Managing Nuclear Medicine Images Gets a Little Easier

"Managing Images Gets a Little Easier" was published by Health Imaging & IT | June 1, 2007 | Inside Molecular Imaging and was written by Jamie Bellavance

The typical PACS doesn’t always cut it when it comes to nuclear medicine.  Mainstream medical imaging technologies have not been designed to handle nuclear medicine’s unique demands, proprietary protocols, or programs, which make them incompatible with radiology PACS.  Hospitals nationwide are finding they have to explore new options when it comes to needs such as display functionality to support nuclear medicine studies. Some nuclear medicine departments have invested in pioneering nuclear medicine solutions or interfaced to radiology department PACS, while others prefer an enterprise-wide, integrated solution.

Nuclear medicine requires specific display capabilities, such as grayscale or color, functional, quantitative and fusion data. Static displays just won’t do for dynamic nuclear medicine studies, planar gated studies, SPECT, PET or PET/CT. PET/CT image review involves viewing of transaxial, coronal and sagittal and maximum intensity projection (MIP) images. For that, physicians need a separate solution to translate data among different file formats.

Nuclear medicine departments across the country have integrated new image management models that facilitate nuclear medicine data flow to benefit department and enterprise workflow.

A solution for all needs

The University of Miami Hospital and Clinics (UMHC) in Miami, Fla., house a total of 120 beds, and conduct approximately 6,000 nuclear medicine procedures each year. UMHC has used Thinking Systems Corp.’s ThinkingPACS for image management in nuclear medicine since 2002. The system includes an MDStation for physicians to perform review of images, quantifications, and image fusion; a QC station for the technologists; and an archive system for archiving all the nuclear medicine images, including SPECT and PET/CT. The ThinkingPACS sends all the images to the radiology RIS-PACS, a GE Healthcare/IDX ImageCast for enterprise-wide access and archival.

UMHC has two ADAC Genesys dual-head SPECT cameras, one Philips Medical Systems Skylight dual-head SPECT camera, and a Philips Gemini PET/CT scanner. ThinkingPACS receives the image data from the SPECT cameras and the PET/CT scanner through proprietary and DICOM connectivity for the purpose of processing, quantification, display and review using the MDStation, and also for archiving.

UMHC chose ThinkingPACS because it is an open architecture, Windows-based system with a robust clinical software package with “the clinical programs, tools, utilities and all necessary functionality that we need in order to perform our work,” says Mike Georgiou, PhD, assistant professor of Radiology and nuclear medicine physicist at UMHC.

The MDStation is used by the nuclear medicine physicians for review of all general nuclear medicine studies (bone, renal, liver/spleen, parathyroid, gastric, lung), SPECT processing and review, quantification for nuclear cardiac studies, and PET/CT fusion for oncology, neurology and cardiology studies. It has all the necessary display/review functions and analysis programs for nuclear medicine studies. For example, the physician has the ability to easily and efficiently manipulate the image data, perform comparisons with current and prior studies, and capture interesting cases for slide presentations, Georgiou says.

The technologists use the QC station to check images that have been acquired, and to ensure that the patient demographic information is accurate. Subsequently, the images are shipped to the university GE/IDX PACS for enterprise-wide access. The QC station also makes CDs.

Currently, UMHC is in the process of purchasing the Thinking Systems “plug-in” solution for its hospital PACS to meet the nuclear medicine needs — including PET and PET/CT — of referring physicians. The plug-in for third-party enterprise PACS, which they hope to install in a few months, will bring the nuclear medicine image programs, functions and tools to the hospital PACS in seamless fashion. The Thinking Systems web server will provide remote access to nuclear medicine images, allowing physicians to read studies from home or any remote location. “Most PACS lack the necessary functionality for nuclear medicine imaging,” Georgiou says. “The Thinking Systems plug-in can provide this functionality and offer a complete PACS solution for nuclear medicine.”

Eliminating manual intervention

Saint Joseph’s Hospital in Marshfield, Wis., stored all nuclear medicine department quality control and patient data on optical disc until December 2004. They knew they needed to change that, says Mike Bull, manager of nuclear medicine, they just needed to figure out how. They also wanted to make sure that their solution would obscure raw data that shouldn’t be seen by physicians.

NumaStore from Numa Inc. was the perfect choice, Bull says. The specialized PACS storage and image management system is designed for nuclear medicine data and studies. It offers secure, long-term storage of patient studies acquired over separate visits and the cataloging of those studies. It also supplies efficient retrieval in a way that facilitates and encourages comparative analysis. These abilities encourage a change in the way nuclear medicine is used, from simply a diagnostic snapshot to a long-term care patient management tool.

NumaStore receives information, or queries the workstation to get all the data, and stores them on the NumaStore server. Then NumaList — a DICOM modality worklist manager — sends only the screen-saved images to the PACS, which is all the referring physicians need to see. NumaList enables importing of vital hospital information system (HIS) and radiology information system (RIS) information into nuclear medicine DICOM headers. Following this, the patient file can be forwarded on to an imaging workstation or PACS. 

For image and data storage, NumaStore eliminated the need for manual invention. Previously, if technologists needed to retrieve data, they had to manually locate the optical disc and load it in the drive. “Now, it’s as easy as querying it back from NumaStore to any of our workstations,” Bull says.  They also don’t misplace as many studies as they did with optical disc. Now that everything’s automated, all studies get pulled or pushed to NumaStore.

An enterprise-wide solution

While some facilities favor a nuclear medicine department solution for image management, an enterprise solution is the choice of others. The radiologists at Diagnostic Radiology Consultants (DRC) wanted an enterprise-wide integrated solution to help read and interpret approximately 200,000 cases per year from the 11 facilities that they service across Chattanooga, Tenn., and northern Georgia. For this job, Specialty Networks, LLC was created as the information technology arm of the radiology practice. Specialty Networks is run by DRC, a private practice group of 10 radiologists who review images in nuclear medicine, MR, CT, and ultrasound for facilities that range from a 300-bed community hospital, to a single CT scanner owned by a urology group.

