Learing Series: Fundamentals of System Architecture & Design
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To provide an overview and differences between the most common workflows being used in today’s imaging facilities. To demonstrate via diagrams different options of system implementations and integration with other systems.
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Learing Series: Fundamentals of System Architecture & Design
- 1. ©1994-2016 RamSoft Inc. All Rights Reserved. Systems Architecture/Design Communicating complex system using simple diagrams and minimizing misunderstandings
- 2. ©1994-2016 RamSoft Inc. All Rights Reserved. Systems Architecture/Design Communicating complex system using simple diagrams and minimizing misunderstandings OBJECTIVE: • To provide an overview and differences between the most common workflows being used in today’s imaging facilities. • To demonstrate via diagrams different options of system implementations and integration with other systems. Please hold questions to the end of this presentation
- 3. Standard Architectures/Workflows in place today • Independent Diagnostic Testing Facilities (IDTF) or Free-standing Imaging Center • Tele Radiology Services • Hospital Radiology Department • Mobile Imaging Services ©1994-2016 RamSoft Inc. All Rights Reserved. 4 most common type of practices in today’s Medical Imaging Industry
- 4. Standard Architectures/Workflows in place today ©1994-2016 RamSoft Inc. All Rights Reserved. Independent Diagnostic Testing Facilities (IDTF) or Free-standing Imaging Center Ramsoft’s RISPACS/PM/MU
- 5. Standard Architectures/Workflows in place today ©1994-2016 RamSoft Inc. All Rights Reserved. Tele Radiology Services Ramsoft’s PACS / Tele Plus / Lite PACS / Tele Lite
- 6. Standard Architectures/Workflows in place today ©1994-2016 RamSoft Inc. All Rights Reserved. Hospital Radiology Department Ramsoft’s PACS
- 7. Standard Architectures/Workflows in place today ©1994-2016 RamSoft Inc. All Rights Reserved. Mobile Imaging Services Ramsoft’s PACS / Tele Plus / Lite PACS / Tele Lite
- 8. Different Environments/options for Implementation • Hosted/Cloud-based vs. Onsite/In-house Environment • RISPACS with or without HL7 Interfaces • PACS with or without HL7 Interfaces • RISPACS with PowerCaches • PACS with Gateway Routers ©1994-2016 RamSoft Inc. All Rights Reserved. 4 Different Scenarios
- 9. Different Environments/options of Implementation ©1994-2016 RamSoft Inc. All Rights Reserved. Hosted/Cloud- Based
- 10. Different Environments/options of Implementation ©1994-2016 RamSoft Inc. All Rights Reserved. Onsite/In-House
- 11. Different Environments/options for Implementation ©1994-2016 RamSoft Inc. All Rights Reserved. RISPACS with HL7 Interfaces PowerServer RIS/PACS Radiologist Interpretation Final Report Distribution Report Creation Billing Post-Charge Billing Software
- 12. Different Environments/options for Implementation ©1994-2016 RamSoft Inc. All Rights Reserved. PACS with HL7 Interfaces Other Vendor’s RIS ADT/Demographics ORM/Orders ORU HL7 Message/Final Report Billing Software ADT/DFT HL7 Messages PowerServer PACS
- 13. Different Environments/options for Implementation ©1994-2016 RamSoft Inc. All Rights Reserved. RISPACS with PowerCaches Gateway Router w/PowerCache Gateway Router w/PowerCache Gateway Router w/PowerCache Facility A Facility B Facility C
- 14. Different Environments/options for Implementation ©1994-2016 RamSoft Inc. All Rights Reserved. PACS with Gateway Routers Gateway Router Gateway Router Gateway Router Facility A Facility B Facility C Tele Radiology Group
- 15. ©1994-2016 RamSoft Inc. All Rights Reserved. Thank You
Editor's Notes
- Hello everyone my name is Carlos Quintero and I am one of the implementation project managers here at Ramsoft. Today we're going to go over some of the systems architecture and design that we use in today's medical imaging industry.
