Integrating PACS with EMRs: the UCSF experience

John Mongan, MD, PhD

Dr. Mongan is the vice chair for informatics at the University of California, San Francisco, where he has led a group from UC Health in efforts to outline the requirements for a UC system-wide decision support system. Dr. Mongan interests include improving quality, safety and efficiency of medical care through increased and improved incorporation of computers and technology. Dr. Mongan, is an assistant professor in residence in the Abdominal Imaging and Ultrasound subspecialties in the Department of Radiology and Biomedical Imaging at UCSF. He received his MD and PhD from the University of California, San Diego. His research interests include dual-energy computed tomography, ultrasound and CT contrast media, and informatics and electronic medical records . UCSF Medical Center serves as the academic medical center of the University of California, San Francisco, which operates three hospital sites and two outpatient imaging centers. The Department of Radiology has more than 100 attending radiologists along with an equal number of trainee residents and fellows, who perform more than 300,000 studies a year.

Q. What is the status of EMR PACS integration at this point in time?

A. In August of 2014 we went live on Radiant, which is the RIS module that is part of the EPIC EHR and we have Agfa IMPAX as our PACS so we have patient level context integration through Radiant. What that means is that the radiologist's experience is you sit down at the PACS station there is a single sign-on through the PACS client that logs you into the PACS and the computation software and the EHR. So when you bring up a patient in PACS that patient is automatically opened in the EHR.

Q. Did that integration go smoothly?

There were definitely some challenges along the way. In a broader perspective, integration of the work environment is the real goal. Anytime you have separate systems there are always barriers to using those systems and transitioning between them. So a major goal for us is trying to get everything as integrated as possible, but there are challenges associated with that. I think some of the main challenges stem from complexity. The more components you integrate, the more pieces from more vendors that are all supposed to be working together, the more challenging, so when something doesn't work, it is often times less clear what component is at fault. If you have just a PACS system that is standalone and it isn't working, it is pretty clear that the PACS vendor is at fault. Once you start integrating other pieces it can become less clear. So for something like this, there is the EPIC EHR software, the Citrix software through which the EHR is provided and then there is the PACS software. An additional operational challenge with that is that we're somewhat, but not entirely unique in having our own radiology IT group here that does our entire PACS infrastructure from the wire up. We control our own networks, our own servers and our clients. 

Q. Did you have to upgrade the network capacity?

There are two different forms of integration. I want to be sure we're on the same page. What I'm talking about is at the radiologist workstation where they are working with the PACS and the integration of their PACS-centric workflow with additional information from the EHR. The other aspect of integration is for non-radiologists who are typically having an EHR-centric workflow having the integration of PACS or enterprise imaging into the EHR. We have that as well but that is a different mechanism.

I am interested in both.

All right, let's talk about the radiologists-centric portion first and the non-radiologist workflow later.

So in terms of radiology and the network, the additional data traffic related to the EHR is negligible compared to the image traffic. But where I was going with that point was that although we control all the radiology stacks completely within radiology, obviously we don't control the EHR because that is a hospital wide system. Part of the challenge of bringing this online and addressing and debugging the system is working with a broader group of people and not all of the management of these systems lies within radiology so you have to work with groups outside of radiology to troubleshoot and solve problems.

Q. Can you give me a specific example of how you solved one of these challenges?

One of the major challenges has been the stability of the integration, maintaining the link and maintaining the EHR open throughout the entire session that someone is using the PACS. This is something we've spent a lot of time on, there have been gradual improvements and we have now gotten to a pretty good place on this, but one of the more recent things we discovered was that, as with many applications, an activity timeout where there was an automatic logout with no user activity was causing disruption. We discovered that the activity timeout did not count activity driven by the PACS, so if you were going through a bunch of patients and the EHR was bringing up the summary page on each of those patients, from your (radiologist’s) perspective you are using that EHR you are looking at the data that comes up in that window, but if you didn't actually click on that window, it didn't count that as activity, so it would log you out after an hour. That was something we were seeing that the radiologists were continuing to use PACS and after a little while the EHR would just disappear. So we had to work with our Citrix team and our EPIC team and they actually created a separate application pool for us on the Citrix farm where we could have a longer timeout for connections coming from the radiology workstation.

Q. Has integration with the EHR affected how you work with referring physicians?

I don't think there is much impact on referring physicians from this aspect of the integration, other than they get higher quality reports because the radiologists have better access to data. But in terms of referring clinicians, this aspect of the integration is pretty much invisible to them. Their interface with the radiology department doesn't really change, which is a good thing. This is more about the radiology environment. We don't want to be unnecessarily complicating the clinician's workflow by whatever the details of how we implement the radiologist's workflow.

