Canada develops ambitious electronic health network

Canadian officials estimate that by 2010, at least half of all residents will have their own electronic health record. The EHR is intended to include a cradle-to-grave clinical history, using a single patient identification number. It will eventually be interoperable across the country and its multitiered healthcare delivery organizations. This prediction is not just a political pipedream, as implementation is already well under way.

The technological underpinnings of the network have been in development for some time. Canada is home to pioneering teleradiology and telemedicine projects, which in the early 1980s proved the clinical viability and potential of transmitting diagnostic images. The country boasts the world's second largest land mass and a population of 32 million. Its medical specialists are located in a few dozen major urban centers. The country's university-affiliated hospitals in Montreal, Toronto, and Vancouver were among the earliest PACS adopters.

Urban hospitals with regional specialty centers were the next to implement PACS. But most community hospitals were slower to adopt, waiting for the technology to mature and costs to decrease. By the time a viable telecommunications infrastructure had been built in most of the country's 10 provinces and the investment in PACS could provide an acceptable financial return, integrated electronic health records had also emerged.

Enter Canada Health Infoway, a federally funded not-for-profit organization created to use technology to improve healthcare in the country. The agency identifies and invests in projects that accelerate technology adoption and works with provincial and territorial governments and local health organizations. Fueled by Can$700 billion, Infoway has committed to investing more than Can$612 million in provincial and regional healthcare information technology projects throughout Canada.

Approximately Can$280 million has already been committed to diagnostic imaging projects, out of an allocated Can$310 million. The organization expects that by April 2007, 8% of its diagnostic imaging-related projects will be completed, 34% will be in an implementation phase, and 48% will be in the planning stage.

Establishing PACS in community hospitals and major outpatient treatment centers in each of the provinces and territories is a big step toward the broader healthcare networking goal. The model of a provincial PACS consists of one or several shared data repositories; site-specific and centralized provincial PACS management; and for many provinces, selection of a single vendor to provide RIS, PACS, or integrated RIS/PACS.

"The benefit of a shared data center that can manage between one and 1.5 million annual studies is that it expedites the benefits of sharing patient reports and images," said Terry Moore, diagnostic imaging program manager for Canada Health Infoway. "It is very cost-effective and builds in sustainability of technology and support."

Nova Scotia, the first province to achieve a 97% filmless status, with images for all hospitals and outpatient treatment centers stored in a fully redundant shared repository, is an excellent example of this concept, he said.

More than 80% of Canada's healthcare facilities are small hospitals and outpatient treatment centers. Infoway does not believe that facilities producing fewer than 20,000 procedures annually can cost-justify a PACS.

It is more effective to integrate them within the infrastructure of a PACS-enabled hospital. These are interconnected within each region, and the regions connect to a provincial repository.

In addition to the usual efficiencies that PACS provides, provincial digital diagnostic imaging repositories will provide rapid access to images by remote healthcare providers. These may include radiologists or specialists who provide offsite primary interpretation. Immediate access to images is expected to reduce a portion of the time patients wait to receive specialized care, including scheduling of additional diagnostic procedures, a contentious issue in almost every province.

In a presentation made at the Canada e-Health 2006 conference in Victoria, BC, Infoway estimated that a countrywide network of provincial PACS will have a Can$9.1 billion positive impact over a 10-year period. With capital investments and operating costs estimated at Can$7.4 billion, the net savings, measured by better utilization of diagnostic imaging resources, will be Can$1.7 billion. This represents a productivity savings of 60% and film-related expense savings of 40%.

At the same conference, Richard Alvarez, Infoway's CEO, called upon the federal government to allocate an additional Can$7.8 billion in capital funds for healthcare information technology projects over the next decade. This level of investment will ensure deployment of healthcare IT systems, including patient registries, electronic health records, and filmless radiography systems throughout the country, he said.

Alvarez called upon regional health authorities and the provincial and territorial governments to match these funds. Since its founding in 2001, Infoway has provided between 50% to 75% of capital funding for these projects.

According to a new report prepared by Canadian Healthcare Technology, based on survey responses from 51 hospital and health region chief information officers, the average percentage of hospital budget devoted to IT in 2005 increased to 2.5%, compared with 1.4% in 2003. The survey identified implementation of PACS as the top clinical IT project in development. Approximately 20% of all hospitals in Canada have installed PACS, representing 32% of the country's annual exam volume. The Canadian Association of Radiologists would like to see 80% to 90% of major hospitals and clinics become PACS-enabled by the end of 2008.

Infoway is mandating that the projects be standards driven and that all PACS vendors meet Integrating the Healthcare Enterprise profile requirements. The emphasis on adhering to international standards is a requirement in all requests for proposals.

At the same time, Infoway is underwriting a research project to determine the amount of lossy image compression that can be considered an acceptable standard of care. The work is pertinent in that compressed images that do not detract from diagnostic interpretation require less bandwidth to transfer and less space for archiving. The research is being conducted by the Canadian Association of Radiologists. Dr. David A. Koff, an assistant professor of radiology at the University of Toronto, heads the project and is soliciting input from radiologists practicing in Canada.

Ms. Keen is a PACS consultant and imaging technology analyst with i.t. Communications, headquartered in Palm Beach, FL. Her industry consulting includes engagements with Agfa Healthcare, Acuo Technologies, Eastman Kodak, GE Healthcare, Imaging Dynamics, IDX, Merge e-Film, Philips Medical Systems, Siemens Medical Systems, SmartPACS, Sorna Corporation, and Talk Technology.