European Journal of Radiology, 16 (1992) 69-13 0 1992 Elsevier Scientific Publishers Ireland Ltd. AU rights reserved. 0720-048X/92/%05.00
EURRAD
69
0036 1
Integration of radiology and hospital information systems (RIS, HIS) with PACS: requirements of the radiologist Hans Mosser a, Michael Urban a, Michael D&-I-~,Wolfgang RUger b and Walter
Hruby
a
“Radiologydept., SMZO/Danube-Hospital. Vienna, Austria bSiemens Medical Group, Erlangen, Germany
Key words: Radiology information
system; Radiology and radiologists,
departmental
management;
PACS
Abstract PACS development has now reached a stage where it can clearly be stated that the technology for storage, networking and display in a fully digital environment is available. This is regected by an already large and rapidly increasing number of PACS installations in USA, Western Europe and Japan. Such installations consist of a great variety of information systems, more or less interconnected, like PACS, HIS, RIS and other departmental systems, d&ring in both hardware and software. Various data - even if they only concern one person - are stored in different systems distributed in the hospital. The integration of ah digital systems into a functional unit is determined by the radiologist’s need of quick access to ah relevant information regardless where it is stored. The interconnection and functional integration of ah digital systems in the hospital determine the clinical benefits of PACS. This paper (1) describes the radiologist’s requirements concerning this integration, and (2) presents some realistic solutions such as the Siemens ISI (Information System Interface), and a mobile viewing station for the wards (visitBox).
Introduction The rapid progress in computer sciences and their application in radiology has resulted in the availability of all the various components of a fully digitally interconnected hospital [ 1,2]. Intrinsically digital imaging devices, networking, archives, workstations, radiology- and hospital-information systems are installed to various degrees, in many radiology departments, mainly in western Europe, USA and Japan [2-81. Yet the full advantage of these systems can only be exploited when they are linked together to form an integrated electronic system within the hospital. The inevitable future of PACS certainly will result in structural changes in the radiology department and in the hospital as a whole which implies a reorganisation of the operational procedures. Implementation strategies will have to be developed, in particular with the involvement of radiologists to ensure the practical oriCorrespondence to: Dr. Hans Mosser, SMZO Hospital Radiology Department, Langobardenstrasse 122, A-1220 Vienna, Austria.
entation of the 6nal product. Thus a cooperation of the radiologic community with scientific PACS developing groups and PACS manufacturers is required and regarded as a prerequisite for a successful implementation [ I$]. This communication describes: (1)the functional requirements of radiologists for the integration of the various hospital and departmental information systems with PACS, based on the experiences of the authors in planning the fully digital SMZO Danube-Hospital, and (2)the first results of the technical realization of these requirements, the Siemens IS1 (Information System Interface), and other solutions such as a mobile viewing station for the wards. The SMZO PACS project: the fully digital hospital SMZO stands for Sociomedical center east, a complex health delivery system, consisting of a 400-bed geriatric hospital, a geriatric communication center, a nursing college, and the Danube-Hospital with 1000 planned acute care beds.
70 The overview of the PACS architecture of the radiology department (Fig. 1) and the associated trauma center (Fig. 2) displays extent and complexity of the project: The Danube-Hospital will officially become operational in April 1992. A 7-month preopening-phase in the radiology department (having started during September 1991) has been planned to evaluate the already installed PACS components with 9 radiologists and 15 technicians preparing the system for clinical use and cooperating with the Siemens Medical Group in Erlangen, Germany and the Siemens PSE in Vienna, Austria, in the integration of the subsystems in accordance with the radiologist’s needs. Informationproduction and interchange in the hospital
Currently in most hospitals many different kinds of communication systems are implemented: HIS -- patient administration (admission, demographic patient data necessary for administration, statistics and billing, dismission) DIS’s -- Specific departmental information systems, e.g. for radiology, nuclear medicine, pathology, laboratory, surgery, internal medicine, etc. PACS -- usually implemented in the radiology departments, with some extensions to other departments, mainly ICUs and trauma centers. The functional “information unit” in a hospital is the patient and the related data containing text and images. The various examinations are performed i.e. data are generated on different locations, at various levels and in different systems in the hospital such as laboratory, nuclear medicine, pathology (cyt- and hist-ology), and
Fig. 1. Radiology department,
the radiology department, and stored in the respective data management and storage systems. The greatest amount of data will be produced by the radiologic images. A lOOO-bedteaching hospital is expected to handle an image data volume of 13-15 GByte per day. Some of these data, scattered throughout the hospital’s departments, are often important for the interpretation of radiologic exams and thus supporting a conclusive diagnosis, or for simply providing a feedback, the basis for quality checking and improvement of diagnostic capabilities, as well as necessary for teaching and research. This should clearly show that nowadays medicine is to a great extent collection and organisation of information. It therefore is mandatory to couple these different pools of patient related data and make them easily accessible to the physician involved. The goal Definition
Integration in this context means coordination and availability of various functions of several digital systems in order to form one for the user imperceptible unit. This implies fast and easy access to all relevant data related to one patient, necessary for the radiologist’s task to perform diagnostic or interventionalradiological therapeutic procedures, irrespectively where these data originate or where they are stored. The folder concept
In the conventional radiology department folders are used to coordinate the patient’s images, exams and
PACS configuration.
