Blurring the Lines: Interfaced vs. Integrated RIS/PACS

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The differences between interfaced and integrated RIS/PACS are no longer cut and dry as industry definitions are redefined and many vendors offer single, integrated solutions with clear benefits.

Determining whether a solution is integrated or interfaced becomes mired in how the two terms are defined within the industry. For some, the difference lies with the inclusion of a broker, or interpreter, between the two systems, communicating Health Level 7 (HL7) messages from the RIS to the PACS. If a broker is involved, the system is interfaced. In this configuration, having an interface broker does serve a purpose, however it can add a level of complexity and cost, due to maintenance or upgrade of the broker.

For others, the main difference is quite simply related to the number of databases used. Interfaced in this case would mean the RIS/PACS have two separate databases; they share one if integrated. In this scenario, the capability to understand DICOM is built into the RIS to manage both the radiology clinical and image workflow.

The definition of an integrated system also has morphed for some into a system with a consistent user interface and a seamless flow of data between the databases—whether it is one or two—and a granular workflow consistency between the RIS and PACS. An interfaced system thus would have a limited exchange of data, not always be immediate.

So what’s a facility to do? In looking for an integrated RIS/PACS, hospitals and imaging centers are looking beyond these differences in definitions and basic questions about brokers and DICOM and HL7, and focusing on systems that will facilitate a paperless environment, systems that improve document management and communication, and overall, improve workflow.


A seamless flow of data



“In the past, the difficulty was that one system was the driver and everything else just responded to those events,” says David Piraino, MD, imaging informatics officer at the imaging institute within the Cleveland Clinic in Ohio. “You simply did not have a consistent user interface.”

With each system, including the EMR, having its own user interface and concepts, users had to learn all the peculiarities of each and transferring data from RIS to PACS could only be done at certain steps. This intermittent approach did not allow the seamless flow of information that a facility like the Cleveland Clinic Imaging Institute—with an annual imaging procedure volume of 1.7 million to 2 million—demanded. The Institute spans multiple hospitals and radiology departments and to ensure the flow of data is not interrupted, a number of software applications, including the syngo Workflow (RIS) and a combination of SIENET Magic (legacy) and syngo Imaging for PACS from Siemens Healthcare, are deployed.

Cleveland Clinic recognized that the next evolution of an integrated RIS/PACS involved interfacing patient content with EMRs. “Ideally, in an integrated system, you would sign-off on a report and immediately the next case would appear. In an interfaced system, you have to sign-off and tell it to go to the next case in the worklist,” he says. “The granularity of how it works begins to break down as you get to the sub-steps in the workflow and have more ‘open and clicks.’” This workflow granularity is an advantage of an integrated system compared to an interfaced. “In a truly integrated system, everything stays in concert,” he says. “Rather than having a delay between HL7 interfaces, you maintain patient exam context in all applications immediately rather than having a single driver and several things that just respond.”

As for any breakdown in communication, Piraino says it mainly occurs between the dictation system and the RIS.  For example, there is about a 10 to 15 second delay between the sign-off in speech recognition and the time it takes for it to reflect in the RIS. This is when everything is working well, Piraino notes. “When it is not working well, the delay can be minutes, during which it is not uncommon for my colleague to try to pick up the case and try to start dictating a study already completed—which interrupts workflow. In the worst case, you could potentially have two dictations on one exam because we have more than one dictation system in use.”


Integrated RIS-driven workflow


An integrated RIS/PACS has helped the MRI Center of Idaho, in Boise, improve workflow processes across its business platform. The center, which performs approximately 10,000 procedures annually, is comprised of a stand-alone MRI facility and a mobile MRI business, serving 35 mobile sites in rural communities. The answer is an integrated Vision Series RIS and Vision Series PACS from Amicas.

“Now things are very quick and the scheduling system is completely different than before,” according to Scott Berger, network/systems engineer/PACS administrator. “What used to take days to get out, can now be done within an hour, if it is needed.”

Berger says the two systems, which have two separate databases, communicate via HL7. Before implementing the RIS/PACS in 2004, the center was working in a semi-filmless environment with a partner hospital that they used for a hosted PACS. The center wanted a more full-featured RIS than the software in use at the time, but at a cost they could absorb. “Having one vendor eased our cost and implementation pressures, as well as interoperability,” he says.

