At the three-hospital University of Pennsylvania Health System (UPHS) in Philadelphia, where physicians produce 700,000 diagnostic imaging studies a year, moving toward a “RIS-driven workflow” remains high on the list of imaging-related priorities.

Dan Morton, the director of medical informatics at UPHS Health Radiology (which handles diagnostic imaging management for the system), reports that Pennsylvania Hospital and Penn Presbyterian Medical Center have achieved RIS-driven workflow, while he and his colleagues at the Hospital of the University of Pennsylvania, the system's flagship facility are still working.

“RIS-driven workflow means a number of things,” Morton says. “It means the proper order information can be applied to every study at the modality level by the technologist; it also means that if a particular study somehow lands inside the PACS incorrectly with the wrong label, it's reported back to the RIS, and can be corrected.” Morton says this means that the RIS always knows where a particular study is within the PACS, so that it can be launched from the RIS. “All of those are components of RIS-driven workflow, and are only possible when the RIS and PACS are thoroughly integrated.”

All this is complicated, Morton concedes, by the complexity of the RIS/PACS landscape within the Penn health system. While all four Penn institutions - HUP, Pennsylvania Hospital, Penn Presbyterian, and the Division of Community Radiology, share the same RIS, Centricity RIS-IC, from the United Kingdom-based GE Healthcare, and while HUP, Penn Presbyterian, and UPHS Health Radiology use different versions of GE PACS, Pennsylvania Hospital remains on a PACS from Siemens Healthcare (Malvern, Pa.).

Morton says having RIS-driven workflow at two of the three hospitals, with its development progressing at the third, has already improved physician efficiency and enhanced physician satisfaction. However, he says, there are always further horizons to reach, including creating a unified approach to physician order entry in the EMR that optimizes the ways imaging reschedulings are handled in the RIS, for example, and standardizing exam codes across all three hospitals.

Fortunately, large academic medical centers like Penn and the 562-bed Fletcher Allen Health Care organization in Burlington, Vt., have the resources to work through the integration and interfacing issues. For such organizations, having different RIS, PACS, and EMR products is not usually a problem, says Chuck Podesta, senior vice president and CIO at Fletcher Allen. Instead, the key issue, Podesta says, is enhancing the productivity of its radiologists (Fletcher Allen has about 32 affiliated radiologists) through optimizing RIS-driven workflow, rather than focusing on matching vendor products across the RIS, PACS and EMR categories.

“At this point, the products in all three areas are mature enough that the interfacing is pretty straightforward,” Podesta says. Such would not be true for small community hospitals lacking the staffing resources to manage those issues, he adds. (Fletcher Allen's RIS is from GE - originally IDX - while its PACS is from Alpharetta, Ga.-based McKesson. The organization's EMR is from Verona, Wis.-based Epic.)

In any case, radiology information systems as a category seem to be overshadowed right now by the HITECH-caused focus on EMR and CPOE technologies. “I've been meeting with a ton of vendors recently,” says Scott Grier, principal at the Sarasota, Fla.-based Preferred Healthcare Consulting. And, Grier says, “I've been finding that the development of software applications that aren't critical to the monies coming out of the government are being left by the wayside.”

As a result, customer satisfaction with existing (and often, aging) RIS products is relatively low, says Ben Brown, general manager of imaging informatics at the Orem, Utah-based KLAS. In fact, says Brown, “It's definitely lower than where the PACS world is today. And that's mostly because there hasn't been a lot of R&D going into RIS products overall, though there have been exceptions.”

In fact, he notes, RIS products, rated as a category in KLAS' mid-year performance review this year, were given an average score of 77.44, compared to an average score of 78.73 for the PACS category, with a number of RIS products falling considerably below that average level.

Brown says one area in particular in which KLAS surveys continue to report demands for innovation, is around “the longstanding thorn in providers' sides regarding activity reporting - who's doing what when, and when the reports are ready.”

Current wave: smaller hospitals

CIOs at smaller hospitals now implementing RIS systems for the first time are definitely working to optimize clinician workflow and productivity. “The strategic goal in RIS and PACS implementation was really to get the workflows in order in radiology, to go filmless, and to gain a lot more of the referral base out there from the referring market,” says Jim Boyer, CIO of the 25-bed Rush Memorial Hospital, a critical access hospital in Rushville, Ind. Rush went live in the spring of 2004 with both RIS and PACS (both products coming from the Milwaukee, Wis.-based Merge Healthcare).

Ease of workflow has continued to be a key focus, with Rush Memorial physicians and staff highly satisfied with RIS performance so far, Boyer says. And being able to offer physicians such functionality is far more than just a “nice thing,” he says.

“We knew this going into it, but from a referral base standpoint, being in a rural community, implementing RIS really got our referral base tuned into the hospital, with referring physicians delighted at being able to see their results online, and with the hospital better able to retain radiologists more effectively,” he says.

Another smaller hospital that has used RIS to a strong advantage has been the 54-bed Chinese Hospital, located in the Chinatown community on San Francisco. “We had a mini-PACS before implementing RIS and a full PACS, but now we're able to work on integration issues that are significantly improving productivity,” says Chinese Hospital CFO and CIO Tom Bolger. (He and his colleagues are using an integrated RIS/PACS solution from Rochester, N.Y.-based Carestream Health.)

Roger Eng, M.D., the hospital's chairman of radiology, sees things changing. “Eliminating film was a very small step compared to eliminating 50 steps out of what had been a 70-step patient care process from sign-in to a final report being sent to the referring doctor,” he says.

An interest that CIOs at all types of organizations share, including those outside the inpatient setting, is in extending the access and functionality of RIS to affiliated physicians who want to connect anywhere.

“One area where this will evolve is in extending the RIS' capability through a Web-based physician portal that allows doctors to schedule appointments, send requests for appointments, view reports, and determine the status of work related to them,” says Allan Shullman, COO and CIO of the Delray Beach, Fla.-based Diagnostic Centers of America, a 28-radiologist imaging group that performs about 65,000 studies annually. Doctors really want those kinds of functionalities inside their RIS, Shullman says. (Shullman and his colleagues use an integrated RIS/PACS system from the Tampa-based Sage Software Healthcare.)

And while the functionalities of RIS products will need to expand outward and upward, Pamela Moseley, director of radiology informatics at Rochester (N.Y.) General Hospital, reminds CIOs, “You need to know your own workflow even before you begin implementation, and understand that you're going to continually be changing it,” in order to be successful with RIS going forward. As of July, Moseley says she is happy to report that physicians at the 528-bed hospital can get into the RIS and PACS with one click, and can even tell families where their loved ones are in the system. “That's a wonderful feature,” she says. “But it takes considerable thought, effort, and planning to lay a good foundation for such functionality.” (Rochester General Hospital is using an integrated RIS/PACS from Carestream.)

As for CIOs who are wondering about the future, Henri “Rik” Primo, national director of strategic relationships at Siemens Healthcare, has some advice. “They definitely need to be thinking about healthcare information interchange among the different elements in their integrated delivery network, and, among other things, about how to provide Web-based and other remote access to RIS users, as well as potentially innovative hardware configurations.”