New South Wales, the most populous state in Australia (capital: Sydney), encompasses 7.24 million citizens, or 32 percent of Australia’s total population. Healthcare IT leaders there are working on some very exciting initiatives these days. The state-managed health system, NSW Health, involves over 200 hospitals and clinics connected to a statewide vendor-neutral archive. What’s more, the broader architecture NSW Health created is this: a statewide enterprise imaging repository, as part of a statewide health information exchange (HIE) architecture.
In July 2012, NSW Health began the statewide rollout of its enterprise imaging repository, engaging a Fujitsu-led consortium, including the Milwaukee, Wis.-based TeraMedica to help them develop and implement the solution. Managed under eHealth NSW, the enterprise imaging repository program pursued a rolling rollout across 2012 and 2013. Among the goals of the overall initiative: to reduce repeat procedures as patients move from hospital to hospital for care; to provide better access to medical imaging information by connecting different health services; and to innovate better models of care through multi-disciplinary collaborations.
Recently, HCI Editor-in-Chief Mark Hagland interviewed a number of key players from the eHealth NSW team: Tony Lopes, enterprise architect; Freeman Wong, program manager; and Neil Frantz, service manager, regarding their team’s groundbreaking initiative, and their perspectives on their progress so far. Below are excerpts from that interview.
Tell us about the impetus and strategy behind this initiative.
Freeman Wong: We’ve focused on implementing a statewide enterprise imaging repository, as well as a range of supporting ehealth elements. The medical imaging program in New South Wales consists of two streams—implementing RIS [radiology information systems] and PACS [picture archiving and communications systems] throughout the state, and creating an enterprise imaging repository. We have a federated model, meaning each district or hospital network has its own implementation of electronic medical record, RIS, and PACS. End result is that NSW Health has a number of disparate RIS and PACS implemented across the state with no real means of communication with each other. That’s where the enterprise imaging repository comes in; it’s not only linking all EMRs through a patient registry, but also provide universal access to the state image repository.
So that means you have a statewide patient registry, too?
Wong: Yes, supporting the statewide enterprise imaging repository, requires linking of patient records across all health jurisdiction. Essentially, at the back end of that the enterprise imaging repository solution is the enterprise patient registry. Every patient treated in each jurisdiction is given a patient number and the enterprise patient registry provides linkage to these identities.
Tony Lopes: We’re mainly publicly funded, and as a result, each local health district has implemented its own systems. So for example, if a patient visited a facility in far northwest New South Wales and then got transferred into Sydney, they were transferring across local health system boundaries; so one key piece of infrastructure we implemented was the statewide patient registry. It’s a statewide master patient index or registry project. But essentially, it receives real-time patient feeds from all the systems from all the districts, and then that enables the subsequent linking of any information from an EMR or any other system. And that allows us to link radiological studies.
Like an HIE?
Lopes: It’s similar to an HIE, but the difference between an HIE model and what we’ve got is that NSW Health adopted a repository model where all medical imaging studies are now stored in a statewide repository. And we are storing clinical documents also; we’re going to store pathology information moving forward. It’s all about having the patient at the center of care, and making the information available to providers irrespective of where information on the patient was collected. And one objective has been to be as little disruptive to the 15 local health districts as possible.
Wong: From a local workflow and clinician and radiologist perspective, they will continue to use their local identifiers.
Is New South Wales the first Australian state to have achieved this?
Lopes: Yes, and the only other organization that has done this in the Asian region is Singapore Health. But the New South Wales implementation is unique.
What kind of volume of data is involved?
Lopes: 17,000 people spend a night in a hospital on a typical day; 6,500 ED patients daily; 5,000 daily admission to a public hospital; 5,000 babies are born every day… more broadly, on a yearly basis, there are about 1.2 million admissions per year, about 1.9 million ED visits; NSW Health employs 150,000 employees, we are the largest health services in Australia. We manage the public health system that is publicly funded. NSW Health doesn’t operate private hospitals or primary care or GPs.
Wong: And with the enterprise imaging repository, we’re talking about 4 million radiologic studies a year. The pilot phase started in 2010. And it went all the way to the end of June 2012, including detailed design, etc. The way we did the pilot system, we chose two local health districts and a children’s hospital that are nearby. Because they operate different RIS/PACS systems, so from the proof of concept’s perspective, we wanted to make sure different vendors and system platform could communicate with each other. At the end of that pilot process, the program was approved to proceed to general deployment phase of the program. We rolled out the enterprise imaging repository solution across the remainder of the state from July 2012 to April 2014.
