NORrad

Health and the Information Highway Division, Health Canada
November 24, 2003

Table of Contents

• 1.0 Introduction
• 2.0 Project Description
• 3.0 Achievements
  • 3.1 Goals Reached
  • 3.2 Additional Successes
  • 3.3 Unreached Goals
  • 3.4 Documents or Product Generated
• 4.0 Main Impact
  • 4.1 Human Resources Impact
  • 4.2 Privacy and Protection of Information
• 5.0 The Future
• 6.0 Communications
  • Awards & Project Profile

1.0 Introduction

NORrad is a $10 million project to re-engineer the delivery of diagnostic imaging services in the most northerly communities in Eastern Ontario by means of implementing digital radiology technology and high-speed networks to move diagnostic images and interpretations between community and regional hospitals. Employing proven information and communications technology as an enabling factor, the NORrad vision will support physicians and other health care professionals in providing new and improved health care services for residents of the area.

2.0 Project Description

The project is also unique in its complexity - bringing together representatives of nine independent health care organizations in and around the Cochrane District and James Bay health districts. This collaboration, known as the Northeastern Health Services Alliance came together for the first time under a common set of goals and objectives for improving health care services and delivery for the 100,000 people living across 150,000 square miles in the most northern communities of Ontario.

The NORrad Project is both a Picture Archiving and Communication System (PACS) and teleradiology initiative. PACS is a high-speed, graphical, computer network system for storage, retrieval, and display of radiographic images. With the addition of teleradiology infrastructure, PACS can be implemented over distant networks to provide remote access to patient images and medical report information. The NORrad Project therefore includes the following elements:

• Ability to convert to or acquire diagnostic images in a digital format and to store these images electronically on a server for future retrieval;
• Ability to view images on a computer monitor within the health care facility or remotely from home or office via the Internet; and
• Ability to transmit images within a hospital/clinic site or to other NORrad hospital sites for access for eventual access by multiple authorized users.

3.0 Achievements

3.1 Goals Reached

Post-Implementation Evaluation Observations

General Impressions of the Technology

• Virtually all staff and medical personnel love this technology and have fully adopted its use
• For the most part, technology has performed well at all sites (notable exception is Cochrane)
• Several physicians suggested that the image quality is better than conventional film
• Physicians love that ability to adjust the image contrast and brightness as required
• Ready access to previous images helps inform a better, more comprehensive report - as well as helping to avoid delays in diagnosis and treatment due to lost or misplaced films

Radiology Report Turnaround

• Dramatic improvement in report turnaround - kudos to the radiology staff at Timmins!
  
  • Under traditional film environment, turnaround was 3-5 days on average
  • Under PACS, regularly have overnight service and often same day service
• Managers are not clear on what process to use when incorrect reports are filed. How to best to resolve this type of problem quickly is of high priority and will be a lesson learned for this PACS implementation. Delays in accurate reporting can impact on appropriate patient care.

Support from AGFA and Timmins technical staff

• Excellent technical support
• Guy Guindon is particularly good and timely in responding to problems at all sites
• Problems with Solo machine in Cochrane. PACS technicians have tried to fix this problem on several occasions; however, manager feels machine should be replaced due to its poor reliability. Machine has been functioning properly over the last few weeks, however.

Productivity, Efficiency and the Working Environment

• At "filmless sites" staff love the cleaner working environment - to chemical orders
• One staff noted that he does not leave work with a headache anymore
• Staff have mixed opinions about whether PACS promotes greater productivity when doing x-rays
  
  • There are several steps in the process at the front end which tends to slow the imaging process
  • Several staff feel that eventually (within 2-3 months) workflows change to help speed the process overall.
  • Sites with a solo machine have particular trouble keeping up with the speed of images during some DI exams (i.e. GI procedures)
• PACS is excellent for eliminating unproductive hours spent locating lost or misplaced films - allows staff to spend more time doing the job for which they were trained!

