Enterprise informatics move from luxury to must-have

Integration of medical informatics systems continues to penetrate deeper into the hospital enterprise, driven by a search for increased efficiencies and better patient care-all on a tight budget. While the integration of radiology information systems and PACS occurs at the radiology department level, the convergence of healthcare informatics reaching across departments and entire enterprises has begun. Orthopedic and women's clinics, cancer and cardiac imaging centers are all adopting digital modalities and attendant support systems.

Healthcare customers are seeking fully integrated yet cost-effective solutions that yield streamlined workflow. The polestar of this search is the realization that facilities with PACS, RIS, hospital information systems, and electronic medical records are able to lower operating costs significantly while improving patient care through error reductions, as well as providing information when and where it is needed.

"Technologies such as RIS, HIS, EMR, and PACS are no longer viewed as luxuries. They are must-haves for any healthcare facility, regardless of size," said Hossein Pourmand, vice president of business development at Candelis.

Yet pressure from falling reimbursements as a result of the Deficit Reduction Act of 2005 are causing many facilities to defer capital expenditures, particularly for PACS and RIS.

"As the sales decline in the big imaging modality companies due to the effects of reimbursement changes, sales of PACS by modality-based PACS providers are also experiencing a decline," said Joe Biegel, vice president of product management and marketing at McKesson Medical Imaging Group.

Vendors are scrambling to meet the realities of a shifting market. Since modality-based PACS solutions are in less demand, customers are now seeking additional value. Simply providing the latest scanning technology is not enough to encourage customers to invest in PACS. Vendors must now respond to a site's total business at the operational level.

PACS players have reacted to the new market by including additional advanced features to their products. Candelis' ImageGrid PACS, for instance, is able to simultaneously receive studies from multiple modalities such as 64-slice CT, dual-source CT, PET/CT, and MRI; archive them on an integrated RAID5 for instant online access; and route images to multiple viewing stations, including 3D workstations.

At the RSNA meeting, Candelis will introduce its ImageGrid RIS, to enable customers to implement a fully integrated RIS/PACS appliance on a single hardware platform, Pourmand said.

Merge Healthcare is set to release new RIS/PACS features focused on user efficiency. The company has also invested in integration technologies that bring additional clinical capabilities to the radiology workstation. Merge will showcase its Fusion PACS MX 3.0, a solution that uses leading-edge platform technology to automatically launch the right clinical application required to view each study.

"Specialized reading like mammography, orthopedics, and PET/CT can now proceed seamlessly within clinical workflow," said Tim Kulbago, senior vice president of strategic business initiatives at Merge.

This feature provides organizations the opportunity to more easily expand into new clinical areas, he said.

Philips Medical Systems will release 3.6 of iSite PACS, which provides productivity tool and hanging protocol enhancements, teaching file support, mammography support, and advanced visualization for 3D multiplanar reformatting and maximum intensity projection. Under 3.6, radiologists will have access to all images within three seconds for the entire patient history, including mammography, said Eric Mahler, Philips' director of marketing for radiology informatics.

Fujifilm Medical Systems continues to enhance its visualization tools, particularly in the area of full-field digital mammography and 3D.

"We will be demonstrating extensions to our distributed 3D software and advances for our Synapse mammography solution," said Bob Cooke, vice president of network business management.

Fuji's Synapse PACS has been extended to incorporate features such as display and management of CAD results, Mammography Quality Standards Act-compliant image overlays, and diagnostic/screening reading protocols. Synapse has also been configured to facilitate connection between geographically separated reading groups.

FLEXIBILITY SOUGHT

System flexibility has emerged as another desirable feature. Clients are seeking software solutions that can be easily configured to their needs, without sacrificing stability and performance.

"Existing facilities are looking to replace expensive interfaces and multivendor systems, while new facilities are realizing the importance of choosing a software company that can provide complete workflow management," said Viztek president Joe Cermin.

These needs extend beyond PACS and RIS, encompassing dictation, transcription, report delivery, tracking, and even billing, he said. Viztek's Opal solution carries the patient from scheduling thru exam completion, continuing to manage workflow for the radiologist and transcriptionist and ending with report delivery and handoff to a billing package.

Siemens Medical Solutions is focusing on providing role-based, context-sensitive, and knowledge-driven solutions. Its syngo software platform includes RIS, PACS, postprocessing, and distribution.

"The goal is to help clinical personnel work more efficiently through providing a system that seamlessly provides information from HIS, lab, RIS, and PACS," said Ajit Singh, Ph.D., president and CEO of Siemens' image and knowledge management.

Siemens will exhibit syngo Dynamics Version 6, a new cardiology image management and reporting solution that integrates image and data management, postprocessing, and reporting for a complete cardiology solution.

