Lynn Witherspoon, M.D., has an unusual background for a CIO. A physician whose clinical specialty was nuclear medicine, Witherspoon first became interested in imaging and image data-management issues while practicing within what is now the Ochsner Health System in New Orleans. As a result, Witherspoon became involved in a project 11 years ago that brought what he calls a "quasi-PACS" system for X-rays to what was then the Ochsner Clinic, and is now the flagship hospital of the seven-hospital Ochsner Health System. This system created digital output of images from X-rays (no CT or MR), and allowed radiologists to print out those images onto film. But without digital storage, the radiographic images were still stored on film.

With its unusual history of having already had a "proto-PACS"-type system that already generated (though did not store) digital images for the physicians, "Our referring doctors had a long culture of reviewing their patients' X-rays," Witherspoon notes. As a result, there already existed pressure for the Ochsner system to use PACS to make diagnostic images more readily available to referring and ordering physicians. And, in turn, the rollout of the EMR system and the diffusion of electronic records to physicians across the community added to the forward momentum at Ochsner. As for integration, Witherspoon reports that, "As the patient chart became electronic, the X-ray jacket was still film, now scattered around the place, and there was a large disconnect. PACS," he says, "allowed us to put a Web portal in the EMR. So now they'll open a folder on a patient record in the EMR, and they can open the PACS." (Ochsner is using a PACS system from Mortsel, Belgium-based Agfa.)

The path forward to PACS-EMR integration hit a fairly big bump, however, when the attempt over the past couple of years to partner with a large core clinical IS vendor to create an enterprise-wide image management capability failed. Still, Witherspoon says he and his colleagues learned a great deal from doing that project, "and we turned back to Agfa to reconnect all the pieces." At press time, Witherspoon and his colleagues were in the process of building out that enterprise-wide image management system, which is fully interfaced with the organization's core EMR. And Ochsner Health System's saga, though varying in certain details, mirrors the long-and-winding-road types of experiences many hospital-based organizations are currently having across the United States, as well as internationally.

Nationwide, a surge in development

Indeed, hospitals and health systems across the United States. and worldwide are facing similar challenges as they push towards the full integration of PACS systems with their core clinical computing systems. Among the key trends and developments pushing comprehensive image management forward are the following:

• a rapid acceleration in the implementation of EMR systems nationwide and worldwide;

• increased sophistication in terms of the capabilities and functions of PACS systems;

• lower prices for PACS systems than a few years ago, due to vendor market competition;

• an explosion in the size and number of diagnostic imaging studies because of the economics of digitization of the diagnostic imaging process;

• the emergence of PACS and PACS-like systems for non-radiology disciplines, including cardiology, surgery/OR, orthopedics, oncology, ophthalmology, gastroenterology, dermatology, and pathology, and the subsequent need to integrate those systems into broader clinical information systems;

• because of the explosion in the size and volume of diagnostic imaging studies, a concomitant explosion in the need for additional image and data storage among hospitals and health systems;

• higher expectations on the part of radiologists, referring and ordering physicians, clinical departments, and other stakeholders, with regard to the availability and share-ability of images and data enterprise-wide.

All of this, of course, means a sense of urgency on the part of many patient care organizations to systematize what could otherwise balloon into a jumble of images and data.

"The topic of integration with EMRs is really becoming the next big thing," confirms Scott Grier, a director at Abrio Healthcare Solutions, Nashville. "I think that we technology geeks have accomplished the majority of things in PACS," says the Sarasota, Fla.-based Grier, who has decades of experience in PACS selection and implementation consulting. "It's a question now of how we use it."

In fact, Grier says, the availability of digital images is rapidly becoming part of the assumed cost of business for all but the smallest and poorest of hospital organizations nationwide.

At the same time, Grier says, "Images are still being treated by the EMR as a red-headed stepchild. They're out there, but detached in terms of process. They sit in their own archive, and they're not easy for the clinician to access."

Some of the largest core-clinical information system vendors are developing such mechanisms as portals in order to facilitate image viewing. The problem, Grier says, is that, "It's not uncommon to take 300-400 slices in a single diagnostic imaging study these days; and the physician needs to get to the right slice, the right image, right away."

As a result, he says, one of the biggest pushes of the next couple of years among patient care organizations and vendors will be the reworking of technologies and processes to streamline the accessing of, sharing of, and storage of, images, within the context of overall clinical computing.

