|From left to right: John Goodwin, MD, medical director, diagnostic imaging, Provincial Health Services Authority; Herman McQuaid, director health informatics, PEI Deptartment of Health and Social Services; Calvin Joudrie, diagnostic imaging technical director, Provincial Health Services Authority; Darlene Gallant, diagnostic imaging information systems manager, PEI Deptartment of Health and Social Services.|
Prince Edward Island is, by far, Canada’s smallest province, but when it comes to deploying a picture archiving and communications system (PACS) province wide, small can be beautiful. Prince Edward Island has a year-round population of about 140,000. In 1908, islander Lucy Maud Montgomery made it famous, even to today’s tourists, as the setting for her novel Anne of Green Gables. Now, at least in the world of health care, Prince Edward Island is getting another chance at fame. It is Canada’s only province with a PACS that displays images from all seven of its hospitals.
The project to bring a PACS to Prince Edward Island that would serve all its hospitals was not easily undertaken, nor was its accomplishment quick. Prince Edward Island is a member of the Atlantic Group of Canadian provinces, which is composed of Prince Edward Island, Nova Scotia, New Brunswick, and Newfoundland. Prince Edward Island participated in a cooperative effort to boost technology called Health Infostructure Atlantic, whose members signed a memorandum of understanding that promoted the implementation of PACS technology in all four Atlantic provinces.
Herman McQuaid, director of health informatics for the Department of Health and Social Services of Prince Edward Island, says, “Advancing PACS was one of our common goals. We had asked for federal funding, and we were successful.”
The Canadian federal government was not willing to pay the entire bill for the Prince Edward Island PACS, however. If it wanted the federal funds, Prince Edward Island would have to obtain matching funds of its own, either from its provincial government, from private sources, or (as turned out to be the case) from both. If the matching funds had not been raised, the federal money would have been spent elsewhere.
A PROVINCE-WIDE PACS
In 1999, McQuaid began to plan the project, which had to be approved by a Prince Edward Island management group, as well as on the Health Infostructure Atlantic and federal levels. Several factors were coming together in the project’s favor at that time. Prince Edward Island was building a new hospital of more than 100 beds in its second largest city, Summerside; this building was to be a replacement for the existing Prince County Hospital. The 274-bed Queen Elizabeth Hospital in the provincial capital of Charlottetown is the island’s main hospital. Rather than install a PACS only at Queen Elizabeth Hospital, planners decided to link it to the new hospital in Summerside, as well.
From there, the scope of the PACS project spread to include the five remaining (and much smaller) hospitals on the island. “We said, Maybe we can put together a province-wide project’,” McQuaid recalls. “The other Atlantic provinces had received some funding, too, but they were not able to complete the agenda.”
Prince Edward Island was successful because it laid out a strategy and pursued it aggressively. It also had the advantage of being small. A provincial PACS for Prince Edward Island could be modest in scope, compared to what other provinces would have needed to install.
Calvin Joudrie, diagnostic imaging technical director for Prince Edward Island’s health services, was on the team that McQuaid assembled to seek provincial and private funding. “We felt that we could not sell PACS just as something for the radiologists,” Joudrie says. “The sale had to be to the referring physicians, so the model that we put forward was that this PACS would dramatically change the way health care services were delivered. If a general practitioner in Souris saw a suspected wrist fracture in the old days, the patient would have been seen in an outpatient emergency department and the radiographs would have been sent by courier to Charlottetown. That report would have been made the next day.” He continues, “We sold the PACS as having a virtual radiologist at every one of these smaller hospitals. With the PACS that we have now, by the time that the clinician calls, the radiologist has looked at the images. It has been a change in the way that we deliver service.”
Planners also expected a PACS to have other beneficial effects. It might help Prince Edward Island retain its radiologists, and it might attract physicians to practice in the island’s rural setting. Prince Edward Island’s population swells to two or three times the normal figure with the arrival of summer tourists, but its winters are long and hard.
John Goodwin, MD, chief radiologist for the provincial health service, says, “The PACS has been a wonderful boon for patients. It is also a recruitment and retention issue. We do need a couple more radiologists. In terms of the image distribution, the rural physicians think it is absolutely wonderful.”
McQuaid and his team had other selling points for the province-wide PACS. By gathering and distributing images for all of the island’s residents, the PACS would fit well in a nationwide effort to build an electronic health record (see “Toward the Electronic Health Record” later in this article) for all Canadians.
By promoting the PACS province-wide as an improvement for health care, McQuaid and his team were able to get funds from all three of their possible sources. According to Joudrie, about 33% of funding was federal, 20% was provincial, and 47% came from private foundations, including foundations at the two major hospitals. The initial cost of the PACS was about Can $4.4 million (US $3.3 million), Joudrie adds.
McQuaid’s first step toward actual installation of the PACS was to get approval for a centralized radiology information system (RIS) that would operate, as the PACS would later, as a provincewide integrated system. The RIS was deployed in February 2002 at a cost of about Can $1.2 million (US $904,000), McQuaid says.
The Agfa IMPAX® was installed in fall 2002. Like the RIS, the PACS was deployed as a province-wide integrated system with a provincial archive located at Queen Elizabeth Hospital in Charlottetown. The installation did involve a few problems. “One of the major issues we faced was the handshake between the RIS and the PACS,” McQuaid says. “Trying to sort out what technology to use, and which web server, was very difficult, and we got different advice from different vendors.”
Eventually, the problems were largely resolved. McQuaid says that users must log in to the RIS and the PACS separately for certain functions; however, information does flow between the two systems. The system is not as seamless as planners would like it to be at this point. Nonetheless, McQuaid says, “Once you log in to both systems, you can move back and forth easily.”
