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.
Voice
RIS
Broker
PACS
Internal Transactions
PACS companies which have
acquired RIS company products.
Still basic brokering, but added
internal HL7/DICOM transactions.
Voice
RIS
PACS
Internal Transactions
De-novo combined RIS-PACS
products.
Some internal interfacing plus
Internal HL7/DICOM transactions.
Voice
RIS
Internal
Transactions
PACS
Different vendors with all the HL7/
DICOM transactions in RIS within
a ‘PACS integration module’
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
Profiles will 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 nonradiological 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)
and IHE 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:
http://nww.connectingforhealth.nhs.uk/nacs/
Data set change notices are published at:
http://nww.connectingforhealth.nhs.uk/dscn
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 UK for
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 Drainage
2. NM Infection Imaging
NINFI
NM Infection Scan
3. CT Thorax/Abdomen/Pelvis
CCHAP
CT Chest/Abdo/Pelvis
Within 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
IBILMS
IBILPS
IBILXD
IBIIXD
EIRDN
EIRDMS
EIRDPS
Biliary Bile Duct Dilatation
Biliary Bile Duct Stent Metal
Biliary Bile Duct Stent Plastic
Biliary External Drainage
Biliary Internal/External Drainage
E.R.C.P. Biliary Dilatation
E.R.C.P. Biliary Stent Metal
E.R.C.P. Biliary Stent Plastic
2.
NGALW1
NGALW2
NGALW3
NLEUK1
NLEUK2
NLEUK3
NWCCE1
NWCCE2
NWCCE
NWIND1
NWIND2
NWIND3
NM Gallium Scan (Part 1)
NM Gallium Scan (Part 2)
NM Gallium Scan (Part 3)
NM White Cell Fab Leukoscan Part 1
NM White Cell Fab Leukoscan Part 2
NM White Cell Fab Leukoscan Part 3
NM White Cell HMPAO (Ceretec, Part 1)
NM White Cell HMPAO (Ceretec, Part 2)
NM White Cell HMPAO (Ceretec,WB)
NM White Cell In 111 Scan Part 1
NM White Cell In 111 Scan Part 2
NM White Cell In 111 Scan Part 3
Plus all their SPECT equivalents
3.
CABDO
CABDC
CCHES
CCHEC
CPELV
CPELC
CT Abdomen
CT Abdomen With Contrast
CT Chest
CT Chest With Contrast
CT Pelvis
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.
Radiological Short Codes
1 2 3 4 5 6
Modality
X – X-ray
F – Fluoro
I – Interventional/
Fluoro
C – CT
M – MRI
U – U’sound
N – Radionuclide
Imaging
P – PET
E- Endoscopy
Z- Image
analysis or
review
Three or four letter body part
/ function code
4th letter reserved
for R, L, B or W
if procedure R or L lateralisable,
Both or Whole body,
otherwise can be used for any
letter or number
Postqualifier
(Extra or subdescriptor)
The 6th Character can be one of:
A
Ablation
B
Biopsy (Core or FNA)
D
Drainage of fluid
E
Embolisation
I
Insertion of device
inJection - as an objective of the procedure, not as part of the
preliminary to this objective
J
L
M
N
Lithotripsy
Mobile - for any modality, but particularly for 'portable' plain films
and use of mobile image intensifiers
P
aspiratioN
tOmography in its wider sense. O may be added to any plain film
examination to define planar tomography - or postcoordinated
Plasty - as in angioPlasty or dacrocystoPlasty - ie balloon
dilatation
Q
obliQue
R
for Radiotherapy planning
S
Stent
T
X
Use of intraThecal contrast
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
O
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
www.pacsgroup.org.uk . 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 funding for activities such as review/discussion/consultation as well as formal reinterpretation of images from external sources.
So called ‘Z' codes to do all this are in the RCR/CfH subset (or perhaps we should say
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 is not 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 a specific
body part or radiological examination. This is a deficiency of 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 count this activity, but it is going
to 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. when they construct PACS worklists prior to MDM review.
