This RIS includes Toshiba digital desktop telephones, plus 24 SpectraLink wireless telephones; these wireless phones were programmed to extend the features and capabilities of the users' desktop telephones to anywhere they roam at the 22-bed hospital; however, other wireless technologies such as cellular, could not be used due to the interference with sensitive medical equipment (Just the right prescription 24). The hospital's chief operating officer, Darryl Thornton, reported, "Being able to be mobile, yet still receive all our telephone calls, has greatly improved our efficiency and productivity. Toshiba's SpectraLink solution was the only one we found that would extend our desktop telephones to the palms of our hands" (Just the right prescription 24). The RIS also accommodated the needs of the hospital's remote users: "The system is so flexible that we were able to connect our remote users and still have it look like they are located at our corporate offices," Thornton added. "Both incoming and outgoing calls are routed via the remote users' extensions through our main system at the hospital, so it's totally transparent that they aren't here at the hospital" (Just the right prescription 24). The hospital also had unique requirements for the Strata CTX670, including paging that could be restricted by area and the ability to restrict long distance on specific telephones, such as those in the lobby and in patient rooms, which required special programming. To deliver the hospital's integrated voice and data communication, Great Plains partnered with TelCove, a provider of business-critical telecommunications services to enterprise customers and carriers, and NetVision Technologies, a provider of data networking services and technology consulting, all with offices in Wichita. TelCove delivered the external network, while NetVision handled the internal network. TelCove installed a fiber connection at the hospital connecting it to TelCove's synchronous fiber-optic network (SONET), to provide both local network services and long distance. The SONET topography design enables all elements on the SONET ring to continuously communicate with each other, with information being routed in both directions, so if an element is inactive for any reason, the network stays active. At the hospital, the optical network terminates the voice services on ISDN, using a primary rate interface (PRI) that runs through the Toshiba switch via PRI cards; the system also delivers a full T-1 of Internet service (Just the right prescription 24).

The reliability of the optical network was, of course, a high priority for the hospital; the system's reliability was tested in the school of hard knocks when a tornado destroyed two miles of the network cabling; however, in spite of the damage, the network did not experience any downtime. NetVision installed the hospital's internal voice and data network, including setting up the wireless local area network, multitiered security and a high-capacity, fully gigabit infrastructure. "The key to the success of both the data networking and voice applications is having a wireless network that is free of interference and fully compatible with both applications" reported Brent Burdick, NetVision president (Just the right prescription 24). NetVision was heavily involved in the overall design of the network, from placements of cabling and wireless access points to infrastructure issues such as heating and cooling. Planning the system before the hospital was built was a critical element to the system's deployment, Thornton says, as was having a battery backup in place as the system was deployed (Just the right prescription 24).

Finally, the hospital's new wireless telephones have proven to be more useful than the planners first imagined: "The ability to be mobile and receive your telephone calls at the same time is one of the biggest benefits I've ever seen in a hospital telephone system. Our telephones have given us a huge advantage in communicating with patients, families, doctors, other medical facilities and each other" (Just the right prescription 24). "Being an open system, this system will let us add voice over IP or other capabilities as our needs change and as we grow," Knocke concluded (Just the right prescription 24).

Benefits of Picture Archive Communication Systems (PACS). According to Creighton (1999), picture archiving and communication systems (PACS) were originally developed to combine viewing of modality images, archiving, and distribution of images (138). "When PACS is integrated/interfaced with radiology information systems (RIS) or hospital information systems (HIS)," he says, "it can merge patient demographics, medical records, and images" (Creighton 139). In their essay, "Computers in imaging and health care: now and in the future," Arenson Andriole, Avrin and Gould (2000) report that, "Early picture archiving and communication systems (PACS) were characterized by the use of very expensive hardware devices, cumbersome display stations, duplication of database content, lack of interfaces to other clinical...

These earlier systems were implemented historically at large academic medical centers by biomedical engineers and imaging informaticists. PACS were nonstandard, home-grown projects with mixed clinical acceptance. However, they clearly showed the great potential for PACS and filmless medical imaging. Filmless radiology is a reality today (Arenson et al. 145).
The introduction of efficient softcopy display of images provides a means for dealing with the ever-increasing number of studies and number of images per study. Computer power has increased, and archival storage cost has decreased to the extent that the economics of PACS is justifiable with respect to film. Network bandwidths have increased to allow large studies of many megabytes to arrive at display stations within seconds of examination completion. PACS vendors have recognized the need for efficient workflow and have built systems with intelligence in the management of patient data. Close integration with the hospital information system (HIS)-radiology information system (RIS) is critical for system functionality. Successful implementation of PACS requires integration or interoperation with hospital and radiology information systems (Arenson et al. 145).

In an effort to address a number of emerging issues involved with communication between PACS and RIS, as well as to facilitate interface development and provide faster turnaround time for clinicians, a number of healthcare organizations have developed standards for the formatting and transfer of clinical data (Creighton 139). In addition, research continues to identify better approaches to resolving these issues. For example, Creighton cites the example of Communication protocol Health Level 7 (HL7) as a standard application protocol that is being used for electronic text data exchange in healthcare by most RIS today. The imaging communication protocol for PACS is the Digital Imaging and Communications in Medicine (DICOM) standard specification protocol; this protocol describes the means of formatting and exchanging images and associated information (Creighton 139).

In their journal article, "DICOM modality worklist: an essential component in a PACS environment," Gale and Gale (2000) discuss the emergence of this evolving communications protocol and report that, "The development and acceptance of the digital communication in medicine (DICOM) standard has become a basic requirement for the implementation of electronic imaging in radiology" (101). These authors point out that DICOM is now evolving to provide a standard for electronic communication between radiology and other parts of the hospital enterprise (Gale & Gale 101). In his essay, "HIS/RIS/PACS integration: getting to the gold standard," Boochever (2004) reports that the technology for acquiring, storing, retrieving, displaying, and distributing images has experienced enormous innovations in recent years. The demand for such enterprise-wide imaging management solutions in which digital images from radiology and other services are integrated in a seamless fashion together with information from clinical information systems and other databases; such digital images can then be accessed seamlessly from a single point of end-user interaction.

Calling it a "gold standard" of system integration, the ideal approach to this integration, Boochever says, would be to provide an integrated platform that provided improved workflow, patient throughput and patient safety, as well as decreased cost. "Unfortunately," he says, "the gold standard remains elusive in most healthcare environments, even those with new systems" (16).

One of the earliest problems that confronted software developers in this regard was the need for a protocol that would allow communication between the HIS/RIS/PACS systems and between Health Level-7 (HL7) and DICOM. "This barrier was solved by the broker -- a software and hardware device that accepts HL7 messages from the RIS then translates, or maps, the data to produce DICOM messages for transmission to the PACS" (Boochever 16). According to this author, technologist workflow requires patient and examination data from the RIS to be communicated to the modality; the broker then provides support for this by exploiting the DICOM Modality Worklist (DMWL); however, two fundamental constraints remain inherent to most brokered configuration: 1) workflow remains paper-driven and 2) RIS information flows in one direction only, resulting in redundant databases (Boochever 16). Resolving the limitations of HIS/RIS/PACS connectivity will require industry-accepted communication protocols and rules; Boochever notes that the Integrating the Health Care Enterprise (IHE) initiative was developed to achieve this level of seamlessness within the HIS/RIS/PACS systems. "The goal of IHE," he says, "is to provide end-users improved access to critical patient and clinical information across all systems within the healthcare…