Closing Technology Gaps

Acquiring new technology and linking it to existing systems is often plagued with problems. Gaps certainly exist, but integration can be accomplished with a combination of standards, technical know-how and willpower. See how some forward-thinking facilities are bridging the technology gaps with the EMR, uniting radiology across the healthcare enterprise, wireless security and decision support.

New imaging and information technologies are hitting the market at a rapid clip, with healthcare facilities everywhere implementing electronic medical records (EMRs), computerized physician order entry (CPOE), wireless technologies and PACS to enhance patient care and improve workflow. Although state-of-the-art solutions certainly benefit healthcare providers and their patients, there are some significant technology gaps that need to be closed to more fully realize their potential.

Many gaps relate to technology integration. Thomas Berg, director of clinical information services for Marshfield Clinic (Marshfield, Wis.), explains, "In most cases, we don't necessarily need to invest in new technology. We need to integrate the existing technology." This requires communication and collaboration among vendors, which is a critical step in fulfilling the mission of the Integrating the Healthcare Enterprise (IHE) initiative from RSNA and HIMSS.

In other cases, the solution may be right around the corner. Paul Chang, MD, director of the Division of Radiology Informatics at University of Pittsburgh Medical Center (Pittsburgh, Pa.), contends that other industries have developed solutions to overcome the interoperability and security issues that plague healthcare, but healthcare has been slow to learn from its IT colleagues outside of medicine.


The EMR is a great breakthrough in consolidating patient information, but the lack of integration between the EMR and the imaging department tops many technology wish lists. Take Evanston Northwestern Healthcare in Chicago. The system is at the forefront of the electronic patient record system. Its three hospitals and 50 outpatient sites rely on a single system to integrate computerized physician order entry (CPOE) and electronic health records (EHRs) with all patient charting; ordering of tests, procedures and medications; registration, scheduling and physician billing.

On the plus side, the single clinical information system is expected to improve patient safety and quality of care while saving the organization $10 million a year. Integrating imaging equipment into the EMR system, however, is proving to be a major challenge.

Mary Ann Cardello, director of clinical applications, points out, "We have achieved partial success with an API [application protocol interface] from our PACS to the EMR. But it's an all-or-nothing proposition that gives physicians access to all patients, which is a HIPAA and a workflow issue. We're at a stalemate where the technology is able to bring us to this point, but isn't able to focus on a single patient."

One attempt to overcome the disconnect focused on cardiac images and fetal and cardiac ultrasound studies. The hospital printed and scanned studies back into its Epic (Madison, Wis.) EMR system for easy access; however, the resulting images weren't diagnostic quality, forcing clinicians to sign off Epic and onto the native system to view studies or track radiologists for results.

Currently, the hospital's internal web system provides access to all PACS images, but users must leave the EMR application to go to the image viewing application. To date, only 12-lead EKG is easily accessed through the EMR; a simple link on the Epic Systems' EMR allows physicians to view EKG images. CIO Tom Smith explains, "We would like to use the 12-lead EKG model for all images. We don't want to store images in both the native system and in Epic."

Smith predicts that eventually Evanston Northwestern will integrate the EMR and imaging technology. The process, however, is somewhat lengthy. The hospital is working with one of its primary vendors, GE Healthcare (Waukesha, Wis.), to provide a link in Epic reports to the PACS web server, but it may take 18 months to develop.

Smith says other sites can learn from Evanston Northwestern's experience. "Our focus on using the EMR to remove patient charts has been successful, but we didn't pay enough attention to ancillary imaging systems when we implemented the EMR. Most vendors are willing to talk to us, but now there is a time delay. You need to start with those people earlier in the process."

The Evanston Northwestern EMR/imaging disconnect is not unique. Other hospitals are wrangling with the same challenges. One solution might be to take cues from other industries. Chang points out that the multimedia EMR component hinges on system interoperability throughout the enterprise. He says other industries have overcome the challenge by using XML, or web services, to force multiple information systems to communicate.

Web services could solve another imaging technology gap-the one-size-fits-all approach to PACS and the EMR. With web services, individual users could increase their efficiency, accuracy and productivity through customized graphical interfaces in the same way that Microsoft Outlook is fine-tuned to individual user preferences.

On the global level, Ferdinand Velasco, chief medical information officer for Texas Health Resources, (Dallas-Fort Worth, Texas) says a solution requires both collaboration and communication among vendors and aligned incentives, which will most likely be funneled through the nation's new national health information technology coordinator, David Brailer, MD, PhD.


A lack of adherence to communications and imaging standards is blamed for interoperability failures every day.

"There is a gap in imaging standards," Velasco opines. "Radiology is leading the way through the IHE initiative, but imaging is broader than radiology images." Clinicians need easy access to conventional radiology images and images from bronchoscopy, endoscopy and laparoscopic surgery. These images, however, are typically not integrated with PACS or the EMR.

