The nexus between digital imaging systems, telematic services, advanced telecommunications and information technology infrastructure has yielded unbelievably creative solutions to a wide array of healthcare challenges. Support for remote healthcare facilities, night-time coverage for overworked radiology departments and facilitation of diagnostic consultation between referring physicians and subspecialty radiologists in far flung settings describe a few of the activities enabled by teleradiology. Here are the tales of three groups for which teleradiology has spelled success.


Narrowing space and time

Since radiological activities serve as a core element of effective healthcare, the Timmins and District Hospital in Timmins, Ontario, Canada has championed a $10 million regional health teleradiology network. The NORrad (Northern Radiology) network began implementation in 2002 to facilitate patient care throughout Northeastern Ontario. This integrated health care system relies on PACS from AGFA Healthcare configured as a "hub with spokes" design over a Northern Telephone telecommunications network infrastructure. NORrad is designed to serve 100,000 patients throughout a 150,000 square mile area.

Some of the positive outcomes include reductions in expensive ambulance transfers between institutions, an enhanced level of local patient care in smaller facilities, improved physician efficiency and easier access to diagnostic studies and information for those clinicians in remote sites.

Mike Gasparotto, PACS System Administrator for NORrad, explains that the first phase of the project is essentially complete. Functional aspects include sending images from all modalities including MRI, CT, ultrasound, computed radiography and nuclear medicine scans as well as secure patient information across the network to central hubs. This has been implemented to enable images and reports to be sent between referring physicians, radiologists and emergency staff.

The final aspect of this integrated healthcare network is the deployment of a Master Patient Identifier (MPI) solution. This functionality, currently being tested and nearing completion early this month, was accomplished in partnership with NORrad, AGFA and Initiate Systems. It is designed to cross-reference patient demographic information supplied by the HIS/RIS to determine matches. The result is a system that is able to discern that John Smith (in city A) and Jonathan Smith (in city B) are the same person by analyzing their demographical information.

Referral patterns in NE Ontario are such that patients often travel to different hospitals for certain imaging procedures. "With the MPI solution, we are able to have the Agfa IMPAX system automatically retrieve a patient's relevant prior studies regardless of what hospital the procedure was done at," explains Gasparotto.

The first phase of the project includes 10 sites. All images can be stored locally for six months to a year, depending on the workload in that specific facility. On a daily basis, all studies are transmitted to Timmins District Hospital to be read and stored on the primary archive, where it is stored for as long as it is required.

Phase II of the project (which is still ongoing), is the addition of a second hub at Sudbury which currently has four remote sites that are filmless and transmitting to that hub. The two hubs are linked currently with a 50 MB "pipe."

The current network is comprised of 15 hospitals (two hub sites of Timmins and Sudbury) on the network. The next two months will see the addition of six more hospitals to the network. The next six months will see the addition of another seven hospitals including Sault Ste. Marie as a third hub site. In total, 28 hospitals in NE Ontario will be PACS equipped and part of the NORrad network in the next six months.

Gasparotto describes an essential partnership with AGFA which provides service 24/7 to the entire network. Most troubleshooting can be done via remote connection, but AGFA service representatives are also onsite in both Timmins and Sudbury.

Aside from many technical hurdles, one of the more challenging aspects of establishing this network was the drafting and signing of an inter-hospital agreement. Given that each of these facilities operates autonomously, this was a major accomplishment. This agreement created a governance structure which is the foundation of NORrad's success and was by far worth the effort.

The vision and leadership of both Claude Vezina, MD, NORrad medical director, and Guy Guindon, manager of Diagnostic Imaging, Cardio and PACS at TDH were instrumental in the successful implementation of this initiative. NORrad's vision of "Removing Geography from the Quality of Care Equation" has vastly improved the delivery of patient care in the north.

In the future, NORrad is scheduled to expand even further. More detail about their work can be found on their website at www.norrad.ca.


Being doctor-friendly

A system that is easy to use by radiologists and referring physicians is another important aspect of teleradiology success.

Headquartered in Brewster, N.Y., Northeast Radiology is a network of full-service imaging centers in New York and Connecticut that was founded in 1996 by two radiologists. Their practice adopted filmless digital capabilities in 1997, according to one of the original partners, Scott Nadel, MD, who now serves as president of Northeast Radiology.

Originally, Nadel read all of the "body" studies while his partner, a neuroradiologist, interpreted the neuro scans. As their practice grew and they added more radiologists, they were able to provide increasing specialization to the group. With a current network of six imaging centers including two hospitals, they are able to provide a full range of radiologic studies read by their 14 board-certified radiologists. Additionally, they have established a relationship with Babies and Children's Hospital of Columbia Presbyterian Medical Center, where they can send pediatric studies for the sub-specialists there to review.

Nadel explains that they maintain consistency in imaging study protocols no matter the setting where the scan is obtained. For example, they may accomplish a neurologic exam at any of the offices, but only their senior American Society of Neuroradiology physician will read it. Since they have two neuroradiologists, those physicians can consult with one another via phone while reading the same study simultaneously in different locations.
Besides their point-to-point connections between some of their centers, Northeast Radiology has employed a private "cloud" network to which all of the centers are connected. PageNet, a communications service provider, supplies their cloud network which is similar to a virtual private network (VPN).

