RADIOLOGY INFORMATION SYSTEMS (RIS)
The accepted definition of a RIS is - Part of an Health Information System that deals with the specific problems of the radiology department or an autonomous system for independent radiology units.
A modern Radiology Information System (RIS) is a pre-requisite for the efficient management of a department of Radiology. The primary function of the RIS will be to process requests, schedule exams and generate reports, as well as capture information on procedures performed and interpreted in the radiology department.
The RIS should send copies of diagnostic reports to a Care Record System (CRS).
Hospitals will have an existing source of patient demographics in a PAS (Patient Administration Systems) or HIS (Hospital Information System) and some will have systems for request management. Many UK hospitals are installing new CRS , which will include ‘request/entry’ and ‘results reporting’ modules, replacing or enhancing existing PAS/HIS, many as a result of national initiatives. All are expected to have such by 2008.
Similarly in the UK the vast majority of departments should have PACS, which archives images of all studies produced by the modalities, by 2007. Concurrently existing RIS systems wilI need upgrading or replacing to maximise the benefits of PACS. The costs of an upgrade to provide full desktop integration with PACS and voice recognition can be very significant and the most cost effective solution for many departments will be to replace the RIS. In England the NHS Cluster Local Service provider may have a preferred RIS to combine with its PACS.
RIS must fully communicate with PACS to allow two way desktop integration. Without this PACS just digitally mimics hard copy film handling and there are few efficiency gains. In up to date parlance PACS must be RIS centric, not the other way round.
RIS may be a dedicated ‘stand alone’ system, be fully embedded within PACS, or be a module of a wider electronic patient record. There is much to be said for the last approach as will be seen below.
RIS-PACS integration can be provided in one of the ways described pictorially below.
Whatever the underlying design the systems – the full Care Record System (CRS), RIS and PACS as well as the imaging modality equipment should have seamless communications for demographics, request-entry and results-reporting, utilising the standard non-proprietary protocols Health Level 7 - HL7 (for data) and DICOM (for images) and also conform to IHE (Integrating the Healthcare Enterprise) profiles.
In every hospital there will inevitably be a number of existing DICOM-capable modalities and some new modalities will be added after the RIS-PACS upgrade is complete. All of these also need to be fully integrated to optimise the functions of RIS-PACS.
Clear identification of operational objectives goals is an important first step in defining the requirements for any new RIS system acquisition or upgrade. Use of the IHE Integration Profileswill help you to meet a specific set of organizational goals.
Below is a list of objectives to meet when acquiring a new RIS or upgrading a RIS and the contributions each relevant IHE Integration Profile will make in supporting these goals.
It should be noted that the medium/long term plans for PACS include its use for non-radiological images e.g. from dermatology, ophthalmology, histopathology. This may have implications for RIS in the future with its possible extension of use outside of radiology.
Details of the IHE Profiles are listed in the RIS-IHE Appendix for those who wish to go into this more deeply.
RIS GOALS
Reduce Errors and Enhance Patient Care
Improve Throughput
Improve resource use recording
All require:IHE Scheduled Worklfow (SWF) and IHE Patient Information Reconciliation (PIR) andIHE Presentation of Grouped Procedures (PGP)
Reduce Operational Costs
Requires: IHE Scheduled Workflow (SWF), Patient Information Reconcilation (PIR), Charge Posting and Presentation of Grouped Procedures (PGP)
Reduce Deployment Cost and Time
Requires all IHE Profiles
It is not always possible to address all operational goals by making a single system purchase.
Achieving the full benefit of an IHE Integration Profile requires that the systems(called Actors in IHE speak) interacting with the RIS also play their roles as defined in the Profile.
Frequently, partial benefits can be achieved by implementing an Integration Profile on a single Actor, such as the RIS, in an environment where the interacting systems have some but not all of the functionality described in the Profile.
ACHIEVING THE GOALS
Selecting IHE Integration Profiles and Actors
Specifying integration requirements for the system you are receiving/purchasing is a straightforward matter of selecting which IHE Integration Profiles and which IHE Actors you want supported.
Note that some Profiles include options that provide additional functionality you may also wish to select, but the SWF and the PIR Profiles form the cornerstone of integrating a RIS with other systems in the institution.
Additional IHE profiles are called
Charge Posting
Presentation of Grouped Procedures
Assisted Protocol Setting Option
Exception Management Option
DSS/Order Filler Actor(which is the key role played by a RIS)
Report Repository
Report Creator
Report Reader
Integration Requirements of your RIS or in your RFP for a RIS
If receiving new systems from national programmes it will be important that your team understands which IHE Integration Profiles (and options) you will be receiving. You may wish to see if it is possible to obtain additional IHE Integration Profiles (and options) as an additional purchase.
If making an institutional purchase specifying IHE support in your Recommendation for Purchase (RFP) is as simple as stating which IHE Integration Profiles (and options) you want the system to support and which IHE Actor roles the system should play in each Profile.