Patient care and convenience

• Improved report turnaround can speed patient diagnosis and treatment
• Technology has virtually eliminated repeat exposures because of poor image quality
• Patients from small sites now don't have to make a special trip to the hospital to pick up films before seeing a specialist in Timmins. Similarly, patients don't have to make a trip into Timmins to pick up films before going to the Cancer Centre in Sudbury - very convenient and well received by patients
• Ready access to a radiologist can prevent patient admissions or even transfers because of diagnostic uncertainty - particularly great for patients in the North
• Technology will help to ensure that a patient is sent to an appropriate level of care the first time - rather than being sent between hospitals

Recruitment of Radiologist, Physicians and Technicians

• Mixed feelings about ability of PACS to be a recruitment tool
  
  • Staff at one small site that makes use of locum DI technicians think PACS will be an excellent recruiting tool - Weeneebayko General Hospital in Moose Factory
  • Many feel hospitals and communities need more than PACS to attract clinicians. PACS is now "expected" by younger clinicians - thus, PACS becomes part of an overall package offered by a community
  • Kirkland Lake radiologist feels this will be an excellent tool for attracting radiologists to the area

Cost Savings

• Too early for many sites to judge extent of cost savings attributable to PACS
• Impressions are that the PACS system his helping to save considerable funds film, chemistry and supplies, and transportation of patients from the North
  
  • Moose Factory noted that eliminating one transfer to Timmins or anther southern location saves approximately $4,000-$5,000
  • Managers in facilities that are "filmless" and who have been operational for several months have noted a dramatic savings in film costs (i.e. from $50,000 to $5,000)
• Managers are unsure, however, if cost savings will be off-set by new costs (i.e. service contacts, PACS administrator costs, etc)
• PACS will likely not save funds via staff reductions - staff functions are being reallocated from conventional duties to new PACS related duties (i.e. scanning and eventually CD burning)

Privacy and Confidentiality

• Mixed feelings about the extent of privacy and security of patient information under PACS
  
  • More secure - fact that access is controlled via passwords and usernames
  • More secure - ability to audit who is accessing system images
  • Less secure - small sites have tendency to share passwords to make workflow more efficient
  • Less secure - some sites have trained nursing staff - allowing more staff to have potential access to images
• In the end, security of patient information will always rely greatly on the integrity of staff in the facility - this is the same under a conventional film or PACS environment

Lessons Learned

• Training
  
  • Need to book down services as much as possible - perhaps close elective service during times of training
  • Should book follow-up training at about 3-4 weeks post-implementation - once staff understand what it is they don't know!
  • Must ensure that all wiring in the building and interfaces between the PACS and HIS/RIS are working properly prior to having training - will impact success of training dramatically if this is not assured
  • Should plan for regular PACS "continuing education" for staff
  • Must be cognizant of physician schedules before booking training - need doctors involved in training
• Documentation and Reporting
  
  • Should provide "user-friendly" documentation about how to resolve problems with PACS
  • Should provide basic information about PACS to give to students in a teaching facility
  • Should have process to regularly ensure that all images have been reported - if not, images must be resubmitted
  • Must develop a process for rectifying radiology reports which are dictated with errors. This is a rare occasion, however, must have a way to correct this error quickly and have an accurate report in the patient record.
  • Should plan for how best to purge old film following implementation of PACS - what are the legal issues since conventional film jacket does not indicate when last x-ray has occurred if hospital is now using PACS. Law states that staff must keep a file active for 5 years following an admission or diagnostic imaging exam.
• Technical Support and Other Issues
  
  • Need a technical support person like Guy who is responsive and good natured when called
  • Comprehensive pre-planning for equipment placement is critical to ensuring improved workflow efficiencies after the PACS installation. For example, in early stages of PACS implementation monitor should be near a conventional view box so that viewing and comparing previous film images to PACS can be done in the same location
  • DI Manager (or person most responsible for PACS) must have a well trained "back-up" with administrative access to the system to ensure proper department coverage in cases of DI Manager sickness or vacation
• Releasing Images to Timmins
  
