1. Post RSNA 2003 Wrap up RIS Systems Overview RIS/PACS Integrations
JANUARY 2004
Rex Osborn
Sr Manager Digital Imaging Practice

2. Topics of Discussion RIS Systems Are No Longer Islands of Information
3 Categories of RIS Vendors
Why One vendor is Chosen Over Another
New F&F Seen Demonstrated at RSNA
RIS Vendors Quick Assessment
Key Functionality Overview
Integration Overview

3. RIS are no Longer Islands of Data
They Must Integrate With
Clinical Data Repository
Electronic Health Record
Clinical Information Systems
PACS
Voice Recognition and Digital Dictation Systems
Financial Systems
Clinical Data Repository (CDR): Most often textual result reports (lab, dictated history and physical exam findings (H&P), anatomic pathology, etc.).
Electronic Health Record (EHR): Both text and image, sometimes a scanned chart.
Clinical Information Systems: Order communications, nursing assessments, etc.
Financial Systems: Billing and Accounts Receivable, and general accounting.
Point of Care: Bedside charting of clinical observations, care plans, etc.
Outcomes Measurement: Disease management, and variance against a critical path.
PACS: Merely a glorified light-box without clinical and patient data, emphasis as of late has been to integrate at the desktop allowing a more clinical connectivity approach towards Diagnostic Workstations; The Radiologists Primary tool
Voice Recognition and Digital Dictation Systems: The source Patient Demographics can come from the RIS and the rules of engaging distributed reports, preliminary, resident reviewed and addendums classifications is the job of the RIS system to the CDR, EHR or the HIS/CIS

4. RIS Systems Fall in to 3 Categories
RIS products fall into three distinct camps: “best of breed” vs.. “integrated” vs.. “RIS/PACS integrated single offering”.
The “best of breed” solution is a pure RIS product that will interface and work with numerous HIS products. Also referred to as a Stand-alone
The “integrated” RIS products are bundled with the vendors HIS and enjoy a significantly larger market share than the “best of breed” products.
And the newest creation is the “RIS/PACS Only” a truly niche player, usually has extensive capabilities in storage or PACS for the OP and Imaging Clinic market Segment

5. Major Reasons Why One Vendor Won a Deal over Another RIS
Reputation
Historical performance
Recommendation
Client installations
Incumbent HIS
What we see performing system selections….

6. What Executives From Hospitals Say Are Important Attributes of a RIS Vendor
Features/Functionality (that address the prospect organization’s specific business needs)
Corporate Stability and Commitment (both to customer support and RIS enhancements)
Technology and Computing Platform (that meet the prospect’s established or planned Information Technology (IT) standards, is this system part of our “strategic plan?”)
Client Installations (number of sites, with emphasis on those most similar to prospect)
Costs (Start-up and On-going Support) (Rule of thumb is 10% of Hardware and 16% of Software for maintenance fees)

7. New Features & Functions in RIS Systems 1 of 3 Slides
Virtual Master Jacket
Film Folder tracking allows multiple master film folder volumes and their subsequent sub folders be it digital films and images or from outside sources CD, DVD, or Foreign Hard Copy Images. Some images are not digitized and need as place to be tracked and managed. Easy to place auditable image access reports here. Can also work for scanned images and tracking of those images to archiving source.
Web functionality for remote access to RIS functions
Allows access to the web via URL and or through an ISP port i.e. Internet Explore and or Netscape. Security is LDAP, SSL and Kerberos. Including Remote access to Scheduling for referring physicians
Web distribution of reference images and related data
Image Management allowing access to ASP based Image Management Systems and or PACS option. Allows URL, embedded sites i.e. Links to Mallinckrodt CME site, and or affiliated Hospital, Healthcare System or University Health Consortium satellite for education for Radiologists or Technologists
Utilization review management reporting
Utilization and Review allows reporting on resources used for Radiology to indicate cost and investment of time and technical expertise to provide executives with a more comprehensive view of what Radiology is doing and can do.
Review Focus will be on only One Feature each Page 1 of 3 Slides:
Virtual Master Jacket
Film Folder tracking allows multiple master film folder volumes and their subsequent sub folders be it digital films and images or from outside sources CD, DVD, or Foreign Hard Copy Images. Some images are not digitized and need as place to be tracked and managed. Easy to place auditable image access reports here. Can also work for scanned images and tracking of those images to archiving source.

