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June 3rd, 2014

Medical Imaging Strategic Plan 2014 – 2025

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Medical Imaging Strategic Plan 2014

Prepared by INSITE Consultancy Inc. 2014 Page 1

Strategic Planning Framework M A N D A T E

To provide a strategic plan for Medical Imaging to 2025, to aid in equipment planning, service provision planning, and to prepare Northern Health for the challenges of tomorrow.

G U I D I N G P R I N C I P L E S

Medical Imaging Services in Northern Health:

Will be innovative in meeting the challenges of service delivery in the North.

Will be inclusive in the planning stage to inform and support decision making.

Will be aligned with the over-all services offered by the facility and with HSDA planning of services.

Will be accessible and provided appropriately based on facility service levels.

Will demonstrate value to the public health system through strategies to reduce capital and operational costs on medical imaging equipment.

Will make decisions on equipment placement and operation that demonstrate acceptable return on investment.

Will seek to maximize equipment util ization through adopting benchmarked throughput targets.

Will uphold and pract ice quality in daily activities, and regards quality as foundational to service provision planning.

Will provide services that are accredited by the Diagnostic Accreditation Program of BC.

DISCLAIMER

This report was prepared by INSITE Consultancy Inc. for Northern Health Authority.

All reasonable care has been taken by Northern Health and INSITE Consultancy Inc. to achieve accuracy of this document, but accuracy cannot be guaranteed. By proceeding to the information beyond this notice, each reader waives and releases Northern Health and INSITE Consultancy Inc. to the full extent permitted by law from any and all claims related to the usage of material or information made available. In no event shall Northern Health or INSITE Consultancy Inc. be liable for any incidental or consequential damages resulting from the use of this material.

Copyright © Northern Health 2014. All rights reserved.

www.insiteconsultancy.com 14564 18A Avenue. Surrey. V4A 8A4 (604) 484-2160


Prepared by INSITE Consultancy Inc. 2014 Page i

Executive Summary The Medical Imaging Strategic Plan 2014 – 2025 is a critical review of current and future state for Medical Imaging (MI) services across Northern Health (NH) over the next 10 years. It is the result of a comprehensive consultation process and detailed analytical study of the current and future demand for services.

The most important challenges and priorities for the future are summarized in the Key Findings and Strategic Priorities, with additional information provided in the following sections and throughout the Strategic Plan.

K E Y F I N D I N G S

WORKLOAD: NH provided over 293,000 exams across more than two dozen facilities in 2012/13. Population is expected to grow 15% by 2020 (driven by LNG projects), but workload projections estimate a 25% to 28% increase in exam volume for the same period, as growth compounds with an aging population.

ACCESS: Rural communities with sparse populations have difficult access to MI services, yet insufficient demand to support the permanent implementation of local services. Alternative service delivery models should be explored, especially for: MRI, CT, Bone Densitometry, Digital Mammography and Ultrasound.

EQUIPMENT: MI services has $47m of equipment assets deployed, yet the replacement process is not centrally coordinated and not consistently evaluated through a business case process. This leads to an automated process of assumed equipment requirements and investment, which in some cases results in expensive assets being significantly underutilized (Bone Densitometry and CT scanners).

INFORMATION TECHNOLOGY: A provincial initiative now underway presents opportunities for NH to participate in provincial sharing of medical images and reports. With a surprising number of cases that are either imports or exports from NH, patients will benefit from continuity of care.

SERVICE PRESSURE POINTS: MRI: This is clearly the most pressing need in the Northeast and Northwest regions. The detailed analysis performed through this work confirmed the findings of the MRI business case (May 2013) and further recommends that specific MRI service locations be constantly reviewed as demand rises.

Ultrasound: This is consistently reported by stakeholders as the second most significant gap in service for the most rural communities. Trained staff shortages are the greatest constraint to address this gap.

Breast Health: Digital Mammography and the Provincial Breast Health strategy present a financial challenge to NH. It is expensive and the proposed deployment model by SMPBC will lead to 3 static units and 1 mobile unit, which are projected to be underutilized. However, breast screening participation rates are known to be related to access, and low participation is linked to late detection of breast cancer. The development of breast health centers of excellent is an opportunity for NH and is supported by strong evidence to be highly effective. Improvements in service are mainly due to process re-design and lead to a very large reduction in the time to diagnosis of suspicious breast cases.

S T R A T E G I C P R I O R I T I E S

Implement cross-education of staff on multiple modalities to address human resource shortage and critical mass issues, particularly in smaller and more remote communities.

Expand and create new rotating and mobile services to improve access in small communities with insufficient demand to safely support a full service locally.

Develop a patient centr ic model to allow users more control and flexibility on the choice of location to receive service, based on available capacity and wait times.

Achieve high equipment util ization through improved capital planning and operating models.


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C O N T E X T

Northern Health (NH) provides health services to more than 300,000 people over an area of 600,000 square kilometers. Services include acute care, mental health and addictions, public health, and home and community care. Within these services, Medical Imaging (MI) is an important support service to other core clinical specialties. MI comprises eight different modalities: Radiology and Fluoroscopy, Interventional Radiology, Ultrasound, Bone Density, Nuclear Medicine, Mammography, Computerized Tomography and Magnetic Resonance Imaging.

Similar to the rest of BC, and Canada in general, the population of NH is growing and aging. The compounded effect of these two factors is additional demand for services. In addition, the recently announced Liquefied Natural Gas (LNG) Strategy is expected to attract a large workforce to areas of NH, further increasing demand into the future.

Given the extent and complexity of MI service delivery, and considering the anticipated growth and aging of NH’s population, it became imperative to look into the future, estimate future demand, and develop service models that efficiently meet the needs of the population.

The MI Strategic Plan 2014 – 2025 looks at the next 10 years and makes projections for the future demand and recommendations for capacity replacement. The evolving nature of the population and service delivery means that multiple factors will continue to change and therefore this strategic planning exercise should be revised on a periodic basis to evaluate current progress and incorporate new planning considerations.

M E T H O D O L O G Y

This plan involved a comprehensive consultation process and analytical study. The engagement and planning process comprised several face-to-face meetings with NH staff, consultation with experts in the field, and a planning workshop with over 30 participants from different regions and areas of work in NH.

The analytical study was based on record-level data from the Cerner Hospital Information System and official population projections from BC Stats (adjusted for LNG workforce increase).

Utilization rates for each service were calculated at the population level for each Local Health Areas (LHA) in NH, using age and gender groups to better capture the aging effect in the population. Referral patterns depicting the sites where residents of each LHA go to receive services were determined. Access to services was also estimated using driving distance to the closest service location from each LHA.

Detailed demand projections were estimated using current utilization rates over the future population, and referral patterns used to distribute demand over the different sites. Two projection scenarios were developed: 1) Baseline, consisting only of current utilization rates and future population, and 2) Adjusted, involving additional service-specific assumptions developed during the consultation process.

To assist the planning process, two decision support tools were developed: the “Access Tool”, and the “Capital Equipment Planning Tool”. These are Excel-based applications with automated calculation routines, reports and charts. They allow the user to alter the present state parameters as equipment or services are developed or removed, and create scenarios to support decision-making.

P R E S E N T S T A T E A N D W O R K L OA D P R O J E C T I O N S

Utilization of MI services across NH varies significantly. The Northern Interior region generally shows high utilization rates across all services, while the Northeast has the lowest. This is in part due to the more limited access to services in the Northeast, resulting in some people accessing services outside NH.

Of special attention is MRI services. NH has the lowest utilization rate in the Province (33% lower), and only one MRI scanner, located in Prince George. MRI utilization rates outside the Northern Interior are extremely low, likely due to very limited access. Based on the size of the population and distance to the existing service location, Peace River North and Terrace are logical future locations for MRI services.


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In contrast, there are 7 CT scanners in 6 different locations and no significant wait times. Equipment utilization is very low (25% or less) at many sites. Despite the available capacity, utilization rates are still lower than the Provincial and National averages, especially for the Northeast region. To reduce inefficiencies, staffed operating capacities should be reduced in all under-utilized CT scanners to achieve a 75% target utilization.

Projected MI exam volumes anticipate significant growth across all services and sites. Exam volumes are estimated to increase by 25% to 28% in 2020. Looking further into the future, population by 2025 is expected to decrease from 2020 due to the conclusion of LNG construction projects. However, even with that reduction in the population, exam volumes will only decrease slightly, mostly due to the aging effect.

Scenario/ Period MR CT NM US BD IR XR MA Total Growth

from 2012

2012/13 5,273 27,917 6,156 55,830 2,364 827 186,503 8,896 293,766 Baseline

2020 6,107 35,595 7,961 70,134 3,096 1,084 232,352 11,529 367,859 25% 2025 5,950 35,942 8,282 66,832 3,304 1,164 226,405 10,857 358,736 22%

Adjusted 2020 9,676 33,815 7,961 70,134 3,406 1,084 236,999 12,913 375,988 28% 2025 8,822 34,145 8,282 66,832 3,634 1,164 230,933 12,159 365,971 25%

Actual and Projected Exam Volume by Service and Period

MRI services are expected to increase significantly as Provincial utilization rates are adopted throughout the region. Exam volumes would double by 2020 under these assumptions. Although there are no finalized plans to implement the recommendations of the 2013 business case, additional service locations will likely be required in the future.

Projected increase in volumes for other services could reasonably be accommodated within the existing sites, although additional equipment and staff may be required to properly handle the additional demand.

A direct consequence of the LNG construction projects, communities like Fort Nelson, Kitimat and Prince Rupert will experience the largest relative growth in demand, creating pressure on local facilities. Fort Nelson General Hospital, Kitimat Hospital and Health Centre and Prince Rupert Regional Hospital will likely experience increased demand for services they provide, like General Radiography and Ultrasound, but will also see an increased need to refer patients to other sites for services like CT and MRI.

S E R V I C E D E L I V E RY M O D E L S

Perhaps the biggest challenge for the provision of health care services in NH is the geographic distribution of its population, with many small communities distant from each other. In many cases, this means low local demand per service at many locations, insufficient to sustain fixed-site service delivery safely from a clinical point of view and efficiently from an administrative perspective.

The response to this situation is demand consolidation at select sites, at the expense of larger distances to access the services. But even with this approach, many times there is not enough demand to warrant the full provision of service, limiting hours of operation.

To improve service efficiency, staff needs to be cross-educated in multiple modalities so they are shared across services. This makes staff more specialized and harder to recruit, especially in more rural locations where they are needed more and often harder to attract. A Human Resources strategy needs to be implemented to address these issues effectively.

Additionally, the implementation of rotating and mobile services aids in the provision of services to smaller communities. This opens further possibilities but requires equipment to be installed in specially conditioned vehicles and suitable parking “pads” (to be shared by different services, such as MRI, CT digital mammography) to be constructed at each location.


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Recommendations on equipment replacement criteria, prioritization and life expectancy from the CAMRT/CAR Lifecycle Guidance of Medical Imaging Equipment in Canada (2013) should be critically reviewed by the Medical Imaging program with an intention of adopting its recommendations.

E Q U I P M E N T A N D C A P I TA L P L A N N I N G

MI equipment in NH is in different stages of their estimated life cycles. Based on the present equipment condition and CAMRT/CAR recommendations for equipment replacement criteria, prioritization and life expectancy, a preliminary equipment replacement schedule has been developed.

The estimated cost of equipment from 2014 to 2025 is $47,621,000, as shown in the following table. Purchases of new MI equipment beyond replacement of existing inventory is not included in this estimate.

Replacement Year

Northwest Northern Interior

Northeast Total

2014 $2,208,000 $4,818,000 $170,000 $7,196,000 2015 $4,888,000 $2,050,000 $70,000 $7,008,000 2016 $2,065,000 $885,000 $1,340,000 $4,290,000 2017 $983,000 $2,425,000 $968,000 $4,376,000 2018 $750,000 $3,976,000 $950,000 $5,676,000 2019 $1,565,000 $2,120,000 $1,588,000 $5,273,000 2020 $750,000 $1,170,000 $2,200,000 $4,120,000 2021 $1,200,000 $2,332,000 $1,940,000 $5,472,000 2022 $1,270,000 $770,000 $2,170,000 $4,210,000 Total $15,679,000 $20,546,000 $11,396,000 $47,621,000

Preliminary equipment replacement cost by HSDA, 2014 to 2022.

Using the Capital Planning Tool and applying more aggressive replacement policies, life expectancy can be extended a few years for equipment with low utilization. Such a scenario could decrease the estimated replacement costs between 2014 and 2025 to $44,421,000 resulting in a capital cost saving of $3.2m.

S U M M A RY O F M O D A L I T Y S P E C I F I C R E C O M M E N D A T I O N S

Radiology and Fluoroscopy

1. Eliminate all film printers as part of a filmless strategy, while developing downtime and service continuity plans that are independent of hard copy images.

2. Require all Digital Radiography (DR) purchasing decisions to be subject to a business case that considers a threshold volume that justifies DR over Computerized Radiography (CR).

3. Consider multi-purpose rooms in place of dedicated fluoroscopy equipment replacement. 4. Review the number of CR readers available in all CR sites; 1 CR reader can support 2 rooms

provided there is one additional reader available for redundancy (regional spare).

Interventional Radiology

1. Continue monitoring volumes to assess utilization and capacity needs.

Ultrasound:

1. Improve access to ultrasound and echocardiography services in underserved communities: a. Initiate a program to cross-educate medical imaging technologists. b. Engage BCIT or a similar institution as a partner to resolve staff shortage in ultrasound and

echo in the North. 2. Apply to the Diagnostic Accreditation Program (DAP) for remote status in ultrasound. 3. Develop a business case for remote ultrasound and echocardiography in under-served communities.


Prepared by INSITE Consultancy Inc. 2014 Page v

Bone Densitometry

1. Review utilization rates per site and alter service delivery models from fixed units to a mobile service. 2. Use the equipment planning and the access to service tools provided to determine the optimal solution

and rotation frequency to maintain current utilization rates in each HSDA.

Nuclear Medicine

1. Closely monitor volumes and referral patterns using data from the Cerner system. Influences such as a shift of referral to alternate modalities like CT and MRI need to be reviewed at least annually.

Mammography

In Europe the breast health organization, EUSOMA1 has developed a first-class operational model for suspected breast cancer. Instead of waiting weeks or months for a definitive diagnosis 80% of patients can receive the “all-clear” the same day and all remaining cases will have a definitive diagnosis in less than 15 working days. Northern Health has an opportunity to excel by developing breast clinic Hubs based on the EUSOMA model. The EUSOMA model is consistent with the provincial breast health strategy that is summarized in Figure 11. The Hubs adopt an operational process by arranging clinical specialties (pathology, radiology, surgery and oncology) arranged in a “one-stop” clinic model. The service providers are arranged around the patient instead of the traditional model which revolves around the “constraints” of the service (Figure 12).

Recommendations for Mammography are:

1. Align the digital mammography strategy for the North with the Provincial strategy for the roll out of the digital mobile screening unit operated by SMPBC.

2. Adopt the Provincial Breast Health Strategy and actively work towards the development of one EUSOMA-based breast health hub with future expansion to one hub per HSDA.

3. Transition to digital mammography, screening and diagnostic (shared unit) using a mobile mammography service.

a. Develop a business case to define the service and justify the capital and operating costs. 4. Consolidate mammography reading on fewer radiologists to achieve the BCCA minimum

mammography reads per radiologist per year.

Computerized Tomography

Access to CT is critical to the treatment decisions of suspected stroke victims. If a cerebral hemorrhage can be ruled out in less than four and a half hours (4.5) of onset2, thrombolytic therapy can be given and long term brain damage can be avoided.

1. In sites with under-utilized CT scanners, increase utilization through a combination of reduced operating hours and reallocation of workload to patient choice based on location and first available appointment.

2. Require all CT scanner replacement (particularly Quesnel in 2015 and Terrace in 2016) to undergo a business case process that considers access to service, mobile options and radiation risk.

3. Using the Capital Planning Tool provided, adjust the equipment replacement plan for CT to avoid replacing or investing in additional CT scanners unless there is sufficient justification within the HSDA.

1 http://www.eusoma.org/Index.aspx 2 NICE technology appraisal guidance 264.Alteplase for treating acute ischaemic stroke (review of technology appraisal guidance 122) Issued: September 2012

http://www.eusoma.org/Index.aspx


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Magnetic Resonance Imaging

1. Implement a new mobile MRI unit serving the Northeast and Northwest, and replace the existing (old) MRI unit at UHNBC.

2. Continue to monitor the MRI service in the context of growth in MRI demand. 3. One year after implementation of the mobile service re-evaluate the demand for MRI and plan for

future investment in fixed MRI using the planning tools provided as an adjunct to this report.

Information Technology

1. Engage with the Provincial Diagnostic Imaging project to enable the NH Picture Archiving and Communication System (PACS) to store data in the Diagnostic Imaging Repository (DI-r).

2. Consider the option to adopt the DI-r as the primary PACS archive for NH once implemented in 2015. 3. Consider extending the PACS and Radiology Information System (RIS) to the local Community Imaging

Clinic (CIC) in Prince George as a means of achieving access to CIC-sourced imaging results. 4. Systems need to shift to become patient centric, allowing from self-booking and changing

appointments to viewing reports and images. Other technology opportunities for patient access to results and services need to be evaluated as well.


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Table of Contents

INTRODUCTION ................................................................................................................... 1

METHODOLOGY .................................................................................................................. 3 Engagement and Planning Process ............................................................................................................... 3 Medical Imaging Services .............................................................................................................................. 3 Service Locations .............................................................................................................................................. 3 Population Analysis .......................................................................................................................................... 4 Demand Analysis .............................................................................................................................................. 5 Referral Patterns and Catchment Areas ...................................................................................................... 6 Demand Projections ......................................................................................................................................... 7 Access Analysis ................................................................................................................................................. 8 Planning Tools ................................................................................................................................................. 10

PRESENT STATE ANALYSIS ................................................................................................ 11 Population Estimates and Expected Growth and Aging ........................................................................ 11 Medical Imaging Exam Volumes and Utilization ..................................................................................... 13 Geographic Access ........................................................................................................................................ 15

FUTURE NEED .................................................................................................................... 21 Demand Projections ....................................................................................................................................... 21 Operating Capacity ...................................................................................................................................... 24

SERVICE SPECIFIC REVIEW ................................................................................................. 27 Radiology and Fluoroscopy ......................................................................................................................... 27 Interventional Radiology............................................................................................................................... 28 Ultrasound ........................................................................................................................................................ 29 Bone Densitometry ......................................................................................................................................... 33 Nuclear Medicine ........................................................................................................................................... 34 Mammography ............................................................................................................................................... 35 Computerized Tomography ......................................................................................................................... 41 Magnetic Resonance Imaging ...................................................................................................................... 44 Information Technology ................................................................................................................................. 46

CONCLUSIONS AND RECOMMENDATIONS ...................................................................... 49 Strategic Planning Exercise .......................................................................................................................... 49 Present State ................................................................................................................................................... 49 Volume and Workload Projections ............................................................................................................. 50 Service Delivery Models ............................................................................................................................... 50 Summary of Modality Specific Recommendations ................................................................................... 51 Equipment and Capital Planning ................................................................................................................ 52

APPENDIX I: ADDITIONAL DEMAND PROJECTION INFORMATION ................................. 57 Demand Projections by Service for each LHA and Period .................................................................... 57 Demand Projections by Service for each Site and Period ..................................................................... 60


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APPENDIX II: PRELIMINARY EQUIPMENT REPLACEMENT PLAN ....................................... 63

APPENDIX III: METHODOLOGY DETAILS ........................................................................... 67 Population Adjustment Due to Increased Workforce .............................................................................. 67 Appointment Data and Exam Counts ......................................................................................................... 67 Projection Assumptions – Adjusted Scenario ............................................................................................. 68 Aggregated Demand Projections by Step ................................................................................................ 69

APPENDIX IV. STAKEHOLDERS CONSULTED IN THE PLANNING PROCESS ...................... 71

APPENDIX V. FACILITY SERVICE LEVELS ........................................................................... 73



Introduction Northern Health (NH), one of the 5 regional health authorities in British Columbia (BC), provides health services to 300,000 people over an area of 600,000 square kilometers. Services include acute care (hospitals), mental health and addictions, public health, and home and community care. More than 7,000 people work in the multiple facilities within NH, including over two dozen hospitals, 14 long term care residences, and many public health units and specialized offices.

Similar to the rest of BC, and Canada in general, the population of NH is growing and aging. These two factors, especially the latter, have a deep impact on the demand for health care services and the associated resources. In addition, the BC government has recently announced a range of new industry projects that will have a profound effect on the region. In particular, the Liquefied Natural Gas (LNG) Strategy is expected to bring a boom of construction that will attract a large workforce to areas of NH. This will further increase the demand for health care services into the future.

Within health care services, Medical Imaging (MI) is an important component. The business of MI is a support service to other core clinical specialties. Referring physicians require the assistance of various modes of imaging technology and expertise to assist with diagnosis and clinical management of their patients. The efficiency and effectiveness of the diagnostic process has a significant impact on treatment decisions, cost and clinical outcomes of patients. It is generally understood that early accurate diagnosis provides a significant opportunity to reduce the length, complexity, anxiety and cost of the entire clinical journey in a large number of disease processes. Typically, excellence in MI services is defined in terms of the quality and timeliness of diagnostic information being presented to referring physicians. To achieve high performance the specialty relies on a range of high-technology imaging equipment and information systems that are used according to the specific diagnostic situation.

MI comprises several different modalities: Radiology and Fluoroscopy, Interventional Radiology, Ultrasound, Bone Density, Nuclear Medicine, Mammography, Computerized Tomography and Magnetic Resonance Imaging. All services combined, NH provided about 293,000 MI exams in the 2012/13 Fiscal Year. Services are provided across the entire region in facilities ranging from large referral hospitals providing all services, to small diagnostic and treatment centres offering core services only.

Given the extent and complexity of MI service delivery, and considering the anticipated growth and aging of NH’s population, it became imperative to look into the future, estimate future demand, and develop service models that efficiently meet the needs of the population.

The MI Strategic Plan 2014 – 2025 presented in this report is a critical review of current and future state for Medical Imaging across Northern Health over the next 10 years.

This Strategic Plan focusses on MI services to 2025 and encompasses the following objectives:

1. Assess / leverage the present state of MI services and the extent to which they meet the health needs of the catchment populations

2. Describe the future state MI service need and mix 3. Propose a blue print for MI equipment in each HSDA for the year 2025 4. Make recommendations for best practice in:

a. Information Management b. Organizational Best Practice


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R E P O R T O R G A N I Z A T I O N

The MI Strategic Plan 2014 – 2025 starts with a brief Introduction to set the context of the report.

