Image Management and the Enterprise: Interoperability, Integration and Workflow
PACS vendors shared several key messages with HIMSS attendees last week. Many touted EMR integrations that allow users to tap into the functionality of both the enterprise electronic health record and image management solution without separate log-ins and allow radiologists and clinicians to follow the patient through the entire continuum of care. Radiologists, for example, may access essential data such as lab results and medications. On the clinician side, new software lets them access imaging files and related studies from the EMR and eliminates the need to move to a dedicated workstation. In addition, more solutions are becoming data-agnostic and storing DICOM and non-DICOM data like waveforms.
Other highlights on the show floor included an array of dashboards. Some are geared to the PACS administrator and enable proactive, at-a-glance monitoring of the PACS for optimal functionality and improved workflow. Other dashboards focus on the economic side of the radiology practices and help sites analyze business metrics to improve the bottom line.
Several vendors also touted the successful validation and support for various IHE actors at the IHE Connect-a-thon held in Chicago in January.

Agfa HealthCare demonstrated IMPAX Data Center and Radiology Clinical Module.

IMPAX Data Center is a conduit into Agfa HealthCare's Clinical Data Center (CDC), a real-time database of all structured and unstructured data from different clinical sources that presents a unified view of a single patient. IMPAX Data Center leverages a central bank of transactional and data services that can permit an enterprise level of data and clinical content management. Agfa HealthCare's CDC allows clinically relevant data from disparate systems to be grouped and restructured so that healthcare practitioners can more easily access the data about their patients.
IMPAX Data Center provides management for all DICOM images and related data elements. IMPAX Data Center helps solve archive and storage issues that require dynamic options for digital imaging and enterprise data storage. It provides a set of demographic data along with a number that uniquely identifies each patient along the continuum of care. This means that IMPAX Data Center can manage multiple patient ID domains. All data stored in CDC is linked to this patient identifier as its primary key.
The scalable and fault tolerant DICOM archive solution is designed to store clinical DICOM data objects, including DICOM encapsulated non-imaging objects (such as waveforms, structured reports and PDFs). It consolidates data of disparate storage systems onto a single point of storage and caters to the needs of enterprise storage for large, multi-site and multi-facility healthcare domains. The solution facilitates data sharing among healthcare providers. Patients also benefit, as their exams and results are made available at every location in the hospital enterprise.
IMPAX Clinical Module is a new software component for the IMPAX RIS/PACS solution that brings disparate clinical data such as lab results, pharmacy and pathology to the IMPAX Radiology Desktop. The system flags abnormal results transmitted by the modality. Integration of clinical evidence to aid the radiologists with the protocoling and interpretation process is delivered through a zero click context sensitive integration to any clinical system in real-time. The module helps meet radiologists’ needs for pharmacy data (such as medications and allergies), results (such as urinalysis for infection and liver function), lab data (such as creatinine, white blood cell count, and pregnancy test results), as well as surgical and cytology pathology reports. The IMPAX Clinical Module advances the practice of radiology to new levels by retrieving that data from multiple clinical systems in real time without separate logins and incorporates that data into the protocoling and interpretation workflow.

AMICAS shared its complete portfolio of imaging IT solutions for hospitals and ambulatory imaging businesses at HIMSS. Highlights included RadStream, Vision Reach, Insight Dashboards, Insight Services and Vision Series PACS.
RadStream is a next generation software product designed to optimize radiology workflow. RadStream is proven to further reduce interruptions by nearly 25 percent and further improve report turnaround time by 40 percent beyond PACS.
Vision Reach was designed specifically to address the unmet needs of the referring physician. Using the latest Web-based technologies, Vision Reach integrates the radiology report with key images and creates a single multi-media report for referring physicians. This report does not require the installation of any software, which improves adoption by referring physicians and should drive imaging volume.
Insight Dashboards is a Web-based business intelligence platform that provides access to customized, easy-to-read graphical data for key performance metrics and indicators. AMICAS customers can leverage the dashboard presentation of their operations to clearly view and understand their imaging business.
Insight Services is a suite of innovative, patient-friendly revenue cycle management services designed to accelerate the time it takes to convert receivables into cash.
AMICAS also showcased Vision Series PACS Version 5.0. The AMICAS booth featured the powerful bi-directional interface between all MEDITECH platforms and AMICAS Vision Series PACS. This smart interface delivers relevant clinical content directly from MEDITECH to the radiologist to improve efficiency and quality in the radiology department.