8. Additional New F&F RIS Systems 2 of 3 Slides
Integration with the CDR on enterprise-wide basis
Allows computerized data record to have radiology information integrated and available via HL7 interface.
Seamless integration with PACS and Image Management Systems
HL7 and DICOM standard interface(s) with Image Management and PAC systems. Allowing image distribution with an integrated demographic and clinical relational data available i.e. Diagnostic Report, patient history and Image Information to include AE title and modality work list interface/countering off of the Scheduled procedures (outpatient only)
End user configuration tools to include Export and Import functions for Implementation (simplification of conversion)
Allows client(s) the option to provide simple data sets for their existing system to be loaded on to a pre-set and or designated spreadsheet (CSV, .xls etc..). This spreadsheet can be downloaded into existing dictionaries. Thereby requiring a limited access build for clients with existing history, patient and diagnostic report files. Simplification of any implementation step is deemed as positive for the overall costs associated with supporting an install.
End user configuration tools to include Export and Import functions for Implementation (simplification of conversion)
Allows client(s) the option to provide simple data sets for their existing system to be loaded on to a pre-set and or designated spreadsheet (CSV, .xls etc..). This spreadsheet can be downloaded into existing dictionaries. Thereby requiring a limited access build for clients with existing history, patient and diagnostic report files. Simplification of any implementation step is deemed as positive for the overall costs associated with supporting an install.

9. Additional New F&F RIS Systems 3 of 3 Slides
Patient Tracking (an Airport Terminal effect for Pt Tracking)
Patient Tracking will allow a Radiology manager and or interested parties within Radiology to peruse real time tracking of patients from the time the patient arrives has the procedure/exam and to the time the patient is discharged from Radiology. The technologists as well as supporting administration will update the system as they interact with the patient at key points during their visit. An up to date interactive screen will update at selected times to show the status of all exams and patients.
Multi media links for web as well as for images
Allows the user to link to appropriate URL’s for education, additional clinical information as well as B2C services, and future applications. Image Management Systems can also be added and or embedded to allow easy integrated access.
A more detailed technologist completion screen that will allow assessments etc…
This should allow the technologists to enter all relative information to the procedure, this is where the additional views can be added, as well as additional relative charges can be added on the fly, and where the exam becomes complete, thereby allowing technical charges to take place. Remember a Radiology procedure is an intervention, think charting!!!
Mammography Module
Allows support of a mammography centric application that meets regional regulations for reporting and statistic gathering. Meets BIRAD requirements.
A more detailed technologist completion screen that will allow assessments etc…
This should allow the technologists to enter all relative information to the procedure, this is where the additional views can be added, as well as additional relative charges can be added on the fly, and where the exam becomes complete, thereby allowing technical charges to take place. Remember a Radiology procedure is an intervention, think charting!!!

11. RIS Vendors Assessed at RSNA 2003

12. RIS Vendors Quick Review - RSNA 2004
Agfa HealthCare - Agfa highlights included a bi-directional interfaced RIS system with embedded VR technology (Talk Technology) at the Diagnostic Workstation. The US version of RIS is truly a work-in-progress version, probably not going to be fully functional until the release of Agfa’s second generation PACS solution Q
Avreo - Avreo demonstrated its OP and Imaging centric RIS system version 2.8, InterWorks RIS application (available Q1 2004). Avreo offers an integrated Imaging product that is web based.
Brit Systems - Brit demonstrated Roentgen RIS (available today), single DB PACS and RIS solution. The RIS has limited functionality and is used primarily with imaging clinics and OP facilities. Brit Systems is known for their government contract work for the military Hospitals DIN-PACS, and are used as a primary storage/archive manage with the IBM solution.
Cerner - Cerner showed RadNet its RIS system complete with an “Envoi” styled Radiologist worklist and protocol list complete with PowerChart access for the EHR (Electronic Health Record “CHIME”). The RIS side of this offering is very competitive and has been successful in sites with over 50K exams.
CPU Medical Management Systems - Web MED/FM the professional and technical billing feature functionality was demonstrated at the RSNA 2004, with a focus on billing this system is capable of managing billing for OP and IP environments, the system reminded us more of a Practice Patient Management system than a RIS. Web based and able to offer a wide variety of management reports complete with trend analysis reporting.
Merge eFilm - Merge eFilm adds RIS functionality via the RISLogic acquisition, the RISLogic product has competed well in the Imaging Clinic and small Hospital market segment and has worked hard to identify better ways to integrate with existing PACS solutions.

