Seven years ago, Crystal Run Healthcare in Middletown, N.Y., implemented an integrated radiology information system/picture archiving and communication system.

Encompassing more than 170 physicians and some 30 mid-level practitioners, the 11-site group practice interfaced the RIS/PACS to its electronic health records system for simple data exchange, such as demographics and results reporting. But by last year, the imaging software "was getting long in the tooth" says Hal Teitelbaum, M.D., managing partner. Necessary upgrades would have essentially amounted to a replacement anyway, so the practice looked at all of its options.

Early this year, Crystal Run started implementing a new RIS/PACS from a new vendor, Carestream Health of Rochester, N.Y. The practice also bought two Kodak digital radiography imaging modalities from Carestream along with a Kodak computed radiography modality. These accompany multiple ultrasound, magnetic resonance imaging and CT scan units. The RIS/PACS went live in July, and the practice continues its effort to integrate it with its existing EHR, from NextGen Healthcare Information Systems, Horsham, Pa.

With some RIS/PACS/EHR integration experience under its belt, Crystal Run wants more comprehensive integration this time around, Teitelbaum says. "We are beyond looking at the relatively simple issue of storing data," he notes. "Now, we're looking to utilize the data."

Today, patient demographic data entered into the EHR transfers to the RIS/PACS, avoiding double entry. When integration is complete in 2010, orders will flow from the EHR to the imaging software. But other critical patient data, such as kidney function test results, also will flow to radiologists and technicians. This data can affect the level of radiation to which a patient can be exposed. And, for the first time, physicians will be able to view medical images from the EHR, rather than going to the radiology or cardiology departments.

In no small part, tighter integration today is far easier than seven years ago because imaging, EHR and integration technologies are much more mature, Teitelbaum contends. "Absolutely, they are light years ahead. The level of standardization is much better today. People are speaking the same language today."

Tighter integration also speeds up radiology readings and report turnaround, while increasing patient safety, says Tim Kulbago, senior vice president of product technology at Merge Healthcare, a Milwaukee-based medical imaging software vendor. "The radiologist has all relevant information without going to two systems," he notes. "Everything you need is probably one click away. And you don't have to worry that there's a piece of information you need in the radiology information system that you haven't seen."

Integrating radiology reports into the EHR is a fairly common practice today, Kulbago says. Increasingly, physicians also want to view the images in the EHR.

These integration efforts likely will accelerate because of provisions in the American Recovery and Reinvestment Act, he contends. Federal advisory committees have recommended that criteria for meaningful use of electronic records, necessary to qualify for Medicare and Medicaid incentive payments, include integration of laboratory and radiology data in the EHR. "In almost any major medical event, there's a radiology component," Kulbago adds.

But there are different ways to integrate. Some organizations have found simple ways to access radiology images and reports in EHRs using Web technology (see story, page 20). Others aren't integrating to the EHR, but they're using a regional health information organization to make imaging exams from multiple hospitals available to community physicians.

Integration 101

Radiology integration starts with the imaging modalities themselves, such as the MRI, ultrasound, CT scan and other systems. These modalities integrate with the radiology information system and picture archiving and communication system, or another type of archive if a PACS is not used. Integrating the modalities and imaging systems has become commonplace with the use of DICOM medical imaging standards.

"Most modalities play well with RIS and PACS," Kulbago of Merge Healthcare says. "They're pretty strong with their DICOM structures." Newer technologies, he notes, enable "no touch" integration that is close to plug-and-play to link modalities to RIS and PACS, and also to link EHRs. Some vendors, such as Andover, Mass.-based Capsule Technologie, have built interface libraries to link with hundreds of medical devices.

A radiology information system is the administrative component of medical imaging software. It handles scheduling, registration, administrative, reporting and sometimes billing functions - everything except the actual images. A PACS stores and distributes images. It's the radiologist's workstation for viewing images, often aided with dictation/transcription and image manipulation software.

A technician performing the actual radiology procedure will capture images on a workstation with multiple monitors. This workstation is a "Q&A" step, Kulbago explains. "Did I capture the right image?" "Did the patient move?" When the procedure is finished, a technician reviews images and sends only the approved ones to the PACS or another imaging archive for a radiologist to pull up for a reading.

Integration to the EHR is done through the RIS, PACS, or both. And such efforts today are aided by better vendor willingness to work with each other, and better vendor understanding of scalability issues, notes Crystal Run Healthcare's Teitelbaum. Sometimes, however, that cooperation has to be demanded by the customer. Roseville, Calif.-based Adventist Health, with 17 hospitals in four Western states, has about nine imaging modality vendors linked to its radiology and PACS systems, along with a clinical information system from Cerner Corp., Kansas City, Mo. Not all the modality vendors, which often sell their own RIS or PACS, are keen on playing with software companies.

