Norway advances toward fully digital healthcare

Norway has one of the highest levels of public health spending per capita in Europe and the highest of all Scandinavian countries. About 35% of the state's annual budget, or 7% of gross national product, is spent on the health and social welfare system. The country's extensive services include expenditures of NOK 50 billion (about British Sterling 7 billion) on hospitals each year, and the social security network is well developed.

Norway is divided into 19 counties, with an average of 240,000 inhabitants in each and a total population of 4.5 million. Two thirds of its 85 hospitals are already using or will soon be using RIS and PACS. By the end of 2005, nearly every hospital across the country will have installed RIS and PACS. This move toward digital radiology should be viewed in the context of hospital reform in Norway.

The Stortinget, the Norwegian parliament, decided in 2001 that central government should take over responsibility for all public hospitals, which would be operated under so-called health enterprises. Hospitals that had been owned and run by individual counties for more than 30 years came under state ownership on Jan. 1, 2002. Five main regional health enterprises were established, with separate boards and a managing director for each region. These regional boards organized the hospitals into approximately 50 minor enterprises. The regions are establishing intraregional broadband communication, and by the end of 2003, the Regional Health Networks will be interconnected, constituting a National Health Network.

We see several paradoxes in the health sector: increasing use of resources, but greater financial problems; increased growth in number of patients treated, but stable and even growing waiting lists; and an increasing number of healthcare professionals, but an apparently greater shortage of healthcare professionals than ever before. Technology can address some of these strains on the system.

ACTION PLAN IN HEALTH

Information technology has been integrated into the Norwegian health system to a considerable extent, particularly in the primary health service. The government's "E-Norway" plan lists general investment in IT and nationwide availability of broadband as two of its aims. The Ministry of Health and Social Affairs' action plan for IT development in the health and social sectors is known as "Say @!" It outlines measures to promote greater electronic interaction. This is an important component of the overall health reform, which aims to provide each Norwegian citizen with a regular general practitioner and free choice of hospital, and has put control of hospitals and specialist healthcare services in government hands. Activities and goals in the "Say @!" initiative are divided into four sections:

?National Health Network. The network will provide a good foundation for electronic interaction and information exchange in the health sector, ensuring data quality, security of information, and protection of privacy during exchange of sensitive information. National funding is provided for the development of different services, standards, and security guidelines as well as investment in broadband.

?Electronic interaction within health and social services. Widespread use of electronic exchange will be realized for central messages, such as referrals, medical records, and reimbursements.

?Telemedicine. People can be treated or nursed in their local environment or homes to a greater extent than before. Telemedicine solutions will be used throughout the country to ensure greater availability of services. This is to be achieved by stimulating broadband development between hospitals, and between hospitals and the primary health services, and by clarifying responsibilities, rules, guidelines, and rates in connection with telemedical consultations.

?Services to the public. Quality-assured information on public health and social services will be made available to the public through the use of Internet services.

TREND TOWARD DIGITIZATION

Most Norwegian hospitals are already making plans to digitize their x-ray divisions, procuring the equipment and systems necessary for digital storage and communication of x-ray images. All hospitals will eventually switch to digital radiology and ultimately become fully digital. When this happens, 3.3 million digital x-ray investigations will be performed each year.

Norway has a tradition of telemedicine usage that goes back 15 years. Teleradiology is used for consulting in emergencies, for second opinions, and for communications between hospitals and primary healthcare service providers. But point-to-point teleradiology is now yesterday's technology, and RIS/PACS to RIS/PACS communication will replace it in the future.

Integration is a key requirement for all PACS in Norway. Each PACS has to be integrated with a RIS, and the RIS has to be integrated with a HIS. The role of RIS and PACS within hospitals is evolving, and PACS is becoming the imaging layer of the electronic patient record (EPR). Future clinicians will not see the PACS as a separate entity but will work directly with the EPR.

Medical images have to be online 24 hours a day. Discussions are taking place concerning archiving strategy and performance, with details about image retrieval times, disaster recovery, integration of images and text, and selection of storage media. Offsite archiving has already been introduced. Some hospitals and private imaging centers plan to use an application service provider. The amount of data produced by imaging modalities is constantly increasing. A storage area network may provide an effective way of managing such huge archives. All images are stored on disk in a SAN, with redundant solutions containing at least two separate archives and a tape robot for backup.

Exchange of digital imaging information will require broadband communication. PACS has become an important part of the regional and future National Health Network, and central storage for regional health enterprises and SAN solutions are growing rapidly. Central archiving is undoubtedly a cost-saving strategy. When combined with Web technology, it allows each enterprise to distribute images, reports, and related data throughout the enterprise.

Some regions in Norway have implemented PACS as a regional solution for all their health enterprises. The different enterprises within one region could share a physical storage unit for all PACS (and RIS) information, but Norwegian legislation prohibits health enterprises from sharing patient information indiscriminately. Consequently, any shared physical storage unit must be divided into logical storage areas so that access can be linked to each health enterprise. Legislation also specifies that access to information owned by a different health enterprise must be evaluated and approved. All access to the storage unit must be logged to enable audit.

Health enterprises sharing a single storage unit must have access to the unit's communication lines. If these lines are not available, the health enterprises cannot send or receive data. Redundant solutions for the storage unit and the communication lines are thus needed to achieve acceptable system performance. Communication lines must be encrypted to maintain confidentiality of transmitted information. Denial of service attacks, an increasing threat, means that a huge amount of data must be handled, resulting in the breakdown of service. A PACS network should be designed with strong access control and made as closed as possible to breaches from outside.

The Norwegian National Cancer Register has initiated a project involving exchange of digital mammography images. This represents a significant information flow and requires excellent broadband access (100 MB/sec to 1 GB/sec). The project will be piloted this year with digital mammography images transferred between the university hospital in Oslo and the university hospital in Tromso, located 2000 km away.