71
I J
OP Thstaters, Wards
Fig. 2. Network conf@ration, trauma center.
reports. This folder organisation has proven to be practical, with certain limitations like mixture or loss of images. The same concept should be used in a digital system, which in addition has the possibility to overcome the conventional folder’s limitations by presenting requested images in a preset order (according to date, exam type, etc.) and offering a feature like a pictorial index, from where selected images can be chosen. The SMZO Danube Hospital also favored this folder concept which offers a variety of possibilities to organize patients, exams, and images. An overview of this folder organization is displayed in Fig. 3. Images are organized according to different parameters. In general it will be divided into two kinds of folders:
(1) Patient-orientated folders for use in clinical routine, and (2) special folders for research, teaching and other, user definable, purposes, consisting of images which are organized according to d&rent criteria like organ and imaging modality. The folders are defined according to their medical and data-technical status: (1) Medical status: unreported, reported, reviewed, signed (2) Technical status: location of storage (workstation, on-line or off-line archive). The access to a folder will be enabled through search parameters such as patient name, ID number, modality, organ, etc.
[ Special-Folders all images of a patient for casedmonsrrarion
all images
ofonepatient
all images ofthe during
patient the hospitalization
011reported images
Fig. 3. Folder configuration.
‘]
12 The change of a folder’s status will be automatically done by the system as far as possible; e.g. the change of an actual folder to the final folder, after the radiologist has signed the report.
The radiology information system The RIS used in the SMZO Danube-Hospital is the commercially available SIMEDOS (Siemens), which was customized for the SMZO during 1991. The RIS is designed with a highly contigurable user interface, thus it can easily be adapted to the departmental requirements. The SIMEDOS l supports scheduling, reporting, documentation l provides organizational worklists and statistics l interfaces with PACS, imaging modalities and HIS. The amount of data produced in the RIS (3 MB per day) is negligible compared to the image data volume of about 13-15 GByte per day as estimated for the “worst case”. The hospital information system The administration of the city of Vienna has been developing a HIS, which is in use in 18 hospitals [9]. The philosophy of this HIS is to provide support for the functioning of the hospital as a whole, and dealing less with specific processes, which are left to the various local systems on the wards and in the institutes. This system reduces the majority of the processes to three phases: the requesting of a service, it’s processing, and the presentation of the results. The aim of the Vienna-HIS is to coordinate these different phases, which certainly differ in time, location and organizational level. The HIS transmits requests e.g. from the internal medicine ward to the RIS, and returns the results to the ward. Images will be accessible on the wards or in the operating theaters as well, where this is necessary. These images are handled by the HIS as another type of data. If the radiologist needs certain data on his patient, like actual lab parameters or additional information concerning the case history, he may access these data in the “patient’s medical records” in the HIS. It is not possible to access directly the LAN of a ward, in order to guarantee data security. The VisitBox If PACS is to replace the conventional film, the physician in the patient’s room will still need an image to
look at, which in earlier times he did by holding it against the window. The physician’s acceptance of PACS will improve tremendously if he/she has the possibility to look at an image at the bedside, in addition to the viewing station on certain locations on the ward or operating theaters. This need was clearly realized by the radiologists of the SMZO Danube-Hospital, who have initiated the developement of the so called VisitBox. The VisitBox is a mobile viewing station, preloaded with images before the physician visits his patients which enables him to look at the patients images at the bedside. We believe that the VisitBox represents a great progress in the integration of PACS in the whole hospital which in turn means a contribution to the further development of PACS . The information system interface The necessity of a consistent user surface and an “invisible” integration of the different subsystems in the radiology department has been realized during the planning - and implementation phases of the PACS in the SMZO Danube-Hospital, which has resulted in the development of an Information System Interface (ISI). The IS1 supports the communication between different clinical network components of the SMZO, like HIS/RIS, PACS and the ima&g devices (Fig. 4). The IS1 l describes data obj>ct& and data flow control for administration, patient data, reporting, etc. allows compatible communication inside the network configuration of the hospital has an open interface for adaption to other vendor’s systems adheres to the ACR-NEMA/SPI standard.
