Effective information management is a key to success for any radiology department. The sheer volume of image and text-based information generated by a busy radiology practice raises the daunting task of managing that data to benefit patient care. Accuracy is essential. Security is vital and efficiency is central to the smooth operation of a radiology department and effective clinical management throughout the healthcare enterprise.
Radiology information systems (RIS) vendors today are incorporating the changing dynamics of the healthcare industry into the products they create to address the challenges inherent in information management.
Historically, a radiology department’s RIS was responsible for maintaining alphanumeric data that included diverse tasks, such as specific patient demographic details for workflow management, billing, quality assurance activities and other administrative tasks designed to direct the efficient use of departmental resources. Meanwhile, picture archiving and communications systems (PACS) corralled images to insure timely retrieval when required for clinical management of a patient.
Philip G. Drew, Ph.D., principal in the Concord Consulting Group Inc. (Concord, Mass.), describes the current RIS market as mature and well-saturated with more than 4,000 RIS installations in place around the country. However, that amount is in the process of revision.
“The thing that changes the position of things today is the increasing popularity of PACS,” says Drew. “It has always been clear that to build a satisfactory PACS, you have to have a satisfactory RIS working inside it or beside it.”
This emphasis has led to the development of integration capabilities either imbedded as a RIS/PACS hybrid or through Web-based systems and other methods that integrate functions.
Shifts in delivery
Over the past few years, dramatic shifts have occurred in the healthcare industry, and in the information technology (IT) market in particular. Three significant factors have produced a profound impact on image and data management: mergers of healthcare institutions, development of digital imaging techniques and the rise of the Internet as a means of information distribution.
“Our customers were becoming more global in their reach,” says Debra Stenner, vice president of development for the radiology product line at IDX Systems Corp. (Burlington, Vt.). “With all the mergers and acquisitions, our customers were managing more and more complex and geographically dispersed institutions. They needed a system that would allow them to have an enterprise-view of the radiology department, as well as an institutional-specific view to manage the work at a discrete institution.”
The development of merged healthcare enterprises into integrated delivery networks (IDNs) raised specific issues for information management vendors.
Considering that radiology resources could be dispersed throughout an IDN, any given patient conceivably could have one radiology exam in one institution and a different study across town. Being able to link those patient encounters so a clinician could view both studies and know, with assurance, they involved the same individual patient presents one hurdle to information management.
An IDN creates other headaches for RIS vendors. Security of patient information requires careful attention to details, and the fact that the number of physicians in a network who require dispersement of reports may increase exponentially.
“When you talk about enterprise-wide deployment of radiology information, it is no longer touching 20 to 50 physicians,” says Vishal Wanchoo, vice president and general manager radiology systems, GE Medical Systems Information Technologies (Waukesha, Wis.). “It now is potentially 5,000 physicians.”
A cross-section of clinical specialties usually are represented in this large physician base, each with unique imaging requirements for their sub-specialty. The new GEMS Information Technologies business unit has turned to Web-based distribution to address these issues.
A second driving force for change has occurred with the stunning development of digital imaging techniques. As radiology departments were able to adopt filmless methods of operation, electronic distribution of images became not only possible, but preferable.
IDX’s Stenner explains that within the context of a geographically dispersed region of care, healthcare institutions need the ability to send patients to various locations for the best possible exams and to have radiologists read results from almost anywhere.
“We embarked on a major rewrite of our current RIS to one that takes advantage of new technology, including full Web-based architecture, so that [the images and information] could be geographically dispersed,” says Stenner.
IDX’s new system includes a concept called “integrated, but separate view of work,” which means that it has multiple organizational capability. Within a healthcare system, each facility can define workflow, but analysis and scheduling is enabled across all of the institutions in the IDN.
Using the Internet as a distribution system for both images and text accommodates the needs of healthcare institutions as a whole, and individual radiologists and other reading physicians in particular.
ScImage Inc. (Palo Alto, Calif.) employs a Web portal for clinical information. PICOMOnline.com serves as a secure enterprise Website to enable physicians to access patient information outside of the firewall of an institution’s intranet.
