By Don Dennison

Radiology information systems (RIS) have played an important role in the transformation of departmental operations from paper to digital. As with other applications, the market has evolved, and industry has adapted their solutions. Health providers today have options, but the market is increasingly being divided into two primary approaches — one for health systems, and one for groups, like radiologist reading groups, serving smaller health providers.

How we got here
The advent of RIS gave healthcare organizations, and specifically departmental leaders, insight and tools to effectively manage their operations. Predating picture archiving and communication systems (PACS), RIS managed human resources, patient records, finances, and other elements to provide significant productivity and quality improvements for hospitals, staff, and patients.

During a significant growth period that saw several mature solutions, installed independently of hospital information systems (HIS) and interfacing through HL7 messages, PACS, with its digital images, was introduced, leading to further benefits.

It wasn’t long before the push began for a combined RIS-PACS solution. At the time, it made a lot of sense. Both systems have a patient and exam database table. Both have HL7 interfaces for patients, orders, and results. Both must manage users. And managing the complete life cycle of an imaging procedure in one system — from order placement, through scheduling, exam protocoling, image acquisition, exam quality control, reading, and results management — promised new opportunities for quality and productivity, with lower costs and less complexity.

Industry responded and companies providing independent RIS solutions were acquired by PACS vendors. Other PACS vendors set out to develop a RIS-PACS solution themselves.

As this convergence was occurring and solutions emerging, something happened: the adoption of the EMR with an embedded RIS module.

RIS in today’s consolidated healthcare enterprise
The rapid and widespread adoption of a shared EMR across a multi-hospital enterprise is often attributed to the incentives provided in the HITECH Act, at least in the U.S. But the operational and financial benefits of using one system to manage records and work tasks, and standardizing operations and measures across facilities, has led to adoption of this approach in other geographic markets as well.

The shift from an independently deployed RIS solution to one provided by the EMR has provided several benefits, with some tradeoffs. It has also resulted in a shift of control. Healthcare providers have reported advantages including:
• System maintenance, including updates, upgrades, backups, failover, hardware refresh, and other efforts, are shifted away from radiology IT staff to the EMR team, reporting into the CIO/CMIO.
• The interface from the HIS/EMR to the RIS system has been eliminated, as the RIS module shares the same database table as the EMR, improving reliability and reducing complexity.
• Access to patient information and reading worklists are available within the same application, simplifying desktop integration.
Radiology staff spend less time on the IT aspects of the system and more time on system configuration and operations. This can often require a shift in departmental staffing profiles and job descriptions.
On the flip side of the benefits, radiology staff report there are tradeoffs, such as:
• Overall planned system downtime, and the timing and scope of testing associated with an EMR upgrade, is decided by a team outside the department.
• Getting operational reports, while technically feasible, can often lag departmental expectations as they need to be developed by a central EMR team that is serving the entire enterprise. Radiology staff often cite a regression in insight into their departmental operations compared to when they had full and direct control of their data.
• System configuration changes, such as how the patient chart is presented, how worklists are configured, what data is stored in the system, and the list of procedures available to order, are all difficult to obtain in a timely fashion. This will vary based on the organization, their operating procedures for system changes, and the working relationship between radiology staff and the EMR team.

Often, the decision to use the reading worklist provided by the EMR’s RIS module, one provided by the PACS, or a stand-alone solution, is heavily debated. There are pros and cons to each, with the EMR-RIS option providing some operational and management benefits, and the PACS (depending on its capabilities) or stand-alone solution providing more flexible and sophisticated workflow orchestration, along with a superior user experience, in many cases.

Additionally, the EMR RIS is typically optimized to provide services for imaging exams performed within the enterprise (which relies upon staff accepting standardized workflows to gain the benefit). In many cases, the EMR RIS only allows orders entered directly and not orders placed by an external system, resulting in added data entry and delays. Radiology staff often have difficulty reading exams that were performed outside the enterprise or accepting orders from outside the enterprise and sending the results back to the system managed by an external organization, such as a referring physician group.

EMR-based solutions often have longer patient registration times due to the number of required fields to be entered. Where imaging center RIS are designed to allow quick registration — for example, an unscheduled patient seeking an X-ray over their lunch hour — EMR are often optimized for inpatient operations and can require extra effort to provide rapid patient registration in outpatient imaging settings.

