Getting The Picture

EXECUTIVE SUMMARY

Facing diverse technology and local-market histories and situations, CIOs and their healthcare IT leader colleagues are working to make electronic health record (EHR), picture archiving and communications system (PACS), and radiology information system (RIS) products interoperable, while optimizing referring physicians' access to images and reports from anywhere. In doing so, they are facing up to organizational, process, and technological complexities-and moving forward in spite of the obstacles involved.

Karen Thomas, vice president and CIO, and Paul Maurer, director of applications, of the integrated health system Mainline Health, based in the Philadelphia suburbs, face a situation common to many healthcare IT leaders. Their 1,200-bed health system, which includes four acute-care hospitals, as well as two rehab hospitals and other services, has grown through merger and acquisition, meaning that their information technology infrastructure is also typically mixed. Thus, the core inpatient EMR at three of their four acute-care hospitals is from the Malvern, Pa.-based Siemens Healthcare, while that of the fourth is from the Kansas City-based Cerner Corp. Meanwhile, they've got different PACS, from the Alpharetta, Ga.-based McKesson Corp. and the Mortsel, Belgium-based Agfa HealthCare; and different RIS, from Siemens and Cerner.

With such a patchwork quilt of information technologies, it was inevitable that Thomas, Maurer, and their colleagues would be compelled forward on a journey towards creating smoother access to diagnostic images, radiology reports, and other information, on behalf of their salaried and affiliated physicians. The Mainline folks have been live for more than 10 years now with a Web-based physician portal (two, actually, encompassing the most recently acquired facility within the system), through which their physicians can quickly access all the images and data they need.

Meanwhile, in the background, Thomas, Maurer, and their colleagues have been working to knit the connections of the various clinical information systems together more seamlessly. In fact, the level of complexity of the IT situation is even more complex than appears at first blush, as they are working to create a single core diagnostic images database, for both radiology and cardiology images. It is a multilayered task.

“When we first embarked on PACS, we did not want separate PACS all over the organization; we wanted a single repository,” Thomas explains. “And McKesson”-the organization's primary PACS vendor-“had partnered with a company called Camtronics for cardiology PACS, but later grew their own cardiology PACS, so we've migrated to McKesson on cardiology, and are working on that single image repository across cardiology and radiology.”

In fact, Maurer notes, “You can get to the cardiology images in the radiology Web-viewer; though for full feature-function, some physicians will go into the cardiology Web-viewer.”

The stakes are high. Mainline's clinician's produce 640,000 radiology studies a year, 36,000 cardiology studies a year; they are already up to more than 400 terabytes of long-term storage, and 120 terabytes of short-term storage, of diagnostic images.

THE KEY FOR CIOS IS TO REALLY UNDERSTAND WHAT KIND OF INVESTMENT, AND HOW MUCH TIME IS REQUIRED, IN ORDER TO ACHIEVE AN INTEGRATED PACS SYSTEM. THESE ARE EXPENSIVE SYSTEMS.-KAREN THOMAS

The key for CIOs, says Thomas, is “to really understand what kind of investment, and how much time is required, in order to achieve an integrated PACS. These are expensive systems. We were very fortunate to have a partner that provided a great deal of integration from the beginning, because we moved aggressively to put as much onto PACS as early as possible” in imaging IT development, she says. And Maurer adds that “The amount of integration and back-end hardware involved makes it very challenging for organizations to support multiple PACS. Clearly, it's requiring extra hardware and resources, so I think you'll see organizations moving towards a single architecture. Meanwhile, he says, “organizations are challenged by the storage issues, particularly with 3D images and multi-slice studies, so the images are getting larger and the volume of images is growing.”

SIMILAR CHALLENGES ACROSS DIVERSE LANDSCAPES

The kinds of challenges that Thomas and Maurer and their colleagues at Mainline are facing are echoed across the country, as CIOs and their colleagues try to move forward on dual tracks, in terms of the back-end imaging and electronic patient record infrastructure and architecture, while moving quickly to optimize physician access to and usability of data and images.

