PACS in Norway
Welcome to EuroPACS 2006:  The 24th International EuroPACS Conference, June 15th to 17th 2006 in Trondheim, Norway

PACS, Teleradiology and Telemedicine in Norway
PACS & Teleradiology and Telemedicine & eHealth in Norway: Administration and delivery of services

KITH - Norwegian Centre for Informatics in Health and Social Care, Trondheim, Norway

Roald Bergstrøm, Senior Adviser, KITH, Sukkerhuset, N-7489 Trondheim, Norway  - roald.bergstrom@kith.no

Abstract

IT in health and social services has the potential to improve welfare, while simultaneously improving the efficiency of the systems.

By the end of 2005 nearly 100 % of the hospitals in Norway will have digital x-ray with RIS and PACS installed.  Norway is the first country in the world to get fully digitized in this field. All the hospitals can communicate in a National Health Network

In this paper I will give an introduction to national IT strategies for the health and social sectors, and point out major challenges for the future of  PACS&Teleradiology and eHealth&Telemedicine in Norway.

IT in home- and community-care will provide the users with better services closer to home in the coming years. National strategies and action plans are important, but the funding necessary for the recommended actions must also be provided. Organisational issues are important

I. INTRODUCTION

A.                Health services in Norway.

    Norway provides extensive health services and a well-developed social security net. About 35% of the annual Norwegian state budget, or 7-8 % of the gross national budget, is spent on health and social care, making it one of the European countries – and the Nordic country – with the highest level of public spending on health per capita. The health and social care sector in Norway, as in other modern societies, faces significant challenges. Its part of the nation’s GNP is already substantial, and the increasing mean life expectancy and falling birth rates will dramatically increase the future burden. A specific Norwegian challenge is the low population density, the consequences of which include the likelihood that inhabitants might have long travelling distances to medical services, hospitals are scattered and some are small, and not all hospitals can contain every medical discipline.

B.  KITH

    KITH, is a national competence centre with close connections to end-users, vendors, research institutions and the government. KITH is owned by the Ministry of Health and Care Services (70%), Ministry of Labour and Social Affairs (10.5%) and the Association for Municipalities (19.5%).

    KITH has 5 focus areas:

·                 Codes and terminology

·                 Electronic Information exchange

·                 Information security

·                 Electronic Health Record systems (EHR)

·                 Digital imaging systems/ radiology.

II. METHODS AND IMPORTENT FACTORS FOR  TELEMEDICINE

A.                National IT strategies and action plans for health and social care

    Investment in IT and making broadband available throughout the country is part of the Government’s E-Norway plan, which has established ambitious goals for IT development within both the private and public sectors.

    IT is also an important tool in the process of implementing the latest national health reform. Some of the main issues in the reform are:

·                 Regular GP: Every citizen has one doctor

·                 Free choice of hospital

·                 Central government ownership and responsibility of the hospitals and specialist health services.

    Information Technology (IT) has been regarded as a useful tool to improve health services for many years, particularly in primary care. Back in 1997, the Ministry of Health and Social Affairs released the first national action plan for IT development in the health and social sectors.

    The main objective was:

·                 stimulate electronic interaction and exchange

·                 strengthen and increase collaboration and efficiency in and between health and social sevices

·                 improve contact with patients, clients and those in need of care

·                 improve the quality of services.

B.   Funding

    In Norway, central government financing of new Telemedicine pilot projects has been important to reach the goals.

C.   National Competence Centre

    A significant contribution to the Norwegian development in health informatics and telemedicine are given by the national centres in the area:

    KITH – The Norwegian Centre for Health Informatics is a limited company owned by the Ministries for health and social care and The Association for Municipalities. KITH is developing and contributing to the development and implementation of standardized terminology and coding systems, secure information exchange and standards for EHR and PACS systems.

    NST – The Norwegian Centre for Telemedicine is part of the University Hospital in Tromsø and aims to provide research, development and consulting in telemedicine, and to promote the introduction of telemedicine services in practice. Since 2002, the NST has been designated by the WHO as a collaborating centre for telemedicine.

    KoKom is a national centre working with emergency medicine. The objective of the centre is to act as advisor to government both centrally and locally. One of the main projects the acceptance of TETRA as the national standard for radio communication in emergency services.

    NSEP - The Research Centre for EHR systems was recently established at the Norwegian University of Science and Technology (NTNU) in Trondheim, with funding from the Research Council of Norway and the university itself. The objectives of the centre are to perform multidisciplinary research and university-level education related to EHR systems

D.   National Broadband Health Net

    The Norwegian Health Net provides a good foundation for electronic interaction and information exchange in the health sector. The Norwegian Health Net shall ensure data quality, security of information, and protection of privacy in the exchange of sensitive information. National funding is provided for the development of different services, standards and security guidelines, as well as for investment in broadband.

