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Integrated approach drives RIS/PACS efficiencies


Chinese healthcare providers have begun to appreciate the value of Integrating the Healthcare Enterprise workflow profiles when working with digital imaging systems.1,2 The IHE scheduled workflow integration profile in particular can increase operational efficiency, and this is now a key demand for RIS/PACS implementation

Chinese healthcare providers have begun to appreciate the value of Integrating the Healthcare Enterprise workflow profiles when working with digital imaging systems.1,2 The IHE scheduled workflow integration profile in particular can increase operational efficiency, and this is now a key demand for RIS/PACS implementation.3,4

Healthcare professionals in China established a relationship with the U.S. IHE organization in 2004, with a view to launching IHE-China. They organized several preparation meetings and an IHE technical framework training session. IHE-China was formally established in August 2007. An IHE working platform is to be set up in Shanghai to promote the IHE concept and experience to the whole country.

The IHE technical framework initially covered medical imaging workflow integration and has since expanded into five domains: radiology, IT infrastructure, laboratory, cardiology, and eye care. Workflow profiles--including scheduled workflow, report workflow, postprocessing workflow, and patient information reconciliation--form the backbone of the IHE framework.

We have been tracking how the IHE technical framework has been implemented in the RIS/PACS of more than a dozen large-scale hospitals in China, mostly in eastern regions. The implementation of workflows has been emphasized and optimized in these installations.

The modern PACS should possess the following qualities: reliability, availability, extendibility, scalability, connectivity, operability, and efficiency. Standardization with IHE guidelines plays a critical role in realizing connectivity and workflow. A RIS/PACS designed according to IHE principles will be built from modular components that are interfaced with standard protocols and driven with regulated transactions. This approach provides tremendous freedoms and helps achieve the above qualities.

We have been working with radiology professionals to implement IHE profiles in RIS/PACS. We start with the workflow and workflow-related profiles and gradually extend to the implementation of detailed profiles (consistent presentation of images, key image notes, nuclear medicine image, portable data for imaging, and evidence documents). The workflow profiles are localized and optimized to make them suitable for real-world routines specific to China.


The First Affiliated Hospital of Zhejiang University and Hang¬zhou First People's Hospital are located in the east coast province of Zhejiang. Both have more than 1000 patient beds. We have realized seamless integration among the HIS, RIS, PACS, and IHE workflow transactions at these sites. Clinical information and imaging data flow fluidly between systems, linking different aspects of a single patient procedure and improving efficiency.

We proposed detailed workflow optimizations according to the hospitals' requirements based on the IHE technical framework and its integration profiles. The accuracy of data is emphasized in the first instance, and the entire system is fine-tuned to ensure consistency in clinical information and image data. This reduces the work required in the patient information reconciliation process.

A modality work list is mandatory for all modalities under the scheduled workflow profile. We have adopted a barcode reader for some heavily scheduled modalities, such as computed radiography and digital radiography, in order to improve operational speed and accuracy.

Many modalities do not support the modality performed procedure steps (MPPS) service. In fact, most modalities do not completely support all DICOM attributes required by IHE. Our solution is to send the image through a quality assurance workstation before it reaches the archive for storage. This allows the image to be consolidated with the necessary DICOM attributes, including information about the requested procedure. The QA workstation also sends the MPPS request to the PPS manager to update the study status.

The IHE report workflow profile comprises interpretation/dictation, transcription, verification, review, comparison, and coding. The procedure is significantly different in China. The main difference is that an initial reporting doctor creates the report, then a chief doctor verifies it.

Different reporting work lists, implemented with the general-purpose work list, are needed for these distinct roles. The reporting task may go back and forth between the initial reporting and verifying doctors. When a doctor revises a report, the previous version of the report is saved in the system for audit purposes.

The reporting work list should be sorted according to the urgency of cases. Emergency cases are given highest priority, while annual physical health checkups are allocated the lowest priority. We use different colors to indicate different priorities on the ADT (admission, discharge, and transfer) workstation.The speed at which requested images appear on the screen directly affects the efficiency of the reporting workflow. We have implemented a "retrieve images on demand" approach. Images populated within the "view port" have the highest priority for retrieval, realizing optimized display speed. View port refers to the display area on the screen for a series of images.

