1. Complete Integration of RIS into PACS: Dream or Reality?
Dr Keith Foord
Consultant Radiologist,
East Sussex Hospitals,
United Kingdom

2. History 1970-2001 1970s – First RIS systems
To manage departmental workflows and store information
Late 1980s/early 1990s – First operational PACS
But did not link information in RIS with images
Mid Image centric PACS with RIS interfaces
Incompatible communication protocols forced ‘Brokers’
Image centric – PACS image DB has to be additionally populated with information INTRODUCED to the system
Some RIS functions have to be duplicated in PACS
Problems with correlation of RIS & PACS data - requires administrator intervention to correct

3. History 2001+ RIS centric PACS
The RIS is prime and controls information flows, including images
Simplifies information management
RIS becoming integrated – integrated Brokers or ‘Brokerless’
IHE integration profiling
Provides DICOM Modality Worklist (MWL) directly to modalities
Uses DICOM Modality Performed Procedure Step (MPPS) – if supported by both modality and RIS

4. Communication issues between IS databases, PACS and modalities
03/10/01
Keith D. Foord
Oct
Foord, Keith D.
HL71
HL72
SPF
RIS
HIS
HL7 i/f
or ‘Gateway’
HL72
DICOM
Although the HL7 protocol is used the data structures may differ e.g. dates may use different formats and fields as may names.
The interface engines, including the PACS broker may be single points of failure in the systems.
SPF
HL7/DICOM
I/f = PACS Broker
Modality
PACS
DICOM
DICOM

5. Unidirectional RIS/PACS
Many RIS vendors have provided Uni-directional
data to PACS via a PACS Broker.
Data not sent back to RIS to update fields related to the exam.
If RIS does not support DICOM MWL or modality
does not support MWL
Demographic data must be entered manually at modality
– high risk of errors.
Errors manually corrected at the Archive or QA station,
Reducing productivity and delaying availability of images.
If not corrected images ‘orphaned’ and not available.

6. Unidirectional RIS/PACS I/f without Modality DICOM MWL
Archive
HL7
RIS
PACS Broker
DICOM minus MWL
DICOM modality worklist is not provided from RIS and there is a known 20% error rate between entry of data in RIS and its transcription into the modality e.g. at the CT console.
If this is not corrected the PACS does not recognise the study as belonging to the patient until errors are spotted and corrected at the QA station. (I.e. the study is orphaned as it has no parent)
Modality QA station
Manual correction of data to match RIS data
If not done up to 20% of studies are ‘orphaned’
DICOM data, no MWL
Manual input of data. Prone to error
Non – MWL Modality
Reporting Workstation

7. Unidirectional RIS/PACS I/f with Modality DICOM MWL
Archive
HL7
RIS
PACS Broker
DICOM
Data incl MWL
PACS does not update RIS regarding the status of the study – the RIS is blind to what is happening within radiology.
But the patient data is transferred correctly to the modality via DICOM Modality Work List so that data matches and there is a greatly reduced rate of lost studies.
But both RIS must provide Work List and the modality must be able to receive and use Work List.
However the RIS is still blind to departmental real time activity.
MWL Modality
Reporting Workstation

8. Bi-directional RIS/PACS
Data on start/finish exam, procedure changes, resource utilisation, number of images and series in study if sent back to RIS enhance QA, increase productivity and allow full integration into Integrated Clinical Systems.
To do this both RIS and Modality must support not just MWL but also DICOM Modality Performed Procedure Step (MPPS)
If RIS provides Work List and also has a bi-directional interface to PACS it can receive simple information about status of the studies occurring within the department.
If it also provides DICOM Modality Performed Procedure Step activity cab be both monitored in real time but also data generated to show how the department is working and how procedures are modified for individual patients. E.g the numbers of CT images per patient can be monitored for variances and start/finish times of procedure steps monitored. This can be useful for management of change and monitoring changes to see if they are effective.

9. Bi-directional RIS/PACS I/f with DICOM MWL and Modality Performed Procedure Step installed in both RIS and Modality
Archive
HL7 +
DICOM +
RIS
MWL/MPPS
PACS Broker
DICOM
HL7
DICOM
MWL/MPPS Modality
Reporting Workstation

10. Integrated RIS/PACS with DICOM MWL and Modality Performed Procedure Step installed in both RIS and Modality
RIS/PACS
Internal HL7- DICOM
& DICOM – HL7
transactions
Archive
DICOM
General Purpose Worklist
(if provided allows
choice Of WS independent of PACS Vendor)
Demographics
MWL MPPS
With everything internal to RIS-PACS the functional difference between RIS and PACS is lost as they share transactions and databases.
DICOM General Purpose Worklist will allow vendor independent workstation use.
MWL/MPPS Modality
Reporting Workstation