ISA RIS HIS
I”bmmtbn Mmg8mmt, stmgm mrd *r*ivospbln Rldbk-ay hlommlbn spbm HcaPiial hfmllnlbn splm
Eyeam l”UrhQ Is1 bfmmaka
Fig. 4. Information systems interface, ISI.
73
Conclusions 1. The integration of the various digital subsystems in a hospital is a prerequisite for a routine clinical operation of PACS and associated systems. The integrated system is more than the sum of its parts, and the extent of this integration, which must include the imaging equipment consoles, will determine user acceptance. 2. This integration mainly has to be based on the radiologists’ requirements, who are primarily involved with production, display, reading and communication of diagnostic images and related data such as comments and reports. 3. Close cooperation between PACS manufacturers and radiologists must be an integral part of PACS development, design and implementation and particularly in the task of integration of the systems to guarantee the practical orientation. 4. The preliminary work of the technical realization of these requirements, the Information System Interface (ISI) of Siemens, provides a toolkit that supports the functional integration of imaging modalities, HIS/ RIS and PACS in the SMZO Danube-Hospital. 5. Further work in a changing environment, in particular having in mind the rapid emerging computer technology and its application in radiology, must be done to customize the product to the changing requirements of the user. So the job is not done with the implementation, but cooperation and discussion between PACS manufacturers and the radiologic community must continue.
References
6
7 8
9
Goeringer F. Medical diagnostic imaging support systems for military medicine. In: HK Huang et al. eds., Picture archiving and communication systems in medicine. NATO AS1 Series, Vol. F74: 213-230. Springer-Verlag Heidelberg 1991. Hruby W, Mosser H, Urban M, Rueger W. The Vienna SMZOPACS-Project: The totally digital hospital. Computer Assisted Radiology, Proc. CAR ‘91: 436-441. HU Lemke et al. eds., Springer-Verlag Heidelberg 1991. Huang HK. PACS research and development - a review and perspective. In: HK Huang et al eds., Picture archiving and communication systems in medicine. NATO ASI Series, Vol. F74: 1-7. Springer-Verlag Heidelberg 1991. Irie TG. Clinical experience. 16 months of Hokkaido universityPACS. In: HK Huang et al. eds., Picture archiving and communication systems in medicine. NATO ASI Series, Vol. F74: 183188. Springer-Verlag Heidelberg 1991. Kangarloo H, Boechat MI, Barbaric Z, Taira RK, Cho PS, Mankovich N, Ho BKT, Eldredge SL, Huang HK. Two-year clinical experience with a computed radiography system. AJR 1988; 151: 605-608. Mosser H, Rueger W, Urban M, Hruby W: Planning a large scale PACS: the Vienna SMZO-project. In: Adlassnig KP et al. eds., Lecture notes in medical informatics 45: 187-192. SpringerVerlag Berlin-Heidelberg 1991. Mun SK, Benson HK, Elliot LP. Total digital department: implementation strategy. Proc SPIE 1989; 1093: 133-139. Ratib 0, Hochstrasser D, Scherrer JR. PACS and related research in Switzerland. In: Huang HK et al. eds., Picture archiving and communication systems in medicine. NATO AS1 Series, Vol. F74: 309-312. Springer-Verlag Berlin Heidelberg 1991. Sack H. The Vienna information system. EDP-assisted management of the city of Vienna. In: Adlassnig KP et al. eds., Lecture notes in medical informatics 45: 41-45. Springer-Verlag Heidelberg 1991
EURRAD
69
0036 1
Integration of radiology and hospital information systems (RIS, HIS) with PACS: requirements of the radiologist Hans Mosser a, Michael Urban a, Michael D&-I-~,Wolfgang RUger b and Walter
Hruby
a
“Radiologydept., SMZO/Danube-Hospital. Vienna, Austria bSiemens Medical Group, Erlangen, Germany
Key words: Radiology information
system; Radiology and radiologists,
departmental
management;
PACS
Abstract PACS development has now reached a stage where it can clearly be stated that the technology for storage, networking and display in a fully digital environment is available. This is regected by an already large and rapidly increasing number of PACS installations in USA, Western Europe and Japan. Such installations consist of a great variety of information systems, more or less interconnected, like PACS, HIS, RIS and other departmental systems, d&ring in both hardware and software. Various data - even if they only concern one person - are stored in different systems distributed in the hospital. The integration of ah digital systems into a functional unit is determined by the radiologist’s need of quick access to ah relevant information regardless where it is stored. The interconnection and functional integration of ah digital systems in the hospital determine the clinical benefits of PACS. This paper (1) describes the radiologist’s requirements concerning this integration, and (2) presents some realistic solutions such as the Siemens ISI (Information System Interface), and a mobile viewing station for the wards (visitBox).