CODES AND THE GOALS
The RIS provides status updates to other components within the enterprise, including the PACS, during the acquisition phase of the procedure.
This includes importation of images from external sources, use of CAD, use of a 3-D workstation, review of images and reports from third parties.
RCR advice is that additional image producing operations should be recorded in RIS. The coding systems referred to below support such actions, as well as supporting RIS codes for review of images from third parties and in the Multi-disciplinary meeting scenario. These have been called ‘Z’ codes.
There is a significant amount of time that goes into creating and keeping various codes in synchronisation between different systems. You will need to establish codes for many parts of your system—from as simple as a set of gender codes to a much larger set of data, like site and provider codes. These codes are typically kept in synchronisation manually, and if they are out of synchronisation, the receiver may not accept data, as it may not be aware of a coded value.
The NHS in England has standard sets of codes for providers, clinicians etc. These are being expanded in scope and these existing and future codes should be used, rather than individual hospitals creating and using their own unique coding system, which will be unintelligible outside of the institution.If sharing servers with other institutions this code management may be handled centrally via the LSP.
These codes are published by Connecting for Health and are in evolution. Coherent and unique Site / location codes and staff codes will be particularly important with fully electronic systems and integrated CRS/RIS/PACS.
See the National Administrative Codes Service NHSnet site at:
Data set change notices are published at:
Please note these are nww sites, not www. These nww sites are not accessible over www only from within NHSnet connected institutions.
The RCR has worked with CfH and other UK bodies to create a UK wide list of radiology imaging, interventional radiology procedures and nuclear medicine procedures. Each has a preferred clinical descriptor and a five or six character code, which uses the format described in the diagram below.
It should be noted that these descriptors and codes will be promoted across the UKfor use both within RIS and also by the request/entry systems of CRS.
For this reason the REQUEST/ENTRY codes may be more ‘open’ ended or allow the use of multiples, whereas the codes for use WITHIN RIS are single codes which allow for the precise recording of events within imaging departments - particularly when there are significant differences in work load and/or costings between procedures, which may not be apparent to the lay reader.
Particular examples of‘open’ ended or ‘multiples’ for request/entry are descriptors such as:
1. Biliary Drainage
IBILDD / Biliary Drainage2. NM Infection Imaging
NINFI / NM Infection Scan3. CT Thorax/Abdomen/Pelvis
CCHAP / CT Chest/Abdo/PelvisWithin a modern post-coordinating RIS these ‘requestables’ should not exist. Using the above‘requestable’ examples the full list of unique RIS descriptors allows for a number of RIS procedures to be logged against each of these.
1.
IBILDP / Biliary Bile Duct DilatationIBILMS / Biliary Bile Duct Stent Metal
IBILPS / Biliary Bile Duct Stent Plastic
IBILXD / Biliary External Drainage
IBIIXD / Biliary Internal/External Drainage
EIRDN / E.R.C.P. Biliary Dilatation
EIRDMS / E.R.C.P. Biliary Stent Metal
EIRDPS / E.R.C.P. Biliary Stent Plastic
2.
NGALW1 / NM Gallium Scan (Part 1)NGALW2 / NM Gallium Scan (Part 2)
NGALW3 / NM Gallium Scan (Part 3)
NLEUK1 / NM White Cell Fab Leukoscan Part 1
NLEUK2 / NM White Cell Fab Leukoscan Part 2
NLEUK3 / NM White Cell Fab Leukoscan Part 3
NWCCE1 / NM White Cell HMPAO (Ceretec, Part 1)
NWCCE2 / NM White Cell HMPAO (Ceretec, Part 2)
NWCCE / NM White Cell HMPAO (Ceretec,WB)
NWIND1 / NM White Cell In 111 Scan Part 1
NWIND2 / NM White Cell In 111 Scan Part 2
NWIND3 / NM White Cell In 111 Scan Part 3
Plus all their SPECT equivalents
3.
CABDO / CT AbdomenCABDC / CT Abdomen With Contrast
CCHES / CT Chest
CCHEC / CT Chest With Contrast
CPELV / CT Pelvis
CPELC / CT Pelvis With Contrast
Other examples include image guided biopsies, which although requested as such should be broken down to their component elements e.g. CT guided biopsy PLUS CT Liver.
Within RIS each element should be coded separately, if necessary retrospectively at the end of procedures, to ensure precise recording of activity and costs.
One problem with this scenario is that many old or ‘legacy’ RIS systems are not capable of post-coordinating such events together to allow the multi-exams to be reported as one composite study from PACS, therefore a number of ‘compromise’ codes exist which are multiples.
In an attempt to differentiate these codes in the lists they are annotated P, R or X
Only procedures labelled P and R should be loaded to modern POST-COORDINATING RIS systems, and those coded X should not be loaded to these systems
Legacy and other RIS systems which do not POST-COORDINATE should use the full lists labelled P, R and X (i.e. ALL procedures listed)
REQUESTING CRS should only use procedures labelled R and X for procedure requesting, as procedures labelled P are specifically for INTRA-RIS use only, to provide internal radiology management data, although these will be exported to CRS when the study is finalised as part of the study and costing detail.
