Encompassing more than 170 physicians and some 30 mid-level practitioners, the 11-site group practice interfaced the RIS/PACS to its electronic health records system for simple data exchange, such as demographics and results reporting. But by last year, the imaging software "was getting long in the tooth" says Hal Teitelbaum, M.D., managing partner. Necessary upgrades would have essentially amounted to a replacement anyway, so the practice looked at all of its options.
Early this year, Crystal Run started implementing a new RIS/PACS from a new vendor, Carestream Health of Rochester, N.Y. The practice also bought two Kodak digital radiography imaging modalities from Carestream along with a Kodak computed radiography modality. These accompany multiple ultrasound, magnetic resonance imaging and CT scan units. The RIS/PACS went live in July, and the practice continues its effort to integrate it with its existing EHR, from NextGen Healthcare Information Systems, Horsham, Pa.
With some RIS/PACS/EHR integration experience under its belt, Crystal Run wants more comprehensive integration this time around, Teitelbaum says. "We are beyond looking at the relatively simple issue of storing data," he notes. "Now, we're looking to utilize the data."
Today, patient demographic data entered into the EHR transfers to the RIS/PACS, avoiding double entry. When integration is complete in 2010, orders will flow from the EHR to the imaging software. But other critical patient data, such as kidney function test results, also will flow to radiologists and technicians. This data can affect the level of radiation to which a patient can be exposed. And, for the first time, physicians will be able to view medical images from the EHR, rather than going to the radiology or cardiology departments.
In no small part, tighter integration today is far easier than seven years ago because imaging, EHR and integration technologies are much more mature, Teitelbaum contends. "Absolutely, they are light years ahead. The level of standardization is much better today. People are speaking the same language today."
Tighter integration also speeds up radiology readings and report turnaround, while increasing patient safety, says Tim Kulbago, senior vice president of product technology at Merge Healthcare, a Milwaukee-based medical imaging software vendor. "The radiologist has all relevant information without going to two systems," he notes. "Everything you need is probably one click away. And you don't have to worry that there's a piece of information you need in the radiology information system that you haven't seen."
Integrating radiology reports into the EHR is a fairly common practice today, Kulbago says. Increasingly, physicians also want to view the images in the EHR.
These integration efforts likely will accelerate because of provisions in the American Recovery and Reinvestment Act, he contends. Federal advisory committees have recommended that criteria for meaningful use of electronic records, necessary to qualify for Medicare and Medicaid incentive payments, include integration of laboratory and radiology data in the EHR. "In almost any major medical event, there's a radiology component," Kulbago adds.
But there are different ways to integrate. Some organizations have found simple ways to access radiology images and reports in EHRs using Web technology (see story, page 20). Others aren't integrating to the EHR, but they're using a regional health information organization to make imaging exams from multiple hospitals available to community physicians.
INTEGRATION 101
Radiology integration starts with the imaging modalities themselves, such as the MRI, ultrasound, CT scan and other systems. These modalities integrate with the radiology information system and picture archiving and communication system, or another type of archive if a PACS is not used. Integrating the modalities and imaging systems has become commonplace with the use of DICOM medical imaging standards.
"Most modalities play well with RIS and PACS," Kulbago of Merge Healthcare says. "They're pretty strong with their DICOM structures." Newer technologies, he notes, enable "no touch" integration that is close to plug-and-play to link modalities to RIS and PACS, and also to link EHRs. Some vendors, such as Andover, Mass.-based Capsule Technologie, have built interface libraries to link with hundreds of medical devices.
A radiology information system is the administrative component of medical imaging software. It handles scheduling, registration, administrative, reporting and sometimes billing functions - everything except the actual images. A PACS stores and distributes images. It's the radiologist's workstation for viewing images, often aided with dictation/transcription and image manipulation software.
A technician performing the actual radiology procedure will capture images on a workstation with multiple monitors. This workstation is a "Q&A" step, Kulbago explains. "Did I capture the right image?" "Did the patient move?" When the procedure is finished, a technician reviews images and sends only the approved ones to the PACS or another imaging archive for a radiologist to pull up for a reading.
Integration to the EHR is done through the RIS, PACS, or both. And such efforts today are aided by better vendor willingness to work with each other, and better vendor understanding of scalability issues, notes Crystal Run Healthcare's Teitelbaum. Sometimes, however, that cooperation has to be demanded by the customer. Roseville, Calif.-based Adventist Health, with 17 hospitals in four Western states, has about nine imaging modality vendors linked to its radiology and PACS systems, along with a clinical information system from Cerner Corp., Kansas City, Mo. Not all the modality vendors, which often sell their own RIS or PACS, are keen on playing with software companies.
"Most modality vendors will stress how much added value you get if you buy their RIS and PACS," says Greg McGovern, chief technology officer. "Everyone's still pushing their products. Everyone's still having a hard time giving up full ownership of their property. But I haven't seen anyone refusing to play."
Adds Adventist Health CIO Alan Soderblom: "Hold your guns and tell them they must work with your other vendors. They are getting more cooperative; they understand that is the future."
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