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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 using the internet and whole-slide
imaging (WSI) systems to link pathologists to
glass slides.
• Pathologist can provided diagnosis using WSI
– The next room
– Across the downtown
– Around the world
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
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
– 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
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
NOTP - Sites
Timmins and District Hospital (TADH), Timmins (2
Kirkland and District Hospital (KDH), Kirkland Lake (1
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
Timmins Cluster
• consultations
• frozen sections
> 100 patients
• completely digital
> 400 miles
Google Maps 2008
within 2 years
Sault Area Hospital
• consultations
• speciality
surgical cases
> 400 miles
Google Maps 2008
High-Level Technical Workflow Review
Laboratory end-users will scan slides which will be stored locally, either on the
controller PC or to a project provisioned storage device.
Meta-data associated with each slide will be sent to UHN’s data centre where it will be
stored for all organizations.
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.
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
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 Overview
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
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
– 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
– 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 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
• Development of in-house guidelines for the
retention of images prior to implementation
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
• 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 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 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
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
Building redundancy into the solution to
facilitate its use for time-sensitive procedures
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
Bridging goals of different institutions
• Development of a change management plan early in the
• 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 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
Thank You