Darlene Gallant is diagnostic imaging information systems manager for Prince Edward Island’s health and social services department. She was part of the PACS planning team that chose the Agfa IMPAX. She says, “Agfa had the functionality that we were looking for, and there were installations with the same RIS that we could reference. Agfa proposed a very good plan, and they had support people close by, in New Brunswick.”
As configured, the IMPAX distributes about 155,000 studies per year across the province, Gallant says. The PACS components at the two major hospitals were installed at the same time in 2002; in 2003, the five small hospitals in Alberton, O’Leary, Tyne Valley, Montague, and Souris were added to the system. All diagnostic imaging, with the exception of mammography, is interpreted using the PACS. General radiography images, rendered digital by using computed radiography units at each of the smaller hospitals, are sent instantly to the PACS.
All images are interpreted at the two major hospitals, with most of them being read at the Charlottetown hub. There are no radiologists at the five smaller hospitals, which have radiology services staffed by technologists. Queen Elizabeth Hospital has CT, MRI, nuclear medicine, general radiography, ultrasound, and mammography available, Gallant says. Prince County Hospital provides CT, ultrasound, general radiography, and mammography. All mammography is still performed using film, but demand is light for film of prior studies in the other modalities now. Gallant says, “We maintain very minimal film libraries. We did not go back and convert old film to digital images.”
Because the higher-tech modalities are only available at the two main hospitals, patients travel frequently between sites.
Clinical workstations are deployed at four of the five small hospitals, Gallant says. Prince County Hospital in Summerside has four clinical workstations and two diagnostic workstations. The hospital also has its own storage area network (SAN) where its images and those of three of the small hospitals are stored and then fed to the central SAN in Charlottetown, which is the main archive for permanent storage.
“The Queen Elizabeth SAN is a 2-terabyte online hard drive,” Gallant says. “We have not filled it yet, but we are getting close and are making plans to upgrade the storage. We are putting some new drives on now to give us another 10 months’ storage. We always wanted a year’s worth online; now, with the cheaper disk space, we are aiming for 2 years’ worth, and will definitely have 18 months’ storage.”
The seven Prince Edward Island hospitals are wired into the system. Separate T1 lines also carry images from the Prince Edward Island network into Nova Scotia and from there to New Brunswick for subspecialty interpretation, Gallant says. Referring clinicians can obtain images over the Internet through a virtual private network, if they have the proper clearance. The emergency departments at the two large hospitals have PACS access, monitors are being deployed in the operating rooms, and access is available on nursing units in all facilities, Gallant says.
Interconnectivity across the province and with the specialty centers in Nova Scotia and New Brunswick “has been a wonderful thing for us,” Goodwin says. Now that the archive has been built up, the need for film of prior studies is minimal. He says, “I was doing CT today; of 23 patients, film had to be pulled for only one. We very seldom have to get hard copy.”
Goodwin says that the five radiologists at Queen Elizabeth Hospital and the two at Prince County all became converts to PACS when they got familiar with it. “It was the people we had to drag in who are the happiest with it now,” he says. “We are probably 25% more efficient, in terms of plain film, so absolutely all of the radiologists are on board. They will gnaw your arm off if you touch their workstations.”
No one is certain whether Prince Edward Island’s provincewide PACS will become a blueprint for other Canadian PACS deployments. “The system is wonderful, from where we sit,” Goodwin says. “If we can get the data together, this might be a model for the national health system.”
Toward the Electronic Health Record
When the four provincial members of Health Infostructure Atlantic signed a memorandum of understanding to pursue picture archiving and communications (PACS) technologies in 2000, they had more in mind than the transmission of radiology images and reports. They saw PACS deployment as part of a larger Health Infostructure Atlantic mandate to integrate health information technology systems in each of the individual provinces (and, eventually, between the provinces), according to Prince Edward Island’s diagnostic imaging information systems manager Darlene Gallant.
In the near term, she reports, Health Infostructure Atlantic is focusing on what is being called Tele-i4, which stands for the interprovincial integration of images and information through telecommunication. What is really being implemented, however, is the groundwork for an electronic health record for all citizens. Herman McQuaid, Prince Edward Island’s health informatics director, says, “All of Canada is looking at how we might move toward an electronic health record. Advancing PACS is one of the goals.”
Prince Edward Island is now in the process of building a common client registry that can be used for patient identification. “Instead of having a hospital identification, we will have a patient identification for everyone who encounters the Prince Edward Island Health System, not just those registered for Medicare,” McQuaid says. “It is population wide.” All Canadians are eligible for health care through the Medicare program.
The goal is to have the common client registry “sit on top of all our systems,” McQuaid says, including the radiology information system (RIS). “You will, at some point, have no need for names and addresses, except in the top registry,” he adds. “Any change in the patient information will take place there.”
McQuaid notes that the client registry is essentially finished and has some systems linked to it, including radiology. “We want to handle the client registry through admissions, but we do not have the technology yet. Pharmacy and laboratory are key components that we are working on,” he says. McQuaid explains that the vital step is building “portal technology that will allow us to access a radiology record and other records on the pharmacy side. We want to make it seamless to access information from other sources. We think we know how to tie the RIS into the system so that the physician could get all this information through a single portal.”
Part of the problem is obtaining the necessary level of funding to finish the job. John Goodwin, MD, Prince Edward Island’s chief radiologist, is optimistic. He says, “It is coming in bits and pieces. You never know what the government is going to fund, but the PACS is part and parcel of a national electronic health record.”
George Wiley is a contributing writer for Decisions in Axis Imaging News.