Three years ago, Specialty Networks was dealing with three PACS and two RIS platforms, all from different vendors, and each with a separate workstation, logon and password. To improve efficiency, they researched a seamless, integrated solution from one vendor that would keep all their databases in sync, using one logon, one keyboard and one mouse.

In 2005, they chose Siemens Medical Solutions syngo Suite to integrate RIS, PACS, post processing and transcription. Syngo Workflow manages the exchange and distribution of patient data and images. Syngo Imaging covers the PACS applications for diagnostic preparation, quality assurance and interpretation. Syngo Voice provides voice recognition and transcription. Specialty Networks also chose Siemens’ partner NextGen Healthcare Information Systems to provide its electronic practice management (EPM) solution. In all, Specialty Networks implemented seven workstations at facilities throughout their network.

With syngo Suite, dedicated workstations for nuclear medicine imaging aren’t necessary, allowing smoother integration while reading other radiology images such as CT and MR. “We weren’t looking for a specific nuclear medicine solution. What we wanted was the solution that brought nuclear medicine into the normal workflow. The last thing you want as a radiologist is a separate workflow for separate types of exams,” says Jim Busch, MD, CEO of Specialty Networks. The nuclear medicine gamma cameras, including the Siemens’ Biograph 16, Symbia T6, Symbia S, and Orbitor gamma camera, as well as a Philips Forte gamma camera, simply plug into syngo Suite, and transfer images to the PACS, Busch says.

The syngo Suite worklist allows radiologists to search for patient images by patient name, medical record number, date, facility, or referring physician. Worklists are organized by priority, need and the radiologist’s physical location, Busch says. For example, while Busch may be located at Tennessee Imaging, half of the exams could be from another facility 50 miles away.

Specialty Networks brought 10 facilities onboard with syngo Suite in about nine months. And the results are impressive: Volume has increased about 15 percent, while workflow efficiency has jumped 27 percent. Report turn-around time also has been cut considerably — dropping to just an hour from 24 hours.

Keeping up with NM

Since radiology PACS often struggle to manage nuclear medicine image needs, vendors have come to the table with specific nuclear medicine solutions that can seamlessly relay data to the department or enterprise-wide hospital PACS. Nuclear medicine departments can now provide fast, accurate image interpretation across proprietary vendor image formats while boosting efficiency and workflow.

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About Thinking Systems Corporation

Thinking Systems is an innovative medical software developer and marketer that brings the power of digital technology to advanced clinical, as well as image management applications, creating highly functional and fully automated imaging environments. With a unique vision of comprehensive enterprise-wide digital image workflow, Thinking Systems’ product portfolio supports the most complete spectrum of imaging modalities available today. Providing truly customized implementations, Thinking Systems translates the power of its versatile product portfolio and expertise into highly effective solutions tailor-made for each installation. Founded in 1996, Thinking Systems’ cutting edge ThinkingPACS and ThinkingRIS have been helping prestigious hospitals and freestanding imaging centers, both large and small, enjoy a fully digital environment. To learn more about Thinking Systems, visit www.thinkingsystems.com.

THINKING SYSTEMS solutions are installed at over twenty sites across Canada and are proudly distributed by Alliance Distribution Network (ADN) Canada. For more information please contact your local ADN Canada sales consultant Toll-Free in Canada at 877-434-5311 or e-mail.  

Note: Any / all product names mentioned in this document may be trademarks or registered trademarks of their respective companies and are hereby acknowledged.

THINKING SYSTEMS WHITEPAPERS

Thinking Systems for Cardiovascular
 PACS (CV-PACS) were the winner of Frost + Sullivan’s Technology Leadership Award for demonstrating “excellence in technology within ones industry”.  The prestigious award further recognizes “excellence in all stages of the technology life cycle – incubation, adaptation, take-up, and maturity – to ensure a continuous flow of improvements, innovation, leading-edge concepts, and pioneering client applications”.  

THINKING SYSTEMS were also the highest rated CVPACS vendor by independent KLAS and are (proudly) some of the industry’s most comprehensive and feature-rich suite of general and specialized PACS and RIS (Radiology Information System) solutions available today.  We encourage you to find out how Thinking Systems technology can help to change the way you manage your practice.  

Thinking Systems WhitepaperS

+ Integrating Modalities to Philips iSite PACS through Thinking Systems

+ Integrating Modalities to Enterprise PACS through Thinking Systems

+ Integrating Molecular Imaging into Enterprise PACS

+ VIEW BROCHURE
+ VIEW REFERENCES

THINKING SYSTEMS solutions are installed at over twenty sites across Canada and are proudly distributed by Alliance Distribution Network (ADN) Canada. For more information please contact your local ADN Canada sales consultant Toll-Free in Canada at 877-434-5311 or e-mail.  Note: Any / all product names mentioned in this document may be trademarks or registered trademarks of their respective companies and are hereby acknowledged.

THE FUTURE OF OSTEOPOROSIS DIAGNOSIS - OSTEOCORE 3™

View Ostercore Brochure 

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ABOUT Alliance Distribution Network (ADN) Canada

With over ten years in business in Canada and over twenty PACS sites installed, Alliance Distribution Network (ADN) distributes KLAS Award winning Thinking Systems PACS and RIS solutions across Canada, as well as both Digirad, Medi-Link, Esaote, and UltraSPECT respectively.   For additional information please contact ADN directly Toll-free at 1-877-434-5311 or via email  Alternatively, please feel free to join the discussion on our new Facebook Page.

Xpress/Xact.Bone™ - Cut Scan Times in Half - or - Double the Resolution.

