EXECUTIVE SUMMARY

The director of radiology at a community hospital discusses the challenges involved in incorporating information from separate RIS and PACS into a single electronic medical record.

It is the new old question in today's healthcare: What exactly is the EMR?

One recent Tuesday afternoon, I got a phone call from the electronic medical records (EMR) team meeting in our hospital. I was on speakerphone and was asked, “Are your techs documenting everything about the radiology procedure in the RIS [radiology information system], or are you keeping records separately?”

After taking the time to investigate, I replied that we were documenting everything in our medical record. “We only have one medical record. Images are not medical records,” I said. The EMR team then asked why the hospital always gets two subpoenas from lawyers. I replied with a question: “One is for medical records and one for radiology films?”

The radiology process begins with an image and ends with a report. The report is sent to the referring physician, and the final signed hard copies are submitted to the medical records department. After the radiologist's review and interpretation, the images are filed away. We in radiology have tunnel vision that begins with the machine and ends with the radiologist.

NEW ISSUES EMERGING

EMR implementation brings new and interesting issues to this equation. For example, our hospital uses a RIS supplied by Meditech, Westwood, Mass., and a picture archiving and communication system (PACS) from San Diego-based DR Systems Inc. Both systems allow the process of passing notes typed by healthcare providers.

With regard to RIS, all the nurse, physical therapy, lab, and other notes are documented into Meditech for the foreseeable future. Many hard-copy charts are electronically scanned at this point and are archived into the Meditech “EMR.” For the radiology department, images are attached to the patients' demographics through the radiology PACS and are interpreted by the radiologist who is in charge of the patient's care. Information such as dosage of contrast bolus administered, allergic reactions, patient motion, extravasation, and other information is passed through notes to the radiologist. Paper documents are scanned into the PACS for the radiologists to use, without anyone else's needs in mind.

Therein lays the largest part of the problem. This may be a non-issue for a new facility that has the means to purchase RIS and PACS at the same time. But for rural health facilities, many of which have had RIS since the 1990s, PACS has not been an achievable goal financially until just recently. In most of these cases, there is a mismatch in PACS/RIS compatibility.

To enable communication between mismatched EMR and PACS, vendors must either have the ability to have their system invoke each other or go through the HL7 interface. What is interesting to consider is the question of whether any or all information, including images and radiology tech notes, can be retrieved easily, as described by the meaningful use guidelines for EMR. Although the EMR can be printed out through the RIS, information in PACS may or may not be present. So which one is the medical record? RIS or PACS, or both? The trend is toward just one, with the primary RIS evolving into being the main EMR.

As with most cases, in our facility the RIS and PACS servers are separate. How can these be viewed as one medical record when the information must be retrieved separately? Meditech RIS can and will invoke DR Systems' PACS for daily use, but the printing of the record electronically or otherwise occurs in two steps from two different servers; two different departments perform the act.

A facility must carefully decide how to integrate and morph these into one EMR while not disrupting imaging's daily routine. Think back to the old file rooms. Medical records had one and radiology had one. What was two, must now be one.

While dissecting this EMR issue, other questions regarding radiology records must be considered as well. Are the voice clips on your PACS being used to diagnose prior to the final report? Are these voice clips being released with a preliminary report attached either internally or externally by ER transfer or referrals? What are the legal ramifications if the voice clips and final reports differ?

It is important to check for loss of pertinent patient information during the transfer of information from PACS into RIS, and to decide how to properly structure your EMR according to your facility's current level of capability. Check to see that you can prove that the actions taken by imaging technologists are documented in both your RIS and your PACS. In the meantime, chances are we will all still be getting two subpoenas for many years to come.

Brian Olsovsky is the director of radiology for Cuero Community Hospital in Cuero, Texas. Healthcare Informatics 2010 November;27(11):20-22