E.   Electronic interaction within the health and social   services

    The EHR system, whether implemented by hospitals, GPs, or other care providers, is the key to an efficient flow of information. All care providers are required by legislation to document what they do, and an extensive implementation of EHR systems amongst all providers is a prerequisite for efficient electronic cooperation.

    Norway has a strong legislation regarding the handling of person-related information. Information security will be addressed by establishing basic requirements for information security, which communicating partners have to declare their adherence to. Specific attention is also given to the widespread implementation of digital signature/PKI (public key infrastructure), where the National Social Security Agency has brought forward a solution available for the whole health-care sector.

F.   Nationwide Social Security Number

    Every inhabitants in Norway get a unique social security number.

III. PACS AND TELERADILOGY

    By the end of 2005 nearly 100 % of the hospitals in Norway will have digital x-ray with RIS and PACS installed., making Norway one of the first countries in the world to be fully digitized within x-rays. 

    The hospitals in Norway are state owned, but they do work as Private Health Enterprises. They are organised in regions with separate boards and a managing director for each region.  The regions communicate via the National Health Network. (Broadband-communication)

A.         Teleradiology traditions

    Another area in which electronic communication between actors in health sector is crucial is teleradiology. Norway has a long telemedicine tradition and the pioneers started with Teleradiology-services many years ago. Teleradiology is in use for consulting in emergencies, for second opinion and for consulting between hospital and the primary health care.

B.   Integration

    Integration is a key requirement for all the PACS-systems. PACS has to be integrated with RIS and RIS has to be integrated with HIS/PAS. Initially PACS was a departmental unit but nowadays it is a part of an enterprise system. The role of RIS and PACS within the hospital has evolved, and is now moving towards fully integration with PACS as the imaging layer of the EPJ (Electronic Patient Journal). In the future the PACS will be invisible for the clinician. They will only see and work with the EPJ with the PACS as an integrated part.

C.   IHE

    The Hospitals in Norway have chosen different solutions for RIS and PACS.    Although all image communication uses the DICOM standard we do not experience that information exchange works seamless between the hospitals. The focus in the future will be on integration and on exchange of information across the hospitals. Norway has join the IHE organisation and do participate in a Scandinavian mirror-group. By the end of 2005 the new XDS-profile will be used for sharing information between different PACS and RIS-systems at different hospitals within a region.

D.   Storage

    Medical images have to be on-line, 24 Hours a day. Discussions about archiving strategy and performance, with details about image retrieval times, disaster recovery, integration of images and text and selection of storage media, are going on. Offsite archiving is introduced and ASP-models (Application Service Provider) are going to be used by some hospitals and private imaging centres. The amount of data produced by the imaging modalities increases constantly and the only way to manage huge digital archives seems to be a SAN-solution (Storage Area Network). All images are stored on disk, with redundant solutions containing at least 2 separate archives and a backup. 

E.              Broadband

    Exchange of digital Imaging information requires broadband communication. PACS has become an important application to the National Health Net. Central storage (for the Regional Health Enterprise) and SAN-solutions are rapidly growing. Central archive is without doubt a cost saving strategy. Central archive combined with Web technology makes it possible for the health enterprise to distribute images, interpretations and related data throughout the enterprise, increasing clinician’s access to PACS with greater value to the organization.

F.   Information security with a shared physical storage

    Some regions in Norway have implemented PACS as a regional solution for all Health Enterprises within the region. In such a regional system one solution is that the Health Enterprises share a physical storage unit for the PACS (and RIS) information. Due to Norwegian health legislation, Health Enterprises are not allowed to share patient information indiscriminately. This means that a shared physical storage unit must be divided into logical storage areas for each Health Enterprise so that access can be linked to the different Health Enterprises. The health legislation also specifies that access to information owned by a different Health Enterprise must be evaluated and approved for each individual access.

G.               Investments

   Digital X-ray represents an important share of investments within the sector. Every year billions of  X-ray examinations are carried out, and every examination produces several pictures. The large amount of examinations and X-rays makes a digital system more practical than paper copies.

    A special emphasis is put on exchanging digital images between hospitals through the Norwegian Health Net, thus allowing cooperation and second opinions, as well as the rational operation and increased availability of radiology services. Standardization is required to communicate between the different systems and, therefore, the Directorate of Health and Social affairs has suggested that a national project on these issues, involving all regional health companies, should be supported. The project also includes the organizational development required to release the benefits, security aspects and cost-benefit analysis.

The project is be based on the successful IHE-NORWAY activities (Integrated Healthcare Enterprise) that started in 2003 with KITH as project manager.

IV. TELEMEDICINE AND eHEALTH

    Telemedicine comprises medical diagnostic and treatment performed using digital information technology to transfer patient information, including medical images and PACS. To a larger extent than before, telemedicine will enable people to be treated, or nursed, in their local environment, or in their homes. Telemedicine solutions has been brought into use throughout the country to ensure a greater availability of services. To achieve this, two types of measures are given priority:

·                 The stimulation of broadband development between hospitals and between hospitals and the primary health services.