Through an exclusive Canadian agreement, ADN Canada is offering Xpress/Xact.Bone™ which utilizes UltraSPECT®’s Wide Beam Reconstruction (WBR™) technology to either cut bone imaging acquisition times in half, or double the image resolution.  Xpress/Xact.Bone™ completes a whole-body acquisition in less than eight minutes – and can display your standard high-resolution images at a quality never before seen in nuclear imaging.  We encourage you to find out how UltraSPECT® WBR™ technology can help to change the way you manage your cardiology practice.

Features: 

• Dramatically reduced scan times
• Superior image quality
• Increased patient throughput and department productivity
• Improved patient comfort and reduced patient motion
• Seamless integration and automated operation

Documents:

• Xpress/Xact.Bone Brochure
• Clinical Workflow
• UltraSPECT.gate DICOM Conformance Statement

For more information on Xpress.Cardiac™ in Canada, please contact ADN Canada.  Your local ADN Canada sales consultant can provide you with product information brochures. You can also obtain additional information on the UltraSPECT website (www.ultraSPECT.com).  We encourage you to find out how UltraSPECT® WBR™ technology can help to change the way you manage your cardiology practice.

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ABOUT Alliance Distribution Network (ADN) Canada

With over ten years in business in Canada and over twenty PACS sites installed, Alliance Distribution Network (ADN) distributes KLAS Award winning Thinking Systems PACS and RIS solutions across Canada, as well as both Digirad, Medi-Link, Esaote, and UltraSPECT.  For additional information please contact ADN directly.   Alternatively, please feel free to join the discussion on our new Facebook Page.

Xpress.Cardiac™ - Cutting Scan Times in Half.

Xpress.Cardiac™ utilizes UltraSPECT®’s Wide Beam Reconstruction (WBR™) technology to cut cardiac imaging acquisition times in half without compromising image quality. Xpress.Cardiac™ will complete a gated stress myocardial perfusion study in as little as six minutes and a rest SPECT acquisition study in less than eight minutes.  Xpress.Cardiac readily connects to most cameras and workstations. Robust, reliable and fully automatic, with a single processing protocol for all patients, it is virtually transparent to clinical work-flow. 

Features:

◦                Dramatically reduced scan times

◦                Superior image quality

◦                Increased patient throughput and department productivity

◦                Improved patient comfort and reduced patient motion

◦                Seamless integration and automated operation

Documents:

◦                Xpress.Cardiac™ Brochure

For more information on Xpress.Cardiac™ in Canada, please contact ADN Canada.  

- - - 

ABOUT Alliance Distribution Network (ADN) Canada

With over ten years in business in Canada and over twenty PACS sites installed, Alliance Distribution Network (ADN) distributes KLAS Award winning Thinking Systems PACS and RIS solutions across Canada, as well as both Digirad, Medi-Link, Esaote, and UltraSPECT.  For additional information please contact ADN directly.   Alternatively, please feel free to join the discussion on our new Facebook Page.

Canadian electronic health record (EHR) projects quadruple in four years

By Richard Pizzi, Associate Editor 08/12/08

Canada's electronic health record projects increased by 12 percent last year and have quadrupled since 2004, according to Richard Alvarez, president and CEO of Canada Health Infoway.

"Canadians want their medical information available electronically to the clinicians who care for them and that's starting to happen in communities across Canada," said Alvarez.

“Collaboration among governments is at an all-time high and with continued federal funding, we are well on our way to providing every Canadian with an electronic health record by 2016."
Canada Health Infoway is an independent, not-for-profit organization funded by the Canadian government. It jointly invests with every province and territory to accelerate the development and adoption of EHR projects in Canada.

Infoway approved $311.5 million in new EHR investments in 2007-08, bringing the total cumulative value of its investments to $1.457 billion, or 89 percent of Infoway's $1.6 billion in capitalization by the Canadian government. The investment brings the total number of projects underway to 254, representing a four-fold increase from the 53 projects that were underway in 2004.

"The electronic health record projects the government of Canada is investing in are coming alive (and) bringing tangible results," said Tony Clement, Canada's federal minister of health.

Clement noted, for example, that in Nova Scotia, a shared diagnostic imaging program provides digital images of X-rays, MRIs, CT scans and ultrasounds to authorized healthcare providers. He said patients in Canada's remote northern communities are connected with healthcare professionals in urban centers through telehealth, and electronic medical records are generating results in the face of growing clinician shortages and administrative demands.

Alvarez said he's seeing steady progress in all Infoway-funded electronic health record programs including registries, diagnostic imaging and laboratory and drug programs. He said Infoway would continue to target investments in "replicable solutions that support health system transformation, such as telehealth and public health surveillance."

Read Original Article

Empowering consumers with their health records: Canada to take a close look at PHR’s

TORONTO, April 17 /CNW/ - As the Internet has enabled consumers to manage important aspects of their personal lives from the relative comfort of their home, it is no surprise that Canadians are becoming increasingly intrigued by the prospect of being able to view and manage their health information using emerging personal health records (PHR) technologies.

Recent announcements by major players in the IT industry suggest such capabilities are just around the corner. Recognizing developments in this area are moving quickly, Canada's federal, provincial and territorial health ministries have expressed support for Canada Health Infoway's (Infoway) plan to discuss personal health record solutions with interested vendors and to explore how these technologies could be made available to Canadians in a secure manner.

"Providing Canadians and their health care providers with appropriate and secure access to their health information has been our goal from the onset," said Richard Alvarez, President and CEO of Canada Health Infoway, the federally-funded, independent, not-for-profit organization that is leading the adoption of electronic health records across Canada. "The prospect of seeing consumer health solutions in the Canadian marketplace is an exciting development indeed. It is also critical that we ensure these offerings provide the appropriate level of trust, protecting the privacy and security of Canadians' health information."