13. RIS Vendors Quick Review - RSNA 2003
DR Systems – The PACS Dominator’s data driver the RIS offers a nice segue of clinical data from a PPM or a HIS system. The RIS product is due out Q2 2004, internet based with the ability to scan in clinical documentation and link those files with the DICOM Images is deemed as a positive step towards eliminating paper in the department. The RIS supports the PACS solutions quest to benefit imaging clinics and community Hospitals, the new RIS will offer scheduling of procedure access to clinicians (very innovative) as well as management reports.
Eastman Kodak Health Imaging - Kodak introduced its new RIS 2010 to the U.S. market, along with newly acquired Algotech’s PACS solution. A lot is missing at the desktop (integration PACS.RIS) but will be linked in the future. Scheduling and Patient Tracking seemed to be the focus of the demonstrations. With the emergence of VR and digital dictation integrations a\]the transcription module will go away and leave the electronic signature and audit trail for dx report distribution. Deeper functionality is required to be competitive in a number of market segments in the US.
Eclipsys – Eclipsys demonstrated the XA Sunrise (EHR) integration and a newly developed Radiologist worklist with their strategic PACS partner Sectra of Sweden (sole provider of PACS for Philips as well). The Knowledge-Based Diagnostic Imaging (KBDI) module is a combination Clinical IS and PACS, no real RIS feature functionality exists today within the Eclipsys portfolio. The focus is on the episode of care rather than the standard RIS features used to drive a PACS. This is where Radiology Informatics is headed but in the mean time departmental management is still a requirement from a competitive RIS.
Epic Systems – With a new strategic relationship with Philips, this RIS/PACS combination will be interesting. EPIC uses cache as its DB, and Philips uses Oracle. The EPIC approach is refreshing as the navigation and UI are more reminiscent of an EHR than the standard dogma RIS approach as is seen with the top RIS vendors. Patient centric data clearly indicated clinical relevance at the Dx Workstation and will require more work to really make the desktop integration as navigation friendly as will be required by Radiologist. Deeper functionality is required but with EPIC’s history, more is soon to come.

14. RIS Vendors Quick Review - RSNA 2003
IDX Systems - IDX brings Imagecast RIS version 10+ to RSNA 2003, the demonstrations were complete with Stentor playing the part of PACS and archive. The RIS centric approach allows MPPS information to be validated between the RIS and Modality allowing better source data to flow to the PACS system. Be it Stentor or a third party PACS solution, IDX has positioned themselves as an innovative integrator using the Imaging Suite as the conduit for any integration using DICOM and or HL7. The Imaging Suite enables version 9 and 10 to integrate well and manage the worklist responsibilities of a RIS/PACS. IDX competes in the complex world of IDN’s and has a split client base with over half of the clients using the older version 9 and all new clients being relegated to version 10. IDX has been successful working with clients to develop dynamic integrations once their RIS is stable and ready to be integrated to a PACS solution.
Inphact (Now Evolved) - Version 4.0 of RadWeb was demonstrated as was the integrated PACS solution, single database java based RIS system. Competitive for the OP and Imaging Clinic and starting to compete in the community hospital market segment. The OP billing component is one of the best we have seen in the marketplace.
Insight Healthcare Information Systems - IHIS is the offering from Insight. This RIS is designed for small to mid-size hospitals but appears to be fully functional rich, but will continue to work to become more competitive in a marketplace where you compete head to head against the monolithic behemoth Meditech.
McKesson Information Solutions – Via acquisition McKesson has brought in a RIS system to drive the McKesson PACS solution acquired from ALI Technologies. The all new Horizon Radiology Manager is available now. McKesson is working on deeper functionality and better desktop integration driving the McKesson PACS to better clinical connectivity. Links currently to the Horizon EHR look great and the clinical data is rich and readily available via a patient centric encounter based approach towards viewing clinically relevant data. The MS Outlook styled menu driven navigation will certainly need some revisions and new feature functionality will come as clients start providing invaluable input to McKesson.

15. RIS Vendors Quick Review - RSNA 2003
Misys Healthcare Systems – MISYS Radiology is a fully functional RIS system available now for environments beyond 50K exams a year. A PACS relationship exists today with eRad to offer a strategic integrated RIS/PACS offering, although several PACS systems have found it easy to integrate with MISYS as a RIS. Using Cache as the DB, MISYS competes well with other major vendors in the RIS marketplace. The latest development effort has been to offer the PACS Integration Module (PIM) to be used as a conduit for HL7 and DICOM bi-directional data transfers, easing the ability for MISYS to interface with any PACS solutions in the marketplace.
RadInfo Systems – Using Chinese development teams the PowerPACS/RIS has been developed in unison, allowing RIS data to be intertwined with PACS workflow. This international product has a niche in small to mid-size Hospitals overseas and Imaging clinics in the US, the core RIS functions mirror a stand alone provider of data to a PACS to allow scheduling and creation of an accession number.
Siemens Medical Solutions - The vendor's Novius RIS has an updated look and feel and has added integration to Siemens MagicWeb, a clinical distribution mechanism for images to the enterprise. The RIS is very competitive for large complex IDN’s and has been a willing integrator using HL7, Siemens has not been as aggressive in the IHE profiles for RIS systems, but has developed a nice desktop integration and bi-directional integration with its Sienet PACS solution. The new Soarian (EHR) product line offers clinical connectivity at the clinician desktop, and allows easy views of encounter based visits and results as well as all interventions.
GE Medical Systems – The Centricity RIS PACS product was demonstrated and the functionality has improved and is still being used as the primary driver of data to the PACS system, with the GE PACS solution carrying the bulk of the management of workflow responsibilities. The RIS system uses and Oracle gateway to communicate to the Sybase based PACS solution and has been slow to grow a large user base as was expected by the industry. The RIS development has gone through several phases and is being offered as a single solution but has not been as successful since being acquired by GE as it was as an independent product in Per’se’s solution suite.

