1 July 2003

Data Management and Information Systems in Radiology

Roberto J. Rodrigues

Senior Consultant, The Institute for Technical Cooperation in Health Inc. (INTECH), Potomac MD
Vice-President, Medical Informatics Foundation, Miami FL
Adjunct Faculty, Science, Technology, and International Affairs Program of the
E. Walsh School of Foreign Service, Georgetown University, Washington DC
Ex-Regional Advisor, Health Services Information Technology, PAHO/WHO

1. Overview: Information in Health and Healthcare

Information is a key resource and prerequisite for the effective provision and management of
healthcare. The utilization of an appropriately designed and properly established data collection,
processing, and communication systems with the objective of producing and disseminating
management-oriented administrative and clinical information for operational support and decision
making has been repeatedly shown to result in greater effectiveness and efficiency [1, 2, 3].
Information systems are critical for attaining the goals of improving access to equitable healthcare
and the practice of evidence-based quality health interventions; for the achievement of cost-efficient
operation and management of health services and health programs; and for the provision of
individualized quality healthcare [4, 5] – indeed, the very quality of patient care and success in the
very complex and competitive health sector is directly related to the reliability and timeliness of the
information available to clinical practitioners and managers [3, 6].

Health information systems, to be useful, must allow for a wide variety and scope of clinical
and administrative data. Health information is any and all information related to health – structured
and non-structured data from patient records and files, with all that they may contain: time-based
graphics; laboratory investigations; biomedical signals, e.g. electrocardiograms; X-ray, MRI, CT,
ultrasound scan, and pathology images; bedside recordings of vital signs; and a large volume of
coded and non-coded data originating from many providers and other professionals. In a broader
sense, health information encompasses also other data sources: demographic data; information on
social, cultural, economic, and environmental determinants of health; profiles on morbidity and
disease specific mortality; findings resulting from clinical practice, biomedical, and epidemiological
research; statistics on the activities of healthcare services, actions of health personnel, and coverage
of health programs. At all levels of the health sector, the greatest need is the establishment of
continuous information systems that enable the recovery of patient-oriented, problem-oriented, and
procedure-oriented data to assist in the day-to-day operation of services, management of the logistics
of care, and in the assessment of the impact of health services on the health status of individuals and
populations.

The variety of environments, priorities, organization, and operational demands of the

healthcare sector require a variety of information and communication technologies and information
system solutions capable of providing support for the challenging and complex interdependent
clinical, public health, and managerial decisions and interventions that characterize health practice.
Long used by the health sector as organization-facing “back-office applications such as enterprise
resource planning, supply chain management, engineering applications and administration, logistics,
and human resource management, health information systems have, accordingly, evolved to support
patient-related “front-office” functions directly related to diagnosis and therapy [7].

2. Trends in Health Services Information and Communication Technologies

The imperative for information and communication technologies (ICT) in health is concrete, is
driven by the operational requirements of patient care, organizational and resource management, and
 2 July 2003
by the dictates of health reforms. Most of those health sector requirements are analogous to
determinants found to be relevant in other service areas such as commerce, retailing, finance,
transportation, and industry [8, 9, 10, 11, 12]:

• Trend toward consolidation of the highly fragmented, expensive, and inefficient fee-for-
service to models based on fixed revenue, e.g. capitation, forcing providers to search for
ways to reduce costs, gain operational efficiencies, add complementary products, control
induced demand, and streamline professional supply.

• In many countries, a significant percentage of healthcare expenditures are due to

unnecessary costs mostly related to redundant tests and medical errors due to poor
communication among providers.

• Health organizations and the form of healthcare delivery are undergoing a shift from an
institution-centered to a citizen-centered model. The prime feature of the model is a new
emphasis on continuity of services supporting health promotion and maintenance
encompassing informed citizens caring for their health and an assortment of stakeholders
responsible for the delivery of a continuum of health services within a region.

• Networks of producers, suppliers, customers, and clients and consolidation and partnering of
stakeholders, physician practice management groups, group purchasing organizations, and
integrated health delivery networks, linking outpatient facilities, diagnostic centers, hospitals,
doctors, and patients have stimulated the reform of traditional health practice and
management.