BRIT Systems highlighted the Roentgen Router.

Roentgen Router DICOM routing module can be used with any vendor’s DICOM-compliant PACS or as the foundation for a facility’s teleradiology capabilities. The Roentgen Router provides auto-routing and prefetching of DICOM studies based on a user defined study criteria, with the sophisticated tools to schedule routes, eliminating human intervention and automating teleradiology environments.  With the Roentgen Router, system managers build routes based on information within the DICOM header of radiographic images, including body region, modality type and referring physician. Routes are scheduled based on time of day and day of the week. They can be queued or held and sent at a later time. Prefetching of comparison studies from any DICOM server or archive is further simplified with the Roentgen Router. A maximum number of prefetches can be established and limited by age of the study, modality or body region. Each route is monitored to facilitate system administration; failure alerts with detailed information can be customized for each site and system manager. Tools within Roentgen Router support the retrying of failed images based upon a pre-determined time frame, which can also be customized per site.

DR Systems demonstrated Unity RIS/PACS at HIMSS ‘07.

Unity RIS/PACS includes new data conversion tools for legacy RIS/PACS replacement; enhanced Web-based scheduling capabilities; RIS workflow management including patient pre-authorization, patient flow tracking, film tracking, and task management; new patent-pending image display methods for improved accuracy and efficiency; enhanced integrated mammography reading, tracking, film digitizing and archiving; enhanced automated exam specific reporting capabilities; enhanced transcription capabilities including Web-based transcription; enhanced multi-database and multi-server capabilities and enhanced PACS access from EMRs and HIS Web portals. Unity RIS/PACS is designed to provide an advanced medical imaging and information management system infrastructure for regional health information organizations (RHIOs). Other highlights of the release include simplified presentation state creation, case study annotation and customizable HL7 and DICOM addressing, said Marketing Manager Doug Dill.

DR Systems also showed a work-in-progress, a patient kiosk that lets patient sign electronic forms.

Dynamic Imaging highlighted IntegradWeb MAMMO for digital mammography primary interpretation, its image viewer, RIS/PACS enhancements and Guardian Diagnostics monitoring tool.
Dynamic Imaging’s IntegradWeb PACS digital mammography capabilities center on complete digital mammography specific workflows that include customizable reading layouts and sequences for any third-party full-field digital mammography system. During HIMSS, Dynamic Imaging announced the successful test of its implementation of the new IHE Mammography Profile at the IHE 2007 Connect-a-thon. At the Connect-a-thon, Dynamic Imaging validated support of the IHE profile for Image Manager, Image Archive and Image Display actor, said Brad Levin, marketing manager. This standards-based approach to integration provides an optimal approach to digital mammography workflow, Levin said.
Also included is support for digital mammography CAD. CAD markings are applied to the original digital mammography study and can be archived for future reference. Because digital mammography studies are treated like all other modalities, they can take advantage of the functionality of IntegradWeb PACS to include anywhere access, saving key images for referring physicians’ print pages, as well as portable data for imaging (PDI)-compliant CD burning and importation of outside PDI CDs.
Dynamic Imaging shared its upcoming release, IntegradWeb PACS Version 3.7, which is being developed for scalability to 1 million annual PACS exams and beyond. Dynamic Imaging is focusing development on the IntegradWeb PACS image viewer as well. With IntegradWeb PACS Version 3.7, the image viewer is being developed to improve upon contemporary industry speeds by 50 percent or more.
The company showed its newest feature of IntegradWeb PACS—AutoFetch-- which speeds local and remote reading workflow for digital mammography interpretation as well as all other modality types. AutoFetch is enabled via IntegradWeb PACS’ Study List, automatically retrieving prioritized unread studies and their relevant priors to the local workstation regardless of location and optimizing performance regardless of the network bandwidth. These studies are stored to local memory, not the local cache, thus safeguarding the temporary storage of protected health information (PHI).
Dynamic Imaging also highlighted its integrated, single-desktop RIS/PACS featuring end-to-end Web-based workflow from scheduling through billing, with document management and digital dictation. This end-to-end workflow expands upon the Web-based architecture of IntegradWeb PACS, fulfilling the complete Web-based workflow needs of ambulatory settings. 