16. RIS Vendors Quick Review - RSNA 2003
SoftMed – A Canadian company using a Java based front end and MS Outlook styled navigation is an icon driven functional RIS system designed for stand alone imaging clinics and OP clinical environments. The product works closely to stay within the framework of IHE providing all necessary links to offer connectivity to a practice patient management as easily as a HIS. Market segment efforts will start to move more towards small community hospitals with future releases.
VitalWorks - Java-based RadConnect RIS is the primary RIS offered by VitalWorks and has proven successful in the Imaging Clinic and small Hospital niche. Deeper functionality is required and work will need to be done to integrate the web based Archive solution Amicas.
XIMIS - XIRIS 5.0, eXtended Internet Radiology Information System is a stand alone RIS system that is slowly building a large user base in the small to mid size Hospital market segment. Platform and Database independent this open system offers folks a software version that is both reliable and affordable. Integration efforts have been effective but more work is necessary to make desktop integrations a reality for sites using XIRIS.
Ferrania – LifeWeb RIS is an Italian based RIS system, a web based RIS system developed in unison with a web based PACS solution, recently named as a finalist for a large IDN in the UK Health System . The RIS as well as the PACS system will be made commercially available in the US in Usually deemed as a ECR (European Congress of Radiology) Capital equipment giant, the latest innovative RIS solution is heavily vested in to the IHE framework and is looking to be an aggressive player in the US marketplace in the coming year.
Creative Computer Applications - CCA written in Cobol and available today offers Imaging clinics and community Hospitals the RIS CyberRad version CyberRad, compliments the Laboratory and Pharmacy systems offered by this clinical informatics company.

18. Key Functionality Within RIS Systems
** Patient Registration (OP) (BDI) ** Scheduling (SU Messages to PACS)
** Order/Exam Requisitioning ** Charge Capture/Exam Billing
** Patient Tracking ** Virtual Master Jacket
** Standard Management Rpts ** Inventory Control (Supplies)
** Equipment Maintenance ** Mammography/Patient FU/MQSA
** Quality Control/Quality Assurance ** Interfaces (e.g., PACS, Digital Dictation, Report Transcription/Electronic Sign/Security, Transcription, Billing, Scheduling, Voice Recognition, Results Report & Distribution)

19. Key Points to Considering a RIS Solutions
Scheduling (Enterprise vs. Departmental)
Patient Identification (How many Patient ID Domains Exist within your IDN?)
Patient Profile/Demographics
Orders/Accessioning
Charges (Professional and Technical)
Work Lists (Via MPPS)
Patient Tracking
Result Reports and Distribution (Via clinical Web Application vs. HL7 Feed to EHR/Results Reporting Module CIS/HIS)
Dictation/Transcription (Digital vs. Voice Recognition)
Film Management (Virtual Master Jacket to include CD’s, Foreign Film, Audit Trails of access)
Department Forms (Requisition vs. Virtual Requisitions)
Management Reports (ad Hoc as well as Standard Stat Reporting)
Mammography (MQSA Standards, BiRADs)
Exam Management
Integration (To the Dx Workstation, to the Web Clinical Image Distribution System to the HIS, CIS, EHR, EMPI and or CDR)
Structured Reporting (DICOM SR)

20. Scheduling, Patient Information
Enterprise-wide identifier
Central vs.. Departmental
Location codes
Physicians
Information from registration and scheduling processes should be available
Access to allergy information, ability to add allergy information
Access to Lab Results
PT’S WILL SCHEDULE PROCEDURES VIA INTERNET, W/ PROCEDURE EDUCATION URL’S

21. Orders/Accessioning Orders Accessioning Registration location Timing
Who enters orders
Where are orders entered
Changes to existing orders
Order flow
Different patient types / order types
Cascading orders (CT of CAP, MR of Head + C-Spine) (IHE PGP)
Order Splitting Logic
Bi-Directional Updates (Status)
Paperless Requisition
Accessioning
Unique accession number per exam
System or manually generated
Accession number suitability with PACS
CPOE WILL REDUCE ORDER ERRORS, AND SOME ORDERS WILL BECOME AN INTERVENTION REQUIRING CHARTING AND ASSESSING SIMILAR TO RESPIRATORY THERAPY AND CARDIOLOGY