Introduction The rapid progress in computer sciences and their application in radiology has resulted in the availability of all the various components of a fully digitally interconnected hospital [ 1,2]. Intrinsically digital imaging devices, networking, archives, workstations, radiology- and hospital-information systems are installed to various degrees, in many radiology departments, mainly in western Europe, USA and Japan [2-81. Yet the full advantage of these systems can only be exploited when they are linked together to form an integrated electronic system within the hospital. The inevitable future of PACS certainly will result in structural changes in the radiology department and in the hospital as a whole which implies a reorganisation of the operational procedures. Implementation strategies will have to be developed, in particular with the involvement of radiologists to ensure the practical oriCorrespondence to: Dr. Hans Mosser, SMZO Hospital Radiology Department, Langobardenstrasse 122, A-1220 Vienna, Austria.
entation of the 6nal product. Thus a cooperation of the radiologic community with scientific PACS developing groups and PACS manufacturers is required and regarded as a prerequisite for a successful implementation [ I$]. This communication describes: (1)the functional requirements of radiologists for the integration of the various hospital and departmental information systems with PACS, based on the experiences of the authors in planning the fully digital SMZO Danube-Hospital, and (2)the first results of the technical realization of these requirements, the Siemens IS1 (Information System Interface), and other solutions such as a mobile viewing station for the wards. The SMZO PACS project: the fully digital hospital SMZO stands for Sociomedical center east, a complex health delivery system, consisting of a 400-bed geriatric hospital, a geriatric communication center, a nursing college, and the Danube-Hospital with 1000 planned acute care beds.
70 The overview of the PACS architecture of the radiology department (Fig. 1) and the associated trauma center (Fig. 2) displays extent and complexity of the project: The Danube-Hospital will officially become operational in April 1992. A 7-month preopening-phase in the radiology department (having started during September 1991) has been planned to evaluate the already installed PACS components with 9 radiologists and 15 technicians preparing the system for clinical use and cooperating with the Siemens Medical Group in Erlangen, Germany and the Siemens PSE in Vienna, Austria, in the integration of the subsystems in accordance with the radiologist’s needs. Informationproduction and interchange in the hospital
Currently in most hospitals many different kinds of communication systems are implemented: HIS -- patient administration (admission, demographic patient data necessary for administration, statistics and billing, dismission) DIS’s -- Specific departmental information systems, e.g. for radiology, nuclear medicine, pathology, laboratory, surgery, internal medicine, etc. PACS -- usually implemented in the radiology departments, with some extensions to other departments, mainly ICUs and trauma centers. The functional “information unit” in a hospital is the patient and the related data containing text and images. The various examinations are performed i.e. data are generated on different locations, at various levels and in different systems in the hospital such as laboratory, nuclear medicine, pathology (cyt- and hist-ology), and
Fig. 1. Radiology department,
the radiology department, and stored in the respective data management and storage systems. The greatest amount of data will be produced by the radiologic images. A lOOO-bedteaching hospital is expected to handle an image data volume of 13-15 GByte per day. Some of these data, scattered throughout the hospital’s departments, are often important for the interpretation of radiologic exams and thus supporting a conclusive diagnosis, or for simply providing a feedback, the basis for quality checking and improvement of diagnostic capabilities, as well as necessary for teaching and research. This should clearly show that nowadays medicine is to a great extent collection and organisation of information. It therefore is mandatory to couple these different pools of patient related data and make them easily accessible to the physician involved. The goal Definition
Integration in this context means coordination and availability of various functions of several digital systems in order to form one for the user imperceptible unit. This implies fast and easy access to all relevant data related to one patient, necessary for the radiologist’s task to perform diagnostic or interventionalradiological therapeutic procedures, irrespectively where these data originate or where they are stored. The folder concept
In the conventional radiology department folders are used to coordinate the patient’s images, exams and
PACS configuration.