The challenges of PACS-EMR integration turn out to be more heavily weighted toward process and other factors rather than toward the available technology per se, says Michael Davis, executive vice-president of HIMSS Analytics, the data analysis and research subsidiary of the Chicago-based Healthcare Information and Management Systems Society (HIMSS).

"The technical challenges of integrating PACS and EMR systems are relatively minor; it becomes a routing and finding issue," says the Denver-based Davis. But, he quickly adds, "Getting the image is not a tough thing; doing the e-mail with an image is not a tough thing; getting the documentation together with the images is the tough thing."

In that regard, he refers to HIMSS Analytics' now well-known seven-stage model of EMR development, which articulates seven broad stages of development that EMR/clinical information systems must go through to become truly comprehensive and fully functional.

According to Davis and his colleagues at HIMSS Analytics, by their reckoning (which is based on on-site evaluations, using very specific criteria), only 12 hospital organizations in the United States, at most, have reached Stage 6 of their schematic, which means that those organizations have a complete infrastructure to support full integration of documents and images within a comprehensive clinical information system, one that encompasses both PACS and CPOE (computerized physician order entry). Interestingly, Davis notes that only two of the 12 hospital organizations in Stage 6 are academic medical centers; the others are community hospital-based organizations.

Vendor stumbling blocks

Not everyone is so sanguine about the technology challenges around PACS-EMR integration being insignificant. John Glaser, Ph.D., vice president and CIO of Partners HealthCare, the eight-hospital, integrated health system in Boston, says that a specific vendor-product issue often gets in the way of true integration. "The challenge with a replacement system," says Glaser, "is that if the PACS is more sophisticated and more like a full clinical information system, with decision support and workflow tools, then integrating it with our core EMR is like integrating two full clinical systems. You've now taken a system that used to be a more modest contributor and made it more of a peer" to the core EMR.

Such issues are far from trivial at Partners, whose clinicians create and share more than 100 million diagnostic images annually, and have a total number of images already in storage of over 500 million, notes Glaser. What's more, the hospital facilities within Partners work with a variety of EMRs, radiology information systems (RISs), and PACS. There are four EMRs within Partners, with the organization's self-developed EMR accounting for 85 percent of physician usage, he adds.

Inevitably, in a multi-hospital, integrated health system such as Partners HealthCare, Web-based connectivity and access will have to provide a part of the integration/interfacing solution, Glaser says. At Partners, physicians connect in through a Web-based portal, and can access data and images from all the systems they need. The technological challenge he sees lies primarily in reining in the PACS systems that provide ordering and decision support components which could clash with the ordering and decision support elements of the organization's EMRs. Good context management, including sign-on management, is part of the solution, he adds.

Progress in Chicago

The same kinds of principles apply at Northwestern Memorial Hospital, the 744-bed academic medical center in the heart of downtown Chicago that has hundreds of physician affiliates working in a variety of groups and practices, says Timothy Zoph, Northwestern's vice president and CIO. At Northwestern, all affiliated physicians have Web-based access to diagnostic images across the enterprise, and can achieve access inside the main hospital facility or remotely. PACS has been live at Northwestern for seven years, and has helped to transform care processes, from the emergency department, to clinical departments in the hospital, to outpatient- and office-based clinical workflow, Zoph says.

Northwestern has gone through several generations of PACS systems while staying with the same vendor, the Chalfont St. Giles, U.K.-based GE Healthcare, and the organization's commitment has been toward greater process integration with EMR use and with clinical computing and workflow more generally, Zoph says.

Where is all this progress headed? Over the course of its use, "PACS becomes more of an information utility" within the broader context of clinicians' work lives. "You'll need PACS because of its viewing, storage and retrieval capabilities. PACS does have some functionalities that are important in terms of how physicians actually read. But you're going to see images become far more integrated in terms of decision support and data management in terms of EMRs."

In that regard, Zoph predicts that radiology information systems will, within the next several years, essentially disappear, as PACS use becomes inextricably linked to core EMR processes. This is a natural development, he says, noting that RISs originally were developed because PACS themselves were conceived of as departmental systems, at a time when few hospitals had fully operational EMRs.

Indeed, all those interviewed for this story also agree that, as PACS and PACS-like image storage and retrieval systems are developed for more and more medical specialties, the need for functional integration will become even more pressing. Currently, many hospitals already have cardiology PACS, but within the next few years, many more will also acquire imaging storage systems for orthopedics, general surgery, gastroenterology, dermatology, ophthalmology, and pathology.

