These are interesting times for imaging informatics. Where there was once a clear separation between three technologies – picture archiving and communications systems, radiology information systems and vendor neutral archives – the lines are beginning to blur, complicating the decisions trusts have to make.
Let the EPR do the job?
The RIS refresh occasioned by the end of the National Programme for IT contracts is now nearly complete, although a number of London trusts are still to choose a RIS supplier.
Fifty-nine trusts in England have deployed HSS, the original RIS supplier for all trusts outside London under the NPfIT. Soliton, the new kid on the block, has been deployed in 24 NHS trusts, while a handful of trusts have opted for bigger, non-RIS specialists such as Carestream, GE and Agfa.
But RIS’s central role in the radiology department may be under threat from two directions. One is the increased adoption of trust-wide electronic patient record systems from vendors such as Cerner and Epic.
The scheduling functionality in these systems could replace that in the RIS, as is happening in the US. Tony Corkett, director at cloud21, says: “If a trust takes a decision to invest in an EPR such as Epic, then that is a significant investment and to get the true benefit from it all departments then have to follow suit.”
Other trusts, he says, might opt for a best-of-breed approach that provides core EPR functionality at the centre while allowing specialist departments such as pathology and radiology to retain their own systems.
Not everyone believes an EPR can adequately replace the functionality of a RIS, however. Chris Yeowart, director of Wellbeing Software Group, which supplies HSS, takes the view that, in an age when different applications are easily integrated, the EPR idea has already passed its best before date.
“You can connect component parts together in the trust – you don't need to take everything out and replace it with a diluted version of all the really advanced, embedded systems.”
Likewise, Bob Childe, business development manager for Soliton, argues that the rich functionality of RIS – scheduling, vetting, reporting and statistics – means it is unlikely to disappear soon.
Consultant radiologist Mark Griffiths agrees: “You need to make sure that you're catching the compliance data somewhere, and lots of the main scheduling systems don't.”
Go for PACS-based reporting?
The other pressure on RIS vendors comes from a move towards PACS-led reporting. Jane Rendall, managing director of Sectra, says that this is partly being driven by an increase in remote working.
“It can be more technically tricky to get a RIS installation at someone's home,” she says. “If they're able to do reporting or voice recognition into a PACS installation, that sometimes gives more options - people can work in both workflows.”
But is this inevitable? Griffiths agrees that PACs-led reporting offers some advantages. These include the ability to link to images in a report, to extract data automatically from measurements to put into the report and, when working remotely, to use a single application instead of attempting to run multiple applications in synch over a virtual private network.
Yet there are also potential problems, he says, particularly when the report is transferred via the HL7 protocol to either the order communications or the EPR system for other clinicians to carry out results acknowledgement.
“HL7 won't cope with embedded links, so I have a worry that this lovely functionality which has been developed in certain parts of reports, such as graphics, may produce problems if people haven't thought through how their reports are distributed and approved.”
Some trusts will want the option to report in both. Bob Childe, business development manager at Soliton, takes the view that, while PACS-led reporting makes sense in certain areas, specialisms such as obstetrics or digital pathology will continue to prefer a RIS-based workflow.
Go VNA-centric?
The move from PACS vendors to incorporate reporting into the PACS needs to be seen in the context of a competing pressure on PACS from VNA vendors.
They argue that, if a VNA can store all a hospital’s images and other non-structured data, then there is no particular need to have a PACS – a VNA combined with a sophisticated viewer will do the job as well.
In practice, however, that may be a long way off. Grant Witheridge, managing director of Agfa, argues that using a VNA in this way adds complexity. “The trickier part is the clinical workflow, not just archiving.
“What we've found is that the broader the scope of content that you archive, the more complicated it becomes to present that in a meaningful way to the clinician.”
Agfa’s own approach has been to integrate PACS and RIS into a single database through its Enterprise Imaging unified management platform.
Witheridge argues the functionality of a RIS, such as scheduling, workflow, reporting and dashboards are “crucially important” to parts of the hospital. But he also argues a RIS’s existence as a separate piece of technology “is a result of history as opposed to any kind of logic.”
Rendall, too, takes the view that it makes more sense to have an integrated PACS/RIS product than two separate products, provided customers can treat it as a modular solution, taking the PACS modules from one provider and the RIS modules form another if they prefer.
Stick with the RIS?
But there remain strong arguments in favour of keeping the RIS. A bespoke product such as a RIS is always likely to offer richer functionality than a more generic product – both of the UK’s specialist RIS vendors, HSS and Soliton, have mobile applications that allow remote reporting, for example.
Rhidian Bramley, radiology clinical director at the Christie NHS Foundation Trust, told the UKRC conference this summer that RIS was here to stay. In particular, he said, regional clusters of trusts sharing a single instance RIS have found it immensely valuable: “Those that have it would not want to lose that functionality.”
Yeowart agrees, and argues that trusts should now be focusing their energies on shared working. “Instead of having an on-call radiologist at every trust, let's have one that services the entire region and do it on a rota basis.
“We can make things more efficient, and that comes down to technology connecting things up and allowing information to flow more readily.”
Integration is not technically challenging, he says, arguing that RIS and PACS vendors should be able to work together to make region-wide reporting possible. Childe agrees about the importance of sharing radiology workloads, and says the biggest barrier comes from information governance rules.
As Corkett points out, for trusts there is “no right answer” – it all depends on their strategic direction over the next five-to-ten years.
But it’s important to make sure that RIS functionality isn’t lost if alternative systems are adopted, Griffiths argues. “It's a bit academic where you call the lines. What you need to do is make sure you've got functionality – and where that is and how that integrates is the important part.”
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