  • Should always ensure that a quality check on the images is completed prior to release to ensure images are properly oriented
  • Where they can agree, radiologists should let all sites know of their references to ensure images are released properly
  • Have discovered that the images related to IVP exams need to be released "last to first" to ensure proper sequencing for the radiologist at the consulting site
• Managing Physician Expectations
  
  • Referring physicians sometimes have the impression that they will have instant access to a radiologist at all hours under a new PACS system. Such expectations must be managed from the outset to ensure healthy, long-term working relationships between referring and consulting physicians.
• Visits to Other Pacs Sites Prior to Implementation
  
  • Highly recommend organizing site visits to other PACS sites prior to implementation
  • Staff who have had the benefit of a visit to an existing PACS site return with a sense of what the equipment looks like, how it functions, best location for equipment placement, etc.

3.2 Additional Successes

Consultation Turnaround and Patient Transfers

Ideally, patients requiring health care should be receiving the most appropriate treatment in the most appropriate setting at the most appropriate time and by the most appropriate provider. Unfortunately, technology limitations, human resource shortages and geographic distance have often worked to prevent some aspects of this desired outcome.

Pre-Implementation Findings

Many rural hospitals have a long-standing practice of physically sending conventional xray films of non-emergency cases to nearby larger facilities for consultation by specialists. Depending on the case in question, delays of several hours, several days, or as much as a week or more are commonplace and considered a fact of current medical practice. One should note, however, these consultation delays occur mainly in non-emergency cases and, as such, generally do not impact greatly on health outcomes of patients. Nevertheless, these delays represent system inefficiencies, additional document transportation costs, and added time for diagnosis and treatment decisions - not to mention inconvenience for the patient. In emergency situations, physicians commonly send the patient and the x-ray films to the referral center. In these cases, treatment delays are unavoidable and health outcomes are more influenced by the mode of transportation chosen.

Post-Implementation Findings

Evaluation stakeholders across the NORrad region are reporting improved speed in report turnaround. Under a traditional film environment, turnaround was three to five days on average. Under PACS, turnaround has regularly become an overnight or often a same day service. Staff and physicians at Weeneebayko General Hospital in Moose Factory have noted a number of avoided patient transfers to Timmins and other referral sites since the installation of PACS. The Diagnostic Imaging Manager estimates that a single avoided transfer can save approximately $4,000-$5,000 in transportation costs.

Occurrence of Lost or Misplaced Films

Research studies in larger hospital imaging departments suggest that the rate of lost or misplaced radiology films usually varies between eight and 15 percent (Siegel & Reiner, 2002, Marchant, 1999, Anderson & Flynn, 1997) translating into hundreds of films being unaccounted for at any one time and going unreported by a radiologists. In many cases, films are recovered only after a replacement image was ordered, necessitating inconvenience for the patient and a delay in treatment. Not surprisingly, some films are never recovered, serving instead as a potential risk to the sanctity of patient identity and medical information.

Pre-Implementation Findings

To varying degrees of severity, all sites are experiencing regular delays in locating films from prior patient encounters due to mislabeling or misfiling within film libraries. In fact, some facilities have instituted processes to manually check each film envelope when it is returned from a consulting site to guard against misfiling. These search and refiling activities, although necessary, represent unproductive staff time and serve to highlight system inefficiencies that can delay diagnosis and treatment.

Additionally, in some cases, films are never located - often because they have been shipped to other treatment facilities and not returned or have been taken off-site by authorized persons (physicians, patients).

Post-Implementation Findings

Clinicians and radiology staff have little to no problems finding and retrieving images from the PACS technology. The benefits of redirecting staff time away from "chasing film" to more productive efforts are already evident in more comprehensive reporting and improved turnaround times by radiology staff. Benefits should improve over time as more and more conventional films are purged from hospital and clinic file rooms in favour of electronically stored digital images with little to no occurrence of loss or misfiling.

