RIS/PACS integration can speed decisions throughout exam chain

Staffing shortages, reduced reimbursements, and healthcare cost containment issues continue to drive radiology departments to pursue maximum productivity and efficiency. The short road to this destination is RIS/PACS integration. Integrating RIS and PACS directly improves efficiency by automating radiology workflow. This is achieved by removing the barriers between images and information, which decreases report turnaround time and significantly refines service to patients and referring physicians.

Studies have demonstrated that the use of RIS/PACS in a hospital radiology department substantially cuts the time needed for completion of x-ray examinations, yielding reductions on the order of 35% to 52% (J Digit Imaging 2006;19 Suppl 1:18-28). By providing the right information at the right place at the right time, integrated RIS/PACS gives radiologists easier and faster access to the images and information necessary to properly interpret an exam.

"To identify [pathological] changes in images and improve diagnostic quality, images and information from previous examinations are essential, whether they were created at the same site, a different hospital, or a different radiology center," said Dr. Petter Hurlen of the radiology department at Akershus University Hospital in Norway.

Ideally, when RIS and PACS are integrated, the RIS work list drives the PACS. Radiology functionality is then delivered to end-users in a single interface, eliminating the need for users to toggle between systems to manage an exam from scheduling to sign off to billing. Integrated RIS/PACS products now exchange information directly in accordance with Integrating the Healthcare Enterprise guidelines, eliminating the need for third-party broker or linking systems.

Not just radiologists benefit from RIS/PACS integration. More information becomes available sooner to each user in the exam process chain, enabling clinical decisions to be made faster. Integrated RIS/PACS solutions allow imaging center receptionists, radiology technologists, transcriptionists, referring clinician office staff, and referring physicians to communicate with each other in a uniform, coherent, paperless manner at all times.

An integrated RIS/PACS combines formerly independent systems to streamline radiology procedures. The DICOM Modality Worklist, for example, provides a list of patients scheduled at different modalities throughout the hospital. The Procedure Scheduled transaction prompts PACS to retrieve a patient's prior images and report history and present the data at the diagnostic workstation. The Patient Update transaction enables technologists to modify patient records, such as recording a phone number or address change. When these transactions are complete, the systems involved interact through the IHE interface to ensure that all records are updated.

"Having RIS drive workflow is very advantageous," said Jeff Broz, director of imaging applications for Alegent Health in Omaha. "The system makes the technologists accountable during image acquisition, intelligently routes images to the specific patient location such as emergency or intensive care, and sends an image copy to the web server for direct access throughout the enterprise."

Without the benefit of an integrated RIS/PACS, referring physicians must wait for the signed transcription to be released.

CLEAR DEMANDS

In response to growing market demands for integration, RIS vendors have developed their own PACS, PACS vendors have developed their own RIS, and acquisitions and mergers between RIS and PACS vendors have created new integration partnerships. The basic business tactic for PACS companies has been to partner with RIS vendors to marry their PACS to as many RIS as possible.

While many solutions integrate data, the real challenge is to implement a single back-end unified database of patient images and data. Confronting the language barrier has been difficult. The mother tongue of RIS and HIS is HL7, while PACS speak DICOM.

Some PACS now feature HL7 interfaces, substantially simplifying the task of partnering with RIS vendors. Siemens Medical Solutions, for instance, features HL7 interfaces in its PACS. The Siemens syngo Imaging system has implemented back-end RIS/PACS interfacing according to the IHE profiles, of which HL7 is part. For front-end interfacing, syngo Imaging has application programming interfaces that enable single sign-on and patient/study selection, even with a third-party RIS.

A seamlessly integrated RIS and PACS allows the operating software to converse in both HL7 and DICOM without translation from an expensive peripheral DICOM-HL7 broker. Incorporating broker functions into the RIS does, however, offer several potential advantages:

• All RIS data on patients, orders, and results are accessible and can be used in different ways to improve workflow.

• Supporting all DICOM services directly from the RIS ensures that the latest, most complete information is always used. For example, DICOM Modality Worklists provided directly from the RIS guarantees that the work lists are updated immediately.

• The RIS can manage the complete order workflow, not just images.

• License, implementation, and support costs are reduced by eliminating HL7 interfaces to an external broker, since there is one less point of potential failure.

"Providing a smooth administrative platform that interfaces with PACS, RIS, and the electronic medical record will be critical to ensuring vendor success," said Ranjit Ravindranathan, a medical imaging analyst at business research and consulting firm Frost & Sullivan.

