Over the past 10 years, radiology information systems (RIS) have been evolving from basic order management tools to all-encompassing work-flow automation solutions. This article will examine the market drivers for this trend, assess key industry trends, describe the impact of technology, look into the advances in functionality, and make some predictions about future RIS directions.
A summary of these items is presented categorically.
The evolution of RIS has included an integration of separate systems into more seamless solutions. For example, it is quite common now to find digital dictation and transcription modules as totally integrated subsystems of the RIS database. Commonplace technology such as the ability to create dictation WAV (Windows Audio Volume) files has made some of this possible, but what really drives the integration is the need to streamline the work flow for everyone involved, eliminate system complexity, and reduce total cost of ownership. This is now a recurring theme that is driving the integration of other systems, most notably picture archiving and communications systems (PACS), to be managed and controlled by the RIS. Other solutions such as billing systems are now also being offered as totally integrated with the RIS. The traditional lines that once delineated RIS, dictation, transcription, PACS, and billing are rapidly disappearing. When the lines are totally gone, a single database solution will emerge that will manage the entire business, imaging, and clinical work flow, a tall order.
As the lines between the systems continue to disappear, so are the lines between industries beginning to blur. Some modality vendors are acquiring information systems vendors, some PACS vendors are signaling their intentions to acquire health care information systems companies, and some information systems vendors are aligning with image management solution providers. It appears that all sides of the equation are preparing to better address the expectations of customers by acquiring companies or product marketing rights to provide some level of integrated solutions.
As the convergence brings health care information technology (IT) and modality and PACS vendors together, some vendors are now touting the importance of the larger scale integration: the electronic medical record (EMR), otherwise known as the holy grail. So the message is that radiology text-based and image information is really just a part of the overall patient record and that the ability to access all patient information, including laboratory, pathology, pharmacy, and surgery, is what is most important. Without question, the point is valid and so we see the potential for a shift in the selection criteria to vendors who can do it all compared to vendors who can just do radiology.
The experiences of PACS users have been chronicled in many industry forums, and the recurring theme is that the biggest problems with PACS result from nonexistent synchronization of the information contained in multiple databases. Brokers are currently handling the important exchange of data between the RIS and the PACS. The desire to eliminate this intermediary has led to the development of applications that manage and track the transactions between the RIS and the PACS and enable the single database approach. The work-flow application is a transaction manager and rules processor that uses standards-based and/or proprietary methods to communicate with the various systems’ components. For example, an order created in the RIS can trigger a query to the database that in turn uses a rule to retrieve studies from a digital archive and move them to a workstation. There is no broker involved. The RIS database has been expanded to include information about the imaging components and to manage the messaging and to keep track of the events. Some RIS vendors are offering work-flow management tools and others are developing them. Some RIS vendors are just now starting to install totally integrated work-flow solutions (RIS and PACS). The experiences gained from these deployments will continue to shape the applications and business models of these vendors for some time to come.
RIS vendors now are offering native DICOM Services Classes. For example, instead of an HL7 to DICOM conversion being required to send the DICOM Modality Work List (DMWL) to a compliant modality, the RIS sends the DMWL directly via DICOM. And if DICOM Modality Performed Procedure Step (MPPS) is available, the RIS will be able to receive those DICOM messages from the modality without the assistance of a broker. Look for more RIS vendors to provide native DICOM services as options and expect to pay for the associated validation and connectivity fees.
Work Lists . Commensurate with the overall focus on work flow, RIS systems are providing work lists to the technologists, transcriptionists, and radiologists. The ability to create these lists is noteworthy because it is a fundamental step toward the elimination of paper. These work lists are designed so that once the patient is selected from the list, all of the information that was previously contained in the paper-based requisition is presented. The user can add or change information and that information will be maintained and provided to other interested parties. All of the information previously contained on the paper requisition is now managed electronically.
Speech Recognition . Speech recognition is the technology used to automatically convert the spoken word into text. Speech recognition technology has been integrated into many RIS vendors’ offerings. Some RIS vendors have created their own integration of third-party speech recognition engines, and others have used other vendors to provide the speech engine integration. The key differences are evident when viewed from the entire reporting work-flow perspective: orders; dictation; transcription; editing; and electronic signature. Some vendors, through third-party integration, end up with another database and an interface to bring the reports that are transcribed in the speech recognition provider’s environment back into the RIS. Other vendors integrate the application seamlessly themselves and avoid the interfaces and additional database. The transcription module and the reporting module are all part of the RIS. Some RIS vendors provide speech recognition as an all or nothing proposition, while other RIS vendors provide options such as the ability to use digital dictation for some examinations and speech recognition for others. Some speech recognition implementations require the radiologists to edit and finalize their own reports, while others allow for the dictation to be handled by a transcriptionist. In this work flow, the transcriptionist is presented with the speech converted text and simultaneously listens to the voice file while reading the text. The transcriptionist makes corrections as required and then sends the file back to the radiologist for final approval and signature.
The integration of speech recognition into the RIS is appropriate for a number of reasons. First, the RIS creates orders for all examinations whether they are filmless or film-based. The radiologist then has one environment in which to operate and do the dictation that covers all procedures and provides all of the context that is needed, including patient history, prior reports, ordering physician identity, who performed the procedure, and the reason for the examination.