This can result in so-called exam volume “leakage”, as referring physician groups send patients to organizations, such as independent outpatient imaging centers, that can provide this type of exchange of orders and results between systems. This can be hard to detect due to insufficient data reporting.

Capabilities to reduce appointment no-shows and enhance the patient experience, like text message reminders and exam instructions, often depend on third-party applications to be integrated and managed.
For healthcare provider organizations, the benefits of the EMR RIS and standardized operations often compete with the flexibility of an independent RIS solution.

The market for independent RIS
As enterprises get larger through acquisition, and more facilities converge on a shared EMR RIS solution, there are fewer opportunities for independent RIS in markets like the U.S. and others. However, many healthcare provider facilities still rely on the reading services of contracted radiologist groups. These groups serve multiple healthcare provider organizations, so they need systems that can receive patient information, orders, imaging exams, and prior reports, from external systems to operate with efficient, automated workflow.

If these organizations operate outpatient imaging centers, they may also need to provide a portal for referring physicians to place orders, access results, and perhaps even view images or chat with a radiologist. In some cases, a patient portal is also provided.

As healthcare provider organizations consolidate, so do large reading groups, which merge with local and regional groups and transition to a managed information and imaging platform.

In addition to reading groups, smaller healthcare provider enterprises that do not have a capable RIS module in their EMR may deploy and interface with an independent RIS solution to provide the desired departmental operations. For smaller organizations, it can be more efficient to have a single RIS solution that can manage both operations and billing.

These groups of buyers may or may not need support for academic workflows, like resident-attending read-out or teaching files, common at large enterprises.

The capability to exchange information with the healthcare provider organizations they serve, and provide tools to imaging centers they support, is critical for them. Now, more than ever, they need platforms that can provide interfaces and integrations for interoperability of data. And they need to be able to develop solutions themselves, without relying on a centralized (and often bureaucratic) IT team or a vendor professional services engagement.

Non-EMR RIS solutions include independent applications, as well as ones provided by traditional PACS vendors. These may be developed in-house, added through acquisition, or licensed through a partnership (sometimes varying by region). In some cases, only specific modules, like critical results management or external order exchange apps, are provided. In other cases, the solution is made up of several integrated third-party applications.

For reading groups covering multiple healthcare provider organizations, RIS or RIS-module solutions that can orchestrate the movement of DICOM data from one system to another can be of high value. For example, using order information to move current and relevant prior imaging exam data from one or more PACS into the PACS used for reading.

While there are solutions for this non-healthcare provider enterprise market, organizations often report that their healthcare provider client is unwilling to provide the necessary information through interfaces. Instead, they sometimes insist that the radiologist use the healthcare provider’s PACS, reporting solution, and EMR to do their work. This can result in the radiologist having to use (and be productive with) several different systems. The logistics of putting a different workstation for each client in a reading room is often not practical. Not to mention the cost and effort to establish secure network connections (that meet all organizations’ information security policies) across enterprises.

The imminent mandate to use clinical decision support (CDS) for some procedures, and the risk to revenue — for organizations that perform the exam and to income for physicians who read exams without providing evidence that a qualified CDS system was used — adds even more complexity. Organizations that provide solutions that put the least amount of impact and disruption on referring physicians may get additional outpatient exam volumes.

Where to next?
Radiology is a complex operation and will always require some software application to manage it. But what is likely to change in the near future?

Reading worklists will probably continue to become increasingly sophisticated to squeeze even more productivity out of radiologists. They will incorporate new information, like upcoming clinical appointments and clinical data, to prioritize which exams get read first. Emerging technology like artificial intelligence (AI) may play a large role here.

Direct reporting into the EMR, instead of a reporting solution, is already happening in some cases — for example, for breast imaging and cardiology. While the current state-of-the-art in EMR-based reporting may be less desirable than traditional solutions, the benefit of eliminating an application and the structured nature of EMR-captured results (for clarity, data analysis, and AI applications) hold promise. This transition will take time and effort to provide a good user experience.

For independent reading groups, and even some enterprises, the use of cloud-based RIS, or specific functional modules of a RIS, like external order and results exchange, is likely to become more prevalent. Using a cloud solution provider for all the IT infrastructure and application management, combined with a pricing model that aligns with actual usage, reduces the capital expense requirements on the organization.

Regardless of the form that RIS takes (if we even use that term in the future), the need for solutions that provide highly efficient workflow for radiology is not going anywhere anytime soon.