• Leasing, membership, service agreement, and strategic alliance models replace traditional
business organizations based on ownership of physical assets and long-term structures.

• Lifetime value of customer retention replaces “one time sell”. Customization capable of
achieving a “one of a kind” product or service and the possibility of instantly changing the
products, prices, promotions, and other content to better meet user needs through economies
of speed, demand forecasting, and customer service and satisfaction are becoming more
important than economies of scale and impersonal service provision.

• Growth of a global marketplace and the ubiquity of interactive communications. Global

demand for telehealth services is estimated to be of US$ 1,25 trillion, of which about two-
thirds is for direct services and the rest for second opinion, consumer information, continuing
education, management and other services.

• Leveling effect of information and communication technologies which, by reducing entry

barriers, allows small firms and poor countries and populations to have access to markets,
information, and other resources, thus balancing the vertical integration competitive
advantage of large corporations

• Availability of front office customer-facing applications such as Customer Relationship

Management (CRM), Customer Interaction Software (CIS) as well as Customer Asset
Management (CAM) with the goal of: identifying, attracting and retaining customers to
generate profitable revenue growth; supporting the overall process of marketing and service
provision; and the exploitation of provider and client information, data, and analyze patterns
of activity among multiple organizational units for competitive differentiation.

• New back office applications including a wide variety of "company-facing" applications:

financial management, accounting, inventory control, logistics, distribution, manufacturing,
human resources, supply chain management, network systems, office tools (like word
processors), and database systems. Even in this well-consolidated area there are emerging
trends in response to increased competition among technological solution suppliers:
 3 July 2003
partnering for technology and content; application outsourcing through an Application Service
Provider (ASPs) model to host products off of client premises; web-enabled solutions that
offer an easy and inexpensive way for clients to integrate their applications into existing
computer facilities; development of affordable complete and highly integrated application
suites; and the targeting of small and mid-sized companies by delivering packaged hardware,
software, and services to meet the business requirements of small and mid-sized
organizations which helps smaller companies keep their costs down by eliminating the need
to do business with different vendors for hardware, software and services.

3. Hospital Information Systems (HIS)

The objective of a hospital information system (HIS) is to use computers and communications
equipment to collect, store, process, retrieve, and communicate patient care and administrative
information for all hospital-related activities and satisfy the functional requirements of all authorized
users. Modern HIS products have the capability of managing integrated multi-facility medical
communication and the storage and retrieval of all patient data during the current and previous
contacts with the healthcare system [13]. Clinical information systems are evolving in the direction of
a “lifetime” electronic health record capable of storing all significant personal health data. To attain
those goals, a number of functional objectives must be achieved:

• Establishment of a database capable of providing and integrated and continuous computer-

stored medical record for all relevant patient data and make it directly accessible to all
authorized health professionals at all times (“24 hours a day, 7 days a week”).

• Communication of patient clinical and administrative data to and from all hospitals services
and between different hospitals.

• Support of all health provider functions, including order entry, results reporting, consultations,
and procedures.

• Provide clinical and administrative evidence-based decision support.

• Have functions capable of supporting logistic and business functions such as eligibility,
registration, scheduling, accounting and billing, personnel, materials management, and
financial administration.

• Assist with quality assurance, accreditation, and regulatory requirements.

• Support research, education, and training requirements.

4. Radiology Information System (RIS)

The rationale for the establishment of a RIS depends greatly on the size and type of practice,
degree of specialization required, and economic determinants. For the clinician user, a RIS means
timely accessibility to reports and the concurrent access to various types of imaging studies, many
done in different diagnostic units. The addition of telecommunication links reduces the lag time
associated with sending studies by mail or courier from small clinics to an off-site radiologist for
interpretation and, conversely, reports, films, and other studies once interpreted can be made
immediately available to remote users.

