© PACS Integration ©

What does integration mean? Essentially it means there should be only one data entry point for all patient information with connectivity to as many portals as needed. This allows retrieval of that same information thus enabling patient data searches, image acquisition, image interpretation and archiving - being radiology specific. This should indicate to everyone the importance of full HIS/RIS integration to PACS with the RIS being the prime enabler between the HIS and the PACS. There are three major areas of integration: HOSPITAL, RADIOLOGY, and ENTERPRISE WIDE. Before any integration can happen there must be the proper infrastructure in place. Knowing what you want your system to accomplish is key to building the proper infrastructure of any enterprise wide imaging solution. Integration begins with ORDER/ENTRY.

To see how true integration should work requires a review of a process for a patient registering for a procedure at XYZ Hospital. Assumptions are made that there is central registration at this Hospital and that the radiology scheduling department has done the appropriate job of verifying the exam with the requesting physician as well as prompting the patient to get to the Hospital with enough time to get through this process prior to their appointment time. This is a simplistic review but should get the idea across as to what can and should happen with a true integration.

ORDER/ENTRY

Remote order entry capability should be available for the Doctors - for both in-patients and out-patients. Remote capabilities will greatly enhance efficiencies. As we all know Radiology is a demand service and there is nothing better than knowing ahead of time what the demand is. The remote capabilities should be limited to point to point dial-up services, for security reasons, unless the IS department feels comfortable with network access.

At the point of order entry many things should occur:

Upon the physician placing the order the system should prompt for a diagnosis,

No diagnosis - no order.

The diagnosis, once entered, should perform a keyword search of the appropriateness criteria database from the ACR,

The order cannot be placed/accepted without a direct correlation between physician order, diagnosis and appropriateness criteria.

The system should verify the acceptance of the order immediately if it is considered a non-scheduled exam and gives an estimated time of the appointment. Should the exam need to be scheduled:

The system should prompt for any special patient needs or room needs and ask about patient mobility as well as other equipment to be transported with the patient.

Depending upon the special needs and the items checked the system will allocate the time needed for the exam.

The order entry system should then search for available times,

Before giving an appointment the system should calculate the time needed for proper patient preparation, and also check for any pre-requisite testing to be done, IE blood work, BUN etc .
The system should also check for exam appropriateness - evaluate whether another exam should be done instead, At this point the system should check if appropriate other exams have been performed and if no history exists ask for previous exam results. IE if a MRI of the lower back is ordered it should ask if a lumbar spine X-Ray was performed, where, when and the results - before accepting the order for the MRI.

Once the order has been accepted and a slot reserved,

The system alerts radiology of the pending exam (places it on the schedule),
Places a flag in the patient chart for nursing,
Prints a dietary restriction, if needed, to both nursing and the dietician,

The dietary department must sign off on this.

Prints a patient prep, if needed, sheet for nursing,

Nursing must sign off on this at each shift change.

HOSPITAL Reception (HIS/RIS)

Upon entering the hospital the patient proceeds to the registration desk where all pertinent insurance and patient information is gathered/verified and the proper exam(s) are ordered/verified and appropriate. The information is then collectively verified with the patient. The information is then processed through to the RIS (because a Radiology Exam has been ordered). The RIS then filters the information and posts the patient in the queue of exams to be done and assigns the patient to the proper modality or modalities. The exams are performed according to a rules-set of exam sequence that has been preset by the facility thus allowing the exams to be done in the proper order. The information is then ready for concerned modality to download the patient data into the units acquisition screen.

RADIOLOGY Reception (RIS/PACS/HIS)

The patient then proceeds to radiology for the exam and notifies the receptionist. The receptionist has the patient review the information on the scheduling monitor to verify validity and makes any changes that are necessary. Any changes are then reflected back to the HIS. The patient then waits for the technologist to perform the exam.

The technologist calls the patient, verifies the information about the exam and patient are correct and then downloads that information to the acquisition screen of the modality and performs the exam. Upon exam completion a quality control technologist reviews the information and either request repeats or releases the exam to be read. At this point the exam is identified by the technologist performing the exam as well as the QA technologist.

The radiologist then either requests additional views or interprets the exam as is, the radiologist also at this point has access to pertinent patient information regarding previous Lab work, old exams etc. etc. Once read the system simultaneously archives the exam and releases it to the facility pending proper medical information release authority as well as notifying the physician of exam completion.

ENTERPRISE WIDE (RIS/PACS/HIS)

Once the exam is released to the enterprise every physician with proper authorization may view the image and report. Depending upon the extent of the enterprise the physicians could have access from within their office. The requesting physician would, at a minimum, get a copy of the report automatically sent their office from within the RIS, whether by FAX, E-Mail or Snail-Mail.

Also at this point the exam can be billed. All the previous information gathered at the order entry point and patient registration is then applied to the bill. This assures that the bill will be paid correctly but not timely.

We all know how insurance companies react to any claim, deny it, never received it, the machine ate it, the file was corrupted, the clerk ate it or the patient is no longer insured with them (but you knew that : ).

Updated March 2000 by Peter C. Veader