DR Systems plans to roll out its Unity RIS/PACS Version 8, which will increase the company's RIS/PACS capability, particularly with regard to new customizable modules: Web Scheduling, Pre-Registration, Quality Assurance, Mammography/Tracking, Peer Review, and Task Track/Documentation.

"Version 8 includes new ways of working with large files created by FFDM and large data sets generated by PET/CT," said Dr. Murray Reicher, chair and cofounder.

DR Systems is also moving ongoing customer training to web-based tutorials that include methods for testing and training documentation.

Sage Software Healthcare will reveal its latest offering, Radiology Navigator, or RadNav. The system streamlines tasks that radiologists typically perform while reading studies and approving reports. RadNav works in tandem with Sage's Intergy RIS, allowing radiologists to access studies and information from their Intergy system, thereby creating efficiencies.

"Radiology Navigator is as much about managing workload as it is about streamlining accessibility to mission-critical reports," said product manager Dave Jones.

RadNav allows radiologists to create work lists that display only unread studies from specific locations. The feature minimizes search time, helping radiologists prioritize and manage their workload.

Agfa Healthcare's acquisition of GWI, Heartlab, and Quadrat has positioned them well to combine IT solutions into a single enterprise offering. Since the requirements of no two hospitals are exactly alike, Agfa is focusing on specific healthcare segments. The company has created a set of six Healthcare IT suites specifically designed to tightly integrate the relevant IMPAX modules for a specific segment, including suites for the enterprise, hospital, radiology, cardiology, orthopedics, and mammography.

"All suites offer the latest Agfa PACS and RIS solutions and are delivered with state-of-the-art clinical applications, designed for the specific environments in which they will operate," said Lenny J. Reznik, director of enterprise imaging and information for Agfa HealthCare, Americas. "Each suite can be tailored at a modular level to fit current and future customer needs."

New clinical applications from Agfa's IMPAX PACS (Registration and Fusion, Virtual Colonoscopy, and Clinical Decision Support) and server-based 3D tools (MIP, MPR, and Volume 3D) will also be exhibited at the RSNA meeting.

Smaller PACS markets continue to entice companies like Radical Radiology and Emageon.

"We believe that smaller hospitals and imaging centers are the ones who truly need products like PACS and RIS to improve patient care and compete better in their local market," said Radical Radiology vice president Amber Trotman.

Radical Radiology plans to offer a new, less expensive small-market RIS that integrates tightly to its PACS product, creating a full solution with features tailored to the needs of these facilities at an affordable price.

Emageon recently launched RadSuite Express, its PACS solution for the small and midsized markets. RadSuite Express offers an appropriately scaled PACS and 3D visualization solution for hospitals and imaging facilities that produce fewer than 80,000 studies a year. The product is delivered using a simplified single-server architecture with controlled visualization and workflow options to meet the price and serviceability demands of that particular market segment.

Early in 2008, Emageon will release HeartSuite 6.10, which will provide the market with its cardiology PACS on the same image archive as the RadSuite product line. This will provide facilities the ability to address the IT requirement of consolidating their radiology and cardiology image environments at the architectural level.

But the smaller markets are also attractive to big modality players, like GE Medical Systems. The company's IT unit, GE Healthcare Integrated IT Solutions, anticipates increased adoption of imaging technologies such as PACS and RIS in community hospitals, outpatient imaging centers and physician offices.

GE will showcase version 3.0 of its Centricity Imaging-PACS. IHE profiles in version 3.0 will automate exam acquisition, reporting, and communication for referring physicians. New customers will also benefit from an updated Linux architecture while current Centricity customers can also implement version 3.0 within their existing infrastructure, the company said.

PLUG AND PRAY

Consolidation and integration, whether on the department or enterprise level, raises interoperability questions. Despite DICOM, interoperability can still be an issue.

"PACS may use DICOM for images, but they often have proprietary structures for notes, overlays, and other vital image criteria," said Janine Broda, vice president and general manager of Compressus MEDxConnect Medical Division. "This approach makes it difficult for other PACS or referring physicians to view complete image files, leading to inefficient healthcare delivery."

Compressus has introduced MEDxConnect, a system designed to achieve enterprise interoperability by mapping data elements and bridging isolated data islands. MEDxConnect mediates interoperability between applications and creates a virtual integrated information system that adheres to the Integrating the Healthcare Enterprise technical framework.

Still, no matter what size the hospital or how slick the interoperability, system implementation often disrupts established workflow. Keeping up business as usual during implementation becomes even more difficult as the complexity of the solution being installed increases. Vendor integration and implementation tactics become important, and determining whether one solution is better than another is no longer the only issue. Outcome, or time-to-value, has emerged as a key factor.