Next, the Methodology section presents a high-level description of the planning process, the services and sites, and the approach used throughout the current and future state analysis and report preparation. Supplementary information is provided in Appendix III: Methodology Details.

The Present State Analysis provides a look at the population today and into the future, summarizes current service utilization across the region, and evaluates access to services.

The Future Need section presents demand projections by service from both a population and a facility perspective, under two planning scenarios. More detailed projections are provided in Appendix I: Additional Demand Projection Information.

The Service Specific Review section looks at each service in more detail, describing its present state, future trends and recommendations.

Finally, the Conclusions and Recommendations summarizes findings from the entire planning process and presents recommendations for MI service delivery and equipment planning. A draft plan for equipment replacement is shown in Appendix II: Preliminary Equipment Replacement Plan.



Methodology E N G A G E M E N T A N D P L A N N I N G P R O C E S S

The MI Strategic Plan is the result of a comprehensive consultation process and detailed analytical study of the current and future demand for services.

The consultation process3 included:

A MI Conference and Workshop with over 30 participants from different regions and areas of work in NH, including physicians, administrators and technicians. The workshop took place on April 10th 2014 at the Prince George Civic Centre.

Face to face meetings held by the MI Leadership across NH to engage over 35 local service providers and gather input for planning the future of service delivery.

Consultation with specialists in the field.

Open communication between NH’s staff and MI Leadership.

The analytical study was a data-intensive process to:

1. Review NH’s population, the current delivery and utilization of MI services, the geographic access across the region and the impact of the recently announce Industrial Provincial Projects taking place in the territory.

2. Develop demand projections for each modality into the future.

Additional information on the specific methodologies used in each part of the analysis follows.

M E D I C A L I M A G I N G S E R V I C E S

MI services comprise 8 major modalities and the supporting technology platform:

Radiology and Fluoroscopy (XR) Interventional Radiology (IR) Ultrasound (US) Bone Density (BD) Nuclear Medicine (NM) Mammography (MA). Computerized Tomography (CT) Magnetic Resonance Imaging (MR) PACS and RIS Information Systems

S E R V I C E L O C A T I O N S

Currently, there are 26 locations across Northern Health providing medical imaging services to different extents. These range from large referral hospitals providing the full range of services and extended hours, to Diagnostic and Treatment Centres where only core services are available. Table 1 shows all the sites, organized by the region where they are located, and the services provided in each of them.

3 Appendix IV includes a list of stakeholders engaged in the planning process



Table 1: Medical imaging sites and current provision of services.

P O P U L A T I O N A N A L Y S I S

The population within NH is organized into 17 Local Health Areas (LHAs), grouped in three Health Service Delivery Areas (HSDAs): Northeast, Northern Interior and Northwest. The LHAs form the basis of analysis for population and service utilization.

The most recent population projections for NH from BC Stats PEOPLE 2013 were used. These are the latest release and provide information at very detailed levels (yearly counts by individual years of age and gender for each LHA).

To account for specific large-scale industry projects anticipated in the region, population projections from BC Stats were adjusted based on expected workforce increase. Information on additional labour (considering direct, indirect and induced employment) for LNG facilities was taken from the Employment Impact Review commissioned by the BC Government in February 2013 to Grant Thornton LLP.

The projected addition in workforce spans over a 9-year period, from 2013 to 2020, as shown in Table 2. Estimates for each year were equally distributed across the 5 regions where the industry projects are expected to have a stronger impact considering extraction plants, pipelines and shipping facilities: Fort Nelson, Peace River South (Dawson Creek), Prince George, Kitimat and Prince Rupert.

To account for both young trade construction workers and senior professionals (architects, engineers, etc.), the additional population was assumed to be concentrated among the 20 to 55 age groups (both genders), and distributed proportionally to current estimates within each group. The original population estimates from BC Stats and the adjusted projections including the workforce increase are shown in more detail in Table 41 on Appendix III: Methodology Details.

Peer Group MR CT NM US BD IR XR MAPeace River South DCDH Dawson Creek & District Hospital Medium Hospital • • • • • •

CGH Chetwynd General Hospital Very Small Hospital •TRDT Tumbler Ridge D&T Centre D&T Centre •

Peace River North FSJH Fort St. John Hospital Medium Hospital • • • • • •HHHC Hudson'S Hope D&T Centre D&T Centre •

Fort Nelson FNGH Fort Nelson General Hospital Very Small Hospital • •Quesnel GRB GR Baker Memorial Hospital (Quesnel) Medium Hospital • • • • • •Burns Lake LDH Lakes District Hospital (Burns Lake) Very Small Hospital •Nechako VSJH St. John Hospital (Vanderhoof) Very Small Hospital • •

FLDT Fraser Lake D&T Centre D&T Centre • •SLH Stuart Lake Hospital (Fort St James) Very Small Hospital •

Prince George UHNBC University Hospital Of Northern BC (PGRH) Large Hospital • • • • • • • •VLDT Valemount Health Centre D&T Centre •VIC Victoria Medical Centre X-Ray Centre •MBDH Mcbride & District Hospital Very Small Hospital •MKDH Mackenzie & District Hospital Very Small Hospital •

Queen Charlotte QCIH Queen Charlotte Islands Hospital Very Small Hospital •NHGH Northern Haida Gwaii Hospital (Masset) Very Small Hospital • •

Snow Country SHC Stewart Health Centre D&T Centre •Prince Rupert PRRH Prince Rupert Regional Hospital Medium Hospital • • • • • •Upper Skeena WMH Wrinch Memorial Hospital (Hazelton) Very Small Hospital • •Smithers BVDH Bulkley Valley District Hospital (Smithers) Small Hospital • • •

HHC Houston D&T Centre D&T Centre •Kitimat KGH Kitimat Hospital And Health Centre Small Hospital • • • •Stikine STC Stikine Health Centre (Dease Lake) D&T Centre •Terrace MMH Mills Memorial Hospital (Terrace) Medium Hospital • • • • •Nisga'a -Telegraph Creek -

Nor

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Current Availability of Services by SiteHSDA / LHA Site

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LNG represents a temporary increase in population. Influx of LNG workforce will peak in 2016/17 then decline towards

end of the project.

Construction Employment 2013 2014 2015 2016 2017 2018 2019 2020 2021 Total

Direct 1,600 1,600 6,900 21,600 21,600 18,500 14,700 11,000 5,000 102,500

Indirect 3,000 3,000 13,400 41,900 41,900 35,900 28,600 21,300 9,700 198,700

Induced 800 800 3,500 11,200 11,200 9,600 7,600 5,700 2,600 53,000

Total 5,400 5,400 23,800 74,700 74,700 64,000 50,900 38,000 17,300 354,200

Table 2: Annual Construction Employment for LNG projects over Nine-Year Construction Period

D E M A N D A N A L Y S I S

Record-level workload data for each MI appointment booked in a NH facility was obtained from the Cerner Hospital Information System (HIS). Each record included the service and exam, site where provided, age and gender of patient, place of residence, and other relevant fields.

Information was obtained for multiple years, with the analysis focused on the most recent complete fiscal year available: 2012/13.

Workload associated with NH residents receiving MI services in other health authorities was not available. Obtaining such information is recommended for future planning.

For each medical imaging modality a process of enquiry was used to determine the projected demand in 2020 and 2025. These questions examined:

Key drivers for MI demand Base utilization rate (historical, benchmark) Population changes: growth, age/gender composition Clinical practice

Clinical indications (used by clinical services) Availability (and waitlists) Overutilization Repeat imaging (unnecessary duplication)

Technological advances

To more accurately capture the effects of the aging population in NH, utilization rates for each modality were calculated by gender and age group. As an example, Figure 1 shows the utilization profile for CT, with a typical pattern of increasing rates for older age groups.



Figure 1: Sample utilization rate profile by gender and age group for CT services.

(2013 calendar year, exams for NHA residents within NHA facilities only)

R E F E R R A L P A T T E R N S A N D C A T C H M E N T A R E A S

Besides looking at each service category, MI demand was analyzed both from a population and facility levels. This means that exam workload was summarized based on place of residence of the patient (the LHAs, where the demand is generated) and where the service was provided (the sites).

To understand the dynamics of demand and supply of services, referral patterns between each LHA and site were analyzed. This allows us to understand, for each service, where patients go to receive treatment (referral patterns), and conversely, which communities are served by each site (catchment areas).

Referral patterns capture the fact that although a facility may be located in one community, depending on the service, that site may serve a much larger population, beyond the local boundaries. This is creates an “inflow” of patients from other communities. That is especially the case for services with limited availability, such as MR and CT. In these cases, the catchment areas for each site include population from multiple LHAs (or all of them for MR).

Additionally, referral patterns reflect that, even if available, not all the residents receive services in their home community. A combination of service accessibility, clinical practice, and convenience and preference for the patient, generates an “outflow” of local patients that seek care elsewhere. This outflow is common in smaller communities, where patients go to larger hospitals/communities to receive MI services.

Figure 2 shows a sample referral pattern for Ultrasound. Patient residence is shown to the left, including residents of other Health Authorities and out-of-Province patients that received services (ultrasound exams in this case) at a NH Facility (shown as columns). The total number of exams for residents of each area is shown in the final column (farthest to the right), and the percent of those exams delivered at the different sites is shown in the middle cells, color-coded by intensity. It should be noted that this referral pattern only captures services delivered within NH facilities, and for residents of other Health Authorities this ‘outflow’ to NH is only a small portion of their total volume of services.

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Figure 2: Illustrative Referral Pattern for Ultrasound Services in 2013

D E M A N D P R O J E C T I O N S

Projections are calculated for individual services at the population level, meaning that demand is estimated for the residents of each LHA based on the rates of utilization by specific age/gender groups.

The calculation of utilization rates by age group in combination with population projections at the same level allow to not only account for the increased workload due to population growth, but also accurately capture the impact of future population structure (aging) to the demand for service (Figure 3). These are the baseline projections where current rates and population factors are taken into consideration.

Figure 3: Illustrative Baseline Projections Methodology

Building on the baseline projections, additional considerations based on expert opinion, historical trends, emerging technologies and other factors are reflected into the projections (Figure 4). The ‘adjusted’ projections are, therefore, based on both population factors and the input from stakeholders with knowledge and insight into emerging trends in medical practice, technology and future practice.

SERVICE HA HSDA LHA QCIH NHGH SHC PRRH WMH BVDH HHC KGH MMH GRB LDH VSJH SLH FLDT UHNBC MBDH MKDH VLDT DCDH CGH TRDT FSJH HHHC FNGHPeace River South 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 3% 0% 0% 0% 95% 0% 0% 2% 0% 0% 4959Peace River North 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 1% 0% 0% 0% 5% 0% 0% 93% 0% 0% 6787

Fort Nelson 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 4% 0% 0% 0% 10% 0% 0% 30% 0% 56% 643Quesnel 0% 0% 0% 0% 0% 0% 0% 0% 0% 97% 0% 0% 0% 0% 2% 0% 0% 0% 0% 0% 0% 0% 0% 0% 7377

Burns Lake 0% 0% 0% 0% 0% 51% 0% 0% 1% 1% 0% 2% 0% 8% 36% 0% 0% 0% 0% 0% 0% 0% 0% 0% 1167Nechako 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 43% 0% 9% 46% 0% 0% 0% 0% 0% 0% 0% 0% 0% 2509

Prince George 0% 0% 0% 0% 0% 0% 0% 0% 0% 2% 0% 0% 0% 0% 96% 0% 0% 0% 0% 0% 0% 0% 0% 0% 11898Queen Charlotte 0% 44% 0% 49% 0% 0% 0% 0% 5% 0% 0% 0% 0% 0% 2% 0% 0% 0% 0% 0% 0% 0% 0% 0% 848

Snow Country 0% 0% 0% 4% 1% 7% 0% 1% 81% 0% 0% 0% 0% 0% 6% 0% 0% 0% 0% 0% 0% 0% 0% 0% 104Prince Rupert 0% 0% 0% 98% 0% 0% 0% 0% 1% 0% 0% 0% 0% 0% 1% 0% 0% 0% 0% 0% 0% 0% 0% 0% 3859Upper Skeena 0% 0% 0% 1% 71% 10% 0% 1% 14% 0% 0% 0% 0% 0% 3% 0% 0% 0% 0% 0% 0% 0% 0% 0% 1073

Smithers 0% 0% 0% 1% 1% 93% 0% 0% 2% 0% 0% 0% 0% 0% 3% 0% 0% 0% 0% 0% 0% 0% 0% 0% 4587Kitimat 0% 0% 0% 6% 0% 1% 0% 54% 37% 0% 0% 0% 0% 0% 1% 0% 0% 0% 0% 0% 0% 0% 0% 0% 2409Stikine 0% 0% 0% 5% 0% 9% 0% 0% 78% 0% 0% 0% 0% 0% 4% 0% 0% 0% 2% 0% 0% 0% 0% 2% 64Terrace 0% 0% 0% 2% 2% 1% 0% 2% 91% 0% 0% 0% 0% 0% 2% 0% 0% 0% 0% 0% 0% 0% 0% 0% 4429Nisga'a 0% 0% 0% 3% 0% 2% 0% 2% 92% 0% 0% 0% 0% 0% 1% 0% 0% 0% 0% 0% 0% 0% 0% 0% 385

Telegraph Creek 0% 0% 0% 6% 0% 4% 0% 2% 81% 0% 0% 0% 0% 0% 5% 0% 0% 0% 2% 0% 0% 0% 0% 0% 970% 0% 0% 6% 6% 4% 0% 3% 9% 13% 0% 1% 0% 0% 28% 0% 0% 0% 12% 0% 0% 18% 0% 0% 800% 0% 0% 1% 0% 2% 0% 0% 1% 89% 0% 0% 0% 0% 4% 0% 0% 0% 2% 0% 0% 1% 0% 0% 14080% 0% 0% 11% 0% 6% 0% 1% 6% 54% 0% 0% 0% 0% 9% 0% 0% 0% 6% 0% 0% 6% 0% 1% 820% 0% 0% 16% 0% 9% 0% 4% 7% 7% 0% 0% 0% 0% 16% 0% 0% 0% 18% 0% 0% 23% 0% 0% 660% 0% 0% 8% 1% 3% 0% 3% 7% 12% 0% 0% 0% 0% 13% 0% 0% 0% 34% 0% 0% 16% 0% 2% 998Unknown / Out of Province

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Once demand is projected at the individual LHAs level, referral patterns are applied to allocate the future demand to the different sites providing services. This provides exam volumes for each service at every site.

Figure 4: Framework for Trend Adjusted Projections

A C C E S S A N A L Y S I S

The objective of this component of analysis is to measure geographic access to MI services. In doing so the driving distance from place of residence to the destination health facility can be used as a proxy for access measurement.

Access is measured at the LHA level using a customized quantitative approach based on driving distance to the closest site within NH providing the service.

The approach taken can be summarised as follows:

• Service-specific access was calculated (e.g. MRI, CT, US, etc.) • Access is calculated at an aggregate-level using Local Health Areas (LHA) for both patient residence

and health facility delivering the service • It is assumed that patients will be served by the closest site with service

Figure 5 below illustrates how driving distance is incorporated into the analysis of access. For each service, the driving distance to each location providing the service (green points) is calculated using specialized mapping software, and then closest location is selected.

Although distance is important on its own, it is not sufficient to determine the largest impact on population. To assess the effective impact, the relative population of each LHA is considered through population or demand ‘weighting’ to the driving distances, resulting in a “Relative Access Impact” metric. This metric is expressed as the percentage of total ‘person-kilometers’ for each LHA out of the total for the entire health authority. It is calculated, for each LHA and service, as the driving distance to the closest site with service multiplied by the population (or demand) of the LHA, and divided by the total population of NH times the average driving distance for the corresponding service.

Clinical practice

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Structure: age / gender / ethnicityEpidemiology: incidence / prevalence / mortality

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Transportation network / distance & travel-time

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…Period t+1

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Figure 5: Analysis of driving distance to service locations

To further illustrate the importance of weighted distance as a measure of relative access to services, Table 3 below shows an example for CT services. It shows the population for each LHA, the distance to service, and the relative access impact (weighted distance x population). Looking at the distance, communities like Stikine and Telegraph Creek show poor access at over 400 Km from the closest service location. But when looking at the relative impact, which considers both the distance and the size of the population subject to that distance, it is actually communities like Fort Nelson and Smithers that have the lowest access.

Table 3: Geographic Access to Service Illustration

053

092

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offering service

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Site NOT providing service

HSDA Closest SiteDistance

(Km)Impact Factor

059 Peace River South 29,147 10% DCDH 0 0%060 Peace River North 37,612 13% FSJH 0 0%081 Fort Nelson 6,552 2% FSJH 381 19%028 Quesnel 24,113 8% GRB 0 0%055 Burns Lake 7,952 3% UHNBC 227 14%056 Nechako 15,284 5% UHNBC 99 12%057 Prince George 98,480 33% UHNBC 0 0%050 Queen Charlotte 4,578 2% PRRH 203 7%051 Snow Country 540 0% MMH 311 1%052 Prince Rupert 14,384 5% PRRH 0 0%053 Upper Skeena 5,452 2% MMH 143 6%054 Smithers 16,315 6% MMH 204 26%080 Kitimat 10,081 3% MMH 64 5%087 Stikine 984 0% MMH 582 4%088 Terrace 20,935 7% MMH 0 0%092 Nisga'a 1,959 1% MMH 102 2%094 Telegraph Creek 715 0% MMH 693 4%

NHA Weighted Average 295,083 44

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Worst access (longest distance)

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P L A N N I N G T O O L S

To achieve the flexibility and responsiveness that Executives need, two planning tools have been developed to support two of the main drivers for this work:

1. The Northern Health MI Access Tool (Access Tool) Objectives: Quantitative assessment of geographic access to MI services across NH Service configuration planning tool

Features: Data-driven, population-based approach Dynamic service mix per site Determines access from each community to closest site with service Easy scenario planning of service configuration and access implications

2. The Northern Health MI Capital Equipment Planning Tool (Capital Tool)

Objectives: Repository of MI equipment inventory Decision support tool for capital investment and replacement planning

Features: Individual list of equipment by site and modality, with replacement costs Tracks equipment age, expected life, remaining years Multi-year planning horizon Easy scenario planning of capital investment and replacement per year, modality, site and

region

These tools are user-driven, Excel-based applications with automated calculation routines, reports and charts. They allow the user to alter the present state parameters as equipment or services are developed or deleted, and create scenarios to support decision-making.

Data collected to support the tools is from the NH Cerner Hospital Information System and, although NH was not able to provide record level data in all circumstances, the data sets used are representative of the present state. In the event NH is able to obtain the required record level data we recommend it be incorporated into the decision-support tools.

These tools were used to support the scenario analysis and preparation of this report.



Present State Analysis P O P U L A T I O N E S T I M A T E S A N D E X P E C T E D G R O W T H A N D A G I N G

The population in NH is estimated at just over 300,000 in 2013, with the Northern Interior HSDA accounting for about half of the total population and the Northeast and Northwest about a quarter each. The largest population centre is the Prince George LHA, with almost one third of NH’s total residents.

Considering the population projections adjusted for major industry projects in the region, NH’s population is anticipated to grow from the current 300,000 to about 314,200 by 2025, a 4.6% increase. However, it is in during this period where a peak in population is expected due to the LNG construction boom.

Besides population growth, and perhaps more importantly for healthcare services in general, NH’s population is aging. The compounded effect of both growth and aging will result in higher demand for services, and it is important to accurately capture how, where and when that will happen.

Table 4 shows the projected population by LHA between 2013 and 2025. Communities in the Northeast, are expected to grow significantly, while other areas will see more moderate or no increase in population.

Table 4: Adjusted Population Projections for Northern Health.

The effect of an aging population is better appreciated in the unadjusted population projections shown in Figure 6. Progressive aging can be clearly seen for the 10-34 and 40-59 age groups in 2013 as they transform into the 25-49 and 55-74 groups by 2025. Because of their significantly higher service utilization, the growth in the 65+ population is of special interest and will result in greater demand for services.

Region 2013 2015 2020 2025Northeast 75,471 85,258 96,602 85,505 28.0% 13.3%

Fort Nelson 7,632 11,415 14,468 7,098 89.6% -7.0%Peace River North 37,612 39,107 42,820 45,969 13.8% 22.2%Peace River South 30,227 34,736 39,314 32,438 30.1% 7.3%

0 0 0 0Northern Interior 146,909 151,785 156,584 150,345 6.6% 2.3%

Burns Lake 7,952 7,937 7,832 7,656 -1.5% -3.7%Nechako 15,284 15,466 15,659 15,717 2.5% 2.8%Prince George 99,560 104,169 108,641 102,277 9.1% 2.7%Quesnel 24,113 24,213 24,452 24,695 1.4% 2.4%

0 0 0 0Northwest 78,103 85,751 92,663 78,344 18.6% 0.3%

Kitimat 11,161 14,906 17,818 10,293 59.6% -7.8%Nisga'a 1,959 1,973 2,002 2,033 2.2% 3.8%Prince Rupert 15,464 19,339 22,632 15,364 46.4% -0.6%Queen Charlotte 4,578 4,612 4,668 4,649 2.0% 1.6%Smithers 16,315 16,516 16,956 17,276 3.9% 5.9%Snow Country 540 537 540 535 0.0% -0.9%Stikine 984 963 974 947 -1.0% -3.8%Telegraph Creek 715 728 726 729 1.5% 2.0%Terrace 20,935 20,688 20,797 20,956 -0.7% 0.1%Upper Skeena 5,452 5,489 5,550 5,562 1.8% 2.0%

0 0 0 0NHA 300,483 322,794 345,849 314,194 15.1% 4.6%

Adjusted Population Projection % Growth 2013-2020

% Growth 2013-2025



Figure 6: Unadjusted Population Projections by Age Group, 2013 - 2020

The temporary increase in population due to the additional workforce modifies the distribution of people by age, resulting in an important increase in the number of people between 20 and 54 years of age (Figure 7).

Figure 7: Adjusted Population Projections by Age Group, 2013 - 2020

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M E D I C A L I M A G I N G E X A M V O L U M E S A N D U T I L I Z A T I O N

Northern Health provided a total of 293,766 Medical Imaging exams during the 2012/13 Fiscal Year (Table 5). The vast majority of exams were General Radiology (X-Ray) at 186,003, followed by Ultrasound at 55,830. University Hospital of Northern BC delivered the largest number of exams (95,824 exams, one third of the total volume) out of the 26 locations across Northern Health.