For the radiologist, a RIS eliminate redundant entry of patient data, allows the reception of
requests electronically, automates image display and storage, facilitates the recovery of previous
exams for comparison, assists the implementation of standardized reports and digital signature, and
allows the integration of voice processing through digital dictation [14, 15]. A RIS that incorporates a
 4 July 2003
full-feature picture archiving and communication systems (PACS) fundamentally changes the nature
of radiology practice and reporting. Technology solutions allow the creation of a multimedia
document consisting of a selected image or a series of images, text of result, supplemented by an
animated pointer or drawing tool to highlight significant findings at the same time that the radiologist’s
spoken interpretation is played [14, 16].

For the patient, the benefits of a RIS relate to better control of exams and results by reducing
the chances of loss or misplacement of images and unnecessary repeat examinations with attendant
cost, radiation exposure and patient inconvenience, and faster reporting and delivery of the right
images to the right user at the right time [17, 18]. If the RIS is integrated to a computerized hospital or
clinical information system one can easily have imaging studies displayed with simultaneous access
to clinical information.

To the manager of a radiology service, the logistical support provided by a RIS allows flexible
and effective scheduling and booking, the administration of queues, precise documentation and
accurate statistics, higher quality and quicker response time in the transcription process, automatic
electronic transmission of reports, exchange of exam and report data with the HIS or payers
(insurance, third-parties) for billing purposes and for statistical data gathering and management
reporting, and improved tracking of documentation and hard copies of image studies that are taken
out from the service archive. The purchase and implementation of a RIS must be seen as the first
building block before the acquisition of a PACS.

5. Generation and Communication of Digital Images

Digital imaging and its impact on the processing and distribution of imaging studies are major
issues both from the logistical and economic perspective. A large number of diagnostic equipment
such as MRI, CT, and ultrasound scanners, and nuclear medicine gamma cameras primarily
generate digital outputs. More recently, the advent of computerized radiography (CR/DR) has added
a new incentive to transition to electronic image management. This has motivated many radiology
departments to convert to filmless or almost filmless operation. Image digitizers (scanners) are used
to transform film-based images from non-digital radiology equipment to digital format.

Digital images are arrays of discrete data elements represented in a matrix in which the
smallest component is called a picture element or pixel. To each pixel a numerical value can be
assigned by a computer systems representing gradations on a grayscale or colors of a palette. The
number of pixels necessary to convey the information in a image depends on the size of the image,
for instance, a matrix of 2,048 by 2,048 pixels may be required to record black and white data from a
chest radiography1. For storage and to reduce transmission time, images can be compressed.
Compression reduces the size and cost of mass storage devices (hard drive arrays, optical media)
and allows fast file loading and display and facilitates distribution over telecommunication networks,
particularly through public networks (Internet)– the most used model is the JPEG (Joint Photographic
Expert Group) standard [19].

Digital imaging and communication standards are essential and presently well established. In
1983 the American College of Radiology in collaboration with the National Electronics Manufacturers

1
If coded at 16 bits a 2,048 x 2,048 pixel matrix requires 8.3 million bytes of data or 8.3 Mbytes for
storage. A single CT or MRI scanner study requires 12 to 25 Mbytes and a CT machine may easily produce
many Gigabytes (1 GByte = 1 x 109 bytes) in a relatively short time span while a fully digital radiology service will
generate several Terabytes (1 TByte = 1 x 1012 bytes) of data in a year. It is clear that storage and retrieval of
this volume of data is one of the core issues in the design and implementation of a system to process and
archive images. It is the number of bytes of an image study, commonly referred as the “size” of the image,
expressed in Kylobytes or Megabytes, that determines the level of resolution or granularity of the image and the
time that will take to transmit the image as a file without compression through a communication channels.
 5 July 2003
Association (NEMA) created and published standards that evolved to become the Digital Imaging and
Communication in Medicine (DICOM) version 3.0 standard adopted in 1993 which, besides imaging,
includes a variety of definitions and communication standards for the whole medical field -- DICOM
specifies a generic digital format and a transfer protocol for biomedical images and image-related
information such as the network environment including physical components and protocols; image
handling standards; data transfer and processing (distribution, display, printing) standards; objects
that include images, reports, lists, measurements, coding tables; and integration standards for
information objects allowing systems intercommunication. Even though the DICOM Standard has the
potential to facilitate implementations of PACS solutions, it does not, by itself, guarantee
interoperability of PACS components 2.