Despite the complexities, vendors are exploring different ways of addressing the issue of RIS/PACS integration. Some PACS vendors are complementing their solutions portfolios with in-house RIS offerings. The advantage to customers is systems that operate on compatible platforms. Vendors that acquire a RIS through mergers and acquisitions must generally perform further internal integration work.

GROWING MARKET

Whichever avenue is taken, integrated and bundled offerings of RIS/PACS products are currently greater in the U.S. than in Europe, according to Ravindranathan, although he sees the European market for integrated systems growing.

"The need for a good RIS, which has the ability to integrate into PACS and EMR, as well as with the enterprise HIS, is well understood in Europe," he said.

Ravindranathan sees the PACS market trending toward optimizing its capabilities in all modalities, thereby providing solutions to a variety of problems.

"This is the primary reason why most end-users look forward to having an integrated solution rather than two separate information management systems," he said.

Overall, the market seems poised to experience steady growth in bundled product offerings as a result of large-scale investments, particularly by government-run health agencies in several European countries.

DEEPER INTEGRATION

Currently, the level of true integration of PACS and RIS with the major modality vendors is variable, but some see potential for even deeper levels of integration.

"This trend is partly due to the relatively large number of customers who want to purchase a single PACS-RIS solution from one vendor," said Dr. Eliot Siegel, vice chair of the University of Maryland department of diagnostic radiology and chief of imaging at the Veterans Affairs Maryland Health Care System.

Siegel said that while there are clear advantages to purchasing RIS and PACS from the same vendor-avoiding the need for custom integration and reducing the points of contact for service and support-the trend toward single-vendor silos also represents a concession: standards that permit deeper integration between PACS and RIS from different vendors do not yet exist, or at least have not yet been adopted.

"Major modality vendors and PACS vendors are realizing that radiology PACS is a subset of image management systems required for applications such as cardiology, pathology, ophthalmology, and document management, which are in turn a subset of the real Holy Grail-the healthcare enterprise information system itself," Siegel said.

Indeed, integrated information systems have begun to spring up in Europe that spread far beyond the local enterprise. The Zurbaran Project in Spain, for example, provides RIS/PACS functionality to eight of 12 public hospitals in the Extremadura region in the country's southwest. The region, with a population of just over one million, includes the two largest Spanish provinces. The remaining four hospitals there are expected to be wired into the system before the end of 2007.

Under this project, digital images and associated patient data can be transferred electronically among medical staff over a 200-Gbps connection network and become readily available throughout the entire region. Radiologists from any of the hospitals in an area nearly the size of Pennsylvania are able to access and share all relevant current and prior clinical information pertaining to any patient. Presently, 86% of examinations (600,000 studies were performed in 2006) are reported within 12 hours, compared with just 3% prior to the introduction of RIS/PACS.

Likewise, in the U.K., more than 70 hospitals in the National Programme for IT are connected to one centralized data center. Over the next 10 years, the program will connect nearly 300 hospitals and over 30,000 English physicians, while also giving patients access to their personal health information, essentially transforming the way the National Health Service works.

"RIS and PACS to a large extent are now seen as components of a total information system, rather than stand-alone systems," Hurlen said.

While RIS/PACS is dedicated to radiology, the information the systems contain is part of the overall medical record, whether on the hospital, network, or regional level.

"It is not only RIS/PACS integration. It's also integration of RIS and PACS with other systems," he said.

Siemens has a massive integration project under way at the Cleveland Clinic Foundation, where upwards of eight hospitals and numerous imaging centers and family healthcare clinics will all be connected under one syngo Workflow system. These facilities are geographically distributed from Idaho to New Jersey and Ohio to Florida. CCF's one enterprise radiology department of well over 100 radiologists reads more than 1.8 million imaging studies a year.

"This integration project will provide RIS functionality and enterprise-level work lists and workflow across the board," said Dr. David Pirano, head of CCF's computers in radiology section.

The new workflow system is currently implemented at six hospitals, and the remainder should be up and running in early 2008. One of the principal benefits of the system will be coordination of unique medical record number schemes across multiple information systems currently employed by the various facilities.

"Making the record number consistent across multiple HIS, EMR, PACS, and RIS is a nightmare, but it's becoming possible," Pirano said.

TAILORED INFORMATION

As integrated RIS/PACS increasingly becomes more service-driven and solution-oriented, some companies with advanced products are already beginning to tailor information based on who and where the user is in the information flow. These strategies address the fact that PACS initially evolved with a radiology-centric view of imaging. The workflow for radiologists is designed to facilitate the production of an imaging report from an imaging study and related exams.