The ability to provide the imaging protocols linked to a CPT4 code and reason for examination is a valuable and fairly recent functionality improvement. For example, all of the information describing the scanning protocol for CT for a particular examination type for a particular radiologist is maintained in the database. If the technologist has any questions about the protocol, it can be easily retrieved. It also conveniently addresses Joint Commission on Accreditation of Healthcare Organizations requirements about imaging protocols as well.
Digital Image Indicators . As radiology departments evolve to filmless operations, it is common that some studies are film-based and others are digital. The RIS creates the orders and tracks the storage location of the films. The PACS stores the digital information for the study. So, if a referring physician checks the RIS, they will see that the examinations have been performed and may assume that the images are on film but may be unaware of the need to also search for images stored in the PACS. Some RIS systems are now adding an indicator as to the existence of images in whatever format they are available. In the described example, the patient history screen would indicate (by icon or text message) that both films and digital studies are available for a patient. DICOM Modality Work List facilitates this capability.
Security and Audit Trails . RIS vendors are working to develop features and functionality to protect patient confidentiality.? Vendors have developed filters that limit access to information about patients for whom a doctor has ordered a study, as opposed to providing a global patient list from which one searches for the patient’s information. A variation on this theme is in multi-facility, multi-entity environments where the need is to restrict access to only those facilities for which a doctor has privileges. Audit trails are also being implemented that track who accessed what record at what time from what location. This is an important feature from the standpoint of the Health Insurance Portability and Accountability Act. The feature that is required for auditing is convenience. One does not want to have to drill down into the database to extract this information. The preferred method is a canned report that can be called up at any time.
Like every system, RIS development technology has evolved over the years. Most RIS use client-server technology. Some RIS vendors are now using web development methods, such as HTML and XML, for their products and some are using web front ends so that some system functionality can run on PCs using browsers while the main database and applications run in the background. The point here is not to bring on a holy war about platforms but to point out the shift. Other industries are using web technology and application development methods to achieve remarkable results. Many customer relations management, supply chain management, and enterprise resource planning and manufacturing systems have shifted to web methods. It seems inevitable that the shift will occur in RIS and health care IT in general.
One of the reasons for the interest in web technology is the desire (particularly in freestanding imaging centers) to provide the capability to order examinations via the web. Some RIS vendors are starting to provide this capability. The actual work flow is still being fine-tuned, but basically one may request an order and/or preregister a patient for a study via the web. The RIS searches the schedule for a time and automatically sends an acknowledgement back to the ordering physician and/or the patient of the time, date, and preparation instructions. Once the examination is complete, the referring physician is provided with a number of secure methods to access the radiology reports and associated images from any PC running a browser. The ability to do these things is valued in terms of cost avoidance, front office staff productivity improvement, convenience for the referring physician, and differentiation for the radiology practice.
Some RIS vendors are looking into a value added integration of applications and technology that automate CPT-4/ICD-9 coding via natural language processing. Using a machine technology that reads the radiologist reports, the code matching is automatically done in a fraction of the normal time. This is another example of the value of work-flow integration. Many of the coding solution vendors have used XML methods to integrate their technology with other RIS vendors’ applications. This is another example of the impact of newer web-based approaches.
Application Service Providers
Two models exist in the arena of application service providers (ASPs) in radiology. One is the financial model in which RIS hardware, software, implementation, and maintenance costs are purchased on a fee-per-examination basis. The value is that a large capital outlay is avoided, and the costs are operationalized.
The other model is one in which the RIS applications and database are hosted in a remote data center and the facility uses nothing but PCs connected via T1 or DSL lines to the data center to use the application. The application runs in the browser. The customer enters into a Service Level Agreement with the ASP vendor and pays for the service on a fee-per-study or monthly subscription arrangement. Most RIS vendors will offer the “financial” ASP, but only a handful can offer the hosted application version. The hosted application version requires a software application that is designed for the web. This business model will appeal to lower volume hospitals and imaging centers.
The last mile in RIS evolution is the ability to manage the important paper-based information that does not exist well in any other format. Items such as transfer of benefits forms and screening surveys need to be included in the patient’s electronic record. Only a few RIS vendors are addressing this need, but it becomes more important especially as radiology departments realize the difficulty of dealing with the paper-based information once the film-based information is eliminated. Both are equally important and must be addressed.
RIS continues to expand its automation scope. New features are being developed that focus on delivering improved work flow with PACS. The need for a single database to manage and control all of the various work-flow components points to the RIS as being the best logical location for this database. The implementation of a totally integrated RIS/PACS offering from RIS vendors is just now beginning to provide the first evidence of how well these solutions will work and how well the vendors can support these systems. Clearly, the pendulum is starting to shift.
Industry consolidation has given way to industry convergence. The inevitable consequence is fewer RIS choices for customers. Clearly, the competitors will be fewer but also will possess greater resources to support complex integrated product offerings such as RIS and PACS, and, eventually, the EMR.
It would appear that RIS is heading into a new era. The lines are clearly disappearing between RIS, PACS, dictation, and billing systems. Perhaps the lines between the other clinical systems will disappear as well. Stay tuned.
James F. Maughan is a Houston-based independent consultant with more than 22 years of sales, marketing, and business development experience, [email protected].
Sherie D. Giles is an independent radiology information system work-flow consultant with more than 22 years of experience, [email protected].