We usually specify a virtual geometric area for a series of images to lay out. This entire layout area is usually much larger than the display area on the screen. We build up the virtual geometric area with a multiple of smaller geometric areas, each of which matches the shape of the display area on the screen. One of these smaller areas is displayed on the screen each time, and prior studies are made available for diagnosis automatically.

Errors in a patient's demographic information can occur for many reasons. The system should be tolerant of errors and support correction mechanisms. Patient updates should be synchronized throughout the entire RIS/PACS. We insist that the system administrator have sole responsibility for patient information reconciliation tasks and that these tasks be performed on a "sooner rather than later" basis. This ensures optimum data integrity throughout the RIS/PACS infrastructure.

Dealing with hard-copy film is another issue that is especially relevant in China. Many patients request a copy of their films. We do not send print service requests directly to the printer server. We have instead implemented a film print routing manager to physically queue these requests. A print-on-demand function then allows the administrator to print films selectively, according to patients' requests. This minimizes film waste.The system is equipped with secondary image data storage for disaster recovery. The cluster technique is adopted to realize system high availability; currently, we set two redundant servers into the high-availability cluster, which is a "failover" cluster.

Orders for imaging examinations are sent automatically to the specified modality. The real-time status of the study can be tracked at the management server. On completion of the examination, the reporting task is added in the diagnostic workstation. The relevant digital images, along with prior studies, will already be available for reporting. The diagnostic report, when complete, will be transferred from the initial reporting workstation to the report verification workstation. This system avoids the need for manual film delivery and paperwork completely, which effectively reduces turnaround time and operational error.

Dedicated maintenance is crucial to keeping the PACS healthy. A healthcare system cannot bear hours of downtime. Measures should be taken to prevent data being lost or mislaid. An organized team with a well-designed maintenance plan is extremely important. Hospitals should have a PACS committee that can oversee the maintenance program and plan for the future of the PACS.5


The functionality of IHE workflow profiles in RIS/PACS installations is being realized. The scheduled workflow and reporting workflow are al¬ready contributing positively to the daily running of radiology departments, according to our analysis.

The National Health Administration Bureau of China specifies that the turnaround time for an x-ray diagnosis should be less than two hours. This is the time between image acquisition and the moment when the diagnostic report is verified and available for the referring physician. IHE workflows have helped to cut this turnaround time by approximately 45%, so it is now well below the two-hour requirement. Turnaround time is already kept to within 30 minutes for emergency cases.

Annual productivity generally increases by more than 25%, with the same level of staffing, after installation of a RIS/PACS. The accuracy of patient records improves significantly. It also becomes much easier to query a patient's history, case-related data, and statistics. Barcodes and smart cards can help boost the efficiency and accuracy of routine operations still further.

Digital imaging has led to revolutionary improvements in diagnostic efficiency. Images for an emergency head CT, for example, will be ready to report within five minutes of the scan being performed. The screens of a diagnostic workstation will display images within one or two seconds. Display workstations are optimized so that even 64-slice CT studies can be turned around easily.

Enterprise-wide access to the system is possible via a web server. This allows on-call doctors working with inpatients to access images and reports through a web browser. Practitioners working in orthopedic and surgery departments can gain access to the PACS as well. They can take advantage of accurate measurement tools when using images for presurgical planning or when checking postprocedural outcomes. All DICOM attributes are preserved for web-based access. This enables referring physicians and surgeons to use the powerful tools for image manipulation provided by the DICOM viewer.

In China, a large hospital's PACS is typically accessed more than 20,000 times each month by doctors using web browser technology. The PACS at the First Affiliated Hospital of Zhejiang University was being accessed 69,000 times per month via the web by the end of May 2007. Monthly numbers at the start of system access had been just 10,000. Web-based usage of PACS tends to increase dramatically during the first mentum within hospitals to take advantage of the new digital technology, once installed.