22. Charges Technical & Professional When charging occurs
How charging occurs
Relationship between procedures and charges
Credits
Billing system integration
RADIOLOGIST WILL CODE/CHARGE PROFESSIONAL VIA STRUCTURED REPORTING MECHANISMS, LINKING A DIAGNOSTIC REPORT AND THE DIAGNOSTIC WORKSTATION; CLICK ON THE PATHOLOGY AND NARRATE THE FINDINGS CODED AS KEY IMAGE ANNOTATIONS ADDED REAL TIME TO THE CDR AND EHR FOR CLINICIAN PERUSAL

23. Patient Tracking & Exam Management
Transport Status – Patient retrieval Time, Patient Availability Status, Patient Arrived in Department
Track procedure times and exam status
Track film use
Reasons for Repeated Studies
Reprint labels, req’s, b/c’s
Technologist Notes
Technologist Completion Function
TECHNOLOGIST WILL CHART INTERVENTIONS AND COMPLETE ORDERS, AS
WELL AS PROVIDE NARRATION OF PROCEDURE/EXAM NOTES (TECHNOLOGISTS CLIPS, PART OF THE EHR)

24. Work Lists Information Needed Format – On-line or manual
Origination and organization
MPPS Bi-directional (Update and Standard Patient Data Message)
RIS Centric vs. PACS Centric vs. EHR Centric
SCHEDULING AND PRE-REGISTRATION (ENTERPRISE) WILL COMMUNICATE WITH EACH MODALITY AND UPDATE THEM REAL TIME ALLOWING A VALIDATION OF PATIENT, PATIENT DATA, PROCEDURE ORDER AND WILL PROVIDE THE PACS SYSTEM RELEVANT PRIOR QUERY

25. Dictation/Transcription
VR vs. Digital Dictation
Transcriptionist vs. Correctionist
PACS based Integration (Dx Workstation) vs. RIS based Integration
Availability of Tech Notes
Viewing and access (images)
Integration with Dictation and Voice Recognition products
Data availability for Radiologist during dictation
Reading by Location vs.. Modality vs.. Subspecialty
Reading across facilities (Central vs. Dispersed)
RADIOLOGIST WILL CODE/CHARGE PROFESSIONAL VIA --- STRUCTURED REPORTING MECHANISMS, LINKING A DIAGNOSTIC REPORT AND THE DIAGNOSTIC WORKSTATION; CLICK ON THE PATHOLOGY AND NARRATE THE FINDINGS CODED AS KEY IMAGE ANNOTATIONS ADDED REAL TIME TO THE CDR AND EHR FOR CLINICIAN PERUSAL; RENDERING, NARRATION, CODING, BILLING, DISTRIBUTION

26. Result Reports Transcribed Report
Electronic Signature / Approved Report (Part of a Dx Workstation)
OR Reports
ER Result Reporting (Nighthawk, Preliminary Reading)
Turnaround Time
Paper Distribution/Faxing to referring physician offices
Preliminary Results
Multiple tests – one report (CT of Chest, Abdomen, Pelvis)
See previous slide…..

27. Film Management (VMJ)
Search process (patient name, MRN, date of service, unit, etc.)
Pre-fetching (Schedule Application Messages to PACS system)
Less Film or Filmless?
Storage
Purging
Sign-out process
Bar-coding
VIRTUAL MASTER JACKETS THAT CAN STORE IMAGES FROM MULTIPLE LOCATIONS (within the IDN) AS WELL AS THE ACKNOWLEDGEME AND TRACK FOREIGN FILMS WILL ALLOW THE RADIOLOGIST TO SEE A TRUE PATEINT HISTORY. EXAM HISTORY OF EACH PROCEDURE WILL ALSO STORE DX REPORTS & CLINICAL NOTES WILL BE AVAILABLE FROM A STANDARD HL7 FEED TO THE RIS OR PACS APPLICATION MANAGING THE VMJ

28. Department Forms Patient History MRI Questionnaire Wet Read Forms
Film Release Forms
Disclosure and Consent Forms
Diabetic Pre-Scheduling Forms

29. Management Reports Patient Wait Times Exam Reports
Technologist Productivity
Radiologist Productivity
Turnaround Statistics

30. Mammography Mammogram Summaries by Radiologist
Mammography Outcomes by Radiologist, BIRADS
Patient Due/Overdue for Follow-up Report
Exam Recommendation Summaries
MQSA Reports

32. Integration
Electronic Health Records: Both text and image data combined with Radiology notes
Clinical Data Repositories: Most often textual result reports (lab, dictated history and physical exam findings (H&P), anatomic pathology, etc.).
Clinical Information System: Order communications, Nursing Assessments/Notes, Protocols, Care Plans, etc.
Hospital Information System: Registration, Billing and Accounts Receivable, and general accounting.
& PACS: HL7, via Broker or Brokerless approach; Registration, Order Management, Order Status, Scheduling SU and Inbound Results Reporting