"The Government of Canada, through its funding of Infoway, is investing in the national transition from paper to electronic health records," said the Honourable Tony Clement, Federal Minister of Health. "I am pleased that personal health record solutions will complement and leverage our investments to date in e-health solutions. With the appropriate ground work in place, PHR's will ultimately deliver greater value to Canadian patients."

"Canadians are taking increasingly active roles in managing their chronic diseases and preventing illness from setting in," said Chris d'Entremont, Minister of Health for Nova Scotia, who serves as the liaison minister between Infoway and federal, provincial and territorial health ministers. "Our investments in the implementation of electronic health records are crucial to our goal of ensuring Canadians have access to the information and tools they need to manage their care. The onset of personal health record solutions can accelerate our desire to enable patients to have these capabilities."

A number of technology vendors have expressed interest in creating solutions that will equip Canadians with the technology they need to view their medical data. Working with Infoway and its partners will help ensure the solutions available to Canadians will leverage the progress made in implementing electronic health record projects across Canada. Using technology solutions that are compatible with Infoway's blueprint will ensure patient privacy and security provisions are adhered to. Infoway has funded 249 electronic health record projects across Canada to date. These secure systems are leading the pan-Canadian switch from inefficient paper-based storage of medical data such as lab test results,prescription history and allergy information to electronic systems that are far more efficient, save money, and save lives.

Canada Health Infoway is an independent, not-for-profit organization funded by the Federal government. Infoway jointly invests with every province and territory to accelerate the development and adoption of electronic health record projects in Canada. Fully respecting patient confidentiality, these secure systems will provide clinicians and patients with the information they need to better support safe care decisions and manage their own health. Accessing this vital information quickly will help foster a more modern and sustainable health care system for all Canadians.

For further information: Dan Strasbourg, Director, Corporate
Communications, Canada Health Infoway, dstrasbourg@infoway-inforoute.ca, (416)
595-3424

The Healthcare Enterprise | Making a case for eHealth Investment

Many healthcare executives look at technology as a cost of doing business. However, investment in strategically chosen technology can enhance revenue while lowering operational costs. Labour, as an example, is the most expensive and valuable resource in a hospital. Therefore, any measurable improvement in the use and efficiency of labour can improve a hospital’s bottom line considerably.

Whether business office staff processing claims information, nurses performing patient assessments, or physicians diagnosing and treating patients, with the current disarray of disparate information databases (and wireless and remote technologies;) users are constantly striving to gather the information required in order to perform and optimize their job function. Strategic implementation of new Technology can significantly improve efficiency in:
• Clinical Operations (ex: Nursing, Physicians and ER)
• Financial Operations (ex: Contract Management, Administration and Registration and Accounts Payables and Material Management)
• IT Operations (ex: Training, Help desk, Network, etc.)

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CLINICAL OPERATIONS
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1. Nursing:
This is the primary area for patient care improvement and enhanced patient revenue. All aspects of technology must perform smoothly – and be transparent to the end user – or nursing will not use it for patient care. When this area is not supported by IT effectively, nurses and other clinicians will revert to paper as the only reliable way to record information regarding patient interventions and notes on the patient’s status. When this happens it significantly lengthens the process, potentially up to two hours per patient per shift. Furthermore it results in duplicate processes and redundant data capture – so much so the caregiver spends too much time managing the clerical tasks, and the patient care process is inhibited. Accurate and timely charging for patient procedures, tests and supplies do not always occur resulting in lost revenue for the hospital. The key technology elements that must all be operating effectively are:
• Robust Clinical Application System including Case Management and Scheduling
• System reliability (99.9% availability)
• System performance (instant response time)
• Easy to use and accessible system devices (e.g., wireless, PDA’s, tablets, printers, etc.)

2. Physicians:
Physicians’ have two main concerns
• time to see patients and
• the timely availability of accurate patient information.

Therefore, creating a way for physicians – no matter where they may be – to continuously receive updated information on their patients addresses both of their primary concerns. Providing this technology is a key contributor to recruiting and retaining satisfied physicians, as well as providing high-quality patient care. The key technology elements that must all be operating effectively are:
• Physician-oriented presentation of patient results information
• Easy-to-Use computerized physician order entry system
• Online access to patient’s diagnostic x-ray and ultrasound information (PACS)
• System reliability
• System performance
• Support for multiple input and output devices (e.g., wireless, PDA’s, tablets, printers, etc.) from in-hospital as well as remote locations
• Integration to their office practice management and EMR systems

3. EMR:
The ultimate goal of most healthcare organizations is a paperless electronic medical record to improve the efficiency and effectiveness of the enterprise workflow process and enhance the revenue generation process. Healthcare management understands, at a conceptual level, that having an automated digital hospital would improve the entire patient care workflow process, and thus, patient satisfaction and staff productivity. The successful automation of previously paper-based processes requires a robust IT infrastructure, and careful planning among all the affected stakeholders.

4. PACS:
A PACS system not only has proven to produce positive bottom-line results, but also is often considered a necessary precursor to the EMR. A wise investment that often pays for itself within 3-5 years, it allows the “reading” of images from all modalities from a workstation that is either in the hospital, or in a remote office. The biggest benefit however is the ability to transmit and view the image to wherever it is needed, and removes all of the barriers to access that exist with traditional film. To achieve all the available benefits, the network bandwidth must be in place to support very large image files, and again, careful planning among all the affected stakeholders is critical to a successful implementation.

5. ER:
Increasingly hospitals are realizing that their ER is a major entry point for patients and should not be overlooked as a revenue source. Providing comprehensive computerized systems that are optimized for the ER’s workflow are mandatory if the hospital desires to realize the potential benefits available. The key technology elements that must all be operating effectively are:
• Emergency Room Patient Tracking System
• System reliability
• System performance
• Easy to access and use input and output devices (e.g., wireless, PDA’s, tablets, printers, etc.)
• Seamless Integration to a hospital’s Master Patient Index to retrieve patient information and provide billing data
• Integration with the EMR to maintain a comprehensive clinical record.

