This report originally appeared in the March 2010 issue of DOTmed Business News

We are entering a whole new paradigm of health IT. Soon, we will no longer be able to talk about picture archiving and communication systems (PACS), radiology information systems (RIS) or hospital information systems (HIS) as separate entities, because they will have morphed into an entirely new and integrated system that requires all-new descriptive terminology.

From the looks of things, open, thin-client and web-based systems are taking over many facilities and new products on the horizon are pushing the information envelope by fusing more data and providing richer and more meaningful applications. Combine those facts with the added incentive of federal stimulus money on the line and it is clear now is prime time for adoption.

Merging Health IT

The old paradigm for PACS was a sort of static departmental system of databases, software and hardware that housed and offered up medical images. The RIS was the vault of radiology information for each patient, helping radiologists keep track of workflow, differential diagnoses and a patient's overall radiological history, whereas the HIS was the mostly administrative and billing side of the larger facility. This isn't so much the case anymore.




"RIS systems now contain more information about the patient, rather than just about the radiology history," says Matt Long, vice president of Healthcare Informatics, Philips Healthcare.. "HIS systems hold more about the clinical side and you're now starting to see more functions around ordering, scheduling and reporting, and results are being much more directly embedded in the PACS."

Not just an archive

The most fundamental purpose of the PACS is to manage medical images - to acquire the legal copy of image data, which is then stored and distributed according to the needs of the diagnostician, the treating physician or referring physician, and to facilitate communication between them. This can mean different things in terms of structure and hardware. Technically, reading monitors and CD burners are components of PACS.

"People will define the term PACS in a lot of ways," says Tim Kulbago, general manager of Merge Healthcare's Fusion Division. "From my perspective, it's always had three components: you have your server or back-end device that stores images and archives them; you have viewing technology specifically for the purposes of diagnosing - the technologies and functions that are displayed for radiologists to do the medicine of radiology; and the third class that usually goes on a PACS is a distribution technology."




All these pieces fit into a very dynamic and quickly evolving system, especially now as web-based technologies fuel the use of increasingly complex clinical applications.

Market forces create opportunities for new technology

Siemens Healthcare is waiting on FDA approval for syngo.plaza, a brand-new PACS driving the company's multimodality clinical IT system, syngo.via. Together, the two will enable two, three and four-dimensional viewing of image data. Henri Primo, national director of marketing and strategic relationships for Siemens' Image and Knowledge Management division, talked with DOTmed about the demands that have stretched health IT to today's grand proportions.

"The first thing that we see is that new applications are becoming increasingly combined with PACS and these new applications have become essential with the advent of new imaging technologies like multi-slice CT scanners and multi-sequence MR, all producing huge data loads and incredible amounts of images," says Primo.

The wizards behind the curtain

You have to have very powerful and versatile technology to be able to handle the data involved in advanced visualization. Multi-planar reconstruction, maximum intensity projection, and other three-dimensional viewing methods - these have been in use for a long time, but mostly within the academic and research environment. Now you see more of these technologies in everyday clinical use.

"PACS have changed because there were new imaging techniques and new clinical questions that came that have been driving the need for PACS to embrace new IT technologies. We all know what they are: we are talking about the thin client instead of the thick client, client server architectures, web-enabled viewing and virtualization like VMware," says Primo. "These are the technologies that came to help handle these massive datasets."

Developers are getting more creative with image viewing, using applications like Microsoft Silverlight which is also used by the popular movie rental company Netflix for the purpose of streaming film, and more and more of the architecture is disappearing into a "cloud" of open, web-based applications and services.




"Basically, technology is helping to improve efficiency and shorten waiting times for loading images and making sure the viewing doesn't have to be linked to a specific physical place," says Primo. "Once you are web-enabled, the viewing can basically happen from wherever you are on the web, as long as you have qualified diagnostic viewing technology."

Even the hardware is getting to be more integrated. In the beginning, everything was proprietary, but now there is a trend toward applications that can run on common-off-the shelf hardware.

Migrating data

If you're cloud computing or using zero or thin client architecture, keep in mind, there is still something more down-to-earth happening somewhere.

"For all the words you'll hear in the literature and the industry about having a web-based solution, you still have to fall back on a set of standards on the back-end servers," says Kulbago. "We have a cloud technology where we host everything. We can do something that's sort of a no-hardware footprint, and we just put everything in the cloud, but we still have software that has interfaces that make the whole workflow of imaging work. There is always something sitting on the backend that requires care and feeding and configuration and maintenance."

All the pieces of the puzzle are getting to be more streamlined, but that's not to say there aren't still some glitches. Maybe there are some integration issues involving one system, perhaps between a PACS or RIS, and they aren't communicating so well. "All of a sudden, you've got two web-based solutions that can't work together because there were other components that needed to be installed," says Kulbago. "When the rubber hit the road, you either got lucky or you didn't."