33. Example of a Standard Integration Workflow
Scheduling
Enterprise Or
Departmental
Interface Engine
PACS
RIS
Clinical Info System
Voice Recognition
ADT
Schedule (engine converts to order)
Schedule
Order
Result
Image (addr)

34. RIS/PACS Integration; a MUST
RIS systems must provide clinically relevant data
Without a RIS a PACS system is merely a Glorified Lightbox!
Eliminating the line between a RIS and a PACS; A Radiology Dream

35. Three examples of DB Integrations:
Key Questions
Single vs. Multiple DB Approach
RIS systems this year showed a variety of DB schemes but most RIS PACS offerings provided a gateway linking databases, but not necessarily a single DB shared from the origination of development
These integrations are not unlike disparate integrations with a few desktop integration effects allowing the Radiologist at the desktop to maintain patient focus and click on a RIS access key on the tool palette
Three examples of DB Integrations:
Proof that separate DB systems can be integrated closely is GE’s Centricity, a PACS system that uses Sybase while the RIS system uses Oracle
The RIS system uses the Oracle Gateway to communicate with Sybase and emulates a single entity DB
RIS & PACS were NOT built by the same Development teams and yet the integration has quality and allows bi-directional navigation
Centricity offers the Radiologist a nice “Physician Access” styled EMR screen
AGFA uses the Quadrat RIS (a Belgian RIS solution), and it integrates in to their PACS product IMPAX
Quadrat and IMPAX are designed by separate development teams and are available in an International version and a US version (set to be released this year)
The integrations started with a general RIS information screen with multiple parts allowing easy access to RIS data on the patient, and bi-directional navigation
IMPAX uses script buttons on the Dx Workstation to access a proprietary conduit called the context server to integrate with disparate third party systems including desktop integration to VR and digital dictations systems
IDX Stentor tout a single database using SQL 2000 as the common DB between their systems
The common denominator for integration is the Imaging Suite offering from IDX, allowing HL7 and DICOM messaging to be managed by IDX
The worklist from Stentor is replaced with multiple styled worklists from IDX (using MPPS allows the RIS system and the modality to do a pre-PACS validation of data prior to offering the Radiologist a view of their daily workload)
IDX allows script buttons on Dx Workstations to access key applications within IDX’s RIS
DB Integration Focus on three examples, detailed notes open discussion after high overview

36. Examples of Approaches:
Key Questions
What strategic relationships exist between third party integration engines and S/W development companies?
When asked about third party tools, most vendors basically have worked to develop their own tools for desktop integration, or have simply not addressed the issue of desktop integration.
Examples of Approaches:
Philips – EPIC (New strategic Partner): Historically Philips did NOT believe that desktop integration, but the latest agreement with EPIC is pro-desktop patient synchronization allowing a script button access to EPICS powerful EMR and newly developed RIS system.
Cerner PACS (Cedara) – RadNet RIS (Strategic Partners): Disparate systems, separate development approaches “Desktop integration can only be achieved when both RIS and PACS are working together.” Cerner does not own their PACS partner and have not moved forward with desktop integrations with any disparate PACS system. “If you want desktop integration you have to buy all Cerner ‘Net’ components.”
DR Systems RIS/PACS (single development approach): The focus here is on innovative integration offerings built in to a common framework allowing workflow to provide Radiologist with the right data at the right time. Most sites using DR Systems needed an RIS solution to provide accession numbers, the RIS system is the latest part of the Dominators quest to become a single source solution for radiology beyond the Imaging clinics where they compete well.
McKesson PACS/RIS: Disparate system acquired, new emphasis is to stabilize functionality and upgrade current features and functions to allow the RIS system to be both competitive and embedded in to McKesson's PACS solution. Desktop integration prior to the McKesson acquisition allowed customized integrations using a variety of methods mostly proprietary approaches. A new standard has been put in to place to make all integrations supportable but they limit desktop integration for third party RIS solutions working in consort with McKesson's PACS. Currently no standard approach is in place for a tight integration beyond HL7 with disparate RIS systems and McKesson's PACS solution, and no interest has been shown to work towards that end.
Evolved RIS/PACS: Developed to generate accession numbers and to manage simple scheduling for the ASP PACS solution the RIS system has since expanded functionality to be a fully functional OP Imaging Clinic RIS solution. Inphact has worked extensively to make the “little RIS that could” be more accommodating for imaging clinics and small community hospitals that could not afford a PACS RIS combination. This ASP based model offers a wide variety of integration points within Inphacts solution. But unlike many vendors Inphact is more than willing to integrate at the desktop with disparate RIS systems. This company supports desktop integration using DCOM, Active x and or socket level integration and is developing xml tools for internet based disparate systems.
Definitely reading material, cover high level differences in integration approach beyond HL7, cover XML, SOAP, ANSI, DCOM, Socket, Active X and context managers

