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Brian Jacobs, M.D., knows all about sharing actual radiologic images with referring physicians. Serving as vice president and chief medical information officer at Washington, D.C.-based Children's National Medical Center, Jacobs has been working for several years to enable widespread access to images across the inpatient setting. "They're valuable for non-radiologists to see," he says. "The internist may get a report from the radiologist describing a four-centimeter round lesion in the right upper lobe of the lungs, but he wants to see it. There is nothing like a picture. It is like describing a Monet without seeing it."

Not all I.T. executives share Jacobs' passion for disseminating images to ordering physicians and other clinicians. But most see the value of integrating their EHR systems-and related workflows-with their picture archiving and communications technologies. The value of an integrated PACS/EHR rests in streamlined ordering, enhanced turnaround time on results reporting, and even alerts embedded within the EHR that make for safer imaging practices.

Attaining this integration is difficult, however. The top hurdle is often financial, as the cost of linking together disparate systems can be excessive, especially for physician group practices that lack the internal I.T. expertise of their hospital peers. The number of imaging systems in play in the inpatient setting-where multiple, image-specific viewing and data capture technologies are used-is another obstacle. It requires a complex assortment of tools to streamline. Regardless, many in the industry have their sights set on weaving together EHR functions with imaging functions and modalities. Forward-looking informatics champions like Jacobs even envision funneling X-rays directly to their patients' smart phones.

During the past several years, the easygoing CMIO has earned the equivalent of a Ph.D. in EHR image management. Children's technology portfolio includes an EHR from Cerner, a PACS from Fuji, and a radiology information system from IDX, now GE. The Fuji system, which is tightly integrated with the reporting writing features of the RIS, accommodates X-rays, CT, MRI, and nuclear medicine studies. "There all these other imaging studies, however," Jacobs says. "EKGs, echocardiograms, endoscopy and colonoscopy, plus we have scattered images, mostly JPEGs from dermatology and ophthalmology. Everyone is acquiring images all over the hospital and keeping them archived in their own separate systems. Three years ago, we said 'this is crazy. We need interoperability with our inpatient EHR.' "

This very proliferation of imaging modalities-and associated reading systems-has led some in the industry to rethink their vendor partner strategy. Dallas-based Parkland Health & Hospital System, a 1,000-bed county teaching hospital, has opted to replace multiple PACS with an enterprise system from McKesson. "Every department had its own PACS archive," says Maviea Easter, manager of diagnostic imaging and informatics. In 2009, Parkland began implementing McKesson's Horizon Imaging Manager, which will act as Parkland's central repository for images. "The project is not just about replacing our PACS, the goal is to have a consolidated archive," Easter says.

Simplified workflows

Parkland also simplified its imaging workflows with the advent of the McKesson imaging archive, which integrates with the health system's EHR, from Epic. Now, radiology tests are ordered in Epic and passed to McKesson, where the images are read and stored. Referring physicians can get to the radiology results and the images via a link in Epic. "They can view the order, the image and the result from within the EHR," says Easter. Other "boutique" imaging modalities are still in play, such as cardiology, but their results and images go to the common archive. "Every time you add a new department, you have to work with McKesson to add archive space," she says.

Uprooting systems, however, is not always feasible. But incorporating imaging studies and results into EHRs can be an exercise in frustration, notes Jacobs, from Children's National.

Jacobs took a do-it-yourself approach to the problem. Over a six-week period, the I.T. department built an interface between the hospital's Cerner EHR and its integrated PACS/RIS set-up. Now, clinicians using the EHR can see a list of available reports and images thru a link embedded in the EHR.

Seeing the images can enhance care delivery, the CMIO says. "They're helpful for both the primary care doctor and the patient," Jacobs says. Nurses too benefit from quick access to images. For example, they can use an X-ray to verify the positioning of a breathing or feeding tube. Patients are identified across the systems by the medical record number.

Hoag Hospital, a recently opened 154-bed community facility in Newport Beach, Calif., that touts an array of state-of-the-art imaging services, is looking to attain a set-up similar to Children's. The hospital has an integrated RIS/PACS, from GE, and wants to "image-enable" its EHR, from Eclipsys (recently acquired by Allscripts), says Dan Wahl, radiology systems manager. "We have smooth interplay between the RIS and PACS," he says. "You can view the relevant prior results and view physician orders in the RIS." Physicians from the orthopedic and neurosurgery departments requested the interoperability with the EHR, Wahl adds. "They like to see images as well as have the results available."

Hoag may find the undertaking to be formidable. But a well-architected imaging-EHR infrastructure can make life easier all around. That's one lesson that has emerged from Memorial Hermann, an 11-hospital system based in Houston. There, a devoted radiology informatics team has been working for several years to not only integrate images and imaging workflows within the EHR, but add rules, alerts and other evidence-based content to ensure safer care. "We want to support the workflow of both the referring physician and the radiologist," says Robert Murphy, M.D., chief medical informatics officer at Memorial Hermann, which operates 45 outpatient radiology sites.

The health system runs a RIS, an EHR and clinical decision support technology from Cerner, a PACS from GE, and, the last to be added, dictation software for radiology reports from Dictaphone. It's a lot of moving parts, but they synchronize well at this point, says Murphy. "Our biggest hurdle was the change to the radiology workflow," says Murphy.