The image distribution functionality is provided by the CoActiv Exam-PACS that is scalable from a single site to enterprise installations. This system includes an archiving module, CD burning module, and Exam-Sender.

"We have all of the offices connected to the cloud which allows each office to 'talk' to one another," explains Nadel. "As soon as an image is produced by the scanner, it goes to our local server and archive and is sent directly to the long-term archive." If a referring physician elects to have Exam-Sender functionality, CoActiv installs software on his or her computer that automatically sends images in the background. When that physician opens his or her computer, a small icon announces that a new image is available. Clicking on the icon opens the image immediately.

CoActiv's EXAM-PACS is hardware-independent since it is intended to work on all Windows platforms and could be implemented as a software-only solution. Especially suited for multi-site facilities requiring speed, accuracy and flexibility as they acquire exams in one locale and read them in another, this system functions as the backbone of Northeast Radiology.

The archiving functionality includes on-line storage on the local Exam-Server and then at two separate off-site archive servers each located in separate data centers for redundancy and disaster recovery purposes. The archive servers store exams for an unlimited time on-line utilizing RAID arrays. Each exam is copied to two DVDs stored both at the data center and with the client.

Northern Westchester Hospital serves as one of the centers within Northeast Radiology, and they accomplish 65,000 exams per year. They use the CoActiv network approach for referring physicians and among the radiologists for consultations. Dave Natoli serves as administrative director at Northern Westchester in Mount Kisco, N.Y., and offers an example of how the system works for a CT scan of a patient sent by a referring physician.

When referring physicians are authorized users and have the software installed in their office (or home), the exam is sent to their computer once it is read. When they log onto their computer, the exam appears on their worklist, so they do not have to search for it. It appears seamless and automatic to them, which has been a very popular feature for all of the orthopedic and neurosurgeons who use this system not only for their own review of studies, but to show scans to their patients as well.

"One thing I cannot stress enough is that if you're going to buy a PACS, be aware of the product you are going to give to your referring physicians," urges Natoli. "Instead of some scaled down viewer, we provide a functional viewer at every level. If you're going to burn a CD for the patient or referring physician, it must have the software to run it."

Using this system, the referring physician can do everything the radiologist can do with all of the features of a first-class DICOM viewer. A version of the viewer is installed on every CD that is created by the Exam-Filer. Additionally, Natoli describes the viewer as intuitive and simple to use as well as easy to learn.


All in a night's work

Given the limitations in the number of radiologists currently working in some healthcare settings requires additional help in reading studies produced during the night in emergency situations such as trauma or stroke patients or other studies required for patient management during off hours.

Nighthawk Radiology Services, headquartered in Coeur d'Alene, Idaho offers board certified, licensed and credentialed American radiologists who read from two central reading centers located in Sydney, Australia and Zurich, Switzerland. Those two cities were selected for the centralized reading centers because they are technologically advanced and have robust and redundant fiber networks so their systems are quite reliable.

Chris Huber, Nighthawk's vice president of operations and CFO explains that once credentialing activities are completed, the implementation for a site that plans to use their services includes creating an encrypted link between the facility's radiology network and Nighthawk's receiving DMZ network. Once the private connection is in place and privileges are approved, the Nighthawk implementation team trains the hospital staff on easy to use procedures for ordering an examination and obtaining reports.

When a patient is scanned, the images are transferred to a DICOM gateway at the customer site.

"The images can be compressed using a JPEG lossless format that allows typically a 2:1 compression ratio, that is reversible to prevent degradation to image quality," explains Huber. The images are then auto-forwarded to a facility in Chicago and then to Sydney or Zurich. Intelligent Image Distribution (IID), Nighthawk's proprietary image distribution system, forwards the study to the least busy, privileged and licensed radiologist for that facility and state. This ensures that images are interpreted and results reported as quickly and accurately as possible.

"Early on, for our technology platform, we realized we had to rely on our own devices," says Huber. "We do use some third-party software, but in terms of our own core workflow, we build our own."

Once images have been read, the radiologist dictates into Nighthawk's proprietary Radiology Information System (RIS), AutoRad, that uses third-party voice recognition software (Dragon Naturally Speaking) for auto-transcription. Following both radiologist and quality control review to check for typographical errors, AutoRad has an integrated fax server capability with all of the appropriate fax numbers for hospital ERs, ICUs, physician offices, and such entered into a database and the report is sent.

"The report is also available on our online service where it is archived," explains Huber. "Each person's login is correlated with the hospital where they work." This system provides information about real-time status for the clinician to see where the imaging study is placed in the process.

The Nighthawk service provides a preliminary interpretation, and then studies are re-read by facility radiologists the next day.


Conclusion

Teleradiology has greatly enhanced a number of critical aspects of patient care. Using technology that is designed to distribute images and reports, institutions can upgrade their capabilities to enhance the healthcare they provide.