Facilitating mobile technologies and telemedicine
With many of the original glitches resolved, the main focus for technology has become a matter of figuring out how much information can be put in the hands of the physician and the referring physician and the quality of that delivered information.

"Those images are often used by the referring subspecialist as they attempt to determine the appropriate treatment path," says Long. "I think that if you go back in time, PACS were designed more around diagnostic use, but the real key now is tying in the diagnostic process with the treatment process."

Better access is essential, but just as important is the user-friendliness of the technology.

"The worst thing that can happen is to spend all this money deploying a system only to have the physician say, 'It's too hard to use. I don't like it. Give me the film,'" says Long.

And the area where Health IT stands to expand the most is in smaller facilities and rural community hospitals.

"Really health care starts in your small community hospital, and they don't have a large IT department," says Lenny Reznik, director of the Enterprise Image and Information Systems division of Agfa Healthcare. "It's pretty much just like any small business that you might find in the United States. They certainly have computers, but they are really dependent on the system being easy to use."

The RIS now has a hand in the automation of diagnostic modalities, such as digital radiography. Many systems can pull information about the patient and preload settings that have a direct impact on image quality. The RIS is also an important guide for the radiologist reading the exam.

"In order to diagnose you have to know about the patient's history, previous examinations and the results of those examinations and most of that information is stored within the RIS system," says Long. "The RIS is really where the patient level information is stored and managed."




As part of the newfound focus on electronic medical records, facilities looking to invest in HIS and computerized physician order entry (CPOE) technologies are set to receive stimulus money as provisions in the American Recovery and Reinvestment (ARRA) Act and the associated Health Information Technology for Economic and Clinical Health (HITECH) Act rollout. The newest technologies are going wireless and on the web, allowing physicians to gain mobile access through tablet PCs and even cell phones. The iPad may just be the next step.

"Many hospitals are using tablet computers today - at the bedside, in the emergency room, and the physicians are carrying them," says Long. "I think the iPad is the next generation. The risk is- at what point is the information too much information? Information with no context is in many cases worse than no information."

Even now there are applications to view diagnostic images via compact mobile devices such as the iPhone or iPad. To date, these technologies are not to be used to make clinical decisions, but one day that may change.

"It's very conceivable that these mobile devices and platforms that are getting smarter, but are not full computers, have the capacity to actually provide a diagnostic quality image," says Kulbago. "There are going to have to be people that make that determination."

Health information exchanges

Developers are not only working to get health information to more handheld technologies, but they are deploying technologies that enable images to be moved easily across vast health information exchanges between medical facilities. This is where concepts like cloud computing and zero-download, zero-client, and thin client technologies really take off. This applies to many departments within the hospital.

"Our IMPACS data center is a medical imaging repository for images that are created in all kinds of diagnostic and clinical imaging departments, such as ophthalmology, dermatology, pathology and cardiology and every other 'ology," says Reznick. "There's no software download required now to view the images - we don't send the images; we use Web 2.0 technologies to stream data to users."

The engine behind health information exchanges, whether between disparate systems within the same facility, or between institutions, is a painstakingly developed set of standards profiles agreed upon by member organizations and vendors within the industry. These standards make very complex information exchange possible by establishing a language that is recognized by all players. The people behind the IHE, aka Integrating the Healthcare Enterprise, call this process "testing the interoperability."

"One of the most public ways, and the way that a lot of big hospitals do it, is through the IHE profiles and the XDS - the standards-based interchanges," says Kulbago. "They hook up their HIS system to their RIS and their PACS system and they are all using HL7 to talk to each other."

Cross Document Sharing, or XDS, is a profile of the IHE, and HL7, aka Health Level Seven International, the international authority on health information system interoperability, with members from more than 55 countries. Another standard that has become synonymous with imaging and PACS is DICOM, which stands for Digital Imaging and Communications in Medicine. As the industry and its technology evolves, so too will the standards.

Financial troubles dip sales for another year

There are several hundreds of vendors offering health information technology today. The top manufacturers are seeing some growth, but minimally, and from an industry standpoint, market research shows that the PACS market alone has dropped in sales over the past two to three years in excess of 20 percent.

"It's the feeling across the board that the PACS and RIS market is down and has been the past couple of years and will be flat at best and probably down again in 2010," says Long.

Vendors are unlikely to encounter the kind of enthusiasm they were seeing just five years ago, because most integrated health networks and large university hospitals already have PACS and market saturation is becoming a reality. Replacement and expansion is where things are going for these institutions. The areas where there is opportunity for growth is in the smaller communities and in specialty departments of large hospitals that, until now, have not had a lot of association with other areas of the hospital.