6. Laboratory:
Laboratory orders are processed promptly because of the need of the patient. However, in a paper-based environment, charges can be overlooked because of the multiple steps required to process a patient chart and the extra work involved in capturing charges. A comprehensive Laboratory Information System (LIS) that is fully integrated with the HIS will alleviate this problem, as well as improve the overall efficiency and effectiveness of the Laboratory staff. The key technology elements that must all be operating effectively are:
• Robust Laboratory Information System including integration with all laboratory instruments
• Integration with hospital’s EMR and/or order entry system
• Integration with any external reference laboratory used to enable a complete view of patient’s lab results
• System reliability
• System performance

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FINANCIAL OPERATIONS:
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The key to strategic gains in the Financial/Administrative area is to invest in the newest technology that enables business processes to function more efficiently, and ensures the most accurate billing practices for the organization. Even small procedural changes can create more effective billing and substantially improve the bottom line. Likewise, the implementation of comprehensive scheduling systems can improve turnaround times and help ensure the optimal use of expensive fixed assets throughout the hospital. Other areas suitable for increased investment are described below.

1. Contract Management:
Many hospital billing operations submit claims based upon the personal knowledge of staff billers. Billers often overlook minute and incremental charge optimization opportunities simply because of the volume of bills and claims that must be generated and submitted. The computerization of code optimization and the underpayment analysis of payer reimbursement will have an ongoing and profound impact on a hospital’s bottom line. Whereas these billers are very knowledgeable, their true value is in the management and adjudication of claims denials. The loss of revenue per claim may be small, yet the total volume of claims equates to a substantial loss. Computerization of the claims submission and denial process quickly pays for itself and can immediately increase the hospital’s cash. The key technology elements that must all be operating seamlessly:
• Contract Management Application System
• System reliability (minimal downtime)
• System performance (immediate response time)
• Adequate storage (retrieve discharged patient’s complete information)
• Electronic interface to primary payors
• Integration with hospital’s patient accounting system

Hospitals will vary on the impact of automating these areas of operation. The cumulative effect can be quite surprising. As PriceWaterhouseCoopers and HIMSS analytics reported in their study of cardiac care in 36 hospitals in March 2005, there was an “85% reduction in medical errors and a 65% reduction in inappropriate denials from payors…” in the hospitals studied.

2. Admissions and registration:
This area requires system speed and a reduction in the complexity of screen layouts. There is typically a lot of turnover in this area. Yet Admissions is the first location for revenue enhancement and the primary source of errors and inaccurate data for billers to deal with claims denials. The key technology elements that must all be operating effectively are:
• Comprehensive admission-discharge-transfer system
• Integration with payors to confirm patient coverage
• Integration with patient scheduling system
• System reliability (no downtime)
• System performance (immediate response time)
• Easy to access and use input and output devices

3. Accounts Payable/Materials Management:
The goal of automating the replenishment of the hospital supplies (using just-in-time processes), while taking maximum advantage of the hospital’s contracts, in an effective and efficient process, has a significant impact on the hospital’s profitability. Accurate, ongoing, and continuous inventory, minimal loss of stock, and maximum chargeability are the key components. Taking advantage of discounts by being able to pay vendor’s invoices within the discount can benefit the hospital’s bottom line. The key technology elements that must all be operating
effectively are:
• Comprehensive Accounts Payable System
• Comprehensive Materials Management System
• Integration between Accounts Payable and Materials Management
• System performance (immediate response time)
• Easy to access and use
• Adequate storage

4. Barcoding:
It has been shown that barcoding data at the bedside, from the pharmacy, and through materials management reduces medical errors tremendously, as well as, improves the automation of input of data into the patient chart. It holds the ability to speed and integrate the purchasing, distribution, administration, charting, and billing for pharmaceutical and other supplies. An effective barcoding strategy not only provides more accurate and timely information, but also saves time and improves the work lives of clinicians, managers, and staffers by making things run more smoothly and simply. To realize the full benefits of a barcoding implementation, attention must be paid to the workflow changes necessary to get maximum returns. When combined with supply chain automation, the entire process of acquiring the correct supplies, packaged and correctly prepared for patient delivery, are made available to the care-giver when needed – and the documentation for billing, inventory reordering, and the patient chart, is captured as a by-product of the patient care process.

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IT OPERATIONS:
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The common thread in improving IT Operations in healthcare is to achieve maximum leverage of the staff resources to implement and support an ever-increasing array of emerging hardware and applications. Through continual centralization of the environment, more ROI is squeezed out of fixed assets and the staff becomes more efficient by giving them the tools to do their job more effectively. Whether it’s server administration, network management, application support, or user provisioning, the innovative investment in the IT infrastructure can improve service levels and ensure optimum utilization of expensive staff resources. Practical examples include:

1. Training:
As the general workflow process is automated, the need for personnel to understand how to use the tools at hand becomes paramount. Training is needed in two distinct areas; the IT staff and the users:
• The IT staff must be trained to understand how to use the servers, switches, software and network to maximize the users’ capabilities. Each IT staff member has a “multiplier effect” upon the user community’s effectiveness. Most should therefore be certified in their area of expertise.
• The automation process is for the benefit of the user and the organization. Therefore, the user must be trained in the optimal usage of the system and the tasks they perform. This means that an ongoing training program should be implemented to ensure employees are accomplished on the system(s) they use and fully understand the implication of their actions when using automated systems to perform their jobs.

2. Help Desk/ Service Level Management:
IT departments may have a phone number for users to call in case of need, however most facilities do not have an automated structured process to monitor
technology, diagnose problems, administer support, and measure performance by automated reporting. It is imperative to be able to understand the source of help desk calls in order to properly plan for the improvements needed to improve customer service.