"This strategy focused on rapid retrieval and presentation of a current study, comparison studies, and the imaging report, as well as the reason for the exam-all of which resulted in optimized radiologist workflow," Siegel said.

Other hospital departments have substantially different workflows, however. Typically, review of current and prior reports is more important than review of the entire imaging study itself.

"When reviewing an imaging study, clinicians often prefer to see the significant or relevant images marked by a radiologist rather than view the whole study," Siegel said.

Clinicians generally want to review the report or images in the context of the entire patient record, including progress notes, discharge summaries, and laboratory values, and they may be interested in a patient timeline presentation that includes imaging as one subset in a continuum of different studies or visits. Cardiologists may want a cardiocentric view that includes hemodynamic information, ECGs, and patient notes.

This is where deeper integration comes in. Tighter integration of RIS and PACS makes it easier to achieve and implement a number of different functions that would have been difficult to achieve without it. Siegel cited the potential of integration with HIS and RIS to improve several areas:

• communication of urgent or other findings seen by radiologists on the PACS;

• creation of patient-specific imaging protocols for studies such as MRI or interventional procedures and communication of those to technologists;

• stratification of radiologist interpretation work lists based not only on type of examination and whether the study was ordered as STAT but on other patient information;

• display of clinical or administrative dashboards and quality of care data that combine information from the PACS, reporting systems, and RIS to derive information not easily accessible on a single system, such as patient waiting times after arrival, time from arrival to image report, and radiologist assessment of image quality to provide feedback to technologists; and

• general assessment of pay-for-performance productivity and quality data, which is expected to be increasingly important in the future.

"The trend toward tighter integration of information systems and role-based workflow fits in very nicely with the general trend in healthcare toward single portals of access to all types of patient information tailored to the needs of the individual healthcare provider, including education and utilization review, decision support, and greater efficiency and accountability," Siegel said.

Still, it remains an open question whether this trend toward deeper integration and role-based workflow means that customers should be constrained to single vendors for RIS, PACS, and HIS.

"I would rather see improved tools and higher expectations by customers for tighter integration using a number of different approaches such as web services, IHE, and others," Siegel said.

Standards must be developed to offer more sophisticated portals, probably at the HIS level, to provide easy access to multiple best-of-breed applications using a combination of server-side rendering and perhaps grid computing solutions, he said.

SERVICE ORIENTATION

One strategy emerging to achieve deeper integration in place of monolithic solutions is service-oriented architecture (SOA).

"With SOA, it is very easy to add new functionality from the marketplace without having to wait for a single vendor to create it in a subsequent version release," said Dr. Keith Dreyer, vice chair of radiology computing and information sciences at Massachusetts General Hospital.

The SOA approach is creating a market for innovators who provide numerous needed solutions: data mining, peer review, critical communications, natural language processing, teaching files, decision support, clinical trials support, multisite workflow orchestration, structured reporting, computer-aided detection, server-side graphics processing unit rendering, 3D visualization, and radiology computerized order entry. These would otherwise not be available to the market for years.

During the image interpretation process, radiologists require from the RIS/PACS certain key elements, including imaging data; patient demographic, genetic, clinical, allergy, epidemiologic, and historical data; protocol and modality information; referring physician information; prior radiological information; current radiological and medical knowledge; and technologist and detailed examination information.

Knowledge resulting from this complex interpretation process needs to represent a clear and concise amalgamation of all of these data and types of information. This knowledge representation will have different forms, however, based on who the consumer is-radiologist, surgeon, or general practitioner.

"The large vendors are beginning to realize that they will never be at the forefront of all of these innovations and that it is in both their shareholders' and customers' best interests to create and provide SOA access to their IT frameworks," Dreyer said.

Some large vendors have already embraced the concept of service-oriented architecture.

"We're taking an evolutionary approach with opening and sharing services, which we see as opportunities to benefit customers," said Henri "Rik" Primo, Siemens Medical Solutions director of marketing and strategic relationships. "Many syngo modules used in our PACS are also used on imaging modalities for DICOM-HL7 connectivity and for image processing."

ORDER IN THE PORT

Role-based portals are one expression of SOA. Portals that provide context-sensitive information about the patient will be key to further improving workflow, quality, and throughput in radiology-all while reducing costs.

"Portals will revolutionize the way healthcare is delivered," Primo said.

Primo expects that physicians, hospital management, technologists, nurses, schedulers, and office staff will all benefit from the portal strategy.