The bottom line in all this development, Zoph says, is that, "You don't want to just have data and images locked up in departmental systems. Increasingly, physicians of all types will be working with images as they all now work with data, and data and images will have to flow, be shared, and stored seamlessly for all hospital organizations to function optimally."

The exploding volume of diagnostic imaging studies — both the volume of studies themselves, and the volume of images within individual studies — will necessitate both greater integration of workflow processes and increased attention to image storage, Zoph says. Northwestern Memorial is one large academic medical center with associated physician groups, so its volume is not quite as high as Partners HealthCare's, but Northwestern nonetheless already has a stockpile of 200 million diagnostic images, taking up 100 terabytes of data, a daunting volume.

Meanwhile, Zoph reports, "We're generating 33 gigabytes of new diagnostic images a day. What's more, our image growth is going up 30 percent a year, while our study growth is growing at 15 percent a year." Put another way, image volume is increasing at twice the rate of study volume. Of course, this is because of the ability of diagnostic imaging to produce more views, or "slices," per study, more efficiently and time- and cost-effectively. "We're replacing 64-slice machines with 128-slice machines and there's no end in sight," he adds.

A "box swap" in Memphis

Those hospital organizations that are going through complete PACS replacements as they gear up to support diagnostic imaging and clinical computing advances are finding that actual replacement of entire PACS systems is quite an undertaking.

Just ask Jim Leonard, an executive for the Long Beach, Calif.-based First Consulting Group who currently works as the outsourced CIO for the Regional Medical Center at Memphis, commonly referred to as "The Med."

"First-generation PACS systems," Leonard says, "were very proprietary in nature, even down to the workstations, so nothing is really reusable. That means going from a first-generation system to a second-generation one means a complete 'box swap,' including all new servers on the PACS side, and all new workstations on the user side."

What's more, moving to a new replacement PACS system also necessitates the migration of images on the old system to the new system, a process that can create numerous headaches for CIOs and clinician executives. The other challenge is a psychological one, Leonard says. "After having used a first-generation PACS, the radiologists understand the system and understand their specific workflow. So on the one hand, less training is needed the second time around, but on the other hand, they're much more demanding, because they know what they want."

Leonard says, "There's been a huge leap in functionality in terms of clinical workflow with the current crop of PACS systems. First-generation PACS was a boon to the radiologist; second-generation PACS is a boon to the whole radiology department."

Future vision

All these parallel and intersecting lines in terms of PACS and EMR development hold numerous implications for CIOs and their teams, agree all those interviewed for this article. One of the most practical is around access management.

"PACS used to be sort of an advanced application area, but it's become quite routine, and it brings along with it the necessity to start working on things like single sign-on, because obviously clinician users want to be able to move back and forth," says Jane Metzger, a director in the Emerging Practices Division at First Consulting Group. "I think that the integration challenge is complicated by the fact that for clinical care, the non-radiologist ordering physician really wants to be able to move back and forth between the written interpretation report, which comes out of the radiology departmental system, and the image," says the Boston-based Metzger. "And they want to be able to do that really seamlessly."

"PACS right now is a very mature environment; even in the second-generation world, there's very little to differentiate among PACS vendors," says The Med's Leonard. Instead, he sees progress in two areas. One is in the technology advancements being made around three-dimensional viewing of images for radiologists and for many other specialists. The other will be "maybe a tighter ability to manage PACS images for other specialties."

Louis Lannum, radiology informatics administrator for the Cleveland Clinic Health System, which encompasses 12 hospitals and 13 family health centers across northern Ohio, says that CIOs and other IT executives need to think strategically about image management in the broadest possible terms. As at Partners HealthCare and Northwestern Memorial Hospital, the Cleveland Clinic organization has seen an explosion of growth in images and needs.

"I've been with the Cleveland Clinic since 1999, and in that time, we've have gone from three imaging servers to 15 right now," Lannum says. The bottom line? "Radiology and imaging people are right now at a crossroads. They can either allow institutions to create silos of imaging and information, or they can take the initiative and truly create an image management department that manages any image, no matter where it was created. What you don't want to have happen is to wake up one morning and find out that orthopedics and vascular and surgery have all gone out and created their own silos. You don't want that, because it will become totally unmanageable in three years."