Electronic transfer of radiology reports to other hospitals and general practitioners RAD Magazine, 40, 467, 23-24 Dr Philip Scott Chair, HL7 UK; Senior lecturer, Centre for Healthcare Modelling and Informatics, University of Portsmouth email: philip.scott@port.ac.uk Introduction Compared to most clinical specialities, radiology has extensive, mature and sophisticated infor- mation technology support. Given this, it is per- haps surprising that transmission of radiology reports is not yet a routine electronic process. In fact, the only information flow in the UK from hospitals to general practitioners that is univer- sally and exclusively electronic is for laboratory results (specifically haematology, biochemistry and microbiology). This has been operational since 1999-2000 and is based on EDIFACT mes- saging. 1 Numerous NHS trusts have implemented local or regional electronic solutions for discharge summaries and outpatient letters, in some cases using the NHS Interoperability Toolkit (ITK) message specifications. 2 However, there does not yet exist a nationally available generic document sharing capability between NHS primary and sec- ondary care. This article is based on a presenta- tion given at UKRC 2013 and specifically addresses transfer of radiology reports to general practitioners, with some consideration of inter- hospital report communication. Healthcare interoperability – the bigger picture Interoperability is defined as “the ability of two or more sys- tems or components to exchange information and to use the information that has been exchanged”. 3 The absence of gen- eral interoperability in healthcare has been lamented, espe- cially in the US health system, as part of the failure to achieve necessary efficiency and safety improvements. 4 Efforts to develop and implement standards for interop- erability are almost as old as the first generation of health information technology (HIT). 5,6 Much progress has been made with intra-organisational interoperability. Most NHS hospitals have a common index for patient demographics, typically in the patient administration system (PAS), which is shared by departmental and central diagnostic systems such as PACS and the radiology information system (RIS). The protocols and capabilities are there for wider informa- tion sharing, but their usage and configuration has depended on local leadership, so diverse solutions have evolved to fit particular health ‘ecologies’. The implementation challenge is primarily human and organisational, not technological. As with any significant organisational change, substantial resources are needed to generate progress. 7 Unlike hospital clinicians, general practitioners were given financial incen- tives to move to electronic patient records (EPRs). 8 This is now institutionalised in that the whole payment system for GPs as independent contractors is driven by information supply, usually at aggregate population level, derived from their EPRs. An additional problem with implementing inter- operable solutions is that the costs and benefits often fall in different places – each node in the information network (GP, radiology, laboratory and so forth) will typically need some upgrade to participate in a new exchange standard, but which users actually get the benefits? Efficiency and financial savings often arise solely for consumers rather than providers in healthcare information communities. For example, for GP reporting the laboratory or radiology depart- ment still has to produce reports in the same way so there is only minimal, if any, cost reduction whereas the general practice will have both process efficiency improvements and potentially cash-releasing benefits from reduction in scanning workload. Therefore, incentives have to be devised at a regional level as shared community benefits and usually require some ‘market management’ from healthcare commissioners. Radiology reporting in the UK An informal survey of health IT vendors and NHS trusts identified five different configurations of electronic radio- logy report transmission in the UK. The following sections describe each category of solution and briefly evaluate their relative merits. 1. Hospital EPR viewer This ‘portal’ approach is simply a GP view of the hospital patient record, usually restricted to patients registered with the given practice. Typically this is only available when the trust has a hospital-wide EPR, although in some cases GPs are given portal access to PACS. This is arguably the least useful solution for the GP as it requires learning how to use a different EPR and having to navigate large amounts of irrelevant detail. Also, it still requires the practice to process the paper report into the GP EPR through a scanning and coding workflow. 2. Shared repository A shared repository, or ‘data warehouse’, aggregates multi- ple data sources into a virtual EPR. This often includes var- ious types of primary care data, hospital correspondence, diagnostic reports and administrative data such as sched- uled clinic appointments. This approach enables the GP and the hospital clinician to see a fairly complete picture of the entire patient journey through various clinics, wards and diagnostic services. This is particularly helpful when imple- mented as a regional shared record that incorporates data from several hospitals. The disadvantages are the same as the portal. 3. Direct messaging Direct messaging of reports into GP systems from the RIS is typically achieved by generating HL7 version 2 messages. HL7 is the dominant international standard for health infor- mation exchange. While the ability to generate HL7 v2 out- put is usually native to the RIS, the capability to receive and process these messages is not standard in UK GP sys- tems. Therefore ‘middleware’ of some kind is generally needed to translate the HL7 format into a structure that the GP system can understand, sometimes using the EDIFACT laboratory reporting mechanism described in the introduction. This approach has the major advantage of inte- gration with the GP system and hence with the practice