System interoperability and functionality were the hallmarks of the Year 2 demonstration of the Integrating the Healthcare Enterprise (IHE) initiative presented at RSNA 2000 and the Healthcare Information Management Systems Society (HIMSS) Annual Conference this year. Building on the Year 1 demonstration, the recent program brought together 32 vendors integrating 66 systems, including hospital information systems (HIS) and radiology information systems (RIS), in a variety of workflow scenarios.

"We demonstrated the functionality," says Paul Vegoda, FHIMSS, IHE liaison to the HIMSS Board of Directors and vice president for business development at MetaLogics, Inc. (Fairfield, NJ). "We had the vendors interconnected and people were actually able to see how the information could flow from one vendor to the next." Each scenario began with patient presentation and continued through to study results reporting (figure 1). "We had admission/registration information, went through placing the order, then went through departmental schedules, image study, and all the steps that are necessary to report on the study. It really showed the whole flow of information," he says.

"I think that the Year 2 demonstration showed that the true function of the IHE process is to act as a point of contact between the healthcare professions," notes Chris Carr, Director of Informatics with RSNA. "It's a useful feedback mechanism; a way for users to communicate their needs to systems developers. It is a point of conversation about what are the most useful paths for implementing standards and the best way to coordinate the implementation of standards for the benefit of end users, and, we hope, ultimately, the benefit of their patients as well."

Genesis and Goals of IHE

"Part of the problem we have when dealing with information systems is that everybody says 'Yes, we are following the standards,' but they can use their own architecture and they can implement the standards differently," says Vegoda. "Therefore, when you go to pull two vendors in that are both compliant with standards, such as DICOM or HL-7, it's a major problem of interfacing."

Spearheaded by HIMSS and RSNA, the IHE was established to address these integration concerns and was designed to promote improved linkage so that information can be shared in a timely and efficient way.

Carr explains that the basic mission of IHE is to set in place a process to make system integration a regular part of professional practice, to create a feedback mechanism between professions and industry, and to share information about how to make systems integrate properly.

"The whole IHE concept is to take existing standards­­because IHE does not develop standards­­and work with the vendors to implement them in a like way," says Vegoda. "We have a planning committee and a technical committee. The planning committee works with defining what kinds of functions and requirements the technical committee should be addressing. The technical committee develops the technical framework. This is then used by the vendors so that they all implement the standards in the same way," he explains.

"Linking different systems is a major problem," notes Vegoda. "Even within the radiology arena itself, taking a modality and a Picture Archiving and Communications System (PACS) and getting them to talk to each other has been a major consideration. We talk about 'plug and play' and interoperability. Well, IHE would provide that interoperability by letting us take two systems that actually have developed their architecture and implemented the standards the same way and let us plug them into each other and they'll be able to share information and talk to each other. It will be a tremendous cost saver and a tremendous time saver once more and more systems are IHE compliant."

Sanjay Jain, Co-Chair, IHE Planning Committee and Director of Engineering, Cerner Corporation, (Kansas City, MO), agrees. "I think that is really the goal. We want to see that the patient care process is improved by the timeliness and accuracy of information being available," he says. "The end-user community should, after implementing IHE-framework based systems, see improvement in operation costs and a reduction in cost of actual implementation because the systems will work in a particular way."

"For the patient," he continues, "information that may be across states or cities or time zones, if it's connected--and we are all connected on the Internet today--will be available to the provider, and that means better care and more accurate diagnosis. So what we will see as we move forward into other specialties and vertical markets of the healthcare enterprise will be improved satisfaction for the user communities, the providers, and the patients themselves."

Benefits of participation

"There is a sense that this model can work; that you can bring people together; that these public demonstrations have PR value; they communicate to the user community that the vendor community is taking certain actions," says Carr. "They also have practical value, in that they give the vendors the opportunity to come together and test their implementations on a neutral turf."