Guardian Diagnostics is a proactive monitoring tool that enables complete remote monitoring of hardware, software and network connectivity. Guardian Diagnostics peers into the performance of the IntegradWeb PACS and RIS/PACS software applications, monitoring routine performance criteria such as image acquisition and compression queues, for example, to proactively alert support teams before end users experience any degradation in system performance.

Eastman Kodak shared CARESTREAM Digital Dashboard and CARESTREAM Enterprise Information Management (EIM) Software. Kodak also showed its CARESTREAM PACS and CARESTREAM RIS at HIMSS.
CARESTREAM Digital Dashboard provides system administrators with a convenient way to monitor equipment performance, storage utilization and volume changes. It is designed to manage KODAK CARESTREAM RIS, CARESTREAM PACS and CARESTREAM Information Management Solutions. Administrators can use the dashboard feature to verify that devices are operating and communicating on the network—without leaving their desks. A red/yellow/green display gives immediate feedback regarding the status of any monitored device. An integrated, product-specific tools menu puts the launching of frequently used tools just a click away. The dashboard also makes it easy to track the number of concurrent users for a device, the number of unread studies and performed orders, as well as the status of other tasks. Additionally, the dashboard provides vital statistics such as patient name and ID conflicts and missing accession numbers that are crucial to maintaining the integrity of PACS and RIS. It also enables administrators to use product maintenance checklists for daily, weekly and monthly tasks that help ensure optimal system performance. CARESTREAM Digital Dashboard was shown as a work in progress at HIMSS; Kodak plans to release the dashboard on April 19. Look for future updates that will allow live chat and rules-based routing, Kodak said. The company also plans to develop a business diagnostics dashboard to help users identify opportunities for efficiency improvements. 
The latest CARESTREAM PACS software provides dynamic streaming capabilities that reduce the need for large bandwidth network connections, even for viewing of 3D, cardiac CT and other extremely large image files. Kodak’s CARESTREAM RIS platform includes a complete outpatient practice management system with patient scheduling, radiologist interpretation, report distribution, management reporting and billing functions. This system equips imaging centers to handle all aspects of patient workflow beginning with verifying insurance eligibility and ending with submission of claims and posting of payments from patients and insurance companies. 
Kodak’s new software option, the Watch Clinician Patient Repository Access for CARESTREAM EIM, offers healthcare providers more convenient access to patients’ medical imaging exams while facilitating integration of images with EMR systems. Physicians can use the software to open imaging files stored in cardiology, oncology and other imaging systems in addition to traditional radiographic procedures available through the PACS. Cardiology and oncology studies are normally available only from dedicated system workstations. This simplified image access enhances the diagnostic process and simultaneously delivers improved staff and clinician productivity by negating the need to go to several locations. Access is tightly controlled by system administrators: physicians and staff may be granted either read-only or read/write privileges, and access can further be limited to individual patients or specific exam modalities.
Kodak’s new viewing software provides access to images through a Web-based content browser that allows users to view patient files archived on systems managed by Kodak’s EIM platform. In addition to imaging studies, the new software option provides access to other types of fixed content, including lab reports and a variety of patient documents.

