Integrated workflow represents Holy Grail for medical informatics


If the aim of digital imaging systems integration is to provide secure access to information and support physicians in clinical decision making, then the model for true integration may exist in New York City. There, a partnership between Siemens Medical Solutions and New York University Medical Center has yielded a product that completely integrates the digital imaging modalities and information systems of NYU's radiology department.

If the aim of digital imaging systems integration is to provide secure access to information and support physicians in clinical decision making, then the model for true integration may exist in New York City. There, a partnership between Siemens Medical Solutions and New York University Medical Center has yielded a product that completely integrates the digital imaging modalities and information systems of NYU's radiology department.

The product is called syngo Suite. For NYUMC, which employs more than 90 radiologists and processes more than 500,000 imaging exams a year, such integration capability represents the Holy Grail of medical imaging informatics.

Radiologists now have access with a single mouse click to all the data they need to perform daily tasks: imaging studies, patient medical histories, relevant priors, postprocessed 3D volumetric data, and speech recognition system.

"This is integration, not interfacing," said Dr. Bernard Birnbaum, vice chair of radiology at NYUMC.

In contemporary reading rooms, it is not unusual for radiologists to be surrounded by computer monitors, with the radiologist swiveling between stations. One station has PACS, another the radiology information system, and others may house 3D postprocessing workstations or PCs for report dictation using voice recognition.

Not only is it a nuisance for radiologists to roll from station to station and sign on to each distinct system, the practice is prone to data entry errors. Integrated workflow not only relieves the annoyance of changing workstations, it also enables dramatic improvements in clinical workflow.

A typical imaging case exemplifies how workflow is improved. First, patient demographics are entered into the hospital information system by the admitting clerk. Those same patient data are transmitted to the RIS, which in turn sends the information to the PACS and relevant imaging modality. Data are entered at one stage only but are automatically recorded by all other clinical systems, thereby maintaining data integrity and eliminating potential errors.

System integration also allows the reading radiologist to sign on to just a single system. Gone are the days when a "broken study" occurs, in which the imaging exam does not match the patient information in the RIS.

"The tighter the integration, the less chance for demographic errors in the different systems," said Chris Petillo, director of PACS at NYUMC.


The packaging of PACS and RIS solutions by major vendors is indicative of the increasing trend toward integration. In the future, expect vendors to combine more than just RIS and PACS, Birnbaum said. At the same time, industry consolidation could create business challenges for smaller vendors.

"Once those integrated products become scalable, then that's it for the little vendors that have gone after special niches," he said.

IT integration is also flourishing in Europe, where the effect on radiology departments is already being seen. One hospital in the Netherlands, Jeroen Bosch Ziekenhuis, achieved an estimated 25% improvement in productivity using an integrated RIS/PACS.

Prior to that integration, most radiologists worked from modality-oriented work lists. Radiologists on daily rotation were expected only to report examinations that appeared on the modality lists to which they were assigned. But sometimes the work list was too demanding for one person, resulting in unreported exams. Some radiologists proved more efficient than others and completed their lists in a shorter time. But they had no way to view or interpret the exams that were piling up unreported.

"Time was being wasted by radiologists who might have read the hanging exams in their spare time, not a very efficient practice," said Dr. Erik Ranschaert, a radiologist at Jeroen Bosch Ziekenhuis.

The hospital recently integrated a new work list system into its radiology practice called Cognos that ensures equitable distribution of radiology exams while guaranteeing emergent cases are handled appropriately.

"Radiologists still rotate on a daily basis, but we now create different work posts," Ranschaert said.

One work post is called "think tank" and the other "flex radiologist." The flex radiologist is responsible for all emergency and semiemergent cases. The flex post is also the contact for clinicians needing to consult with a radiologist. The think tank is a quiet reading room dedicated to complex exams, mostly CT and MRI. Radiologists are able to work there undisturbed, permitting increased concentration, Ranschaert said.

"Now only a few examinations are assigned to a specific radiologist; namely, those cases about which a radiologist gave specific instructions or those that a radiologist specifically supervised or made a preliminary report on," Ranschaert said.

All other examinations are posted in an overflow list, accessible by all radiologists, who tackle those exams once they've completed their own work lists. The system results in shorter report turnaround, with no exams left hanging in the system.

"Since we have no more hanging examinations, clinicians receive the results much quicker, which is also improving the efficiency of medical care," Ranschaert said.

