & District Hospital, Lillooet, British Columbia.
• 100 Mile House District General Hospital, 100 Mile House, British Columbia.
• Cariboo Memorial Hospital, Williams Lake, British Columbia.
• Whitehorse General Hospital, Yukon

The system would also allow for the digital archiving of all modalities and the transfer, electronically of these to referral hospitals or Physicians.

The project has been completed on time and within budget and has turned out to be very successful in furthering Patient Care in all areas that the system encompasses.

2.0 Project Description

Residents of rural and remote areas of Central British Columbia and Yukon Territory benefit from faster medical diagnoses, thanks to a secure, high - speed telehealth network being built for the rapid transmission of X - ray images.

The data network uses a Picture Archiving Communications System (PACS) to allow 10 rural and remote hospitals and diagnostic and treatment centres to consult almost instantly with Radiologists in Kamloops, Comox, Williams Lake and major referral hospitals in lower mainland BC. Until now, images had to be couriered, resulting in lengthy delays in obtaining medical diagnoses.

Moreover, if patients must be transferred, an electronic transmission system can ensure their X - rays and reports accompany them to their destinations.

The Thompson Cariboo Shuswap, Health Service Area of Interior Heath, has led this CHIPP - supported initiative in partnership with that of the Yukon Hospital Corporation.

The partners worked initially with Telus, the largest telecommunications provider in the area, to improve the current telecommunications infrastructure. For example, an existing Wide Area Network was upgraded and a secure Virtual Private Network was implemented to connect Whitehorse to the telemedicine project.

Because of the paramount importance of personal privacy, an alphanumeric system will be used to identify patients and safeguard the confidentiality of their medical information.

Once the network is installed and in operation, its use can be expanded beyond tele - imaging to other telehealth applications.

3.0 Achievements

3.1 Goals Reached

Work plan achievements:
All elements of the original work plan have been achieved. The essentials included:

• Upgrade of the WAN (wide area network) to accommodate the data traffic as well as upgrades and new LANs (Local Area Network) at various sites for the new equipment. Originally most sites were connected by means of a "Frame Relay" network operating at 56 kB/s to 256 kB/s. This has been replaced with an ATM, fibre network currently operating at 10 MB/s. In addition, new managed data switches have been installed and the network is constantly monitored and managed.
• Implementation of VPN (Virtual Private Network) links to Doctors offices and between Whitehorse and Kamloops. This addresses secure (triple - DES encryption) Doctor's access to the network.
• Installation, commissioning and testing of servers and multiple workstations for Doctors and staff. All equipment is the best quality available at the time e.g. Diagnostic workstations are equipped with 2k x 2k pixel dual, flat screen, LCD monitors, which can show magnified images at 4k x 4k pixels.
• Installation, commissioning and testing of the SAN (storage area network), which allows for the very reliable storage of Terabytes of data storage. The data in - turn is backed - up automatically by means of a tape library.
• Installation, testing and implementation of the PACS software. In this case Fujifilm's Synapse PACS was the chosen application.
• Installation, testing and implementation of the various Dicom modality interfaces to Ultra Sound, CT, MRI and Nuclear Medicine modalities.
• Installation, testing and implementation of 11 CRs (Computed Radiography) units for X - Ray. These provide for the reading of the digital X - Ray media, which replaces the conventional film media.
• Training of all the staff, which included Radiologists, other Specialists, X - Ray Technologists and IT staff.

Contributing key factors:
The principal contributing key factors to the success of the project were:

• Staff "buy - in" to the overall tele - imaging project from the initial conception.
• Clear and thorough planning of all stages of the project. This included risk analysis, careful selection of products and Vendors and the allocation of sufficient resources for project implementation.
• Efficient financial management of the project.
• Good and helpful guidance from the OHIH Team. This was helped with the Ottawa workshop/conference held at the beginning of the project.
• Stable project management and implementation crew for the duration of the project.
• Supportive backing from Management and our fund raising Foundation.

Obstacles or challenges:
In general, the main obstacles and challenges were as follows:

• Technical problems arose relating to the interfacing of the PACS Synapse software with that of the Meditech RIS software. This took longer than anticipated to finalise, but with perseverance a very good result was achieved. As Whitehorse was operating a different version of Meditech RIS, a modified interface was needed for this site. This caused some delay in the final integration of PACS and RIS at this site.
• A delay occurred due to the Vendor being late with software upgrades, but this time was recovered
• A change in the storage architecture for Whitehorse was implemented, which substantially improved Whitehorse's data retrieval rates.
• Network problems are still occurring with the connection to Comox, which is on Vancouver Island. This is currently being addressed by Telus.
• Some reluctance by some Specialists to accept a "film - less" diagnostic imaging environment. This is being addressed, by means of training and coaxing to accept the "new" way of viewing images. Workstations are being installed in strategically accessible places to make it easier for the doctors to view images e.g. at Nursing stations on the Wards.
• Reluctance to use the system in the operating theatres. Surgeons demanded to still have the images on film. This was overcome, by installing workstations in a theatre and showing the "nurses" how to use the equipment. In a very short time the system was in demand in all the theatres!
• In December 2001, the Thompson Health Region together with the Chilcotin and Cariboo health areas, were incorporated into the new Interior Health Authority of BC. In January of 2002, the new Authorities put the project on hold, in order to ascertain, that it would not require any more internal funding and that it would be sustainable on completion. This review took a month to complete and was successful in allowing the project to proceed.

3.2 Additional Successes

The following may be taken as components that were over and above that envisaged under the original work plan:

• The overall system performs faster than originally envisaged.
• The system is easier to use than originally envisaged.
• The leaning curve has been shorter than anticipated.
• The system allowed site to become "film less" far earlier than planed.

Contributing factors are:

• Overall enthusiasm of the staff to work with the new Tele - imaging system.
• Newer technology, within the original budgets, was available by the time of installation

The obstacles that were encountered were:

• Problems with the two - way, software interfaces between the PACS and the RIS. This occurred both with the Thompson RIS and with the Yukon RIS. The PACS system is Fujifilm's "Synapse" and the RIS is Meditech's RAD module. Synapse uses a "brokerless" interface, but the issues were mainly defining common data base "keys', in matching field sizes and their configuration. Once this was achieved, the interface has proved to work very well and reliably.
• The Yukon were concerned about the reliability of accessing their data over the VPN. Initially all their data was to be stored on the SAN at Royal Inland Hospital, Kamloops. A risk assessment was carried out and from this they decided, that although the risk was not excessive, they needed a more reliable system. Thus, they opted to purchase their own SAN, which would provide local storage, with the Kamloops SAN being used for archival use and backup as needed. This addition to the overall system has proved to work extremely well.

3.3 Unreached Goals

All elements and goals of the original Work Plan, were achieved.

3.4 Documents or Products Produced

Document /Product Name	Available in Paper and/or Electronic	Licence Fee Required for use (Yes/No)	Previously Provided to Health Canada (Yes/No)	Appended to the Report (Yes/No). If yes, please provide Appendix Name /Number)
Template(s) for vendor RFP	Electronic	No	No	Yes APPENDIX A
Template(s) for vendor contract(s)	N/A
User Guide(s) and/or Training Manuals	Vendor's Manuals	Yes	No
Template(s) for equipment testing	N/A
Policy and Procedure Manual(s)	N/A
Job Descriptions	Electronic	No	No	Yes APPENDIX B
Software Application(s), includes: EHR application Security /access alert software Telehealth scheduling software Other	N/A
Standards, includes: Data (includes minimal data sets) Image Messaging Other	N/A
Clinical Training Protocols	N/A
Clinical Program Protocol(s)	N/A
Video Conference Protocols and Etiquette Guide	N/A
Quality Assusrance Procedures	N/A
Confidentiality and Privacy documents
Sustainability Plan	Budget has been done	No	No	Yes APPENDIX C

4.0 Main Impact

The project has had a huge impact on the physicians working in the remote smaller centres. Physicians now have immediate access to Specialists and other health care personnel in the region at any time of the day or night. Previously they had to rely on their judgement, when reviewing X - rays. Now they can consult over the phone and provide better, quicker care for their patients.

There have been many instances, where review of cases has prompted immediate patient transfers for surgery and expanded care.

This was clearly demonstrated early on in the project. In Williams Lake, a small child was seen in the emergency department with severe pain in the left elbow. The emergency Physician was unsure if there was a fracture to the humerus, so she called a Radiologist in Kamloops. The Radiologist was able to confirm over the telephone that there was indeed a fracture and that it may need immediate surgical attention. An Orthopaedic Surgeon was consulted and it was confirmed that the child needed surgery. That surgery was organized within the hour and the child had surgery in Kamloops the next day. Previously this scenario would have taken several days to unfold, as firstly the x - ray films would have been couriered to Kamloops for the Radiologist to report on and only after that would have surgery been organised.

In another case, a woman in Clearwater, who had chest pains, was x - rayed and the Physician there, not seeing anything abnormal immediately called the Radiologist in Kamloops (1.5 hours away). The Radiologist was able to view the x - rays within minutes and diagnosed that she had a ruptured aorta. This patient was immediately transferred to Kamloops, where she had emergency surgery. Under the old system, it is unlikely that this patient would have survived, as it would have taken more then 12 hours for a diagnosis, due to the delay in couriering the X - Ray films.