6. Picture Archiving and Communication System (PACS)

PACS is a combination of hardware and software that digitally stores and manages medical
images and information and there has been an accelerated adoption of digital equipment and
implementation of PACS. By using PACS, medical professionals can quickly and efficiently access
radiological images. Unlike older film-only systems, multiple users, even those in different remote
facilities, can view images simultaneously. PACS can interface with other clinical systems to access
the patient medical record and other clinical, diagnostic, and administrative data and make these
available along with images to provide an integrated diagnostic perspective.

The heart of a PACS is a computer server that provides control and routing of digital
information. Because medical image files are typically very large, the server has to manage the
storage and archiving of information as well as the routing. The server is also responsible for the bi-
directional communication with the HIS and RIS and image distribution to provide medical
professionals with all elements for an evidence-based and timely diagnosis. There are two general
categories of output devices used with a PACS: workstations (diagnostic and review) and laser
printers.

PACS components communicate through electronic networks and may use a Local Area
Network (LAN) within a health facility or nearby facilities, a Wide Area Network (WAN) between
distant facilities, or a Public Network (Internet). The network provides the physical means by which
the various components exchange information and the data communication device and type of link
(dial-up, dedicated line, local cabling or fiberoptic, etc.) will determine the transmission
characteristics. For the PACS/Internet distribution system to access patient data and be able to
associate it with image records, we need to add a computer that can communicate with both systems
through a HIS/RIS gateway.

2
The DICOM specification is usable on any type of computer and interfaces are available for nearly all
types of imaging devices. It has been adopted for use in pathology, internal medicine, veterinary medicine, and
dentistry. In 1995 and 1997 new additions were made to the standard to incorporate teleradiology requirements
and linkages to SNOMED (Systematized Nomenclature of Human and Veterinary Medicine) and LOINC (Logical
Observation Identifiers, Names, and Codes) coding structures. DICOM also has a close relationship with the
Health Level 7 (HL-7) standard and internationally it is compatible with the CEN/TC 251 WG4 MEDICOM
standard of the European Union and the JIRA and MEDIS-DC of Japan [1, 14]. A few years ago, the IHE
(Integrating the Healthcare Enterprise) initiative was undertaken. The IHE initiative is a project designed to
advance the state of data integration in healthcare. Sponsored by the Radiological Society of North America
(RSNA) and the Healthcare Information and Management Systems Society (HIMSS), it brings together medical
professionals and the healthcare information and imaging systems industry to agree upon, document and
demonstrate standards-based methods of sharing information in support of optimal patient care. It is important to
ask potential vendors of PACS components and other information systems of their participation in the IHE
initiative.
 6 July 2003

7. Fully Integrated RIS/PACS solution

A fully integrated RIS/PACS solution offers the most promise for advanced image and
information management. With the RIS as the primary manager of information between RIS and
PACS, one can handle almost any imaging environment. When multiple imaging environments are
part of the institution, the ability to use the RIS system for management is particularly advantageous
and attractive. The core of a RIS/PACS product is a server and its electronic archive (Figure 1).

RIS/PACS
DIGITIZING HARD COPY SERVER & ARCHIVE
FILM STATION ARCHIVE
PROCESSOR PRINTER REMOTE
IMAGING USER
WORKSTATION

WEB

CT SCANNER

MRI SCANNER
WEB SERVER
CT/MRI CONSOLE

ULTRASOUND
PRINTERS
GAMMA
CAMERA
HIS SERVER

DIGITAL RADIOLOGY DIAGNOSTIC

HIS TERMINAL RIS/HIS
SYSTEM WORKSTATION
GATEWAY

Figure 1. Components of a RIS/PACS System Linked Through a Local Area

Network (from Kodak™ PACS/Web Distribution System Concepts Course, modified)