37. Differentiators
PACs/RIS combinations; What differentiates your integration schema from what you do with other RIS systems or other PACS systems?
By and large PACS and RIS combinations be it strategic or in-house developed seem to be better integrated because they have an incentive to offer tight integration beyond HL7. Therefore they share DB mapping and the integrations appear more complete and sometimes are just as unstable as a third party if the work is not QC validated!
Few vendors will explore desktop integration with third party (disparate) systems except for the rare effort by IDX’s (via its Imaging Suite) integrations with the major PACS vendor (offered via IFID documents created due to demand of IDX clients) the only real differentiator with its RIS centric approach towards integration is sharing a single DB with its strategic partner Stentor. 3rd parties as well as Stentor have to use Imaging Suite!
Stand alone RIS systems that do not have a strategic relationship with a PACS vendor are more than willing to use a third party conduit, or self developed integration tools to integrate and bring better quality data to the PACS solution investment made by its clients
CCA
VitalWorks
Ximis
Merge
SoftMedical
Vendors willing to customize integrations if necessary to meet the needs of clients
More Reading Material

38. PACS/RIS (Major vendors)
Strategic Integrations
RIS to PACS
PACS to RIS
HIS to PACS
Single Vendor Development
Acquired PACS to Integrate
RIS Solution
Acquired RIS to
Integrate with
PACS Solution
IDX – Stentor
Misys – eRad
CCA – eMed
Philips – Epic
Eclipsys – Sectra
Cerner – Cedara
eMed – Cedara
DR Systems
Ferrania
RadInfo Systems
Inphact (Evolved)
Avreo
Brit Systems
WebMD
VitalWorks – Amicas
Kodak - Algotech
Agfa – Quadrat
McKesson – WebMedx
Siemens – SMS
GE – Per’Se (Consort)
Merge - RISLogic

39. INTEGRATIONS SUPPORTED
RIS VENDORS
INTEGRATIONS SUPPORTED
RIS Centric
PACS Centric
HIS EHR Centric
Custom Integrations
Agfa HealthCare
Avreo
Brit Systems
Cerner
CPU Systems
CCA
DR Systems
Eastman Kodak Health
Eclipsys
Epic Systems
Ferrania Imaging GE
IDX
Inphact
Insight Healthcare
N/A 
McKesson
Merge eFilm
MISYS
Ferrania
RadInfo Systems
Siemens
SoftMed
VitalWorks
XIMIS

40. Innovative RIS Integrations
HL7 & XML
URL Calls and links to Multi Media Files (a few do not support this but by and large the RIS vendors have embraced this)
Digital Dictation Integration (allows transcribed reports to reside within the RIS, where Electronic Signature will be available for the Radiologist)
Protocol List (ordering modifiers can be edited here via protocol for procedure(s))
OP and Imaging clinics need ability to have on-line adjudication via PPM to update status in RIS
Bi-directional HIS Order Management and Update Registration capabilities
Scheduling to the Enterprise
Pre-fetching HL7 SU messages
Order Management and Update messages
MPPS data send and update via command from modalities
Results Reporting (PRN) Diagnostic Report availability depending upon pre-set rules based logic (i.e. View Preliminary Y/N, View Resident or ER Initial Review Y/N)
Decrement for interventional and special procedures linked to logistics system enterprise
Cost Accounting Reports
Explain practical application; Digital Dictation and VR integration, cover RIS url calls

41. HIS/RIS
HL7
DICOM
PACS/Modalities
Workflow
Manager
Orders
Reports
ADT
Exam Details
Exam Updates
Report Updates
Patient Updates
Worklist Query
HIS Verification
Report Query
Patient Query
When MPPS is more readily available a connection will occur between RIS and Modalities (Worklist, Patient Data & Patient Update Status)

42. Data validation, patient information updates
HIS/RIS
PACS/Modalities
Admissions, Discharge
and Transfer Data
Orders and Scheduling
Information
Radiology Reports
Data validation, patient
information updates
(w/ MPPS Validation can also
be done via RIS/Modality)
Enable worklist manage-
ment and pre-fetching of
prior studies from long
term archive to online
storage
Allows physicians to
view images and reports
simultaneously

43. PACS Integration Requirements
Modality
PACS Data Flow
Patient data
Order Information
MPPS Validation
Patient Data
Scheduling Data
Orders
Reports
HIS/RIS
Patient Data
Scheduling Data
Orders
Reports
Study Data
RIS-PACS
Interface
PACS
To achieve the workflow and automatic data validation benefits of PACS, organizations must have tight integration between their HIS/RIS, modalities and PACS.
Data Validation
Image Routing
Pre-fetching
On-Demand Query