Kodak’s content browser is capable of launching applications (such as DICOM viewers, ADOBE ACROBAT Reader, MICROSOFT Paint) so the desired medical record can be displayed on any PC. An EMR can use a URL link to provide access to Kodak’s software, just as the EMR links to other databases in an organization. Kodak’s EIM platform also provides the ability to capture a variety of reports from clinical and hospital information systems using an HL7 interface and supports XDS protocols initiated by IHE to enhance sharing of fixed content records.

ETIAM introduced DICOM Broker 1.06 and CD-In.
DICOM Broker 1.06 connects the hospital information system to various modalities. It allows sites to manually enter data over the web if necessary. DICOM Broker 1.06 was validated for the Patient Admission Management and Patient Identification Reconciliation profiles at the IHE Connect-a-thon.
CD-In balances the requirements for security and complex processing and the need for a simple and automatic procedure. CD-In automatically integrates radiology examination images recorded on DICOM CDs and DVDs into a PACS.

Fujifilm Medical Systems highlighted its acquisition of ProSolv.
“The acquisition positions Fuji to drive forward with its Comprehension vision,” said Aaron Waitz, president and CEO of Prosolv. The company is primed to expand into information management and clinical specialties outside of radiology. Over the last few months, the companies have focused on integrating Synapse and Prosolv. The integrated solution will provide economies of scale via a shared IT infrastructure while allowing each specialty to maintain its unique distinctive workflow experience. The view, said Waitz, is patient-centric, rather than radiology- or cardiology-centric and provides access to the complete patient view. “Although the companies share a similar architecture and philosophical approach both Fuji and Prosolv remain committed to vendor neutrality and third-party integrations,” summed Waitz. In the future, look for Fuji to expand capabilities related to cardiac CTA and volume visualization.

GE Healthcare demonstrated Centricity PACS, Centricity Imaging AW Suite 2, Centricity Imaging Radiology and Centricity Imaging Application Service Provider (ASP). The company highlighted the interoperability of its solutions and showed Centricity RIS/PACS connected to the EMR, and it touted its commitment to the small hospital and imaging center market.
Centricity PACS includes new tools to help hospitals and imaging centers improve efficiency. The system provides GE’s flagship Centricity product at a price point and hardware commitment scaled to the small hospital and imaging center market, said Imaging Product Manager Don Woodcock. The system is designed to grow with customers as sites can add modules such as storage and advanced visualization tools as their needs evolve.
New IHE profiles within Centricity PACS version 3.0 automate exam acquisition, reporting and communication for referring physicians. Decision support tools such as the Business Intelligence Portal help administrators maximize valuable resources, and enhanced security features protect patient information, providing access only to those who truly need it. Voice-driven commands and highly configurable worklists manage exams with greater efficiency.
Centricity Radiology brings together Centricity PACS product with the Centricity RIS-IC. The combined Centricity Radiology solution allows radiologists and other care providers to manage workflow and leverage a common radiology information system across geographically dispersed locations. Additionally, clinicians have immediate access to significant clinical findings and associated images as well as tools for reducing errors inherent with manual data entry.
Centricity Imaging ASP provides an outsourced and scalable DICOM archive solution that enhances, protects and optimizes radiology and cardiology workflow. The company has offered disaster recovery services in Chicago and plans to commercialize the offering, particularly for smaller hospitals. Customers can take full advantage of Centricity Enterprise Archive and Centricity Web application functionality while improving their cost structure through a pay-per-exam model that allows institutions to match costs to revenues for better-managed cash flow. Finally, changes can be deployed rapidly, alleviating the need to plan for archive upgrades.

Medweb demonstrated its range of PACS and teleradiology solutions including fully hosted RIS/PACS/PM with DICOM Workflow Grid; completely 3D, web-based PACS; disk publisher with a touchscreen interface and enterprise-wide monitoring, service gateway and statistics program for managing clinical workflow across multiple PACS/RIS/HIS systems.

