This is the second installment of a three-part series examining the major strategic trends in the imaging/PACS space. This story looks at the challenge of integrating RIS and PACS systems with core EMR and CPOE systems. In Part III, which will appear in August, we will look at strategies for working with vendors.

Perhaps the thorniest question surrounding the installation, replacement, or upgrading of RIS and PACS software management is the integration of these applications with the core EMR systems in any patient care organization. There is no easy answer to the underlying question, which is how, when, and what to do about the integration issue.

For one thing, hospitals and health systems are implementing, replacing and upgrading clinical information systems of all kinds on different schedules and according to different strategic and tactical timetables. And then there is the core question of whether to try to move as closely as possible towards a single-source strategy. For many CIOs and imaging IT leaders, the whole discussion becomes something of a Rubik's cube-type conundrum, especially given the ever-changing vendor market.

Even patient care organizations with unusual advantages in this area find the issue a challenging one. Take, for example, Beth Israel Deaconess Medical Center in Boston, which years ago became among the earliest organizations to adopt an EMR through self-development, under the leadership of John Halamka, M.D., its senior vice president and CIO (Halamka is also CIO of the CareGroup Health System, of which Beth Israel Deaconess is a part).

“We're a GE PACS shop,” Halamka says, referring to the Chalfont St. Giles, U.K.-based GE Healthcare, “while we've had a self-developed EMR for a number of years. But you need one totally integrated system, so we asked GE to give us one URL or XML query to use, so that doctors could do either of two queries. The first would be, ‘Show me all images about Mrs. Smith,’ for example. And the second would be, ‘I'm now in the middle of Mrs. Smith's diagnostic imaging mammogram — show me that one.’”

Halamka concedes that there's a fundamental underlying tension here. On the one hand, he says, “I don't want to have to learn two different user interfaces, or two different passwords, or whatever. But that doesn't solve the problem that cardiology, gastroenterology, obstetrics, and pulmonology now all have images. So you have to think beyond departmental image management and think about enterprise-wide image management. Departments can manage own their own workflow; but images need to be centrally managed.”

The goal for CIOs in all this? “You must support full integration for the clinician users, so that they have a one-place solution,” he says. “And workflow is absolutely at the core. But you also need business rules — because what is the value of a five-year-old chest X-ray? Not that high. So we keep our near-term images on fast storage, but automatically move them to lower-level storage.” The schedules involved in shifting images to lower-level storage depend on a host of elements, including applicable federal and state regulations regarding the specific type of image (mammogram versus chest X-ray, for example) and its purpose. But experts agree on the overall importance of moving chunks of data to less-expensive forms of storage as appropriate.

Says Robert Tkachyk, a Cleveland-based consultant at the Falls Church, Va.-based CSC Corporation, “The biggest issue is the fact that EMRs don't normally have an embedded image viewer that allows clinicians to go directly into the images. And the other component that usually becomes troublesome is the PACS system itself, because some products don't even have the ability to identify an image within a study.”

A multi-phase process

In very large multi-hospital systems, such issues can require intensive work over long periods of time. For example, Greg McGovern — CTO at Adventist Health, an 18-hospital system spread out across four Pacific states and based in Roseville, Calif. — reports that the first hospital in his system began implementing a new interoperability architecture two years ago. That facility will be finished creating a fully integrated system across all 18 hospitals by the end of next year.

McGovern and his colleagues have a core EMR live from the Kansas City, Mo.-based Cerner Corporation, and are using a Cerner product called MD-Bus, a medical device bus, as a key linkage mechanism among the disparate elements of the RIS, PACS, and EMR architecture across all the hospitals in the system.

“The biggest challenge is interoperability and standardization between and among vendors,” McGovern says. “Architecturally speaking, the hardest part is agreeing on how the different Legos will be snapped together, because you're talking about the distribution model, as well as storage and lifetime management.” Thus, it's not surprising that such a process would require two years in a large system like Adventist Health, he says.

Even smaller patient care organizations face challenges in this area. For physician groups, a core element is limitations on resources of all kinds, including financial and IT staffing.

When James Busch, M.D., director of informatics and PACS, Diagnostic Radiology Consultants, P.A., a 10-radiologist practice in Chattanooga, Tenn., went shopping for an EMR for the group, he already had an idea of what he needed to do. Diagnostic Radiology Consultants had already been live with the Malvern, Pa.-based Siemens Medical Solutions' RIS/PACS for four years, and the group had also already been live with the practice management system from the Horsham, Pa.-based NextGen Healthcare. So it was a logical next step for Busch and his colleagues to select NextGen's core EMR.

Convenient access from anywhere was a major concern, Busch says. “We read for 11 sites,” he notes, including one hospital and nine outpatient sites.

“In the future, we'll be able to support best-of-breed, but right now, that's not possible,” he says. “SOA (service-oriented architecture) is here now, but the vendors aren't producing anything really incorporating it yet. So that's why we went with NextGen, because they've got a bidirectional communication mechanism with Siemens, which means that they really are integrated” functionally.

“Radiology is a service-oriented industry,” Busch adds. At present, a 24-hour turnaround for study reports to referring physicians is expected, if not considered a bit slow. So ease of access and ease of use on the part of radiologists has become a key to success, as well as patient care. Fortunately, by keeping ahead of the local market tech adoption curve, he says, “our business is growing significantly, precisely because of our service.”

In the end, whether in an academic inpatient environment, a multi-hospital, multi-state system, or at a busy radiology group, all those interviewed for this story agree that CIOs are increasingly expected to solve the PACS/RIS/EMR integration problem for end-user physicians and other clinicians.

In the future, Halamka predicts further integration of RIS and PACS systems by vendors, as well as “enterprise image management products that will provide a way to store and view all image modalities.” In the meantime, he advises CIOs, “Partnership with your image-generation departments is absolutely key. In our case, a year ago, I established an enterprise image management committee, staffed with representatives from radiology, cardiology, pulmonology, GI, endoscopy, vascular, and OB/GYN, all the image-producing departments.”