Other institutions have experienced similar productivity gains. Dr. Volkher Engelbrecht of Klinikum St. Marien in Amberg, Germany, said 95% of final radiology reports are available in the HIS by 4 p.m. each day, allowing same-day access by referring clinicians.


Radiologists aren't the only benefactors of systems integration. Access to the complete patient history in the form of an electronic medical record improves communication between referring physicians and radiologists, said Henri Primo, manager of image management and PACS for Siemens.

"With the EMR, the referring physician has a holistic view of the patient's condition, diagnosis, and treatment," he said. "The importance of an EMR is clear. There are just too many paper charts to be handled, filed, updated, and retrieved efficiently."

Traditional paper charts all have the same flaw: they can only be in one place at a time and frequently are not where they are supposed to be. Primo said treatment options are more effective when all variables in the patient's health equation are readily accessible.

Workflow rules embedded in the EMR permit computer-assisted medicine, with online access to best medical practices, which improve quality of medical care for the patient while reducing costs incurred by suboptimal choices, he said.

Integration of IT systems also means referring physicians and radiologists can share a complete view of the patient record and discuss options regarding diagnosis, treatment, and discharge.

Primo coaches radiologists to conduct these information exchange sessions daily as part of the normal workflow, which is contrary to the current trend of outsourcing radiology services.

"The kind of interaction with referring physicians enabled by systems integration strongly promotes the professional value of the radiologist," he said.

Something similar is already happening at Specialty Networks in Chattanooga.

Having an integrated PACS, RIS, and voice recognition system generally means faster report turnaround. What was once a 24-hour report turnaround time is now often an hour at Specialty Networks.

Overall, consultations with referring physicians have decreased significantly following systems integration, said Dr. James M. Busch, an interventional radiologist and director of Specialty Networks. But while the number of consults is down, the quality of the communication is up.

"We find ourselves calling physicians only about complex cases, those that really need a verbal touch, or where there is a management decision to be made based on imaging findings," he said. "A lot of times the referring physicians already have the report, so they can ask any questions they may have, which tends to make our communication a lot more efficient."


Institutions are beginning to recognize the potential that exists for integrated IT to optimize workflow in radiology and throughout the enterprise. Efficiency gains are the principal attraction.

"When one talks more about efficiency, the key point is optimization over departments," said Erwin Bellon, Ph.D., of the department of information systems at Leuven University Hospital in Belgium.

Optimization requires sharing information and policies among departments.

"When different information systems are used, sharing information is simply not practical. Duplicating the same information in every system would be ludicrous in principle and impossible in practice," he said.

Implementing the same policies in different systems is also not feasible, unless one agrees on a common denominator that is so weak that optimization is canceled from the equation as a result.

"A number of optimizations become relatively easy to implement in a central system," Bellon said.

For example, requests for CT scans that do not meet specific preconditions can be discouraged.

"For any such example, one will be surprised at the number of information items that need to be available in order to make the decision," Bellon said. "This in itself is an argument to have the information centrally available."

The result is predictably higher quality of care. According to Hospitals & Health Networks magazine's 2005 Most Wired Survey and Benchmarking Study, the 100 most wired hospitals in the U.S. have, on average, risk-adjusted mortality rates that are 7.2% lower than other hospitals. While there may be many reasons for this dramatic improvement, it appears that technology helps clinicians do a better job of caring for patients.


Integration of IT systems also changes the working lives of hospital chief information officers and IT administrators, but not always for the better.

"Integration has made managing effectively more complex," said Chris Van Pelt, director of healthcare provider information technologies at Computer Sciences Corporation based in El Segundo, CA.

Increasingly, systems are required to be operational at all times, and downtime or system incompatibility issues are no longer options, he said.

Enterprise-wide and department-level integration requirements dramatically affect the priorities, projects, and daily workloads of hospital IT departments, said John Paganini, senior director at Guardian Technologies, an integrated RIS/PACS vendor based in Herndon, Virginia. Depending on the size of the institution and the number of integrated systems, personnel will be required to monitor these systems around the clock.

Additionally, as new vendor information systems are brought into the integration mix, a project plan for integration is required. As with any project, goals, resources, and activities must be clearly defined and managed.

Interdepartmental politics often arise as a pothole on the road to progress.

"One question that needs to be answered is, who owns the data?" said Joel Rosenfield, director of sales and marketing for Compressus, a Washington, DC, software house specializing in digital medical image management and disaster preparedness.

Rosenfield said it takes strong hospital leadership to foster changes in the way that departments interact. IT departments remain neutral in this regard, charged with facilitating access to the data, protecting and archiving the data, and maintaining the entire system.

