Post on 19-Apr-2018
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Hong KongHospital Authority
Territory-wide Sharing of Digital Images in the Hong Kong Hospital Authority
Dr CP WongMBBS MRCP FRCP FRCPE FRCPG FHKCP FHKAM MHA
Chairman, Hong Kong Society of Medical InformaticsChairman, Clinical Informatics Programs Steering & Executive Groups
Hong Kong Hospital Authority
Hong KongHospital Authority
Outline
o Development of Electronic Health Records in Hong Kong
o The Image Distribution Project 2004o Success Factorso Conclusions
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Hong KongHospital Authority
Hong KongHospital Authority
Healthcare in Hong Kong
12%
70%
3%
15%
Primary CarePrimary Care
10%
90%
Secondary & Tertiary CareSecondary & Tertiary Care
OthersOthersDept HealthDept HealthPrivatePrivate Hospital AuthorityHospital Authority
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Hong KongHospital Authority
HK Hospital Authority (HA)
o Established 1991• 43 Public Hospitals• 46 Specialty Clinics• 74 General Clinics• 13m Outpatient attendances
o 29,022 Beds• 2.4m AED attendances• 1.2m Inpatient Discharges
o 52,000 Staff• 4,454 Doctors• 19,674 Nurses• 4953 Allied Health Staff
o 6.9 million populationo HA budget:
• US$4 billion 5% GDP• IT budget: 1.5%
Hong KongHospital Authority
The Clinical Management System (CMS)
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A Single Platform
Hong KongHospital Authority
The Clinical Management System (CMS)
o Used at all hospitals and clinics in the HA• 30,000 users• 12,000 workstations
o Multidisciplinaryo Information sharing
o Built by the HA ITD since 1993
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Hong KongHospital Authority
A long journey of development
o 1990 “Green field” – no legacy system o 1991 Patient Administration onlyo 1992 Pharmacy System addedo 1993 Lab results onlineo 1994 Radiology Information Systemo 1995 Clinical Management System
• Order Entry & Outpatient progress notes & Discharge summaries
o 2000 Electronic Patient Recordso 2004 Radiology Images onlineo 2006 ePR Sharing with Private Sector
Hong KongHospital Authority
Each Day
o 12,000 userso 90,000 patientso 2,000,000 transactions with data entrieso 300,000 data retrievals
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Hong KongHospital Authority
Functionality
o Direct clinician entry• Orders• Diagnoses, procedures, discharge summaries• Reports and letters• Notes
o Departmental data• Laboratory data• Radiology records
o Review, audit and research
Hong KongHospital Authority
Architecture of ePR
LIS PMS/EDSRISIPAS/ADT
SCIS
OPAS
Clinical Notes, D/C Summary, OE
H K P M I
H P I
Common Front End
Retrieve / EnqPatient Record
ReplicationePR
Replication &
Transformation
Longitudinal Patient Data(Central Storage of All Patients Data)
ePR
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Hong KongHospital Authority
The ePR (Electronic Patient Record)
o The comprehensive lifelong (womb to tomb) multimedia record of all relevant clinical data
o Patient centred vs function based• Breaking the silos
o Corporate based from hospital basedo Standardization of structure and content
Hong KongHospital Authority
Huge Data Warehouse
o 7.6 million patient recordso 57 million episodes of careo 540 million lab resultso 34 million radiology resultso 400,000 image studieso 1.5 Terabytes data volume + 3 Terabytes
images datao Sub-second response timeo Near real time update
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Hong KongHospital Authority
Screenshot
Hong KongHospital Authority
Longitudinal laboratory
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Hong KongHospital Authority
Data
o Simple numeric/texto Codeso Structured datao Images/PDFs
Hong KongHospital Authority
The ePR-Image Integration Project
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Hong KongHospital Authority
Images in the Hospital Authority
o Picture Archive and Communication Systems• Departmentally implemented and operated
o Increasing demand for image integration into CMS/ePR
o Estimated cost of comprehensive corporate PACS• HK$220million
o Budget for current project• HK$20million
Hong KongHospital Authority
Project Brief
o Distribute radiology images to clinicians via electronic Patient Record (ePR) on existing CMS workstations• Consolidate images from existing mini-PACS• Compress to clinical reference quality• Integrate images into the ePR/CMS• Gateway to support teleradiology• An infrastructure for all image types
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Hong KongHospital Authority
An interim step to full PACS
o “Reference quality” images vs “full quality”• 10 – 30 x compression
o Image selection vs store all images• Massive reduction for multidetector scanners
o Not “filmless” (maybe “less film”)• No requirement for 99.999% availability
o Leverage of existing infrastructure• No new networks and workstations
Hong KongHospital Authority
Major issues
o Workflowo Image quality
• Clinical suitability
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Hong KongHospital Authority
Wait for old filmLoan filmRe-take examination
Clinical
Radiology
Radiology
Radiology
(Re-)print filmFile film & envelopeTrack of missing film
Support callsTraining
Image Distribution
Admin/support image transfer
Image Archive
-Select imagesImage selection
Do Less?Do More?
Workflow - Do more or less?