- Today’s session objectives are: 1. To provide an overview and differences between the most common workflows being used in today’s imaging facilities. 2. To demonstrate via diagrams different options of system implementations and integration with other systems. Yes, there will be a lot of diagrams which I hope will help you better understand the different environments and scenarios used in today’s medical imaging industry as well as meeting today’s learning objective. So, let’s get started.
- We are going to start with a standard architectures and some of the workflows in place today. I put together diagrams with examples of the 4 most common type of practices available today. We have: your independent testing facilities or freestanding imaging centers which are mostly privately owned and operated by either doctors or entrepreneurs There are also teleradiology services groups which are a group of radiologists who offer their interpretation services to local hospitals or imaging facilities Then we have hospitals radiology department which offers all type of medical imaging and diagnostic services for inpatient or outpatient in a hospital And then you have your mobile imaging services which basically offers imaging procedures to patients that are not able to go to a facility or hospital. Mostly the handicapped patients.
- The first diagram we see here is a typical workflow of an independent testing facility or freestanding imaging center with a Ramsoft only RISPACS system. Starting from the left top corner we start with ordering and scheduling. Typically, scheduling personnel receive the orders via fax, phone or rapid results and calls the patient to make the appointment. Then appointments are confirmed via text message or phone call. Next the patient arrives at the facility the day of the study and it gets registered at the front desk. Paperwork is filled out, signed and scanned into the system. Once the patient is ready to be scanned, modality worklist is usually populates at this point so that the technologies can see the study in the modality. Then the procedure stars, images are acquired and then sent to Ramsoft. Completed images are checked by the technologist who performs the QC to make sure the study is ready to for interpretation. At this point, the study will show up on the Radiologist work list and they start the process of interpretation and creation of the diagnostic report. Sometimes, they use a transcriptionist to transcribe the reports in which case, the workflow can be adjusted accordingly. After the report is created, it is signed by the Radiologist and automatically distributed by the system, via fax, HL7 message or direct messaging. At this point, the images and final report can be accessed by Referring physicians via Rapid Results. Then, the study is ready for billing. Billing personnel will perform the coding and prepares the study to be transferred to PracticeSuite or their desired billing software for further processing and submission to the insurance company. And that completes the workflow cycle.
- In this diagram, we have the typical workflow of a Teleradiology practice using Ramsoft’s PACS only system. Starting from the left top corner, we have imaging facilities or hospitals performing the studies. Then, these VERIFIED studies are sent over via the internet to the Teleradiology’s group Ramsoft’s PACS. How are these studies sent over via the internet in a secured and HIPAA compliant way? We have to ensure that these connections are done encrypted via a VPN, TLS, or the easiest way which is with a gateway router. When many studies are received by Ramsoft’s PACS, we have the ability to normalize these studies. In other words, we can adjust the name of the facility, study status, Issuer of patient ID, etc. In addition, we can implement DICOM scripts to further normalize the data being received. Once the study arrives from an imaging facility, the study will show up on the Radiologist work list and they start the process of interpretation and creation of the diagnostic report. Sometimes, they use a transcriptionist to transcribe the reports in which case, the workflow can be adjusted accordingly. After the report is created, it is signed by the Radiologist and automatically distributed by the system, via fax, HL7 message or direct messaging. At this point, the images and final report can be accessed by Referring physicians via Rapid Results. Then, the study is ready for billing. Typically, the Tele radiology group will only bill for the “professional component”, meaning: the interpretation fees only. Then, the imaging facility will bill for the “technical” component. In other words, the fees for acquiring the images and performing the procedure.
