A Massive Undertaking

June 24, 2011
David Piraino, M.D. Think it's tough trying to integrate RIS (radiology information systems), PACS (picture archiving and communications systems),
David Piraino, M.D.
Think it's tough trying to integrate RIS (radiology information systems), PACS (picture archiving and communications systems), and the EMR (electronic medical record) across a single hospital? Imagine for a moment that you've got 12 hospitals, 14 clinics, 20-plus imaging centers, 1,800 salaried physicians across 100 medical specialties and subspecialties, 53,000 annual inpatient admissions, 3.1 million outpatient visits, and a national teleradiology program to manage.

That's what the clinical and IT leaders at the Cleveland Clinic integrated health system have been working with, as they pursue their RIS/PACS/EMR integration plan.

Albert Edwards, Jr.
Indeed, the past two years have been a blur of activity at the health system, as the organization has completed its implementation of its core EMR (from Madison, Wis.-based Epic Systems Corporation), the installation of a nearly complete second-generation RIS (from Malvern, Pa.-based Siemens Medical Solutions USA), and has been working steadily on the integration of both its RIS and its PACS (also from Siemens) with its EMR. And as if that's not enough, in addition, it's been forging ahead with the development of an enterprise master patient index (EMPI).

Among the tasks to be addressed have been a very large amount of interfacing and integration, the automation of remaining Cleveland Clinic outpatient sites, and the ongoing coordination of efforts with both major vendors to create the EMPI.

Obviously, all this activity involves a tremendous amount of work for everyone involved — the organization's core IT team, its radiology IT specialists, its other staff, and its clinicians. But it's all worth it, says David Piraino, M.D., a practicing musculoskeletal radiologist who is also section head of the Computers in Radiology area.

“We believe that any image should be able to be read and interpreted and seen anywhere,” Piraino says. As a result, the Cleveland Clinic organization consolidated all its disparate PACS systems at the various hospitals into a single, integrated PACS for the entire enterprise. “At the same time,” he says, “we also had the vision that you can't just do the PACS system, you also have to facilitate the viewing of the images by referring physicians. So as we've rolled out our EMR, we have been integrating the imaging component and interfacing that with the EMR, so in the EMR, you can see the results and clinical history from the different hospitals. You can also see the images from the different hospitals, even if you have different medical record numbers,” using the EMPI that is being worked out at the present time.

In fact, says Albert Edwards, Jr., director of clinical integration and interfaces for the health system, working out the EMPI has turned out to be a major practical challenge, as the legacy RIS system that had been in place had not been written to accommodate 12 hospitals with 12 different medical record numbers.

“Today, we route the local medical record number to the Siemens system and route the same thing into the Epic system, which internally identifies that patient, assigns an EMPI number to that patient's record, and uses a ‘boomerang’ or ‘rebound’ interface” to identify that record for clinicians at any of the various hospitals who access that individual patient's record,” he says.

Right now, any physician in the Cleveland Clinic system can access any patient record through the organization's EMR, regardless of where the patient has been treated. And with regard to radiology, a radiologist or other physician can go into the EMR and find all a patient's records, though at present, it requires an extra step if one begins in the RIS or PACS system.

“What we're working towards is having a more enterprise-global view of the patient,” including from the radiology system point of view, Edwards says. “Will it happen? Yes. We expect it to be completed within the year.”

Different kinds of challenges

Managing and coordinating the sheer size and scope of this initiative is clearly the greatest overall challenge, Piraino and Edwards agree. In addition, there have been challenges that one might not immediately anticipate, some related to how physicians work.

One that has required considerable process work, Piraino says, is the need that was identified at a certain point for standardization of imaging orders as primary care physicians and specialists were ordering diagnostic imaging scans in a variety of ways. The differences that made imaging reporting in the information systems cumbersome and uneven, and complicating the rollout of the CPOE system for the enterprise.

Piraino gives a for instance. “The ordering of knee X-rays is a good example,” he says. “We have orthopedic surgeons who, when they order, they specify ‘bilateral standing with lateral view/tunnel merchant view,’” he says. “And then sometimes, they'll further specify, ‘obliques,’ whereas the PCPs will just say, ‘knee X-ray.’” Such discrepancies in ordering practices have not only caused confusion in the past, but have made documentation in the RIS and EMR difficult.

As a result, he reports, “We compromised, so there's now a standard general knee X-ray order. And we standardized that means with the patient standing. And then we made it more specific on the specific views. So if you're general practice, you can order a two-view knee X-ray and get what you want. Then the specialists can add on what else they want from a menu.” This order standardization is now reflected in both the EMR and the CPOE, he notes. But it took a fair amount of back-and-forth discussion between and among different groups of physicians to reach a consensus in this area and then apply that consensus to order definition.

Another development that took place in 2006 helped advance integration work process significantly, Edwards notes. One element that helped advance this was when the radiology and IT departments came together to accelerate progress, he says, moving away from having outside project managers run the project. Piraino coordinated a collaboration between his office and Edwards's, and established meetings between his administrator and Edwards. The two “put together timelines and good project management tools to make things visible, to say, here's where we're going, this is our goal, and started itemizing, from a patient financial point of view, how are we getting orders, dealing with registration, etc.,” Edwards says.

The pair's advice to CIOs trying to tackle such a broad initiative? Edwards says coordination between the radiology area and IS is essential, as has taken place at Cleveland Clinic. Without tight collaboration, he warns, integration work can become bogged down and confused.

Adds Piraino: “Do the EMPI early; we didn't.” Determining process around the creation of the EMPI and its rollout might seem like a detail, but it is a critical one in the attempt to integrate systems across a large number of hospitals, clinics and imaging centers. And not tackling such issues early, he says, could prove disastrous.

Above all, they agree: CIOs need to work collaboratively at a high level, with clinicians and across teams, in order to move forward an effort as broad as the one that has been bearing fruit at the Cleveland Clinic organization. Without a strategic approach, they agree, success is a long shot.

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