The Project has also had an impact on bed management for the region. Patient cases can now be reviewed from referral centres, which in some cases may save transporting a patient to another facility. Decision making regarding patient transfers has greatly improved.

There has also been a quicker turn around time for all imaging reports. Previous examinations are now instantaneously available for comparison along with reports. Radiologist's reports are also available to all facilities and physicians in the Thompson Cariboo Shuswap, Health Service Area (TCS HSA) via the Hospital Information System, Electronic Health Record (EMR). The associated images are also available, by means of "clicking" on an icon adjacent to the report, indicating that an image is available with the report. This is available throughout the hospitals and also available instantly to any Physician offices throughout the region via means of VPN connections from their homes or offices. This provides a huge advantage to Physicians, who are now able to view images simultaneously and discuss cases even though they are miles apart.

There are no more incidents of "lost films", which meant repeated x - rays, resulting in more radiation exposure, costs and unnecessary patient inconvenience.. Films also do not get misplaced and fewer exams are repeated because of this.

The project has changed how we archive patient files. Previously images were filed in shelving at the originating site and transported on request by courier. This model of storage has vanished.

Imaging services are now more responsive to physician practices now that reports and images are more accessible. Treatment decisions are made faster.

Another, important outcome of the system, is that it is far more environmental friendly. No more plastic films needing disposal and the elimination of chemicals is a boon both to City sewage systems and the elimination of "dark room" disease. One of the X - Ray Technologists in 100 Mile House was on WCB payments after been diagnosed with this malady and was able to return to work once the new system was operational.

Finally, the system has been well received by both Doctors and Imaging Staff and statistics are being gathered to ascertain what performance improvements have been achieved.

4.1 Human Resources Impact

The project has had far reaching impact on computer skills for many health care providers. Many Imaging Technologists have increased their computer skills and knowledge with this technology. Other health care providers have also had to make advances.

We have developed a position of PACS Administrator and have changed the nature of several jobs, especially clerical staff working in imaging file rooms. The poison of Regulator Clerk has already been eliminated.

Initially there was many staff concerns and apprehension about changing work environments. This has abated somewhat and many staff is now expressing renewed enthusiasm for their work.

This project has allowed us to close down and remove up to ten film processors. This has made for a healthier work environment. One staff member was able to return to work after an absence of 18 months due to health conditions caused by processor chemicals.

4.2 Privacy and Protection of Information

• The procedures for the protection of personal health information have stayed the same, but staff has been made very aware of privacy issues relating to the new system.
• Our Policies and procedures are continually been revised and we have a Manager in charge of all Privacy and FOI matters.
• A 'Privacy Impact Assessment' has been completed and quotation of summary from the report is as follows:

  Summary
  "Overall, The Central BC and Yukon Te1emedicine Initiative has developed a sound privacy program. There is, however, some room for improvement to reach a best - practise level as identified in the gaps section of the report. Those gaps identified, refer to precautions the project should take to ensure safeguards for patient information remain strong and if an incident or question does arise, it could be responded to quickly.

  Policies and Procedures: The Central BC and Yukon Telemedicine Initiative is utilizing the Thompson Health. Region's privacy and confidentiality related policies, such as Access to Patient/Client Information; Collection, Use and Disclosure of Information; Confidentiality; and Internet Usage. These policies have been revised to comply with BC's. Freedom of Information and Protection of Privacy Act, but have not been revised specifically for this initiative. The initiative will need to review their policies and procedures as the network is expanded to include sites that are not within the TCS HSA. It will be important to ensure these sites have comparable information safeguards and procedures are documented detailing how the initiative as a whole will handle privacy - related matters (e.g. use the policies of the respective sites or choose another alternative).

  Tools: A threat and risk analysis and routine privacy and security audits have been done. The BC Office of the Information & Privacy Commissioner undertook a review of the privacy Practices surrounding the Region's electronic patient record. Where direct connections are not possible (Yukon and Comox), encryption technologies will be utilized."

Lesson Learned: Personnel stated that they were surprised how different P ACS applications vary when it comes to security. They stated that the Fuji Synapse system being implemented by the initiative is very configurable.

• Policies have been updated to address the issues raised as a result of the recent Privacy Impact Assessment.
• We did participate in the CHIPP Privacy and Security Survey conducted in August 2002 and we have implemented the recommendations provided.
• We did not receive any patient views/concerns/compliments on the handling and use of their personal information.
• None of our privacy/confidentiality rules/guidelines hindered our health care providers (all staff) to provide patient service.
• Patient privacy was not raised as an issue in any way during the trial.
• Paper consent forms are used for obtaining and managing patient consent.
• To our knowledge, there were no instances where patients refused consent.
• We will be conducting regular Privacy Impact Assessments (PIA).
• We have participated in discussions with representatives of provincial health infostructure networks on privacy and protection of personal health information.
• This project has influenced privacy policy and process development within Interior Health and the Privacy review by Health Canada has been passed on to Interior Health's Security Manager to incorporate the recommendations into new policies.