3. Network:
The network is the nervous system of an organization’s information flow. There are a number of components of a network that must be able to transport data at a guaranteed minimum volume.

4. Switches, bridges, and routers:
The switches, bridges and routers are the devices that route data from one part of the network to another. Considering that a fully automated healthcare workflow process will have a minimum of 25 major applications that will route data for 30 departments, the switches need to be configured to handle the volume of traffic anticipated.

5. Backplane:
A backplane acts as a “traffic cop” for the data that comes from all of the different switches within the network. Therefore, it must handle the accumulated burstable volume of the network. For a fully integrated and automated workflow process, a backplane may need to burst to 4 Gigabytes/sec. of volume.

6. Network Management Software:
Many of the major network vendors have the ability to continuously “ping” the network through a technology called SNMP. This allows IT to proactively monitor the “health” status of switches, PCs and servers. The same software now also keeps an inventory of hardware and software, as well as version control, so that the network can now distribute patches, updates, and fixes to the users quickly. Finally, most of these network vendors now have integrated help desk and service level management automation into their support process. Therefore, IT can now receive a request for assistance, log it, prioritize it, and escalate it automatically. They can then diagnose and fix (either remotely or by the system dispatching a person) user’s hardware and software. Finally, the IT tools can then print out a report that shows the amount of time systems were up for the month, how many service calls were responded to by prioritized need, who was serviced and when, as well as the outcome of that service call.

7. Wireless and Remote Capabilities:
Wireless PDAs, tablet PCs, smartphones and laptops are transforming the way information is gathered and processed. Systems can now be structured so that physicians may plug their device into the hospital system and be uploaded with what happened to their patients overnight. Additionally, caregivers and hospital staff can now work from home.

8. VoIP:
Currently the dual networks and dual support staffs to run a network and a PBX system are costly. Time and again, the return on investment (ROI) to move the phone system onto the network, department by department over a period of time, has shown to be a good investment. There is no charge for moves, adds and changes (MACs) now, the administration of two systems can be handled internally by one group, and future cabling costs are minimized.

9. Cabling:
Cabling is an infrastructure issue and often its importance is overlooked. But, it is foundation of the information highway for a hospital. In addition, as hospitals are adding increasing computerization, cabling installed two years ago may soon be outdated. Cabling should be an integral part of a hospital’s computer plan.

10. Standardization:
Standardization means that the technical components of servers, switches, and PCs should have the same memory, cache, and storage. The reason for this is that servicing a few standards reduces the complexity of support, which has shown time and again to be the best way to reduce the cost of operations.

11. Servers:
Most servers are currently purchased as individual standalone machines. This creates two problems: first, it means that each server is a single point of failure for its own data and there is no failover capability from one server to another; and second, the storage usage of each machine is usually less than 50% of capability. Therefore, the architecture of servers should be configured into a storage array network (SAN) of blade servers configured to backup each other.

Conclusion:
The implementation and continued automation of the healthcare workflow process is analogous to building a house. All departments run their own operation, but are interconnected and dependent upon each other to provide a complete workflow environment. The foundation of said “digital house” however, is the technological infrastructure. Any weak points in the infrastructure will create bottlenecks in the workflow process. The demand for quick and accurate patient information in hospitals is continuously on the increase. Hospitals have to improve their technological infrastructure in order to meet the needs of caregivers and to enhance their revenue. Healthcare workflow process improvement will take time to accomplish in a coordinated, synergistic manner that will improve patient care and hospital revenue.

Lessons from the Past: How other disruptive technologies became mainstream

In the increasingly wired world of healthcare, there are hundreds of technologies designed to improve patient care and ease the workload of healthcare providers. The proliferation of information and communications technologies over the past five years has been overwhelming. Yet the rate of adoption of some of these technologies has been slow.

The introduction of new technologies has always represented an uneasy shift. Welcomed by some, it has been rejected by others who see it as disrupting the accustomed way of doing things and creating new demands. I am a firm believer that the past can offer many insights to those who are trying to introduce new ideas or concepts. Therefore, to better understand the factors influencing the uptake of new technologies it is helpful to look back in time. Looking at the printing press, the telegraph, the radio, the automobile, the telephone, the fax machine, the cell phone, the Internet, and the World Wide Web, we asked some key questions. What were the conditions that permitted the adoption of technology? What was the pace at which technologies were dispersed, and why? What role did the government play?

What is a disruptive technology?
Most new technology is self-sustaining and improves performance along dimensions that the mainstream customers in major markets have historically valued. By contrast, disruptive technologies typically have worse performance, at least in the near term. But:
* They have features that a few fringe and generally new customers (mavens) value and which represent a key source of competitive value in the future;
* Products based on them are typically cheaper, simpler, smaller and frequently more convenient to use -often representing a new product architecture.
* They often bring a new and different value proposition.
(Adapted from The Innovator's Dilemma: When New Technologies Cause Great Firms to Fail by Clayton Christensen)

Applying an analytical framework to the adoption of nine significant technologies from our past allows us to observe key elements and uncover lessons from history that may hold true for the adoption of healthcare technology today.

"Several variables seem essential to the successful uptake of technology: providing an infrastructure, finding a function, establishing the right price point, and becoming a necessity."

There's no question that these "disruptive" technologies have changed the way we work. But from the printing press to the telephone, the telegraph to the World Wide Web, this analysis identifies the common attributes and conditions which determine how fast a technology is adopted, how quickly it is diffused, and how well it is received.