Films in Constant Transit

Proper diagnosis and treatment of patient conditions and injuries is often dependent on ready access to the radiographic image when required. In a conventional film environment, access to the film at particular times is hampered when the image is in transport to or from a distance referral centre.

Pre-Implementation Findings

Rural hospitals under the NORrad project are currently required to physically send away conventional films, via taxi, courier or bus, for consultation by specialists at the Timmins and District Hospital. In fact, in most cases, films are picked up and delivered twice weekly. This constant transport of film, although ensuring a relatively quick turn around for reporting, has had a detrimental impact on the availability of films when requested for viewing by local physicians and other health care providers. Survey participants suggest that an inability to access films is the greatest challenge they face. This problem has often delayed diagnosis and treatment and may be a contributor to increased hospital length of stay.

Post-Implementation Findings

This problem has been eliminated with implementation of PACS. Currently, physicians are able to access images in support of diagnosis and treatment decisions. Although average length of stay in a health facility can be influenced by a myriad of factors, several stakeholders feel that PACS technology will play a key role in promoting reduced hospital stays. Empirical data is not yet available to substantiate this belief.

Producing, Reading and Reporting Images

The speed at which a technologist can produce conventional x-ray films and complete procedures with a patient relies on a number of factors including ready access to a functioning and reliable film processor. Subsequently, the reading and reporting of films by a radiologist is also influenced by a number of factors including, ready access to previous images, the amount of clerical time spent in physically handling films, and the workload currently being experienced by transcribing staff.

Pre-Implementation Findings

Diagnostic imaging technologists expect a marked improvement in throughput. An ability to avoid x-ray development or printing, labelling and filing is expected to save time and avoid delays. Additionally, the need for re-takes - cases where the conventional film image is distorted and unreadable - is expected to be virtually eliminated as electronic images can be manipulated for brightness and contrast; thereby, compensating for initial poor quality.

Some radiologists expect the electronic storage and retrieval of images may speed the reading and reporting of x-rays by as much as 25 percent. The improvement in throughput is caused by an avoidance of "clerical" duties in locating, reading and refilling plastic images.

Although not expected to be a significant issue for the radiologists in Timmins, who make use of a multi-loader device and have staff available to assist with film manipulation, the radiologist in Kirkland Lake does expect to see some increased throughput as a result of the PACS technology. He currently manipulates all films personally and does not have access to a multi-loader.

Post-Implementation Findings

Overall, radiologists and family physicians are reporting significant improvements in report turnaround. In non-emergency cases, turnaround is said to have dropped from several days on average to an overnight or often same day service in many cases. PACS has eliminated the need for immediate patient transport to an urban center in urgent cases. Now radiologists and other specialists can be contacted and consulted within 30 minutes, thereby allowing for more informed treatment decisions, potentially less inconvenience for the patient, and better health outcomes.

Image Manipulation and Ready Access

Ready access to digital radiography images at all hours and an ability to manipulate these images to improve diagnostic findings form the hallmark of a PACS system. Unquestionably, such capabilities must function efficiently and reliability for a PACS system to be widely accepted and adopted by family practitioners, radiologists and other medical specialists.

Pre-Implementation Findings

Image Manipulation - The ability to manipulate images to varying degrees is expected by stakeholders to improve diagnostic accuracy and precision and to help avoid retakes because of poor image quality.

Access to Prior Images - Electronic storage of images will virtually eliminate the costly and time-consuming problem of misplaced, misfiled or lost films. Barring technical problems, physicians will have ready access to prior patient images at any time of the day or night, thereby, reducing the waiting time required for diagnosis and treatment and improving patient outcomes. This will be particularly useful to emergency room physicians who must staff the department during periods when film library staff are unavailable.

Multiple Provider Access to a Single Image - NORrad technology will allow two or more authorized providers to view the same image at the same time. This is not possible with conventional film. Multiple consultations in this way are expected to improve diagnostic accuracy and lead to improved diagnostic knowledge for the referring practitioner.