You’re already three-and-a-half years into this?
Were there any challenges at the beginning?
Wong: From our perspective, one of the key challenges has been interoperability across different systems. The solution involves four different RIS PACS vendors running on ten separate instances utilizing both DICOM and HL7 platform. Another one of the challenges has been the siloing of data across the Health Service as a result of the federated model. We developed and deployed a common data model approach, to make sure information sent from one jurisdiction can be consumed and communicated with all others.
Lopes: At first, many PACS/RIS vendors said the enterprise imaging repository project couldn’t be done. So it’s a credit to the team and to TeraMedica, that we have been able to achieve all the outcomes we’ve been able to achieve. The challenges, and this is typical of any integration project, are the interoperability challenges. Issues around messaging; not so much around HL7 or DICOM standards themselves, but the intricacies and variations of how these standards have been implemented and the way the PACS and RIS systems have been configured, has been quite challenging, because they’re all different. We have four different vendors—GE, Siemens, an Australian vendor, CDN [Central Data Network], and Carestream, and they’re all slightly different, with different versions being live at different facilities. In some ways, from what we’ve heard, this could be unique in the world in terms of the level of connectivity and interoperability involved. In our case, unlike in others, radiologists don’t have to use any non-native applications or workstations; they simply use the PACS system they’ve been using all along, and because of the data integration via HL7, enterprise service bus, and patient registry, all the information flows as expected. So a GE study will show up in a Siemens PACS, if it’s necessary for a radiologist to diagnose and treat a patient. And it all happens automatically, and that’s really unique. That’s a straight PACS-to-PACS communication, or a RIS-to-RIS communication.
Going back to a point made earlier, one of our fundamental principles in this is that we wanted to implement a solution as minimally disruptive to the clinical workflow as possible, so that the clinicians would use the systems they use today in their own workflow and practice.
What has been the response of clinicians?
Lopes: It’s been very, very positive. We’ve especially seen positive comments among physicians around transferred patients. For example, a patient who had a traumatic incident in far west, rural New South Wales, and who had to be transferred into a metro hospital; the patient’s studies are now immediately accessible to the physicians here. That reduces access block, increases throughput, decreases costs, potentially decreases a patient’s exposure to excessive radiation or repeated tests. And the general physicians can now view these studies in their native EMRs.
They also don’t have to do anything special?
Wong: One of the key benefits, or outcome we achieved with the enterprise imaging repository really is leveraging the platforms already established in the RIS PACS stream and having imaging information being able to be shared across the entire state. Clinicians from various settings can have access to this valuable information.
Tony Lopes: And in terms of our metropolitan local health districts, we have cross-border flows of up to 20 percent; that’s 20 percent of patients for whom we in the past didn’t have ready access to their records. So a woman who might have had mammography tests in a different hospital or district, now, the radiographer, following a breast cancer diagnosis, would have access to those mammographies and other priors.
What have been the main lessons learned so far?
Wong: Even though it is the same RIS/PACS vendors, they have different deployments and settings within each RIS PACS instance; so the cookie-cutter approach we thought might work initially during the pilot phase, didn’t actually work. From a local workflow perspective, each hospital operated differently, so concessions had to be made for individual settings. Before the enterprise imaging repository project, things were quite siloed. Now, with patients in the enterprise imaging repository, or EIR, clinicians are now able to view radiology information across the state and irrespective of where it was obtained.
Lopes: Clinical buy-in and support have been very, very important. We had a steering committee from the beginning involving radiologists and referring physicians; we also had executive support at the highest levels of New South Wales Health, and that was absolutely essential. Freeman’s touched on the delivery side of things. I was involved through the procurement. You really have to get your requirements right; and your architecture right, on such a complex project..
Neil Frantz: And I think it’s worth mentioning that what we’re doing on a state level is consistent with a national approach across Australia.
Lopes: What we’ve tried to do as well through our architectural approach was to make sure the solution we’re implementing was aligned with the national level in Australia. For example, Freeman talked about standardizing a common radiological data model across the state. So now we can use this work as the basis to standardize radiology data nationally. And one project is the personally controlled electronic health record. It’s another repository that allows other state jurisdictions and the private sector to view radiology and other health information on a patient. Support for these nationally solutions wouldn’t be possible if we hadn’t implemented standards and the supporting infrastructure here in New South Wales.