In Diffusion of Innovation (1995), Everett Rogers defines the five following attributes as being important variables in determining how fast a technology is adopted:

Relative Advantage: the degree to which an innovation is perceived as better than the idea it supersedes

Compatibility: the degree to which an innovation is perceived as consistent with existing values, past experiences, and needs of potential users

Complexity: the degree to which an innovation is perceived as relatively difficult to use and understand

Trialability: the degree to which an innovation may be experimented with on a limited basis

Observability: the degree to which the results of an innovation are visible to others

To begin, is the technology perceived as being better than the idea that preceded it, thereby having a relative advantage? Is it compatible with existing values, needs, and past experiences? What about complexity -- how difficult is it to learn, understand and use? Can the idea be piloted, on a limited basis, to demonstrate its trialability? And finally, can the results be observed by those who may use it or be affected? These are the attributes that determine how successful an innovation will be. But what about the conditions which can nudge a technology along and get the ball rolling? Several variables seem essential to the successful uptake of technology: providing an infrastructure, finding a function, establishing the right price point, and becoming a necessity.

Change takes time
In a world where we have become impatient with delays and accustomed to rapid change, the slow embrace of new technologies can be frustrating, but we shouldn't be surprised, or discouraged. It has always been that way, despite the pervasive belief that change is instantaneous.

Take the telephone. We are so dependent on this technology it is difficult to imagine that when it was first introduced in 1877, people had to be convinced that it was useful. Despite its simple design and seemingly obvious value, it took 75 years for the telephone to reach 50 million users, and it wasn't until the 1960s that users saw a residential phone as a necessity.

Even the printing press, with its obvious advantage over laborious copying by hand, was not an instant success. Although the technology was seized on quickly by the Protestant Church, which encouraged literacy, it took centuries for the technology to be used for a mass publication newspaper -- the New York Sun took to the streets on September 3, 1833, more than 300 years after Gutenberg invented the first printing press.

The printing press has important parallels to today's revolution in information technologies. Like the Internet, it suddenly made information available to many more people, and the increase in the spread of information led to confusion and mis-information. Different scientific and religious theories appeared simultaneously -- which one was right? There was no peer review necessary to publish, no infrastructure in place to regulate the publishing industry.

The healthcare community and patients themselves face similar issues as medical information proliferates on the Net. Whose research is correct? Which is credible? How can people sort out the truth from the quackery? Many patients believe it would help if they received medical information online from their own doctors, someone they could trust.

Comparison: Rates of Diffusion
Although it's difficult to define exactly when a technology is fully "diffused", it is interesting to compare how quickly technologies were adopted.

The printing press: 400 years following its invention it was finally used to reach a wide public audience with the publication of the first mass newspaper in 1833.

The automobile: 75 years from the introduction of the first internal combustion engine in 1885 to the point of market saturation in 1960

The telephone: 85 years from 1876 when Bell applied for his patent to full saturation in the 1960s

The fax machine: 144 years from its invention in 1843 to 1987, when enough people were using fax machines for it to make sense for everyone to get one

The Internet: 30 years, from 1968 to mid-2000 when an estimated 130 million Americans had access to the Internet

The diffusion of the telegraph was somewhat faster than the printing press. Samuel Morse presented his prototype of the electric telegraph to the US Congress in 1838, and by 1873 Western Union had carried more than twelve million messages. One of the reasons for the telegraph's rapid success was the creation of the infrastructure which supported it -- reliable connections, cheap and predictable rates, and a shared language. Common standards and a high degree of inter-operability made the telegraph a relatively easy sell.

"...any new technology must eventually be seen as a necessity. It must become part of the everyday way of doing things,...It's hard to remember life before 'What's your e-mail address?' "

But what about more recent technologies? It took five decades for the telephone to reach 10 per cent of U. S. households, but it took only five years for the Web to do the same. In fact, the Internet has reached 330 million users in only 30 years, arguably the fastest diffusion rate in history.

This is partly because the Internet builds on an existing communications infrastructure, and its speed and efficiency are easily observed. In the case of the Internet and the Web, users can develop their own functions, and generate their own content. These decentralized conditions allowed technology to spread quickly.

So what can we learn from these experiences, and how can we apply this knowledge to the health sector?

FROM STRUCTURE AND FUNCTION TO NECESSITY
One of the most important lessons is the importance of providing the critical underpinnings that will support a technology as it attempts to break new ground. This infrastructure varies, from the entire political and social structure, as with the printing press, to the regulatory environment in the case of the telegraph, the telephone and the radio.

For technologies to succeed, they must also find their function, sometimes creating a need where none existed before. With technologies that basically did the same thing, only faster, like the printing press or the fax machine, function wasn't really an issue. But the social function of the residential telephone was largely ignored by industry for the first half of its history.

What we can deduce from this is that frequently the consumer determines the use of a technology, not the inventor, the vendor, or the marketer. This is especially true of technologies like the Internet and the Web. Finding the right price is another important variable, although it would seem an obvious one. And finally, while it may take decades to get there, any new technology must eventually be seen as a necessity. It must become part of the everyday way of doing things, as "invisible" and as vital. It's hard to remember life before "What's your e-mail address? '

Cheaper, faster . . . better?
For many sectors, such as manufacturing and retail, the main contribution of information technologies has been to provide cheaper, faster handling of information. In other words, nothing particularly new, just a better way of doing it. A good example is the banking industry. For the cost of opening a branch to serve a single neighbourhood, a bank can set up a web site accessible to more than 15 million households. Cheaper, faster, an obvious function, and a ready-made infrastructure.

But most sectors share similar problems. Introducing a new technology can be a complex process, and it takes both time and effort to change the way people work. There are also issues of security and privacy -- a key issue in the transmission of sensitive information. Ironically, many sectors have found out that word -of -mouth is one of the most effective ways of persuading people to try out a new technology. Opinion leaders who act as champions play a key role in getting it adopted and creating a demand.

Applying the old to the new
By applying the analytical framework and deriving the lessons of history and the experiences of other sectors, we can shed light on how we expect the medical community to adopt information technologies, and on the role the government can play in making it work.