Andy Fisher, medical director of radiology at Sky Ridge Medical Center (Denver), explains, "Right now, we can't incorporate non-radiology modalities into our paperless system and EMR."

There are certainly challenges to enterprise medical imaging. For example, digitally capturing all of the data on a pathology slide isn't feasible, but it could be possible to photograph a field of interest and store the image on a PACS. Velasco concludes, "The technology for enterprise medical imaging is there. The standards are there. Vendors need to work together. IHE will help in this regard."

Integrating all imaging modalities within a single healthcare system can certainly benefit patient care by providing physicians with timely access to a more complete picture of the patient's condition. But there are other ways to deploy technology to improve patient care. Fisher points out, "We also need enhanced standards to allow us to share images among disparate institutions." For example, a traveling cancer patient may experience an acute illness and visit a local ER. There are a number of barriers-credentialing, HIPAA, patient confidentiality and security-that prevent the emergency physician from easily accessing the patient's past imaging studies. "A reasonable short-term solution to this would be to develop a way to share images among local facilities," Fisher says. "The ultimate step is an online repository."


Wireless technology is a hit in healthcare. The reason is simple; there is a definite clinical benefit to having information accessible throughout the enterprise, and hospitals are racing to install wireless networks. Chang says, "This is a case of our eyes outpacing our stomachs. As hospitals rush to implement wireless networks, they are neglecting wireless security. What I find in hospitals is a lack of deep understanding of wireless security infrastructure."

The major components of wireless security are authentication, encryption and message integrity. Chang notes, "This isn't a gap in technology as much as attitude and knowledge."

Viable and robust wireless security options are beginning to hit the market. Wi-fi protected access (WPA), which will become the 802.11i standard, is absolutely necessary for security, says Chang, but is not sufficient to ensure security by itself. WPA includes extensible authentication protocol (EAP) for secure authentication; however, EAP requires an independent authentication server. Very few hospitals with WPA have installed independent authentication servers. Encryption also presents a challenge. The current solution, temporal key identity protocol (TKIP), can be broken, but the wireless industry is moving toward advanced encryption standard (AES). "The problem is that AES requires a hardware component that places a greater burden on the wireless CPU capabilities," Chang says. Wireless access points cannot handle AES. Wireless switch architecture (also known as WLAN) or radio transceivers feeding a central data center provide the performance, scalability and manageability to support AES. But very few hospitals have installed switches instead of access points, says Chang. Finally, an intrusion detection system (IDS) is necessary to prevent unauthorized access and use of the wireless network. But, once again, few hospitals have taken this step.

Chang says other industries like banking have taken a proactive approach to wireless security and implemented the necessary security infrastructure to support next-generation wireless security, but the medical business has not yet leveraged the expertise of IT colleagues outside of medicine. Instead, while the medical IT community attempts to devise solutions to meet what is viewed as medicine's unique security needs hospitals neglect available options and fail to plan for future solutions. Chang says the solution to this gap is to adapt and adopt wireless security measures from other industries.


Ramin Khorasani, director of the center for Evidence-Based Imaging at Brigham and Women's Hospitals (Boston), says, "Decision support is a challenge, but the technology is here. The cornerstones of decision support are structured CPOE and structured reporting tools." The integration of the technologies provides the IT infrastructure for the actual content. Today, content is readily available for medication ordering, enabling vendors to develop software solutions for medication ordering.

"It is much tougher for industry to access banks of information [content] for imaging," Khorasani continues. The key to developing decision support for medical imaging is communication and collaboration between radiology community and vendors.

While vendors and the academic radiology community collaborate on the development of more sophisticated decision support tools, clinical practices are deploying decision support and identifying potential gaps. Berg explains, "We need another Moore's law or two to take place before we can fully implement decision support. We need more horsepower on today's computers before we can implement point-of-care decision support."

"Even with this gap, we can do 80-20 decision support. That is, 20 percent of the rules impact 80 percent of the patients," Berg continues. This allows a hospital to gain the most traction by implementing rules for the most common indications such as diabetes and asthma.

The Homegrown Solution

Marshfield Clinic in Marshfield, Wis., lives on the cutting edge of technology. The healthcare system rolled out the electronic medical record (EMR) 10 years ago and is now on course to deploy tablet computers to implement a chartless environment by 2006. The clinic also has bridged the EMR-imaging chasm. Director of Clinical Information Services Thomas Berg says, "We deliver all types of images including colonoscopies and endoscopies on wireless tablets all over the system. An image tab within the EMR allows clinicians to call up images over the wireless network." (The images displayed on tablets are information or educational quality-not diagnostic quality.)

Berg and his team are currently writing a laboratory system for the clinic. While the clinic has not yet decided whether it will store surgical pathology slides or digital images to represent findings, Berg says digital photos could be stored in the same repository as radiology images and accessed with the same ease as other images.

The clinic has achieved this high level of integration through a concerted internal development program; it bypasses vendor software solutions and instead does all software development internally. Berg admits, "We might not be able to do this if we didn't have 30 years invested in internal development."