Integrated solutions and work-flow management are hot topics in the radiology industry today. This article will define these topics, provide some perspectives on their importance, and explore their evolving relevance in successful system design and implementation.

The business of radiology starts with a patient, a reason for an examination, and an order. From that point everything flows through a series of steps that culminates in the distribution of the final radiology report to the requesting source. The completion of work requires the interaction between a number of players, devices, and systems. Figure 1 illustrates the work-flow interrelationships between the various radiology systems.

Figure 1. Illustrates radiology work flow and interface interaction through the work flow.

Over time, individual systems have been introduced to automate the transactions required to perform the business of radiology. Radiology information systems (RISs) and dictation and transcription, speech recognition, image management, and billing systems are all now essential elements of most radiology operations.

Each individual system provides special value by automating a step in the overall process, but with the proliferation of all of these systems, complexity has increased. For example, the radiologist now may have to interact with multiple systems in order to render a final report. Images are viewed on the PACS workstation (and most likely the light box), the radiologist’s voice is recorded into a dictation or speech recognition system, patient history must be queried in the hospital information system (HIS), and the final signature of the report is done in the RIS. Each of these systems has different user interfaces and user rules and may operate on separate computers. Having to interact with these separate systems can be confusing and inhibit productivity.

Figure 2. The typical work-flow pattern for a hospital-based RIS with a PACS, requires multiple interfaces.

All of these systems have a common need in that they must receive patient demographic and order information from the HIS or RIS so that the individual systems are synchronized. This is accomplished through application interfaces that enable the various systems to communicate with each other. The need to interface these independent systems is fraught with shortcomings that have led to a new concept: a totally integrated solution (TIS).

The following is a review of the shortcomings of current radiology information management systems that are paving the way for the TIS concept.

A. Disparate systems from several vendors joined together by interfaces or brokers. Tables 1, 2, and 3, which describe these various interfaces, are posted online at

1. Interfaces include patient demographics, orders, results reporting, and scheduling. Traditional HIS or RIS systems do not have the ability to send out scheduling messages and some RIS systems are just now beginning to implement outbound messages for PACS. Information needs to pass between systems (bidirectional) as status changes. Figure 2 illustrates interface functionality.

2. Interfaces require cooperation by both vendor parties. Some companies are more complex to deal with than others.

3. Interfaces require testing; sometimes they just do not work consistently.

4. Interfaces are time-consuming to design, implement, and support.

5. Interfaces require a one-time charge, which is based on the hours of technical effort required to achieve the interface. They can range from $15,000 to $90,000 for the software, which carries an ongoing support charge usually in the range of 16% of the one-time interface charge, plus a $10,000 to $85,000 implementation fee.

6. Software version upgrades can require interface redesign. Version control can be a problem.

7. Brokers or middleware applications that convert HL7 to DICOM require separate license agreements, and possibly hardware, which adds to system complexity and cost.

B. Patient information exists in different places, requiring interaction with several devices or systems.

1. Images for the same patient may be stored in different systems leading to some confusion as to where an interested party needs to search in order to view the entire patient radiology record, which includes images, results, and order status information. The PACS knows only what is stored in its database and archive; the RIS only knows order information, and where the films and reports are stored.

2. The user may need to query multiple systems in order to find the information needed about the patient. In that case, it must be quite clear to the user that information is stored in multiple locations.

C. Paper-based information is not well addressed.

1. Information about the patient is printed on paper and located in file folders stored in the film file room.

2. Information that occurs during the procedure needs to be recorded. For example, a technologist may want to let the radiologist know that a patient was unable to hold breath, which led to marginal image quality. In cases where an RIS and PACS are implemented, the requisition that is printed from the RIS is manually routed to the diagnostic read station, and if the images have been routed based on rules to each diagnostic read station, the technologist must be aware of the rules. In cases where images are routed to remote locations for reading, the requisitions may be sent by courier or the radiologist reads the images without this information.

3. Surveys and questionnaires are relevant but still on paper. Clerks must move this information to the required source.

D. Multiple databases are difficult to manage and synchronize.

1. Managing John Doe patients, patient merge (upon change of marital status), and multiple patient identifiers.

E. Information about the patient or the procedure, as entered into the modality, does not match the information entered at the RIS.

1. This disparity leads to orphan or penalty box situations.

F. Status information, such as the time of patient arrival, procedure complete, preliminary report, and final report, is difficult to manage across multivendor systems.

G. The role of the technologist is often overlooked.

1. For example, the examination completion step consists of data entry about the examination including procedure notes and surveys.

2. Information about the supplies used in the examination can be entered and, if views or studies are added, that information can be added at the point of completion where the information is most fresh.

3. The technologist, when planning to do the procedure, may wish to review the patient history and the prior images to determine positioning or technique used.

On The Horizon

Figure 3. A schematic for a hospital-based totally integrated solution (TIS) illustrates just one interface.

Totally integrated solutions are being developed to provide the ultimate work flow through the integration of the traditional RIS, voice capture, and image management systems with the objective of eliminating the current disparate system shortcomings (Figure 3 illustrates a hospital-based TIS).