Among the numerous factors complicating the journey forward for hospitals and health systems are the following:

• The intense focus on meeting meaningful use requirements under the federal American Reinvestment and Recovery Act/Health Information Technology for Economic and Clinical Health (ARRA-HITECH) Act are forcing an emphasis on EHR development, but a lack of clarity on the degree to which diagnostic imaging-related IT will fit into requirements under Stages 2 and 3 under HITECH is clouding imaging IT development issues at present.

• At a time when the industry's focus is primarily on EHR-related development, many hospital-based organizations are facing the prospect of needing to upgrade or replace aging first-generation PACS and RIS, while coping with straitened finances.

• Ongoing hospital system consolidation, as in the case of Mainline, is complicating the tasks around back-end integration, interfacing, and interoperability.

• Accelerating development in cardiology RIS and PACS is further complicating the kinds of choices healthcare IT leaders will need to make as they architect their clinical information systems.

• Increasing demands around mobility on the part of physicians are making the front-end (and sometimes the back-end) interoperability and navigation issues more time-sensitive for healthcare IT leaders.

COMPLEXITY CUBED IN PITTSBURGH

Some organizations face even more complicated sets of tasks and choices than Mainline Health. At the sprawling 20-hospital University of Pittsburgh Medical Center (UPMC) health system in metropolitan Pittsburgh, Jim Venturella, CIO, Hospital and Community Services Division, and Rasu Shrestha, M.D., medical director for interoperability and imaging informatics, are facing up to an imaging and clinical informatics environment that is complexity cubed. While their hospitals mostly have Cerner for their core inpatient EMR and an outpatient EMR from the Verona, Wis.-based Epic Systems Corp., they have several different PACS and RIS vendors. Even in cases where facilities share the same general PACS or RIS vendor, they are in some cases on very different versions of those vendors' products. In addition, it was at UPMC that the Stentor PACS solution (now iSite, from the Andover, Mass.-based Philips) was first developed and launched (and which continues to be used, as iSite).

Where are the PACS and RIS Markets Headed? One Expert's Perspective

Joe Marion, principal in the Waukesha, Wis.-based Healthcare Integration Strategies LLC, sees a diagnostic imaging IT market in serious transition. Marion, who has been in the industry for decades, recently shared his perspectives on some vendor-related issues with HCI Editor-in-Chief Mark Hagland. Below are excerpts from that interview.

Healthcare Informatics: Where are we as an industry with regard to RIS/PACS/EHR interoperability?

Joe Marion: Most organizations are taking a pretty straightforward route by selecting EHRs that support an application program interface (API), a mechanism that allows me, if I'm a clinician, to click on an icon, and which then triggers a URL to take me to a particular image within my organization's PACS.

HCI: Do you see PACS products as being pretty much commoditized right now?

Marion: Very much so. I think there is very little differentiation anymore among PACS products.

HCI: What about RIS?

Marion: Because there's been such a high state of integration between RIS and PACS, the lines are blurring between the two, and in some respects, the RIS is probably more critical than the PACS.

HCI: Where are EMR/EHR vendors in terms of making end-user physicians happy, and where are CIOs in terms of pushing their vendors to do so?

Marion: I would expect that customers are putting more of the onus for that on their EMR vendors than on their PACS vendors. Their expectation is that the electronic health record is a consolidation of the patient information, so they'd be looking to the EMR vendors to offer that capability. And then it's a question of which companies that vendor works with, or supports, in terms of doing that.

HCI: Are PACS vendors in different places these days in terms of interoperability?

Marion: Five years ago, I would have said there could be differences. But today, they're pretty much in the same place. Pretty much every PACS vendor offers some version of a Web-viewer, and can support an API to launch that. So to me, that's a non-differentiator in the market today. That being said, a couple of the biggest EMR vendors claimed several years ago to have a solution that interfaced PACS products to their own Web-viewer, but one vendor in particular had a highly proprietary solution that didn't support others. And that caused a lot of consternation in the marketplace at the time.

HCI: What would your advice to CIOs be, per satisfying physicians?

Marion: All the buzz and dollars seem to be going towards the front-end of meaningful use right now. And clearly, imaging is not part of that equation; so there's not a lot of emphasis on imaging at all. But people in the industry are very concerned about that gap. To me, it's like putting up the siding on the house without having the frame. Indeed, using images is very much a focal point for physicians, and of great value to them. So, I think people should certainly not be looking at an EMR that can't support the API infrastructure to launch imaging. In other words, don't short-change that area to get some of the EMR monies, and cut off your nose to spite your face, because if you rush to judgment, you may in the long run be throwing money away.