PACS could potentially benefit whole hospitals, not just radiology departments. The Ministry of Health, as owner of Norway's hospitals, is interested to learn of any potential for realizing profit from the move to PACS. Imaging departments are undergoing a transition from a film-based to a filmless environment. Workflow processes have to be examined to identify opportunities for improvement. The goal is to make hospitals not only filmless but paperless as well. In the virtual radiology department, physicians will be able to order, schedule, perform, read, dictate, and distribute a study from anywhere.

PIONEERING NETWORKED PACS

Mid-Norway is the first region to have installed RIS/PACS using broadband communication in a regional health network. Eight hospitals in mid-Norway, which together produce 460,000 images per year, have agreed to buy and install a common network-based PACS and RIS. A high-speed redundant network is giving the hospitals the capacity necessary to exchange images. Central storage has been installed, and the first hospital went filmless in early January 2003.

A networked PACS raises issues regarding data safety and network redundancy. The regional PACS scheme addresses these potential problems in several ways. Information can flow in both directions in the ring network, so physical network rupture will not affect the PACS. Two different providers will run the network. If one broadband network is not functioning, the other broadband network takes over automatically. For all the electronics, there are two of every component. The redundant storage is mirrored, with two identical copies of the archive at different locations. A tape robot provides backup, and every hospital offers local storage as extra security and a buffer when traffic is high.

A joint regional PACS technology base introduces substantial potential for organizational development, and economic benefit is also expected to result. The regional health authority responsible for mid-Norway has set up a project to identify any cost savings. The project will focus on individual radiology departments, on collaborations between radiology departments and different clinical departments within the same hospital, and on overall radiology functionality and service structure within the whole region.

Initially, the project will identify a number of hypotheses about potential economic savings in close cooperation with users. A selection of these initial hypotheses will be expanded into business cases that include baselines, potential savings, and a high-level implementation scheme. Finally, a prioritized short list of recommended measures will be drawn up. Selection will be based on several key criteria, including attractiveness (from a user and management point of view), economic value, difficulty of implementation, risk level, and quality. Each selected measure will be described in terms of an implementation plan, complete with budgets and timetables.

LINKING NORTH NORWAY

North Norway is a large geographical area with a relatively scarce population. Approximately 450,000 inhabitants receive care at 10 small community hospitals, one central hospital, and a 500-bed university hospital. Of 430,000 imaging procedures performed each year throughout the region, 124,000 take place in the university hospital.

The geography and demography of this region provided the stimulus for teleradiology solutions. In fact, most pioneering teleradiology projects in Scandinavia originated in this region at the university hospital in Tromso. Teleradiological activity has been constantly high since 1992, with approximately 7500 examinations transferred electronically every year. In 2002, this number rose to about 15,000. Tromso became the first university hospital in Scandinavia to move to a full PACS (with the exception of mammography) in January 2000. Eight of the 12 hospitals in the region now run full PACS, and the remaining four plan to install PACS during 2003.

All regional hospitals have had the option of sending their emergency CT cases to a university hospital for assessment since the mid-1990s. Although the networking capacity was initially poor, establishment of the Regional Health Network in 2001 has facilitated transport of images and accompanying information between institutions. Teleradiological services in north Norway have helped reduce the number of emergency journeys made under difficult conditions.

Strategic plans are exploring the potential advantages if all institutions choose a common RIS and PACS. The major challenge for this region is obtaining access to a redundant broadband network at an affordable price. The aim is to interconnect all institutions, in a scheme similar to that running in mid-Norway, allowing PACS in all 12 hospitals to share a common basic infrastructure.

NATIONAL COORDINATION

Despite use of the DICOM standard for image communication, information exchange between hospitals is not seamless in practice. Individual hospitals in Norway have chosen different solutions for RIS and PACS, and integration and exchange of data between hospitals will receive more attention in future. Norway has joined the Integrating the Healthcare Enterprise (IHE) organization and IHE-Norway was formally established on May 15, 2003. Norway will participate in a Scandinavian mirror group to be established later this year, and participation will be anchored in the ongoing standardization program in Norway.

We recommend putting more effort into national registers for imaging services, standardization, and collaboration through the IHE initiative and improving collaboration between primary health service and hospitals in imaging.

Norway is making great economic investments in PACS and RIS, but we know little about the consequences this will have on health services and patient treatment. These should be examined. We need to ask how imaging services can be reorganized to get a better, more effective healthcare system. We need a better idea of what profits the introduction of PACS and RIS will bring. If imaging services could be reorganized as an expanded collaboration or as virtual imaging divisions, the best specialist could always be consulted wherever he or she was available with a virtual imaging system. Capacity could be utilized through sharing images over a network. Any future organization of imaging services in Norway should be based on the changes technology can provide.

Collaboration between different health enterprises through PACS presupposes a high degree of security that allows confidentiality, quality, and accessibility. RIS and PACS are communication-intensive, and security is also a prerequisite in the intermediate infrastructure. Safeguards are needed to ensure that patient confidentiality is maintained when radiological images and information are exchanged between hospitals, within or between regions. Regional and/or network-based solutions must also control access to important information in a secure manner.

All Norwegian hospitals will have PACS and RIS within three to five years. Considerable effort is going into standardization, harmonization, and integration. But challenges remain. Norway must work with the IHE initiative and use its National Health Network to get the best RIS/PACS solutions for the country's hospitals.

DR. BERGSTROM is senior advisor at the Norwegian Centre for Health Informatics (KITH) in Trondheim, Norway, and DR. STORMER is head of the radiology department at the University Hospital of North Norway in Tromso. Assisting with the preparation of this manuscript were Tor Olav Groetan and Magnus Alsaker, both of the KITH.