Maintaining flexible accessibility with PACS-EMR integration

Antonia Wells, Chief Research &
Development Officer

By some estimates over 90 percent of the data in medical science is attributed to imaging. Whatever the actual number may be, it was certainly a factor in IBM’s decision to acquire Merge Healthcare, announced in August. Merge Healthcare is a Chicago-based provider of enterprise imaging, interoperability and clinical systems aimed at advancing healthcare. It was recently recognized as a top vendor in the KLAS 2015 Midterm Performance Review: Software & Services report. It provides enterprise and cloud-based technologies for image intensive specialties that provide access to any image, anywhere, any time. Merge’s technology platforms are used at more than 7,500 U.S. healthcare sites, as well as most of the world’s leading clinical research institutes and pharmaceutical firms to manage a growing body of medical images. Merge also provides clinical trials software with end-to-end study support in a single platform and other intelligent health data and analytics solutions.  PARCA eNews spoke with Merge’s Antonia (Toni) Wells, Chief Research & Development Officer at Merge Healthcare, Mark Bronkalla, vice president of Solutions Management, and Jim Boritz, VP PACS Development about integrating PACS with EMRs and EHRs.  In the Q&A format below, T. stands for Antonia, M. is Mark and J. is Jim.

Jim Boritz, VP PACS Development

According to the press release IBM’s vision for acquiring Merge is that these organizations could use the Watson Health Cloud to produce new insights from a consolidated, patient-centric view of current and historical images, electronic health records, data from wearable devices and other related medical data, in a HIPAA-enabled environment. Unfortunately, due to the ongoing negotiations with IBM, the trio were not able to talk specifics about the acquisition.

Q. Last month it was announced that IBM would acquire Merge Health. Without going into any specifics about that, do you see other such mergers and acquisitions coming as traditionally non-healthcare companies try to buy entry into healthcare?

T. Image analysis using cognitive machine learning has been a key element of Merge’s strategy.  Our partnership with a strong analytics partner is something that Merge was pursuing.  The pending acquisition by IBM is the strongest partnership that we could have achieved. 

Mark Bronkalla, VP Solutions
Management

Q. Will we see many more mergers and acquisitions?

T. I believe that these types of partnerships will be formed, whether they result in acquisition that will be significant, like the one between Merge and IBM remains to be seen, but these type of partnerships are being formed to enhance decision support and analytics in Healthcare.

Q. In a 2010 Imaging Tech News article about integrating PACS with EHRs, you said, “The forklift replacement strategy, which involves enforcing an enterprise PACS design across all departments, is neither cost-effective nor practical from a time perspective.”  What did you mean by forklift replacement strategy?

T. We felt and still do today that as health systems converge and create either larger health systems or integrated workflows that it wasn't reasonable for each information system to be replaced with a single vendor. So what Merge set out to do was focus on interoperability and focus clearly on the broad platforms that we have today, so that in the event if certain information systems were required, we had it, but we also focused on what it would take to connect these healthcare systems. We came out with a platform, a group of solutions called the iConnect suite. A good example of that, and I'll let Mark go into the details, but we've actually delivered on an enterprise viewer that not only provides viewing technology for both DICOM and non-DICOM content at an enterprise level, but also image enables EMRs by aggregating information from multiple systems and presenting it in the EMR within the context of a patient’s medical chart.

M. Imaging-enabling the EMR is one of the big milestones in terms of getting value out of the EMR. Being able to have your physician community operate the EMR and get instant access to any of the imaging studies is a huge win. What we were able to do was to do that without having to replace the individual PACS systems or replace the archive. Ideally you've got an vendor neutral archive or archive that is under everything that provides the speed of access that you'd like but it is not an absolute requirement.

Once this is done the viewing out of the EMR goes from being what was thought of as a luxury to a day-in, day-out necessity. The other thing that happens is if you take a PACS down for an upgrade you are going to get radiology and ER upset. If you take out your enterprise imaging app, which in our case is iConnect Access, the phone starts ringing all the way up to the C level almost instantly. So it places a new emphasis on high availability and business continuity of your imaging suite.

Q. There are so many options for integrating a PACS into EMR, how does a PACS administrator narrow the options?

M. You can start by looking at your user types. In many ways I think of the reading radiologist and reading cardiologist as one class of user who are operating and living within the PACS but they need access to the EMR, so they need to be able to launch the EMR in context, just like they would launch their voice recognition or document management in context with that study and to be able to do that rapidly. 

Conversely, almost everyone else operates within the EMR as their primary application. They have to be able to launch the imaging app within the patient context, with security so they can't go browsing through other studies, because in many cases the hospital or clinic wants to be able to use the EMR not only as the access point to the patient record, but also as the controller choke point so that the users only look at the images to which they are entitled. So it (the imaging app) needs to have the ability to launch the study and to be able to get to the priors for that particular patient, but otherwise have the search capability turned off within the viewer.

Q. So in terms of the PACS administrator it comes down to who needs what in terms of the solution to choose?

M. And their starting point. That's where, in talking to many customers, it boils down to two user sets, the reading radiologists and reading cardiologist class and then just about everyone else.

Q. Is there a process you've used with your clients that works well in helping them address their organization's integration of PACS with EHR?