Access to Images Stored Off-Site - Electronic storage of images will virtually eliminate the costly and time-consuming problem of acquiring films held off site. Additionally, with access to the long-term image archive, authorized physicians will have immediate access to patient images and information completed at other sites, thereby, potentially speeding diagnosis and treatment and improving outcomes in situations where comparison with previous images is desired.

Access to Images From Home or Office - Authorized physicians will access patient images from a home or office personal computer via a web-server. Such technology has a potential for positively influencing patient care and improving quality of life issues for providers. Viewing an image from home and telephoning a report to the attending physician may speed diagnosis and treatment for patients who present at the facility during off-hours. Additionally, viewing images from the office will help physicians avoid delays in diagnosis or treatment in cases where previous or current conventional films are not immediately available for viewing.

Post-Implementation Findings

All stakeholder expectations for PACS in the areas noted above are being realized. Family physicians and specialists praise the ability of PACS to provide ready access to current and previous images and to allow adjusting of image quality as needed to better diagnose and prescribe treatment. Subsequently, technologists are reporting a near elimination of retakes due to poor image quality.

Radiologists are identifying web-based access to images while outside of the hospital radiology department as a particular benefit and one which is key to the successful deployment and adoption of NORrad technology. Recent research by Swaton (2002) supports this finding. Radiologists who now have the option of reading and reporting studies from home express a feeling of improved quality of life - provided they are not overburdened with after-hours requests for consultations.

Receiving similar benefits are patients who no longer have to arrange special trips into the hospital to pick up films prior to medical appointments as outside clinics or in another town where the physician has local area network or web-enabled access to the required PACS images. In such cases, PACS technology could conceivably eliminate treatment delays in the occasional circumstance where images were not transported in timely fashion from the hospital to the site of the medical appointment or where patients themselves simply forgot to pick up the x-rays prior to the appointment.

Reduced Requirement for Film Storage Space

Facilities are required by law to store films images of adult patients for a period of some years. For children, this period is extended to the age of majority and beyond. To accommodate this requirement, several sites have large rooms dedicated to film storage. These areas need to be maintained and constitute largely unproductive space. In some cases, larger facilities also have additional off-site storage locations.

Pre-Implementation Findings

To varying degrees, most evaluation sites are dealing with the issue of storing conventional radiology films. Some smaller sites are enduring restricted working spaces because of the need to store film in hallways and offices. To complicate matters, these same facilities may also be dealing with the challenge of managing current space requirements for modern, non-PACS, imaging equipment including processors and consoles.

The ability to store images electronically is expected to eventually have a tremendous impact on many facilities. As the storage time imposed by legislative requirements elapses, many conventional films will be purged from existing film libraries, thereby, freeing up substantial space for reallocation to more productive uses.

3.3 Unreached Goals

In contrast to the radiologists, some diagnostic imaging technologists report few productivity benefits from the PACS installation. These findings are contrary to current research on PACS and may be influenced by the following factors:

• Most NORrad sites have not completed a detailed analysis of imaging department workflow to assess where efficiencies may be obtained through the use of PACS technology; and,
• NORrad sites with a single cassette CR reader have difficulty keeping pace with the speed of image generation during some imaging procedures, thereby, slowing productivity.
• Stakeholders had mixed opinions regarding the potential of NORrad technology to solicit overall cost savings for the health system. Significant savings are currently being witnessed from reductions in the use of conventional film, chemistry and supplies. However, any cost savings realized must be weighed against the added costs of technology support, including PACS administration and service contract maintenance. Such added costs have not been fully calculated to date.
• Stakeholder opinions of vendor sponsored training were mixed. Several thought the quality and duration of training was good to excellent. At a couple of sites, however, training was disrupted by technical problems with the interfaces between PACS and other hospital systems. Another site experienced a shortened training schedule because of statutory holidays; these lost training days were not recovered. Virtually all stakeholders agreed that a brief follow-up training session for should be implemented after about four weeks of operational experience.