- This next diagram, represents the typical workflow of a Hospital Radiology department. Basically, the Hospital uses their Hospital Information system HIS to schedule appointments, manage patient records, electronic forms, scanned documents, etc. It is sort of a RIS system but more comprehensive and accessed by many departments within the hospital. In most cases, the Ramsoft’s PACS is located onsite, inside the hospital or within their own private datacenter. With that being the case, modalities usually push the studies directly into the PowerServer and they arrive in the VERIFIED status after being QC’ed by the technologist. Or they can have the option to perform the QC from a Technologist workstation with PowerReader. Then, the workflow follows the same steps as previous examples, where Qc’ed studies will show up on the Radiologist work list and they start the process of interpretation and creation of the diagnostic report. At hospitals, reports distribution might be a little different and it might not be done via Ramsoft. Simply the final report could be sent back to the Hospital information system and then accessed by treating doctors, nurses, consulting physicians, etc. The same goes for billing. Hospitals have their own billing processing system that it is different from Independent diagnostic testing facilities or IDTFs.
- The last diagram shows a pretty similar setup as Teleradiology practices. However, the actual imaging procedure is performed at a mobile unit at the patient’s home or a strategic location. Some of the mobile units are used as backup for when a modality at an imaging facility is down or under maintenance. If the mobile unit is equipped with internet access, then studies are pushed from the mobile unit into the PowerServer somewhere in the cloud via VPN, Gateway router or TLS connection. If the unit does not have remote internet access, then images are stored locally until they get to a location where they can be replicated to the Ramsoft’s PACS. So, studies arrived at the Powerserver in the verified status and they get normalized, if needed. Then, the Radiologist interprets the study, report gets signed and distributed and the study is then billed accordingly.
- Now we are moving on to explaining the different environment and options available for implementation. For this presentation, I chose 4 different common scenarios of how our system gets implemented and integrated with others…..
- This next diagram is for a Cloud-based or hosted scenario. We have a Main imaging facility or headquarter to the left and a Second imaging facility or Satellite location at the top. Each facility have their own modalities. As you can see, there is a gateway router at each location. Both facilities are connected to the internet behind a firewall. In a hosted environment, the Ramsoft server is located on a remote datacenter. Most likely at Hostway or Radius. It is important that the imaging facilities have good enough internet connection with enough bandwidth to handle the traffic of studies. Under this scenario, all modalities will push studies to the local gateway routers located at each facility and the GR will replicate the studies to the hosted server at the data center. Because of the gateway routers, there is no need to have a VPN connection between the facilities and the datacenter. However, if they are using our RISPACS software, we would need to have VPN tunnels in order to allow traffic related to Modality worklist. Notice that the gateway routers could also have Powercache. If that’s the case, the workstations at both facilities wouldn’t have to retrieve studies from the datacenter via the internet. Instead, the studies are retrievable locally from the GRs with powercache which allows users to enjoy faster speed when opening and viewing DICOM images in their PowerReader application. Ok, let’s move on to
- Onsite or In-house server scenario. Same structure as before, one headquarter and one satellite location. However, we have eliminated the datacenter from this picture. Now, the PowerServer is located at the main imaging facility or headquarter and it is typically joined by a backup server which can also be located at the satellite location for strategic redundancy. The 2 locations are connected via a site-to-site connection and they are both considered to be on the same Local area network or LAN. IN this case, the use of the internet to access studies via PowerReader is only used for teleworkers or Referring Physicians accessing studies and reports via Rapid Results. Everything else is accessed locally directly from the onsite PowerServer. Modalities push studies directly into the powerserver, eliminating the need of gateway routers.
- Now we are going to introduce and scenario with integration with other systems via the exchange HL7 messages using Ramsoft’s PowerServer RISPACS. HL7 or health level seven is a standardized language of communication that allows the transferring of clinical data between different health information systems. In this scenario, we can see how our Ramsoft’s RISPACS exchanges data to PowerScribe 360 and a billing software. The first part of the workflow starts with your typical RISPACS where studies are ordered, scheduled, confirmed, completed and verified for interpretation. At that point, an ORM or orders HL7 message is triggered and sent to PS360. This communication could be local, meaning both system at the same location, or could be via the internet. HL7 messages can be sent directly to a local or external IP address and port or via SFTP to a remote designated folder. Once the order message arrives at PS360, the radiologist will see the study to be interpreted in their PS360 worklist. Upon clicking on it, PowerReader’s viewer is launched on the diagnostic monitor and the Radiologist starts interpreting the study while using PS360’s voice recognition and report creation method. After the report is finalized in PS360, another HL7 message, in this case, an ORU/Report type message is sent back from PS360 to the Ramsoft’s RISPACS. The report then gets attached to the corresponding accession or study and the report gets distributed by the facility’s desired method via PowerServer. The second part of the workflow, is billing. Let’s say the customer prefers a different billing software instead of Practicesuite. Via an HL7 billing interface, we can do that. A typical billing interface is an outbound only of ADT for patient’s demographics and DFT for insurance and charges types of messages. In some instances, billing software are able to display diagnostic reports in their system. If needed, an ORU /report type of message can also be sent with the report in PDF or text format.
