Complete Integration of RIS into PACS: Dream or Reality? Dr Keith Foord Consultant Radiologist, East Sussex Hospitals, United Kingdom www.esht.nhs.uk keith.foord@esht.nhs.uk

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 1990-2001 - 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

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

Communication issues between IS databases, PACS and modalities 03/10/01 Keith D. Foord Oct. 01 2003 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

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.

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

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

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.

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

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

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

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.        

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

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

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!

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

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

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

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

-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

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

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