Theoretically, a TIS should include the following features:

1. A clinical application commonly referred to as a RIS that includes all the traditional RIS components,1 which manage orders, scheduling, forms, production, hard copy or electronic, film file room, breast imaging, patient examination history, transcription, and management reporting.

2. A radiologist desktop appliance that consolidates several functions into one device. The radiologist uses this component to review the electronic requisition that contains patient demographics, clinical patient data, order information, and technologist notes and to manage their work list. It offers the ability to review historical results and record their voice (digital WAVE or analog tape) so that a transcriptionist can listen to the recording and type the words into a word processing program and then submit that word file to the radiologist for editing and/or final approval as signified by the radiologist’s signature (manual or electronic). It also may include integrated speech recognition technology that automatically converts speech into text. When electronic images are available, it is also the diagnostic image review system. This system (hardware and software) provides an electronic means of displaying patient images that have been digitally acquired, commonly referred to as a diagnostic workstation. It is used in conjunction with a light box, which displays conventional film-based patient images.

3. A work-flow manager. This application manages and tracks the movement of patient image files from acquisition to display to long-term storage. It provides event notification to the system and users as the order moves through the system. Individual user profiles are maintained for individual users that define how the images are to be formatted on the monitors and what historical image files are required to support the current diagnosis. It applies the business rules that control the movement of the patient files to designated workstations and the management of work lists.

4. A storage management system for both text-based and image information, consisting of hardware and software that manage the storage of images and results. The system manages the migration of media; it maintains a database of the stored patient studies, and controls user access. It is aware of the location of film-based and digital images.

5. A technologist quality assurance station that facilitates the examination completion process. A list of examinations is presented to the technologist. For modalities that cannot handle a modality work list, the technologist picks the patient information from a list and matches it to the information entered at the modality. Corrections are made prior to commitment to storage. This function allows the capture of wait times and actual procedure performance time, the capture of supplies, any incidents with the patient, and what films were utilized for productivity analysis management reporting. The radiology manager can utilize information captured in this function, for resource utilization analysis and evaluating patient turnaround times.

6. Methods to provide access to/or distribute patient images, results, order status, and information to the requesting source. The component manages the distribution of the final radiology report to the requesting source. Automatic faxing or email is common. Web-based access is becoming more prevalent. Courier delivery is quite common when duplicate films are required in addition to the report.


There are a number of potential benefits that could be obtained by using a TIS provider.

  • Lowers potential cost of ownership
  • Decreases order cycle time
  • ?Expands the traditional radiology database that includes image data
  • Image status-study started, study complete, QC complete
  • Image storage-tracks location of images
  • Image validation and access
  • One database to maintain for RIS/PACS/voice recognition
  • One point of contact for RIS/PACS/voice recognition, one user interface
  • Users save time by accessing one system for comprehensive database of patients, orders, results, and image location
  • Eliminates the need for paper-based information
  • Eliminates orphaned images by automatically linking the examination data to the image’s unique identifier, thereby reducing radiologist wait time at the diagnostic workstation and ensuring a higher level of clinical integrity
  • Consolidates and integrates all the tasks associated with the production of a radiology report, resulting in quicker report turnaround and improved referring physician and patient satisfaction.

Buying into the TIS concept when it finally is a reality should happen only with a few caveats in mind. Although a few vendors are making significant progress toward the TIS vision, no totally integrated systems have been implemented. Some DINPACS deployments may be an exception.

Total dependence on one vendor for imaging management purposes could be risky, and leave an institution in a weakened bargaining position.

There is also the possibility that the concept is just too good to be true. Clinical work-flow management, image management, voice recognition integration, browser-based systems, storage management, and image display are all complex applications in their own right. It will be a tremendous challenge for a single vendor to be able to manage all of these tasks well.


The objective of initial PACS designs was to eliminate film. As noble a goal as that seemed to be at the time, the narrow focus on film elimination was flawed because it automated only one step in a process that by definition is not to produce film but rather a final radiology report. The narrow focus also overlooked the need for radiology image and information access by the other constituents in the patient care process. And finally, PACS implementations did not adequately take into account the interdependencies with other information sources and systems in the overall process.

Awareness of the importance of work flow and integration is a growing design consideration for information and image management solutions. The integration of speech recognition reporting systems with diagnostic review applications is common today. It is also quite common to find the integration of speech recognition systems into radiology information systems as well.

Close integration of radiology information systems and image management systems is in its early stages. Based on the recent industry consolidation involving modality, film, PACS, and HIS/RIS vendors, it is apparent that the potential for totally integrated work flow is imminent. The IHE (the Integrated Healthcare Enterprise) emphasis on the importance of work flow and methods for disparate systems to integrate is further evidence of this trend.

As the industry continues its convergence, expect a new breed of integrated radiology work-flow solutions to become available. The distinctions between systems and functions will begin to blur and finally disappear.


1. Giles SD. A RIS for all reasons. Decisions in Axis Imaging News. 2001;14(3):24-28,49.

Sherie D. Giles is an independent radiology information system work-flow consultant with more than 26 years of health care information experience; [email protected]

Jim Maughan is a Houston-based independent consultant with more than 22 years of sales, marketing, and business development experience in the radiology industry. He can be contacted at (713) 871-8160 or by email at [email protected].