Table 5: Utilization rate per medical imaging service for each LHA, 2012/13.

While looking at services provided at each site is very important, it is also relevant to determine who the users of those services are. Current utilization of services varies significantly across communities in Northern Health. Table 6 below shows crude utilization rates (exams per 1,000 population) per service for each LHA.

An important driver of service utilization is availability. In areas where services are not provided in the sites nearby, utilization is lower as patients have reduced access, and will need to travel farther to get access to the services.

Readers are cautioned that these are “crude” rates, calculated using the total number of exams and population in each LHA. LHAs differ in their population structure (e.g. some LHAs may have a younger population than others), which produce different aggregate utilization levels. Comparisons among communities should be done over “standardized” rates that remove the effect of

MR CT NM US BD IR XR MA TotalPeace River South DCDH Dawson Creek & District Hospital - 3,030 - 5,582 244 26 14,430 1,136 24,447

CGH Chetwynd General Hospital - - - - - - 4,188 - 4,188 TRDT Tumbler Ridge D&T Centre - - - - - - 1,711 - 1,711

Peace River North FSJH Fort St. John Hospital - 2,249 740 6,891 60 - 18,661 1,302 29,904 HHHC Hudson'S Hope D&T Centre - - - - - - 312 - 312

Fort Nelson FNGH Fort Nelson General Hospital - - - 389 - - 4,178 - 4,567 Quesnel GRB GR Baker Memorial Hospital (Quesnel) - 2,613 - 8,879 376 - 15,665 1,799 29,332 Burns Lake LDH Lakes District Hospital (Burns Lake) - - - - - - 4,733 - 4,733 Nechako VSJH St. John Hospital (Vanderhoof) - - - 1,133 - - 6,205 - 7,338

FLDT Fraser Lake D&T Centre - - - 340 - - 1,311 - 1,651 SLH Stuart Lake Hospital (Fort St James) - - - - - - 1,905 - 1,905

Prince George UHNBC University Hospital Of Northern BC (PGRH) 5,273 13,215 3,735 14,053 1,205 730 57,345 268 95,824 VLDT Valemount Health Centre - - - - - - 1,141 - 1,141 VIC Victoria Medical Centre - - - - - - - - - MBDH Mcbride & District Hospital - - - - - - 889 - 889 MKDH Mackenzie & District Hospital - - - - - - 2,281 - 2,281

Queen Charlotte QCIH Queen Charlotte Islands Hospital - - - - - - 1,365 - 1,365 NHGH Northern Haida Gwaii Hospital (Masset) - - - 384 - - 1,391 - 1,775

Snow Country SHC Stewart Health Centre - - - - - - 578 - 578 Prince Rupert PRRH Prince Rupert Regional Hospital - 1,161 - 4,644 90 71 10,956 979 17,902 Upper Skeena WMH Wrinch Memorial Hospital (Hazelton) - - - 927 - - 3,387 - 4,314 Smithers BVDH Bulkley Valley District Hospital (Smithers) - - - 5,195 - - 9,760 1,113 16,068

HHC Houston D&T Centre - - - - - - 1,403 - 1,403 Kitimat KGH Kitimat Hospital And Health Centre - - - 1,448 389 - 7,842 701 10,380 Stikine STC Stikine Health Centre (Dease Lake) - - - - - - 500 - 500 Terrace MMH Mills Memorial Hospital (Terrace) - 5,649 1,680 5,965 - - 14,365 1,598 29,257 Nisga'a - - - - - - - - - - Telegraph Creek - - - - - - - - - -

Total All Sites 5,273 27,917 6,156 55,830 2,364 827 186,503 8,896 293,766

Actual Exam Volume - 2012/13HSDA / LHA Site

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It is important to consider that the exam volumes shown in this report correspond to services provided only in Northern Health locations. Some areas may

be closer or have better access to facilities from other health providers, such as hospitals in Alberta or Interior Health. Without knowing the volume of

services provided elsewhere, it may seem that residents of those regions have a much lower

utilization than in reality.



different population structures. The calculation of standardized rates was outside the scope of this report.

Table 6: Crude utilization rate per LHA for each medical imaging service, 2012/13.

To more accurately capture the effects of the aging population in Northern Health, utilization rates for all MI services combined and each modality were calculated by gender and age group (Figure 8).

The utilization profiles differ significantly by service, although they consistently show higher utilization rates for the older age groups. For all MI services combined, females show a higher rate than males, across all age groups. Within individual services, the differences in utilization by gender are most noticeable for Ultrasound (higher use for women in fertile age), Bone Density (post-menopausal women screening for osteoporosis) and Mammography (cancer screening for women aged 40 to 79).

Region MR CT NM US BD IR XR MA TotalNortheast 1.3 69.5 10.5 171.6 4.2 0.9 556.8 32.8 844.6

Fort Nelson 1.4 49.1 7.1 99.0 0.3 0.4 611.0 10.2 767.2Peace River North 1.4 53.7 13.1 184.0 3.2 0.2 504.2 33.7 789.8Peace River South 1.2 94.4 8.1 172.2 6.4 1.8 612.1 36.7 932.3

Northern Interior 29.3 102.9 24.3 158.2 9.2 4.1 590.2 14.2 934.1Burns Lake 28.5 90.6 18.7 146.8 6.0 3.5 698.2 5.3 992.4Nechako 29.2 103.4 21.7 165.6 9.3 3.9 751.6 2.3 1,081.9Prince George 31.4 102.2 27.4 121.5 9.6 4.6 528.9 2.3 829.8Quesnel 21.1 109.2 15.3 306.5 8.7 2.7 702.5 73.1 1,246.0

Northwest 10.8 93.4 23.6 236.6 7.2 2.0 683.6 57.2 1,115.4Kitimat 5.5 96.2 32.2 239.3 9.8 1.9 701.3 80.0 1,170.2Nisga'a 10.3 112.7 28.6 197.3 7.7 1.2 712.3 42.0 1,112.4Prince Rupert 5.4 81.6 11.8 270.2 10.6 1.9 697.1 61.1 1,139.5Queen Charlotte 0.9 54.2 6.7 186.1 2.6 4.5 632.2 16.9 893.5Smithers 22.2 87.3 20.7 282.8 5.9 1.9 749.9 62.4 1,233.6Snow Country 15.1 82.9 34.2 195.3 3.7 0.0 688.7 22.5 1,036.2Stikine 1.1 60.5 8.9 67.6 1.0 3.8 740.3 7.3 876.4Telegraph Creek 5.7 90.3 10.3 137.6 1.4 0.0 168.3 9.9 431.7Terrace 9.8 115.3 35.5 213.2 6.0 1.9 645.9 63.0 1,096.1Upper Skeena 15.2 86.7 16.8 197.4 6.8 1.8 651.0 25.0 997.8

NHA 17.6 92.2 20.7 181.7 7.5 2.8 606.1 29.9 958.8

Exam Utilization Rates (per 1,000 Population) - 2012/13



Figure 8: Utilization rate profiles by age group and gender for MI services (2013)4

G E O G R A P H I C A C C E S S

Access to services was analyzed using the Access Tool developed during this planning process. The Tool allows estimating the geographic access to services for each community using a quantitative approach.

Table 7 below shows the present state geographic access for all MI services by LHA. Each cell represents the driving distance (in kilometers) between each LHA and service. Results for each service are color-coded based on access: red (longer distance, worse access), orange (medium) and green (shorter distance, better access).

From this table it is clear that, at an aggregated Health Authority level, accessing MRI services has the largest distance at 286 Km on average, which is consistent with MRI services being centralized at UHNBC in Prince George. Conversely, access to X-Ray is the best with almost all the LHAs having X-Ray services locally.

Within each service, the LHAs with longer distances are highlighted in red. Telegraph Creek, with no MI services provided locally, is consistently the community with the lowest absolute access, while Prince George, with all MI services available within the LHA, is the community with best absolute access.

4 Source: Cerner data for 2013 calendar year.

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50-5

4

55-5

9

60-6

4

65-6

9

70-7

4

75-7

9

80-8

4

85-8

9

90+

Exam

s pe

r 1,

000

Popu

lati

on

Age Group

NHA Exam Rate for BD 2013

F M

0

20

40

60

80

100

120

1-4

5-9

10-1

4

15-1

9

20-2

4

25-2

9

30-3

4

35-3

9

40-4

4

45-4

9

50-5

4

55-5

9

60-6

4

65-6

9

70-7

4

75-7

9

80-8

4

85-8

9

90+

Exam

s pe

r 1,

000

Popu

lati

on

Age Group

NHA Exam Rate for NM 2013

F M

0

50

100

150

200

250

1-4

5-9

10-1

4

15-1

9

20-2

4

25-2

9

30-3

4

35-3

9

40-4

4

45-4

9

50-5

4

55-5

9

60-6

4

65-6

9

70-7

4

75-7

9

80-8

4

85-8

9

90+

Exam

s pe

r 1,

000

Popu

lati

on

Age Group

NHA Exam Rate for MA 2013

F M

0

50

100

150

200

250

300

350

400

450

1-4

5-9

10-1

4

15-1

9

20-2

4

25-2

9

30-3

4

35-3

9

40-4

4

45-4

9

50-5

4

55-5

9

60-6

4

65-6

9

70-7

4

75-7

9

80-8

4

85-8

9

90+

Exam

s pe

r 1,

000

Popu

lati

on

Age Group

NHA Exam Rate for CT 2013

F M

0

5

10

15

20

25

30

35

40

45

1-4

5-9

10-1

4

15-1

9

20-2

4

25-2

9

30-3

4

35-3

9

40-4

4

45-4

9

50-5

4

55-5

9

60-6

4

65-6

9

70-7

4

75-7

9

80-8

4

85-8

9

90+

Exam

s pe

r 1,

000

Popu

lati

on

Age Group

NHA Exam Rate for MR 2013

F M

0

500

1000

1500

2000

2500

3000

3500

4000

1-4

5-9

10-1

4

15-1

9

20-2

4

25-2

9

30-3

4

35-3

9

40-4

4

45-4

9

50-5

4

55-5

9

60-6

4

65-6

9

70-7

4

75-7

9

80-8

4

85-8

9

90+

Exam

s pe

r 1,

000

Popu

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on

Age Group

NHA Exam Rate for All MI 2013

F M



Table 7: Closest Distance to Service by LHA, 2013

(original BC Stats population projections used to estimate NH average).

A complementary view of the access analysis is the corresponding definition of catchment areas for each site providing the services. Table 8 below shows which communities are served by each site, based on closest distance to service.

Table 8: Estimated Site of Service by LHA Based on Closest Distance, 2013.

However, it is important to factor in the analysis the size of the population that is affected by the calculated distance to services. To this end, the calculated driving distances are weighted by the estimated population (or demand) in each LHA, resulting in a “Relative Access Impact” metric, as shown in Table 9. For each service, the relative access impact percentage represents the proportion of the total “person-Km” in Northern Health attributable to each LHA.

MRI CT NM US BD IR XR MA050 Queen Charlotte 921 203 349 0 203 203 0 203051 Snow Country 697 311 311 255 361 433 0 311052 Prince Rupert 718 0 146 0 0 0 0 0053 Upper Skeena 445 143 143 0 202 289 0 76054 Smithers 371 204 204 0 263 350 0 0080 Kitimat 631 64 64 0 0 209 0 0087 Stikine 968 582 582 526 632 704 0 582088 Terrace 573 0 0 0 64 146 0 0092 Nisga'a 618 102 102 102 164 238 102 102094 Telegraph Creek 1,079 693 693 637 743 815 112 693028 Quesnel 121 0 121 0 0 0 0 0055 Burns Lake 227 227 227 129 227 227 0 144056 Nechako 99 99 99 0 99 99 0 99057 Prince George 0 0 0 0 0 0 0 0059 Peace River South 406 0 76 0 0 0 0 0060 Peace River North 438 0 0 0 0 76 0 0081 Fort Nelson 776 381 381 0 381 455 0 381

NHA Average 286 44 71 8 51 83 1 27

53 Northeast

Distance (Km) to MI Services - 2013HSDA LHA

51 Northwest

52 Northern Interior

MRI CT NM US BD IR XR MA050 Queen Charlotte UHNBC PRRH MMH QCIH PRRH PRRH QCIH PRRH051 Snow Country UHNBC MMH MMH WMH KGH PRRH SHC MMH052 Prince Rupert UHNBC PRRH MMH PRRH PRRH PRRH PRRH PRRH053 Upper Skeena UHNBC MMH MMH WMH KGH PRRH WMH BVDH054 Smithers UHNBC MMH MMH BVDH KGH PRRH BVDH BVDH080 Kitimat UHNBC MMH MMH KGH KGH PRRH KGH KGH087 Stikine UHNBC MMH MMH WMH KGH PRRH STC MMH088 Terrace UHNBC MMH MMH MMH KGH PRRH MMH MMH092 Nisga'a UHNBC MMH MMH MMH KGH PRRH MMH MMH094 Telegraph Creek UHNBC MMH MMH WMH KGH PRRH STC MMH028 Quesnel UHNBC GRB UHNBC GRB GRB GRB GRB GRB055 Burns Lake UHNBC UHNBC UHNBC VSJH UHNBC UHNBC LDH BVDH056 Nechako UHNBC UHNBC UHNBC VSJH UHNBC UHNBC VSJH UHNBC057 Prince George UHNBC UHNBC UHNBC UHNBC UHNBC UHNBC UHNBC UHNBC059 Peace River South UHNBC DCDH FSJH DCDH DCDH DCDH DCDH DCDH060 Peace River North UHNBC FSJH FSJH FSJH FSJH DCDH FSJH FSJH081 Fort Nelson UHNBC FSJH FSJH FNGH FSJH DCDH FNGH FSJH

53 Northeast

Closest Site Providing Access to MI Services - 2013HSDA LHA

51 Northwest




Table 9: Relative access impact metric for each service by LHA, 2013

(original BC Stats population projections used to estimate relative impact).

This revised access indicator provides a better picture of where services are needed most, as it considers the “population need” together with access to services. From the results in this table, the communities with poor access to service can be identified, and considered as candidates for future provision of service. Table 10 summarizes the communities with poor access.

Service Lowest Access Community

Other communities with low access

MRI Peace River North Terrace, Peace River South, Prince Rupert CT Smithers Fort Nelson, Burns Lake, Nechako NM Smithers Quesnel, Fort Nelson, Peace River South US Burns Lake Stikine, Telegraph Creek BD Smithers Fort Nelson, Burns Lake, Nechako IR Smithers Terrace, Fort Nelson, Peace River North XR Nisga’a Telegraph Creek MA Fort Nelson Nechako, Burns Lake, Queen Charlotte

Table 10: Communities with Lowest Access (Larger Distance) to Services, 2013.

Access Scenario Analysis 1

The same methodology to evaluate access to services can be applied to a future state of the system, with a different configuration of services. Multiple scenarios can be defined and analyzed using the Geographic Access Analysis Tool developed by INSITE Consultancy for Northern Health.

As an illustration, consider a future state scenario where services are now provided in the communities previously identified with the current lowest access for each service (Table 10). The results are shown in Table 11. Comparing the absolute distance to service between the present state (Table 7) and this hypothetical scenario shows that the implementation of services in the communities with lowest access yields significant improvement, reducing the current average driving distance to between 54% and 68% of current values for MRI, CT, US, BD, IR and MA, 78% for NM, and 28% for XR.

MRI CT NM US BD IR XR MA050 Queen Charlotte 5% 7% 8% 0% 6% 4% 0% 12%051 Snow Country 0% 1% 1% 6% 1% 1% 0% 2%052 Prince Rupert 12% 0% 10% 0% 0% 0% 0% 0%053 Upper Skeena 3% 6% 4% 0% 7% 6% 0% 5%054 Smithers 7% 26% 16% 0% 28% 23% 0% 0%080 Kitimat 8% 5% 3% 0% 0% 9% 0% 0%087 Stikine 1% 4% 3% 22% 4% 3% 0% 7%088 Terrace 14% 0% 0% 0% 9% 12% 0% 0%092 Nisga'a 1% 2% 1% 9% 2% 2% 71% 3%094 Telegraph Creek 1% 4% 2% 20% 4% 2% 29% 6%028 Quesnel 3% 0% 14% 0% 0% 0% 0% 0%055 Burns Lake 2% 14% 9% 44% 12% 7% 0% 14%056 Nechako 2% 12% 7% 0% 10% 6% 0% 19%057 Prince George 0% 0% 0% 0% 0% 0% 0% 0%059 Peace River South 14% 0% 11% 0% 0% 0% 0% 0%060 Peace River North 20% 0% 0% 0% 0% 12% 0% 0%081 Fort Nelson 6% 19% 12% 0% 16% 12% 0% 31%


53 Northeast

Relative Access Impact (% of Population x Distance) - 2013HSDA LHA

51 Northwest



Similarly, the access analysis can now be performed over this new service configuration for the system. The relative access impact metric can now be used to identify the next round of communities with poor access and prioritize the implementation of new service locations.

Table 11: Illustrative scenario – Future state scenario with services added in communities with highest relative access impact in present state

(original BC Stats population projections used to estimate NH average and relative impact).

Access Scenario Analysis 2

As an example of iterative analysis, consider the following case for MRI (Table 12):

• Current state access analysis shows that Peace River North, Terrace and Peace River South are the communities with highest relative access impact, at 19.5%, 14.2% and 14.0%, respectively.

• “Step 1” is a future state scenario where MRI services are now implemented in Peace River North (highest impact). Access then improves significantly for both Peace River North and Piece River South, and relative access impact becomes now highest for Terrace (21.2%).

• “Step 2” would then consider implementing MRI services in Terrace, which will make Smithers the community with highest relative impact.

These results are consistent with current considerations to implement a mobile MRI service rotating between Fort Saint John Hospital (Peace River North) and Mills Memorial Hospital (Terrace).

It should be noted that these access analysis scenarios are only an illustration of potential future states and limited to geographic implications only. Further consideration of many other factors, including critical mass volumes to sustain practice, availability of other services, staffing, cost and others, is required before any formal recommendations can be made.

MRI CT NM US BD IR XR MA MRI CT NM US BD IR XR MA050 Queen Charlotte 921 203 349 0 203 203 0 203 8% 11% 10% 0% 10% 5% 0% 17%051 Snow Country 697 311 311 255 329 329 0 311 1% 2% 1% 10% 2% 1% 0% 3%052 Prince Rupert 718 0 146 0 0 0 0 0 19% 0% 13% 0% 0% 0% 0% 0%053 Upper Skeena 445 76 76 0 76 76 0 76 4% 5% 2% 0% 4% 2% 0% 8%054 Smithers 371 0 0 0 0 0 0 0 11% 0% 0% 0% 0% 0% 0% 0%080 Kitimat 631 64 64 0 0 209 0 0 11% 7% 4% 0% 0% 12% 0% 0%087 Stikine 968 582 582 526 600 600 0 582 2% 6% 3% 39% 6% 3% 0% 10%088 Terrace 573 0 0 0 64 146 0 0 21% 0% 0% 0% 14% 18% 0% 0%092 Nisga'a 618 102 102 102 164 238 0 102 2% 2% 1% 15% 3% 3% 0% 4%094 Telegraph Creek 1,079 693 693 637 711 711 112 693 1% 6% 3% 35% 5% 3% 100% 9%028 Quesnel 121 0 121 0 0 0 0 0 5% 0% 17% 0% 0% 0% 0% 0%055 Burns Lake 227 144 144 0 144 144 0 144 3% 13% 7% 0% 12% 6% 0% 21%056 Nechako 99 99 99 0 99 99 0 99 3% 18% 9% 0% 16% 9% 0% 28%057 Prince George 0 0 0 0 0 0 0 0 0% 0% 0% 0% 0% 0% 0% 0%059 Peace River South 76 0 76 0 0 0 0 0 4% 0% 14% 0% 0% 0% 0% 0%060 Peace River North 0 0 0 0 0 76 0 0 0% 0% 0% 0% 0% 19% 0% 0%081 Fort Nelson 381 381 381 0 381 455 0 0 5% 30% 15% 0% 27% 18% 0% 0%

NHA Average 185 28 55 4 31 56 0 18

53 Northeast

HSDA LHA

51 Northwest


Distance (Km) to MI Services - Future State Relative Access Impact - Future State



Table 12: Illustrative scenario – Iterative changes in system with MRI services added in communities with highest

relative access impact in present state (original BC Stats population projections used).

Current Step 1 Step 2 Current Step 1 Step 2050 Queen Charlotte 921 921 349 5.0% 7.6% 7.6%051 Snow Country 697 697 311 0.4% 0.7% 0.8%052 Prince Rupert 718 718 146 12.2% 18.7% 10.2%053 Upper Skeena 445 445 143 2.9% 4.4% 3.7%054 Smithers 371 371 204 7.2% 11.0% 16.1%080 Kitimat 631 631 64 7.5% 11.4% 3.0%087 Stikine 968 968 582 1.1% 1.7% 2.6%088 Terrace 573 573 0 14.2% 21.2% 0.0%092 Nisga'a 618 618 102 1.4% 2.2% 0.9%094 Telegraph Creek 1,079 1,079 693 0.9% 1.4% 2.3%028 Quesnel 121 121 121 3.5% 5.2% 13.8%055 Burns Lake 227 227 227 2.1% 3.2% 8.3%056 Nechako 99 99 99 1.8% 2.7% 7.2%057 Prince George 0 0 0 0.0% 0.0% 0.0%059 Peace River South 406 76 76 14.0% 4.1% 11.2%060 Peace River North 438 0 0 19.5% 0.0% 0.0%081 Fort Nelson 776 381 381 6.0% 4.5% 12.2%

NHA Average 286 187 70

Relative Access ImpactHSDA LHA

51 Northwest


53 Northeast

Distance (Km) to MRI



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Future Need D E M A N D P R O J E C T I O N S

Two main projection scenarios were considered:

1. Baseline: current utilization rates + projected changes in population (growth + aging) 2. Adjusted: baseline + additional service delivery assumptions5 (from process input)

Table 13 below summarizes exam volumes for both scenarios for every modality and period.

Table 13: Projected exam volume by scenario for each service and period.

Both scenarios consider significant growth in demand due to population growth, population aging, additional people due to increase workforce (LNG projects) and other service-specific assumptions made by NH experts throughout the planning process.