3.4 Documents or Products Generated

A large number of documents were created and are appended to the NORrad Final Report. These documents include policies that must be used in a digital radiology environment such as:

• Release of diagnostic films and reports
• PACS printing policy
• Release of Information to Physicians/Institutions Outside NORrad
• Release of Information to Lawyers/Insurance companies/Coroner
• Release of Information to Patients
• Duplication of films
• Records Retention and Destruction
• Securing Images for Legal Cases
• CD Disposal
• Verbal Reports
• Emergency Reports
• Reports and Returned Reports
• Delinquent Reports
• PACS Access Password Policy
• Request for PACS Access Form
• Daily Back-ups
• Monthly Reports on Servers
• Transmission of Examinations
• Request for Previous Examinations
• Scanned Requisitions
• Request for PACS Exam Fix
• Downtime
• PACS After Hours Service
• Patient Confidentiality
• Privacy Program
• Disaster Recovery Plan
• Computed Radiology (CR) Workflow Analysis
• Ultrasound Workflow Analysis
• Nuclear Medicine Workflow Analysis
• Computed Tomography Workflow Analysis
• Magnetic Resonance Imaging Workflow Analysis

* See Appendix 1 for a review of the aforementioned documents.

4.0 Main Impact

Implementation of the NORrad Project is considered by evaluators to be very successful and a potential catalyst for shepherding a new era of actively adopting information and communications technologies to improve health outcomes. Evaluation stakeholders should be recognized and applauded for their vision and foresight in advancing this project under the CHIPP fund.

Diagnostic imaging technology across Northeastern Ontario is clearly on the cusp of a revolution. The production, storage and transmission of electronic x-ray images will open new possibilities for more efficient and effective patient care. Positive experiences to date show the following:

• An ability to manipulate the PACS image has virtually eliminated the need for retakes due to poor image quality, thereby, reducing the need for repeated patient exposure to radiation;
• Patients no longer have to make special trips into the hospital to pick up conventional x-rays when going to see a clinician who has access to the PACS server;
• Viewing electronic images will eliminate clerical duties associated with the use of conventional film, thereby, increasing the rate at which radiologists can read and report patient x-rays;
• Ready access to previous patient images is expected to eliminate the current problem of misplaced, misfiles, or lost films, thereby reducing existing wait times for diagnostic and treatment services in many instances. This is particularly beneficial for managing cancer conditions where previous films (images) are used as a reference;
• Lengthy patient transfers for treatment at consulting sites may be avoided after specialists view electronic images of the injury;
• Electronic storage capabilities will eventually free-up currently unproductive physical space within many health care facilities; and
• PACS provides opportunities for significant cost savings in film, chemistry, and related supplies. Additional costs for service contract fees, a PACS Administrator salary, transmission costs, etc., may mostly offset these savings, however, these data were not available at the time of this report.

Overall, staff and physicians are excited and enthusiastic about the technology and clearly recognize its potential for improving health services delivery and patient outcomes in the immediate and long-term. Concerns expressed to date with the technology and training issues appear to be resolvable with time and additional resources and as such do not pose a serious threat to the viability of the technology.

4.1 Human Resources Impact

Recruitment and Retention of Medical Personnel

Recruiting and retaining physicians in communities across Northeastern Ontario has been a source of long-standing activity and concern for medical recruiters, health care administrators, community members and local governments. As part of the interview process during pre- and post-implementation evaluation activities, referring and consulting physicians were asked their opinions as to whether the NORrad technology would help attract and maintain physician resources in their respective communities.

Pre-Implementation Findings

For the most part, PACS technology is expected to have a positive influence on physician recruitment and retention in the NORrad evaluation sites. An ability to complete some work at home will improve quality of life issues for the radiologists in Timmins and Kirkland Lake and may serve to attract additional specialists to these areas. Additionally, improved access to specialists in larger areas, via the PACS technology, may encourage general practitioners to come to and remain in more rural areas of the NORrad region.

