By 2020, more than 20% of the population is estimated to be at least 65 years. Residents in Oslo’s nursing homes are 85 years old on average, have 3-4 chronic diseases and 70-80% are demented. 50% of the hospital referrals are for X-ray. Bringing mobile X-ray equipment to these patients instead of transporting them to stationary equipment is cost-effective (one examination in an institution saves 30% of the costs and 2 examinations 60%), and complies with national strategies to organise health care on the lowest effective level of care. Our project involved public/private partnership that produced mobile digital X-ray equipment (now commercialised) and has resulted in routine use of the product. On-line transferral of images has been piloted with Wimax, a public WLAN-like technology with an extended range, with good results. Our case exploits and realizes the opportunities inherent in available and coming e-technology, as recommended by eNorway 2009.
Policy Context
Social inequalities in health are a public health concern and an expression of unacceptable systematic injustices, says Sylvia Brustad, Norwegian Minister of Health and Social Affairs. The Ministry of Health and Care Services has in Report No. 20 (2006–2007) to the Storting recommended a National strategy to reduce social inequalities in health http://www.regjeringen.no/en/dep/hod.html?id=421. In report No. 25 (2005-2006); aging population (a steep increase is expected in the coming years), scarcity of health-care personnel and medical follow-up are mentioned as 3 of the 5 main challenges within health-care. Some citations from the National Health plan for 2007-2010 follow: “We want the services to be of a high quality, to be available within acceptable waiting times and distances, and the provision to reach out to everyone regardless of their financial situation, social status, age, gender and ethnic background… The health service faces considerable challenges in the years ahead because there will be more senior citizens… One of Norwegian health services’ core values is that everyone should have equal access to good health services funded through public schemes.. One recurrent theme in reports, evaluations and criticisms from user organisations is that the interaction is too poor and that the services are not cohesive enough… Treatment and follow-up shall continue to be organised according to the lowest, effective level of care principle (known in Norway as the LEON principle). The Ministry of Health and Care Service's have a strategy plan for 2004-2007 concerning electronic cooperation in the health and social sector (not translated to English). The government realizes that ICT is an important tool for better cooperation across geographical and organisational barriers, and "eNorway 2009" is all about exploiting and realising the opportunities inherent in the technology.
Description of target users and groups
Immobile patients who can be diagnosed or treated more cost-efficiently at lower healthcare levels than current practice, i.e. outside of hospitals e.g. in nursing homes, retirement homes, prisons, rehabilitation centres, psychiatric institutions and immobile patients living at home.
Description of the way to implement the initiative
Ullevaal University Hospital (UUH) is in charge of the project on behalf of the South-Eastern regional health authorities, and has cooperated with industry to develop a equipment that is now commercially available (Section 1.13). The digital radiography equipment is brought to the patients where they are; the radiographer (normally employed by the regional health authorities) who is also chauffeur, takes the X-ray images and transfers them either to a memory stick (or similar) or on-line to an interpretative central in a hospital. If the examination reveals conditions that require an operation the patient is immediately transported to the hospital, otherwise the radiographer is not allowed to inform the patient about findings. Practical solutions are needed to solve the “gap†between Norwegian primary health care and secondary specialist services concerning who pays for the service. In Oslo and Bergen the service is cost-effective irrelevant of who pays, but this is not the case in other Norwegian regions. The service can be more cost-effective in the districts by managing it from local medical centres. Norwegian Radiation Authorities have approved the service under certain fulfilled conditions. An centralised operation central should be responsible for organising, managing and maintaining the service and equipment.
Technology solution
All approaches imply transferral of images in a mobile X-ray unit to a mobile PC. Image files on PCs can be transferred to communication offices at radiological sections in hospitals via small, hand-held hard discs, memory sticks or CD-ROMs or electronically. The information is thereafter sent electronically through the communication office (that quality assures the material) to a Picture Archiving and Communication System and a digital X-ray patient system. The main challenge in the project is on-line transferral of images to the hospitals, but this should soon be solved. New UTMS standards will have the capacity to send information from the hospital to a mobile PC, and also to send images to hospitals. There are several suppliers of Wireless Local Area Networks (WLAN). We have piloted the use of Wimax, a public WLAN-like technology with an extended range (available within few years) with good results. Secure solutions are available to meet most demands, unfortunately they cannot use all networks that require log on, but this is something the suppliers will change within a relatively short time. In the long run it would be best that the nursing homes can have full net-based coverage within a well functioning public Health-net.
