In the beginning, there was film and paper reports. After quite some time, radiology information systems came on the scene, speaking Health Level 7, and then PACS joined in, speaking yet another language, DICOM. While the two could communicate through an interface broker, that added a layer of cost and complexity to the relationship. And now, there is integrated RIS-PACS - speaking one language and bringing harmony to health images and information everywhere (well, at least that's the intention).


DEFINING INTEGRATION

Designing an integrated radiology information system-picture archiving and communication system means making the RIS and the PACS talk to each other - seamlessly. Often, the two systems continue to each have their own database, especially if the RIS and PACS each come from separate vendors. But a variety of RIS-PACS product offerings, like that of Stentor, make use of a single database.

Stentor makes use of Imaging Suite, an IDX Corp. workflow product that helps a RIS work with any PACS. When combined with a Stentor PACS, the two systems communicate through the HL-7 protocol, allowing the RIS to drive the workflow. "It is truly an integrated RIS-PACS," says Matt Long, vice president of marketing for Stentor.

Siemens Medical Solutions also offers an integrated RIS-PACS that features a RIS-driven system with a single worklist that is generated at initial registration. The latest version of the Cosmos system, first shown at RSNA 2003 and then launched at the Society of Computer Applications meeting in May in Vancouver, has attained FDA approval. The system is in beta testing at several sites and should be generally available in late 2004.

VitalWorks also is actively involved in RIS-PACS integration. "Integration is probably [our] biggest project," says Kevin Collins, CTO. VitalWorks' systems use IHE (Integrating the Healthcare Enterprise) standard integration profiles to produce a base level of integration. These profiles establish a common means of communication among systems. "You should be able to [share data automatically] over an Ethernet cable," he says.

Gary Jump is the CIO of Our Lady of the Lake Regional Medical Center in Baton Rouge, La. He applauds the safety and convenience of the integrated RIS-PAC system the hospital recently purchased from Cerner Corp. "There are no interfaces; orders are immediately available in radiology," he says.

Jump appreciates the way the online work queue helps clinicians manage their workflow. "Images are immediately available to all medical staff via the web [as part of] the electronic record," he says. This eliminates the need to switch from system to system in order to view images, read patient notes, and respond to work orders.

For example, a radiologist will see an image appear in his or her work queue, read the image, and dictate the findings - all from one system. The dictation is sent immediately to transcription and is electronically attached to the patient record, eliminating rejections from the transcriptionists because they cannot identify the patient.

In the emergency room, physicians can use the wet read functionality to add their notations to an image for a radiologist to consider along with the image itself. Radiology requests also are automatically posted to the ER tracking board, allowing for better management of workflow.

Improved workflow is not only a benefit for radiologists and referring physicians using RIS-PAC systems, but also for radiologic technologists. "Technologists used to have to log into the RIS to make sure a bill was created, then send the images to the radiologist through the PACS," says Teresa David, global product manager of RIS and RIS-PACS for GE Healthcare. With an integrated RIS-PACS, a log-in to a single system is sufficient for the technologist to manage all parts of his or her workflow. "We've collapsed those two steps; much [more] work can be done in a single step," David says. The additional work that is possible includes the on-the-fly recording of notes from the technologists regarding information gathered during the exam, difficulties encountered, and other information that will be useful to the radiologist as he or she reads the images.

Adoption of an IDX/Stentor RIS-PACS has meant a dramatic increase in efficiency for The Milton S. Hershey Medical Center in Hershey, Pa., says Douglas Eggli, director of medical imaging, information technology department, and chief of the division of nuclear medicine. One very important result of the use of the integrated system is the elimination of broken studies, or instances in which a patient's images become separated from the remainder of his or her demographic information.

Broken studies occur frequently in the ER, where unidentified patients-or John Doe's-are often identified after treatment and record creation have already begun. Eggli says that the Center used to have eight people working two days a month fixing the broken studies or reuniting John Doe images with properly identified records. However, with the integrated RIS-PACS, a change to the patient record automatically migrates to the images. In one case, "[the record] updated in the time it took to walk from registration to CT. We have no broken studies at the end of the day," says Eggli.

Efficiencies also come in the area of billing, where timely submission of invoices means the difference between receiving payment from insurers or being told that the bill is too old to pay. Eggli notes that, whereas four medical coders once handled only 40 percent of the billing work volume, five individuals can now handle the entire workload, which also has grown by 15 percent. This makes for much more efficient use of FTEs.


EFFICIENCY, IMPROVED PATIENT CARE

Although a truly integrated RIS-PACS has long been a goal for many, some of the additional features and benefits that have come along with integration are a welcome surprise. Take, for example, the addition of voice recognition.