The 6th Character can be one of:
A / AblationB / Biopsy (Core or FNA)
D / Drainage of fluid
E / Embolisation
I / Insertion of device
J / inJection - as an objective of the procedure, not as part of the preliminary to this objective
L / Lithotripsy
M / Mobile - for any modality, but particularly for 'portable' plain films and use of mobile image intensifiers
N / aspiratioN
O / tOmography in its wider sense. O may be added to any plain film examination to define planar tomography - or postcoordinated
P / Plasty - as in angioPlasty or dacrocystoPlasty - ie balloon dilatation
Q / obliQue
R / for Radiotherapy planning
S / Stent
T / Use of intraThecal contrast
X / eXtraction - eg in retrieval of intravascular foreign bodies or removal of temporary IVC filter
Y / phYsics or radionuclide therapY
1 / First part of study
2 / Second part of study
3 / Third part of study
4-0 / 4th to tenth parts
The system does not generally allow for separate paediatric coding or projections etc. as it assumed this information can be obtained from sub-fields at a local level.
The important information is that a single cost-able procedure has been performed, not the sub-detail of how it has been performed.
These are mapped to the new system of SNOMED CT DI codes which will be used to record activity and will be mapped to OPCS codes which will be important for resource allocations (HRGs) and ‘payment by results’.
The list has now been finalised as per the RIS Codes Appendix to this section and can also be found on the PACS and Teleradiology Special Interest Group website . These and the SNOMED CT DI codes remain in evolution and will become more accurate and precise with time.Updates of SNOMED CT DI codes and descriptors and OPCS codes are likely to be added in new versions.
Changes/additions to these can be requested from the SNOMED CT National Diagnostic Imaging Procedures Subset Management Group which has representation from the RCR and BNMS as well as the National and English Cluster RIS-PACS communities.
Radiologists should request changes/additions via the RCR IT Committee or National or English Cluster RIS-PACS providers, who shall in turn pass these on to the above group.
The codes and descriptors are detailed in In the interests of professional consistency all UK radiology and nuclear medicine departments are advised to co-operate with the use of this coding system or to map their existing coding systems to these.
Of particular note is that radiologists and nuclear medicine specialists need coding to get the justifiable fundingfor activities such as review/discussion/consultation as well as formalre-interpretation of images from external sources.
So called ‘Z' codes to do all this are in the RCR/CfH subset (or perhaps we shouldsay superset)of SNOMED CT DI which is expected to be loaded to all CfH RIS,following agreement at the CfH Diagnostic Coding Sub-Group that SNOMED CT DI isnot yet mature enough/RIS supported enough to be the prime coding system for use within RIS.
However 'Z' codes cannot yet be SNOMED CT DI coded as they do not refer to aspecific body part or radiological examination. This is a deficiencyof SNOMED which has yet to be addressed, but it is possible that such activities will be OPCS resource coded.
For the first time imaging departments will have the means to countthis activity, but it is goingto be very dependent on clerical staff making new RIS entries whenever an image is imported and radiologists retrospectively booking reviewed studies as'procedures' or getting their secretaries/PAs to do this e.g. whenthey construct PACS worklists prior to MDM review.
The 'Z' RIS codes asdefined at present cover:
Reviews of external images , imports of such images ( whether they be from a source under contract to the Trust or non-contracted images from Third parties) and for additional work such as
Z3DST 3 D studyZ4DST 4 D study
ZWORK Additional use of workstation
ZSUPN Image superimposition study
ZRREV Review of report
ZRMDT Review Images at/for MDT (PER STUDY OF COURSE!)
ZRADD Addition to report
ZDIGF Digitised Film
ZABAN Abandoned procedure
The coding structure allows for the addition of non-radiological imaging by the use of new pre-fixes. Already it includes some procedures where the prime modality is endoscopy(E) and a few non-nuclear medicine physics procedures (Y). It is foreseen that further pre-fixes such as H for Histopathology and O for ophthalmology will be devised in the medium term.
A set of HRGs for Radiology were developed and published in 2002 but these were never mandated for use within the NHS. The grouping proposals included plain film, fluoroscopy, ultrasound, CT and MRI in specialty consultation with the Faculty of Clinical Radiology.
Although not mandated for use in the NHS these HRG sets have been used in the private sector since 2002 with great success and with positive feedback for their design.
This body of work is now being revised to create an expanded set of HRGs that will include the increasingly significant area of nuclear medicine, including PET scanning. This will use as a source the RIS coding data and its SNOMED CT DI mapping as described above.
The project is being conducted in consultation with the NHS who also provide costing and activity data, and includes input from representatives of the British Nuclear Medicine Society. The project is also guided by a Clinical Lead, nominated by the Royal College of Radiologists. This ensures the delivered product will meet the needs of these health professionals.