Hong KongHospital Authority
Images Selection
Acquire Images
Print film
1. Sendprinted images(standard set)
MedicalImage
DistributionSystem
Review Images Mini-PACS
2. Selectkey images(optional)
Exclude some thin cut images
Radiographer Radiologist
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Hong KongHospital Authority
Data volume
80 terabytesper year
Hong KongHospital Authority
JPEG compression 15x “visually lossless”Kocsis O et al Comp Meth Prog Biomed. 71(2):105-15
MRI 10-20x no impact on brain lesion detectionTera S et al, J Digit Imaging, 13(4):178-90
CT scans 8-20x acceptableZalis ME, et al, Radiology 220(2):387-92Megibow AJ et al. Imaging, 15(2):84-90
Zheng LM et al, Acta Radiol;41(2):116-21
Research on image quality
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Hong KongHospital Authority
More studies
Ultrasound 9x no impactPersons KR et al
J Digit Imaging 15(1):15-21
Chest radiographs 15-40x acceptableSlone RM et al, Radiology 215(2):543-5
Savcenko V et al, Radiology, Vol 206, 609-616Kotter E et al, Investigative Radiology,38(5):243-9
Erickson BJ et al, J Digit Imaging, 10(3):97-102
Hong KongHospital Authority
Image quality
o What compression ratio is acceptable?o Type of studyo Degree of pathologyo Context-specific
• Initial impression• Definitive diagnosis• Review and study comparison
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Hong KongHospital Authority
Image quality study
o 160 clinicianso Several studies
• Normal• Marginal• Pathological
o Different compression ratios
Hong KongHospital Authority
1x 10x 20x
40x 100x
Image quality
What is the highestacceptable compression ratio?
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Hong KongHospital Authority
Data volume
80 terabytesper year
5 Tb/year
Hong KongHospital Authority
Architecture
Radiology Dept. B – mini PACS
onlineModality
Workstations
DICOM images
(1 month)
DICOMVia WAN
CentralArchive
CentralWeb Servers
ePR(with RIS /
Images link)
RIS integrated mini-PACS
Agfa: PYN, RHTSK, TKO(hospital-wide)
GE: QEH, TMH
Siemens: PWH, QMH
Secured internet access for on-call
radiologist(uses existing CMS
workstation)
ReviewImages
Clinical quality images
(life long)
Radiology Dept. A – mini PACS
online
On demand push images
Local Gateway /Web Server
tele-radiology web server
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Hong KongHospital Authority
Hong KongHospital Authority
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Hong KongHospital Authority
Hong KongHospital Authority
Benefits
o Clinician friendly access to images• From any clinical workstation
o Access to all of a patient’s images• Lifelong• From all sites
o Remote access to imageso Possibility of reducing film printingo Offline image backupo Sharing of ePR -> sharing of imageso Affordable
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Hong KongHospital Authority
Other images
o Computer generated images• Print images
o Digital photographso Scans
Hong KongHospital Authority
Endoscopy report
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Hong KongHospital Authority
Hong KongHospital Authority
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Hong KongHospital Authority
Hong KongHospital Authority
Privacy Measures
o Role-based restriction of view authority of users
o 2-factor authentication toolso SMS codes and notificationso Need to know / patient under care basiso Detailed audit trail loggingo Privacy ordinance
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Hong KongHospital Authority
Critical Success Factors
o Clinicians engagemento Requested by the clinicianso Designed by the clinicianso Built for the clinicianso Used by the clinicianso Governed by the clinicians
Hong KongHospital Authority
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Hong KongHospital Authority
CMS Utilization Figures (1)MOE utilisation for Outpatients
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Jul-06 Aug-06 Sep-06
HKECHKWCKECKCCKWCNTECNTWCOverall
Hong KongHospital Authority
GCR-LRS Utilization Report - In-Patient
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
TKO UCH QEH KWH PMH YCH CMC PYN RH QMH AHN NDH PWH TMH
KEC KCC KWC HKEC HKWC NTEC NTWC
Per
cent
age
of U
tiliz
atio
n
Jun/06
Jul/06
Aug/06
Sep/06
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Hong KongHospital Authority
Other Success Factors
o Unique citizen identity cardo Non-Big Bang Approacho Home-built systemo Careful implementation policieso Pilots siteso Dedicated User training teams
Hong KongHospital Authority
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Hong KongHospital Authority
Awards won
o 2004 Stockholm Challenge (Health)o IT Excellence 2005o APICTA 2005
Hong KongHospital Authority
Patient benefits
o Whole medical record available at point of care anywhere
o Saving money for repeated testso Saving lives by providing real-time and
accurate information for clinical decisionso Ensuring security and confidentiality of
patient data
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Hong KongHospital Authority
Clinician benefits
o More efficient clinical practice• No need to search for data
o Make decisions with comprehensive clinical information
o Avoid errors associated with paper records
o Access data and images at home or remote sites for expert consultations
Hong KongHospital Authority
The health system benefits
o More efficient and cost effective quality health service
o A massive clinical database for planning and research
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Hong KongHospital Authority
Summary
o A pragmatic approach to corporate image distribution
o Leveraging existing infrastructure and systemso Clinicians engagement is essentialo Issues
• Clinical suitability• Compression ratios• Workflow issues (less film?)• Other image types
Hong KongHospital Authority
Acknowledgementso Dr Wing Nam WONG, Manager (Health Informatics), Hospital Authorityo Mr Anthony CHEUNG, Senior Systems Manager, IT Division, Hospital Authorityo Dr NT CHEUNG, Executive Manager (Health Informatics), Hospital Authority