McKesson believes the true value of PACS comes from enterprise integration.

"Our 15 years of experience integrating total solutions with other vendors ensures a disruption-free implementation, so time-to-value realization is faster," Biegel said.

As the complexity of integration increases and more vendors become involved, McKesson's experience ensures that sites get the most from their solution, whether from a single provider or a best-of-breed platform, he said.

Any successful filmless migration or integration implies secure access to images both inside and outside the facility. BRIT Systems claims that a single PACS/RIS database helps ensure that all clinicians have accurate and timely information for more confident diagnoses.

"BRIT has long provided a single database RIS/PACS solution designed for distributed environments, enabling facilities to share resources such as a centralized archive, disaster recovery, and business continuity," said company president Shelley Fisher.

BRIT's specialized Smart-Synch tools allow for hub-and-spoke or peer-to-peer disaster recovery/business continuity solutions to be built in real-time. BRIT has also seen a need for a vendor-supplied professional reading environment to support teleradiology. The company will introduce at the RSNA meeting an advanced set of tools and services that enhance teleradiology reading and reporting.

A number of other commercial solutions are emerging to manage the evolving teleradiology business model. Neurostar Solutions has configured its Virtual Radiology Network outsourced image management platform to support virtual radiology practices with practice management tools.

"We're expanding the platform to other aspects of the outsourced radiology practice management-an area not addressed by traditional RIS," said Kobi Margolin, Neurostar's vice president of marketing and business development.

Imaging On Call also sees teleradiology maturing into a full-service industry, with RIS/PACS moving beyond the hospital enterprise to web-based solutions. IOC has responded by developing solutions that enable radiology groups to become more profitable and innovative, according to COO Rodney Sappington.

"IOC's technology facilitates extremely fast image transmission, the fastest in the industry," Sappington said.

Intelerad has noticed some traditional radiology groups expanding into teleradiology in order to boost revenues and leverage their PACS investment. Its IntelePACS has been positioned to handle specialized teleradiology requirements.

"Given the unavoidable challenges of variable network infrastructures, and ever increasing imaging study size, our aim is to provide flexible yet robust solutions specifically designed to operate over wide area networks that can handle the demands of complex radiology and teleradiology workflow," said Chris Henri, executive vice president of business development.

Features such as redundant interface gateways with automatic failover mechanisms, intelligent streaming algorithms for image display, and optimized compression methods have all been given high priority.

NICHE PLAYERS

Other unfilled market needs are also being followed. RIS Concepts is in the process of developing a RIS enhancement that automatically schedules time-lapsed multistep exams such as nuclear medicine and PET/CT that require multiple appointments or delays between exam segments.

"Since our solutions are entirely web-based and written in ASP and Java, RIS Concepts is able to move products more rapidly through the development cycle," said Christie Hentschel, vice president of marketing and sales.

Last year, for instance, the Miami firm created an integrated web-based voice command recognition module and also introduced a teleradiology RIS called RAD-RIS to complement their standard RIS. The turnkey RAD-RIS manages multisite reporting and separate billing for each site.

Commissure, an industry leader in structured speech report creation, is following several other trends. Existing company development ranges from decision support for appropriate diagnostic order placement to addressing management of pay-for-performance initiatives and reimbursement reductions-toolsets that allow customers to "see" their data for the first time.

"Incorporating data from even more sources will allow for greater understanding of the massive amounts of radiology information an institution collects," said marketing manager Jonathon Dreyer.

Other players are focusing on storage solutions. DeJarnette Research Systems expects the storage component of PACS to be something that stands alone in the not-too-distant future and is acquired without necessarily purchasing a vendor's display and workflow components, according to Wayne DeJarnette, president and CEO. DeJarnette's xDL, announced in 2006, is already being installed in more than 80 facilities as a centralized offsite storage management option.

Moore's Law governing exponential increases in computing power every two years unfortunately does not apply to network capacity. While multislice CT may add clinical value in radiology procedures, management of the associated data avalanche often remains an issue, resulting in poor network performance.

"This issue is a hot topic but is surprisingly not discussed as much as one could expect considering the cost of wait time," said Martin Hakansson, Sectra's vice president of marketing.

Sectra's RIS/PACS approach incorporates considerations for advanced data representation and image transfer methods.

"From a RIS/PACS perspective, it's important to work with these trends, not against them," Hakansson said. "Facilities need to do the math-what is the cost of having 10% longer read times than necessary for all MSCT cases?"

In the coming months, Sectra expects to roll out a new workstation that exploits high-performance image transfer. Their radiology management solution, a dashboard called ControlTower, now provides 24/7 real-time monitoring and management of such parameters as system status, reading time, and waiting room waits.