Venturella and Shrestha admit frankly that the infrastructure and architecting issues they face are challenging, given that UPMC encompasses 20 hospitals, 4,200 licensed inpatient beds, 30 imaging centers, and more than 2 million diagnostic imaging procedures a year. The organization's 2,700 employed physicians are accessing images and data through UPMC Connect, a Web-based connection into the health system's virtual private network. “They're not getting a generic portal, but rather the pure application, via our VPN,” Venturella notes. In addition, he says, “We're working on a portal for our affiliate physicians that will give them access to similar information,” even as they can connect remotely to UPMC Connect. The broader goal, he says, is that “We're trying to encourage online access rather than paper-based.”

As for the mix of solutions involved at UPMC, they include not only multiple radiology PACS products, but multiple cardiology PACS solutions as well. The organization's broader clinical IT strategy is “horizontal,” Venturella says, meaning that it's focused on creating some kind of broadly coordinated approach across the entire UPMC system, rather than simply looking to create consistency across a particular facility. “And as we look at the imaging side of it, the PACS side of it,” he adds, “we are thinking through an overall strategy for PACS.”

The work on the back end will necessarily continue forward for years, and, says, Shrestha, “We don't know where it will end up.” Given the heterogeneity of vendor systems involved, providing a consolidated view of data and images for clinicians has been top of mind, he emphasizes. “One of the technologies we've developed here at UPMC is called SingleView,” which UPMC clinical informaticists developed a few years ago with the Pittsburgh-based dbMotion, a semantic interoperability vendor. “SingleView was created primarily to handle the fact that across our hospitals, we have upwards of a dozen different implementations of the Philips iSite technology, and they weren't talking to each other at all,” he says. “So with SingleView, we've overcome the need to go into every different PACS for different images taken at different sites or hospitals within UPMC.” In other words, the consolidated view of patient data and images that clinicians access through SingleView is the bridge that Venturella, Shrestha, and their colleagues have built in order to overcome the inevitable forest of products they're working with.

Optimizing accessibility and usability for physicians and others is inevitably challenging in this environment, Venturella and Shrestha agree. “It's a lot easier to put the PowerPoint presentation together on the planning than to actually do it,” Venturella jokes, adding that “We do as much as we can with our [imaging IT and other clinical] vendor partners, but we're really dragging them along to where we need to get. Still, we're breaking some fairly new ground here.”

CIOs and CMIOs at other hospital-based organizations are also finding ways to manage the back-end complexity while providing physicians and other clinicians with the front-end ease of use they need. For example:

• At the 295-bed Concord (N.H.) Hospital, CIO Deane Morrison faces the challenge of separate radiology and cardiology PACS, but at least in his organization's case, they are from the same vendor (McKesson). “Outside of EKGs, the need for referring physicians to actually access cardiology studies is very limited. So our focus has mainly been on image and report availability in radiology, where they can access general-quality images. Those general-quality images, as well as EKGs, and radiology reports, are available through our portal; and in fact, the radiology reports are what they're most often looking for.”

• At the two-acute-care-hospital, 350-bed Heartland Health in St. Joseph, Mo., CIO Helen Thompson says she and her colleagues have benefited from the decision a few years ago to strongly hew to a core-clinical-vendor strategy. “We particularly wanted PACS-EHR integration,” she notes. Thus, she and her colleagues went with Cerner for EMR, PACS, and RIS. “Our physicians use [Cerner's] PowerChart for everything; they don't go to any separate place to view images,” she says. “That was really a requirement for us. And whether it's a CT, MR, or EKG, all of that presents to the physicians through that venue.” Further, Thompson says, “Mobility is becoming No. 1 on their radar. They want to be able to view those images from wherever they are, and to be able to have the capability to drill down into those images.” Her physicians are quite pleased with their image access, on a variety of devices, including iPads and iPhones, she reports.