System vendors agree. Fred Prior, Director of Research and Development of Kodak's PARIS Segment (Rochester, NY) cites two main reasons for Kodak's participation. "First," he notes, "it's good for the industry. It is trying to evolve to a state where we have better interoperability and we're improving the awareness of the whole user community about key issues of information system interaction that are important."

Secondly, he continues, "It's a way to show how our products fit within that framework and to learn a bit more from the other players about some of the interaction issues by working them out in a laboratory-like environment." He describes the IHE demonstrations as an opportunity for competitors to work together in a controlled environment to evolve the state of the industry.

Cor Loef, Program Manager for Interoperability, Phillips Medical Systems (Best, The Netherlands) sees danger in not participating. "If you don't participate in programs like IHE, then what you normally have is some problems connecting the systems together in the hospital. If you only have standards like DICOM, it might be that one vendor takes one section and another vendor takes another section [of the same standards] and they still don't work together," he continues. "By the means of IHE and defining particular connections out of standards, you can focus your development efforts much better so that you know that what you are putting in [your products] has a much higher chance of getting together with another system."

For the vendors, says Jain, "A very important aspect is to be able to get information from various systems that are used in the healthcare enterprise: hospital, admitting center, integrated networks, and others. RIS and PACS have been two independent units in the past. With HL-7 and DICOM standards available, there were still different interpretations and all installations have their little variations." Currently, he notes, integration at installation can take anywhere from 4 to 8 weeks. With broad-based implementation of IHE standard, he hopes to see that time drop to 2 to 3 weeks.

"When we look at IHE, what it's trying to do is exactly what our goal is; to bring the enterprise one integrated fashion," says Jain. "It's directly in line with what we want to achieve. We believe we can get there through IHE participation. Because we participate, we know what's going on in the industry; we know what the problems are. As participants, we are able to tell our prospective clients that we are able to connect and work with so many different PACS vendors. It gives our customers more confidence in what we are producing."

From a business perspective, Gary Larson, General Manager, Kodak Health Imaging PARIS Segment, notes that the IHE process has helped them focus their internal efforts in some key areas and prioritize their forward direction. He notes, however, that this process "is not the end-all of defining 100% how we are going to provide an integrated workflow for our customers. We are using it as a key element, but not the only one."

"We believe what is being done at IHE is the right thing to do," says Jain. "They have given a common vocabulary, they have provided a framework and if we operate within that framework, we will be more successful.

"It's good for the industry," summarized Larson. "It's good for our customers because it offers the opportunity to get the competitors from the IT and medical imaging sides working together. And if it's good for the customers, then, obviously, from a long-range perspective, it will help the business grow."

Client awareness

Everyone agrees that, as this process continues, clients and end users are also becoming savvier regarding the concerns of system integration.

"Compared with last year, the awareness is much higher," says Jain, "especially for those customers who integrate RIS and PACS. They are asking 'Are you doing IHE?' That is very positive for them. It makes them more comfortable that we are there at IHE, that means that we are looking for interoperability."

Vegoda agrees, noting that HIMSS as been working closely with chief information officers (CIOs) at several healthcare organizations. "Once they're convinced--and they're the ones that write the requests for proposals (RFPs) and do the analysis of the RFPs--they can then put pressure on their vendors to cooperate," he says. He warns "if the radiologists and the CIOs are writing up RFPs requesting that functionality be compliant with the IHE technical framework, then anybody who isn't compliant is not going to be able to compete for the business."

Increasing participation by IT vendors

Although there was increased participation this year by information technology (IT) vendors, the IHE initiative has not been embraced by the IT community with the same level of enthusiasm as by the radiology community.

"The participation of the information systems vendors is still somewhat limited," notes Prior. "Perhaps, we [the IHE] are still not reaching that state where we are playing correctly in the broader IT environment in healthcare. Maybe that is because we were focused too much on imaging, or maybe we were focused too much on DICOM. I don't know why we are not getting as much participation from the healthcare IT vendors. It was much better this year, but it's still not there."