5.0 The Future

Sustainability

Current Situation:

Currently the following Tele - Imaging PACS (Picture Achieving and Communications Systems) for Diagnostic Imaging exist in In6terior Health.

In the TCS HSA: A fully integrated Fuji Synapse PACS and Meditech RIS (Radiology Information System) system is currently been implemented to cover the following centres:

• Royal Inland Hospital (RIH), Kamloops
• North Shore Radiology, Kamloops
• Chase Health Centre, Chase
• Dr. Helmcken Memorial Hospital, Clearwater
• Barriere Health Centre, Barriere (Future - needs CR)
• Nicola Valley General Hospital, Merritt
• Ashcroft & District General Hospital, Ashcroft (Future - needs CR)
• Lillooet & District Hospital, Lillooet
• 100 Mile House District General Hospital, 100 Mile House
• Cariboo Memorial Hospital, Williams Lake
• And is linked to the Yukon (Whitehorse General Hospital

This system will cover all modalities except Mammography. Total cost is $5.7M

In the OK HSA: A GE mini PACS is operational at Vernon. This only is connected to the multi - slice CT scanner at Royal Jubilee Hospital and is not integrated with the Meditech RIS system.

In the KB HSA: Nakusp hospital has a digital CR unit and the X - Ray images from this are currently being viewed and reported on from an AGFA PACS system at St. Joseph Hospital in Vancouver.

In addition, a mini - MAC PACS system is currently in use for ultra sound images from Nelson, Trail, Boundary and Creston Hospitals. This system is in poor shape and should be replaced as soon as possible.

In the EK HSA: Creston ultra sound is connected to the Kootenay Boundary

"MAC" PACS system.

Suggested Recommendations for the Future:

Mini - PACS systems tend to only address a small section of the modalities and the total number of X - Ray film produced. They are not integrated with Meditech and thus tend to become "throw - away" PACS. They also do not address the need for Tele-imaging.

A fully integrated PACS/RIS system and Tele-imaging system is said to pay for itself over a period of 5 to 10 years and has been proven to be equal or more sustainable than current systems.

We do not believe, that PACS and Tele - imaging should be implemented for "cost savings", but rather because X - Ray film is fast becoming a medium of the past. It has been around for over a century (since 1895) and Diagnostic Imaging is now moving very quickly to a digital medium, with all the related benefits and the huge benefits that are acquired in using it in a Tele - imaging mode.

The obvious problem is the cost of extending our integrated PACS/RIS system to the rest of Interior Health. It is important to understand that our PACS/RIS system is scaleable. This means that we can incrementally build upon the core system when funding is available and priorities are high. The following are priority principles of how this should be approached:

1. Failing Systems
2. Highest Volume Film Producers
3. Access of Rural sites to Radiologist Services

Based on these principles, the recommended approach is as follows:

1. We should firstly address the failing MAC PACS system in Kootenay Boundary HAS, which services their ultra sound modalities.
2. We should then address those centres where the most X - Ray film is being produced. Theses would be the centres with multi - scan CT's and MRI's. KGH, VJH, PRH and EKRH..
3. It is important that in conjunction with the above - suggested implementations, that each HSA identifies remote Centres that should be linked to PACS via Tele - imaging. This will improve the response time of Radiology reports to Doctors and patients in remote locations. To reduce costs at smaller centres, scanners can be implemented to send the X - Ray images digitally to the reporting PACS centre.

Budgets:

We have estimated, using the same technology as implemented in the TCS HSA, the estimated cost will be ~$12.6million.

Sustainability Plan

See Appendix "C"

6.0 Communications

Clearly, communications is important in generating support for projects -- support in the community and among other interested groups. What methods or tools did you use to communicate with your external stakeholders?

Methods or Tools	Date	Target Audience	Documents or Presentations Produced
Conferences	September, October and November 2002	Doctors	PowerPoint slide shows and lectures explaining tele-imaging and PACS.
Media Events	December, January 2002	General Public	Radio & TV interviews were given to explain the new systems.
Publications	March 2002 to January 2003	Staff and the General Public	Articles in local newspapers, publications from the hospital foundation and from IT (See Appendix "d")
Open House	December 2002	Government & Press	"Official" Opening of the system by the Premier of BC
Marketing/ Advertisement	Nil
Website (please provide the Web site address)	Was on the Thompson Health Region Website, but this has been succeeded by the new Interior Health Web Site and is no longer mentioned.