I recently read an article on AuntMinnie.com that addresses how certification will impact radiology services. While the article addresses all aspects of impact, including how radiology services can comply (CPOE, Test Results, etc.), I was intrigued with the comments on the interaction of Radiology Information Systems (RIS) and Picture Archiving and Communications Systems (PACS) with an EHR. I am especially concerned with the statement “But certification does not guarantee compatibility with any other certified EHR module. ONC spokesperson Nancy Szehraj explained the rationale for not testing interoperability. The ONC-ATCBs test and certify to the criteria adopted by the standards and certification rules, which are intended to assure the capability of users to meet the phase 1 meaningful use criteria. Interconnectivity is addressed at this point via the exchange requirements.”

An EMR system can include the ability to access associated images when a physician is reviewing a diagnosis. This is usually done by means of an “application programming interface” or API that enables the EHR to request a web URL that launches the web viewer for a PACS. The question is - where does the image come from? If the facility still relies on departmental storage, then the image most likely comes from the PACS archive. However, if the facility has implemented any form of an enterprise archive, the image could potentially come from an enterprise source independent of the PACS.

In some instances, particularly where a vendor may have both an EMR and PACS offering, the EMR may have its own integrated web viewer. In this case, the image may be accessed as part of an EHR application, and not a PACS application. In the case of accessing the PACS for the image, this would be interoperability. In the case of an EHR-based viewer, is this interoperability?

According to the current meaningful use guidelines, it is all a moot point, since imaging is not part of Stage 1 requirements. I am concerned about implications for the eventual inclusion of imaging in Stage 2/3. Does this mean that a certified EHR module needs to be re-certified once imaging is included? Or, does this not matter, as this would be defined as interoperability? And what of the instance where an EHR module includes a web viewer? In that case, it would be part of the EHR. But, even if the image viewer is part of the EHR, if the image comes from either a PACS or enterprise archive, is this still considered interoperability?

This is why in a prior blog I raised concern with addressing imaging at the end of the meaningful use process, not the beginning. If EHR's today are certified only based on Stage 1 criteria and need to be recertified later for subsequent phases, there may be a financial impact for facilities and/or vendors. From an imaging perspective, this is a shame, as current PACS-EMR applications are already bringing real benefit to physicians.

I would be curious if anyone has a perspective on addressing imaging and an EMR/EHR. Does the ONC expect that this will be handled by interoperability, and if not, what are the implications for certification? As always, I welcome your comments.