Post-Implementation Findings

Evaluation participants have mixed opinions about the ability of PACS to attract and keep medical personnel. On one hand, staff at a small NORrad site that makes regular use of locum diagnostic imaging technologists believe PACS will be an excellent recruiting tool for new staff. Similarly, the radiologist in Kirkland Lake feels the technology will be an excellent tool for attracting new radiologists to the area. In contrast, other family physicians and specialists feel that hospitals and communities in the Cochrane and James Bay Health Districts need more than PACS to attract and keep clinicians. Access to continuing medical education, financial incentives, spousal considerations and locum relief are a few factors that are likely to have a greater influence on attracting and keeping physicians in rural areas.

Literature on this topic is also mixed at this point. Several research studies have noted the potential for workload redistribution and rebalancing among radiologists as a key driver behind in some PACS installations (Keen, n.d.; Ratib et al, 2000). Access to images and reports, via a web-server, from locations outside of the radiology department; namely, in a office or home setting may dramatically impact the quality of life for specialists who traditionally travel some distance into their respective hospitals to provide required consultations at all hours of the day and in varying weather conditions.

Ultimately, evaluation participants agree that PACS technology is quickly becoming viewed by most medical school graduates as a standard clinical apparatus supporting efficient and accurate diagnosis and treatment. Hospitals and clinic sites without PACS technology will likely loose favour with this graduates and consequently remain in a cycle of chronic shortage. This belief is supported by Kainberger and Huber (2002) who suggest that the digital exchange of information will soon become a ubiquitous standard, and hospitals without digital imaging capabilities will likely lose credibility with clinical and technical personnel.

4.2 Privacy and Protection of Information

Health care managers and clinicians have long recognized that placing patient information on computer databases creates potential difficulties in protecting the security of private medical records and information. In a PACS environment servicing multiple users in locations both within and outside of a given institution, server systems must detect if requests coming from persons or client stations have authorization to receive the requested data, information or service. Given these complex system interactions, stakeholder confidence in the security and privacy of patient information is a key variable under consideration in this evaluation.

Pre-Implementation Findings

Evaluation participants generally had mixed opinions regarding the ability of PACS technology to ensure the privacy and security of patient information. Many noted that traditional film images are very often readily available from the film library. Physicians generally have open access to retrieve images from the library during off hours. As a result, conventional films are sometimes left in unsecured locations.

Conversely, electronically stored images will be held in one location and will only be accessible through user identifications and passwords. The technology, however, does allow for multiple points of access. Additionally, many interviewees suggested usernames and password may eventually be shared through a facility where staff work in a trusting environment. Such practices would open the door for potentially unauthorized access to images and reports. Electronic storage devices are also expected to monitor and track access to files by all system users - leaving electronic markers when images are accessed. Some interviewees acknowledge this security feature but argue that additional resources will be needed to regularly monitor who is access the PACS images.

Post-Implementation Findings

Evaluation stakeholders continue to have mixed feelings about the extent of privacy and security of patient information under PACS. Arguments can be made across many dimensions as follows:

• More secure - fact that access is controlled via passwords and usernames;
• More secure - ability to audit who is accessing system images;
• Less secure - sites have a tendency to share passwords to make workflow more efficient; and,
• Less secure - some sites have trained nursing staff - allowing more staff to have potential access to images.

Additionally, the benefits of having nursing staff trained in the operation of PACS technology is a matter of particular debate among several evaluation stakeholders.

Some suggest that the availability of trained nursing staff is essential in the off-hours to facilitate smoother imaging department operations - particularly when locum physicians are on duty and may not be familiar with the technology. Others suggest that training nursing staff is unnecessary and poses a security risk by increasing the number of persons with potential access to patient information via the PACS system. No consistent approach to this issue is evident.

The PACS Administrator is currently working with Diagnostic Imaging Managers from all NORrad sites to create or update privacy and security policies for the region. This work is necessary to ensure consistent approaches to these issues at all sights.

In the end, security of patient information will always rely greatly on the integrity of staff in the facility - this is the same under a conventional film or PACS environment.

