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Healthcare IT advances are pulling together to manage an expanding universe.
INTEGRATING  PACS - by Mark Hagland

Ten years ago, picture archiving and communications systems (PACS) were new, and the first hospital implementations were greeted with some skepticism. Five years ago, despite having proven their technological worth and ability to improve day-to-day practice, PACS were still seen largely as image-viewing tools for radiologists. Today, industry experts say that the future of PACS lies in evolving systems toward integration and interoperability.

Executives at leading-edge healthcare organizations see a cluster of factors pushing integrated PACS forward: the rise of electronic medical record/electronic health record (EMR/EHR) systems, growing consensus on technical standards, clinician demands for technical capabilities, and an ever-greater need to save costs and improve operational and patient care efficiency. Experts also see everything getting linked together: PACS; radiology information systems (RISs); images from cardiology, gastroenterology, and pathology; plus all relevant data from the EMR/EHR. Seamless sharing of all the data and images that clinicians will need for patient care is the vision for the future of PACS. "

As recently as the late 1990s, people thought of PACS as a radiology department solution," says Keith Dreyer, M.D., Ph.D., vice chairman of radiology at Massachusetts General Hospital, Boston, and an assistant professor at the Harvard Medical School. "Now they think of it as an enterprise solution."

Tool in the EMR
Dreyer, who speaks widely on PACS topics, says that the rise of EMRs and, especially, computerized physician order entry is creating an environment in which physicians not only want but demand access to images and data from a variety of specialties. In that environment, PACS cannot remain something that radiologists "own." It must become another of an emerging array of clinical tools.

Referring physicians won't necessarily want to access the diagnostic-level PACS images that radiologists will still use, but in the coming years, they will have electronic access to a far wider range of data and images from multiple specialties, Dreyer says. And the technology is already there to facilitate this access. Partners Healthcare, the gigantic integrated parent organization for Mass General, has had a hierarchical management system central archive in place since 1999, so "anybody in any department can see the images from anywhere else," Dreyer says. Partners also developed its own EMR and supports its archiving with jukebox technology.

No more than a tiny handful of patient care organizations are as far along as Partners, but the general trend for the future is obvious, says Deborah Kohn, a principal at San Mateo, Calif.-based Dak Systems Consulting. "PACS has been expanding horizontally, and then vertically," she says. "First, images started being relayed to all the people who wanted to see them--in the ICU, the ED, the OR and the orthopedics department, for example. That was the horizontal movement. Now, we're starting to see vertical integration of technology, with cardiology and the other image-driven disciplines."

The key to getting the most from PACS is for it to go "hand in hand with the EHR," Kohn says. "As the EHR gets implemented, this is a piece of that. The video from ultrasound is a video element, and the audio from an echocardiogram is an audio element." Together, the elements make up the complete patient record, she says. "But this will take a long time. We're just starting to see pieces of structured, coded data, like order entry, now finally coming around. And happening with it is the PACS, whether just for radiology or cardiology or all of the above." And the CIOs she works with "are making sure that [the pieces] all converge together," she says.

CIOs say yes
CIOs are definitely on board, although they still struggle with the technological, standards, workflow and political aspects of such a comprehensive move forward. "It still gets back to the online EMR," says George Evans, CIO at 292-bed Lexington Medical Center in West Columbia, S.C. Customers have to start making vendors structure their systems so data can be easily exchanged, Evans says. "I want to pick my EMR product and then tell the vendors, 'You've got to be able to feed my EMR product, and then you're my vendor.'" Evans looks for products that adhere to established standards and operate on open platforms, and when he selects an EMR, he wants to be able to tie all the pieces together. "A lot of vendors feel that continuing in their proprietary fashion is most protective of their market," but when it comes to partnering with such companies, he says, "I personally feel the opposite."

There are practical reasons why interoperability will have to be the watchword going forward, says G. Daniel Martich, M.D., vice president of e-records for the University of Pittsburgh Medical Center (UPMC) and codirector of the Cardiothoracic Intensive Care Unit at UPMC-Presbyterian Hospital, Pittsburgh. "I don't anticipate the big EMR/CIS systems coming out with a state-of-the-art PACS system to rival the big PACS systems," he says, "so I think it's got to be interoperability that will take us there." Martich says that he and his colleagues at UPMC have already mapped out a path toward true interoperability and are busy moving along it.

Step one, already accomplished, is to create a strong EMR/EHR-based repository in which all digital images, sounds and data can be stored, Martich says. Step two, largely accomplished, is to change workflow. Martich and his colleagues have asked radiologists and cardiologists to provide preliminary reports for referring physicians and others to access. Step three, on which some preliminary work has begun, is to create a "context-related, single sign-on for multiple clinical applications," Martich says. He and his colleagues are utilizing HL7's CCOW standard and working with UPMC's access management, EMR, PACS, cardiology and other vendors to create the broad access and single sign-on. Step four, to be accomplished in the next few years, is to create a standardized data set that clinicians can plug into and also populate as they care for patients. Step five, still far into the future, will take place when clinical care advances make it possible to proactively prevent developments like sepsis and heart attacks. Clinical and IT leaders need to envision that future, Martich says, and move toward it comprehensively.

Work to be done
Organizations that have moved boldly toward integrated systems, like Partners and UPMC, are decidedly in the minority. Most hospitals are just taking their first steps toward new ways of working with images.

Beaverton, Ore.-based Planar Systems manufactures PACS workstations and in December 2004 commercially introduced one specifically designed for use in the operating room. Only a few early-adopter hospitals seem ready even to extend PACS into the OR, reports Matt Harris, vice president of marketing. "The overwhelming majority of items we sell are still product-focused on the radiology suite," he says. "We hear from hospitals and doctors that there's a real issue as to how you extend PACS into the OR in a cost-effective way. We think that's going to be the next hurdle that hospitals need to overcome."

PACS technology still has penetrated only a minority of hospital facilities nationwide, though that is changing, says Antonio Garcia, an industry analyst in the San Antonio office of Frost & Sullivan. What's more, he notes, "so-called integrated RIS/PACS packages still have some bugs to be worked out. We're going through two or three releases for some of the earlier companies that got involved in that, and some companies still haven't been able to come to market with a truly integrated product."
Still, some major vendors are making headway in that area, Garcia says, and overall there's no question that integration, interoperability, and better storage solutions will be the main themes going forward. He adds that although it is always difficult to precisely predict a timeframe for widespread adoption of emergent technologies, five years seems like a reasonable period of time in which to expect significant progress toward integration, interoperability and near-universalization of PACS. Financial barriers remain among the most significant, he notes.

Key word: interoperability
Consensus among experts and IT and clinician leaders is strong: Ultimately, PACS will be integrated as one element in a comprehensive array of clinical IT tools and will be interoperable with other key clinical systems--allowing sharing of data, sounds and images among appropriate clinicians. "All of this is going to improve the quality of care," Kohn says. "By making a base system available and providing information more quickly to the referring physician and the consulting physician as well, that will all improve care quality."
(extraído da publicação Healthcare Informatics, focada no estudo de TICs para Healthcare) Fevereiro 2005