Main results, benefits and impacts
Our mobile X-ray service project received the EUROPACS award for best practice within tele-radiology in 2006. The award was briefly presented as follows on the EURPACS website: The use of PACS-technology and broadband: The impact new technology will have on organizational development and the potential economic savings as a result for Health organizations.* The European Society for Radiology will have a special session on how mobile X-ray and imaging should be developed to meet the increasing proportion of elderly in society, in their conference in 2008. Our concept has been presented in Swedish television’s main program about medical issues and on the Norwegian Broadcasting company’s main news programme. The cases’ main novelty is transporting digital, miniaturized diagnostic equipment instead of patients. The goal is more flexible health-care, both in acute situations and for improved palliation and medical care in the large proportion of chronically ill and elderly. Hospitals can be relieved by provision of an improved basis for giving diagnoses ensuring safer treatment. With mobile diagnostics in local communities, access can be given to competent medical expertise by use of available technology and continuous on-line communication. Modern net-based technology and digital radiography enables separation of the X-ray examination itself and the competence-demanding interpretation- and reporting procedures. Nursing home patients, that are currently receiving sub-optimal care (20-25 % fewer X-ray examinations than others), are given a health care service that is diagnostically equivalent to that currently used, in a more cost-effective (30 % for one examination in a nursing home and 60 % for two per stop in Oslo) and user-adapted way (health-care personnel do not need to follow patients [and pay for substitutes], patients avoid the stress and complications of transport and the users do not compete with ambulance services). The Renault Kangoo car is the only one in Europe of its kind carrying a light-weight digital X-ray unit and can serve up to 12 patients per day depending on distance. The simple radiology equipment combined with a sophisticated digital detector unit was especially developed for this project, has now been commercialised, is routinely used in 54 nursing homes in Oslo and is on the verge of being used in hospitals in Sweden and Switzerland. New solutions are needed to meet the increasing proportion of elderly. Our case is a prize-awarded (EUROPACS 2006) example of how to organise a specialist service that may be used by e.g. ultrasound and CT in addition to conventional X-ray examinations.
Return on investment
Return on investment: Not applicable / Not availableTrack record of sharing
Norwegian politicians in central positions have been contacted, a collection of Norwegian articles have been published in Michael (a publication series of The Norwegian Medical Society) and in international journals (Diagnostic Imaging and Elsevier's International Congress Series), the concept has been broadcasted on Norwegian and Swedish television. Norwegian (the Norwegian military services) and International (International Court of Justice [Haag], Swedish and Swiss health care centres) health-care providers have adopted the equipment, or want to change their routines. The EUROPACs award 2006 was given at one of the world’s largest gatherings of specialists in medical imaging and digital systems for eHealth (speakers from 26 countries), and provided excellent publicity for mobile specialist (X-ray) services to physicians, radiologists, scientists and health care professionals from around the world. Two hospitals and Bergen municipality have formed a committee that is currently considering mobile X-ray service. It is also being discussed in Stavanger. Lund University Hospital has planned to start using mobile X-ray, but need to provide financing. The same technology and concept is currently being tested in Geneva and Basel, in understanding with the Swiss government. The pilot project financed by the Research Council of Norway’s HØYKOM programme used mobile X-ray as an example of how specialist service could be organised, and the positive results are likely to influence the organization of other specialist services as well (e.g. ultrasound, CT).
Lessons learnt
Thorough cost-benefit analyses have shown that society has much to save by transporting mobile digital X-ray units to patients instead of transporting patients to hospitals or other sites with stationary X-ray equipment. The results from needs analyses, pilot studies and routine use of equipment developed in our project should be strong and concrete enough to convince management in health-care institutions and politicians that implementation of our proposed solution will be 1) cost-effective, 2) medically adequate (better in many respects) and more 3) ethical. It saves old sick people the stress, pain (fractures are the most frequent finding in X-ray examinations) and discomfort associated with transportation and the the demented the anxiety that they experience when they come to new environments. Medically, the service does not only provide adequate results, but also enables giving a diagnosis more quickly, so the needed follow-up can be started right away (some fractures require immediate operation). Nursing home residents are currently examined 20-25% less frequently than the rest of the population, but considering their health-status they need to be examined more often. Development of faster and more available on-line solutions will render mobile digital X-ray services even more cost-effective.
Scope: Regional (sub-national)