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For other articles and previous issues click here. May 16, 2005 PACS’
Place In the Universe — Boldly Going Beyond Radiology Someday digital imaging will be integrated into the broader electronic medical record. Thinking in radiology-centric terms isn’t looking to the future. When asked why he was such a great hockey player, Wayne Gretzky once replied that the key wasn’t skating to where the puck is, but the ability to skate to where the puck is going to be. Anticipating where the PACS puck is headed was a central theme of PACS 2005 in San Antonio. The title of this year’s meeting, “The Expanding Integrated Digital Healthcare Enterprise,” certainly qualifies as anticipating the future, especially in an environment where approximately one-half of the hospitals don’t yet have PACS. Survey data gathered from 4,000 hospitals by HIMSS Analytics in 2004 showed that 33% of hospitals had PACS in place and another 10% were under contract but were awaiting implementation. At this point in mid-2005, that number has only moved upward. Eventually, just having PACS won’t be enough. Someday, and in most places it is a long way off, PACS will be part of a facilitywide and systemwide integrated electronic medical record (EMR) system. James M. Walker, MD, the chief medical information officer for Geisinger Health System, based in northeastern Pennsylvania, spoke at PACS 2005. Walker said Geisinger physicians already participate in 80 programs where physicians are paid extra for using EMR. “This is coming from every major player like a freight train,” Walker said. “Whether it’s right or not, it’s coming in the next 10 years.” Proprietary Issues “Proprietary boundaries are growing around health information at the same time that talk about interoperability has become commonplace,” Brailer said in an address to the Healthcare Information Management Systems Society (HIMSS) annual meeting in February. “Enterprise investments in non- or semi-interoperable information systems make strategic assets of health information silos. This will limit the way health information is used to promote consumer choice and to streamline population health improvement.” Brailer also told the HIMSS audience that the Certification Commission for Healthcare Information Technology expects to complete standards for EMRs in ambulatory settings by this summer. He sees it as a key to developing a system of standards that would provide a floor of interoperability among different companies’ systems and push companies toward a more integrated healthcare information system. Under the developing plan, within 10 years the government envisions a network of regional systems that can exchange data formatted under yet-to-be-announced standards. These regional health information organizations (RHIOs)—have been started in Colorado, Indiana, Rhode Island, Tennessee, and Utah. At least four more state legislatures are working on legislation to form similar prototype RHIOs. The obvious importance of including diagnostic images in a patient’s records and the growing prevalence of digital images means handling images will be a key part of those standards. In some ways, the road to electronic records will go through radiology. “We in radiology are well-suited to play, if not a dominant role, an important role in implementing the electronic medical record,” Paul J. Chang, MD, told attendees at PACS 2005. Chang is a professor of radiology and director of radiology informatics at University of Pittsburgh Medical Center. He is also a cofounder of Stentor, a PACS and healthcare information technology (IT) company. Looking Ahead • PACS application. To work in an EMR environment, Chang said a system must be scalable to grow with the enterprise’s needs; be cost-effective and leverage a facility’s existing IT resources; be capable of handling enterprisewide image distribution; be able to accommodate all types of images, including non-DICOM images; and be easy to integrate into the larger EMR system. • Enterprisewide image distribution system. An EMR-enabled system needs to be able to distribute full-fidelity images to everyone on the network who needs them in a timely manner. To illustrate the demands on a distribution system, Chang gave an example from Pittsburgh. He noted that busy orthopedists who may spend four or five minutes with a patient in an office visit are not going to wait five minutes for an image to be prefetched, making on-demand archives increasingly popular and important. He added that the orthopedic surgeons often don’t read the radiology reports; instead, they interpret the images themselves. While Chang admitted he doesn’t like that as a radiologist, when he looks at the issue as an IT guy, it makes the point that any system needs to provide diagnostic-quality images to other physicians. On top of making full-fidelity images quickly available to physicians throughout the system, Chang pointed out that systems need to be scalable, cost-effective, usable with most existing client personal computers, secure, and easily integrated into the electronic record system. Chang pointed out that traditional PACS models “have significant limitation and liabilities” in how they’ll function in a multimedia environment. One particular challenge is many PACS systems’ reliance on workstations that are simply too expensive to be widely installed throughout a healthcare system. • A way to handle non-DICOM images. While DICOM images aren’t as universally portable as many believe, they are much closer to standardized than the non-DICOM images used outside of radiology. Retinal photography and fluorescein angiography in ophthalmology and skin photography in dermatology are just two examples of non-DICOM images used throughout medicine. If an electronic record is to be complete, such “PACS” information needs to be included. Chang said a truly integrated system will either need a separate archive and database or be brought into the DICOM archive with some kind of “wrapper” formatting to preserve the image and tie the data to the proper patients. The RIS-like information from those noncompliant imaging systems must somehow be brought into the record, too. That job is a huge task facing people developing integrated medical record systems. • Integrate with the electronic record. The three previous components all require an effective integration into medical record systems, which is simply easier said than done and makes integration its own challenge. In his presentation, Chang pointed out that many of the existing EMR systems are “not ready for prime time.” Plus, existing system vendors use a number of different underlying languages and standards. “All EHR software is immature,” said Geisinger’s Walker. Even software regarded as the best EHR software available is substantially immature in his view. Planning a PACS implementation that will prove compatible to a larger system is hard to do—especially when the system you’ll connect to hasn’t really taken shape yet. Even as EMR software matures, achieving interoperability faces a difficult industry hurdle. Vendors are leery of broad interoperability because they fear it could require sharing proprietary database architecture or interfaces. In general, interoperability blurs the distinction between systems, eroding the brand value leading companies covet. Context Management “I don’t want your end application, I want your data structure,” Chang said in describing the CCOW approach. “I want the content but will run it through middleware that does what I need it to do.” Chang and other speakers at PACS 2005 noted that the CCOW may prove a valuable transition technology on the road to true integration. He also noted that other industries use context management approaches, also known as context sharing. Industry is widely receptive to the approach because the companies protect their proprietary programming. In addition to sorting out the technical issues, facilities must adjust people’s workflow. In a panel discussion at the meeting, Chang noted that paper often serves two functions in healthcare. “Paper wasn’t just the way data was communicated,” Chang said. “Paper was the baton that drove decisions and gave signals to drive workflow.” All those big and little steps need to be accounted for when changing workflow under the EMR. Learn Before You Leap While thinking about how PACS will integrate into an EMR may seem like wasted effort in a hospital still up to its waist in film, seeing the future so you can navigate a smart path toward it is an important reason why institutions send people to meetings such as PACS 2005 and the Society for Computer Applications in Radiology. — A Radiology Today staff report.
• a network of healthcare facilities that uses electronic information capture, distribution, storage, and display instead of paper and film; and • the facilities’ component systems must be integrated. Horii considers a single facility meeting the above criteria a digital healthcare environment. The difference between a digital environment and enterprise is largely one of scale. Does the Term PACS Need
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