·                 The clarification of responsibility, rules, guidelines and costs in connection to telemedical consultations.

A.                Telemedicine services

    Telemedicine – excellent health services available to all. One of the main reasons for the Norwegian emphasis on telemedicine is to achieve the vision of equal health services for all patients in a country with a low population density and long travelling distances to the nearest hospital, or medical expert. Operational solutions are in place in a variety of medical disciplines and care situations.

    Some examples are:

·                 Sounds, images and videos recorded by the primary care doctor and transmitted to a specialist. Examples are stethoscope, dermatology, ear-nose-throat conditions, examination of optic fundus for diabetes patients.

·                 Telepathology - pathological support for hospitals lacking this capacity

·                 Teleradiology - as imaging goes digital, support can be given at distance

·                 Videoconferencing for psychiatry and cancer care.

B.              Home-care

    Care in the homes of the elderly and of other groups in need of care is presently undergoing a development in which IT plays an important role. Important developments within this field include systems that can communicate with the hospitals and other organizations within the health sector, and mobile computers that enable communication while “in the field”, without the need to go to a common office.

C.      IT for groups at risk for social exclusion

    The Information Society promises new opportunities for social inclusion, and have the potential to overcome traditional barriers to mobility, distance and knowledge resources. They can generate new services for disadvantaged people and for people seeking employment, or at risk in the labour market. On the other hand, IT also introduces new risks of exclusion that need to be prevented. Internet access and digital literacy are a must for maintaining employability and adaptability, and for taking economic and social advantage of on-line contents and services.

D.              EHR – the core of patient information

    According to the Norwegian legislation, each health-care service provider has to keep its own records, which can be in digital form, and information between service providers is only to be transferred on a need-to-know basis. A national EPR standard was released in 2001. This standard mainly covers issues related to architecture, archiving and security. A requirement specification for health stations and health-care in primary schools, and another requirement specification for community care, are based on this standard.

    With few exceptions, all GPs and private specialists have EHR systems; this has been the situation for some years. 80% of hospital patients are covered by EHR.

E.              IT for communication in health-care

    The Nordic countries are at the fore-front in eHealth applications. The number of general practioners using EHR is among the highest in Europe.

V. The future for eHealth and Telemedicine

A.                Challenges

    The application of information technology in health-care can be seen as follows:

·                 An adequate technical infrastructure allows easy and secure many-to-many communication.

·                 An agreed information structure secures a common understanding and correct interpretation between the various applications.

·                 Standardisation and common concepts for information security tie it all together.

    Governments are under pressure to deliver more value for taxpayers’ money. Administrations have to deliver more and better services, with equal, or fewer resources. The challenge is to achieve productivity growth in the public sector, in order to create more opportunity for service improvement at equal cost. Moreover, with the ageing of the population, public administrations will have to make do with fewer employees and fewer working taxpayers, while still having to provide largely the same number of services of better quality. Civil servants demand more interesting jobs, with more opportunity for self-development and personal interaction.

IT is not a universal solution for all challenges, but it may reduce the stress on the public sector and create new opportunities.

B.      Information technology might provide an answer

    ”eHealth is the single-most important revolution in healthcare since the advent of modern medicine, vaccines, or even public health measures like sanitation and clean water”.

    This statement is promising, but also radical, since information technology, in contrast to medicine and sanitation, is not an integral part of medical practice. Evidence for the above statement is still modest, but support is provided by drawing parallels to other sectors of society. The penetration of information technology into industry and private services (car industry and banking are prominent examples) has had dramatic effects on quality and productivity; the time might now be right for public services to adopt it as well.

C.      IT for health, care and social services

    IT in health and social services has the potential to improve welfare, while simultaneously improving the efficiency of systems. There are several driving forces for IT in these sectors. One of the strongest is the demand for increased efficiency. This requirement can be expected to be even stronger as the population gets older in combination with limited financing. Another driving force is the demand for individual treatment and care, combined with requirements for participation and information. Care in the homes is increasing and, for this group, IT may provide new opportunities.

    Trends in favour of IT in health and social service:

·                 Increased proportion of elderly people.

·                 Working time gets more expensive and computers   less expensive

·                 Increased IT maturity

·                 Increased demand for individualized care

·                 Increased demand for more information and partici-  pation

·                 Increased requirements for integrity

·                 Increased demand for documentation and evaluation

·                 Increased demand for seamless service processes

·                 Increased care in the home

          Forces that work against IT:

•              Slow adjustment of laws and regulations

•              Lack of management for change

•              Lack of coordination and overview

•               Old organizations and work processes

•               Lack of common standards

•               Attitudes

•        Insufficient education and competence