Depending on the scenario, growth of about 25%-28% and 22%-25% from current (2012/13) levels is expected for 2020 and 2025, respectively. It becomes evident from the projected exam volumes that higher volume is anticipated by 2020 instead of 2025. This is a direct result of the temporary effect expected from the construction boom associated with the LNG projects, which is predicted to peak by 2016-17 and end by 2012 as shown earlier in Table 2.

Under the baseline scenario, all services but MR show similar growth. This is the result of disproportionally lower utilization rates for MR outside the Northern Interior HSDA. Conversely, in the adjusted scenario MR now becomes the service with the largest proportional growth as a result of adopting the provincial average utilization rate across each LHA in NH.

As additional reference, summarized volumes for all services by LHA of patient residence and projection period are shown in Table 14, and by site of service delivery and projection period on Table 15. Additional details on demand projections for both scenarios are provided on Appendix I: Additional Demand Projection Information.

The LHAs with the highest projected growth in exam volume are Fort Nelson, Kitimat and Prince Rupert, with 135%, 79% and 63% growth from current volumes by 2020. This is again the direct effect of the anticipated increase in workforce in those regions due to LNG projects. A similar effect is also observable, although to a lesser degree due to the larger population size, in the other communities with LNG projects: Peace River South and Prince George, with 40% and 21% growth by 2020.

5 Specific assumptions for each service are described on Appendix II: Methodology

Scenario/Period MR CT NM US BD IR XR MA Total Growth from 2012

2012/13 5,273 27,917 6,156 55,830 2,364 827 186,503 8,896 293,766Baseline

2020 6,107 35,595 7,961 70,134 3,096 1,084 232,352 11,529 367,859 25%2025 5,950 35,942 8,282 66,832 3,304 1,164 226,405 10,857 358,736 22%

Adjusted2020 9,676 33,815 7,961 70,134 3,406 1,084 236,999 12,913 375,988 28%2025 8,822 34,145 8,282 66,832 3,634 1,164 230,933 12,159 365,971 25%

Actual and Projected Exam Volume by Service and Period



Table 14: Projected exam volume by scenario for all services combined by LHA and period.

A similar effect of the LNG projects is observed from a facility perspective. Fort Nelson General Hospital, Kitimat Hospital and Health Centre and Prince Ruper Regional Hospital show the highest growth in MI exam volume by 2020, at 113%, 65% and 57% increase from 2012/13, respectively. The sites located in the Peace River South LHA (Dawson Creek & District Hospital, Chetwynd General Hospital and Tumbler Ridge D&T Centre) also show significant projected increase in exam volume by 2020, at about 36%-38%.

Region 2012/13 2020 2025 2020 2025Northeast 61,196 85,732 80,738 89,445 84,100

Fort Nelson 5,057 11,874 6,399 12,415 6,671Peace River North 29,276 36,154 40,616 37,800 42,409Peace River South 26,864 37,704 33,723 39,230 35,020

0 0 0 0 0Northern Interior 135,290 157,687 162,443 158,610 163,286

Burns Lake 7,931 8,744 9,050 8,814 9,118Nechako 16,464 18,460 19,449 18,586 19,564Prince George 81,070 98,040 100,039 98,143 100,060Quesnel 29,825 32,443 33,904 33,066 34,543

0 0 0 0 0Northwest 83,513 109,550 99,734 112,772 102,475

Kitimat 11,740 20,970 14,191 21,698 14,651Nisga'a 2,173 2,462 2,572 2,527 2,639Prince Rupert 16,279 26,602 19,906 27,516 20,568Queen Charlotte 4,121 4,748 4,981 4,936 5,172Smithers 20,003 22,809 24,372 23,233 24,810Snow Country 557 624 627 637 640Stikine 247 273 277 299 302Telegraph Creek 299 338 356 353 372Terrace 22,653 24,605 25,982 25,313 26,707Upper Skeena 5,441 6,119 6,470 6,260 6,614

0 0 0 0 0Non-NHA 13,267 14,889 15,822 15,162 16,111

Rest of BC 7,768 8,711 9,217 8,854 9,368Out of Province 5,498 6,177 6,604 6,307 6,743

0 0 0 0 0NHA 293,266 367,859 358,736 375,988 365,971

AdjustedBaseline

Actual and Projected Exam Volume by LHA



Table 15: Projected exam volume by scenario for all services combined by site and period.

2020 2025 2020 2025Peace River South DCDH Dawson Creek & District Hospital 24,447 33,715 30,796 34,118 31,169

CGH Chetwynd General Hospital 4,188 5,717 5,215 5,831 5,320 TRDT Tumbler Ridge D&T Centre 1,711 2,319 2,123 2,366 2,165

Peace River North FSJH Fort St. John Hospital 29,904 37,724 40,905 38,242 41,483 HHHC Hudson'S Hope D&T Centre 312 385 424 393 433

Fort Nelson FNGH Fort Nelson General Hospital 4,567 9,746 5,684 9,923 5,788 Quesnel GRB GR Baker Memorial Hospital (Quesnel) 29,332 32,143 33,623 32,617 34,112 Burns Lake LDH Lakes District Hospital (Burns Lake) 4,733 5,209 5,389 5,313 5,497 Nechako VSJH St. John Hospital (Vanderhoof) 7,338 8,195 8,588 8,334 8,733

FLDT Fraser Lake D&T Centre 1,651 1,839 1,928 1,869 1,958 SLH Stuart Lake Hospital (Fort St James) 1,905 2,130 2,237 2,172 2,281

Prince George UHNBC University Hospital Of Northern BC (PGRH) 95,824 114,957 117,453 119,268 121,064 VLDT Valemount Health Centre 1,141 1,352 1,381 1,379 1,408 VIC Victoria Medical Centre - - - - - MBDH Mcbride & District Hospital 889 1,055 1,078 1,076 1,099 MKDH Mackenzie & District Hospital 2,281 2,724 2,766 2,778 2,821

Queen Charlotte QCIH Queen Charlotte Islands Hospital 1,365 1,581 1,656 1,613 1,689 NHGH Northern Haida Gwaii Hospital (Masset) 1,775 2,047 2,128 2,080 2,162

Snow Country SHC Stewart Health Centre 578 663 681 676 695 Prince Rupert PRRH Prince Rupert Regional Hospital 17,902 28,148 21,753 28,607 22,106 Upper Skeena WMH Wrinch Memorial Hospital (Hazelton) 4,314 4,849 5,102 4,925 5,183 Smithers BVDH Bulkley Valley District Hospital (Smithers) 16,068 18,215 19,328 18,593 19,730

HHC Houston D&T Centre 1,403 1,592 1,695 1,624 1,729 Kitimat KGH Kitimat Hospital And Health Centre 10,380 17,107 12,498 17,562 12,842 Stikine STC Stikine Health Centre (Dease Lake) 500 500 500 500 500 Terrace MMH Mills Memorial Hospital (Terrace) 29,257 34,446 34,306 34,630 34,504 Nisga'a - - - - - - Telegraph Creek - - - - - -

Total All Sites 293,766 368,359 359,236 376,488 366,472

Nor

ther

n In

terio

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orth

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t

Baseline

Actual and Projected Exam Volume by LHA

Adjusted2012/13HSDA / LHA Site

Nor

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O P E R A T I N G C A PA C I T Y

To estimate staffing needs, projected exam volumes need to be translated into operating hours at each site. This is done using the following reference volumes and utilization rates obtained from CAMRT/CAR “Lifecycle Guidance of Medical Imaging Equipment in Canada (2013)” report:

Service MR CT NM US BD IR XR MA Annual volume per shift6

4,000 7,500 3,000 2,000 5,000 2,000 10,000 3,500

Utilization rate7 75% 75% 75% 75% 75% 75% 75% 75%

Table 16: Reference exam volume and service utilization for different medical imaging modalities.

Using these reference values, operating capacity expressed in number of hours per day for each service and site is estimated (Table 17) based on the following formula:

Operating Capacity [hrs] = Projected Exam Volume / [Reference Volume x Utilization Rate]

Operating Hours per Day (5 days/week)

Service Location 2012/13 2020 2025 Baseline Adjusted Baseline Adjusted

MRI UHNBC 14 16 26 16 24

CT

DCDH 4 6 6 6 5 FSJH 3 5 4 5 4 GRB 4 4 4 4 4

UHNBC 19 23 22 24 23 PRRH 2 3 2 2 2 MMH 8 10 10 10 9

NM FSJH 3 4 4

UHNBC 13 17 18 MMH 6 8 8

US

DCDH 30 42 36 FSJH 37 46 49

FNGH 2 5 2 GRB 47 51 54 VSJH 6 7 7 FLDT 2 2 2

UHNBC 75 90 91 NHGH 2 2 2 PRRH 25 40 29 WMH 5 5 6 BVDH 28 31 33 KGH 8 14 9 MMH 32 38 36

BD

DCDH 0.5 0.7 0.8 0.8 0.9 FSJH 0.1 0.2 0.2 GRB 0.8 1.1 1.1 1.2

UHNB 2.6 3.3 3.6 3.5 3.9 PRRH 0.2 0.3 0.3 KGH 0.8 1.1 1.3 1.2 1.3

6 Refers to typical exam volume achievable in an 8-hours 5 days/week shift configuration. 7 Target utilization rate for the service (relative to a fully operating unit).



Operating Hours per Day (5 days/week)

Service Location 2012/13 2020 2025 Baseline Adjusted Baseline Adjusted

IR DCDH 0.1 0.2 0.2 UHNB 3.9 5.1 5.5 PRRH 0.4 0.5 0.5

XR

DCDH 15 21 21 19 20 CGH 4 6 6 TRDT 2 2 3 2 FSJH 20 25 27 28 HHHC 0 0 0 FNGH 4 9 10 6 GRB 17 18 19 19 20 LDH 5 6 6 VSJH 7 7 8 8 FLDT 1 2 2 SLH 2 2 2

UHNBC 61 73 74 74 75 VLDT 1 1 1 2 VIC -

MBDH 1 1 1 MKDH 2 3 3 QCIH 1 2 2 NHGH 1 2 2 SHC 1 1 1 PRRH 12 18 19 14 15 WMH 4 4 4 BVDH 10 12 13 HHC 1 2 2 KGH 8 13 14 10 STC 1 1 1

MMH 15 17 18

MA

DCDH 3 5 4 5 FSJH 4 5 6 6 6 GRB 5 6 7 6 7

UHNBC 1 1 1 PRRH 3 5 4 BVDH 3 4 4 5 KGH 2 4 3 MMH 5 6 5 6

Table 17: Calculated operating hours based on projected volumes and reference workload & utilization per service.

From the calculated operating hours above, the following can be observed:

MRI at UHNBC currently requires two 8-hour shifts/day and could increase to three shifts/day depending on the scenario considered

o This model does not take into account any additional MRI services in NH CT services require about half an 8-hour shift at most locations except UHNBC (2 to 3 shifts/day) and

MMH (1 to 1.5 shifts/day) NM at FSJH requires about half an 8-hour shift/day, while UHNBC needs two shifts/day and MMH 1

shift/day US is in high demand across many sites, requiring multiple teams operating 8-hours or longer. The

exception are FNGH, FLDT and NHGH where less than half an 8-hour shift/day is required



BD requires less than one hour per day of service at all locations except UHNBC where it could be up to half an 8-hour shift/day

IR also shows low operating capacity except at UHNBC (about half an 8-hour shift/day) XR is a service requiring operating capacity across all sites, although smaller sites need only a few

hours a day of staffed capacity MA requires between half and one 8-hours shift/day at most sites

Based on required operating capacity and similarities in service delivery between modalities, combined service delivery and cross-education of staff can be planned at each site.



Service Specific Review R A D I O L O G Y A N D F L U O R O S C O P Y

General radiography is the conventional use of x-rays to image the human anatomy for diagnostic purposes. In 2012 NH converted the last of its film based sites to Computerized Radiography (CR), which utilizes digital cassettes together with conventional analog X-Ray machines. CR enables the transition from film to digital imaging without replacing existing x-ray units, offering a low cost solution for entry into a Picture Archiving and Communication System (PACS) environment. Digital Radiography (DR) is the final step in digital imaging where images are generated on a digital receptor without the need for handling cassettes. DR effectively automates part of the imaging process by obviating the need for cassettes and in so doing improves throughput but at an increased capital cost. The business case for DR requires high demand. And consideration of the following:

DR is approximately three times the cost of comparable analog machines. Service costs are 8-12% cost of equipment. DR can process a higher number of patients than traditional CR rooms, decision to replace equipment

should include utilization of existing equipment. Dose reduction to the population needs to be considered in the context of the population size and the

radiation dose reduction benefit.

Fluoroscopy is a real-time procedure that allows medical staff to see tissues and organs in motion, as well as capture them on still film. In almost all cases, fluoroscopy is done at sites where a radiologist is present or in the OR (using a C-Arm) with an orthopedic surgeon. In recent years there has been a gradual reduction in the use of fixed fluoroscopy equipment and as a result many of the existing machines are underutilized. Mobile fluoroscopy (C-Arms) continues to be required to support orthopedic and some other surgical procedures.

General Radiography services exist at each of the 25 NH sites. General radiography (x-ray) continues to be a basic component of diagnostic imaging portfolio and in many communities is the sole modality available. Within NH there are8:

40 X-ray units (mix of X-ray, X-ray/fluoroscopy and IR machines) 26 portable X-ray units 8 C-arm X-ray units 7 film printers 33 CR units

Trends

Recent trends in radiography include:

Lowest growth (2%) modality in BC9 The move to “complete” digital imaging (DR), eliminating the need

for cassettes Radiation dose reduction with the implementation of DR. Implementation of PACS and the associated workflow Full integration of PACS with the NH HIS/RIS

While fluoroscopy is necessary for some procedures, there is considerable movement toward the use of CT scan for abdominal procedures (bowel studies) and angiography. It is conceivable that NH will not be 8 SOURCE: NH Biomedical Engineering Medical Imaging Inventory (August 2013) 9 BC Health Enterprise Architecture Program. Medical Imaging Pilot Vision. May 18, 2013. V0.6

Annual general radiography demand grew by an average of 2% provincially in the last five

years and accounts for approximately 60% of all

medical imaging in BC.



replacing several fluoroscopic units when they come to the end of their life expectancy. This will result in several significant impacts:

Fluoroscopic procedures are done in conjunction with a radiologist or other trained medical staff (i.e. Orthopedic Surgeon).

Fewer fluoroscopic procedures may result in decreased capital expenditures for fluoroscopic equipment based on service delivery models.

Increased CT scanner usage (for provision of alternate/similar type studies) may impact the delivery of CT services.

Fluoroscopic equipment will still be required for speech pathology group, which depends on the equipment for modified barium swallow studies. Decreased utilization of fluoroscopic equipment for abdominal studies/angiography may mean more time available for speech pathology’s swallow studies; a decreased waitlist for these studies is anticipated.

Recommendations

1. Of the 7 printers in use, few are ever used. We recommend eliminating all film printers as part of a filmless strategy. Downtime and service continuity plans need to be developed that are independent of hard copy images.

2. All DR purchasing decisions must be subject to a business case that considers a threshold volume that justifies DR over CR.

3. Multi-purpose rooms need to be considered in place of dedicated fluoroscopy equipment replacement.

4. Review the number of CR readers available in all CR sites; one CR reader can support 2 rooms provided there is one additional reader for redundancy (regional spare).

I N T E R V E N T I O N A L R A D I O L O G Y

Interventional Radiology is the name given to many procedures that are minimally invasive and use imaging as a guide. Interventional radiology can be used for diagnosis and for treatment. A list of procedures includes:

Angioplasty and Vascular Stenting Needle Biopsy of Lung (Chest) Nodules Catheter Angiography Permacath Insertion Catheter Embolization Radiofrequency Ablation of Liver Tumours Chemoembolization Thrombolysis Computed Tomography – Angiography Transjugular Intrahepatic Portosystemic

Shunt (TIPS)

Cryotherapy Ultrasound-guided Breast Biopsy Detachable Coil Embolization Uterine Fibroid Embolization Endovenous Ablation of Varicose Veins Vascular Access Procedures Magnetic Resonance (MR) – Angiography Vertebroplasty Magnetic Resonance (MR) – Breast Biopsy X-Ray Guided Breast Biopsy

Interventional Radiology is a specialized field and few Radiologists are trained in the discipline. Advances in technology are resulting in an increased amount of interventional patient care within Medical Imaging departments, performed by radiologists instead of in operating rooms by surgeons. Interventional procedures decrease demand for operating room time. Typically interventional procedures are performed quicker, are less invasive, and require less recovery time than the same procedure if performed in the operating room.

Currently interventional procedures are performed only at Dawson Creek, UHNBC and Prince Rupert. In general, the medium sized sites perform a limited scope of these exams whereas UHNBC provides a more complete array of Interventional work.



Ultrasound services generate more MSP income than their operating costs, resulting in a net revenue

generate service.

Recommendations


U L T R A S O U N D

Ultrasound is a modality that uses high frequency sound waves displayed and recorded in real time on a monitor. Ultrasound is a valuable modality because it provides dynamic imaging without the use of ionizing radiation (as is used in CT and general X-ray) to obtain the image. It is the modality of choice in a wide range of anatomical sites and conditions, including:

• Abdomen –especially liver • Heart (echo) • Veins (Deep Vein Thrombosis) • Female pelvic organs • Breast follow up • Soft tissues • Fetus-standard for prenatal care &

assessment of fetal development & wellbeing10

• Arteries (carotids) • Thyroid

• Prostate • Scrotum

Ultrasonography is a valuable component of patient care that provides physicians with the information they require to determine diagnoses and develop treatment plans. Many Interventional procedures such as Biopsies and Drainages are performed in the MI Ultrasound department replacing the need for a surgical suite, surgeon and OR staff. There is considerably less risk and discomfort to the patient and faster recovery times as general anaesthetic is not required. The numbers and types of interventional procedures provided under Ultrasound guidance within Imaging Departments are increasing.

Ultrasound services are provided at 13 NH sites in different capacity and predominantly to outpatients, with payment for services by the provincial medical services plan. Ultrasound services typically generate revenue for NH in excess of the cost of providing the service. Consequently, the provision of ultrasound services is sometimes seen as a business opportunity by clinicians and by facility administrators.

NH waitlist data is collected regularly and does not project any immediate changes in trends. The current wait times are listed below.

Ultrasound Wait Times Community

Wait Times (days) OB NON OB

Prince George 25 49 Prince Rupert 10 10 Terrace 22 22 Dawson Creek 5 12 Kitimat 8 8 Smithers 8 11 Hazelton 20 20 Vanderhoof 13 13 Quesnel 14 14 Fort St. John11 102 102 Fort Nelson 26 26

Table 18: Ultrasound wait times (July 2013).

10 Society of Obstetricians and Gynecologists national clinical guidelines: SOGC CPG 187; Recommendation 1; Feb 2007 http://www.sogc.org/guidelines/index_e.asp 11 FSJ extended wait times due to US staffing shortages

Annual Ultrasound demand grew by an

average of 4% provincially in the last five

years and accounts for approximately 17% of

all medical imaging in BC.

http://www.sogc.org/guidelines/index_e.asp



The shortage of ultrasonographers is the

most significant issue facing the NH

ultrasound service.

Ultrasound in the North is an increasingly demanded service that meets a variety of physician and patient needs. US exam utilization continues to grow in all HSDA’s. Factors driving growth include:

Increasing population Replacing Fluoroscopy and OR procedures with Ultrasound (biopsies, drainages, injections) Increase in shoulder and MSK ultrasound exams due to lack of MRI resources and long MRI wait times

In nearly every British Columbia Health Authority, sonographers, are the least available medical imaging staff. According to a survey conducted by the Provincial Imaging Council (July 2013) there is currently 72.47 vacant FTE’s comprising 102 vacant positions in Health Authorities of BC. This data shows that the human resource shortage related to Ultrasonography services is significant.

Staffing is the major issue facing the delivery of Ultrasound service in NH. It is geographically and financially challenging for rural NH residents to attend formal education in the lower mainland. NH currently has 7.8 vacant FTE ultrasound positions. It is anticipated this number will rise with the increase in US workload, aging staff, population, and staff repetitive strain injuries.

A proposal has been drafted to address the chronic shortage of Ultrasound Technologists in Northern BC and was to be submitted for approval December 2013. The Sonography Training At Rural Sites (STARS12) proposal is designed to train currently employed Medical Imaging technologists in the skills of sonography to a level where they are prepared to write national certification exams in general ultrasound. This 18-month process can be delivered through the community hospitals in Northern BC currently offering ultrasound and thus, train and retain staff at a local level.

Nor thern Health Shor tage12

In relation to the specific challenges encounter by NH, a current snapshot of our ultrasound vacancies is listed below:

Site FTE Positions FTE Vacancy Comments

Fort Nelson 0.6 0.6 Locum service when available Fort St John 2.9 2.0 One vacancy is a term

Dawson Creek 3.1 - (+new Mat leave vacancy March 2014 0.7 FTE) Prince George 6.5 2.0 One vacancy is a term

Quesnel 3.7 - Vanderhoof 1.0 -

Terrace 1.6 1.6 Locum service Kitimat 0.6 0.6 Locum service

Prince Rupert 1.6 1.0 Chief technologist jointly holds the ultrasound position (1 FTE), retiring in June 2014

Smithers/ Hazelton 2.0 - 2.0 FTE shared between the sites Total 23.6 7.8 33.0 % vacancy rate

Table 19: Current ultrasound vacancies.

There are also growing service needs that support the ability to have ultrasound services in smaller communities outside of centers where there is not a sonographer. The presence of a sonographer and on-site radiologist is the preferred standard of care. However, tele-ultrasound services are being provided in communities throughout Canada where the shortage of sonographers prevents establishment of a resident or visiting service and the alternative is no study at all.

12 Northern Health Sonography Training At Rural Sites-October 11, 2013



Some physicians and surgeons are acquiring small portable US units to perform quick bedside scans in OR, ER and on the patient wards. These exams are not supported by the Medical Imaging departments or by the onsite Radiologists and is not an MSP billable service. The quality of these services are not known, however it is reasonable to question diagnostic quality if such modalities are used by minimally trained personnel.

Obstetrical Ultrasound in smaller communit ies

Many smaller communities would benefit from having a local ultrasound service, especially those sites where travel in and out of the community is difficult. An ultrasound service would be beneficial in monitoring maternity patients as ultrasound fetal assessment is part of the clinical practice guidelines for prenatal care of the Society of Obstetricians and Gynecologists of Canada. Being able to perform an ultrasound examination requires a great deal of skill and may only be performed by staff having the appropriate certification. The challenge is in finding sufficient qualified Sonographers to accommodate these sites.

