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Title and Description
Imaging Network in Valencia
Reviewed/ candidate case
Quality reviewed case
Short description
The Imaging Network project integrates digital imaging technologies in the region of Valencia, Spain. The regional health network consists of 27 hospitals and around 900 primary care centres which share images across the entire health system in the Region.
The objectives of the project are to: - Reducerepeated hospital visits by improving information flows between providers - Improvediagnosis by providing physicians with a clearer picture of the patient’s condition and historical imaging tests. - Shorten waiting lists by reducing radiology bottlenecks and demand for imaging facilities - Improvediagnoses by facilitating groups of specialists to view images simultaneously from multiple locations - Ensureinteroperability between information systems and telecommunications in the health system - Reduce costs by eliminating dedicated DICOM networks through integrating other, non-DICOM medical imaging modalities into the DICOM system
Detailed description
The aim of the project is to develop a regional integrated digital imaging network. The system consists of connecting radio-diagnostic services to hospital information systems (HIS) and radiology information systems (RIS) which allow images to be viewed from a single access point (independent from image modality) at anytime and any authorized place. Interfacing between multiple modalities provides a more consistent and more reliable dataset. There is less risk of entering an incorrect patient ID for a study as patient ID and name are retrieved from the HIS preventing data entry errors during acquisition. Once the acquisition is complete, the PACS can compare the embedded image data with a list of scheduled studies from RIS, and can flag a warning if the image data does not match a scheduled study. The timeframe to implement PACS is detailed in Figure 1.
To date, all regional health facilities are equipped with digital imaging interconnected with the HIS, PACS and RIS. The next step is to integrate the independent systems into the regional network.
The health authority has allocated a budget of €45 million to achieve their strategic results in modernising health information systems from 2005-2009. This funding covers all planned services, hardware and software for all information systems including the integrated imaging network. The imaging network project is funded solely through public financing and over the past 10 years, the regional government of Valencia has invested around 7.5 million Euros to establish a medical grade network.
The regional health authority aims to develop a fully interoperable digital imaging system, interconnected between all public health centres. To achieve this, the first challenge was to develop a single DICOM gateway to make the existing five PACS vendor systems interoperable. The gateway was developed to initially be compatible with any standard PACS or Radiology Information System (RIS) and then was further enhanced to integrate other imaging modalities used in clinical specialities including anatomopathology, traumatology, cardiology, dermatology, digestive, gynaecology, ophthalmology, otorhinolaryngology, pneumology, urology, and technical imaging procedures used in more than one specialty, such as endoscopy. Secondly, a common storage solution for all DICOM and non-DICOM images, stills or video was developed to ensure storage in the same format for all images. Thirdly, the project developed a technical solution to overcome the latency issues in the current wide area network so that images can be transferred quickly.
The vision for the project began in 2001 as the government specified the plans to implement digital imaging technologies in the health facilities in the region with the aim to integrate these systems region wide. The full realization of this modernization is further detailed in the Strategic Health Plan for the Valencia Region 2005-2009
2005-2006 Improve the WAN bandwidth to allow the stable, secure transmission of images. The imaging project was an early priority, so the network requirements of the integration software were a significant factor in determining capacities.
3rd milestone
Improve security on the network to ensure full compliance with European Union regulatory mandates on data protection. Unencrypted images are transmitted separately from any contextual data, which travels through a secure socket tunnel, until they are reunited only at the point of use which is regarded to fully satisfy regulatory requirements.