The government has frequently regulated a new technology, or created the rules that allow commerce to take place fairly. But the government has also played a larger role by developing appropriate policies for technology's use and distribution, by providing strategic funding, and by showcasing their own use of technology.

The government can also act as a catalyst. Apparently even the most skeptical critics of the telegraph were convinced of its advantages when the successful nominees at a United States' Whig National Convention, transmitted by telegraph, were announced to the crowd 64 minutes before the list arrived by train. It was the U. S. Congress that paid for the first of Morse's telegraph lines.

There's no question that the computerization of health data and the emergence of information technologies has created unprecedented opportunities for providing better health care services. But, like any other sector, and as with any new technology, the medical community has to be convinced the new way is better than the old. Remember relative advantage?

The Brookings Task Force on the Internet concluded that the US healthcare system could significantly reduce their costs by using the Internet to handle information faster and cheaper. Nothing new, but better. Other studies of information technologies applied to healthcare have shown that the benefits could include improved management of patient-care delivery, improved access to information, reduced medical and medication errors, more timely care, and a better quality of life for chronically-ill patients.

Information technologies applied to healthcare also stand a better chance at succeeding if they are compatible with the medical culture. For example, more than 50 per cent of US physicians use wireless or handheld devices -- a technology that fits comfortably into the working environment of hospitals. Government-funded sector councils can be pro-active in this area, making sure that the design, development and marketing of healthcare technologies takes the healthcare provider's needs into account.

"The medical community is not averse to new technology, but they need to see and understand how it fits into the way they work, without disrupting the care of patients."

For many in the health care system, the time crunch is a genuine barrier to the adoption of new technologies. So, the less complex the technology, the more likely it is to succeed. For health workers already struggling with the demands of paperwork, one more thing to learn can seem like too much. Of course sometimes a technology is perceived to be complex, when it really isn't, and here is where extensive trials and demonstrations can be useful. Tips and lessons on how to use a technology can be spread throughout a healthcare organization by an on-site "e-vangelist", someone within the organization who can also offer useful feedback to government.

The communication of the lessons learned from trial runs is a vital step in getting technology accepted. The government can use e-services directly to communicate with the health care sector, using technologies such as online conferencing. Outsourcing can also provide an excellent trial run for healthcare technologies -- for example, one online platform service where patients log on and pay by credit card for prescription renewals, non-urgent medical advice, sick notes etc, has already been picked up by hundreds of physicians. It's one thing to try a technology out, another to have it observed. Successful examples of information technologies being used in health care need to be promoted at all conferences, symposia and workshops, as well as models of the government's own success in using them. Marketing strategies can also make use of the mainstream and specialized press to get the message out, increasing public profile. Healthcare opinion leaders and champions must also speak up, widening the net of influence and acceptance.

Creating the right conditions
So far, the lessons on how certain attributes contribute to the adoption of technology apply as much to telemedicine as they did to the telephone or the automobile. But what about the essential conditions: providing the infrastructure, finding a function, finding the right price and becoming a necessity?

A significant legal and policy issue for the healthcare sector is privacy, and this is one of the most critical areas for government policy. Medical data is a sensitive area. Canadians will need to be reassured that the information technology used here is secure and reliable, before a corresponding infrastructure can be provided.

In addition, as with the telegraph, there also needs to be a common language, and standard definitions for data. The significance of this kind of infrastructure was borne out by the experience of the big three automakers in the US, who created the Automotive Industry Action Group to standardize processes. This group also started the Manufacturing Assembly Pilot Program, which ensured that everyone involved spoke the same language.

With earlier technologies, function was king. But with healthcare technologies today, who determines the function? The patient. According to the Toronto Star, most Canadians want online communications with their care providers, while most providers do not. For physicians and other health workers, it's probably a question of time. For patients, it's a matter of convenience. But it's this interaction that will likely determine the ultimate function of e-mail in the healthcare setting.

The right price point is also a key condition for technology's success, and this applies as much today as it did a hundred years ago. Faced with tight budgets and a wide variety of competing innovations, the healthcare sector will certainly take price into consideration when considering the adoption of technology.

And finally, new technology must become a necessity. In the case of the Internet, the patient is determining what healthcare services will become essential. Some 84 per cent of Canadians who reported using the Internet in 2001 said they would like online access to their doctor to ask general health or education questions. In another survey, 62 per cent said they would also like to go online to make appointments or renew prescriptions.

The medical community is not averse to new technology, but they need to see and understand how it fits into the way they work, without disrupting the care of patients. Take the automobile, a technology that was quickly embraced by doctors who saw it as a better, faster way to reach the patients who needed them.

But if a laptop takes four minutes to boot up, and a doctor has only seven minutes with his first patient, the old hand-scribbled medical chart is going to seem like a more efficient way to enter patient information. Perhaps the key lies in integrating new technologies with established practices? For example, wired personal digital assistants can help doctors retrieve medical records quickly while they're consulting with their patients, and avoid mistakes in filling prescriptions that may be hard to read.

There are hundreds of examples, and the healthcare community needs to be selective in deciding which technologies work, and which don't. Their value must be clear, and where the function is patient care, there is a natural low tolerance for risk.

To sum up, if there is one vital lesson we have learned from the experiences of the past, it is this: change takes time. Solutions need to incubate, but we have discovered that as technologies are introduced, there are ways to influence the rate at which they are adopted. Governments, health care workers, patients themselves all have an active role to play in this process, especially in our increasingly inter-connected world. The rewards of this involvement will be an improved healthcare system, and better health for Canadians.

William Pascal, Director General
Office of Health and the Information Highway, Health Canada.
In Healthcare Information Management & Communications Canada, Vol. XVI, No. 2, 2nd Quarter, June 2002 http://www.hc-sc.gc.ca/hcs-sss/pubs/ehealth-esante/2002-lesson-lecon-pass/index_e.html