Accreditation standards require that ultrasound services be provided under the supervision of a physician recognized by the College of Physicians and Surgeons to monitor and interpret ultrasound examinations. Normally this is a Radiologist. However, there is at least one Obstetrician in Northern BC who is also certified to interpret obstetrical ultrasound images. The potential ultrasound workload in smaller communities would not support a resident sonographer. An option for communities where there are less than 150 ultrasound scans each month is to seek ‘remote status’ from the Diagnostic Accreditation Program. Having that status allows a radiologist to provide supervision from a distance.

Echocardiography

Echocardiography examinations are advanced ultrasound procedures that are used to examine the heart. Echocardiography allows clinicians to see the heart visually and to measure the velocity of blood and cardiac tissue. This information equips clinicians in making informed decisions around treatment for heart conditions. Echocardiography is performed at fewer sites than general ultrasound.

In Northern Health, echocardiography exams are subject to technologist training and staffing limitations. Technologists who wish to perform echocardiograms are required to complete the specialized Echocardiography training program. The scarcity of sonographers naturally translates to a shortage of echo techs as well. Terrace is currently training 2 of its radiology staff to perform dedicated echocardiography exams.

NH has reduced the echocardiography waitlist times significantly from 2006 to 2013:

Echocardiogram Wait List Community 2006 Waitlist July 2013 Waitlist Prince Rupert 98 20 Quesnel 180 15 Prince George 106 90 Dawson Creek 60 12 Fort St John 91 63 Terrace 21 Smithers 17

Table 20: Echocardiogram wait list, 2006 and 2013.

This reduction in wait times in due significantly to the hiring of an external echocardiography solution service, Canadian Cardiac Solutions.

With the ongoing shortage of ultrasound technologists, 7 of the 8 NH sites performing cardiac ultrasounds, have contracted this company to perform echocardiography while utilizing their NH ultrasound technologists to perform general ultrasound exams.

Some centers have been utilizing this service for the last 5 years to alleviate their staff shortages and echo waitlists. 11% of the total workload exams at PGRH and 14% of the total workload exams at Mills



Memorial in 2012-13 were performed by Canadian Cardiac Solutions. There is a substantial risk to service at these sites while dependent on an external company to provide such a large portion of the workload.

The recognized acceptable wait time for an outpatient echocardiogram is within 28 days. Due to the nature of the test, waitlists of this length are unacceptable and often render the examination unnecessary, as physicians are forced to treat patient symptoms without the information from the echo. The physician may be choosing other tests of less diagnostic value.

Equipment

Northern Health’s ability to replace the ultrasound units as they become outdated is a concern. Northern Health has 38 ultrasound units accounted for:

2 dedicated echo 30 general ultrasound 5 portables 1 Interventional

Five of these units are designated to the departments of Maternity, Emergency, Oncology & OR.

The replacement costs spanning 2014/15 – 2021/22 for these 38 units total $ 5.3M. The rapidly changing technology in this area has prompted other Health Authorities to implement an ultrasound purchase replacement strategy of every 5 or 6 years.

Ultrasound capital equipment purchase considerations:

Ultrasound equipment in Northern Health is well-utilized. Trained staff is the limiting factor to increasing the number of examinations performed.

The accepted life expectancy for an ultrasound machine is 8-12 years depending on utilization. US machines not designated to MI departments should be purchased and expensed to the individual

department utilizing the machine.

Trends

Future trends in ultrasound include:

Continued growth in demand as a versatile and relatively low cost modality. Improved PACS viewer capabilities for echo that will enable improved remote access to specialists. Increased computer power and, therefore image quality and capability. Greater capability in small, hand-held or portable devices. Increased adoption and use of 3DUS and 4DUS, especially in areas of volume imaging and functional

imaging. Real-time transmission of images across networks for remote supervision (Tele-ultrasound).

Recommendations

1. All ultrasound purchases to be subject to a business case. 2. Develop a business case for remote ultrasound and echocardiography in under-served communities:

a. Initiate a program to cross-educate medical imaging technologists, or other suitably qualified staff, to obtain their ultrasound and echo diplomas.

b. Continue to engage BCIT or a similar institution as a partner to resolve the staff shortage in ultrasound and echo in the North of BC.

c. Approval of STARS program. d. Continual advertising and recruitment of applicants to STARS program.

3. Apply to the DAP for remote status in ultrasound. 4. Support use of Canadian Cardiac Solutions until such time that NH can service the ultrasound workload

internally.



B O N E D E N S I T O M E T RY

Bone Density is a radiologic procedure that uses X-Rays to measure the density of bones to assess the patient for osteoporosis. Currently Bond Density services are provided on a part-time basis at 6 NH sites, 2 in each HSDA:

Northeast: services are provided in Fort St John and Dawson Creek. The Dawson Creek service is a long standing program with the Fort St John program launched in 2012.

Northern Interior: services are provided in Prince George and Quesnel. Unlike other centers, the Prince George bone density is operated out of the Nuclear Medicine Department.

Northwest: services are provided in Kitimat and Prince Rupert. The Kitimat service is a long standing program with the Prince Rupert program launched in 2012.

Equipment

Bone Density capital equipment purchase considerations:

Scanner lifespan is generally accepted to be 10 years. Although there have been limited changes in the hardware aspects of bone density, software and

computer processing continues to improve at a high rate. NH replacements (based on 10 year cycle)at approximately $120,000 per unit is as follows:

o Kitimat: 2016/17 o UHNBC: 2017/18 o Dawson Creek: 2020/21 o Quesnel: 2021/22 o Fort. St John.: 2021/22 o Prince Rupert: 2022/23

Trends

Bone Density exams have decreased significantly over the past 5 years and although an aging population could marginally increase the demand, the impact would likely be minimal. Recent changes to the MSP reimbursement schedule have changed the frequency of insurable scans from a 2 to 3 year cycle appear to have negatively impacted the utilization of this exam.

In 2005/06 NH was operating 4 scanners providing approximately 2,800 exams annually, in 2012/13 there are 6 scanners providing 1,940 exams. Wait list data is not being tracked for this modality

Bone Density Activity by HSDA HSDA 2012/13 2011/12 2010/11 2009/10 2008/09 5 YEAR

CHANGE AVG ANNUAL

CHANGE Northeast 305 307 254 249 260 17.3% 3.5% Northern Interior 1481 1817 1682 2157 3279 -54.9% -11.0% Northwest 154 278 593 613 626 -56.2% -11.2% TOTAL 1940 2402 2529 3019 4165 -53.5% -10.7%

Table 21: Bone density activity by HSDA13.

Recommendations

1. Review utilization rates at each site and alter the service delivery model from fixed units to a mobile service.

2. Use the equipment planning and the access to service tools provided to determine the optimal solution and rotation frequency to maintain current utilization rates in each HSDA.

13 Source: Northern Health Imaging Volumes- March 2013

Bone Density equipment is significantly underutilised and the utilisation trend is

declining.



N U C L E A R M E D I C I N E

Nuclear Medicine Imaging involves injecting a radioactive isotope into a patient. As the isotope decays, gamma rays are emitted and detected by a gamma camera to produce an image. Nuclear medicine is used to detect cancer, as well as a number of cardiovascular, neurological and physiological abnormalities. In addition to diagnostic assessments, Nuclear Medicine provides therapeutic procedures for thyroid cancer, hyperthyroidism and occasional palliative therapies for metastatic bone cancer.

Nuclear Medicine is provided in three NH sites, one in each HSDA: Fort St. John (Northeast), UHNBC (Northern Interior) and Terrace (Northwest).

Northeast: Nuclear Medicine services in the NEHSDA were interrupted in 2013 with the departure of the sole technologist from Fort St John. A replacement was recruited and the service has resumed however the lack of relief staff limits the delivery of service to the NE. Nuclear imaging is done using a GE Hawkeye (2005) SPECT/CT Gamma camera (non-diagnostic CT tube for attenuation correction). Medical interpretive services are provided by a part-time onsite radiologist and/or select radiologists located in Prince George.

Northern Interior: Nuclear Medicine services in the NIHSDA are well established and provided by a 2 camera department in Prince George. Nuclear imaging is done using a GE Hawkeye (2007) (non-diagnostic CT tube for attenuation correction) which is the newest SPECT/CT Gamma camera in NH and a Skylight Gamma Camera (2003). Medical interpretive services are provided by full-time onsite radiologists.

Northwest: Nuclear Medicine services in the NWHSDA are well established and provided by a single camera department using a Skylight Gamma Camera (2003). Medical interpretive services are provided by nuclear medicine radiologists located in Prince George.

Equipment

Gamma Camera lifespan is generally accepted to be 10 years. Gamma Camera configurations and approximate costs are as follows:

Basic SPECT unit $500,000 No significant renovations required SPECT/CT non-diagnostic $700,000 Possible limited renovations required SPECT/CT diagnostic 8 slice) $800,000 Renovations required; can be used as backup CT

scanner or secondary scanner SPECT/CT diagnostic 16 slice $900,000 Renovations required

A foundation project is currently underway to replace the UHNBC Skylight.

From 2015/16 through 2017/18 Northern Health will be faced with annual Gamma Camera replacements expenditures (based on a 10 year lifespan) of approximately $1,000,000.

Trends

Nuclear Medicine is a low volume, labor intensive service that, apart for myocardial perfusion imaging, shows little signs of significant growth. Provincially, the volume of nuclear medicine scans reduced by 3%over the past five years. Recent isotope shortages have resulted in service delivery issues and although the current supply is stable, there are concerns that without significant changes, future shortages may reoccur.

Other trends in Nuclear Medicine include:

The development of Positron Emission Tomography (PET) as valuable diagnostic tool. Note: PET scanning is generally limited to sites that are near the cyclotrons that produce the isotopes used in PET imaging.

The development of SPECT/CT cameras where concurrent Nuclear Medicine and CT imaging is done improves the clinical accuracy of some Nuclear Medicine procedures.

PET/CT is specialized hybrid technology that enables one test to provide both functional (PET) and structural (CT) images which can significantly enhance the effectiveness of diagnosis. A cyclotron unit is required to manufacture the radioactive compound. There is currently only one PET/CT in BC located at the BCCA site in Vancouver.



Potential for high speed multi slice CT scanners or cardiac MRI to replace a proportion of the nuclear medicine cardiac imaging.

Increasing cost and uncertain supply of isotopes. Northern Cancer Center may increase the demand for nuclear medicine procedures across the Health

Authority. There is an overall decline in the number of Nuclear Medicine exams in Northern Health, partially the

result of staffing issues.

Recommendations


M A M M O G R A P H Y

Mammography services are divided into two distinct streams of activity, screening mammography and diagnostic mammography. Screening mammography is administered through a provincial program, the Screening Mammography Program of BC (SMPBC), under the BC Cancer Agency. The SMPBC contracts with health authorities and community clinics to provide an annual quota of screens for the target population. The current service delivery locations are shown in Figure 9.

The SMPBC closely monitors screening volumes by region and site on a reporting period basis. The screening statistics are provided in the following chart current to Period 7, 2013/14.

Site Annual Target

YTD Actual

YTD Assigned

YTD Variance

% Variance

Wait Time (Weeks)

Prince Rupert 700 305 394 (89) -22.5% 3.5 Kitimat 600 246 337 (91) -27.1% 0.5 Terrace 1,100 515 618 (103) -16.7% 2.0 Smithers 770 384 433 (49) -11.3% 0.5 Prince George Community Clinic

6,000 3,228 3,312 (84) -2.5% 2.0

Quesnel 1,300 727 731 (4) -0.5% 0.5 Dawson Creek 800 312 450 (138) -30.6% 3.5 Fort St John 1,000 500 562 (62) -11.1% 6.5

Table 22: Period 7, 2013 /14 Screening Mammography Status Report



Figure 9: Current Mammography Services in Northern Health

Capacity and Exam Mix

A review of mammography exam procedures was completed for all northern sites doing screening and diagnostic procedures. NH data was crossed referenced with SMPBC data to ensure data accuracy (Table 23.

Observations:

The annual screening volume target for northern BC is 14,500 exams / year. The annual screening volume on the digital mobile unit is targeted for 14,500 exams / year. There are very small volumes of both screening and diagnostic procedures being performed across

the north.

Diagnostic Services

Screening Services



Mammography reading in small centers provides insufficient volume to meet expertise levels14 There is a large amount of over capacity from an equipment perspective across the north. Concentration of diagnostic mammography volume at the HSDA level could generate sufficient volume

to justify EUSOME15- based health center(s) of excellence. Vernon has one film based mammography unit with a higher throughput of screens and diagnostic

procedures. Exam volumes do not warrant two digital mammography units in Prince George.

Site Diagnostic Procedures

Fine Wire Localizations

Stereotactic Core Biopsies/

FWL

Total Diagnostic Exam Mix

Total Screening

Target

Total Exams per Unit

Prince Rupert 239 2 - 241 700 941 Kitimat 80 - - 80 600 680 Terrace 476 8 19 503 1,100 1,603 Smithers 386 - - 386 770 1,156 Prince George (UHNBC)16 8 49 92 149 - 149 Prince George (CIC)17 3,000 - - 3,000 6,000 9,000 Quesnel 486 2 - 488 1,300 1,788 Dawson Creek 524 7 - 531 800 1,331 Fort St. John 438 16 - 454 1,000 1,454 Comparative Site Data Vernon (1 FFDM unit) 3,500 37 76 3,613 6,075 9,688

Table 23: Summary of mammography volumes by site (Public and Private). Source: SMPBC Database 2013.

Digital versus Analogue Mammography Technology

Full Field Digital Mammography (FFDM) has led to improved throughput, lower radiation dose and improved image quality in breast imaging. The target productivity volume per technologist proposed by SMPBC is 5000 mammograms per year. The equipment utilization target is 17,500 mammograms per FFDM unit per year in order to justify the additional technology cost. In NH there are no locations that can justify having a dedicated, fixed FFDM unit based on the SMPBC recommendation.

The combination of FFDM and PACS, with mammography software, presents a great opportunity to manage breast imaging services with increased efficiency and effectiveness. Remote reading can be concentrated on fewer sub-specialized radiologists, thus increasing the expertise of the reading radiologist.

Software to automate the detection of abnormalities in digital mammograms is becoming increasingly advanced. Computer Aided Diagnosis (CAD) represents both an efficiency opportunity as well as a potential quality improvement opportunity when used appropriately.

Table 24: Comparative Costs of Digital and Analogue Mammography equipment

14 BCCA recommends min 1000 reads per radiologist/year. Eusoma recommends 5000 reads per radiologist /year 15 European Society of Mastology 16 The mammography volume shown at UHNBC is mainly associated with stereotactic biopsies 17 The mammography volume at this Community Imaging Clinic is not part of Northern Health volume

Capital Equipment Maintenance (per year)

Equipment Maintenance (per screen)

Analog $ 191,154 $ 14,173 $ 2.12 Digital $ 448,182 $ 37,750 $ 5.66

Figure 10: FFDM Equipment and Digital Image Display



Site Estimated Digital

Conversion Costs

Annual Service Contract

10 – year Amortization

Exam Volume Targets

(2013/14)

Average Cost per Exam

Prince Rupert $700,000 $36,000 $106,000 700 $151.43 Kitimat $700,000 $36,000 $106,000 600 $176.66 Terrace $850,000 $66,205 $151,205 1,100 $137.46 Smithers $700,000 $36,000 $106,000 770 $137.66 Prince George (UHNBC)18

$850,000 $66,205 $151,205 6,000 $25.20

Prince George (CIC)19

$700,000 $36,000 $106,000 6,000 $17.67

Quesnel $700,000 $36,000 $106,000 1,300 $81.54 Dawson Creek $700,000 $36,000 $106,000 800 $132.50 Fort St John20 $850,000 $73,705 $158,705 1,000 $158.75 Estimated Conversion Costs for all NH sites

$6,750,000 $422,115 $1,097,115 12,270 $89.41

Table 25: Conversion costs for Mammography services for all existing Northern Health sites.

Site Cost Comments Terrace $850,000 Screening and diagnostic procedures Prince George $850,000 Screening and diagnostic procedures Fort St John already converted Screening and diagnostic procedures SMPBC Digital Mobile planned for 2015 Screening procedures

Table 26: Summary of Digital Mammography Conversion Costs – SMPBC proposed approach.

The transition from film based mammography to full field digital mammography technology has provided the following benefits:

Significantly improved image quality Continuity of reporting and patient record Increased productivity for the reading radiologist via PACS Increased productivity for the technologist Elimination of physical record storage requirements

Although there are many noted benefits to digital mammography, the capital costs and operating costs require a substantial volume per machine to justify the investment.

Breast Health Centers

The time from suspicion of breast cancer to diagnosis and start of treatment can make the difference between life and death for this patient group. In a 2008 study at Fraser Health (FH) by INSITE Consultancy the longest time to diagnosis was over six months and the average was three months. With process re-engineering the

18 The UHNBC mammography unit is currently used for diagnostic work only, however it could be replaced with a digital unit capable of screening and diagnostic work 19 SMPBC currently contracts with the Community Imaging Clinic to offering screening services in Prince George 20 Fort St John was converted to digital mammography through external funding in conjunction with the new hospital building. Fort St. John service costs are based on actuals

Improve quality by consolidating digital mammography into a mobile

service with dedicated reading radiologists reading 1000 per year.



maximum time to diagnosis can be reduced to 15 working days and FH have been able to achieve that performance in a large number of cases. The model, known as the EOSOMA model is well understood and represents an opportunity for NH to deliver such a service for its residents and, we commitment from all clinical specialties and management can consistently achieve the EUSOMA performance standards.

Figure 11: Diagram representing the BCCA model for Breast Health in BC

BCCA has adapted the EUSOMA model in a provincial breast health strategy that is summarized in the diagram above (Figure 11). The Hubs are coterminous with EUSOMA breast health clinics with operational process and clinical specialties (pathology, radiology, surgery and oncology) arranged in a “one-stop” clinic model. The service providers are arranged around the patient instead of the traditional model which revolves around the “constraints” of the service (Figure 12).



Figure 12: Patient Centred Breast Health Clinic (Hub)

Regulatory Standards

In October 2013, Health Canada released new federal safety standards entitled “Radiation Protection and Quality Standards in Mammography: Safety Code 36”.

These standards have the goal of providing optimal mammographic image quality, while ensuring the personnel working within the department and the general public are safe. These federal standards contain the quality control requirements for mammography departments. The quality control requirements and quality assurance practices of the Diagnostic Accreditation Program of BC, and the Mammography certification of the Canadian Association of Radiologists are requirements for all SMPBC screening sites.

Fulfilling the increasing regulatory standards is a factor in the decision of where to locate mammography services.

Delivery Options

Delivery of mammography services should be aligned with the developed Provincial Breast Health Strategy, which is focused on improving patient navigation, improving screening rates, and decreasing time to diagnosis. A delivery model that provides consistency of service, independent of local staff availability, would be one factor in improving over-all screening rates in the north. Currently many sites have very few mammography certified technologists, and availability of staff becomes the limiting factor in providing effective mammography screening.

Available technical staff Digital equipment Integrated electronic reporting Hubs of Excellence for diagnostic procedures Available radiologist support Cost effective



Recommendations




a. Develop a business case to define the service and justify the capital and operating costs. 4. Consolidate mammography reading on fewer radiologists to achieve the BCCA minimum

mammography reads per radiologist per year.

C O M P U T E R I Z E D T O M O G R A P H Y

Computerized Tomography (CT) scanning is considered the modality of choice in clinical identification of many diseases and conditions; the modality is increasingly being utilized for screening purposes such as for colorectal cancer. Modern CT scanners are capable of acquiring multiple cross-sectional images in a single revolution of the x-ray tube, thus collecting a volume of image data that can be processed and displayed as cross sectional “slices” or as 3-D images of the anatomy. Advances in CT technology in the past five years have focused on faster scanning times, decreased radiation dose to the patient and advanced imaging procedures such as coronary CT angiography, CT colonoscopy and similar advanced imaging techniques.

Access to CT is critical to the treatment decisions of suspected stroke victims. If a cerebral hemorrhage can be ruled out in less than four and a half hours (4.5) of onset21, thrombolytic therapy can be given and long term brain damage can be avoided.

There are presently seven CT Scanners situated across six NH facilities, all of comparative age and technological capacity. In response to the region’s large geographic catchment area, CT services were supplemented with the purchase of a second scanner at UHNBC (2008) and a new scanner in Fort St John (2009) and are spread out across the health authority (two in the NW, three in the NI, and two in the NE).

Jurisdiction Number of CT Exams per 1000 Population

Number of Exams per CT Scanner per Year

Northeast 69.5 2,639

Northern Interior 102.9 5,273

Northwest 93.4 3,405

NH Average 94.6 3,988

British Columbia (2009) 106 9,452

Alberta 124 10,739

P.E.I 104 7,291

New Brunswick 193 11,199

Nova Scotia 155 10,025

Canada 121 9,387

USA 228 5,298

OECD 139 -

Table 27: Utilization rates per 1,000 population for CT and exams per CT scanner22.

21 NICE technology appraisal guidance 264.Alteplase for treating acute ischaemic stroke (review of technology appraisal guidance 122) Issued: September 2012



CT utilization rates are below the Provincial average (Table 27), with the Northeast HSDA showing the lowest rate. Observations from the above table:

Overall the NH region is under-utilizing CT relative to other Canadian jurisdictions based on population.

The Northeast and Northwest HSDAs have the lowest utilization rate for CT. CT wait times are very low and for practical purposes there is no meaningful wait time at any site in

NH.

CT wait times (Table 28) are significantly lower than the average for BC (4 weeks) and other jurisdictions. This is in part the result of the considerable capacity available across Northern Health and the low utilization of the CT scanners.

CT Wait Times Community Wait Times (days) Comments

Prince George 1 days Dec 18 2013 Quesnel 2 days Dec 18 2013 Terrace 14 days Dec 18 2013 Prince Rupert 9 days Dec 18 2013 Dawson Creek 1 days Dec 18 2013 Fort St. John 7 days Dec 18 2013

Jurisdiction British Columbia 4 weeks 2012 Alberta 2.9 weeks 2013 Manitoba 4 weeks 2013 Ontario 35 days 2013

Table 28: Wait times for CT23.

CT Services Site Summary

Prince Rupert Regional Hospital: A 64-slice Toshiba Aquilion CT scanner was purchased in 2013. This is the newest scanner in Northern Health and utilizes the latest in dose reduction software, allowing scans to be performed at dose levels 30-50% less than on older 64 slice models. CT coronary angiography services are not performed at this site however CT Colonography is provided. The scanner is capable of serving 30-40 patients per day and is currently processing approximately 6.