Neurostar Solutions highlighted Virtual Radiology Network (VRN) Version 6.4 at HIMSS 2007.
Neurostar Solutions VRN clinical image workflow platform provides   turnkey solutions that enable conversion to a digital radiology environment.  Users can connect to the VRN through the Internet to gain the full advantages of digital workflow as well as connect with radiologists worldwide to outsource reading or take on new clients to boost income. 
The latest VRN release delivers important new features that include:
  • Online system ordering and setup through Neurostar’s eStore.
  • Online support and training materials and tools.
  • Access to an online community of users with a variety of collaborative tools.
  • Access to just-in-time online consults available via Rad Expert Opinion – a novel service that employs Templeton Readings’ extensive network of radiology subspecialty experts.
  • Enhanced dynamic routing of studies to the appropriate physicians as needed based on resource allocation and optimization.

NovaRad Corporation showed NovaPACS 6.5.
The new release provides enhanced administration console tools and increased tool availability on the referring physician viewer, and an additional administration console tool features enable better sorting, reporting and information gathering and viewing. The “Referring Physician Specialist Viewer” provides the complete set of tools that are available on PACS workstations. NovaPACS 6.5 also provides NovaRad the ability to monitor the installation in real time to help further enhance its support capabilities. Also offered is an option for a CD/DVD publisher/printer. The new version also includes stat reads and enhances the ability for the PACS to support multiple site codes.
Philips Medical Systems demonstrated systems that streamline complex workflow and enable clinicians to focus on patients throughout the entire care cycle from settings both inside and outside the hospital. Booth highlights included Philips iSite PACS 3.5 and iSite Advanced Visualization.
Philips iSite PACS extends the power of radiology to caregivers throughout the hospital. The system employs an enterprise-first approach and enables enterprise-wide access to diagnostic quality images and relevant information. iSite also provides a patient history timeline, helping to optimize care through insight into complete patient history. To help improve overall hospital workflow, iSite also provides collaborative worklists that are shared by multiple radiologists for better utilization and efficiency gains. Via the iSite Application Programming Interface (API), iSite also interfaces with Philips’ SpeechQ solutions and the hospital’s choice of clinical applications, enabling customized workflow and better connected care.
Additionally, Philips iSite with Advanced Visualization tools (work-in-progress) makes common 3D techniques, such as multiplanar reformation (MPR), maximum-intensity projection (MIP) and advanced Volume Visualization, available to radiologists on the desktop.  Delivering real-time (less than three seconds), full-fidelity imaging, this Philips solution leverages existing hospital infrastructure and allows all users to navigate through large volumetric datasets, without having to download the full dataset first or having a dedicated server infrastructure to provide the reconstructed views to the client.
RIS Concepts, Inc. showed RAD-RIS, its Web-based radiology group workflow application fine-tuned for the needs of radiology groups reading studies for multiple client facilities. 
RAD-RIS creates an integrated worklist combining studies across multiple enterprises and locations, while simultaneously interfacing PACS from different hospitals and clinics. It also features a component for billing clients on a per-exam basis. 

Other features include:
  • Client Facility portal to enable a radiology group’s contracted facilities to manage their own exam workflow using the radiology group’s RIS.
  • Advanced Radiology Group Routing Rules to assign exams to individual radiologists and radiology sub-specialists by facility, referring physician and modality.
  • Client Contract Management feature includes management and tracking of reading activities by client and provides invoicing reports for contracted imaging facilities. Invoices detail per-exam reading transactions based on contracted amounts for each modality or procedure type. 
  • Radiologist Activity Reports track the ongoing reading activities of radiologists for workload balancing and radiologist payout calculations.
  • Fax and email Report Distribution is provided to the ordering imaging facility and referring physician. Reports can be printed by all users.
  • Referring Physician Portal lets group clients manage their own referring clinicians and allows access to the radiology group system itself as an Imaging center referral user. 
  • Exam Report Fax-on-the-Fly allows client facilities to fax reports from the RAD-RIS when needed.