71
I J
OP Thstaters, Wards
Fig. 2. Network conf@ration, trauma center.
reports. This folder organisation has proven to be practical, with certain limitations like mixture or loss of images. The same concept should be used in a digital system, which in addition has the possibility to overcome the conventional folder’s limitations by presenting requested images in a preset order (according to date, exam type, etc.) and offering a feature like a pictorial index, from where selected images can be chosen. The SMZO Danube Hospital also favored this folder concept which offers a variety of possibilities to organize patients, exams, and images. An overview of this folder organization is displayed in Fig. 3. Images are organized according to different parameters. In general it will be divided into two kinds of folders:
(1) Patient-orientated folders for use in clinical routine, and (2) special folders for research, teaching and other, user definable, purposes, consisting of images which are organized according to d&rent criteria like organ and imaging modality. The folders are defined according to their medical and data-technical status: (1) Medical status: unreported, reported, reviewed, signed (2) Technical status: location of storage (workstation, on-line or off-line archive). The access to a folder will be enabled through search parameters such as patient name, ID number, modality, organ, etc.
[ Special-Folders all images of a patient for casedmonsrrarion
all images
ofonepatient
all images ofthe during
patient the hospitalization
011reported images
Fig. 3. Folder configuration.
‘]
12 The change of a folder’s status will be automatically done by the system as far as possible; e.g. the change of an actual folder to the final folder, after the radiologist has signed the report.
The radiology information system The RIS used in the SMZO Danube-Hospital is the commercially available SIMEDOS (Siemens), which was customized for the SMZO during 1991. The RIS is designed with a highly contigurable user interface, thus it can easily be adapted to the departmental requirements. The SIMEDOS l supports scheduling, reporting, documentation l provides organizational worklists and statistics l interfaces with PACS, imaging modalities and HIS. The amount of data produced in the RIS (3 MB per day) is negligible compared to the image data volume of about 13-15 GByte per day as estimated for the “worst case”. The hospital information system The administration of the city of Vienna has been developing a HIS, which is in use in 18 hospitals [9]. The philosophy of this HIS is to provide support for the functioning of the hospital as a whole, and dealing less with specific processes, which are left to the various local systems on the wards and in the institutes. This system reduces the majority of the processes to three phases: the requesting of a service, it’s processing, and the presentation of the results. The aim of the Vienna-HIS is to coordinate these different phases, which certainly differ in time, location and organizational level. The HIS transmits requests e.g. from the internal medicine ward to the RIS, and returns the results to the ward. Images will be accessible on the wards or in the operating theaters as well, where this is necessary. These images are handled by the HIS as another type of data. If the radiologist needs certain data on his patient, like actual lab parameters or additional information concerning the case history, he may access these data in the “patient’s medical records” in the HIS. It is not possible to access directly the LAN of a ward, in order to guarantee data security. The VisitBox If PACS is to replace the conventional film, the physician in the patient’s room will still need an image to
look at, which in earlier times he did by holding it against the window. The physician’s acceptance of PACS will improve tremendously if he/she has the possibility to look at an image at the bedside, in addition to the viewing station on certain locations on the ward or operating theaters. This need was clearly realized by the radiologists of the SMZO Danube-Hospital, who have initiated the developement of the so called VisitBox. The VisitBox is a mobile viewing station, preloaded with images before the physician visits his patients which enables him to look at the patients images at the bedside. We believe that the VisitBox represents a great progress in the integration of PACS in the whole hospital which in turn means a contribution to the further development of PACS . The information system interface The necessity of a consistent user surface and an “invisible” integration of the different subsystems in the radiology department has been realized during the planning - and implementation phases of the PACS in the SMZO Danube-Hospital, which has resulted in the development of an Information System Interface (ISI). The IS1 supports the communication between different clinical network components of the SMZO, like HIS/RIS, PACS and the ima&g devices (Fig. 4). The IS1 l describes data obj>ct& and data flow control for administration, patient data, reporting, etc. allows compatible communication inside the network configuration of the hospital has an open interface for adaption to other vendor’s systems adheres to the ACR-NEMA/SPI standard.
