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Interfaces are for Rookies

May 29, 2008
by Mark Hagland
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Moving to a second generation PACS or RIS is a great opportunity to achieve true integration.

Randall shortt

Randall Shortt



This is the first installment of a three-part series that will examine the major strategic trends in the imaging/PACS space. This story examines the biggest challenges and opportunities involved in replacing first-generation PACS and RIS systems with second-generation ones. Part II, coming in July, will look at the issues involved in creating real integration between these image management systems and core EMR and CPOE systems. Finally, Part III, slated for August, will uncover the best strategies for working with vendors in the replacement area.

When the folks at Centra Health, a three-facility hospital organization based in Lynchburg, Va., began planning for a replacement of both their radiology information system (RIS) and their picture archiving and communications system (PACS), they knew they would be facing multiple challenges.


Peggy pollard, r.n.

Peggy Pollard, R.N.


On the PACS side, Centra Health's imaging informatics and management leaders were headed towards a straightforward replacement of their PACS system via an upgrade from their PACS vendor (the Atlanta-based McKesson Corporation). On the RIS side, they were looking to replace a first-generation RIS that had been attached to the hospital system's old mainframe clinical information system (an earlier version of the core McKesson electronic medical record, or EMR, product).

Fortunately for them, at the time they were evaluating RIS vendors, their PACS vendor announced a new version of its RIS offering. Though Centra leaders did not decide to go with the same vendor for both system replacements per se, they were delighted to find that a single vendor met their functionality needs with regard to both RIS and PACS.

The key to meeting their needs was some level of functional integration between the RIS and PACS replacement systems in order to optimize clinician workflow, says Randall Shortt, Centra Health's radiology information systems coordinator.

“Prior to the integration, our doctors viewed images in PACS; the department worked their orders in the mainframe; the doctors dictated into a separate dictation system; and it was transcribed into yet another system. So every time we performed a study, we used four un-integrated systems,” Shortt notes. “Now, when the doctor looks at images in the PACS, the program synchs up the dictation module, he or she dictates into it, it launches the transcription, and sends out the report when it's ready.”

In that regard, says, Peggy Pollard, R.N., the health system's director of clinical informatics, “Integration improves quality and efficiency far more than you can even imagine with interfaces. You just can't get there with interfaces to the extent you can with an integrated system.”

And so, not surprisingly, the strategic thinking behind the RIS/PACS replacement at Centra health involved a goal among leaders, including Shortt and Pollard, not simply to upgrade technology, but to leverage that upgrading process to improve patient care and clinician workflow with regard to imaging overall.

Workflow optimization, enterprise-wide strategizing

Such considerations are among the main issues hospital and health system imaging and IT leaders are looking at as they begin to replace first-generation RIS and PACS systems with second-generation ones, say healthcare leaders and industry observers.

Put another way, says Honora Roberts, chief operating officer of The Breakaway Group, a Denver-based consulting firm that specializes in performance improvement work in healthcare, it all comes down to optimizing clinician workflow in order to improve both patient care quality and operational efficiency.

“The biggest pain point as organizations look to upgrade their RIS and PACS systems is in the workflow redesign area,” Roberts says. “I led a project recently involving a pretty significant RIS upgrade, and there was poor workflow built even into the upgrade,” she reports. “Our group was brought in on that project not to redesign workflow, but to support end-user adoption and learning. Unfortunately, what that client organization had already done was to institutionalize workarounds to the system.”

Roberts says this included imaging technologists not following their electronic patient check-in lists, and allowing physicians' staffs to continue to fax referrals, even though an electronic system had been put in place for sending automated referrals directly from physicians to the imaging department.


Tim zoph

Tim Zoph


The challenge of optimizing clinician workflow for improved patient care and enhanced efficiency relates to, and overlaps with, the other big issue that industry experts cite around RIS/PACS replacement: the challenge of enterprise-wide thinking, planning, and strategizing.

Put simply, says Joseph Marion, principal, Healthcare Integration Strategies, Waukesha, Wis., “The biggest issue is looking at radiology as being part of the enterprise,” and not as a standalone phenomenon. Marion, who has been in the diagnostic imaging planning and implementation area for over 30 years, says that it is becoming increasingly important on both a strategic and a practical level to think very carefully about the RIS/PACS replacement issue.

“If a hospital has a committed strategy with regard to a particular vendor, then that has to have a big impact on this,” he says. What would the point of picking a GE IDX RIS if you're already in a Soarian PACS environment?” he asks, referring to products produced by the Chalfont St. Giles, U.K.-based GE Healthcare and the Malvern, Pa.-based Siemens Medical Solutions. “People ask me, what's your favorite vendor? And I say, that question doesn't make sense. I'm not going to go into a strong McKesson shop and recommend a Siemens RIS, or vice-versa.”

Instead, Marion says, “They key has to be workflow, which is why people are struggling over issues around creating a truly integrated RIS and PACS solution.” The bottom line, as far as he's concerned? “The fewest number of interfaces I create, the greater the likelihood of success.”

It's also important to look at RIS and PACS in the broader context of clinical information systems generally, says Tim Zoph, vice president and CIO at Northwestern Memorial Hospital in Chicago. It will become increasingly important to plan for RIS and PACS systems within the broader context of clinical IS planning, he says. “You're going to see images become far more integrated in terms of decision support and data management in terms of EMRs,” he says. (The second article in this series, to appear in the July issue of Healthcare Informatics, will explore this issue more fully.)

Longer-term strategy needed?

The other global key success factor in RIS and PACS replacement is taking a far longer view than is currently the norm, says Scott Grier, a director at the Nashville-based Abrio Healthcare Consulting. “People right now are thinking out perhaps as far as five years” when it comes to image systems planning, says the Sarasota, Fla.-based Grier. “I'm saying it has to be 10 years out.” The reality for many CIOs in particular, Grier says, is that, “Because CIOs, CFOs, and others are changing jobs so often these days, one CIO will go through the contracting process on a new RIS or PACS system, and another CIO will have to deal with the implementation, and then a third CIO will be sitting there with a production model going.”

Instead, he says, CIOs can begin now to develop a more global continuity around imaging management systems planning and strategy. “People have a chance now to start building their longer-term strategy, which is to say, what am I going to do with all of my images, and what's my strategy?”

Done right, however, RIS and PACS replacement initiatives can prove important on multiple fronts. Says Centra Health's Pollard, “If I were doing my budget for next year on big clinical wins, PACS would be at the top of the list. There are so many things competing for your dollars on clinical systems — where do you start? But PACS was just an immediate gain in terms of PR with physicians and on patient care. That was a home run.”


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