“From an administrative standpoint, we were looking really at functionality and the ability for our technologists to easily come up to speed,” Berger adds. “We did not want the headache of building an interface and need to still integrate with another third-party software vendor.”

According to Erika Krishnek, information system operations coordinator/RIS administrator, the RIS is the brainchild of the whole operations, sending information to the PACS through HL7 messages—a workflow that begins when the patient is scheduled.

Jim Acevedo, IT supervisor at the MRI Center, says the RIS/PACS looks and feels like an integrated product, despite understanding that there are some interfaces that happen behind the scenes. “As customers, to us it is integrated,” Acevedo notes. “We work with other companies that have totally separate systems, but we would have to come up with some HL7 gateway to communicate with them.”


Decentralized operations


“Whether we are talking about RIS-driven workflow or integration, it is a system that supports paperless operations which matters to us,” says Andy Strickland, director of imaging informatics, at the University of Washington Medical Center in Seattle.  In a paperless environment, specifically within radiology, operations are decentralized, creating valuable real estate for other sources of revenue.

Strickland says that with Centricity RIS-IC from GE Healthcare, they have found the paperless support in an integrated, RIS-driven system.

“The technology behind that is still essentially an interface—there is still a server that communicates information—but it is fair to call it integrated because RIS drives the workflow,” Strickland notes. The medical center can still operate the RIS and PACS independently since they are each on separate databases with no broker vendor in the mix.

RIS is really the driver no matter what the radiologists interact with, he says. “Before, the rads were interacting with PACS and the dictation system, which had to take messages back to the RIS. Today, the rads are interacting directly with the RIS. Now, they are talking directly to the master, whereas before they were talking to an auxiliary.”

Having the radiologists use the RIS to read has been very helpful, in that the information available is more robust when reading the exams, and the way it manages who is reading what is more sophisticated, he notes. For example, a blue lock on an exam in the worklist means it is selected and a red lock means it is in process. “This helps with referring docs who come in and ask who read what case—anyone can see who read that case very easily,” Strickland says.

“We have truly simplified things,” he adds. With fewer components and fewer servers, maintenance is easier. Before Centricity, 20 percent of service calls had to do with keeping the voice, RIS and PACS in sync. “They were all working correctly, but the communication was getting mangled for whatever reason. With GE, we have eliminated those problems with the support and integrated solution we now have.”


Driving efficiency


The staff at Tower Imaging, which provides MRI, CT, ultrasound and x-ray scans to residents around its base in Alabaster, Ala., have gained momentum toward a completely paperless office with the implementation of the Opal-RAD and Opal-RIS from Viztek. Hollie Hayes, office manager and primary RIS user, says the system has streamlined billing workflow since its implementation in December 2007.

With RIS/PACS, there is no longer the need to have someone gather all the billing information at the end of the day. Instead, information is pulled from the RIS and PACS and Hayes says she is able to process billing paper-free. Report turn-around time has improved since the implementation as well. “What previously was a 24-hour turn-around has been trimmed down to two or three hours, depending on the patient load for a given day,” she says.

Hayes also says that the RIS/PACS is good for scheduling. “It leaves a nice audit trail on the patient, allowing notes to be made on each encounter, which makes it easier to serve the physician referring base,” she adds.

Providing referring physicians with quick and accurate access to patient information has been the greatest impact of the implementation for radiologist Ben McDaniel, Jr., MD. “Within 15 minutes of a report being complete, the referring physician can have it in hand—that is the biggest return we have seen.”


Future directions


With integrated PACS, whether they are single or dual databases, if they are well integrated, the difference between the two should not be easily seen, according to Piraino. “The reality of the market is that we are starting to see systems that are truly becoming integrated instead of interfaced,” he says. “The vast majority seem to still be interfaced, not integrated; however, the lines are starting to blur—or rather the definitions are starting to change.”

There is another ingredient that is being added to the discussion around integrated vs. interfaced RIS/PACS—the concept of the portal. With the portal, the hope is that every application and system—be it RIS, PACS, HIS or EHR—can be accessible without switching or upgrading systems. It is a way to have different vendors functionality, but get the benefit of an integrated system, Piraino adds. With a portal, the radiologist has one entry point to RIS and PACS functions.

“The advantage is that maybe you don’t have to buy it from a single vendor, but get the benefits of an integrated system—that is the promise. Whether that is the reality is still up in the air,” he says.