ScImage discussed PicomEnterprise Version 3.0.
The unified multi-department workflow system enables exams from multiple departments to be scheduled, tracked, reported, archived and distributed via a single web-based logon by employing a single database to organize varied data from each of these departments. At its core, PicomEnterprise boasts one database and a shared infrastructure that simplifies workflow for multiple departments. The solution features several clinical applications for radiology, cardiology, nuclear medicine and orthopedics. 

Siemens Medical Solutions showed syngo Suite.
syngo Suite connects the entire image management workflow to support efficient end-to-end workflow. It increases the efficiency of diagnostic and therapeutic cycles, providing fast, intuitive and role-based access to information. The syngo Suite offers advanced RIS, PACS and processing in a comprehensive package for all imaging needs in radiology, cardiology and other -ologies. It comprises: syngo Workflow, syngo Imaging and syngo Dynamics.
syngo Suite offers a variety of archiving storage options and can be interfaced to clinical or hospital information systems to allow the distribution of results in a variety of formats and help create filmless and paperless environments.
syngo Workflow drives the radiological workflow from order entry to image and report distribution. Data consistency between RIS and PACS provides radiologists and clinicians with coordinated images and results throughout the organization. Worklists are based on the role of the user and can be tailored to meet user requirements. For example, radiologists can multi-select from their interpretation worklist, post a note from Web signoff and maintain their own passwords. Enhanced messaging enables radiologists, technologists and transcriptionists to communicate information electronically. Integrated dictation offers radiologists the flexibility to correct typos on their own or send reports to transcription for editing. Turnaround time can drop from 24 hours to as little as two minutes, Siemens said. Clinical alerts are part of syngo Workflow and put processes—and clinical best practices—directly into the user’s workflow to help reduce medical errors and facilitate optimal patient care. 
syngo Imaging improves usability, speeds load time, and leverages integration. Features include Smart Select, which supports the daily work of a radiologist. Smart Select enables access to the most frequently needed functions directly in the diagnostic screen, which allows the user to keep his or her eyes focused on the clinical images. Faster loading with Dynamic Loading saves the radiologist time as the images appear immediately after they are called up. Images are dynamically loaded from compression states for storage and transmission, saving space and time. The resolution quickly increases to the full level. The closely integrated solution is supported by an intuitive user interface. Advanced processing functions, which are available as a task card, are integrated directly into the diagnostic workstation. The complete examination, including 3D and other image processing functions can be performed at one workstation.
syngo Dynamics is a multi-modality, dynamic image review, diagnosis and archiving system. It enables evidence-based reporting to improve the efficiency of clinical procedures for cardiology, general imaging, OB/GYN and MFM. It includes integrated cardiology, general imaging and OB/GYN solutions; efficient and intelligent reporting capabilities; integration into hospital information systems, including study transfer and report upload and DICOM Structured Reporting Integration with third-party ultrasound machines to enable measurement transfer. syngo Dynamics supports structured reporting and stores DICOM reports. Moreover, users can import cardiology data including hemodynamic data into the system for a one-stop view of the patient.

Swearingen Software, Inc. introduced Radiologist Task Center.
The Radiologist Task Center feature integrates a one-stop radiologist dashboard into RISynergy. This new Task Center provides a single screen where radiologists may perform all of their tasks, such as viewing the procedures they are required to perform for any given day, viewing the schedule of all procedures and visits for the day; viewing, editing, and signing off transcribed reports; viewing a list of completed exams waiting to be read; syncing auxiliary systems, such as a PACS system and/or dictation system on the displayed patient’s record and accessing patient visit history, current visit detail record or schedule detail record and all previous transcribed reports for any given patients.