Start of routine operation
2005
Evaluation
In the past
Ongoing
Characteristic of the application
Country
Spain
Part in the healthcare chain
Diagnosis
Therapy
Level of Implementation
Regional
Technology
Customised solution
Details on Technology
The integrated imaging network is based on a scalable, high-performance Cisco Medical-Grade Network, which enables the acquisition, processing, and delivery of high-resolution radiology images to clinicians. The three main provincial nodes of the network – at Valencia, Castellón and Alicante –run on a core bandwidth of 155Mbps. Service is extended at 34Mbps to 22 connection nodes each covering part of the regional health authority and in turn link to local medical centres at speeds of up to 2Mbps, depending on local needs. Within hospitals, LANs speed ranges between 1-10Gbps. Image viewing terminals typically connect to the network at 100Mbps. The integration of the network uses the regional government’s Rhapsody™ integration platform, operating over a Solaris platform. Rhapsody™, from Orion Health Companyiv, offers guaranteed delivery of messages, with effective management of the resending process, traceability and auditability. It is flexible and easy to deploy, employing Java to apply a variety of functional adaptations before the actual construction phase, and has proved equally adeptable to handling common medical formats such as HL7 and DICOM.
As of 2006, all 900 primary care centres on the Valencia network were envisioned to be able to connect with the 20 hospitals in the Valencia network. The connectivity was planned to allow for quicker, easier access to clinical information including all reports and images to improve the accuracy and speed of diagnosis and the evaluation of treatment options. By 2007, the capability of image transfers between primary care and specialist hospitals were developed. In an initial study on emergency teleneurology, examinations could be made at a general hospital to decide whether a patient needs transferring to a specialist unit, for instance. The images were then accessed by the specialist unit on the network and evaluated by its experts, reducing the time patients spend at the unit and cutting out needless patient travel between sites. Although the project enjoyed great success at this stage, the momentum for the initiative decreased substantially with changes in local political health priorities resulting in restricted budgets for the project. While the technical infrastructure to digitalize images is established in the regional health facilities, the interconnectivity- the integrated network is still under development.
Wider impact
Once further established, Valencia plans to use the integrated network to develop several other telemedicine programmes taking advantage of digital imaging. The telestroke programme, electro-cardiology programme, and telemammography programme are examples. In telemammography, the system can store and analyse 30,000 mammograms collected at screening centres throughout the region.From a cost position, the replacement of some specialist departmental imaging systems for instance, in ophthalmology – has already brought savings. In a single hospital, €100,000 a year was saved on licensing fees and a further €20,000 on maintenance. Across the region as a whole, the savings could potentially exceed €1 million a year.
Results expected?
The range of imaging modalities and devices integrated with the digital platform includes not only radiology, but all the specialised medical colour imaging modalities. Although the five PACS types installed in separate facilities each use their own DICOM system, they can now work with a common standard. Devices that have been successfully integrated with the platform include microscopes, ultrasound machines, digital cameras, endoscopy cameras, echocardiographs and others. In ophthalmology, at least 15 device types from four vendors are part of the system. In surgery, equipment in the operating rooms is able to display relevant images to help surgeons in real time.
Success factors
The following factors have been critical to the success of the project: - Selecting and implementing the right technology. A solid WAN infrastructure, interoperability between systems and integration technologies which allow conversion to DICOM and storage in PACS independent of vender technology has been invaluable. - Effective communication throughout the project with the health professionals reinforcing the benefits of the new system, its potential, and providing the appropriate training at frequent intervals. - A community wide commitment to the project including policy makers (top level decision makers), healthcare facility directors, and vendors is essential
Failure factors
The following factors have lead to challenges in rolling out the project as planned: - Prioritization. It is essential that the project is and remains a priority for the high-level decision makers throughout a longer period of time. Health authorities face consistent pressure to deal with a wide variety of demands on the health system, limited resources and competing concurrent projects. . - Continuous changes in key stakeholders. Health authorities, by their very nature, change as elections are held and various political parties gain power. In a public health system such as that in Valencia, a political change within the timeline of the project cascades into changes in many of the key actors involved in the project including political and provider authorities. An effective mechanism to mitigate for continuous changes in key actors is essential.
References
References and dissemination
The case study could not have been completed without the valuable assistance of the persons involved in the Imaging Network in Valencia project. We are grateful for the interviews and research materials provided by Oscar Lopez from C2C and Augustin Capilla from Cisco and for their helpful insights on the project.
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