The 'Z' RIS codes as defined 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
Z4DST
ZWORK
ZSUPN
ZRREV
ZRMDT
ZRADD
ZDIGF
ZABAN
3 D study
4 D study
Additional use of workstation
Image superimposition study
Review of report
Review Images at/for MDT (PER STUDY OF COURSE!)
Addition to report
Digitised Film
Abandoned procedure
The coding structure allows for the addition of non-radiological imaging by the use of new prefixes. 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.
Once developed, the Radiology HRGs will be delivered to the Department of Health for them
to determine the tariffs to implement PbR. The Radiology HRGs are expected to come into
use in 2008. For more information on HRGs contact enquiries@ic.nhs.uk
Relating IHE To The IHE-UK Diagnostic Imaging Scenario
The IHE-UK Diagnostic Imaging Scenarios document seeks to provide guidance on how to
think through the physical events that take place when an imaging procedure or set of
imaging procedures is performed. This is necessary in order to be sure that information is
delivered in the correct order. For instance if a CT scan cannot be performed until the patient
appears on a worklist, and wards refer patients directly to the scanner, it will be necessary
that someone (the Operator e.g. CT Radiographers) book-in these patients at the scanner. If
current practice is to book-in (i.e. confirm on the RIS that the patient has arrived in the
department) retrospectively then this work practice may have to change.
An imaging service request may be for a set of one or more imaging procedures e.g. a lung
ventilation imaging procedure and a lung perfusion imaging procedure.
With respect to data the integrated activities can be organised within IHE Profiles by utilising
Health Level 7 Clinical Context Management Specification (CCOW).Some detail of this can
be found in the RIS-IHE Appendix
The following links are to a paper and a set of slides that present an overview of the CCOW
standard, how it works, and the impact that it is having on the healthcare industry.
CCOW Overview Document :
https://www.hl7.org/library/../library/committees/sigvi/ccow_overview_2001.doc
CCOW Overview Slides :
https://www.hl7.org/library/../library/committees/sigvi/hl7_ccow_2001.ppt
The RCR recommends the maximal use of IHE profiles and the related HL7 CCOW by
all modalities and IT systems within radiology and linked to radiology to ensure full
and efficient communications across the spectrum of radiology activity, from
conception of the imaging or interventional radiology request to delivery of reported
images.
Acknowledgement : Much of the above information and data in the RIS-IHE Appendix is
modified from and added to for the UK from :
IHE Radiology User’s Handbook 2005 Edition
http://www.ihe.net/Resources/upload/ihe_radiology_users_handbook_2005edition.pdf
HL7 Organisation
http://www.hl7.org and http://www.hl7.org.uk
Diagnostic Imaging Implementation Guide
for IHE in the UK 2nd June 2005 ( BIR IHE-UK Technical Committee)
http://www.ihe-uk.org/IHE-UK__05-06_Guide_June_2005.pdf
also see http://www.ihe-europe.org/
Integrating the Healthcare Enterprise (IHE) is a joint organisation of the RSNA and HIMSS. IHE aims to define how
existing standards may be used in order to facilitate communication between computer systems used in healthcare.
In Europe, IHE has been organized under the sponsorship of the European Association of Radiology (EAR) and the
medical imaging industry, through its trade association, COCIR.
HL7 was founded by a group of American hospitals and their suppliers in 1987. HL7 is an accredited standards
development organisation, regulated by ANSI (American National Standards Institute). It collaborates with other
healthcare standards groups such as ACR/NEMA DICOM (used for medical imaging), the European CEN/TC 251
and the International ISO 215 technical committees, with substantial cross-membership of these groups, as well as
with general IT standards bodies including W3C, OMG and OASIS. The mission of HL7 UK is to support the
development, promotion and implementation of HL7 standards in ways which meet the needs of healthcare
organisations, health professionals and healthcare software suppliers in the United Kingdom.