11. PACS companies which have acquired RIS company products.
Still basic brokering, but added
internal HL7/DICOM transactions.
RIS
PACS
Internal Transactions
Broker
Voice
De-novo combined RIS-PACS
products.
Some internal interfacing plus
Internal HL7/DICOM transactions.
RIS
PACS
Internal Transactions
Voice
Different vendors with all the HL7/
DICOM transactions in RIS within
a ‘PACS integration module’
RIS
PACS
Internal
Transactions
Voice

12. Structured reporting
DICOM SR – is an ‘envelope’, but within this useful structure is available.
User decides how much structure to use and controls with templates the type of content, if it is mandatory or optional and modes of expression
Incorporated into the report are captured images of key findings (which can be exploded to full screen presentation), structured diagnosis information, recorded audio, the ability to sort findings by anatomy or priority, to view prior findings associated with the corresponding patient and hyperlinks to related information.
       

13. Structured reporting Link Features to Description New nodule
superimposed
with right
fourth rib
10% Pneumothorax
Cavitation
Free air

14. Structured reporting David Clunie
Development Director, Imaging Products
ComView Corporation – Paper at SPIE, 2001
Structured reporting

15. Complete Integration of RIS into PACS: Dream or Reality?
With an old non HL7 RIS – forget it
With an old HL7 Brokered RIS – limited
With a new HL7(IHE) RIS
- very nearly a reality with a PACS integration module
- this allows freedom to choose best RIS and best (IHE) PACS
With a same vendor combined RIS-PACS
– internal HL7/DICOM transactions
….But what about the modalities, DICOM MWL and MPPS?
Don’t forget the need to integrate the HIS and Integrated Clinical Systems too!

16. Internal Transactions
IMELDAHOSPITAL
Bonheiden, Belgium
HIS
EPR
At the Imelda Hospital in Bonheiden, Belgium there is an integrated Agfa RIS-PACS, with different vendor HIS and EPR which allow electronic ‘Order-Entry’ and ‘Results Reporting’.
Dr Jan Schillingbeeck reports a 25% productivity gain within his department and a much more stress free and quiet environment with many fewer interruptions of staff
RIS
PACS
Internal Transactions
Broker
Voice
With thanks to Dr Jan Schillingbeek

17. RIS Extern call No access to HIS Paper document Request Access to HIS
General Scheduler
Order placed
Part I: Administration
RIS
Order
Communication
Analogue request
Demande.est introduite pour un ou plusieurs
examens.
Via un système électronique de prise de
rendez vous,soit centralisée, soit via le RIS.
Communication de demande vers le RIS
Order filled
available
as scanned image
Analogue request

18. PACS RIS Prefetched images DS Display station + archive Modality
Prefetching
Prefetched images
RIS
Order filled
PACS
Modality
Image manager +
archive
Long-term
Archive
Les procédures de la demande sont envoyées
aux modaltées et parviennent à la
DICOM modalaty worklist.
Le système central d’archivage est interogé
sur l’existence d’éventuels examens préalables.
Ces examens sont mise on-line via un
mécanisme de”recherche préalable” “prefetch”
DICOM
Modality
Worklist

19. PACS RIS RIS Part II: Image production Finished Order filled Listed
Started
Arrived DS
Registration
PACS
Une fois inscrtit la demande recoit le statut
“Enregistré”
Dès que le patient se présente il recoit le statut
“Arrivé”
Dès que le patient et pris en charche il recoit le
statut “Commencé”
Imagemanager +
archive
Modality

20. -Desktop integration: 1 mouse & 1 keyboard - Speech recognition
-Access to HIS
-Access to RIS
-Access to EPR
Set up trois moniteurs donc un de couleurs
pour la module 3D.
Notez 1 clavier, 1 souris.
Pour le protocole un système de dictée numérique
est utilisé avec module de reconnaissance vocale
Accès au HIS/RIS/Dossier central.
Statut Protocole enrégistré
Statut Approuvé
-MPR
-MIP
-Volume Rendering
Part III: Reporting

21. Electronic Patient Record
EPR DS
Webserver
URL
Electronic Patient Record
Billing
report
RIS
Report
print
Paper
print
PACS
Imagemanager +
archive
Pendant lun de ces statuts les images et le
protocole peuvent etre mis a la disposition du
médecin requérent. Le moment choisi pour
l’exécution de cette procédure varie d’intitution
a l’autre.
Les image peuvent etre visulisées via la technolgie
WEB. Dans des conditions normales il s’agit
d’un PC standard avec écran standard.
Ce serveur Web peut etre interogée en direct, soit
commandé par le dossier électronique central.
Les données de tarification sont également mise à
la disposition de la solution de facturation. CD
Part IV: Distribution

22. Complete Integration of RIS into PACS: Dream or Reality?
DEFINITELY POSSIBLE !