Mills Memorial Hospital (Terrace): A 64-slice Toshiba Aquilion CT scanner was installed in 2006, making it one of the oldest scanners in Northern Health. The scanner is capable of serving 30-40 patients per day and is currently processing approximately 21. The cardiac imaging function of the scanner is currently not being used. This Aquilion 64 is not upgradable to the latest dose reduction software.

G.R. Baker Memorial Hospital (Quesnel): A 32-slice Aquilion CT scanner was installed in 2006, making it one of the oldest scanners in Northern Health. The scanner is capable of serving 25-30 patients per day and is currently processing approximately 9. CT coronary angiography services are not performed at this site. This Aquilion 32 is not upgradable to the latest dose reduction software.

University Hospital of Northern British Columbia (Prince George): UHNBC has 2 CT scanners (2008) in operation, a 320 slice Toshiba Aquilion ONE and a 64 slice Toshiba Aquilion. Each scanner is capable of serving 30-40 patients per day and are currently processing approximately 28. CT coronary angiography

22 Figures reflect year of latest available information (2013 calendar year for NH and 2008/09 for national and OECD data). Regionally the number of CT exams per 1000 population has increased by 13% since 2008/09. 23 Sources: Northern Health Wait Time Reports July 2013; Fraser Institute “Waiting your Turn” 2012; http://www.gov.mb.ca/health/waittime/diagnostic/ctcat.html; http://waittimes.alberta.ca/WaitTimeTrends; http://www.waittimes.net/SurgeryDI



services are performed at this site. The Aquilion ONE was recently upgraded to the latest version of dose reduction software and the Aquilion 64 is upgradable.

Dawson Creek District Hospital: A 64-slice Toshiba Aquilion CT scanner was installed in 2009. The scanner is capable of serving 30-40 patients per day and is currently processing approximately 9. CT coronary angiography services are not performed at this site. This Aquilion 64 is upgradable to the latest dose reduction software.

Fort St. John Hospital and Health Centre: A 64-slice Toshiba Aquilion CT scanner was installed in 2009. The scanner is capable of serving 30-40 patients per day and is currently processing approximately 8. CT coronary angiography services are not performed at this site. This Aquilion 64 is upgradable to the latest dose reduction software.

Equipment

Scanner lifespan is generally accepted to be 10 years. 64 slice scanners will likely phase out of production in 2-3 years, CT technology changes in recent years have focused on the

following areas: From 2015/16 through 2021-22 Northern Health will be faced

with annual CT replacements that (based on a 10 year lifespan) will result in a yearly capital expenditure of approximately $1,000,000.

Trends

The provincial CT volume increased by an average of 5% per annum over the past five years24 and is the second greatest growth modality behind MRI. Factors driving growth include new and emerging applications for CT and the growing and ageing population in the Province. Examples of the enhanced application of CT are listed below:

Coronary angiography (or diagnostic cardiac catheterization) is the reference standard for the diagnosis of coronary artery disease. CT continues to develop as an acceptable way to non-invasively image and detect coronary artery disease. Continued broadening of the clinical criteria for Cardiac CT could result in significant volume increases in facilities with the proper CT technology.

Advances in CT software and data processing technologies have proven to significantly reduce the radiation dose from CT procedures. As dose reduction improves this may increase the demand for CT services.

Colonoscopy is considered to be the gold standard for the diagnosis of colorectal cancer. CT Colonography (Virtual Colonoscopy) is a minimally invasive procedure that provides a viable alternative to traditional colonoscopy in the diagnosis of colorectal cancer. The Canadian Association of Radiologists (CAR) has developed standards which define best practices in developing this service25.

CT could replace as much as 80% of barium enema procedures for colonoscopy, much of which is done on an outpatient basis.

In regions without MRI, physicians continue to utilize CT as a “best available alternative”. As the abilities of CT continue to increase, coupled with dose reduction CT will provide a larger

component of the overall number of diagnostic procedures. The literature supports the projection that the use of CT will only increase and will be a consideration when traditional x-ray units are due for replacement.

24 BC Health Enterprise Architecture Program. Medical Imaging Pilot Vision. May 18, 2013. V0.6 25 Source: CAR-CT Colonography Standards

The NH region currently has excess CT capacity. The population weighted

access limitation for Smithers is the greatest in NH. CT utilisation will increase

during the LNG project period.



As dose reduction technologies become available, a screening program for lung cancer using Low Dose Chest CT could be developed, increasing the use of CT.

Age profile data shows CT utilization increases sharply as patients approach “middle aged” and peak for the segment of population between 70 – 89 years of age. As Northern Health’s population ages it can be expected there will be continued growth in the number of CT scans.

Demand for CT could be reduced significantly with the implementation of new MRI service locations, as in many cases it is clinically preferable to use MRI instead of CT and avoid the exposure to radiation.

Recommendations

The following recommendations are influenced by three factors:

• Northern Health has excess CT capacity and, effectively, no wait lists. • Access to CT and thrombolytic therapy in less than 4.5 hours for stroke patients is recommended. • The utilization trend is increasing with the age of the population and will be affected by the LNG

development. • Having made the investment in CT it is not pragmatic to propose decommissioning such assets.

Recommended strategies for CT are, therefore:

1. In sites with under-utilized CT scanners, increase utilization through a combination of reduced operating hours and reallocation of workload to patient choice.


3. Using the Capital Planning Tool provided, adjust the equipment replacement plan for CT to avoid replacing or investing in additional CT scanners unless there is sufficient demand within the HSDA.

M A G N E T I C R E S O N A N C E I M A G I N G

Magnetic Resonance Imaging (MRI) is a radiology technique that uses a powerful magnet, radio waves, and a computer to produce cross sectional images of human anatomy. The patient is placed on a moveable table that is inserted into the center of the magnetic field. The strong magnetic field aligns the protons of hydrogen atoms, which are then exposed to a beam of radio waves. This spins (excitation) the targeted protons at an angle away from the original alignment direction until they gradually return to the magnetically aligned direction. In the re-alignment phase (relaxation) the protons release energy that is characteristic of the tissues within they are bound. The relaxation energy is detected by receiver coils that is then amplified and processed into an image.

The images produced by MRI able to demonstrate clear differences in tissue composition which is highly valuable in diagnosing wide range of pathological conditions without the use of ionizing radiation.

For some procedures, contrast agents, such as gadolinium, are used to help differentiate different tissue types or pathological conditions Patients with cardiac pacemakers, some metal implants or foreign cannot be scanned with MRI because of the effect of the strong magnetic field. High field strength magnets (3 Tesla and above) are known to increase the heating effect in some tissues / materials and need to be used with increase caution.

The present mode of delivery of MRI services in Northern Health is a centralized model with one unit at the University Hospital of Northern BC (UHNBC) in Prince George. This unit has reasonably high utilization but could achieve a higher level with operational improvements and increased hours of operation. However, challenges that would make this difficult include; the age and condition of the scanner and the desire to perform specialized procedures such as cardiac imaging, breast imaging, angiography, etc. These specialized procedures cannot be performed with the current equipment. Image quality is a serious concern of radiologists that have cited cases where lesions have not been visible on the current scanner but clearly identifiable on newer units.



This UHNBC MRI serves patients from the entire Health Authority. Northern Health is large and sparsely populated, which makes access to MRI services difficult for people in remote areas. People in the Northwest often find it easier to go to Vancouver for their MRI, while those in the North East have easier access to Alberta than Prince George.

In 2012/13, a total of 5,273 MRI exams were provided at UHNBC. This translates to an average of 17.6 exams per 1,000 population, which is the lowest rate among all the BC Health Authorities (Figure 13). The provincial average of 27.4 scans per 1,000 of population is the target for Northern Health and within each of the HSDAs.

Figure 13: MRI utilization rates per 1,000 population26.

Service utilization across different areas within Northern Health varies significantly, as shown in Table 5 in the following sections of this report. The Northern Interior HSDA with 49% of the population used the service 86.1% of the time. In contrast, the Northwest and Northeast have 26% and 24% of the population and used the service 16% and 2.8% of the time, respectively. The result is that many patients in the NE and NW go outside the NHA for MRI exams or do not receive an MRI at all.

Equipment

The UHNBC MRI scanner is 10 years old and is at or close to the end of its useful life. The estimated replacement cost of the UHNBC MRI is $2,500,000.

Trends

The constrained availability of MRI in Northern Health, with a single service location, is the single most relevant factor limiting its use by the population. The addition of new service locations would allow appropriate access to MRI, increasing demand and utilization to Provincial standards.

26 Source: OASIS/HAMIS April 24, 2013 Ministry of Health, Management Information Branch.BC Stats Population Estimates, 2012.

18.2

21.5 22.4

27.4

31.4

34.4

NHA IHA FHA BC VIHA VCHA

MRI Exams per 1,000 Population

GA

Gap

= 3

3% o

f BC

rat

e



This report has confirmed the findings of the Business Case for MRI in 2013 using different analytical methods: NH Access to MRI is the lowest in BC The UHNBC MRI scanner is in need of

replacement One shared MRI between NE and NW will

enable access to match BC average Annual MRI demand increased by an

average of 8% provincially over the past 5 years

In 2013 a business case27 was commissioned by NH that made recommendation to address the access issue experienced by the residents of the NE and NW HSDAs. The analysis completed for this report supports the findings and recommendations of the business case.

Recommendations

The following recommendation is influenced by

Mobile MRI is mature technology Demand projections suggest half scanner capacity

for each of NE and NW The NH MI Access Tool supports the findings of the

business case and should be used to monitor the future impact of the strategy

The recommendation for MRI services is, therefore:

1. Invest in a new mobile MRI unit serving the NE and NW and replace the existing (old) MRI unit at UHNBC.



The implementation and tactical plan for the mobile MRI proposal is described in the 2013 business case.

I N F O R M A T I O N T E C H N O L O G Y

All sites in Northern Health are now on the same PACS platform (AGFA) allowing each site to send images electronically. This integration allows the reading radiologist to be located in any site where a physician review station is present, resulting in an increased utilization of radiologist’s time. It should be noted that having an onsite radiologist in the medium sized facilities is preferential as it allows for a wider scope of services to be delivered.

The Radiology Information System (RIS) is a module of the Hospital Information System (HIS) provided by Cerner. British Columbia is strategically moving towards an information systems environment that reduces variability and improves interoperability between systems. Patient information can be more easily shared and continuity of care with less risk of missing information can be achieved. NH is well positioned to participate in Provincial information sharing (eHealth) initiatives through its single platform regional PACS and Cerner system.

NH treats a significant number of patients from other HA catchment populations and a sizable proportion of its residents seek medical imaging service from outside of NH, especially Vancouver. It is therefore in the interest of all and all Health Authorities take steps to enable sharing of patient information to authorized users.

Provincial Diagnostic Imaging Project

In recent months Provincial Health Services Authority (PHSA) completed an RFP for a replacement PACS for VCH /PHC and PHSA together with a provincial Diagnostic Imaging Repository (DI-r). The goal of the DI-r is to transform the existing Provincial DI Viewer (PDIV) into a robust, fault tolerant, highly available DI-r that will enable seamless information sharing and sustainment of the existing viewer. Philips Healthcare will provide the DI-r to all health authorities and PACS to PHSA, VCH and PHC.

27 INSITE Consultancy Inc. Northern Health MRI Feasibility Study. Version 1.0 May 2013



The DI-r will store imaging data held on the HA PACS archive, which presents an opportunity for NH to leverage the DI-r as the primary PACS archive for NH. This would save NH the full cost of owning and maintaining its existing PACS archive.

NH already has PDIV resources that will be leveraged for the DI-r upgrade work. Subject to NH’s agreement, one of the first upgrades from PDIV to DI-r will occur in NH allowing NH to begin realizing the benefits of seamless access to provincially stored DI results (images and reports). Physicians who currently use PDIV to view images from other health authorities will continue to do so but, over time, the integrity of the DI data will be improved and there will be improved availability of studies through the DI-r than is currently the case.

Community Imaging Clinics perform 32% of all Medical Imaging in BC. While the conditions exist for CICs to adopt the DI-r by archiving their images on the Philips DI-r there few, at this point, that realize this potential of have chosen to adopt it. Without access to the CIC volume the DI-r will not achieve its full potential to improve patient care. IHA and VIHA have extended their PACS environment to all CICs in their catchment and will, automatically have access to CIC-sourced imaging results.

Recommendations

1. Fully engage with the Provincial DI project to enable the NH PACS to store data in the DI-r. 2. Consider the option to adopt the DI-r as the primary PACS archive for NH once it is fully implemented

in 2015. 3. Consider extending the PACS and RIS to the local CIC in Prince George as a means of achieving

access to CIC-sourced imaging results. 4. Systems need to shift to become patient centric, allowing from self-booking and changing

appointments to viewing reports and images. Other technology opportunities for patient access to results and services need to be evaluated as well.



Conclusions and Recommendations S T R A T E G I C P L A N N I N G E X E R C I S E

Northern Health’s Medical Imaging Strategic Plan 2014 – 2025 is the result of a comprehensive consultation and planning process to look at service delivery for all medical imaging modalities across all sites into the future.

This plan is the response to a growing and aging population that will demand more services and better service delivery models.

While this plan looks at the next 10 years and makes projections for the future demand and recommendations for capacity replacement, it a static plan for a dynamic future. The evolving nature of the population and service delivery means that multiple factors will continue to change and therefore this strategic planning exercise should be revised on a periodic basis to capture progress to date and new considerations.

In particular, the potential for a significant increase in population due to the Liquefied Natural Gas (LNG) projects in the region needs to be revisited regularly. There are many factors that can change in this new business venture. The anticipated projects may take place in different or additional locations than originally planned, current estimates for new workforce may be surpassed, or this temporary population may end up using health care services differently than expected.

Planning is an evolving and iterative process.

P R E S E N T S T A T E

Currently, NH has a population of just over 300,000 people. Similarly to the rest of British Columbia and Canada in general, NH’s population is growing and aging. The compounded effect of these two factors is additional demand for health care services, and medical imaging in particular.

However, NH is experiencing unprecedented growth in its population due to the construction boom associated with more than 5 different large-scale LNG projects all taking place in different parts of the region. These include construction of extraction plants, transporting pipelines and shipping terminals, and are scheduled to occur between now and 2021, with a peak in 2016/17.

With employment at capacity in many communities, these projects will demand new workers. As a result of normal population growth and the additional workforce needed in the region, it is anticipated that an additional 45,000 people will live in NH by 2020, representing a 15% growth. Some communities, especially those where the LNG projects are located, will capture most of the population growth, and the facilities in those areas will be subject to increased demand for services.

Northern Health currently provides medical imaging services across 26 facilities in the region. Service availability in each community is based on having sufficient demand volumes to support safe and efficient delivery of care. While some services like General Radiography have large demand and therefore are available in every site to serve their local population, other services like CT and Mammography do not have enough demand in each community.

Utilization of MI services across NH varies significantly. The Northern Interior HSDA generally shows high utilization rate across all services. In contrast, residents of the Northeast HSDA have the lowest utilization



rates within NH facilities. This is in part due to the more limited access to services in the region, resulting in some people accessing services outside NH.

Of special attention is MRI services. NH has the lowest utilization rate in the Province, and only one MRI scanner, located in Prince George. MRI utilization rates outside the Northern Interior are extremely low, likely due to very limited access. Based on the size of the population and distance to the existing service location, Peace River North and Terrace are logical future locations for MRI services.

In contrast, there are 7 CT scanners located in 6 different locations and almost no wait times. Equipment utilization is very low (25% or less) at many sites. Despite the available capacity, utilization rates are still lower than the Provincial and National averages, especially for the Northeast region. To reduce inefficiencies, staffed operating capacities should be reduced in all under-utilized CT scanners to achieve a target utilization of 75%.

V O L U M E A N D W O R K L O A D P R O J E C T I O N S

The projected medical imaging exam volumes anticipate significant growth across all services and sites. While population growth is projected at 15% by 2020, exam volumes are estimated to increase by 25% to 28%.

Looking further into the future, population by 2025 is expected to decrease from 2020, mainly due to the anticipated conclusion of the LNG construction projects by 2021. However, even with that reduction in the population, exam volumes will only decrease slightly, mostly due to the aging effect of the remaining residents.

In terms of specific services, MRI is expected to increase significantly as Provincial utilization rates are adopted throughout the region. Exam volumes would double by 2020 under these assumptions. Although there are no finalized plans to implement the recommendations of the 2013 business case, additional service locations will likely be required in the future.

Projected increase in volumes for other services could reasonably be accommodated within the existing sites, although additional equipment and staff may be required to properly handle the additional demand.

A direct consequence of the LNG construction projects, communities like Fort Nelson, Kitimat and Prince Rupert will experience the largest relative growth in demand, creating pressure on local facilities. Fort Nelson General Hospital, Kitimat Hospital and Health Centre and Prince Ruper Regional Hospital will likely experience increased demand for services they provide, like General Radiography and Ultrasound, but will also see an increased need to refer patients to other sites for services like CT and MRI.

S E R V I C E D E L I V E RY M O D E L S

Perhaps the biggest challenge for the provision of health care services in Northern Health is the geographic distribution of its population, scattered in many communities distant from each other. In many cases, this means low local demand per service at many locations, insufficient to sustain fixed-site service delivery safely from a clinical point of view and efficiently from an administrative perspective.

The response to this situation has been the consolidation of demand in select sites, at the expense of larger distances to access the services. But even with this approach, many times there is not enough demand to warrant the full provision of service, limiting hours of operation. To avoid waste of resources, staff needs to be cross-educated in multiple modalities so they are shared across services, which in turn makes staff more specialized and harder to recruit, especially in more rural locations where they are needed more and often harder to recruit.

Nevertheless, service consolidation and staff cross-education will continue to play a major role in the future of service delivery for medical imaging in NH. An additional measure, also currently available to different extents in the region, is the implementation of rotating and mobile services, so that it is not the patients who



travel but the service. This opens additional possibilities and will require equipment to be installed in specially conditioned vehicles and suitable parking “pads” to be constructed at each location. Such pads will serve multiple modalities and can be shared between, say, MRI, CT, digital mammography and bone density services.

The operating hours for each service and site were calculated (Table 17) based on projected exam volumes. This information can be used to plan, train teams that deliver several modalities in low-volume settings and schedule visiting mobile services.

S U M M A RY O F M O D A L I T Y S P E C I F I C R E C O M M E N D A T I O N S

Radiology and Fluoroscopy

1. Eliminate all film printers as part of a filmless strategy, while developing downtime and service continuity plans that are independent of hard copy images.

2. Require all Digital Radiography (DR) purchasing decisions to be subject to a business case that considers a threshold volume that justifies DR over Computerized Radiography (CR).

3. Consider multi-purpose rooms in place of dedicated fluoroscopy equipment replacement. 4. Review the number of CR readers available in all CR sites; 1 CR reader can support 2 rooms

provided there is one additional reader available for redundancy (regional spare).

Interventional Radiology


Ultrasound:

1. Improve access to ultrasound and echocardiography services in underserved communities: a. Initiate a program to cross-educate medical imaging technologists. b. Engage BCIT or a similar institution as a partner to resolve staff shortage in ultrasound and

echo in the North. 2. Apply to the Diagnostic Accreditation Program (DAP) for remote status in ultrasound. 3. Develop a business case for remote ultrasound and echocardiography in under-served communities.

Nuclear Medicine


Bone Densitometry

1. Review utilization rates per site and alter service delivery models from fixed units to a mobile service. 2. Use the equipment planning and the access to service tools provided to determine the optimal solution

and rotation frequency to maintain current utilization rates in each HSDA.

Mammography




a. Develop a business case to define the service and justify the capital and operating costs.



4. Consolidate mammography reading on fewer radiologists to achieve the BCCA minimum mammography reads per radiologist per year.

Computerized Tomography

1. In sites with under-utilized CT scanners, increase utilization through a combination of reduced operating hours and reallocation of workload to patient choice.


3. Using the Capital Planning Tool provided, adjust the equipment replacement plan for CT to avoid replacing or investing in additional CT scanners unless there is sufficient demand within the HSDA.

Magnetic Resonance Imaging

1. Implement a new mobile MRI unit serving the Northeast and Northwest, and replace the existing (old) MRI unit at UHNBC.



Information Technology

1. Engage with the Provincial Diagnostic Imaging project to enable the NH Picture Archiving and Communication System (PACS) to store data in the Diagnostic Imaging Repository (DI-r).

2. Consider the option to adopt the DI-r as the primary PACS archive for NH once implemented in 2015. 3. Consider extending the PACS and Radiology Information System (RIS) to the local Community Imaging

Clinic (CIC) in Prince George as a means of achieving access to CIC-sourced imaging results. Systems need to shift to become patient centric, allowing from self-booking and changing appointments to viewing reports and images. Other technology opportunities for patient access to results and services need to be evaluated as well.

E Q U I P M E N T A N D C A P I TA L P L A N N I N G

The range of Medical Imaging equipment currently available within Northern Health is in different stages of their estimated life cycles. Some equipment is well past their life expectancy (X-Ray at certain locations) while other will be due for replacement within the next couple of years.

In the current model of capital purchasing, equipment selection is often driven by cost and service considerations with clinical use given lower priority. Although this model works relatively effectively it may result in equipment purchases being made based on vendor offerings without due consideration of the degree of medical services being provided or HSDA requirements.

The Canadian Association of Medical Radiation Technologists (CAMRT) in conjunction with the Canadian Association of Radiologists (CAR) recently released a document entitled Lifecycle Guidance of Medical Imaging Equipment in Canada (2013) which should be critically reviewed by the Regional Director of Diagnostics with an intention of adopting its recommendations.

The CAMRT/CAR report provides guidance to integrate replacement criteria, prioritization and life expectancy based on a reasonable range of years specific to each modality. Table 29 below reproduces the recommended device life expectancy in the report.



Table 29: MI Equipment life expectancy guidance (utilization and age related)28.

RECOMMENDATIONS – MEDICAL IMAGING ASSET MANAGEMENT

Based on the CAMRT/ CAR report the following changes are recommended to the capital purchasing process for medical imaging equipment:

1. Diagnostic Services coordinate all capital purchases in order that a NH regional perspective can be taken in all cases.

