The beauty of PACS lies in the sheer ease of electronically storing, managing, distributing, and viewing images. Likewise, a RIS provides the same functions with medical information by streamlining scheduling, patient files, appointments, registration, billing, and management reporting. By integrating both solutions, facilities are provided with a highly desirable, complete workflow solution.

So, the marriage of the two systems seems like a perfect match. But what happens when the honeymoon is over, and you’re left with multiple systems that find it hard to communicate? As with any successful marriage, communication is key, especially with imaging solutions. So if RIS uses HL7 standards for text-based messages, whereas PACS uses DICOM standards to track images, just how does your facility integrate the two so that the systems talk easily? Needless to say, a host of issues must be ironed out when acquiring systems for your facility.

What Is the IHE?

Integrating the Healthcare Enterprise (IHE) is a standards-based initiative sponsored by the Healthcare Information and Management Systems Society (HIMSS of Chicago) and the Radiological Society of North America (RSNA of Oak Brook, Ill) to improve and expand the use and functionality of computers in healthcare. Just 7 years old, this partnership by two healthcare powerhouses?HIMSS works to maximize the use of healthcare information technology (IT) while RSNA works to develop the highest standards in radiology?has created a new era for integration. It aims to increase the pace of nonproprietary integration of information systems within healthcare environments. The IHE is focusing on integrating multivendor environments and optimizing the clinical workflow by applying established healthcare IT standards.

Along with the IHE Initiative in North America, international branches of this initiative?IHE Europe (IHE France, IHE Germany, IHE Italy, with efforts under way in the United Kingdom and other countries) and IHE Japan?have been established to endorse and provide a world-class integration platform.

One Step Further

Looking to network with more experts about the future of RIS/PACS? The Society for Computer Applications in Radiology (SCAR of Great Falls, Va) is hosting its annual meeting?and 25th-anniversary celebration?on June 2?5 in Orlando, Fla. As an added benefit, SCAR has teamed with the Society of Interventional Radiology (SIR of Fairfax, Va) to provide joint sponsorship of continuing medical education (CME) at the conference and for the preconference PACS administration course on June 1. In addition, SCAR will send the annual meeting program and the PACS administration overview course to the American Society of Radiologic Technologists (ASRT of Albuquerque, NM) for approval of Category A CME units for technologists. For more information, visit

Henri “Rik” Primo, division manager of image management-PACS at Siemens Medical Solutions (Malvern, Pa), believes that one day, RIS/PACS will be integrated thanks to the IHE’s efforts. “Siemens is making significant contributions to advancing and promoting all of these international IHE activities,” he says. Siemens Medical’s syngo software is deployed across all of its imaging modalities as well as its image information and management systems. “IHE profile changes are incorporated in new syngo releases, and, as such, are automatically included in all our systems,” Primo adds.

Recently, the IHE held its first multi-domain Connectathon in North America with systems from radiology, cardiology, laboratory, and IT infrastructure. The Connectathon participants learned how to manage processes for implementing standards, advice from industry insiders, and effective testing in a controlled environment.

Universal Challenges

Data inconsistency, testing, and HIPAA compliance are three key challenges facing the arduous?and often complicated?task of seamless integration. For example, PACS and RIS can use the same data in different ways. Sometimes, the difference can be trivial; other times, it can pose the potential for a serious adverse event. What happens when an organization uses a series of zeroes as part of a patient’s tracking number, but the PACS has been designed to remove those leading zeroes? Does the RIS find the report, or will it be lost in the shuffle of PACS confusion? Even worse, what if one medical record is confused for another similarly labeled report?

Many IHE profiles aim to decrease potential Sentinel Events. “When the CT scan reports to the PACS sending all the images, how does PACS know that [the scan] is not a fake and mistakenly adds the scan to the wrong patient’s record? How is PACS authenticating the CT scanner itself? Initially, it’s a lot of work, and the transactions are rigorous and thorough,” says Nogah Haramati, MD, chief of radiology services at the Jack D. Weiler Hospital’s Montefiore Medical Center (Bronx, NY). “Yet, when a vendor makes a transaction once, they’re doing it for every single vendor in the world. One interface works with every other interface in the world. That is the present and future of integration, and the IHE gave profiles in which to do this.”

When testing, experts suggest covering a range of HIS/RIS message types and procedures, in addition to covering as many modalities as possible. Be sure to hold conference calls when working with multiple vendors to facilitate efforts. To comply with HIPAA regulations, look for software that offers secure reporting methods. One available option is the Centricity RIS/PACS from GE Healthcare (Waukesha, Wis). It has Web-enabled reporting applications, offering secure reporting methods. This software offers advanced security features at the user, application, and function levels, including security logs and audit trails.

“The IHE already was well on its way with new protocols but had an impetus to develop certain profiles. With the implementation of HIPAA, the IHE added two profiles: enterprise-user authentication and audit trail,” Haramati says. In the past, the audit trail would log and audit trails, but every vendor had to create its own version of a log. Under HIPAA regulations, users have 60 days to view a patient’s folder. Therefore, the IHE’s version came up with a standardized audit trail. As Haramati explains, “The IHE makes no standards. For every problem, it tries to develop a solution.”

