Experts provide tips for buying RIS, optimizing EMR, implementing evidence-based radiology
Establishing priorities for buying RIS, optimizing the EMR for radiology and evidence-based radiology were among the priorities discussed at the SCAR U session on IT on Thursday at SCAR. Janice Honeyman-Buck, PhD, of University of Florida instructed participants on the ins and outs of buying or upgrading a RIS. Katherine P. Andriole, PhD, of Brigham and Women's Hospital provided suggestions geared toward optimizing the EMR for radiology. And Ramin Khorasani, MD, MPH, of Brigham and Women's Hospital focused on evidence-based radiology.

Honeyman-Buck provided a thorough overview of the issues and pitfalls of purchasing a RIS. She divided RIS into three categories: simple, more complex and complex.

The simple RIS orders and schedules studies and manages reports. Typically, a stand-alone system that doesn't interface to other systems, the simple RIS includes two to four workstations. A more complex RIS adds functionality such as a billing module or an interface to the billing system, film tracking and image checkout. It grows to 10 to 20 workstations. A very complex RIS is defined by interfaces and may offer interfaces to HIS and PACS as well as a web interface for report access and patient tracking tools. It may include more than 100 workstations.
"Step one," says Honeyman-Buck, "is to specify what you want." Hospitals and imaging centers should form a task group composed of key users including IT and billing staff, radiology administration, technologists, radiologists, film librarians, patient registration staff and the PACS administrator.
The task group needs to write specific goals to include in the RFP. Which work processes should be automated? "Use the exam workflow to look at processes," recommends Honeyman-Buck. She offers sample goals and objectives:
  • Integrate and automate front office and billing processes with electronic claims submission to accelerate cash flow and reduce lost charges
  • Interface with PACS to integrate images and reports
  • Increase referring physician satisfaction
  • Process more patients with the same FTE count
Objectives should be measurable, and the RFP should include all requirements such as order entry, ICD9 support and inventory management. Sites upgrading a RIS should list needed features and specify migration of current data and when and who completes the migration. The RFP should detail expected performance -- such as a query for the patient record should return results in less than two seconds. Hospitals need not specify how requirements must be met unless they have specific needs like a running on 10 megabit network.
Honeyman-Buck suggests assigning a weight to each requirement to facilitate ranking of proposals. Other components of the RFP include institutional background, installed systems that must be interfaced, timelines and a proposal format.
After proposals are received, the task group ranks each requirement with higher ranking for the best system. When scores for each requirement are multiplied and then added, the group will have a clear numerical 'winner.' Still, a buyer-specified demonstration with real data is essential before a contract based on the RFP is written.
Honeyman-Buck concludes with 10 mistakes to avoid when buying a RIS:
  • Not using a structured process
  • Not defining needs
  • Hiring a consultant with a bias
  • Too much attention to bells and whistles
  • Not including key users in the selection process
  • Buying more than needed
  • Allowing the vendor to drive the process
  • Letting the 'powers that be' choose the system
  • Confusing the salesperson with the product
  • Not using the RFP process
Andriole outlined the functionality and technology necessary optimize the EMR for radiology. She listed components of the EMR, important features for radiologists and key implementation issues.
The EMR is a multi-faceted system that includes the HIS, CPOE, RIS, PACS, report generation systems, decision support and teaching files. "Radiologists need to be aware of healthcare enterprise information management systems. PACS and RIS can increase workflow and reduce costs, but radiology can't eliminate film and paper without embracing other systems, integrating with IT and disseminating knowledge enterprise-wide,"  Andriole said.
To understand radiology and the EMR, radiologists should understand functions of its components. The HIS is the point of patient entry into the healthcare system and contains lab values, clinical notes and billing and tracking data. Point-of-care CPOE can unify information capture, reduce paper, costs and inefficiencies and provide decision support. The RIS fills exam orders, schedule and tracks patients and exam status and serves as a report archive and radiology billing system. PACS performs image archive, distribution and display functions, but typically does not include history or the reason for the exam. Report generation systems include dictation and transcription system, speech recognition and structured reporting systems.  
Key issues in EMR integration include standards and data models such as DICOM, IHE and XML; availability of single sign-on and a master patient index and context and user sensitivity. That is, if a radiologist checks lab values from the PACS workstation, the system should maintain the patient and exam.
A variety of factors can predict the success of the EMR, Andriole pointed out. Ease of integration into the workflow is a primary issue; however, sites may re-engineer workflow to optimize the system. Does the EMR add value? Is the user-interface simple? Are there well-defined goals and metrics of improvement? Is the system configurable, fault-tolerant and redundant? Are there organizational support and a vision for the project?
"Medical imaging is increasingly the key triage event in patient care," concluded Andriole. Rapid access to information can improve economic and enhance patient care, but to achieve this goal hospitals must bridge the information gap between radiology and the enterprise, she said.

Khorasani referred to the 2001 Institute of Medicine Crossing the Quality Chasm report, which outlines great waste in the U.S. healthcare systems and the need for systems change, as a rationale for evidence-based radiology. Furthermore, he said, there is an enormous body of scientific literature and evidence. It takes 7 to 14 years for studies to be adopted into clinical practice, and adoption remains heterogeneous. The focus on decreasing medical errors and improving the quality of care will continue.
Evidence-based radiology begins with a few requirements. Sites must be prepared to close the knowledge gap and accept that physicians make mistakes; systems are needed to prevent mistakes, says Khorasani. Knowledge must be distilled into a brief, actionable format accessible at the point of care in clinical context. Thus, it should provide brief summaries of research relevant to the specified indication and test.
Evidence-based radiology is needed in a number of areas, says Khorasani. This includes determining if the right test is ordered, if the exam is performed and interpreted correctly and if the right action follows the test. Multiple studies of inpatient and outpatient exams across modalities reveal that 10 to 25 percent of radiology exams are unnecessary and inappropriate. Medical errors may be over-use (ordering a head CT a without realizing the study was completed recently), under-use (failure to recommend screening mammography) or mis-use (ordering the wrong study) of radiology resources.
"Now is the time for evidence-based radiology," Khorasani emphasized. "Errors and waste are real, and IT solutions exist. The focus on medical errors, increasing use of high cost imaging studies and attention by payers and government will continue to raise the stakes for radiology."
Khorasani offers a list of barriers to evidence-based radiology including leadership, information systems, knowledge gaps and costs. Intelligent CPOE that incorporates context-specific decision support is a necessary infrastructure for evidence based radiology. Productivity gains can provide an incentive for physicians to use CPOE, so integrate it into the electronic record, says Khorasani.
Evidence-based radiology has been successful at Brigham and Women's -- with 85 percent of referring physicians ordering electronically and evidence-based radiology decreasing the number of inappropriate studies.