“Our Webservice becomes a virtual jukebox,” explains ScImage President and CEO Sai P. Raya, Ph.D., who describes the system as a combination Web server and Web service. “If they don’t have a budget for a filmless solution, we give them an entry-level enterprise Web server and they can archive all cases to the Website.”
Using a fee-for-service structure, Raya maintains that this approach reduces the need for a capital expenditure and, therefore, is helpful for smaller or financially constrained healthcare institutions.
Chris Woodhouse, M.D., EBCT (electron-beam computed tomography) radiologist at Mt. Sinai Cardiac Prevention Center (Miami, Fla.), uses the ScImage system to read his cases remotely when necessary.
“Some of our examinations require two physicians to interpret them,” says Woodhouse. “Specifically, the coronary artery screening study, where the cardiologist interprets from a cardiac perspective and the radiologist looks for incidental findings.”
Since two physicians physically may be in two separate geographic locations, having Web access to images and other information facilitates the diagnostic process.
While the Web enables widespread image and information distribution, many vendors have continued to direct their efforts toward refining in-house capabilities through integrating RIS/PACS functions.
Initial integration activities led to bi-directional interfaces that used a repository as an intermediate step to link RIS and PACS functions, says Henri (Rik) Primo, director of information systems and PACS in the department of clinical networking at Siemens Medical Systems Inc. (Iselin, N.J.). Still, customers wanted a more complete interface leading to the development of Siemens’ new integrated RIS/PACS workstation that performs and displays all functions in a radiology command station.
“Using speech recognition, the radiologist — without leaving the desk — can consult previous results, read the image on a high-resolution screen, dictate the report, edit the report after dictation and send information,” says Primo. This capability greatly improves the speed for report generation.
Siemens has included a Web-browser function that will permit workstation access to resources of the World Wide Web, such as the latest research data from the National Institutes of Health. Finally, the system is designed to generate work lists for radiologists and technologists within the department.
“We’re getting to the point where the modalities, since they ‘know’ when a study is beginning and ending, will be able to tell the RIS when a study was started and stopped and exactly what study was done, so that absolutely appropriate billing can take place,” Primo adds.
The system also is designed to provide capital savings to an institution, as well, since both applications operate from single terminal stations. The system also offers additional clinical information.
In the protocol-setting stage of a patient’s visit, the radiologist may need to review laboratory results, other clinical information from scanned-in documents or cardiology data. The Siemens workstation supports those needs.
“Many departments can now go completely paperless and just rely on electronic media to perform their functions,” adds David Truncer, Siemens’ Novius radiology product manager.
Yet, still another approach is “RIS-centric” image management from Cerner Corp. (Kansas City, Mo).
“As you go into a filmless world, the RIS contains data and clinical information, which makes it an ideal place to manage the entire workflow of the department and the workflow of the image,” explains Bill Waters, Cerner’s vice president for radiology and cardiology. “There needs to be something in the middle that does a good job of routing and pre-fetching previous studies…The data element you need is resident in your RIS.”
Validation is an important component in the process.
“The technician should do a QC (quality control) validation check to make sure the DICOM header is correct…that the information that came from the RIS in terms of the [physician’s] order, medical record number, and patient name is consistent with what is in the DICOM header [on the imaging study],” Waters adds.
Challenges and Solutions
As RIS vendors strive to solve RIS/PACS integration issues to make radiology information flow seamlessly in an electronic environment, certain inherent challenges arise. Chief among these issues are identification of each unique individual and the need to maintain patient confidentiality.
Identifying individual patients is a complex matter that IDX Systems has addressed using imbedded technology with weighted patient algorithms to develop their Master Person Index.
“Our customers were doing work at a number of institutions, which all had different hospital information systems [HIS],” says Stenner. “If you want to send the same patient to different [imaging] resources at different institutions, and those institutions generate different medical record numbers, the patient ends up with multiple folders that you cannot tie together.”