"X-ray and ultrasound alone create over 2000 studies each day in our hospital," said Prof. Zhang Minming, dean of the Medical Imaging Center at First Affiliated. "It would be a totally different story if we did not have RIS/PACS. Since installation of the PACS, the turnaround efficiency has improved dramatically. It makes scientific research and education easier. Furthermore, it provides a solid technology foundation for accurate and timely healthcare services. Implementing PACS with an IHE approach has revolutionized our daily work."


Our case studies show that an IHE approach to workflow optimizes routine operations, increases efficiencies, and improves accuracies. The benefits on offer from IHE go beyond im¬provements in efficiency, however.

RIS/PACS should, first and foremost, be a long-lasting system. Hardware and software will have a limited lifetime, but the system itself should grow while the hardware and software are fading. IHE provides an ideal solution for such longevity. A modular approach with standardized interfaces between all modules creates a solid foundation for continuity. Any future migration of system components and image data to newer and more powerful hardware, software, and resources should then be successful.

The adoption of standard code systems is critical if automated healthcare systems envisioned for the future are to become reality. IHE emphasizes the use of such codes. A procedure code should be used from the scheduled workflow to charge posting. The interpretation result should be tagged with a diagnostic code.

IHE promotes a number of powerful features. These include structured reporting, presentation state, key image notes, encapsulated document, waveform, spatial registration, and removal media storage. With structured reporting, for example, a diagnostic report can be associated with visual evidence support. Its diagnostic code allows the machine to understand without ambiguity, and it is accurately organized in a DICOM study. We can encode an "ICD-9-CM" diagnosis code in the concept code sequence. The code (429.3, ICD-9, Ventricular hypertrophy, for example) would not mean anything else. Code modifiers and supporting measurement values can be accurately encoded as well. It is easy to instruct the computer to perform exact matches to these standard codes. In this way, the computer can know exactly what the report talks about.

The soft-copy presentation state object covers the way that doctors display an image, including pixel brightness and graphic annotations. It also allows images to be reconstructed on a different workstation with the exact same presentation.


The dynamics of RIS/PACS are being constantly enriched. Success requires a full understanding of the technology and a willingness to follow trends closely. Hospitals' technical personnel must increase their level of knowledge and demand higher standards from modality and PACS vendors.

We have gained some initial experience in how to localize IHE profiles to meet requirements specific to hospitals in China. Formalizing China-specific IHE profiles requires extraordinary hard work from all major RIS/PACS players operating throughout the country. The first Connectathon was hosted by IHE-China and held in Shanghai on 20 to 23 November 2007; five vendors participated. The event may play a crucial role in accelerating the pace of this process.

Most RIS/PACS implementation in China is occurring in hospitals in relatively better developed areas, particularly along the east coast. With closer cooperation between hospitals and vendors, we hope to developmore advanced and sophisticated IHE-compliant systems. This may help bring better and more affordable modern healthcare systems to the whole country.

Dr. Xu is general manager, and Mr. Cao is chief technology officer, both at RADinfo China. Dr. Zhang is chief technology officer at RADinfo Systems in Dulles, Virginia, U.S.

1. Siegel EL, Channin DS. Integrating the healthcare enterprise: a primer. Part 1. Introduction. Radiographics 2001;21(5):1339-1341.
2. Channin DS, Siegel EL, Carr C, Sensmeier J. Integrating the healthcare enterprise: a primer. Part 5. The future of IHE. Radiographics 2001;21(6):1605-1608.
3. O'Donnell K. Scheduled workflow: The first profile, IHE 2006 workshop--RAD--scheduled workflow, V2, ppt. www.ihe.net/Participation/upload/1_IHE_Rad_Scheduled_Workflow.ppt
4. RSNA & HIMSS. IHE success story. www.ihe.net/Resources/user_success_stories.cfm.
5. Reed G, Hobe Reed D. The PACS committee: the all-important human element. www.ahraonline.org:80/RM/RMShow.asp?ID=278.

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