"Most modality vendors will stress how much added value you get if you buy their RIS and PACS," says Greg McGovern, chief technology officer. "Everyone's still pushing their products. Everyone's still having a hard time giving up full ownership of their property. But I haven't seen anyone refusing to play."

Adds Adventist Health CIO Alan Soderblom: "Hold your guns and tell them they must work with your other vendors. They are getting more cooperative; they understand that is the future."

Regions Hospital in St. Paul, Minn., has seen good cooperation on integration projects among its imaging and EHR vendors, says Kim LaReau, vice president and CIO. "The challenge is to get all the appropriate people together at one time when it comes to issue resolution."

How It Works

Here's how integration can speed radiology workflow and turnaround time to the physician:

At Regions Hospital, a physician ordering an imaging examination does so through the EHR from Epic Systems Corp., Verona, Wis. The order then sits in the EHR until the patient arrives. At the time of arrival, a message is sent from the Epic radiology information system, integrated with the EHR, to data bridge software linked to the PACS from Merge Healthcare.

The modalities, which are constantly querying the data bridge, pick up the recently arrived order and populate its work list. The radiology technologist, who has been made aware through the EHR that the patient has arrived, will then choose the appropriate exam from the work list. The technologist will change the order status to "begin" in the EHR and proceed with image acquisition. Images taken during the exam are then sent to the PACS, and the technologist will make any pertinent notes and change the exam status to "end" within the EHR.

Now, it's time for the radiologist to study the images and complete a report. The reading station consists of five monitors - one for PACS information, one for accessing the EHR, one for accessing dictation/speech recognition software and two high-resolution monitors for viewing images. The EHR feeds exam information into the PACS in the form of a work list that appears on the PACS monitor. The radiologist chooses the study, and images load on the high-resolution monitors. This action opens the appropriate patient chart and synchronizes all patient data between the PACS, the EHR and the dictation/speech recognition software.

Once the radiologist completes a report, a message is sent to the patient's EHR that the exam has been read, and a message is then sent to the PACS to tag the exam as read. The study is closed and the work list is available for the radiologist to choose the next exam. The transcribed report is sent to the EHR and PACS. A link to the images in the EHR is established, enabling physicians to view those images within the EHR while reading the report.

The beauty of the integration is that for all referring clinicians, "this is a one log-in system," says Paul Norsten, manager of RIS/PACS systems at Regions Hospital and parent delivery system HealthPartners.

The project took several years with radiology reports, including image links, being fed to the EHR in 2005. The bulk of integration work was done by August 2008. The work cost a little more than $1 million in software, equipment and labor, Norsten says. But the real benefit - to do exams, read them and receive reports faster - is priceless, he adds. "Patient satisfaction and quality is a huge advantage."

In general, turnaround times for reports now are three or four times faster than before the integration. Some reports can be turned around in under an hour, with trauma center reports turned in 15-30 minutes, Norsten notes. "That equates directly to that emergency patient getting faster care."

Grunt Work

When I.T. professionals tie computer systems together during an integration initiative, clinicians, staffers and administrators in the organization often are steeped in detailed and laborious "grunt work." The heavy lifting includes data migration, system mapping and interface creation.

That's no different when it comes to integrating radiology and EHR systems, those tackling the task say. But the toughest grunt work can vary among organizations.

For Crystal Run Healthcare in Middletown, N.Y., the tough work is migrating data from the old RIS/PACS to the new one, says Teitelbaum, the managing director. After seven years, there's a ton of imaging data to migrate. Physicians, for instance, want to compare new mammograms with the previous two or three exams. Beyond that, the practice exceeds various record retention laws with its policy of keeping all data indefinitely. "Whether we can keep that up remains to be seen," Teitelbaum adds.

The hard work stems from the difficulty of coding data moving to the new RIS/PACS with more granularity. That assures the practice can properly document care in a complex regulatory environment while cataloging the data in the new system. "Cataloging schemes are very proprietary," Teitelbaum warns. "That is something people should be paying a whole lot more attention to."

Plenty of grunt work also evolved from making sure the integrated RIS/PACS/EHR was compatible with end-user workforce needs. Crystal Run did a good job involving clinicians and staff in selecting the new radiology vendor and figuring out workflow issues, Teitelbaum says. But given a second chance, he'd involve even more users. The big lesson so far from the project, he advises, is the amount of time needed for training. "Whatever amount of training you think is needed to get used to the new integrated systems, double it."

For Regions Hospital in St. Paul, Minn., the grunt work with medical imaging integration was more related to changing departmental workflows. "It's amazing what you find out about how departments run," says Kim LaReau, vice president and CIO.

In particular, Paul Norsten, manager of RIS/PACS systems, and Carrie Boren, director of radiology, worked to design a paperless radiology department. "There was a huge cultural change for their staff," LaReau recalls.

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