Portals efficiently package RIS and PACS data together by providing a snapshot of a specific patient's historic data, not merely a single occurrence. Referring clinicians view images using the same tools as radiologists, which is helpful if clarification is needed. Specialists have the ability to see histories for new patients. Office staff can track patient status to coordinate scheduling.

"Just like we now research information through web-based search engines, healthcare workers will access whatever specific patient information they need to deliver healthcare," Primo said.

Much of this information can be available through the EMR, but navigating through this can be a time-intensive task for the radiologist. Role-based portals provide an information view that is specific to the role of the individual in the care delivery process.

A portal for the radiologist offers several advantages over traditional RIS, PACS, and EMR access at the workstation. Probably the greatest benefit is that everything is organized via a dashboard-all the information a radiologist needs for specific work processes is laid out on a single computer screen. New imaging studies are presented with referral information and indications for the exam, along with relevant prior images, reports, and medical history, whether online or nearline on PACS. Images from offline CDs from other hospitals or clinics, digitized films, allergy history, clinical and technology notes, lab results, and medications are also available.

Every element on the screen is expandable and collapsible, so radiologists can manipulate as much or as little as they wish to see of each item. Precisely where the various data are stored under independent systems is transparent to the user. At installation time, the portal is provided with links to the appropriate PACS, RIS, EMR, lab, and HIS databases, so the portal search engine can retrieve relevant information to present to the user once a patient is selected on the portal work list.

Advanced systems also enable the radiologist to create ad hoc workflows, an important function not available in the past. If the radiologist is reading an exam at the PACS workstation and a referring physician calls for a consultation, for instance, the radiologist can do a quick patient inquiry and bring the relevant exam up on the workstation without interrupting the work list and images already being interpreted and without losing a dictation that may have already been started.

Although faster report turnaround times for referring clinicians and improved medical outcomes for the patient are obvious outward advantages of integrated RIS/PACS solutions, the imaging center itself benefits from systems integration. Productivity and time-saving benefits of RIS/PACS integration and auxiliary improvements in the form of portal development are sometimes so pronounced they seem almostfanciful.

Specialty Networks is a private practice group of 10 radiologists in Chattanooga. They review 200,000 annual images in nuclear medicine, MR, CT, and ultrasound for facilities ranging from a 300-bed community hospital to a single CT scanner owned by a urology group. They were able to eliminate one full-time radiologist and still increase reading volume.

"The most expensive part of any radiology practice is the radiologist," said Dr. James Busch, CEO of Specialty Networks. "RIS/PACS integration basically let us drop one full-time radiologist and still boost efficiency about 27%. Any time you can get 27% more work out of radiologists and still not work them any harder, that's huge."

Mr. Page is a contributing editor to Diagnostic Imaging.

RIS/PACS integration glossary

New concepts emerge as digital evolution continues

DICOM-HL7 broker: RIS/PACS integration can sometimes encounter a language barrier, since RIS and PACS adhere to different data formats. RIS traditionally use HL7, while PACS use DICOM. A DICOM-HL7 broker is a separate interface engine to translate data from one format to the other.

Modality Worklist: This DICOM standard enables a modality to directly download a work list along with patient demographic data from the RIS, obviating the manual input of patient data at a modality's console that had frequently proven to be a reason for data inconsistencies in an archive.

Portal: A single point of access on the web designed to reach protected internal hospital resources. A client-server agent that enables remote access to data in a usually closed HIS. Portal schemes index all medical data, permitting complex, in-depth search queries for data retrieval. Radiologist and referring physician portals combine information from HIS, RIS, and PACS into a single user interface and work space. Portals provide referring physicians, for instance, with real-time exam status, images, and reports directly from the RIS, ensuring the most up-to-date information possible.

RIS/PACS integration: When the RIS and PACS are integrated to function as a single system, better utilization of radiology resources increases productivity. PACS enables near-instant access to images and patient data within radiology, hospital clinical areas, and other, remote, users. When the PACS is merged with a RIS, images can be integrated with the radiology report, thereby significantly improving service to patients and referring physicians.

Service-oriented architecture: The coexistence of different information systems that are unable to communicate is a persistent problem in healthcare. Service-oriented architectures enable hospitals to more easily integrate these systems. With an SOA, connectivity becomes less complicated by abstracting dependencies away from each application into a brokering service. Applications are then connected to the broker. Systems can also be modified whenever necessary to support flexible and dynamic business processes through platform-independent, standardized interfaces.