2. All future purchasing decisions be based on a business case using a consistent process that takes into account

o the relative priorities for NH as a whole, o demand for service relative to reference metrics or benchmarks o population, weighted access impact relative to other sites in NH (using the tools provided with

this report) o clinical investment priorities for the NH region o capital and operating costs o operating constraints such as staffing and clinical risk management

28 Source: CAMRT/CAR report. Notes: Maximum life expectancy and clinical relevance should be no longer than 15 years for any technology. New and emerging technologies should be integrated into equipment and financial plans within the organization. (a) Some ultrasound scanners may be subject to a faster rate of obsolescence. Ultrasound requires a high level of diagnostic

capability and optimum technology is considered essential. (b) Mammography units require a high level of diagnostic capability and optimum technology is considered essential.

HIGH, e.g.,24 hours 5 days /week or 750 8-hour shifts/ year

MID, e.g.,16 hours 5 days/ week or 500 8-hour shifts/ year

LOW, e.g.,8 hours 5 days /week or 250 8-hour shifts/ year

Radiography, general 10 – 12 – 14 > 20,000 10,000 – 20,000 < 10,000Radiography, mobile 10 – 12 – 14 > 6,000 3,000 – 6,000 < 3,000R/F fluoroscopy(conventional/remote)

8 – 10 – 12 > 4,000 2,000 – 4,000 < 2,000

R/F interventional integrated c-arm

8 – 10 – 12 > 4,000 2,000 – 4,000 < 2,000

R/F urology 8 – 10 – 12 > 1,500 750 – 1,500 < 750Mobile C-arm(all types including O-Arms)

8 – 10 – 12 > 2,000 1,000 – 2,000 < 1,000

Angiography (1/2 plane)/ interventional

8 – 10 – 12 > 4,000 2,000 – 4,000 < 2,000

Cardiac suite (single/biplane) 8 – 10 – 12 > 3,000 1,500 – 3,000 < 1,500CT scanner 8 – 10 – 12 > 15,000 7,500 – 15,000 < 7,500MRI scanner 8 – 10 – 12 > 8,000 4,000 – 8,000 < 4,000Ultrasound 7 – 8 – 9 (a) > 4,000 2,000 – 4,000 < 2,000SPECT/gamma 8 – 10 – 12 > 6,000 3,000 – 6,000 < 3,000SPECT/CT 8 – 10 – 12 > 4,000 2,000 – 4,000 < 2,000PET (likely replace with a different technology such as PET/CT)

8 – 10 – 12 > 6,000 3,000 – 6,000 < 3,000

PET/CT 8 – 10 – 12 > 4,000 2,000 – 4,000 < 2,000Bone densitometry 8 – 10 – 12 > 10,000 5,000 – 10,000 < 5,000Mammography 8 – 9 – 10 (b) > 7,000 3,500 – 7,000 < 3,500Lithotripter 8 – 10 – 12 > 3,000 2,000 – 3,000 < 2,000

Device type (analogue or digital)

Device life expectancy based on utilization:HIGH – MID – LOW(see columnsto the right)

Utilization based on exams / year



3. Biomedical Engineering to be responsible for assessing service costs and deliverables based on current capacity.

4. Service deliverables to be based on best practices to ensure that properly qualified individuals are in place to meet Health Canada safety Code 35 service requirements.

5. Local/regional medical advisors (Radiologists) evaluate the available models from a clinical perspective.

6. HSDA administration (COO and/or HSA) evaluate models based on current and future services to be delivered.

7. Any fluoroscopic equipment purchasing decisions should critically evaluate the option of multipurpose equipment that can effectively meet the needs for general radiography as well as fluoroscopy

The estimated cost of replacement for current MI equipment from 2014 to 2025 is about $47,621,000.

Additional details on the condition of existing equipment and planning considerations for equipment replacement are provided in Appendix II: Preliminary Equipment Replacement Plan.

Using the recommended approach from the CAMRT/CAR report, the present state of MI equipment across NH sites, and the existing and future needs of the population, a preliminary equipment replacement plan has been developed. A detail list with an inventory of all the MI equipment, descriptions, location, anticipated replacement costs and preliminary year of replacement is available on Appendix II: Preliminary Equipment Replacement Plan.

Table 30 shows a summary of the equipment replacement costs by HSDA based on preliminary planned replacement years, and Figure 14 shows the same information by service and year.

Replacement Year

Northwest Northern Interior

Northeast Total

2014 $2,208,000 $4,818,000 $170,000 $7,196,000

2015 $4,888,000 $2,050,000 $70,000 $7,008,000

2016 $2,065,000 $885,000 $1,340,000 $4,290,000

2017 $983,000 $2,425,000 $968,000 $4,376,000

2018 $750,000 $3,976,000 $950,000 $5,676,000

2019 $1,565,000 $2,120,000 $1,588,000 $5,273,000

2020 $750,000 $1,170,000 $2,200,000 $4,120,000

2021 $1,200,000 $2,332,000 $1,940,000 $5,472,000

2022 $1,270,000 $770,000 $2,170,000 $4,210,000

Total $15,679,000 $20,546,000 $11,396,000 $47,621,000

Table 30: Planned equipment replacement cost by HSDA, 2014 to 2022.



Figure 14: Preliminary equipment replacement costs by service and year.

2014 2015 2016 2017 2018 2019 2020 2021 2022XRAY-P $350,000 $210,000 $140,000 $140,000 $140,000 $210,000 $140,000 $230,000 $360,000

XRAY $2,550,00 $3,710,00 $1,430,00 $1,090,00 $3,100,00 $3,260,00 $1,700,00 $4,020,00 $2,730,00

US $396,000 $428,000 $400,000 $826,000 $936,000 $603,000 $960,000 $722,000

SPECT-G $1,200,00 $1,000,00 $1,000,00 $1,000,00

MRI $2,500,00

MISC $260,000

CT $1,000,00 $1,000,00 $1,000,00 $1,500,00 $1,000,00 $1,000,00 $1,000,00

CARM $200,000 $400,000 $200,000 $200,000 $200,000 $200,000 $260,000

BD $120,000 $120,000 $120,000 $240,000 $120,000

0

1000000

2000000

3000000

4000000

5000000

6000000

7000000

8000000

Preliminary Equipment Replacement Costs per Service and Year

BD CARM CT MISC MRI SPECT-G US XRAY XRAY-P



Appendix I: Additional Demand Projection Information D E M A N D P R O J E C T I O N S B Y S E R V I C E F O R E A C H L H A A N D P E R I O D

Table 31 shows current (2012/13) exam volumes for each service by LHA of patient residence.

Table 31: Baseline scenario – Actual Demand by Service and LHA, 2012/13.

Region MR CT NM US BD IR XR MA TotalNortheast 96 5,019 761 12,389 305 62 40,195 2,368 61,196

Fort Nelson 9 319 46 643 2 2 3,969 66 5,057Peace River North 52 1,983 483 6,787 118 8 18,600 1,245 29,276Peace River South 35 2,718 232 4,959 185 52 17,626 1,057 26,864

Northern Interior 4,252 14,926 3,527 22,951 1,339 599 85,634 2,063 135,290Burns Lake 226 721 148 1,167 48 28 5,551 42 7,931Nechako 442 1,567 328 2,509 141 59 11,384 35 16,464Prince George 3,077 10,009 2,683 11,898 940 446 51,789 227 81,070Quesnel 507 2,629 367 7,377 210 66 16,909 1,759 29,825

Northwest 818 7,050 1,779 17,857 540 150 51,000 4,320 83,513Kitimat 56 969 325 2,409 99 19 7,059 805 11,740Nisga'a 20 220 56 385 15 2 1,392 82 2,173Prince Rupert 77 1,165 169 3,859 152 26 9,957 873 16,279Queen Charlotte 4 247 30 848 12 20 2,882 77 4,121Smithers 361 1,415 336 4,587 96 30 12,165 1,013 20,003Snow Country 8 44 18 104 2 0 368 12 557Stikine 1 58 9 64 1 4 103 7 247Telegraph Creek 4 64 7 97 1 0 119 7 299Terrace 204 2,395 738 4,429 125 38 13,415 1,308 22,653Upper Skeena 83 471 91 1,073 37 10 3,539 136 5,441

Non-NHA 107 922 89 2,633 180 16 9,175 145 13,267Rest of BC 40 600 45 998 19 7 5,967 91 7,768Out of Province 67 322 44 1,634 161 8 3,208 54 5,498

NHA 5,273 27,917 6,156 55,830 2,364 827 186,003 8,896 293,266

Actual Exam Volume - 2012/13



Baseline Scenario

The following tables (Table 32 and Table 33) show demand projections under the baseline scenario for each service by LHA of patient residence and period.

Table 32: Baseline scenario – Projected Demand by Service and LHA, 2020.

Table 33: Baseline scenario – Projected Demand by Service and LHA, 2025.

Region MR CT NM US BD IR XR MA TotalNortheast 136 7,228 1,095 16,936 434 89 56,582 3,232 85,732

Fort Nelson 23 779 115 1,619 6 5 9,142 185 11,874Peace River North 62 2,576 654 8,186 166 12 22,926 1,572 36,154Peace River South 51 3,872 327 7,131 262 71 24,514 1,475 37,704

Northern Interior 4,886 18,112 4,411 26,392 1,695 774 99,158 2,258 157,687Burns Lake 237 818 182 1,285 58 33 6,083 48 8,744Nechako 487 1,828 400 2,767 172 75 12,690 40 18,460Prince George 3,643 12,502 3,403 14,434 1,212 586 61,982 278 98,040Quesnel 520 2,963 425 7,906 254 80 18,404 1,892 32,443

Northwest 964 9,196 2,350 23,840 745 201 66,382 5,872 109,550Kitimat 112 1,686 559 4,689 164 32 12,282 1,448 20,970Nisga'a 21 249 72 433 17 4 1,579 88 2,462Prince Rupert 133 1,873 267 6,477 237 41 16,125 1,450 26,602Queen Charlotte 4 299 39 941 15 22 3,331 97 4,748Smithers 388 1,700 419 5,132 118 40 13,821 1,192 22,809Snow Country 10 46 19 110 3 0 422 13 624Stikine 1 64 12 71 1 5 112 7 273Telegraph Creek 4 75 8 106 1 0 134 9 338Terrace 205 2,662 849 4,686 148 46 14,595 1,416 24,605Upper Skeena 87 543 107 1,195 43 11 3,981 152 6,119

Non-NHA 121 1,059 105 2,966 221 20 10,229 168 14,889Rest of BC 45 692 53 1,114 23 10 6,672 103 8,711Out of Province 76 368 52 1,851 198 10 3,558 65 6,177

NHA 6,107 35,595 7,961 70,134 3,096 1,084 232,352 11,529 367,859

Projected Exam Volume (baseline) - 2020

Region MR CT NM US BD IR XR MA TotalNortheast 123 7,005 1,168 15,911 479 89 52,712 3,251 80,738

Fort Nelson 12 440 81 767 4 4 4,991 100 6,399Peace River North 67 2,963 769 9,090 197 15 25,725 1,789 40,616Peace River South 43 3,602 318 6,054 278 70 21,996 1,362 33,723


Northwest 879 8,784 2,306 20,680 755 195 60,994 5,141 99,734Kitimat 65 1,215 425 2,763 156 28 8,566 973 14,191Nisga'a 21 257 76 447 16 4 1,665 86 2,572Prince Rupert 82 1,511 221 4,552 232 29 12,184 1,094 19,906Queen Charlotte 4 320 43 973 16 23 3,502 101 4,981Smithers 402 1,870 461 5,464 127 44 14,741 1,264 24,372Snow Country 10 45 19 107 3 0 432 12 627Stikine 1 65 15 72 1 5 111 7 277Telegraph Creek 5 79 9 111 2 0 140 10 356Terrace 204 2,843 922 4,922 157 50 15,450 1,435 25,982Upper Skeena 86 580 115 1,269 46 13 4,203 158 6,470


NHA 5,950 35,942 8,282 66,832 3,304 1,164 226,405 10,857 358,736

Projected Exam Volume (baseline) - 2025



Adjusted Scenario

The following tables (Table 34 and Table 35) show demand projections under the adjusted scenario for each service by LHA of patient residence and period.

Table 34: Adjusted scenario – Projected Demand by Service and LHA, 2020.

Table 35: Adjusted scenario – Projected Demand by Service and LHA, 2025.

Region MR CT NM US BD IR XR MA TotalNortheast 2,647 6,867 1,095 16,936 478 89 57,714 3,619 89,445

Fort Nelson 396 741 115 1,619 6 5 9,325 207 12,415Peace River North 1,173 2,448 654 8,186 183 12 23,384 1,760 37,800Peace River South 1,077 3,679 327 7,131 289 71 25,004 1,652 39,230


Northwest 2,539 8,736 2,350 23,840 820 201 67,709 6,576 112,772Kitimat 488 1,602 559 4,689 180 32 12,527 1,621 21,698Nisga'a 55 236 72 433 19 4 1,610 99 2,527Prince Rupert 620 1,780 267 6,477 260 41 16,448 1,624 27,516Queen Charlotte 128 284 39 941 17 22 3,397 108 4,936Smithers 465 1,615 419 5,132 129 40 14,097 1,335 23,233Snow Country 15 44 19 110 3 0 431 15 637Stikine 27 61 12 71 1 5 114 8 299Telegraph Creek 20 71 8 106 1 0 137 10 353Terrace 570 2,529 849 4,686 162 46 14,887 1,586 25,313Upper Skeena 152 515 107 1,195 47 11 4,061 171 6,260


NHA 9,676 33,815 7,961 70,134 3,406 1,084 236,999 12,913 375,988

Projected Exam Volume (adjusted) - 2020

Region MR CT NM US BD IR XR MA TotalNortheast 2,343 6,654 1,168 15,911 526 89 53,767 3,641 84,100

Fort Nelson 194 418 81 767 4 4 5,091 112 6,671Peace River North 1,260 2,815 769 9,090 217 15 26,239 2,004 42,409Peace River South 889 3,422 318 6,054 306 70 22,436 1,525 35,020


Northwest 2,147 8,344 2,306 20,680 830 195 62,214 5,758 102,475Kitimat 282 1,154 425 2,763 172 28 8,738 1,089 14,651Nisga'a 56 244 76 447 17 4 1,699 97 2,639Prince Rupert 421 1,436 221 4,552 255 29 12,428 1,226 20,568Queen Charlotte 127 304 43 973 17 23 3,572 113 5,172Smithers 473 1,776 461 5,464 140 44 15,036 1,416 24,810Snow Country 15 42 19 107 3 0 440 14 640Stikine 26 62 15 72 1 5 114 8 302Telegraph Creek 20 75 9 111 2 0 143 12 372Terrace 574 2,700 922 4,922 173 50 15,759 1,607 26,707Upper Skeena 152 551 115 1,269 51 13 4,287 177 6,614


NHA 8,822 34,145 8,282 66,832 3,634 1,164 230,933 12,159 365,971

Projected Exam Volume (adjusted) - 2025



D E M A N D P R O J E C T I O N S B Y S E R V I C E F O R E A C H S I T E A N D P E R I O D

Table 36 shows current (2012/13) exam volumes for each service by site.

Table 36: Baseline scenario – Actual Demand by Service and Site, 2012/13.



Peace River North FSJH Fort St. John Hospital - 2,249 740 6,891 60 - 18,661 1,302 29,904 HHHC Hudson'S Hope D&T Centre - - - - - - 312 - 312



Prince George UHNBC University Hospital Of Northern BC (PGRH) 5,273 13,215 3,735 14,053 1,205 730 57,345 268 95,824 VLDT Valemount Health Centre - - - - - - 1,141 - 1,141 VIC Victoria Medical Centre - - - - - - - - - MBDH Mcbride & District Hospital - - - - - - 889 - 889 MKDH Mackenzie & District Hospital - - - - - - 2,281 - 2,281


Snow Country SHC Stewart Health Centre - - - - - - 578 - 578 Prince Rupert PRRH Prince Rupert Regional Hospital - 1,161 - 4,644 90 71 10,956 979 17,902 Upper Skeena WMH Wrinch Memorial Hospital (Hazelton) - - - 927 - - 3,387 - 4,314 Smithers BVDH Bulkley Valley District Hospital (Smithers) - - - 5,195 - - 9,760 1,113 16,068


Total All Sites 5,273 27,917 6,156 55,830 2,364 827 186,503 8,896 293,766

Actual Exam Volume - 2012/13HSDA / LHA Site

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Baseline Scenario

The following tables (Table 37 and Table 38) show demand projections under the adjusted scenario for each service by LHA of patient residence and period

.

Table 37: Baseline scenario – Projected Demand by Service and Site, 2020.




Peace River North FSJH Fort St. John Hospital - 3,199 1,055 8,574 86 - 23,085 1,726 37,724 HHHC Hudson'S Hope D&T Centre - - - - - - 385 - 385



Prince George UHNBC University Hospital Of Northern BC (PGRH) 6,107 16,268 4,680 16,893 1,535 949 68,205 318 114,957 VLDT Valemount Health Centre - - - - - - 1,352 - 1,352 VIC Victoria Medical Centre - - - - - - - - - MBDH Mcbride & District Hospital - - - - - - 1,055 - 1,055 MKDH Mackenzie & District Hospital - - - - - - 2,724 - 2,724


Snow Country SHC Stewart Health Centre - - - - - - 663 - 663 Prince Rupert PRRH Prince Rupert Regional Hospital - 1,760 - 7,418 136 99 17,147 1,588 28,148 Upper Skeena WMH Wrinch Memorial Hospital (Hazelton) - - - 1,030 - - 3,819 - 4,849 Smithers BVDH Bulkley Valley District Hospital (Smithers) - - - 5,815 - - 11,095 1,304 18,215

HHC Houston D&T Centre - - - - - - 1,592 - 1,592 Kitimat KGH Kitimat Hospital And Health Centre - - - 2,699 534 - 12,630 1,244 17,107 Stikine STC Stikine Health Centre (Dease Lake) - - - - - - 500 - 500 Terrace MMH Mills Memorial Hospital (Terrace) - 7,127 2,226 7,196 - - 16,080 1,817 34,446 Nisga'a - - - - - - - - - - Telegraph Creek - - - - - - - - - -

Total All Sites 6,107 35,595 7,961 70,134 3,096 1,084 232,852 11,529 368,359

Projected Exam Volume (baseline) - 2020HSDA / LHA Site

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Prince George UHNBC University Hospital Of Northern BC (PGRH) 5,950 17,036 4,979 17,107 1,648 1,037 69,374 321 117,453 VLDT Valemount Health Centre - - - - - - 1,381 - 1,381 VIC Victoria Medical Centre - - - - - - - - - MBDH Mcbride & District Hospital - - - - - - 1,078 - 1,078 MKDH Mackenzie & District Hospital - - - - - - 2,766 - 2,766




Total All Sites 5,950 35,942 8,282 66,832 3,304 1,164 226,905 10,857 359,236

Projected Exam Volume (baseline) - 2025HSDA / LHA Site

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Adjusted Scenario

The following tables (Table 39 and Table 40) show demand projections under the adjusted scenario for each service by site and period.








Prince George UHNBC University Hospital Of Northern BC (PGRH) 9,676 15,455 4,680 16,893 1,688 949 69,570 357 119,268 VLDT Valemount Health Centre - - - - - - 1,379 - 1,379 VIC Victoria Medical Centre - - - - - - - - - MBDH Mcbride & District Hospital - - - - - - 1,076 - 1,076 MKDH Mackenzie & District Hospital - - - - - - 2,778 - 2,778



HHC Houston D&T Centre - - - - - - 1,624 - 1,624 Kitimat KGH Kitimat Hospital And Health Centre - - - 2,699 588 - 12,882 1,394 17,562 Stikine STC Stikine Health Centre (Dease Lake) - - - - - - 500 - 500 Terrace MMH Mills Memorial Hospital (Terrace) - 6,771 2,226 7,196 - - 16,401 2,035 34,630 Nisga'a - - - - - - - - - - Telegraph Creek - - - - - - - - - -

Total All Sites 9,676 33,815 7,961 70,134 3,406 1,084 237,499 12,913 376,488

Projected Exam Volume (adjusted) - 2020HSDA / LHA Site

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Prince George UHNBC University Hospital Of Northern BC (PGRH) 8,822 16,184 4,979 17,107 1,813 1,037 70,762 360 121,064 VLDT Valemount Health Centre - - - - - - 1,408 - 1,408 VIC Victoria Medical Centre - - - - - - - - - MBDH Mcbride & District Hospital - - - - - - 1,099 - 1,099 MKDH Mackenzie & District Hospital - - - - - - 2,821 - 2,821




Total All Sites 8,822 34,145 8,282 66,832 3,634 1,164 231,433 12,159 366,472

Projected Exam Volume (adjusted) - 2025HSDA / LHA Site

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Appendix II: Preliminary Equipment Replacement Plan The following is a preliminary list with a detailed inventory of Medical Imaging equipment organized by their planned year of replacement, HSDA, site and service. A description of each equipment and the estimated costs of replacement are provided.

