Digital imaging has focused attention on picture archiving and communications systems (PACS), the masterminds of storing and managing digital images. While PACS enables radical changes in how an imaging center or radiology department manages its business, the intelligence features of the radiology information system (RIS) manage department workflow.
RIS has always been crucial to managing critical imaging business functions such as order entry; patient scheduling, tracking and billing; and inventory control. But an integrated RIS/PACS gives IT managers access to more complex data that can be used for advanced business planning, such as which modalities are most profitable, which referring physicians are most active, employee productivity levels, which time periods are the busiest, and patient throughput rates.
If a healthcare facility can leverage the strengths of RIS and PACS by creating a seamlessly integrated RIS/PACS, the result is a productivity tool that can drastically change the way an organization is managed.
The rise of PACS has influenced the RIS market by creating the need for a more robust and functional RIS. More than 80 percent of U.S. inpatient facilities and hospitals already have a RIS, says market research firm Frost & Sullivan. And North American PACS adoption will grow about 15 percent per year for the next few years (Frost & Sullivan). With growth that strong, a lot of eyes are focused on the synergy and future of RIS-PACS.
SPEAKING THE SAME LANGUAGE: PROTOCOLS & DATABASES
Two major issues that drive any discussion of RIS/PACS integration are data protocols and database sharing.
Digital Imaging in Communications and Medicine (DICOM), the transmission protocol adopted for PACS product design, was developed for image management. Health Level 7 (HL7), the standard adopted for hospital information systems (HIS), including RIS, is used for the management of patient information. HL7 can't read DICOM data, which means that RIS can't manage PACS imaging data unless it has a DICOM interface.
In addition to protocol differences, older RIS/PACS systems consist of separate databases - one for patient images and one for patient records. Patient data in the PACS database may not be an exact duplicate of the same data entered in the RIS database. If patient's name or other demographic data is entered differently in the two databases, the system can't correctly access all relevant records.
INTEGRATED OR INTERFACED?
A "brokered" or "interfaced" RIS/PACS has a DICOM interface that's known as a PACS broker or a gateway. The PACS broker is a separate device combining hardware and software that interprets DICOM data for the RIS. A PACS broker requires its own database - creating yet another point of failure on the network and further degrading data integrity.
In "brokerless or integrated" RIS/PACS, the capability to understand DICOM data is built into the RIS, which eliminates the additional database. The most obvious benefit of an integrated database is improved data integrity. But there is one downside to brokerless PACS - if your system is integrated, it's harder to replace one part of it if you're unhappy with performance or want to upgrade.
Some RIS/PACS systems may appear integrated because they have a common user interface and workstations. Similarly, a solution may be touted as a brokerless PACS because there's no additional equipment needed. However, in some cases, even though there is no visible PACS broker and the end user sees a common interface and shared workstations, a separate database is required and is built into the RIS/PACS. "The real question is: how many different databases are there?" says Sheri Giles, an independent RIS consultant. "How many instances of the patient data and images are stored?"
For a RIS and PACS to be truly integrated, the system must be brokerless and use a single database. "Many vendors are claiming to provide a totally integrated/brokerless RIS/PACS solution, but upon further scrutiny one may find that the level of integration is not as intimate as one would expect," says Jim Maughan of Maughan Consulting, a PACS/RIS consultant. "It might not be a brokerless PACS, but an interfaced PACS/RIS that's controlled by fewer vendors."
UPGRADING RIS OR RIS/PACS
Efforts to improve the way computer systems such as PACS and RIS share healthcare information began in 1998 with the formation of Integrating the Healthcare Enterprise (IHE), a joint initiative by Healthcare Information and Management Systems Society (HIMSS) and the Radiological Society of North America (RSNA). IHE drives the adoption of standards such as HL7 and DICOM by providing vendors with integration profiles - which help healthcare facilities choose interoperable solutions. A cardiology initiative is also now underway.