* See Appendix 2 for NORrad privacy documents and policies.

5.0 The Future

NORrad is a fully functioning program in all of the nine hospitals in and adjoining the Cochrane District. The project is fully functioning without any major hitch for several months. The conversion from x-ray film to digital imaging has occurred in all areas planned in the conversion.

NORrad personnel have been active in providing support, advice and information to other northern hospitals and radiologists. To date, Kenora and Sudbury have adopted a strategy employing the same technology, albeit it on different scales.

In July 2003, NORrad lead a consortium of other northern Ontario hospitals to develop a submission to seek Ministry of Health support to approve Medical Equipment Funding 2 (MEF2) over the next three years to allow the expansion of the NORrad PACS program beyond Timmins and Cochrane District. The expansion proposal included hospitals in Network 6 (North Bay and area hospitals), Network 9 (Sault Ste. Marie and Algoma West hospitals), and Network 11 (Sudbury and area hospitals), and at key health care resources including the North Eastern Ontario Regional Cancer Centre and the new Northern Ontario Medical School. In addition, there would be regional infrastructure to support communication between each of the Network's and the regional hospital in Sudbury.

A key feature of the expansion would be the creation of a regional Master Patient Index for the purpose of developing an Electronic Health Record (EHR). Some important building block infrastructure for an Electronic Health Record is already in place with the existence of NORrad, NEON, and other regional collaborations for laboratory and other clinical services. The proposed expansion of NORrad would be the basis for not only creating a regional PACS capability but also developing the necessary infrastructure and network cooperation for an Electronic Health Record system.

Attached you will find a copy of the NORrad MEF2 NORrad Phase 2 Proposal. Implementation is beginning at the Sudbury Regional Hospital with the inclusion of a major investment in PACS using the same general technology solution.

Discussions have been initiated with the Regional Cancer Centre in Sudbury and the Department of Radiology at Sick Childrens' Hospital in Toronto in an effort to create a digital link between the NORrad hub site (Timmins) and these two important referral centres for northern Ontario patients. It is expected that there will be live connections which will provide sub-specialized care and decrease the amount of patient traveling year round.

6.0 Communications

Methods or Tools	Date	Targeted Audience	Documents or Presentations Produced	Appendix Name/Number
Conference
eHealth Conference	05/25/03	Hospital, government, consultants, healthcare workers	PowerPoint Presentation Dr. C. Vézina Mr. R. Foley	Digital Imaging in Northeastern Ontario
Medical Imaging Clinics of Ontario PACS Seminar	09/21/03	Radiologists and technologists	Two PowerPoint Presentations Dr. C.Vézina Guy Guindon	Removing Geography from the Quality of Care Equation What Everyone Needs to Know About PACS
Ontario Hospital Association Annual General Meeting	04/11/03	Hospital Ceos, senior management, technical staff	Mr. R. Foley	Modernized Service Delivery: The Northern Ontario PACS Experience

* See Appendix 3 for copies of the PowerPoint presentations

Awards & Project Profile

The NORrad PACS Project was awarded the DIAMOND AWARD in the category of "Working Together," which the highest possible award at the Showcase Ontario Ceremony, which awards E-Government projects in Ontario.

The NORrad PACS Project was awarded the Bronze Medal in the category of"Innovative Cross-Jurisdictional E-Government Projects" at the GTEC Ceremony, which awards E-Government projects in Canada.

NORrad made a presentation at the 2003 Ontario Hospital Association's Annual General Meeting in Toronto. The presentation provided a review of the NORrad technology, the project implementation, and best practices that have resulted in the implementation of a PACS project in an underserviced area.

A visit is currently being organized in conjunction with the Ministry of Health and Canada Health Infoway to facilitate a review of the NORrad implementation and technology for the South Western Ontario (SWO) hospital consortium. Approximately thirty SWO hospitals recently received Infoway funding for a major regional PACS project. They are also interested in the multi-governance model developed for the NORrad project.