Where are we going anyway?

….and what are the chances of getting there via the NPfIT

Dr Keith FoordConsultant Radiologist,

East Sussex Hospitals,

United Kingdomwww.esht.nhs.uk

keith.foord@esht.nhs.uk or secretary@pacsgroup.org.uk

Objective 1 for this group?

Complete Integration of RIS and PACS

or as near as possible,with some points from history

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

PACS

HL7 i/for ‘Gateway’

HIS RIS

HL7/DICOMI/f = PACS Broker

HL71 HL72

HL72

DICOM

DICOMDICOM

20/11/03Keith D. Foord

Nov. 20 2003Foord, Keith D.

SPF

SPFModality

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 MWLDemographic 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

Unidirectional RIS/PACS I/fwithout Modality DICOM MWL

RIS PACS Broker

Non – MWL Modality

Modality QA station

HL7

Reporting Workstation

Archive

DICOM minus MWL

DICOM data, no MWLManual correction of data to match

RIS dataIf not done up to 20% of studies are ‘orphaned’

Manual input of data. Prone

to error

Unidirectional RIS/PACS I/fwith Modality DICOM MWL

RIS PACS Broker

MWL Modality

HL7

Reporting Workstation

Archive

DICOMData incl MWL

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)

Bi-directional RIS/PACS

Bi-directional RIS/PACS I/fwith DICOM MWL and Modality Performed Procedure

Step installed in both RIS and Modality

RISMWL/MPPS PACS Broker

MWL/MPPS Modality

HL7 +

Reporting Workstation

Archive

DICOM

DICOM

DICOM +

HL7

Integrated RIS/PACS with DICOM MWL and Modality Performed Procedure

Step installed in both RIS and Modality

RIS/PACSInternal HL7- DICOM

& DICOM – HL7transactions

MWL/MPPS Modality

Reporting Workstation

Archive

DemographicsMWL MPPS

DICOMGeneral Purpose Worklist

(if provided allows choice Of WS independent

of PACS Vendor)

PACS companies which haveacquired 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 plusInternal HL7/DICOM transactions.

RIS PACS

Internal Transactions

Voice

Different vendors with all the HL7/DICOM transactions in RIS withina ‘PACS integration module’. Advantage – best of breed

RIS

PACSInternal Transactions

Voice

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!

Complete Integration of RIS into PACS: Dream or Reality?

Objective 2 for this Group

The same complete Integration of RIS-PACS and non-Radiological Images

Example: UGI Tumour managementText and image data gathered at initial presentation and diagnosis plus local staging – followed by centre assessments

History + added HistoryClinical examinationBlood testsEndoscopyHistopathologyCT/CXR/Ultrasound AbdoECG/PET/EndoultrasoundSpirometry/Cardiac NM

Text

Images

Text

TumourTypeTNM

GeneralCondition

ofPatient

Images

Text

RIS PACS

Internal Transactions

Broker

Voice

HIS

EPR

PACS needs to store more than Radiology images !

EndoscopyColposcopy

HistopathologyECGs

Medicalphotographs

Opthalmology

Dermatology

Cytology

Blood films

EEGsVideos

‘X’IS/PACSInternal

HL7/DICOM/XMLtransactions

Viewing

Archive

But….we need the same standard of integrationas with a modern Radiology RIS-PACS

‘X’IS

Webserver

DICOM 2o capture

HL7 and / or XMLdata

Non-DICOMimages

DICOMimages

HIS

EPR

Objective 3 for this Group

Full Integration of RIS-PACS and non-Radiological Images intoa comprehensive National Integrated Clinical Information System working with NPfIT

Integrated National Multi-IS/PACS

ASPArchive

WiderNHS

Wider NHS

Local ICRS

PACS

Huge and long term International efforts have gone into protocol optimisation and framework standards with RIS and PACS to make them fully synergistic - DICOM HL7 IHE

These deep integration issues need to be matched by other Clinical IS systems – not just ‘top layer’ with XML but using HL7 and DICOM

Old RIS systems have been a compromise and need replacing wholesale across the country to make PACS fully efficient, but must not be replaced ‘with just any’ new RIS

From www.pacsgroup.org.uk data

RIS systems installed in UK by supplier

So..What are the chances of getting there via the NPfIT? cont..

The best ‘buy’ PACS, from an LSP view, might not be the best clinical PACS. *LSPs appear to have 3 or 4 recognised suppliers each, so this is unlikely to be a problem

The best ‘buy’ PACS may not integrate well with the best ‘buy’ RIS or particularly an historic RIS! Integrated RIS-PACS or a RIS with an Pacs Integration Module/DICOM MWL/DICOM MPPS may not be available from your LSPEven if they are is your imaging equipment base up to it?If the LSP has only one system per clinical speciality and these come from multiple sub-suppliers how will these fit ‘deeply’ with existing clinically satisfactory systems? *LSPs appear to have only ONE prime EPR supplier each, so this may be a problem with some hereditary systems.

What if clinicians on the ground don’t like what the LSP supplies – could there be clinical IT wastelands?

With thanks to Simon Daniell’s friend“Messages to NPfIT……………………………”

1. A good specification which must be achievable is paramount. This is usually acknowledged by the purchaser but they fail to recognise the responsibility this places on them.

2. Where risk persists, you must have a work around solutions. This often means spending more money in the early phases on alternative solutions; each being dropped as their need diminishes.

3. The prime contractor must identify the risks at the outset, but to declare the risks fully to the purchaser before contract award may reduce their chance of winning.

4. The bigger, or more complex, the system the more important it is to manage the risk. 5. Purchasers can relax too much when they force their supplier into fixed price

contracts involving significant development. If the supplier gets into trouble it can rebound on the purchaser, especially with regard to timescale and even occasionally cost. If one major sub-contractor falls down there can be considerable cost impact on the other sub-contractors.

6. The easy way to select a supplier of a development system is on cost, where he who underestimates most wins.

7. He who has never implemented such a new system before is the more likely to underestimate.

8. He who does not have ‘buy in’ from the end users advances at peril.