IDX Systems Corp. is one vendor offering a RIS product that can be integrated brokerlessly with an existing PACS, creating a RIS/PACS with a single database. "Upgrading RIS [with an existing PACS] is easy as long as the vendors play nicely together," says Kim Stavrinakis, product manager for workflow solutions at IDX.
Conversely, it's harder when a healthcare facility wants to keep its RIS and upgrade their PACS, says Stavrinakis. The facility has to ensure that its RIS will support all of the features of the new PACS, and could unexpectedly find itself in the market for a new RIS as well as a new PACS - a situation that it may not be prepared for financially.
If a facility is simultaneously upgrading both its RIS and its PACS, or a new facility is opening, it's easier to make sure new components interface correctly, especially if they're from the same vendor. Although some vendors may trumpet the benefits of an end-to-end (single-vendor) solution, the best RIS and PACS for your organization may not always come from the same vendor. As long as the systems are interoperable, they don't have to be from a single vendor.
If you decide on a single-vendor solution, make sure you understand if the vendor's expertise lies in imaging or information management, Giles recommends. "It's nice to go with one vendor in terms of having better communication," she adds. "But you have to go with [multiple vendors] if you only want to switch out one component, or you don't like the vendor solution for one [of the components]."
An organization may have to use a PACS broker if it's upgrading only one of the components, especially those from separate vendors. "Sometimes if you want to have best-of-breed, you have to live with some type of interface," says Giles.
When shopping around for a new RIS or RIS/PACS, make sure to qualify vendor claims of DICOM support. The RIS should support all the DICOM service classes that are appropriate to your PACS. Be sure to understand clearly what is meant by vendor claims of RIS/PACS integration. Make sure they're not intentionally or unintentionally confusing integrated with interfaced. "Commit to a certain list of requirements and deliverables that [the vendor] must deliver," says consultant Maughan. "You need to have some protection for yourself."
Single Vendor RIS/PACS Solutions
When choosing a new RIS/PACS, many healthcare organizations prefer single-vendor RIS/PACS solutions because of the ease of implementation and servicing.
As vendors have realized the benefits of offering their customers a single RIS/PACS solution, many have attempted to create a solution by acquiring the technology. For example, Siemens Medical Solutions acquired Shared Medical Systems Corp. in 2000. At the time, Siemens was primarily a PACS and modality vendor, so the acquisition of SMS gave Siemens a fully developed RIS that could be developed and marketed as an end to end solution with its existing PACS. Healthcare information company McKesson Corp. entered the PACS market last year with its acquisition of A.L.I. Technologies. McKesson integrated A.L.I.'s PACS technologies to enhance its own RIS product.
Other companies have formed strategic alliances or partnerships to provide a RIS/PACS solution. While not a true single-vendor offering, these companies say that testing and integration efforts provide a seamless product. Information systems vendor Eclipsys Corp. partnered with PACS provider Sectra Imtec AB; PACS vendor Amicas Inc. teamed with information systems specialist Medical Information Technology Inc. (Meditech); and Merge eFilm this past July acquired RIS Logic to mingle their respective PACS and RIS technologies.
Other participants in the RIS/PACS market include GE Medical Systems Information Technologies, Agfa Healthcare, Cerner Corp., IDX Systems Corp., Fujifilm Medical Systems USA Inc., Stentor Inc., Vital Works Inc., Misys Healthcare Systems, Switzerland-based WDS Technologies S.A., IMCO Technologies Corp., and Source Medical Solutions Inc.
Still other suppliers believe "homegrown" solutions are superior to those that have been united by acquisition or partnerships. These vendors have expanded their product line through internal development. For example, Image Technology Laboratories, Inc. began marketing its ITL WarpSpeed PACS/RIS - an internally developed software-based product - in 2003. RADinfo Systems Inc. added RIS functionality to its Power PACS product in late 2002 to create its Power RIS/PACS product.
Whether the solution was created internally or via acquisition or a partnership, healthcare facilities should carefully evaluate vendors' claims of integration. Keep in mind the golden rule that a truly integrated solution uses a single database, while an interfaced solution may not.