This list is provided only for reference of expected capital expenditures required in the upcoming years. Equipment replacement and budgetary decisions are yet to be made. Year HSDA Site Service Area Device Type Maker Model Cost 2014 Northwest BVDH XRAY-P Portable AMX3 $70,000

HHC XRAY Philips Radiology Optimus $500,000 MMH US Diagnostic Imaging General-purpose Siemens Medical Systems Inc Sequoia 512 $198,000

XRAY GE Radiology Advantix $800,000 NHGH XRAY-P Portable AMX110 $70,000 PRRH AMX4 $70,000 SHC XRAY Shimada Radiology Tisolc $500,000

Northern Interior

MBDH XRAY-P Portable AMX4 $70,000 MKDH Portable $70,000 UHNBC MRI Siemens Symphony 1.5 T $2,500,000

SPECT-G Philips Nuc Med Skylight $1,200,000 US Diagnostic Imaging General-purpose Siemens Medical Systems Inc Sequoia 512 $198,000

XRAY Siemens/Tosh Radiology Polydorus SX80-Tos-Rad $500,000 VIC Compact Plus $70,000

VSJH CARM GE C-arm OEC 9600 $200,000 GRB XRAY Contact 400 Printer $10,000

Northeast FNGH Dryview 8100 Printer $10,000 DryView 8200 Printer $10,000

HHHC Bennett Radiology HFQ-6000SE $150,000 2015 Northwest BVDH Agfa CR 25 $100,000

Agfa CR 75 $70,000 Drystar Printer $10,000 Siemens/Tosh Radiology Polydorus SX80 $500,000

Toshiba DUA 450 Fluoro $700,000 MMH SPECT-G Philips Nuc Med Skylight $1,000,000

US Diagnostic Imaging General-purpose Siemens Medical Systems Inc Sequoia 512 $198,000 XRAY Drystar Printer $10,000

PRRH CARM Siemens C-arm Arcadis $200,000 MISC CT injector $165,000

Insuflator CT Colongraphy $20,000 Vitrea workstation $75,000

XRAY Toshiba Radiology DUA 450 Fluoro $700,000 QCIH Philips Optimus $500,000

XRAY-P Portable Explorer II $70,000 KGH XRAY GE Radiology Proteus XR/A $500,000

XRAY-P Portable AMX4 $70,000 Northern Interior

UHNBC US Diagnostic Imaging General-purpose Siemens Medical Systems Inc Sequoia 512 $180,000 Emergency SonoSite Inc. 180 $50,000

VIC XRAY Toshiba Radiology Toshiba Kxo-80F vintage- VIC MED

$500,000

GRB CARM Phillips C-arms BV Pulsera $200,000 CT Toshiba Aquillion 32 slice $1,000,000

XRAY Compact Plus $70,000 SOLO $50,000

Northeast HHHC XRAY-P Portable AMX4 $70,000 2016 Northwest BVDH XRAY Siemens/Tosh Radiology Polydorus SX80 $500,000

MMH CT Toshiba Aquillion 64 slice $1,000,000



Year HSDA Site Service Area Device Type Maker Model Cost US Maternity General-purpose SonoSite Inc. 180 $35,000

XRAY Agfa CR 25 $50,000 Agfa CR 75 $70,000

PRRH US Oncology Portable GE Medical Systems LOGIQe $50,000 XRAY Agfa CR 25 $50,000

Agfa CR 75 $70,000 XRAY-P Portable AMX4 $70,000

WMH US Diagnostic Imaging GE Medical Systems LOGIQe $50,000 KGH BD GE Bone Density Model 8734 $120,000

Northern Interior

FLDT US Diagnostic Imaging General-purpose Ultrasonix Medical Corp (001334)

Q-Sonic $65,000 SLH Sonix 02 $50,000

UHNBC Sonix 02 $50,000 VLDT XRAY-P Portable AMX4 $70,000 VSJH US Diagnostic Imaging General-purpose Ultrasonix Medical Corp

(001334) Sonix 02 $50,000

XRAY Agfa CR 25 $50,000 Siemens/Tosh Radiology Polydorus SX80 $500,000

LDH US Diagnostic Imaging General-purpose Ultrasonix Medical Corp (001334)

Sonix 02 $50,000

Northeast DCDH XRAY CR 975 $70,000 FNGH CR 850 $70,000 FSJH CARM Siemens C-arm Arcadis $200,000

SPECT-G GE Nuc Med Hawkeye $1,000,000 2017 Northwest HHC XRAY CR 825 $70,000

PRRH US Diagnostic Imaging General-purpose Philips Medical Systems Canada iU22 $198,000 QCIH Portable SonoSite Inc. M-Turbo $35,000 WMH General-purpose Philips Medical Systems Canada iU22 $180,000

XRAY Siemens/Tosh Radiology Polydorus SX80 $500,000 Northern Interior

UHNBC BD Hologic Bone Density Discovery $120,000 CARM C-arm Arcadis $200,000

CT Toshiba Aquillion 64 slice $1,000,000 SPECT-G GE Nuc Med Hawkeye $1,000,000

US Operating Room Portable SonoSite Inc. M-Turbo $35,000 GRB XRAY-P AMX4 $70,000

Northeast CGH XRAY Siemens/Tosh Radiology Polydorus SX80 $500,000 DCDH US Diagnostic Imaging General-purpose Philips Medical Systems Canada iU22 $378,000

XRAY DryView 8150 Printer $10,000 XRAY-P Portable AMX4 $70,000

TRDT XRAY DryView 8150 Printer $10,000 2018 Northwest BVDH US Diagnostic Imaging General-purpose Philips Medical Systems Canada iU22 $180,000

MMH XRAY GE Radiology Proteus XR/A $500,000 PRRH XRAY-P Portable AMX4 $70,000

Northern Interior

FLDT XRAY GE Radiology Quantum $500,000 UHNBC CT Toshiba Aquillion - One 320 vol $1,500,000

XRAY Toshiba Radiology Infinix VCI $700,000 Ultimax $700,000

VSJH US Diagnostic Imaging General-purpose Philips Medical Systems Canada iU22 $198,000 GRB iU22 $378,000

Northeast DCDH XRAY Toshiba Radiology Ultimax $700,000 FNGH XRAY-P Portable AMX4 $70,000 FSJH US Diagnostic Imaging General-purpose Philips Medical Systems Canada iU22 $180,000

2019 Northwest BVDH Emergency Portable SonoSite Inc. M-Turbo $45,000 XRAY-P AMX4 $70,000

MMH US Diagnostic Imaging Echo GE Logic E9 $180,000 WMH XRAY-P Portable AMX4 $70,000 KGH CARM Siemens C-arm Arcadis $200,000

XRAY Toshiba Radiology Kalare $500,000 STC KXO-80S $500,000

Northern Interior

FLDT CR 30X $50,000 MBDH Toshiba Radiology KXO-80S $500,000 MKDH $500,000 UHNBC XRAY-P Portable AMX4 $70,000 VLDT XRAY Toshiba Radiology Polydorus SX80 $500,000



Year HSDA Site Service Area Device Type Maker Model Cost GRB Kalare $500,000

Northeast CGH Classic/Elite CR $70,000 DCDH CT Toshiba Aquillion 64 slice $1,000,000

US Diagnostic Imaging General-purpose Toshiba Aplio $180,000 FNGH XRAY Classic/Elite CR $70,000 FSJH US Diagnostic Imaging General-purpose Philips Medical Systems Canada iU22 $198,000 TRDT XRAY Classic/Elite CR $70,000

2020 Northwest MMH XRAY-P Portable AMX4 $70,000 PRRH US Diagnostic Imaging General-purpose Toshiba Aplio $180,000

XRAY Toshiba Radiology KXO-80S $500,000 Northern Interior

SLH $500,000 UHNBC US Diagnostic Imaging echocardiography GE Vivid E9 $200,000

General-purpose Toshiba Aplio $180,000 Interventional GE Venue 40 $40,000

VSJH XRAY-P Portable AMX4 $70,000 GRB US Diagnostic Imaging General-purpose Toshiba Aplio $180,000

Northeast DCDH BD Hologic Bone Density Discovery $120,000 CARM Siemens C- arm Arcadis $200,000 XRAY Classic/Elite CR $100,000

DRXM51 $100,000 FSJH CT Toshiba Aquillion 64 slice $1,000,000

US Diagnostic Imaging General-purpose Toshiba Aplio $180,000 XRAY Toshiba Radiology Radrex $500,000

2021 Northwest BVDH XRAY-P Portable AMX4 $70,000 HHC XRAY Agfa CR 30X $50,000

MMH Toshiba Radiology ZEXIRA $700,000 NHGH US Diagnostic Imaging General Toshiba $150,000 QCIH XRAY Agfa CR 30X $50,000 KGH US Diagnostic Imaging General Toshiba Aplio 500 $180,000

Northern Interior

MBDH XRAY Agfa CR 30X $50,000 MKDH $100,000

Toshiba Radiology KXO-80S $500,000 UHNBC CARM Philips C-arm BV Pulsera $260,000

US Dianostic Imaging Gen and Echo Toshiba Aplio 500 $212,000 XRAY Toshiba Radiology Radrex $500,000

XRAY-P Portable GE $90,000 GRB BD Hologic Bone Density Discovery $120,000

XRAY Toshiba Radiology Radrex $500,000 Northeast DCDH $500,000

XRAY-P Portable AMX4 $70,000 FNGH US Diagnostic Imaging General Purpose Toshiba Aplio 500 $180,000

XRAY Classic/Elite CR $70,000 Toshiba Radiology KXO-80S $500,000

FSJH BD Hologic Bone Density Discovery $120,000 TRDT XRAY Toshiba Radiology KXO-80S $500,000

2022 Northwest PRRH BD Hologic Bone Density Discovery $120,000 CT Toshiba Aquillion 64 slice $1,000,000

QCIH 64 slice $2,000,000 SHC XRAY Agfa CR 30X $50,000

WMH $50,000 STC Agfa CR 25 $50,000

Northern Interior

SLH $50,000 UHNBC Agfa DXG $180,000

Carestream Radiology DRX Evolution $400,000 XRAY-P Portable GE $90,000

VLDT XRAY Agfa CR 30X $50,000 Northeast CGH XRAY-P Portable AMX3 $90,000

DCDH XRAY Toshiba Radiology Radrex $500,000 FSJH Ultimax $1,400,000

XRAY-P Portable GE $180,000



Appendix III: Methodology Details P O P U L A T I O N A D J U S T M E N T D U E T O I N C R E A S E D W O R K F O R C E

Table 41 below shows original population projections from BC Stats, the estimated impact of additional workforce from LNG projects in the region, and the resulting adjusted population projections. The LHAs affected by the projects and adjusted for the workforce increase are highlighted.

Table 41: Population projections, estimated workforce increase and adjusted population projections by LHA.

A P P O I N T M E N T DA T A A N D E X A M C O U N T S

Record-level data from the Cerner information system was obtained for all the medical imaging appointments booked in a Northern Health facility over the last few years. In general, there is a direct relationship between the number of appointments and the medical imaging exams performed. The Cerner data provides information on patient encounters, but it was not possible to extract the actual number of exams performed in each appointment.

To account of for cases where more than one exam is performed per appointment, which may be the case in general radiology (X-Rays and Interventional Radiology), Ultrasound and Nuclear Medicine, an appointment-to-exams factor was calculated from aggregated billing data.

Region 2013 2015 2020 2025 2013 2015 2020 2025 2013 2015 2020 2025Northeast 73,311 75,738 81,402 85,505 2,160 9,520 15,200 - 75,471 85,258 96,602 85,505

Fort Nelson 6,552 6,655 6,868 7,098 1,080 4,760 7,600 - 7,632 11,415 14,468 7,098 Peace River North 37,612 39,107 42,820 45,969 37,612 39,107 42,820 45,969 Peace River South 29,147 29,976 31,714 32,438 1,080 4,760 7,600 - 30,227 34,736 39,314 32,438

0 0 0 0Northern Interior 145,829 147,025 148,984 150,345 1,080 4,760 7,600 - 146,909 151,785 156,584 150,345

Burns Lake 7,952 7,937 7,832 7,656 7,952 7,937 7,832 7,656 Nechako 15,284 15,466 15,659 15,717 15,284 15,466 15,659 15,717 Prince George 98,480 99,409 101,041 102,277 1,080 4,760 7,600 - 99,560 104,169 108,641 102,277 Quesnel 24,113 24,213 24,452 24,695 24,113 24,213 24,452 24,695

0 0 0 0Northwest 75,943 76,231 77,463 78,344 2,160 9,520 15,200 - 78,103 85,751 92,663 78,344

Kitimat 10,081 10,146 10,218 10,293 1,080 4,760 7,600 - 11,161 14,906 17,818 10,293 Nisga'a 1,959 1,973 2,002 2,033 1,959 1,973 2,002 2,033 Prince Rupert 14,384 14,579 15,032 15,364 1,080 4,760 7,600 - 15,464 19,339 22,632 15,364 Queen Charlotte 4,578 4,612 4,668 4,649 4,578 4,612 4,668 4,649 Smithers 16,315 16,516 16,956 17,276 16,315 16,516 16,956 17,276 Snow Country 540 537 540 535 540 537 540 535 Stikine 984 963 974 947 984 963 974 947 Telegraph Creek 715 728 726 729 715 728 726 729 Terrace 20,935 20,688 20,797 20,956 20,935 20,688 20,797 20,956 Upper Skeena 5,452 5,489 5,550 5,562 5,452 5,489 5,550 5,562

0 0 0 0NHA 295,083 298,994 307,849 314,194 5,400 23,800 38,000 - 300,483 322,794 345,849 314,194

Source: Population Projections from BC Stats PEOPLE 2013; Workforce increase from Employment Impact Review (Grant Thornton LLP)Note: Workforce distribution was assumed to be equal among the affected regions (each receiving one fifth of the projected increase).

Population Projection Workforce Increase Adjusted Population Projection



Table 42 shows exam volumes from the billing data, appointment volumes from Cerner, and the resulting appointment-to-exams ratio.

Volume by Service - 2012/13 FY

MR CT NM US BD XR+IR MA29 Total

Exam volumes30 5,273 27,917 6,156 55,830 1,940 186,830 4,940 288,886

Appointment volumes31 5,217 27,119 5,063 47,650 2,364 155,451 8,896 251,760

Appointment-To-Exams Ratio 1.01 1.03 1.22 1.17 1.0032 1.20 1.0033

Exam volume (adjusted) 5,273 27,917 6,156 55,830 2,364 186,830 8,896 293,766

Table 42: Exam and appointment volumes based on billing and Cerner data.

It should be noted that using this appointment-to-exam ratio is an approximation. Actual exam counts per site could differ from these estimates. It is recommended to investigate mechanisms to obtain record-level data for exams directly from the Cerner information system.

P R O J E C T I O N A S S U M P T I O N S – A D J U S T E D S C E N A R I O

Projection assumptions for the “adjusted” scenario are derived from input provided by physicians, clinicians and administrators at the Northern Health Authority – Medical Imaging Planning Conference and Workshop session held on April 10th 2014 at the Prince George Civic Centre.

The following are the main assumptions applied over the baseline scenario. Additional information from the output of the workshop is available in a summary document.

Service Assumption

XR 5% increase due to improved staffing in rural areas 2017+ 3% decrease due to correction of inappropriate imaging 2018+

BD 10% gradual increase next 5 years CT 10% increase starting 2016+ due to lung cancer screening

5% to 10% decrease as a result of improved MRI utilization (shift from CT to MRI 2016+) 5% decrease due to improved decision support tools 2018+

IR None MA +2% 2015/16+

+10% 2017+ MR Adoption of Average BC utilization rates for each LHA in Northern Health NM None US +5% tech capabilities 2018+

-5% due to decision support tools 2018+

29 Mammography billing is handled differently; exam volumes are not accurate in billing data 30 Exam volumes based on billing information (Finance) 31 Appointment volumes based on bookings (Cerner) 32 Exam volume for BD is less than appointments; number of appointments taken as correct 33 Due to differences in billing procedures for mammography exams, the number of appointments was taken as correct



A G G R E G A T E D D E M A N D P R O J E C T I O N S B Y S T E P

Demand projections were developed based on service-specific utilization rates calculated for each age/gender group in every LHA and adjusted population projections.

To illustrate the impact of the different projection steps, and specially the importance of accounting for the “aging” effect in the population, Table 41 shows summarized exam volumes by service and period at each calculation step:

Step 1: Use current utilization rates per LHA and apply over future population projections (totals per LHA).

Step 2: Use current utilization rates per age/gender and LHA and apply over future population projections (counts per age/gender and LHA group)

Stage 3: Use current utilization rates per age/gender and LHA and apply over future adjusted population projections (addition of workforce)

Stage 4: Incorporate service-specific assumptions based on MI Planning Workshop

Table 43: Communities with Lowest Access (Larger Distance) to Services, 2013.

Scenario/Period MR CT NM US BD IR XR MA Total

Step 0 Current Exam Volume2012/13 5,273 27,917 6,156 55,830 2,364 827 186,503 8,896 293,766

Step 1 Pre-baseline w/ Population Growth(population growth) 2020 5,438 29,195 6,404 58,809 2,474 856 196,182 9,370 308,728

2025 5,504 29,735 6,513 60,169 2,522 867 200,374 9,593 315,276

Aging effect Additional Volume Due to Population Structure (Aging)2020 300 3,830 1,122 3,923 504 183 15,266 900 26,0262025 447 6,208 1,769 6,664 781 297 26,031 1,264 43,460

Step 2 Pre-baseline w/ Population Growth and Aging=Step 1 + Aging 2020 5,738 33,025 7,525 62,732 2,977 1,039 211,448 10,270 334,754

2025 5,950 35,942 8,282 66,832 3,304 1,164 226,405 10,857 358,736

LNG workforce Additional Volume Due to Additional Workforce2020 369 2,570 436 7,403 118 46 20,903 1,260 33,1052025 0 0 0 0 0 0 0 0 0

Step 3 Baseline=Step 2 + LNG 2020 6,107 35,595 7,961 70,134 3,096 1,084 232,352 11,529 367,859

2025 5,950 35,942 8,282 66,832 3,304 1,164 226,405 10,857 358,736

Workshop asumptions Additional Volume Due to Workshop Assumption Adjustment2020 3,569 -1,780 0 0 310 0 4,647 1,384 8,1292025 2,871 -1,797 0 0 330 0 4,528 1,303 7,236

Step 4 Adjusted=Step 3 + Workshop 2020 9,676 33,815 7,961 70,134 3,406 1,084 236,999 12,913 375,988

2025 8,822 34,145 8,282 66,832 3,634 1,164 230,933 12,159 365,971



The results in the previous table shows that failing to properly account for the aging of the population could result in underestimating future exam volumes by 26,000 and 43,000 by 2020 and 2025, respectively.

Similarly, the effect of the LNG projects in the region will have a significant impact, increasing projected exam volumes by an additional 33,200 by 2020. (LNG construction book is expected to conclude before 2025, resulting in no significant increase in population due to additional workforce.)

Finally, the additional service assumptions obtained from the MI Planning Workshop have different effects on different services. At the aggregate level, there seem to be no significant impact on total volume. However, the most important consequences are observed as a result of the partial shift in demand from CT to MRI, a significant reduction in US and some impact for XR.

It should be noted that this is an approximation developed entirely for illustration purposes; small differences in the numbers are expected as the result of rounding and other estimates necessary to derive these figures.



Appendix IV. Stakeholders Consulted in the Planning Process Medical Imaging Strategic Planning Conference: April 10th 2014 Name Role / Title Sandy Theroux CNC Associate Dean, School of Health Sciences Beth Ann Derksen NH Critical Care Program Lead Findlay Sinclair NH Director, Business Development David Shields NH Biomedical Heidi Johns UHNBC Manager Ambulatory Care & Diagnostics Kim Ewen UHNBC Director of Perioperative & Ambulatory Care Lorraine Guillet UHNBC MI Chief Technologist, Prince George Mike Hoefer NH Regional Director, Capital Planning Lisa Kan BC Cancer Agency Senior Director, Screening Programs Mira Rosche CNC Instructor/Clinical Advisor, School of Health Sciences LeeAnne Evanow CNC Instructor/Coordinator, School of Health Sciences Barb Crook Health Services Administrator, Mackenzie Nicole Ludvigson Combined Laboratory & X-RAY Technologist, Mackenzie Theresa Kennedy MI Chief Technologist, Fort St. James Pam Amante MI Chief Technologist, Prince Rupert Chris Andrews MI Chief Technologist, Terrace Perry Cherniwchan MI Chief Technologist, Fraser Lake Ken Maggs MI Chief Technologist, Kitimat Craig Smith MI Chief Technologist, Vanderhoof Norm Smith MI Chief Technologist, Hazelton Chris Simms Health Service Administrator, Terrace Blaine Curry MI Chief Technologist, Dawson Creek Mitch Griffith NH Rad Safety /Interim Home and Community Care, Terrace Tara Arrowsmith MI Chief Technologist, Quesnel Andrea Bradford MI Chief Technologist, Smithers Charlene Cavers MI Chief Technologist, Fort St. John Tracy Isaak NH MI Quality Assurance Technologist Michael McMillan Ken Winnig

NI Chief Operating Officer NH Regional Director of Diagnostic Services

Dr. Jan Burg General Practitioner/Critical Care, Prince George Dr. Jaco Fourie Chair NW Breast Health Team, Terrace Dr. Sean Ebert Rural Practice Physician, Vanderhoof Dr. Lyle Daly Head of Neurology, UHNBC Dr. Michael Kawerninski Dr. Greg Shand Dr. Shyr Chui

Rural Practice Physician, Stewart Radiologist, UHNBC NH Medical Imaging Lead

Table 44: Participants of MI Strategic Planning Conference (April 10th 2014).



Face to Face Meetings and Interview: April - May 2014 Name Role / Title Dawson Creek Dr. Charles Larsen Radiologist Dr. Leroy Erickson Radiologist Blaine Currie Chief Technologist DCDH Tracy Isaak NH Medical Imaging QA Technologist Fort St John Dr. Chuck Coffey Locum Radiologist Charlene Cavers Chief Technologist Angela De Smit Health Services Administrator Kathryn Peters Director of Care Lucinda Regan , Senior Technologist Fort Nelson Sharon Scott Chief Technologist Christene Morey Health Services Administrator Mary Eaton locum ultrasound technologist Ken Huffman locum radiography Technologist Kitimat Ken Maggs Chief Technologist Dr. Van Der Merwe Orthopedic Surgeon Dr. Derek Carstens Chief of Staff Dolly House OR manager Laurel Angela Pace Physiotherapy Manager Chelsea Bemis Mammography Technologist Degoeij – Living Well Program Manager Prince Rupert Dr. Marius Pienaar Chief of Staff PRRH, OB/GYN Dr. Alf Smith Orthopedic surgeon Dr. Kevin Browne Internist PRRH Pam Amante Chief Technologist Loretta Robinson BCAMRT President Susan Winther Ultrasound Tech Erica Bayer CNC Student Jessica Perry CNC Student Erica Pienaar Ultrasound Student Kathleen Jardim Medical Radiation Technologist Monica Belgardt Medical Radiation Technologist Melissa Jardim Medical Radiation Technologist Dr. Jeff Simmons Pediatrition Michelle Bartel Chief Lab Tech Lori McWilliams Regional Lab Tech

Table 45: Participants of face to face meetings and interviews (April – May 2014).



Appendix V. Facility Service Levels

Level of Care Description Communities

Level 5 –Regional Hospital Urban Prince George

Level 4 – Hospital with Limited Specialty Service

Rural Centre Wide Referral Base Quesnel Prince Rupert Fort St John Dawson Creek Terrace

Level 3- Small Community Hospital

Rural Centre Smaller Referral Base

Vanderhoof Smithers Fort Nelson Kitimat Hazelton

Level 2 – Small Hospital Small Rural Centre Mackenzie Fort St. James McBride Chetwynd Masset Queen Charlotte City Burns Lake

Level 1 – Community Health Centre

Rural Community Less Isolated More Isolated

Fraser Lake Hudson Hope Houston Tumbler Ridge Stewart Dease Lake Valemount Atlin Granisle Southside

Table 46: Service levels by facility.

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