That situation would be complicated further by different PACS in each institution, so the patient has different digital image folders. Finally, there is a high likelihood that the institution’s HIS and outpatient information systems are completely separate units. Under these circumstances, a radiologist may be unable to meet the American College of Radiology standard of practice of reviewing at least one related prior exam, because that study cannot be retrieved.
Using its imbedded technology, IDX utilizes patient demographic data, such as social security number, date of birth, sex and mother’s maiden name as identifying characteristics. “Then we create a merged candidates list, so our customers can link those patients,” Stenner says.
“With the connectivity of the RIS and PACS, it is very common for there to be a problem with what we call ‘orphan procedures,” says Steve Massey, vice president of sales of radiology at Sunquest Information Systems Inc. (Tucson, Ariz.).
During the performance of the imaging study, a physician may decide to change the procedure requested. For example, a two chest view may replace an order for a single chest view. In this scenario, since there is not an exact match, the RIS will understand the result as a two separate patient encounters.
Massey explains that Sunquest has included a functional component in its software that requires a technologist to verify that a completed procedure matches the study ordered. This feature eliminates “orphan procedures” that appear to be totally different events.
Heightened Security
One of the primary concerns with merging data and images in electronic media is the intense need for secure systems to protect patient confidentiality. RIS and PACS vendors have dedicated enormous time and resource towards addressing these concerns and building systems that are as secure as possible.
The Health Insurance Portability and Accountability Act (HIPAA) of 1995 mandates security standards be applied to individual health information in electronic form.
Password-protected, limited access is a front-end method that reduces the number of people who can gain entry to electronic patient files. Encryption of data is used when information is sent outside the network. There are other functions that track individuals who have gained access to the information.
“We keep a full audit trail,” says IDX Systems’ Stenner. “An electronic audit trail means that every interaction with the system is captured and stored. So, there is limiting access on the front end and measuring access on the back end.”
On the Horizon
Considering technology advances in imaging modalities, additional information issues inevitably will arise.
“With the next generation of CT scanners, we’re going to have studies with 300 slices of the abdomen,” explains Mt. Sinai’s Woodhouse, who uses the ScImage system. “Using source images is not going to be valuable.”
Specific images that a radiologist selects and exports to the electronic storage system will benefit clinical management. “I can send an image with a caption, ‘an ill-defined nodule on the left lower lobe,’” Woodhouse says. Then a referring physician can review images and text on the same Website.
Sunquest systems also feature what the company calls Clinical Event Manager. An alerting system, this product takes information from a laboratory or pharmacy information system and evaluates the data. Based on certain pre-selected rules, it sends a message to a pager or another alerting device to inform a physician of potential conflicts or to recommend another exam.
“For example, if you were going to do an arteriogram, and the system just picked up that the patient was on high doses of Coumadin, you might want to reconsider the timing of that order,” explains Massey. “It is not a diagnosis. It just takes the data that exists among different clinical systems, analyzes it and, based on a certain set of conditions, might send a message to the clinician.”
Matthew Barish, M.D., vice chairman of radiology at Boston (Mass.) Medical Center uses FlexiRad from Sunquest Systems.
“From the clinical side, the main aspect for the radiologist is the speed and ability for us to access, sign, and correct transcribed reports,” Barish says. “Sunquest has done a good job in coming up with a user interface that allows us to do all of that easily, without switching from one platform to another.”
Barish and his colleagues also are working to design a Clinical Event Manager that will use radiology results to alert physicians to potential problems.
“It is much more difficult to make that decision for what is an abnormal result in radiology since it
is all text-based material,” adds Barish. “We’re working with them to design ‘tags’ that the radiologist could use, such as ‘Level one abnormal result, level two abnormal report, or normal.’ Those would trigger different events to occur.”
Information management is a critical component to the smooth operation of any excellent radiology department. To accomplish clinical diagnosis and treatment, images and related information must be available to clinicians responsible for patient care. Given the complexity of the issues, RIS vendors must continue their efforts to integrate information to make it secure yet accessible with those who need it now. 