- On this next environment we have two integrations via HL7 as well, but this time it is with Ramsoft’s PowerServer PACS only. Let’s pretend the customer have another 3rd party RIS system but they prefer Ramsoft’s PACS. How do we communicate with their RIS? via HL7 messages. So, the first part of the workflow on the top left starts with your typical RIS only workflow, where studies are ordered and the patient gets registered at the time of the exam on the 3rd party RIS. When the study is ordered and scheduled, the RIS system will send an ADT/Demographics type of message to Ramsoft’s PACS in order to have the demographics information for the patient being scheduled. After the patient is registered at the front desk and it is marked as Ready for Scan, a second HL7 ORM/order type message is sent to Ramsoft’s PACS containing the actual study information. At this point, the study shows up on the Technologist’s worklist as ready for scan. Then, the study gets completed, verified and the report created and signed in Ramsoft. Then, the report is sent back to the 3rd party RIS system via an HL7 ORU type of message. In some cases, this message also includes an URL link to access the study’s images via PowerReader or RapidResults depending on the desired configuration. Then, if the billing is started from Ramsoft’s PACS, the billing staff will code the study and Post charges which will trigger an ADT and DFT type of message to the desired billing software. This could be with PracticeSuite as well.
- In these next 2 diagrams I will show you the differences between Gateway routers with Powercache in a hosted environment and regular gateway routers used for a tele radiology practice. This first scenario, shows 3 imaging facilities which could be part of the same enterprise with one being the headquarter or main facility. All three facilities have reliable internet connection and they sit behind a firewall. The Ramsoft RISPACS server is located at the Datacenter. Again, it could be Hostway or Radius. As you can see, there is no need for the sites to be interconnected with each other via a site-to-site connection. They all connect to the PowerServer via the internet. However, in order to bring efficiency and high speed when opening dicom images, gateway routers with PowerCache are must for each location. PowerCaches essentially act as mini local servers that store DICOM images temporarily to allow fast retrieval by any of the local users of PowerReader. Mostly the Radiologist will be benefit from this type of architecture that allows big files of DICOM objects to be accessed locally instead of via the internet. So, if a Radiologist opens up a study, the workstation looks first at the local Powercache and tries to retrieve the study from there. That’s how it basically works.
- This last scenario shows the use of gateway routers to simply route and send studies via the internet in a rapid and secure way. Let’s imagine this type of setup for a teleradiology group. A teleradiology group needs to receive studies from many imaging facilities or hospitals in order to be interpreted and reported. With gateway routers at client’s locations we can easily eliminate the need to of unreliable VPN tunnels and route studies in a HIPAA complaint way. Moreover, all modalities at the local facilities can be configured to communicate via DICOM to a local device instead of a PACS server located remotely. In addition, if a VPN tunnel fails or the local internet connection goes down, the studies will continue to flow from the modalities to the gateway routers. Once the internet comes back, they will automatically replicate to the Ramsoft’s PACS server at the Teleradiology practice eliminating a very common headache of re-pushing failed studies from the local modalities. Gateway routers can also act as local normalizers of data. In other words, DICOM scripts, imaging facility names, Issuer of Pt IDs can all be applied or modified at the local gateway router level before they are routed to the PowerServer PACS. And this completes today’s learning session.
- I would like to thank you all for your time today and I hope you enjoyed the session. Please feel free to ask any questions at this point. Thank you