• Meanwhile, Charles E. (Chuck) Christian, CIO at Good Samaritan Hospital in Vincennes, Ind., is looking forward into the health information exchange (HIE) environment for trans-organizational solutions going forward. “Here in Indiana, we have a pretty rich HIE environment,” he notes. “So we've been approached by quite a few other facilities to create a VPN environment for image-sharing.” Christian, however, has some security concerns with a VPN-based approach that goes outside the hospital organization. So instead, he says, he's been discussing a proposal with the Indianapolis-based Regenstrief Institute for “something like a radiology image drop-box concept”-in other words, creating the capability to send a radiology study and associated images to a “holding place” that would allow appropriate viewing access within 48 to 72 hours, after which the data and images would disappear. Christian has been researching the idea, while trying to find out what he can about what he believes is an existing patent on a similar idea.

SO WITH SINGLEVIEW, WE'VE OVERCOME THE NEED TO GO INTO EVERY DIFFERENT PACS FOR DIFFERENT IMAGES TAKEN AT DIFFERENT SITES OR HOSPITALS WITHIN UPMC.-RASU SHRESTHA

WHAT END-USERS WANT

The HIE-based approach, which Heartland Health's Thompson is looking into for image-sharing (Heartland already has its own general HIE) is one that David Voran, M.D., a practicing family physician and the medical director of Heartland Clinic of Platte City (an affiliate of the Heartland Health system), heartily endorses going forward. “First and foremost,” Voran says of physicians' needs, “is access to both images and data, because an image in isolation from a report or from a patient's medical record, is really limited. All too often,” he adds, “I think people have too narrow a view of what clinicians' needs are at a given time. What's frustrating is when only 30, 40, or 50 percent of the information needed to make decisions is accessible. For example, if I send a patient to an imaging center, and an image comes back, that particular image would be confused in my mind with all the other images I might have received within a week, so I'd have no context for it. So the information I need to help me figure out what it has got to be there.” He approves of the access he has to images and reports through the Heartland Health physician portal, and believes that an HIE-oriented global solution will carry the day for physician end-users in the future.

Meanwhile, when it comes to purchasing RIS, PACS, and EMR systems, some trends have become clear in the past few years, says Ben Brown, general manager, imaging informatics, at the Orem, Ut.-based KLAS Research. “The inpatient EMR is really the primary influencer on adding a RIS now,” says Brown. “So whether it's a Meditech, Cerner, Siemens, Epic, or McKesson, in most cases, if you've got that EMR vendor-and with a few exceptions related to McKesson's RIS and Eclipsys's relatively small customer base-most hospitals would prefer to have a single vendor across RIS and vendor. There's a huge driver for tight integration between the patient record and the ancillary system that's sending radiology reports,” he adds. For smaller community hospitals, and in the ambulatory space, a focus on RIS-PACS integration can sometimes make sense, he says. “But for the most part, CIOs are preferring integrated RIS-EMR.”

THE INPATIENT EMR IS REALLY THE PRIMARY INFLUENCER ON ADDING A RIS NOW.-BEN BROWN

LIVING WITH CORE COMPLEXITY

For CIOs and their colleagues, it turns out that accepting the complexity at the core of many of their organizations' operations is the beginning of progress forward. That's certainly how Scott MacLean, CIO of Newton-Wellesley Hospital in Newton, Mass., one of eight owned acute-care hospitals in the Boston-based Partners HealthCare system. As Partners has grown through merger and acquisition, hospitals like Newton-Wellesley, among those acquired, have benefited from the size and strengths of the parent organization, but have also had to accept how complicated a large system involving both academic medical centers and community hospitals can be. Partners has developed what is called a crosswalk viewer for physicians employed by or affiliated with any of the hospitals in the system; at the same time,
MacLean reports, “Each of our hospitals has a different [individual hospital] viewer, based on its [PACS] vendor.” Fortunately, the crosswalk viewer has created capability to bridge the eight different PACS at the eight different hospitals, and MacLean reports, physicians are delighted with their access to the image repositories across the Partners system, as a result.

Interoperability: Imaging Center CIO Viewpoint

For Lyle Backenroth, CIO of the Hicksville, N.Y.-based Diagnostic Imaging Group, interoperability is a nearly all-consuming challenge. His organization, which encompasses two large groups of imaging centers-21 centers in the New York metropolitan area, and 17 across the state of Florida, employs 1,500 people, including about 65 radiologists and radiology specialists, and performs 1.4 million diagnostic imaging procedures a year.