ISA RIS HIS
I”bmmtbn Mmg8mmt, stmgm mrd *r*ivospbln Rldbk-ay hlommlbn spbm HcaPiial hfmllnlbn splm
Eyeam l”UrhQ Is1 bfmmaka
Fig. 4. Information systems interface, ISI.
73
Conclusions 1. The integration of the various digital subsystems in a hospital is a prerequisite for a routine clinical operation of PACS and associated systems. The integrated system is more than the sum of its parts, and the extent of this integration, which must include the imaging equipment consoles, will determine user acceptance. 2. This integration mainly has to be based on the radiologists’ requirements, who are primarily involved with production, display, reading and communication of diagnostic images and related data such as comments and reports. 3. Close cooperation between PACS manufacturers and radiologists must be an integral part of PACS development, design and implementation and particularly in the task of integration of the systems to guarantee the practical orientation. 4. The preliminary work of the technical realization of these requirements, the Information System Interface (ISI) of Siemens, provides a toolkit that supports the functional integration of imaging modalities, HIS/ RIS and PACS in the SMZO Danube-Hospital. 5. Further work in a changing environment, in particular having in mind the rapid emerging computer technology and its application in radiology, must be done to customize the product to the changing requirements of the user. So the job is not done with the implementation, but cooperation and discussion between PACS manufacturers and the radiologic community must continue.
References
6
7 8
9
Goeringer F. Medical diagnostic imaging support systems for military medicine. In: HK Huang et al. eds., Picture archiving and communication systems in medicine. NATO AS1 Series, Vol. F74: 213-230. Springer-Verlag Heidelberg 1991. Hruby W, Mosser H, Urban M, Rueger W. The Vienna SMZOPACS-Project: The totally digital hospital. Computer Assisted Radiology, Proc. CAR ‘91: 436-441. HU Lemke et al. eds., Springer-Verlag Heidelberg 1991. Huang HK. PACS research and development - a review and perspective. In: HK Huang et al eds., Picture archiving and communication systems in medicine. NATO ASI Series, Vol. F74: 1-7. Springer-Verlag Heidelberg 1991. Irie TG. Clinical experience. 16 months of Hokkaido universityPACS. In: HK Huang et al. eds., Picture archiving and communication systems in medicine. NATO ASI Series, Vol. F74: 183188. Springer-Verlag Heidelberg 1991. Kangarloo H, Boechat MI, Barbaric Z, Taira RK, Cho PS, Mankovich N, Ho BKT, Eldredge SL, Huang HK. Two-year clinical experience with a computed radiography system. AJR 1988; 151: 605-608. Mosser H, Rueger W, Urban M, Hruby W: Planning a large scale PACS: the Vienna SMZO-project. In: Adlassnig KP et al. eds., Lecture notes in medical informatics 45: 187-192. SpringerVerlag Berlin-Heidelberg 1991. Mun SK, Benson HK, Elliot LP. Total digital department: implementation strategy. Proc SPIE 1989; 1093: 133-139. Ratib 0, Hochstrasser D, Scherrer JR. PACS and related research in Switzerland. In: Huang HK et al. eds., Picture archiving and communication systems in medicine. NATO AS1 Series, Vol. F74: 309-312. Springer-Verlag Berlin Heidelberg 1991. Sack H. The Vienna information system. EDP-assisted management of the city of Vienna. In: Adlassnig KP et al. eds., Lecture notes in medical informatics 45: 41-45. Springer-Verlag Heidelberg 1991