Just a few short years ago, voice technologies were on the "to-do list" for inclusion into a RIS-PAC system, with radiologists and physicians depending on traditional dictation to record notes and diagnoses. But most of the current generation of RIS-PACS hybrids include a voice component, allowing this to be done as part of a single log-in.

This efficiency can mean real time savings, as Lori Martin, global marketing manager for RIS and RIS-PACS for GE has found. "We've combined all workflow for reading, reporting, editing, and approval - all at the same desktop. Some customers average a 20-minute report turnaround," she says. GE's system currently includes digital dictation capabilities, with plans to move into voice recognition technology. Ultimately, this could mean that some hospitals could eliminate or redirect the FTEs currently dedicated to transcription.

Another issue coming to the forefront is the need for large amounts of digital image storage. While previous years may have seen patient records with just a few physical x-ray films, current and future medical records can easily include thousands of images, such as those captured during a traditional colonoscopy or the fly-through created by combining scans from a virtual colonoscopy. "Data sets will be huge tomorrow," says Laura Serrano, marketing manager for RIS-PACS for Cerner Corp.

"The technological challenges to move into areas such as pathology are significant due to such issues as large image size [and] storage requirements, but these are future areas of development because of the benefits to departmental workflow, efficiency across the enterprise, and access to a patient's health record," says Greg Arnsdorff, vice president and general manager for McKesson Medical Imaging.

Integrated RIS-PACS may lead the way to a truly paperless operation. With many of the traditional paper-generating activities handled in digital form by the more robust systems, hospitals are discovering their use of paper diminishing. Serrano tells of one center that has adopted Cerner's unified RIS-PACS with plans to go live in the fourth quarter of 2004. This center's paper creation has already dropped dramatically, and a paperless operation is possible.

The path to paperless operation is one that Stentor's Long expects many healthcare institutions to follow, and he suggests that computerized physician order entry (CPOE) systems are a key piece of making this transition. "Most sites are doing everything they can to go paperless," he says, noting that the decision to adopt CPOE, along with the use of EMRs and an integrated imaging strategy, will be key decisions that impact future healthcare operations.

Finally, and most importantly, integrated RIS-PAC systems can play a role in improving patient care. Long notes that in a study done by M.D. Anderson Cancer Center in Houston, Texas, physicians view an image an average of just over one time for images not viewed on a RIS-PACS versus viewing them more than 10 times on average with a RIS-PACS. By making it easier for physicians to revisit images, diagnoses and treatment plans are sure to improve.


MAKING THE TRANSITION

Few, if any, hospitals are coming to the integrated RIS-PACS with no experience with either technology. "Eighty percent of hospitals already have a RIS," says Stentor's Long. And while some may want to scrap their older systems in favor of purchasing an entirely new integrated RIS-PACS, many will need to hold on to their still-functional systems.

Most vendors say that they can work with older systems, but with varying results depending on the need for an interface. For example, Long notes that Stentor "can provide an integrated [solution] with a legacy RIS" that is as much as 10 years or four generations old.

Other vendors are looking to those who wish to replace their legacy systems with an all-new integrated RIS-PACS. "The RIS market is a replacement market," notes Pamela Toner, marketing specialist at Siemens. "Most [hospitals] are looking at updating to meet the demands of HIPAA," she says. "Upgrades are sometimes as costly and difficult as replacements."

Finally, it is worth noting that different market segments have different needs for RIS-PACS. Stuart Long, vice president of sales for Amicas, has found that the hospital market tends to be led by the hospital information system (HIS), which is taking on more functionality and blending with both RIS and PACS. In the imaging center market, however, the RIS is the leading system, and centers overwhelmingly ask for a RIS-PACS solution from a single vendor. Long believes that Amicas' web-based option not only eases access for all users, but also opens the door for imaging centers to offer services to the hospital across the street and community across the country. "[Imaging centers] can take highly specialized services to areas that are underserved," he said.

Overall, the union of RIS and PACS is leading the way to more integrated functioning across modalities, departments and healthcare enterprises. In many cases, future improvements depend on human factors rather than technology. "As medical imaging drives beyond radiology into other clinical departments, education and training will be needed to smooth learning curve issues, much like that [which] occurred in radiology departments five to seven years ago," says McKesson's Arnsdorff. However, he looks for greater comfort levels to mean greater penetration for the integrated systems. "As the combination of productivity, financial, and patient care benefits outweigh the fear of change, the adoption rate in these other departments across the enterprise will increase at a faster rate." In the future, a single system may regularly handle functions from record creation and maintenance to image storage to billing - with RIS-PACS leading the way.