44. Clinical Systems Integration a “Trinity”
Data Integration
Share ADT, orders and reports
HL-7/DICOM Broker/Integration Conduit
Mostly unidirectional interface
Desktop Integration
Clinical Systems and Ancillary Systems able to operate on single Dx workstation
Able to share data between applications
Common user interface
Single Point Login
Database Integration
Both systems use the same database to define worklists and routing rules
Ability to see reports completed prior to EIMS
Common administration
Today
Vendor Partnerships & Proprietary Approaches
H7-Clinical Context Object Standard and/or IHE Approach

45. Integration Confirmation Part 1 of 2 HIS – RIS - PACS
Clinical Results; Multi-Disciplinary (HIS/CIS), Diagnostic Reports available to the PACS (as needed, RIS Responsibility to PACS)
Radiology History of Procedures & Order Entry (RIS or HIS/CIS)
Bi-directional Order Management and Registration (RIS HIS/CIS)
Clinical Data; Primary Diagnosis, Medications, Allergies, Nurse Notes (HIS/CIS)
Modality Work List (MWL), Protocol List and Clinical Exam Note (RIS)

46. Integration Confirmation Part 2 of 2 HIS – RIS - PACS
Client Responsibility to manage integrations with vendors:
Test the Integration of (RIS, CIS, HIS) Product with the Diagnostic Display Workstation
Request a Tech. Spec. document for the Configuration of the integration from each vendor
Create a Test Plan / Report for the integrations
Create a document to be used for supporting the integration and who to call if any component fails or is in need of analysis

47. Integration capabilities that add the most clinical © and or economic value $.
Share common data / indexes with RIS / HIS and enterprise data repository: $ ©
Share common communications protocol, e.g., HL/7, DICOM, etc ©
Pre-fetching of historical comparison exam images according to user-defined rules: $ © (not necessary with on-demand, but rules for relevant priors will have to be considered)
Support for DICOM Structured Reporting: $ ©
Distribution of multimedia patient related information across the enterprise: $ © - via web based clinical image systems
Common user interface, i.e., Web browser to standardize presentation and reduce training and support requirements (IE Explore 5.0 and higher, Netscape 4.5 and higher, version 6.0 at present has many problems with encryption): © - via web based clinical image systems
Indexing and catalog capabilities according to ACR codes to facilitate clinician education, training and service levels: ©
Use of industry standard compression algorithms to insure compatibility across wide range of hardware and software platforms (Wavelit image viewing through URL or portal from main application): $ © - via web based clinical image systems
Work flow capabilities to increase personnel productivity and organizational service levels: $ ©
Controlled access to RIS via remote Web access, e.g., intranet and/or internet: ©

49. Enterprise Defined
CMPI: A system used to track patients across the IDN. The solution accommodates patient movement throughout the health care network, greatly reducing the chances for misidentification and duplication of records, provides accurate data integration into clinical data repositories, and supports heterogeneous application system environments. The CMPI resides one level above each individual institution and or clinic's) MPI.
ES: An enterprise-wide patient scheduling system allows healthcare organizations to easily and cost-effectively schedule patients throughout the enterprise; Inpatient, Outpatient, and Surgical environments. The system allows scheduling to be performed centrally or in a distributed fashion for any facility in the organization.
EHR: The EHR serves two primary purposes: 1. It provides a current summary of the patient's status and it offers direct access to frequently consulted parts of the record, such as: previous visits, diagnoses, sensitivities, past history, current medication, and latest test results. The EHR can provide a view of the status of the patient at any date between the patient's first visit and today. Patient data can also be accessed at a more detailed level than a patient visit or a set of lab results. 2. The EHR supports browsing through all past clinical data via visit and or encounter based timeframes. Information can be viewed such as: patient complaints, medications, allergies, discharge summaries, clinical notes, H&P’s, VSIO, charting notes/annotations, graphs of normal/abnormal ranges, lab test results, radiology diagnostic reports and diagnoses both past and present.
CDR: Clinical Data Repository (CDR) allows institutions to store patient data permanently. The CDR is a data dictionary driven, relational database that manages relevant patient information such as demographics, insurance coverage, patient medications, medical documents, laboratory results and radiology results. In addition, the CDR allows images and other data formats such as voice and video to be embedded into the CDR database.
If you don’t understand the Enterprise you won’t understand RIS and PACS technology and where it fits….
Glossary of Terms used in Presentation for Radiology folks….

50. Rex_Osborn@yahoo.com Rex Randall Osborn
Over 17+ Years Healthcare IT Background; Extensive Clinical IT, PACS & RIS experience
Over 64 Projects from Implementation, System Selections, Project Management, Project Planning, Product Management to General DI Consulting
Available to present in detail with IHE Requirements for RIS and or PACS. Will Provide detailed RFP questions for new RIS or PACS System Selections as well as Product Management Strategy or Product Review and Analysis for Market Segment(s)