The image server and archives provide access to images and related information to any part
of the network, locally or remotely, and through appropriate gateways support the connectivity with
other internal and external networks and information systems. Speed and safety are as important as
the effective use of hardware and manpower. Hard disk technology has evolved considerably and
supports inexpensive storage and fast access to images. For long-term storage, other devices can be
used, if desired, but online short-term and long-term storage on hard disk is more and more becoming
the solution of choice. Workflow demands for a specific service need to be carefully assessed and
analyzed and ideally one should aim for a seamless automated workflow. To define detailed user
requirements and specify systems is a laborious process. It is particularly difficult to establish what is
needed to synchronize patient relevant data avoiding duplication of data entries and having a system
that operates within a consistent patient data set in a bi-directional way between the RIS and other
clinical and administrative applications (Figure 2).

There are three categories of RIS vendors: (a) Single-source vendors - offer all the different
healthcare information systems including hospital information systems (HIS), laboratory information
systems (LIS), radiology information systems (RIS), pharmacy systems, etc.; (b) Multi-product
vendors - offer more than one product but not a complete product line like the single-source vendors.
While it is true that every single-source vendor is a multi-product vendor, not every multi-product
 7 July 2003
vendor is a single-source vendor; and (c) Single-product vendors- offer a single product such as an
RIS and no other products. The vendor category selected will greatly influence the capabilities and
overall functionality of the RIS system one gets.

report
report
Registration Report
report
Repository

patient Diagnostic Film

information Workstation Lightbox
images
retrieved

Orders Placed
procedure
scheduled
Image Manager
Prefetch any relevant
examination orders & Archive
prior studies
Acquisition
modality images
Modality
Orders Filled worklist stored
acquisition
completed
acquisition Film
completed
in-
in-progress images
printed

Figure 2. Typical HIS/RIS/PACS Workflow [20]

Within the category of single-source vendors there are those that developed all the software
themselves and therefore offer integration and there are those that did not develop all the software
and, therefore, must rely on interfaces. Because of the frequent confusion among buyers of the
meaning of the terms “interfaced” and “integrated”, it is not uncommon for single-source vendors, who
offer an interfaced product line, to pass themselves off as integrated. A single-source vendor may
have written their own hospital information system and laboratory information system but acquired a
radiology information system and a pharmacy information system from third parties in order to
complete their product portfolio offering. But just because one can purchase all products from a single
vendor it does not mean that the products are actually integrated.

Multi-product vendors, like single-source vendors, may have developed their software or may
have acquired some or all of their software from other sources. Since multi-product vendors don't
offer a total solution, they must rely, at least in part, on interfaces. Multi-product vendors, including
single-source vendors, typically have one or more strong products that drive the company, as well as
one or more products that aren't as strong. For example, they may offer a strong HIS, an average
laboratory information system (LIS) and a limited RIS. The reason for this is that vendors supporting
multiple products are going to put efforts into the products that have the greatest potential to generate
revenue. The other systems may not receive this preferred status and can therefore remain static for
extended periods of time.

Most best-of-breed vendors fall under the single-product category because they can devote
all their attention to only one product. By focusing total energy and attention on a single product, it is
possible for a single-product vendor to offer a RIS product that is superior when compared to other
RIS products and, by definition, best-of-breed relies on decentralization. If so, why would a hospital or
 8 July 2003
clinic select anything but a best-of-breed vendor? Best-of-breed will definitely provide the best
combination of products, but, facilities striving for centralization and integration prefer the control of
keeping everything together even if they sacrifice some features and or functionality. So, to the buyer,
the question comes down to maximum control versus maximum capabilities. Radiology managers
usually prefer maximum capabilities while the information systems department usually prefers
maximum control. Therefore, facilities with strong information systems departments generally prefer
to purchase a RIS from a single-source vendor. Conversely, facilities with limited or non-existent
information systems departments generally prefer to purchase their RIS from a best-of-breed vendor
3
.