"Too often, we fail to realize the scope of what IT does," Rosenfield said. "It has the ability to fill those interdepartmental potholes."


Since the U.S. government is active in protecting the rights of patients, privacy and security are at the forefront of integration conversations.

"Healthcare industry applications have evolved to manage security by level or position and to grant audit capability across domains," Van Pelt said. "In addition, we have introduced multiple applications that have their own security layers, such as single-sign-on (SSO), which extends rights from one level to the next."

Ideally, physicians should only have to sign in one time, Van Pelt said. SSO enables that. Still, some experts believe systems integration may aggravate the data privacy issue.

Traditional approaches to providing proper security in a clinical application involve "role-based access." This approach ensures that an end-user has access only to information appropriate to his or her role within the organization. Admitting staff may have access only to certain patient demographics, for example. Or referring physicians may be able to see only results relevant to their patients.

"The security problem becomes greater when the information exists on various integrated systems," Paganini said.

An example is when the physician may want to see lab and cardiology results. The information physically resides on two separate clinical information systems. Without an integrated workflow, the physician needs to sign into each system individually. This requires a high level of IT administrative support to ensure that sign-ons, passwords, and proper access roles are assigned.

In an integrated workflow, however, the physician's access would be validated only once. Hence, physicians who are reviewing lab results for patients and want to also view cardiology results have access without being prompted for a sign-on and password. Theoretically, this contradicts good security policy.

Elmar Kotter, vice chair of radiology at Albert-Ludwigs Universitat in Freiburg, Germany, sees no contradiction between security and systems integration. Indeed, he said, data privacy and system efficiency are often contradictory in current systems.

"You have to keep a good balance between patient privacy and access to patient data," he said. "That was one of the reasons we developed our own EMR at Freiburg University Hospital."

Freiburg's EMR is able to handle dynamic access rights for every user. All users are granted temporary access to data of all patients they treat. Access rights are then withdrawn two weeks after the last encounter.

Leuven University Hospital, on the other hand, believes it is simply easier to provide security in an integrated system than in separate or semicoupled systems, and that ultimately the quality of care can be improved when data are easily available.

"Over the years, any discussion in our hospital about which groups of physicians are allowed access to which types of information has reinforced the policy of granting access to the nearly complete patient file," Bellon said. "There are simply too many medically sound reasons why a clinician from one discipline may benefit from access to information from another discipline."

In contrast, Bellon said the hospital is relatively restrictive when it comes to whether a physician has access to an individual medical record in the first place.

"That access is based on individual patients," he said.

Leuven does not allow clinical users to select images in PACS. Instead, clinicians select a case in the EMR, which in turn instructs PACS to present the corresponding exam, depending on the relationship between that clinician and the patient as defined in the system.


Most initiatives involving the EMR to date ignore the fact that computers can compute, said Dr. Donald Rucker, chief medical officer for Siemens. He maintains the healthcare industry so far has regarded the computer largely as an efficient file cabinet.

Rucker makes a pitch for a more ambitious EMR that exploits the potential in today's computers and networks. In his vision, a given piece of data is entered once and only once into a system smart enough to send it everywhere it needs to go: the medical record, lab, and pharmacy; but also to supply, billing, admitting, cost accounting, quality measurement, and perhaps even to devices such as smart IV pumps.

Other industries are already doing this, and Rucker wonders why it can't be done in healthcare.

"We have to stop looking at the EMR as chart storage and start looking at it as automated monitoring of processes," he said. "Coordination of care right now is manual. We have to look at the EMR as communication and make the information actionable."

The key is automated workflow management, he said. It is the logical next step for hospitals, once they adopt computerized physician order entry and barcode medication administration, which he expects to reach 50% industry penetration by 2009.

An EMR with embedded workflow engine and decision support logic will eventually become the gold standard in healthcare, Primo said.

"An enhanced EMR will help healthcare providers achieve optimal patient care in an increasingly complex world with a multitude of tests and treatment options to choose from, all under stringent quality and cost control," he said.

In the end, the aim of systems integration is provide secure access to patient information to enable providers to make informed clinical decisions.

"A well-designed integrated workflow can provide this capability," Paganini said.

Still, many organizations lack the vision to drive a successful outcome. Information systems will not morph into a cohesive, integrated tool set all by themselves.

"It is imperative that healthcare organizations check their course and speed to a destination. Many are on a bad path," Van Pelt said.

Mr. Page is a contributing editor to Diagnostic Imaging.

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