Information Technology Issues to Consider When Information Technology Issues to Consider When Implementing Telepathology Links with Remote Locations:Implementing Telepathology Links with Remote Locations:

Lessons Learned from University Health Network's Northern Lessons Learned from University Health Network's Northern Ontario Telepathology ProjectOntario Telepathology Project

Terra Ierasts, Project Lead

Pathology services over a distancePathology services over a distance

• Telepathology (TP) enables pathology services over a distance using the internet and whole-slide imaging (WSI) systems to link pathologists to glass slides.

• Pathologist can provided diagnosis using WSI from – The next room

– Across the downtown

– Around the world

The University Health Network ExperienceThe University Health Network Experience

UHN’s Experience to date with WSI TP

• Primary frozen section diagnosis• Maintaining 24/7 sub-specialty coverage of

transplant pathology services• Sub-specialty pathology service to hospitals in

Northeastern Ontario

Northern Ontario Telepathology Project (NOTP)Northern Ontario Telepathology Project (NOTP)

• Enabling Northern Ontario Hospitals greater and faster access to the UHN pool of expert sub-specialty pathologists for the review, diagnosis and reporting of frozen sections for intra-operative support, and complex pathology consultations.

• More specifically, the objectives of this initiative are to:– Maximize diagnostic capacity through sub-specialist pathology

networks– Minimize the need for transporting patients or their specimens

over great distances reducing wait times for treatment– Allow sites to potentially expand the set of surgical procedures

offered to patients via inter-operative frozen section analysis capabilities

Key Clinical Issues for NOTPKey Clinical Issues for NOTP

• Shortage of pathologists, no sub-specialists• No pathologist in Timmins 1-2 weeks/month• Glass slides shipped to UHN

– Limitations:• Frozen sections

• Lost/damaged slides

• Delays with transporting slides

NOTP - SitesNOTP - Sites

1. Timmins and District Hospital (TADH), Timmins (2 scanners)

2. Kirkland and District Hospital (KDH), Kirkland Lake (1 scanner)

3. Sensenbrenner Hospital (SH), Kapuskasing (1 scanner)4. Notre Dame Hospital (NDH), Hearst (1 scanner)5. Sault Area Hospital (SAH), Sault Ste. Marie (2

scanners) 6. University Health Network: Toronto General Hospital

(TGH), Toronto

Timmins ClusterTimmins Cluster

• consultations

• frozen sections> 100 patients

• completely digital

within 2 years

Google Maps 2008

> 400 miles

SaultSault Area HospitalArea Hospital

• consultations

• speciality surgical cases

Google Maps 2008

> 400 miles

High-Level Technical Workflow ReviewHigh-Level Technical Workflow Review

1. Laboratory end-users will scan slides which will be stored locally, either on the controller PC or to a project provisioned storage device.

2. Meta-data associated with each slide will be sent to UHN’s data centre where it will be stored for all organizations.

3. When pathologists log into NOTP and call upon a slide, this command will flow to the central server, and the central server will call upon the required slide at the designated remote site. This process will be invisible to the end-user, and ensures a single process is used to access the slides stored at various organizations.

4. The pathologist will use a web-based application to view the slide. This slide viewer has magnification and scrolling capabilities, allowing it to act as the virtual microscope.

5. As the Telepathology software is not integrated with any other laboratory information systems (LIS), the Telepathology data flow will end here, whereby which the pathologist will then report results using their current laboratory information system

Workflow Logical OverviewWorkflow Logical Overview

IT Challenges during the implementationIT Challenges during the implementation

• Adequate bandwidth and connectivity• Storage and retention of digital slides• Privacy Impact and Threat Risk Assessments• Building redundancy into the solution to facilitate

its use for time-sensitive procedures • Bridging goals of different institutions

Adequate bandwidth and connectivityAdequate bandwidth and connectivity

• Ontario e-Health’s ONE Network is to support the viewing of digital slides generated at these remote sites by UHN pathologists in Toronto

• Benefits:– Accessibility – ONE Network supplies connectivity to the health care

sector, including to the Government of Ontario Network and Internet.– Availability – ONE Network meets or exceeds industry standards for

uptime.– Cost Efficiency – The ONE Network connectivity suite contains a wide

range of common infrastructure components, offering a cost-effective network solution that realizes economies of scale.

– Security – ONE Network is a private, independent network that helps ensure the protection of any personal health information within the network.

– Technical Currency – We are continuously evolving and enhancing ONE Network by leveraging industry developments.

• Key Success Factor: Ensure project has adequate time to test connectivity, working with the e-Health early in the project

Storage and Retention of Digital SlideStorage and Retention of Digital Slide

• Glass slides are retained as per Ontario Association of Medical Laboratories (OAML) Guidelines for Retention of Laboratory Records and Materials. There are no guidelines on keeping of the digital images.

• Development of in-house guidelines for the retention of images prior to implementation

Privacy Impact & Threat Risk AssessmentsPrivacy Impact & Threat Risk Assessments

What is a Privacy Impact Assessment?• A PIA is a formal risk management tool used to

identify the actual or potential effects that an activity or proposal may have on individual privacy.

• PIAs also identify ways in which privacy risks can be addressed. This is increasingly important as health information is collected, stored and disclosed in electronic form

Privacy Impact & Threat Risk AssessmentsPrivacy Impact & Threat Risk Assessments

What is a Threat Risk Assessment?• A TRA is a formal risk management tool based on a

formal review of the information holdings and systems under assessment

• The identification and rating of the risk is derived from – the classification of the sensitivity of information and assets, – the assessment of potential threats to the information and assets, – and the identification and assessment of vulnerabilities in the

administrative and organizational, personnel, physical, and technical categories of the business.

Privacy Impact & Threat Risk AssessmentsPrivacy Impact & Threat Risk Assessments

• The PIA and TRA are typically conducted by third party vendors

• Key success factors:– Clear and organized documentation– Frequent communication and planned check-

in meetings– Engage third party vendor early in project

schedule

Building redundancy into the solution to Building redundancy into the solution to facilitate its use for time-sensitive procedures facilitate its use for time-sensitive procedures

• High availability was required to support the time-sensitive nature of procedures at Timmins and District Hospital

• Teams needed to consider significant redundancy including:– Additional scanners– Backup network– Additional storage

Building redundancy into the solution to Building redundancy into the solution to facilitate its use for time-sensitive proceduresfacilitate its use for time-sensitive procedures

Building redundancy into the solution to Building redundancy into the solution to facilitate its use for time-sensitive proceduresfacilitate its use for time-sensitive procedures

• Key Success factors– Collaborative development with participation for

various stakeholders to create a robust system with strong security design

– Clear understanding of the business goal and requirements for high availability network

– Frequent communication through out design phase– Build activities did not begin until the detailed designs

were finalized and agreed to by all teams.  This mitigated the challenge of geography in case of issues and changes as all build had to be completed locally before shipping the equipment to remote sites

Bridging goals of different institutionsBridging goals of different institutions

• Development of a change management plan early in the project.

• Detailed stakeholder analysis and engagement plan early in the project life cycle

• Biweekly communications to all stakeholders• The project implement a weekly meeting to discuss

unresolved issues, concerns and next steps• The technical team maintained very frequent

communication with the 5 sites and Product, Service Delivery, Operations and Threat Assessment teams to identify issues and concerns early and have acceptable resolutions that were well understood

Factors that support project successFactors that support project success

• Key themes emerged throughout the project to help overcome strategies– the development of strong relationships with

stake-holders in our partner organizations,– effective communication throughout the project– a clear understanding of its business goals– dedication to innovative IT solutions

Questions?Questions?

Thank YouThank You