8. Electronic Networks and Teleradiology

Radiology is the ideal clinical service for telehealth. Radiology was one of the first medical
specialties to embrace telecommunications for the transmission of images from and to remote
locations. The majority of imaging studies are standard diagnostic procedures performed in a
standardized manner and reported in a “production line” process and in the majority of cases, the
radiologist is not constrained by appointment time and does not have to be present when the
procedure is performed except for a small number of diagnostic studies such as image-guided
biopsies and contrasted procedures. Patient clinical information and the reason for conducting the
investigation are present in request forms or, if an electronic patient record exists, can be directly
accessed. From the organizational viewpoint, many small clinical care facilities have no specialized
procedures done, most of the work is routine chest, abdomen, and bone studies, yet they require the
presence on an on-site radiologist solely to interpret and report on those rather standard procedures
and online radiology groups can provide patients and referring physicians with a 24x7 access to
state-of-the-art diagnostic interpretation regardless of location [21, 22, 23, 24, 25, 26].

9. Integrating Health Facilities and Services

The advent of client/server computing, more sophisticated digital image compression

technologies, improved computer network technologies, DICOM and HL-7 protocols, and integration
between radiology information systems (RIS), picture archiving and communications systems (PACS)

3
Independent of the product and vendor option, there are common features that must be present: a
user-friendly system interface, high flexibility, quality, and safety as well as integration between the RIS/PACS
and the HIS and other information systems. Web technology promises users cost effectiveness. A broad range of
functionalities must exist: streamlined registration, scheduling, patient tracking, film and electronic image
management, transcription, historical index, multiresource scheduling, department monitoring, supply control,
word processing, digital dictation (and voice to text) and a wide array of user-defined management reports.
Patient tracking must support adding, canceling, modifying, or providing reasons for repeating a procedure. At
the same time, it must allow for the capture of service activity, resource utilization, supplies used, reactions,
technical factors, and quality assurance information. To ensure that images and patient data are tied together the
system must automatically update the RIS for tracking functions, eliminating technologist intervention. The
system must strive to achieve as much as possible a paperless workflow through worklists and messaging
allowing technologists to provide efficient, quality patient care and permitting technologists, radiologists and
clinicians to effectively communicate the progress of a patient's exam without disturbing their workflow. Film
management functions provide comprehensive borrower information and track film movement among
departments (and location of digital images, if on other storage medium), hospitals, and outside facilities tracking
and displaying a patient's folder, subfolders, and procedure. The system must provide for audit trails, purge lists,
overdue and return file notices, file reservations, and the automatic printing of bar coded jacket labels and pull
lists. Image viewing and routing will route critical images from film management to anywhere in the enterprise.
Management reporting management eases reporting efforts by enabling administrators to efficiently receive
comprehensive reports that help them make critical decisions. Web-based radiology results can make critical
healthcare information available anytime, anywhere.
 9 July 2003
and clinical and administrative systems (ex.: HIS) have all combined to bring the realization of
enterprise-wide radiology information management within reach.

Health care information, especially high-volume image data used for diagnostic purposes --
e.g., X-ray CT, MRI, and digital angiography -- is increasingly collected at tertiary (centralized)
facilities, and may now be routinely stored and used at locations other than the point of collection.
Diagnostic and image data being generated at different facilities while the images, or other large data
objects they produce, need to be used from a variety of other locations such as doctor's offices or
local hospitals. The use of a highly distributed computing and storage architecture to provide all
aspects of collecting, storing, analyzing, and accessing such large data-objects through network
interfaces between the object sources, the data management system, and the user of the data is of
great practical interest. The importance of distributed storage is that it is technically feasible to
maintain a large-scale digital storage system, and an affordable, easily accessible, high-bandwidth
network can provide location independence for such storage.

The importance of remote end-user access is that the health care professionals at any care
facility, frequently remote from the tertiary imaging facility, will have ready access to not only the
image analyst's reports, but the original image data itself. As the data is being stored, a cataloguing
system automatically creates and stores condensed versions of the data, textual metadata and
pointers to the original data. The user is able the view the low-resolution data with a standard Internet
connection and Web browser. If high-resolution is required, a high-speed connection and special
application programs can be used to view the high-resolution original data [27].

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