Bring in the specialty PACS

There is a growing desire in the industry to have a single PACS that can handle all modalities, including specialized cardiology and molecular imaging data. This is the cutting edge of PACS technology today.

"Most major hospitals have a cardiology PACS and some form of specialty PACS for molecular imaging. However, only a few of the larger health care providers in the country have integrated solutions allowing them to provide comprehensive PACS solutions for all modalities," notes Xiaoyi Wang, president and co-CEO of Thinking Systems. "Currently, none of the PACS from the major OEMs are capable of doing so, leaving room for specialty PACS/RIS to flourish."

Until the technology catches up with the demand in the industry, upgrades and integrated software can help bridge that gap. One of Thinking Systems' functions is to work with leading vendors to provide those integrating technologies.

"Although many institutions may have a mini-PACS, or specialty PACS, solution for providing some kind of archive or viewing, if it requires radiologists to go to specific dedicated workstations to access the images for interpretation, it is a workflow bottleneck," Wang remarks. "Many institutions are either searching for third-party plug-in solutions to enhance existing PACS, or integrated solutions for new PACS purchases. For the major radiology PACS vendors, such plug-ins, or integrated solutions, are still provided by third-party vendors."

Never before pressures on vendors

The ARRA and HITECH Acts are already having a major impact on the health IT industry. The provisions from the ARRA are now more focused on the electronic medical record, but this may expand over time to more fundamental and architectural components of health care IT like PACS.

As president for the consulting firm H.I.S. Professionals, based in Oakton, Va., Bill Bogutski has a unique view of how recent legislation and the promise of funding are playing out.

"The field of health care information technology has been very busy this past year," says Bogutski. "It's just been a blur. We've seen two direct results of the ARRA stimulus and HITECH activities - one is the amount of time it takes to schedule vendor presentations. It's at the point now where it's taking two to three months to line up vendor presentations because of the tremendous demand. Another thing is that implementation is being projected to start 6 to 12 months after contract signing. That's never been the case in the HIS industry."

The new acronym
With health information technologies morphing and becoming more integrated, the industry is sure to outgrow the old terms and usher in more meaningful vocabulary.

"I think the industry is still looking for a better name for the comprehensive radiology information system," says Reznik. "There is still some acronym out there that hasn't been universally accepted yet."

As the electronic health record takes off with the help of vehicles like PACS, RIS and HIS, there are sure to be ongoing matters to address, and numbering among them will certainly be those issues of patient privacy, technological interoperability and the implementation of legislative mandates that may dictate the next generation of medical informatics. If all goes well, access to secure, comprehensive patient data could become the norm in the not-so-distant future.

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DOTmed Registered PACS-RIS-HIS Equipment Sales & Service Companies
Names in boldface are Premium Listings.

Domestic
Ken Trotman, Comfort Enterprises, LLC, AL
Mike Battin, PACSHealth, LLC, AZ
Klaus Kraemer, Multi Imaging Systems, Inc., CA
Ted Huss, Medical Imaging Resources, CA
DOTmed certified
Shane Yaghmai, Allied Health Products, CA
Edward Heere, CoActiv Medical, CT
Ronald Lorg, Allied Resource Technology, Inc., FL
David Denholtz, Integrity Medical Systems, Inc., FL
DOTmed certified
DM100
Xiaoyi Wang, Thinking Systems Corporation, FL
Henri Primo, Siemens Healthcare, IL
Katie Meister, NEC Display Solutions, IL
Neal Thompson, JD Imaging Corporation, IL
DM100
Scott Wasson, Radiology Services, LLC, IN
DOTmed certified
Mike Andrews, Hudson Digital Systems, NJ
Kevin Fix, Ultimate Medical Services, Inc., LA
John Stinson, Clear Image Devices, MI
Shanna Flanagan, DMS Health Technologies, ND
Joseph Jenkins, International Imaging, Ltd., NV
JoAnn Linder, Carestream Health, Inc., NY
Brett Schaeffer, NHD, OH
Charles Patti, NCD Medical Corporation, OH
Todd Allman, DR Systems, Inc., PA
Richard Stock, Radiological Imaging Services, PA
DOTmed certified
DM100
Melissa Armstrong, Medrad, PA
Colin Kelley Jr., Kelley X-Ray Co., TN
Paul Shumway, NovaRad Corporation, UT
William P. Bogutski, H.I.S. Professionals, LLC, VA
Dave Dressler, Northwest PACS Network, WA
Julie Pekarek, Merge Healthcare, WI
Greg Whelan, IMCO Technologies, WI

International

Vijay Ramanathan, RamSoft, Inc., Canada

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