M. Our single biggest complete set of integrations are with Epic and we put together a white paper that outlines all the things you can do and discusses your starting point for the various actions. Let's say you want your referring physicians to be able to view radiology studies, or cardiology studies. The EMR has to know the study is available, so there is a study notification that has to be sent from the PACS or the vendor neutral archive in order to be able to light up the link. You don't want them clicking on a link if there may or may not be images available.

J. I want to add that from an interoperability and integration flexibility and just making it work point a view our approach tends to focus on a heavy reliance on standards and in addition to those standards for data interchange, DICOM and HL7, we also then take the approach of allowing a lot of flexibility for the technical integration components, whether that is integrating via XML,  command line launch or URL launch, there are a lot of ways vendors have come up with for integrating, or crossing the boundaries between two applications, and so rather than picking one choice and saying ok, everybody you've got to work with our approach we work to put all those different kinds of integration or cross app data exchange mechanisms into our solutions.

T. So we would say to PACS administrators to look for that in a vendor and in a solution.

J. Exactly, you want to have as many different options for integration as possible because you never know what is going to come up and bite you.

M. There are also physical deployment challenges that you get into too. For example the EMR in many cases is deployed as a CITRIX application, so you need to have a viewer that can be launched out of the CITRIX session so you can render locally and not be encumbered with the "lossiness" that comes with that. And the other part is when your docs are at home, often radiologists or cardiologists want to be able to read at home, whether they are on call or are pulling a night shift or just want to work from home, make sure your choice of doing integration supports them getting access to that EMR from the PACS while they are at home that is just like when they are in the office.

Q. What are the top challenges PACS administrators face in integrating all these systems?

M. The first step if they are doing a new EMR is getting image enabling of the EMR as one of the top priorities for that first wave of integration. All too often the EMR teams are heavily influenced by nursing which is not as involved in images, so the PACS team or enterprise imaging team, whichever you've got, has to get in front of the EMR integration team and also call upon the department verticals, such as cardiology, radiology, that are interested in promoting their outpatient and referral business, to help promote getting image enablement as one of the first phase tasks. Time and again it (image enabling the EMR) is often going to be done in the second or third wave, making it two or three years out, and it is not that huge a task, and it is such a win in the referring physician community that you don't want to ignore it, but the PACS admin needs to team up with the people responsible for the revenue of radiology or cardiology to get this on the EMR implementation team's high priority list.

Q. I've read that 90 percent of medical data is imaging, is there a danger that by integrating all this imaging data into the EMR we can be overwhelming primary care physicians in terms of workflow?

M. Actually it is the converse. For example, your primary care physician is working in your EMR and he or she is going to go through, and say Mrs. Smith comes in for a visit following an imaging test that was previously ordered, so the doctor is looking to see if the results are available. The first thing they are going to do is look for the report results, which are present in the EMR, but about 10 percent of the time there is an added question for something noted in the report that requires looking at the images. The important thing is that when looking at the report for the current study in the EMR they’ve got the link directly to that study in the imaging system without having to search. That is the key to keeping it (all this imaging data) from being overwhelming. 

If the doctor has to use a completely separate process and separate viewer and they have to search for Mrs. Smith's study from last year, it isn't going to happen, or they are going to find the wrong study. That's where having the link straight to that study within with single viewer with security, makes it easy for the primary care physician to get access to the images while also providing the lock-down security that makes the EMR security team happy and improves the workflow.

Q. In terms of what the PACS administrator can do, then, is to make sure these kinds of links are simple, and make it easy to get to the images.

M. And that they link directly to the report, and on a broader enterprise level, as we look at imaging enabling other departments such as dermatology, pathology, and so on, that the images are linked to the visit or visit note that explains what they are all about.

T. Another part of that example is for the PACS administrator or radiology department to add additional value to the hospital system, or the continuum of care. By thinking about this level of interoperability or accessibility to the images in the various continuums of care, access to those could be turned into additional services that are served up by the radiology department just by having the ability to provide the access to those images.

Q. How do you see the role of PACS administrator evolving over the next few years?

M. They are having to respond much more to people outside of their department. They can no longer be heads down within the radiology or cardiology department anymore. They are taking on a broader role and providing the guidance and workflow guidance to other departments, as far as how do you troubleshoot the imaging issues that may come up, how do you provide proper data control as far as the quality of the data that is coming in. 

J. It presents a challenge to them because they have to move outside of just PACS and they have to be familiar with all these interface integration points, because as Mark said, there is a desire to get this data in other departments and to interface and integrate with other parts of the enterprise solution. So all of a sudden it has gone from departmental solution to an enterprise solution and those integrations tend to be complex to carry out.

Q. So you see PACS administrators taking on a leadership role in the process of integration and interoperability.

J. Yes, they need to because the people in the other departments don't tend to know anything about imaging. So when you look at the imaging data volumes and the challenges around imaging are huge, and those other departments tend to deal with reports that are very small in size and data that is small and easy to move around within the enterprise, but when it comes to imaging it is not easy to move that data around, so they need to make sure those other departments and other groups understand some aspects of imaging to make those integrations work.

T. At the same time, PACS admins still remain the custodians of the images because the whole premise is access to that information and availability and not necessarily moving it around the enterprise, but allowing the enterprise to access the information and that is a huge value to the institutions.