If you thought that buying a digital radiography machine was confusing – get ready to have your head spin. Even the people selling you integration are confused!

At a recent trade show,  we quizzed the practice management (PM) vendors and digital radiography vendors about their software if they advertised “integration with practice management” or “integration with digital radiography.”

The interesting thing we found was that 75% of the sales people didn’t know what they were selling. The vast majority overstated the functionality they offered and one vendor could not even explain why their form of “integration” was important to the veterinarian.

Veterinarians are asking PM and digital vendors for “integration.” I hear this every week in our prepurchase consultations. The PM and digital vendors, eager to offer “integration” are happy to oblige and slap the term integration on whatever they happen to be selling.  As you can see from the following examples, the term “integration” means so many different things, it is essentially meaningless.

• The ability to open digital radiographic images in a viewer within the practice management software 
• The ability to import jpegs from a thumb drive that were exported from a digital system

• The ability for a digital system to control an x-ray machine and import exposure factors into the DICOM header.
• The ability for a veterinarian to order studies from practice management and have the study order show up on the digital radiography machine
• Integration defined a piece of “middleware” software that was a go between practice management and digital radiography
• The ability for practice management to automatically bill for a study sent to a digital radiography system but not automatically adjust charges if something other than the original order was done in radiology.
• The ability to order a study from practice management, have the study appear on the digital radiography system and automatically bill no matter what was done in radiology.
  
  

As you can see, integration can mean just about anything. It is time to bring some order to this madness and define what “integration” means in veterinary medicine.  Only after we define what functionality is available can veterinarians determine if the additional cost is necessary for their practice. 

Last thing before we get started: Open Standards

When you email someone they are able to receive your email regardless of what type of computer they are using or what mail viewing client they use. This is possible because the internet was built on open standards.

Open standards allow you to choose your practice management vendor and digital radiography vendor independently. If the integration between your practice management vendor and digital radiography system utilize open standards, it is very easy, in theory, to swap out PM or digital vendors in the future.

Presently, there is very little support for open standards in veterinary practice management.  Proprietary methods of integration are the rule rather than the exception.

If you chose a proprietary form of integration you may have some headaches if you decide to leave your digital or PM vendor; or if your PM and digital vendor decide to change their software or get in a fight it might cause you some pain. 

Does this mean that proprietary forms of integration should be avoided altogether? At this point in time, I am not sure. If the functionality you receive from a propriety method of integration is important and you understand the potential downfalls of all proprietary bridges between digital radiography and PM, proprietary functionality may still make sense as there are currently few  other alternatives in veterinary medicine.  Veterinarians should pressure vendors to support open standards and improve the future of veterinary informatics.

Step 1: abandon the term integration

Step 1 in bringing order to this confusion is to abandon the term “integration” in any sales pitch or purchase. Vendors must not allow veterinarians to use ask for “integration” but, rather,  make them define what functionality they are looking for. Similarly, veterinarians should not allow vendors to use the word integration in any sales pitch. Rather, they should  force vendors to define the functionality they offer.

Furthermore, I propose that the functionality is defined as proprietary or nonproprietary.

Step 2: Defining terms

The following is a list of the functionality that PM vendors are offering under the title of “integration.” The bolded and underlined word are what I propose as a title to describe this functionality during a purchase or sale.

JPEG “walk the image across the hospital”  STUPIDITY: Some vendors claim integration with digital radiography and have veterinarians export JPEG images and upload them into the patient record. This manual approach to integration is a time sink and really does not offer the veterinarian anything that should be included under the banner of integration. Attaching digital radiographic images to the patient record is nothing more than attaching a photograph to the patient record.Exporting images as JPEG's loses important information that is contained in the original digital image.

• Pro: The main benefit of this level of functionality is to save a few mouse clicks when viewing patient images.
• Con:  Some of the viewers that the PM vendors offer are very basic and lack advanced functionality to efficiently view images, compare old studies etc.  Beware of proprietary methods that require importing images into PM. Ideally digital radiographic images should be stored in their own database.
• Do you need it? This is a functionality that I always question the value. Personally, I would not trade off using a proper digital radiography viewer for a basic viewer provided by the PM vendor. That said, many veterinarians seem to find this functionality important to their workflow.

• Pro: MWL saves steps for your technical staff as they will not need to enter patient information into radiography. Most importantly, your technical staff will not have the opportunity to make mistakes when entering information into the digital modality. Mistakes are all too common. Searching for old films can be difficult if mistakes were made in data entry at the time of radiography.
• Con: none other than expense
• Do you need this? This functionality is extremely important for high volume clinics. For smaller clinics doing only a few cases per day, the cost of implementing this service must be weighed against the benefit (fewer data entry errors)  of this service.  You will likely need to purchase this service from your PM and digital vendors as DICOM MWL is generally not provided in the base software package of CR or DR machines.

DICOM Modality worklist with forward billing: some vendors have enhanced their DICOM MWL functionality by allowing for automated FORWARD BILLING. With this functionality veterinarians are able to charge for studies at the time they are ordered. HOWEVER – THIS IS IMPORTANT – DON’T SKIP THIS SENTENCE -if the technician changes the order or the order is not completed or os altered  in radiology, the veterinarian must remember to go back to PM to adjust the invoice. For example, if a veterinarian orders  stifle radiographs but the technician obtains a thorax, abdomen, and stifle, the extra studies will not automatically be billed. In this situation, every study that is performed must be checked for completeness or there will be billing errors.

• Pro: this is a good first step in automating communication between radiology and practice management software.
• Con: veterinarians and technicians must not get complacent or forget that billing is not actually automated. If the orders are changed in radiology, these changes must be reconciled in PM.
• Do you need this: with this functionality, things are getting interesting, However, it cannot be overstated that this is not automated billing. Everyone in the hospital must fully understand that billing must be checked after studies are obtained in  radiology.  The cost of implementation vs. the benefit to the practice must be weighed to determine if this functionality is important to your practice.

DICOM Modality worklist with automated billing: This level of functionality takes the previous level one step further. Billing is entirely automated. Data entry errors in radiology are reduced with the MWL functionality and no matter what the technician does in radiology; the PM software automatically reconciles things with practice management or alerts users to the potential for a billing discrepency. 

To my knowledge, there are only 2 vendors that currently offer this level of integration***. Idexx Cornerstone provides this service as a proprietary bridge with their CR and DR units. Eklin VIA supports this service using open standards with any PACS database that supports DICOM Q/R and any digital modality supporting DICOM MWL.

• Pro: this functionality will increase efficiency in your practice and, for the most part, eliminate lost charges in radiology.  Revenue capture is a benefit of this level of functionality.
• Cons: other than the expense of implementation, cons are few and far between.
• Do you need this?   this type of functionality will help just about every veterinary practice.  It is almost a no brainer for larger or emergency practices but a cost vs. benefit analysis must be done for smaller hospitals.