Based on his experience at Montefiore Medical Center?a 381-bed facility adjacent to the Albert Einstein College of Medicine of Yeshiva University?Haramati maintains that seamless integration is possible. “When you negotiate with vendors, be knowledgeable about the IHE, and don’t get a stale contract,” he says. Further, he offers the following three tips:

  1. Have flexibility with your vendors?allow room for new profiles and domains. And make sure your vendor agrees to give you profiles and a pass to important, relevant upgrades.
  2. Train your legal counsel?Montefiore has trained two healthcare attorneys in IHE. “We sit with the lawyers to get the right contractual language,” he says.
  3. Form a committee?”Every organization should have an IHE steering committee,” he adds. With so much to focus on, be sure your efforts in all departments are reflected in the devices that you buy.

Without Walls

Siemens Medical promotes its medical-imaging efforts as building radiology departments “without walls,” where radiologists at any given location are able to read any image, anywhere, anytime. Some of the integration solutions include syngo, which integrates imaging data, and Soarian, which directs and standardizes workflow processes. For example, Soarian Clinical Access interfaces with PACS to enable users to view information from multiple departments on any syngo-speaking workplace. Beyond streamlining the workflow, it offers a seamless transition between diagnostic and patient record views, since no separate sign-on is required.

“Siemens has developed a strategy to enable a single RIS to manage all the radiology worklists and workflow,” Primo explains. “All imaging modalities in the enterprise would send the images to the central PACS server. All patient ADT would be forwarded to the central RIS server. Any radiology diagnostic workstation would be connected to the central RIS/PACS server.” Health-system management can upgrade imaging modalities throughout the enterprise to make sure they can communicate with the RIS/PACS servers in the central campus. Using upgrades according to the IHE profiles and using the DICOM modality worklist, according to Primo, healthcare facilities can achieve their vision of a radiology department without walls.

“Better integration enables more accessible information. Better information enables better knowledge. Better knowledge enables better care,” he says, offering these three tips for negotiating with a vendor and researching integration profiles in your facility:

  1. Think people, processes, and products?map the current workflow in the radiology department. Who is doing what and when? Then, decide where quality improvements in the process are required: turnaround time from exam to report, patient throughput, access to previous exams, and so on. “Use RIS/PACS products as enabling tools for an improved workflow process,” he says. “Cut the use of film and paper wherever possible. Finally, measure the outcome of the change, and use the findings to start another cycle of improvements.”
  2. Think enterprise?integration is not just about radiology; it also involves all users of “imaging information” in the enterprise. As such, “when planning PACS and integration, involve all users and understand their requirements. Creating a steering committee, where all disciplines are represented, is a good start to define requirements,” he adds.
  3. Think standards?when acquiring new imaging and IT systems, make sure these systems adhere to open standards and support the IHE Integration Profiles, he recommends.

Paper Charts and 8-Tracks

With more than 1,500 clients worldwide, Cerner Corp (Kansas City, Mo) is working on “taking the paper chart out of healthcare” with a variety of solutions. Cerner Provision PACS offers the complete range of image-management products, including image acquisition, storage, display, and Web-distribution devices. The Cerner ProVision Study Validation Server offers validation and synchronization of patient demographic and exam data with image data. The Cerner ProVision Web delivers flexible integration with the EMR. And finally, the Radiology Desktop offers a single-screen tool for workflow ease.

Nanticoke Memorial Hospital (Seaford, Del) is a 140-bed hospital and the only facility within a 30-mile radius. The less than technologically advanced hospital contracted with Cerner to provide its RIS/PACS solutions and now has more than 17 systems, creating a seamless solution.

“We started searching for IT 10 years ago but couldn’t find anything that met our needs, so we decided to back off altogether. But with a big push by [federal] government regulations, our hospital’s president asked vendors to come in to get the ball rolling,” says Sandy Moody, CRA, BSRT(R)(M), FAHRA, project manager at Nanticoke. “We spoke with Cerner, who became our vendor of choice. Then we went out to research laboratory systems, and we thought we would go with the ?best of breed’ with each vendor.”

Yet the hospital quickly realized that this method would pose logistical and training problems for its three-person IT department. Ultimately, the hospital chose Cerner for its RIS, laboratory, and pharmacy needs. PACS was still the missing piece, and the hospital chose Cerner again. In November 2003, the hospital went live with 17 programs, including electronic scheduling, a total lab package, radiology with special emphasis on mammography, pharmacy, and a back-end system (such as registration and transcription). Not bad for a game of electronic catch-up, and the facility was poised to move ahead.

“We had a huge file room, and film librarians were spending so much time there. Technologists would carry previous X-rays and hand-write on studies. [The Cerner solution] eliminates technologists having to carry and hand-deliver films,” Moody says. “Yet, as we transition to filmless, we still have a need for old studies. As patients come in, librarians have a big volume of older records that they need to digitize. For example, referring doctors might want to see older images, so the librarians burn CDs for them.”

Moody offers three tips for working out the kinks when investigating integration at your facility:

  1. Have a CIO on board?”we did not, and the CIO is the person who pulls all the players together to provide communication throughout the process. It would have been more helpful if we had a CIO involved, since it’s critical to continuity and understanding the whole process,” she says.
  2. Evaluate workflow?do not undersize your numbers when negotiating with vendors. Give accurate, even slightly inflated numbers. “When we were looking at digitizing images, we chose the smaller, less expensive option. We really underestimated our digitizer, so be sure to evaluate your workflow correctly,” she remembers.
  3. Negotiate, negotiate, negotiate?make sure that the contract with your vendor specifies language regarding uptime guarantees. If you encounter an unforeseen problem, you could lose productivity, so be sure your contract includes some sort of reimbursement.

Elaine Koritsas is a contributing writer for Medical Imaging.