Carr agrees, noting that in the Year 2 demonstration, there was much greater participation on the part of IT vendors. "More vendors are at the table now and we hope that their numbers will continue to grow," he says. "As they are more present in the committees that determine the scope of the presentations, their concerns become a more prominent part of the demonstrations, and they get to do more 'fun stuff' at the demonstrations. As we move from implementation of the core DICOM imaging and workflow standards to implementation of the standards for such aspects as reporting, it becomes more of an information systems problem."

Carr explains that initially, IHE focused mainly on workflow and integration within radiology. With the Year 2 demonstration, however, IHE is beginning to make the connections with other hospital systems. "We hope to encourage other disciplines to advance down that same path, to move forward with vertical integration in their areas. We want to start coordinating that activity between disciplines and then look at the horizontal infrastructure pieces and figure out how we can come together to agree upon, for example, what the outlines of a really workable master patient index really need to be. Then you can start to move toward talking about really making the electronic medical record a reality."

Confidentiality concerns

With increased interoperability comes increased concerns regarding patient confidentiality. To date, the IHE has not placed much emphasis on privacy concerns, but that is likely to change.

Carr notes that IHE hasn't needed to address confidentiality concerns until recently because its scope has been limited to workflow within the radiology department and only touched on the connection to registration systems. However, he says, privacy issues need to be addressed. "I think IHE can be at least one of the important forums in which that is addressed. From my perspective, it seems like yet another incentive for bringing groups together to work on coordinating implementation of standards," he says. "It's a new set of requirements and the more complex the requirements are, the greater the need for coordination."

"Most of the Health Insurance Portability and Accountability Act (HIPAA) requirements are not technology requirements," explains
Vegoda. Instead, most of the requirements necessitate business process reengineering with the way the healthcare givers and the payers work with the information. "It's not a technology issue as much as it is 'What do I do and how do I do it?'" he says. "What we are looking at in terms of IHE is some ideas in terms of seeing how we can restrict access to information, which is the security piece. Most of that is more on the networking and database side and less on the actual technology side."

"There are absolutely concerns in that area," agrees Jain, "especially with the HIPAA regulations coming into effect. What we are doing right now is enabling the systems to talk a common vocabulary, which does not necessarily mean how they encrypt or how they are secure. That is left to the application."

Jain predicts that IHE will attempt to develop the framework to incorporate security information and other requirements that HIPAA may impose. "We have to build that into the framework," he says, "but I think IHE is not going to attempt to tell the vendors 'Come up with one solution of how to implement it.' It will come up with a framework in which all that is feasible."

Prior notes, "This is an area where what I see happening is a very good thing; that the imaging companies are trying to not compete against one another, but to work together with our customers to come to a common understanding of what the right response should be. There are many answers for what can be done, but I think it's important for us to come to a common approach for computer security and for providing proper privacy for information."

The future of IHE

"Our goal is to expand into other clinical specialties," says Vegoda. "We plan to have, over a 5-year period, a number of different vertical areas such as radiology and pathology, etc., then link them in a horizontal way."

"For year 3," he notes, "there is going to be a minimum of additional functionality added on the radiology side, but we are going to be working with the vendors so that they can begin implementing the technical framework into their products. We already have some vendors whose products now have functions as defined by IHE and hope to have a lot more by the end of the third year."

Conclusions

"I think that there is tremendous potential for this type of initiative in healthcare information and I think that this is the way of the future," says Vegoda. "I think IHE is just the first of what I hope will be many initiatives that are going to take standards organizations and work closely with them and have the vendors work with them so that a standard truly becomes standard. I think that the message that needs to come out is that there be no system boundaries, that there be complete interoperability, and it's going to definitely reduce costs in healthcare and it's definitely going to improve the flow of information and improve the quality of healthcare."

"From a vendor's perspective," concludes Jain, "it's a good thing to be there in the forefront, to be able to look at the framework, to be able to implement the framework. Then we can tell our prospective customers, our clients, that we are building our systems with a standards-based approach and that we use standards in a consistent manner. It's extremely rewarding to me to be in the middle of 30-plus vendors and to be able to say that our systems worked as expected." AR