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Information Technology Issues to Consider When Implementing Telepathology Links with Remote Locations: Lessons Learned Information Technology Issues to Consider When Implementing Telepathology Links with Remote Locations: Lessons Learned from University Health Network's Northern Ontario Telepathology Project Terra Ierasts, Project Lead

Pathology services over a distance • Telepathology (TP) enables pathology services over a distance Pathology 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 2

The University Health Network Experience UHN’s Experience to date with WSI TP • • The 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 3

Northern Ontario Telepathology Project (NOTP) • Enabling Northern Ontario Hospitals greater and faster access 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 4

Key Clinical Issues for NOTP • Shortage of pathologists, no sub-specialists • No pathologist Key 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 5

NOTP - Sites 1. 2. 3. 4. 5. 6. Timmins and District Hospital (TADH), NOTP - Sites 1. 2. 3. 4. 5. 6. Timmins and District Hospital (TADH), Timmins (2 scanners) Kirkland District Hospital (KDH), Kirkland Lake (1 scanner) Sensenbrenner Hospital (SH), Kapuskasing (1 scanner) Notre Dame Hospital (NDH), Hearst (1 scanner) Sault Area Hospital (SAH), Sault Ste. Marie (2 scanners) University Health Network: Toronto General Hospital (TGH), Toronto 6

Timmins Cluster • consultations • frozen sections > 100 patients • completely digital > Timmins Cluster • consultations • frozen sections > 100 patients • completely digital > 400 miles Google Maps 2008 within 2 years 7

Sault Area Hospital • consultations • speciality surgical cases > 400 miles Google Maps Sault Area Hospital • consultations • speciality surgical cases > 400 miles Google Maps 2008 8

High-Level Technical Workflow Review 1. Laboratory end-users will scan slides which will be stored High-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 9

Workflow Logical Overview 10 Workflow Logical Overview 10

IT Challenges during the implementation • • Adequate bandwidth and connectivity Storage and retention IT 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 11

Adequate bandwidth and connectivity • Ontario e-Health’s ONE Network is to support the viewing Adequate 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 12

Storage and Retention of Digital Slide • Glass slides are retained as per Ontario Storage 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 13

Privacy Impact & Threat Risk Assessments What is a Privacy Impact Assessment? • A Privacy 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 14

Privacy Impact & Threat Risk Assessments What is a Threat Risk Assessment? • A Privacy 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. 15

Privacy Impact & Threat Risk Assessments • • The PIA and TRA are typically Privacy 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 checkin meetings – Engage third party vendor early in project schedule 16

Building redundancy into the solution to facilitate its use for time-sensitive procedures • High Building redundancy into the solution to 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 17

Building redundancy into the solution to facilitate its use for time-sensitive procedures 18 Building redundancy into the solution to facilitate its use for time-sensitive procedures 18

Building redundancy into the solution to facilitate its use for time-sensitive procedures • Key Building redundancy into the solution to facilitate 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 19

Bridging goals of different institutions • Development of a change management plan early in Bridging 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 20

Factors that support project success • Key themes emerged throughout the project to help Factors 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 21

Questions? 22 Questions? 22

Thank You 23 Thank You 23