Q. How does the EMR affect the workflow for radiologists? 

I think that is the biggest goal of integration is to improve the workflow for radiologists and that is where we've seen the largest improvements. Prior to the implementation of this integration we had particularly cumbersome workflow for radiologists to access the EHR, which required them to log in twice, and because the timeout was set pretty short typically you would have to go through that whole double login process pretty much every time you wanted to look at a patient. First they had to log in into Citrix, then they had to wait for that login to complete then had to open the EHR app and then do a second login to the EHR. Then once they had done that they had to transcribe the medical record number for the patient they were looking at and wait for it to open that patient. 

So the total time from deciding you would like to see more information on this patient to actually getting the most recent patient notes was over a minute. So we saw a substantial time savings in terms of not having to go through that process.

We saw a major improvement in efficiency around the time it took to look up additional data in the EHR, but what I think is actually more valuable and more important is if we looked at how often the radiologists were using the EHR we saw that radiologists actually go to the EHR to get clinical data more frequently since we have implemented the context integration, which makes sense. Anytime there is something someone could do they make a mental calculation about how much time it will cost and what the value they will get back and if you make it convenient you decrease that cost and you get people doing that more frequently. 

In something like this, I think it is particularly valuable because you don't know what is in the record until you go looking for it, so I think people often underestimate the value of that data and tend to not go looking for it when it is inconvenient to look for it, but when it is right there already because it has already been opened for you then there is a much higher tendency for people to look at it and get the full value of the clinical context of the study they are interpreting.

Q. And that has resulted in the increased the quality of the reports you spoke of?

I think so, now I will say with a caveat that while I have looked at how often radiologists are looking in the EHR, I have not done a direct measure of radiology report quality, which is a much more difficult thing to measure, but I believe and there is some evidence in the literature to suggest that radiology interpretations are of higher quality and change depending on clinical context. 

There was a study recently by Franczak in Health Affairs where they looked at whether a radiology study would have been interpreted the same way based on data that was not in the imaging request but was available in the EHR, and they found that about 6 percent of time the read would have been different based on the additional data that was in the EHR. So yes, I believe integration is generating higher quality reads for us.

Q. How are you using it for clinical informatics?

The way I look at clinical informatics is using technology to support the clinical work of physicians and in our department radiologists. My view is that this is clinical informatics: Configuring these systems such that they are integrated, that they facilitate better, faster more efficient access to data to encourage people to access the data they need to practice medicine better. So my view is that this context integration is clinical informatics that has a direct positive impact on clinical care.

Q. How were your PACS administrators involved in solving the issues you had?

We have a really excellent PACS team who are committed, very experienced and well versed in all these systems, who made major contributions to the integration. As I said, once you start to integrate a bunch of components from a bunch of different vendors and technologies, it starts to get complex and there can be a lot of finger pointing. A major contribution of our PACS team was really staying on top of that process and really continuing to push the issue forward with all of the parties involved and not allow it to become party A saying it is party B's fault and party B saying it is party A's fault and it just drops there. Our PACS administrators were very good about continuing to push issues forward and facilitate the dialogue between all the different stakeholders, they saw these issues through to resolution.

Q. So they had great troubleshooting and negotiating skills?

Yes.

Q. Are we ready to talk about the other side, the referring physician having access to the imaging through the EHR and having that impact their workflow?

Yes that is something we've done for a much longer period of time, since we went live on EPIC probably five or six years ago. So within our EHR when they look at an imaging report there is a link that launches a viewer that provides them with full access to review the imaging. About a year ago, we changed which viewer we used. We went from a more heavyweight traditional Windows fat client PACS solution to an in-client web-based viewer (eUnity).

Q. A universal viewer? 

It has some universal capabilities but at present we are only serving radiology through it.

Q. What was the reason for that change?

There were a couple of reasons. We were not going to be able to stay on the PACS, at the time we had two separate PACS systems one for radiology and one that was used as an enterprise viewer for the rest of the hospital. There was a Windows and Internet Explorer upgrade that would be incompatible with the PACS viewer so we were either going to have to upgrade to a newer version of the software or change to a different platform. The web-based viewer was something we already had in place on a much smaller scale for remote image viewing off-hours within radiology, so by going with that we could consolidate our systems count, and it was a much less expensive option and it provides a lot of functionality that was not available in our traditional PACS viewer. It is accessible from mobile clients and Mac laptops as well as Windows systems. It also has some collaborative viewing features that were not available in the other system.

Q. Are both radiologists and referring physicians happy with the integration?

My sense is that they are. On the clinicians' side they are happy with the ability to get to the imaging with the link directly out of the EHR. On the radiologists' side there were initially some issues with overall stability as I mentioned that people found frustrating, but the overall experience of not having to do this laborious double login and having that EHR data readily available is something people are appreciating the benefit and utility of, and I think people are pretty happy with that.

I think it serves as a concrete example that illustrates the importance and benefits of context integration and unified workflow that is all in one place and doesn't have these unnecessary disruptions between trying to do one thing in one system and then having to log in to another system and trying to correlate things across but having a single unified workflow for the physician.