The Diagnostic Imaging Group's picture archiving and communications system (PACS) is from the Rochester, N.Y.-based CareStream Health, while its radiology information system (RIS) vendor is the Tampa-based Sage Healthcare. Doshi Diagnostic, the New York branch of the organization, uses Sage's Intergy product, while Signet, the Florida group, uses Sage's older Medical Manager product. There is electronic medical record (EMR) functionality in the organization's RIS, though since the organization is a radiologic group, it is at the RIS level, rather than at the inpatient hospital level of features and functions. Backenroth spoke recently with HCI Editor-in-Chief Mark Hagland regarding his challenges and opportunities.

Healthcare Informatics: Do you have any kind of physician portal?

Lyle Backenroth: Yes. We have CareStream WebPACS for referring physicians, which is essentially what the radiologists have, just minus the advanced tool sets. And in New York or Florida, they can see the radiology reports as well as the images.

HCI: Are some of the referring physicians using mobile devices right now?

Backenroth: We haven't gotten many requests just yet for them to see some of these images. I'm not opposed to it, but there is a mobile device screen resolution issue.

HCI: How well integrated are the RIS and PACS?

Backenroth: Pretty well integrated, because we use a third-party broker from a company called UltraRad [West Berlin, N.J.]. We've been using their broker, and it's fairly customized. We need a fair amount of customization, not only for our radiologists' use, but for the use of the referring physicians' groups as well, for example, with regard to order messages and reports; and I can also receive messages from them, as well as update the patient demographics. The product is called UltraBroker.

And it allows HL7 messages to flow from my RIS to my PACS over the broker; and from the RIS, reports can flow directly to a doctor's EMR. Or if they want to view the reports along with the images, through a Web interface, they can do that through Care Stream's WebPACS. So they can go in manually through CareStream; or if they want the reports, as soon as they're medically approved by a radiologist, our broker facilitates that, through a VPN.

HCI: What are the largest challenges you face in the context of what we've been talking about?

Backenroth: Probably multi-vendor integration. I have to deal with Allscripts, MDLand, eClinicalWorks, and NextGen, for example; I have to interact with those vendors in order to drop in HL7 messages. I also have to make sure that the HL7 component in CareStream, IS-Link, the HL7 engine running in CareStream, operates successfully with the rest of my internal RIS, and my broker. So the biggest challenge really is inter-vendor interoperability, with the EMR vendors, and with the modality vendors as well. And the modality vendors have to use a DICOM modality worklist, for example.

And there are nuances with using all those different worklists. All the vendors set their worklists to a standard, and I have to manage all that. And in reality, DICOM is not a true standard. When a vendor says, I subscribe to a DICOM standard, they're telling you how they conform to the standard. You put out a DICOM conformance statement explaining how you conform to DICOM; and they all do it differently. And nuclear medicine is an example of where the vendors all do their own variation on DICOM, and that causes all sorts of variations that I have to handle.

So there's a lot of tweaking that happens, and these vendors are very myopic. And our situation is different from a hospital's, because we have to stay in the black, we have to be profitable. If I were to get very close to a very large vendor, they could start dictating terms to me, so I have to balance multiple vendors in order to keep their prices honest. The reality is, I try very hard not to marry any of my vendors. It's a constant balance in terms of finding the best prices, best products, and maintaining quality and service at all times. So I have to constantly manage the inter-vendor situation in terms of standards. Thus, inter-vendor interoperability is my biggest challenge.

ALL TOO OFTEN, I THINK PEOPLE HAVE TOO NARROW A VIEW OF WHAT CLINICIANS' NEEDS ARE AT A GIVEN TIME.-DAVID VORAN, M.D.

In the end, all those interviewed for this story agree: There will be no magic bullets in this area, particularly with regard to the back-end interfacing and interoperability work. Fortunately, some of the portal- and viewer-based solutions that have been created so far have pleased referring physicians, and satisfied the needs of an ever-more-mobile group of practicing clinicians.

Healthcare Informatics 2010 November;27(11):10-18